Lake Norman Home Health

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on agency policy, home visits, clinical record review, and staff interviews, the Plan of Care [POC] failed to include all medications the patient was using for 2 of 4 home visits [# 8 and 9]. The findings included: The policy, Plan of Care [POC] [9/1/24], was provided by the agency administrator on 10/16/24 at approximately 8:30 am. The policy stated, “...The POC includes...medications and treatments...all patient care orders...” 1. Patient # 8 had a Start of Care date of 9/16/24 with admitting diagnoses of secondary and unspecified malignant neoplasm of nodes of multiple regions, secondary malignant neoplasm of right lung, and acute diastolic [congestive] heart failure [heart doesn’t pump effectively]. The patient was hospitalized from 10/4/24-10/7/24. Review of the resumption of care [comprehensive assessment completed after in patient stay] POC included orders for PT [physical therapy] 1 time a week for 1 week, 2 times a week for 1, 1 time a week for 3 weeks. A joint visit was conducted with PT # 4 on 10/15/24 at 11:30 am. During the visit, a medication review was conducted using a medication profile provided by the agency. The following discrepancy was noted: The medication profile listed Omeprazole [reflux] 2o mg daily. During an interview with the caregiver, the caregiver reported the patient no longer takes the medication and “has not taking it since coming home from the hospital”. During an interview with employee # 1 on 10/16/24 at approximately 11 am, employee # 1 confirmed the POC did not include all medications the patient was taking. 2. Patient # 9 had a Start of Care date of 9/5/24 with an admitting diagnosis of encounter for surgical aftercare following surgery on the digestive system. Review of the Plan of Care [POC] for the certification period 9/5/24-11/3/24 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 3 weeks, 1 time every 2 weeks for 4 weeks. On 1016/24 at approximately 9 am a joint visit was made with RN # 3. During the visit a medication review was conducted using a medication profile provided by the agency. The following medications were not included on the patient’s POC: Imodium [antidiarrheal] 2 mg. Take 1 tablet every 6 hours for diarrhea for up to 10 days. The bottle of medication included a start date of 3/6/23. During an interview with the patient, the patient reported she continues to use the Imodium as needed for diarrhea. Aleve PM [sleep aid]. Take 2 tablets as needed at bedtime for sleep. During an interview with the patient, the patient advised she has been taking the Aleve PM as needed to help with sleep and pain. During an interview with employee # 1 on 10/16/24 at approximately 11 am, employee # 1 confirmed the POC did not include all medications the patient was taking.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews the agency failed to change the infusion cap for 1 of 1 patient with a vascular assess device [medical device that provides access to a patient’s blood stream for administration of medications or obtain blood for lab work] [#5] in accordance with the physician’s order; and failed to flush a vascular access device with the correct amount of normal saline after obtaining a blood specimen in accordance with the physician’s order for 1 of 1 patient with a vascular access device [#5]; and failed to obtain the patient’s weight each visit in accordance with the physician’s order for 1 of 4 patients who received a home visit [#8]; and failed to obtain oxygen saturations in accordance with the physician’s order for 1 of 4 patients who received a home visit [#8]. The findings included: The policy, Physician Orders [10/1/23], was provided by the agency administrator on 10/16/24 at 8:30 am. The policy stated, “...No medications, treatments, diagnostic studies...will be administered without the order of a qualified physician or authorized practitioner...” 1A. Patient # 5 had a Start of Care [SOC] date of 9/18/24 with admitting diagnoses of infection/inflammation reaction due to internal right knee prosthesis and encounter for adjustment and management of VAD [vascular access device [ medical device that provides access to a patient’s blood stream for administration of medications or obtain blood for lab work]. Review of the Plan of Care [POC] for the certification period 9/18/24-11/16/24 included orders for SN [skilled nursing] 2 times a week for 1 week, 1 time a week for 5 weeks, 2 times a week for 1 week and “Skilled nurse to perform site care for infusion access device...once a week and prn [as needed]…injection cap change once a week and with each lab draw...” Review of the clinical record revealed RN # 6 conducted a routine visit on 9/20/24. The clinical record revealed the RN did complete site care for the infusion access device. The RN failed to change the injection cap in accordance with the POC. During an interview with employee # 1 on 10/16/24 at approximately 11 am, employee # 1 confirmed the injection cap was not changed in accordance with the physician’s order. 1B. Patient # 5 had a Start of Care [SOC] date of 9/18/24 with admitting diagnoses of infection/inflammation reaction due to internal right knee prosthesis and encounter for adjustment and management of VAD [vascular access device [ medical device that provides access to a patient’s blood stream for administration of medications or obtain blood for lab work]. Review of the Plan of Care [POC] for the certification period 9/18/24-11/16/24 included orders for SN [skilled nursing] 2 times a week for 1 week, 1 time a week for 5 weeks, 2 times a week for 1 week and “Skilled nurse to perform lab draw...in 2-3 days from SOC and every week...Skilled nurse to flush with 10 ml of normal saline prior to specimen draw...flush with 20 ml of normal saline...after specimen draw...” Further review of the clinical record revealed LPN # 5 conducted a routine visit on 9/23/24 to obtain labs via the vascular access device. Review of the documentation by the LPN revealed she flushed the access device with 10 ml of saline after obtaining the specimen instead of 20 ml of saline. During an interview with employee # 1 on 10/16/24, employee # 1 confirmed the LPN failed to flush the device in accordance with the physician’s order. 2A. Patient # 8 had a Start of Care date of 9/16/24 with admitting diagnoses of secondary and unspecified malignant neoplasm of nodes of multiple regions, secondary malignant neoplasm of right lung, and acute diastolic [congestive] heart failure [heart doesn’t pump effectively]. Review of the Plan of Care [POC] for the certification period 9/16/24-11/14/24 included the orders for SN [skilled nursing] 1 time a week for 3 weeks, 1 time a week every 2 weeks for 6 weeks and “Skilled nurse to obtain weight every visit and notify RN/Physician of weight gain or loss of 3 pounds within 1 day or 5 pounds within 1 week”. Review of the clinical record revealed RN # 3 conducted SN visits on 9/24/24 and 10/3/24. The clinical record revealed no evidence of a weight was obtained. During an interview with employee # 1 on 10/16/24 at approximately 11 am, employee # 1 confirmed the weight was not obtained in accordance with the physician’s order. 2B. Patient # 8 had a Start of Care date of 9/16/24 with admitting diagnoses of secondary and unspecified malignant neoplasm of nodes of multiple regions, secondary malignant neoplasm of right lung, and acute diastolic [congestive] heart failure [heart doesn’t pump effectively]. Review of the Plan of Care [POC] for the certification period 9/16/24-11/14/24 included the orders for SN [skilled nursing] 1 time a week for 3 weeks, 1 time a week every 2 weeks for 6 weeks. A supplemental order was written on 9/25 24 for SN to “check 02 sat [saturation] next visit while at rest, while exercising and with oxygen in use, while exercising with oxygen not in use...Fax results...” Review of the clinical record revealed LPN # 5 completed a routine visit on 10/1/24 [this was the first SN visit after the order was obtained]. The clinical record does not include any documentation related to the 02 sat related to the supplemental order. During an interview with employee # 1 on 10/16/24 at 11 am, employee # 1 confirmed the 02 saturation was not obtained in accordance with the physician’s order.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on policy review, client record review, and staff interviews, the agency failed to provide home health aide supervision for 1 of 1 home health aide records reviewed [#7]. Findings included: Review of policy “Home Health Aide Supervision” revised 6/1/24 was received from the agency director on 10/16/24 at 8:35 AM. The policy stated,” …at least every 14 days with or without aide present with an onsite visit with aide at least annually…” Patient #7 had a SOC (start of care) of 7/12/24 and included diagnoses of pressure ulcer of sacral region; stage 2; major depressive disorder, anxiety disorder, hypokalemia (low potassium), and hypertension. Home health aide orders were for 1 time a week for 9 weeks. Review of home health aide visits for 9/13/24, 9/20/24, 9/27/24, and 10/2/24 revealed no aide supervision visits were made until 10/9/24.”