Pruitthealth at Home - Brunswick

“Coordination of Care CFR(s): 484.60(d) Standard: Coordination of care. The HHA must: This Standard is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews the agency failed to notify the physician of missed social work, nurse and occupational therapy visits for 3 of 6 active patients. (#4, #6, #7) Findings included: A policy, Attempted Visits/Missed Visits Policy for Home Health (revised 05/18/2022) was received on 01/09/2024 at 11:30 AM from the clinical manager. The policy stated, “If the visit is not able to be made and is missed, the patient’s physician is to be notified of the missed visit this is to be documented in a Missed Visit Coordination Note.” Patient #7 was admitted on 12/19/2024 with a diagnosis of epilepsy (neurological disorder with sudden episodes of sensory disturbance). The plan of care for 12/19/2023-02/16/2024 included orders for skilled nurse (SN) visits 1 time a week for 9 weeks, physical therapy 1 time a week for 8 weeks, and occupational therapy (OT) 1 time a week for 8 weeks beginning 12/24/2023. There was no evidence in the clinical record of physician notification of a missed SN visit the week of 12/24/2023. There was no evidence in the clinical record of physician notification of a missed OT visit the week of 12/30/2023. An interview was conducted with the clinical manager on 01/09/2024 at approximately 12:00 PM. The clinical manager was unable to state why the visits were not conducted as ordered or if the physician had been notified. 1. Patient #4 was admitted to the agency 12/07/23 with diagnoses including a thoracic spine (part of the spine where the chest/ribs are located) fracture, hypertensive (high blood pressure related) chronic kidney disease, and dementia. Plan of Care from 12/07/23 to 02/04/24 revealed orders for physical therapy one time per week for five weeks, and occupational therapy one time per week for one week, two times per week every two weeks, two times per week for one week, and one time per week for two weeks. Employee #5, occupational therapist, conducted an evaluation on 12/13/23 and documented, “Pt [patient] moved out of her home of 20 years…her dtrs [daughters] are helping her and she sold the home today. Pt reports feeling emotional about this. She understands that it was no longer appropriate or her to be living home alone…she decided to move to independent senior living…forgetful at times and reports anxiety. She has not been sleeping great and has ‘a lot on her mind’” The visit note included documentation for an add-on medical social work (MSW) evaluation and on 12/15/23, Employee #5 entered an order for the add-on MSW evaluation for “anxiety management” one time per week for two weeks, effective 12/31/23. There was no evidence that a medical social work evaluation was conducted for Patient #4 and there was no evidence that the physician was notified. In an interview on 01/09/24 at 9:38 AM, Employee #2, clinical manager, stated, “Initially it [MSW evaluation order] went in…The social worker was on vacation so it was scheduled for this week…Typically, if there is going to be a delay, it would be the clinician to notify the physician.” In an interview on 01/09/24 at 9:55 AM, Employee #6, medical social worker, stated, “[Employee #2] rewrote the order for this week…It [MSW evaluation visit] never appeared on my tablet [schedule] for the [week of the]31st. Otherwise I would have [notified the physician].” 2. Patient #6 was admitted to the agency 11/30/23 with diagnoses including neurocognitive disorder with Lewy bodies (a progressive dementia leading to declines in reasoning and functioning), history of falling, and hypertension. Plan of Care from 11/30/23 to 01/28/24 revealed orders for skilled nursing one time per week for four weeks, physical therapy one time per week for one week, two times per week for four weeks, and one time per week for three weeks, and occupational therapy, effective 12/03/23, one time per week for six weeks. Employee #4, registered nurse, conducted a skilled nursing visit on 12/20/23 and documented, “Today’s visit was supposed to be discharge [sic] from SN [skilled nursing] service, but will discharge next week after following up on recent events and the results from today’s visit regarding UA [urinalysis-a test to help identify the presence of urinary tract infections] …” An order dated 12/20/23 was entered with a skilled nursing frequency one time per week for one week effective 12/24/23 with the description “New event req [requesting] one addtl [additional] visit” There was no evidence that a skilled nursing visit was conducted after the 12/20/23 visit and there was no evidence that the physician was notified. In an interview on 01/09/24 at 12:35 PM, Employee #4 stated, “I didn’t know I had to put in an order for another visit at the time.” In an interview on 01/09/24 at 1:05 PM, Employee #2, clinical manager, stated, “The clinician did not document it [the additional skilled nursing order] under the right area.””

“Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA’s governing body. This Standard is not met as evidenced by: Based on clinical record review, staff interview, and fall report review, the agency failed to document falls reported by the patient and/or caregiver on the fall report for 1 of 1 patient with documented falls (#6). Findings included: Patient #6 was admitted to the agency 11/30/23 with diagnoses including neurocognitive disorder with Lewy bodies (type of progressive dementia leading to declines in reasoning and functioning), history of falling, and hypertension. Plan of Care from 11/30/23 to 01/28/24 revealed orders for skilled nursing one time per week for four weeks, physical therapy one time per week for one week, two times per week for four weeks, and one time per week for three weeks, and occupational therapy, effective 12/03/23, one time per week for six weeks. Employee #3, physical therapist, conducted a visit on 12/12/23 and documented, “[Patient #6] and ger [sic] spouse report a fall on Sunday, with no injuries.” This fall was not documented on the agency’s fall report. Employee #5, occupational therapist, conducted a visit on 12/13/23 and documented, “Pt [patient] had 3 falls since last visit.” These falls were not documented on the agency’s fall report. Review of the agency’s fall report did not include any documented falls related to Patient #6. In an interview on 01/09/24 at 1:05 PM, Employee #2, clinical manager, stated, “They [clinicians] should be reporting the fall and entering the fall report.””

“Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This Standard is not met as evidenced by: Based on agency policy, clinical record review and staff interviews the agency failed to collect data on newly acquired infections and/or infectious diseases for 2 of 2 patients diagnosed with an infectious disease or infection. (#1 and #3) Findings included: Findings included: A policy, Infection Prevention and Control Program Surveillance Reporting (revised 11/30/2023) was received from the Agency Director on 01/08/2024 at approximately 1:00 PM. The policy stated, “The IP [Infection Preventionist] is responsible for collecting, analyzing, and providing infection data and trends to staff… Patient/resident infection cases are monitored and documented by the IP.” 1. Patient #1 was admitted on 12/05/2023 with a diagnosis of surgical after care following surgery on the circulatory system. The plan of care for 12/05/2022-02/02/2023 included orders for skilled nurse visits 1 time a week for 4 weeks and 2 PRN (as needed) and physical therapy (PT) visits 2 times a week for 2 weeks and 1 time a week for 6 weeks. The PT visit of 12/08/2022 PT #8 stated, “New cellulitis on left LLE [left lower extremity].” PT visit of 12/13/2022 PT #8 stated, “Cellulitis [bacterial infection of the skin] left LLE [left lower extremity].” There was no evidence of the new infection being reported or documented in the infection/incident report. PT #8 was unavailable for an interview. An interview was conducted with the clinical manager on 01/08/2024 at 12:24 PM. The clinical manager stated, “It would be the expectation that cellulitis [infections] would be reported as a new event in the infection log. 2. Patient #3 was admitted on 11/13/2023 with a diagnosis of chronic pain. The plan of care for 11/13/2023 – 01/11/2024 included orders for PT (physical therapy) visits 2 times a week for 3 weeks and 1 time a week for 5 weeks and OT (occupational therapy) visits 1 time a week for 2 weeks and 2 times a week for 3 weeks. On 12/21/2023 an order stated, “Holding until next week due to patient having COVID [infectious respiratory disease].” On 12/26/2023 an order stated, “Skip second visit this week D/T [due to] PT [patient] Covid-19 illness.” On 12/28/2023 an order stated, “Patient COVID positive. Hold PT [patient] visits until week of 01/01/2023 [sic].” On 12/28/2023 an order stated, “Hold visits this week D/T [due to] PT [patient] with recent COVID positive status.” There was no evidence of the new infectious disease being reported or documented in the infection/incident report. An interview was conducted with the clinical manager on 01/08/2024 at 1:23 PM. The clinical manager stated, “There are no reported infections for 2022 or 2023.” An interview was conducted with registered nurse #4 on 01/08/2024 at 3:45 PM. RN #4 stated, “If there were a new infection I would contact [name of clinical manager] and then document a new event. COVID 19 is an event.” An interview was conducted with the agency administrator on 01/09/2024 at 9:30 AM. The agency administrator stated, “The expectation is to create an infection/incident report [for infections/infectious diseases]. It was unclear on a corporate level we are correcting that procedure now.” The agency administrator provided the name of the infection preventionist. An interview was conducted with the infection preventionist (IP) on 01/09/2024 at 1:00 PM. The IP stated, “No [was not made aware of these new infections/infectious diseases]. I am from corporate, not the IP that oversees that office.””

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews the agency failed to provide all the services in the plan of care for 3 of 6 active patients. (#4, #6, #7) Findings included: A policy Coordination and Management of Home Health Services (revised 09/22/2022) was received on 01/09/2024 from the clinical manager at 1:19 PM. The policy stated, “Services are provided in accordance with the attending physician’s orders and the written plan of care.” A policy, Attempted Visits/Missed Visits Policy for Home Health (revised 05/18/2022) was received on 01/09/2024 at 11:30 AM from the clinical manager. The policy stated, “If the visit is not able to be made and is missed…this is to be documented in a Missed Visit Coordination Note.” Patient #7 was admitted on 12/19/2024 with a diagnosis of epilepsy (neurological disorder with sudden episodes of sensory disturbance). The plan of care for 12/19/2023-02/16/2024 included orders for skilled nurse (SN) visits 1 time a week for 9 weeks, physical therapy 1 time a week for 8 weeks, and occupational therapy (OT) 1 time a week for 8 weeks beginning 12/24/2023. There was no evidence in the clinical record of a SN visit, or a missed SN visit the week of 12/24/2023. There was no evidence in the clinical record of an OT visit, or a missed OT visit the week of 12/30/2023. An interview was conducted with the clinical manager on 01/09/2024 at approximately 12:00 PM. The clinical manager was unable to state why the visits were not conducted as ordered. 1. Patient #4 was admitted to the agency 12/07/23 with diagnoses including a thoracic spine (part of the spine where the chest/ribs are located) fracture, hypertensive (high blood pressure related) chronic kidney disease, and dementia. Plan of Care from 12/07/23 to 02/04/24 revealed orders for physical therapy one time per week for five weeks, and occupational therapy one time per week for one week, two times per week every two weeks, two times per week for one week, and one time per week for two weeks. Employee #5, occupational therapist, conducted an evaluation on 12/13/23 and documented, “Pt [patient] moved out of her home of 20 years…her dtrs [daughters] are helping her and she sold the home today. Pt reports feeling emotional about this. She understands that it was no longer appropriate or her to be living home alone…she decided to move to independent senior living…forgetful at times and reports anxiety. She has not been sleeping great and has ‘a lot on her mind’” The visit note included documentation for an add-on medical social work (MSW) evaluation and on 12/15/23, Employee #5 entered an order for the add-on MSW evaluation for “anxiety management” one time per week for two weeks, effective 12/31/23. There was no evidence that a medical social work evaluation was conducted for Patient #4 and there was no evidence that the physician was notified. In an interview on 01/09/24 at 9:38 AM, Employee #2, clinical manager, stated, “Initially it [MSW evaluation order] went in…The social worker was on vacation so it was scheduled for this week…Typically, if there is going to be a delay, it would be the clinician to notify the physician.” In an interview on 01/09/24 at 9:55 AM, Employee #6, medical social worker, stated, “[Employee #2] rewrote the order for this week…It [MSW evaluation visit] never appeared on my tablet [schedule] for the [week of the]31st. Otherwise I would have [notified the physician].” 2. Patient #6 was admitted to the agency 11/30/23 with diagnoses including neurocognitive disorder with Lewy bodies (a progressive dementia leading to declines in reasoning and functioning), history of falling, and hypertension. Plan of Care from 11/30/23 to 01/28/24 revealed orders for skilled nursing one time per week for four weeks, physical therapy one time per week for one week, two times per week for four weeks, and one time per week for three weeks, and occupational therapy, effective 12/03/23, one time per week for six weeks. Employee #4, registered nurse, conducted a skilled nursing visit on 12/20/23 and documented, “Today’s visit was supposed to be discharge [sic] from SN [skilled nursing] service, but will discharge next week after following up on recent events and the results from today’s visit regarding UA [urinalysis-a test to help identify the presence of urinary tract infections] …” An order dated 12/20/23 was entered with a skilled nursing frequency one time per week for one week effective 12/24/23 with the description “New event req [requesting] one addtl [additional] visit” There was no evidence that a skilled nursing visit was conducted after the 12/20/23 visit and there was no evidence that the physician was notified. In an interview on 01/09/24 at 12:35 PM, Employee #4 stated, “I didn’t know I had to put in an order for another visit at the time.” In an interview on 01/09/24 at 1:05 PM, Employee #2, clinical manager, stated, “The clinician did not document it [the additional skilled nursing order] under the right area.””

“Assure patient needs are continually assessed CFR(s): 484.105(c)(4) Assuring that patient needs are continually assessed, and This Element is not met as evidenced by: Based on agency policy review, clinical record review, and staff interview, the agency failed to follow-up regarding a suspected urinary tract infection (UTI) for 1 of 1 patient with a suspected UTI (#6). Findings included: A policy titled, “Coordination and Management of Home Health Services”, effective 12/01/06 and revised 09/22/22, was received from the clinical manager on 01/09/24 at 1:19 PM. This policy revealed, “All partners providing services shall maintain effective interchange so that all services are effectively coordinated between the members of the Interdisciplinary Team, clearly outlining each member’s responsibilities, in an effort to…evaluate the adequacy of treatment and the effectiveness of services provided…determine whether services for a patient should be continued and/or future plans for care…provide the attending physician with an ongoing assessment of the patient…promote continuity of care through the sharing of relevant patient information…” Patient #6 was admitted to the agency 11/30/23 with diagnoses including neurocognitive disorder with Lewy bodies (type of progressive dementia leading to declines in reasoning and functioning), history of falling, and hypertension. Plan of Care from 11/30/23 to 01/28/24 revealed orders for skilled nursing one time per week for four weeks, physical therapy one time per week for one week, two times per week for four weeks, and one time per week for three weeks, and occupational therapy, effective 12/03/23, one time per week for six weeks. On 12/19/23, Employee #3, physical therapist, conducted an unplanned, check-in visit with Patient #6. Employee #3 documented that the agency had attempted contacted with the patient and her caregiver over the previous 24 hours and “…PCP [primary care physician] recommended the patient to be seen in the emergency room due to suspected UTI [urinary tract infection]. Patient denied being seen in the emergency room, which is the reason for todays [sic] follow up.” Further documentation revealed Patient #6’s caregiver was also ill at the time of the check-in visit and Employee #3 felt the patient was not safe, but the patient and caregiver declined calling EMS (Emergency Medical System) due to cost and denied having anyone else available to drive them. The PCP was contacted and requested that the agency call EMS on behalf of Patient #6 and her caregiver, which was done. Patient #6 did not go to the hospital on this date. On 12/20/23, Employee #4, registered nurse, conducted a skilled nursing visit and documented, “Today’s visit was supposed to be discharge [sic] from SN [skilled nursing] service, but will discharge next week after following up on recent events and the results from today’s visit regarding UA [urinalysis-a test to help identify the presence of urinary tract infections] …” On order dated 12/20/23 was entered with a skilled nursing frequency one time per week for one week effective 12/24/23 with the description “New event req [requesting] one addtl [additional] visit” There was no evidence of follow-up regarding the UA or the suspected UTI for Patient #6. There was no evidence that a skilled nursing visit was conducted after the 12/20/23 visit. In an interview on 01/09/24 at 12:35 PM, Employee #4 stated, “Things got hectic…I guess I forgot to follow-up…” In an interview on 01/09/24 at 12:40 PM, Employee #2, clinical manager stated, “The clinician needs to be following up and contacting the provider with the results and following whatever the provider recommends for treatment…””