Mcauley Seton Home Care Corp Chha

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on record reviews and staff interviews, the agency failed to ensure that all completed Outcome and Assessment Information Set assessments (M0090) were transmitted to the State/Centers for Medicare and Medicaid Services when completed. This is evident for one (1) of one (1) clinical records reviewed that required transmission (Patient #18). Failure to ensure that all completed Outcome and Assessment Information Set assessments are transmitted to the Centers for Medicare and Medicaid Services contractor or state within 30 (thirty) days has the potential for negative patient outcomes. The agency failed to ensure that all completed Outcome and Assessment Information Set assessments (M0090) are transmitted to the Centers for Medicare and Medicaid Services contractor or state within 30 (thirty) days as evidenced by: Pre-survey the “Home Health Agency Error Summary Report” on 04/22/2024 revealed the agency has 347 (three hundred and forty-seven) late submissions of the Outcome and Assessment Information Set assessments (M0090) from 04/22/2023 to 04/22/2024. Patient #18 – This 72-year-old therapy-only patient with the diagnoses of aftercare following joint replacement surgery, presence of right artificial hip joint, and hyperlipidemia was admitted to the home care agency on 06/22/2023 and discharged on 07/06/2023. Review of the Physical Therapy Outcome and Assessment Information Set Start of Care completed by the Physical Therapist revealed the Outcome and Assessment Information Set Assessment (M0090) was completed on 06/22/2023. Review of the Home Health Agency Error Submission Report provided by the agency on 05/01/2024 at 02:15 PM revealed the patient’s Outcome and Assessment Information Set Assessment (M0090) was submitted on 07/25/2023 (33 (thirty-three) days after the assessment was complete. During interview on 05/01/2024 at 02:00 PM, the Vice President of Patient Services stated the agency is on a new electronic medical record system and realized that whenever there is even just a small change to the person’s assessment, the system marks it as a resubmission. The agency now has a process in place to minimize reports of false late submissions by manually going through each change. However, this record was a true late submission.”

“Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient’s condition warrants due to a major decline or improvement in the patient’s health status, but not less frequently than- This Standard is not met as evidenced by: Based on clinical record review and staff interview for three (3) of eighteen (18) patients (Patient #’s: 2, 13 and 17), requiring updates to the comprehensive assessment based on a major change in the patient’s health status, the agency failed to ensure the assessments were of sufficient scope to identify current patient needs. Failure to ensure comprehensive assessments contain complete and accurate information has the potential for unmet patient needs. The agency failed to ensure the assessments were of sufficient scope to identify current patient needs as evidenced by: Patient #2 – This 62-year-old patient with the diagnoses of hypertensive heart disease with heart failure, chronic obstructive pulmonary disease, and type II diabetes mellitus without complications was admitted to the home care agency on 04/06/2024. Review of the Home Health Plan of Care dated 04/06/2024 revealed the patient uses oxygen 4 (four) liters per minute continuously. Review of the Physical Therapy Initial Evaluation dated 04/11/2024 revealed the Physical Therapist documented the following assessment: Home oxygen safety: patient uses oxygen in the home: no. During interview on 05/02/2024 at 10:52 AM, the Physical Therapist stated the patient was using oxygen during the visit. The assessment was documented in error. Patient #17 - This 69-year-old patient with diagnosis including spondylolisthesis, lumbar stenosis, and lumbar ligamentum flavum hypertrophy was admitted to the agency for Physical Therapy only on 09/06/2023. This patient was identified on the Potentially Avoidable Event Patient Listing Report for Development of Urinary Tract Infection. Review of the Physical Therapy Home Visit Note dated 09/08/2023 revealed the Physical Therapist documented the patient’s last bowel movement was on 08/31/2023. Review of the Physical Therapy Home Visit Note dated 09/08/2023 lacks documentation of the Physical Therapist assessing the patient for constipation. During interview on 05/02/2024 at 09:22 AM, the Physical Therapist stated that he did not assess the patient for constipation but did notify the physician that the patient’s last bowel movement was eight (8) days ago. The agency failed to ensure the assessments were of sufficient scope to identify current patient needs as evidenced by: Patient #13 – This 66-year-old therapy only patient with diagnoses that include broken internal right knee prosthesis, mechanical loosening of internal left knee prosthetic joint and essential hypertension was admitted to the home care agency on 03/24/2023. Review of the Physical Therapy Home Visit Note dated 03/28/2023 revealed the patient was constipated and the last bowel movement had occurred on 03/21/2023. Additionally, the Physical Therapist documented speaking with the Physician Assistant who recommended increasing the patient’s water intake and starting miralax. Review of the clinical record lacks documentation of follow-up regarding the patient starting miralax for constipation. During interview on 05/01/2024 at 09:40 AM, the Physical Therapist stated the patient reported having a bowel movement at the next visit occurring on 03/30/2023, without taking miralax. The Physical Therapist stated the patient also reported she was not going to obtain and use miralax but failed to document this.”

“Property and person treated with respect CFR(s): 484.50(c)(1) Have his or her property and person treated with respect; This Element is not met as evidenced by: Based on an observational home visit and staff interview, for one (1) of eighteen (18) patients (Patient #10) the agency nurse failed to accommodate the patient’s request for disposal of soiled dressings in the patient’s home. Failure to accommodate reasonable patient requests has the potential to result in limiting the patient’s rights and inclusion as an active partner in the delivery of care. The agency failed to ensure the patient’s right to respect for person during the home visit was accommodated as evidenced by: HV Patient #10- This 86- year-old patient with the diagnoses of venous insufficiency (chronic)(peripheral), non-pressure chronic ulcer part of right lower leg with unspecified severity, and essential (primary) hypertension was admitted to the home care agency on 04/19/2024. During an observational home visit on 05/01/2024 at 01:23 PM, the patient requested, on three separate occasions, for the nurse not to put the bag of soiled wound care dressings in her kitchen garbage can. She requested the nurse put them on top of the kitchen garbage can (not inside) or in the garage garbage can. The nurse interrupted the patient while putting soiled dressings in the kitchen garbage can after she was asked not to. The patient shrugged her shoulders and supinated her hands on the third request and stated, “I will take it to the garage myself”. During interview on 05/02/2024 at 10:28 AM, the Registered Nurse stated the patient did request for soiled dressings not to be put in the kitchen garbage. During an interview on 05/02/2024 at 10:30 AM, the Vice President of Patient Services stated that it is not acceptable for the nurse to ignore the patient’s requests. This is not what the agency does, and it will be addressed.”

“Skilled professional performs assessment CFR(s): 484.55(a)(2) When rehabilitation therapy service (speech language pathology, physical therapy, or occupational therapy) is the only service ordered by the physician or allowed practitioner, who is responsible for the home health plan of care, and if the need for that service establishes program eligibility, the initial assessment visit may be made by the appropriate rehabilitation skilled professional. This Element is not met as evidenced by: Based on review of clinical records and interviews with agency staff, for two (2) of ten (10) therapy-only patients (Patient #’s 11 and 16), the agency failed to ensure the Physical Therapist conducted an initial assessment of the patient within twenty-four (24) hours of referral or on the physician-ordered start of care date. Failure to conduct the initial assessment within the required time frame has the potential to result in unmet patient needs and negative patient outcomes. The agency failed to ensure the Physical Therapist conducted an initial assessment of the patient within 24 (twenty-four) hours of referral or on the physician-ordered start of care date as evidenced by: Patient #11 – This 71-year-old therapy-only patient with the diagnoses of idiopathic aseptic necrosis of left femur, hypertensive heart and chronic kidney disease with heart failure and stage one through stage four chronic kidney disease, and congestive heart failure was admitted to the home care agency on 04/12/2024. Review of the Referral Intake completed by the Registered Nurse on 04/05/2024 revealed the patient was referred to the home care agency on 04/05/2024. Review of the Referral Intake completed by the Registered Nurse on 04/05/2024 revealed the patient requested the start date of 04/10/2024. Review of the clinical record lacks documentation to explain why the start of care was 04/12/2024, 48 (forty-eight) hours after the requested start of care date of 04/10/2024. During interview on 05/02/2024 at 10:06 AM, the Vice President of Patient Services stated the Physical Therapist called and stated the patient requested the start of care date be moved to 04/12/2024 due to renovations in the home. However, the Physical Therapist stated she failed to document the request in the patient record. Patient #16 – This 83-year-old therapy only patient with diagnoses that include bilateral primary osteoarthritis of knee, unspecified asthma and hypertensive heart disease with heart failure was admitted to the home care agency on 07/07/2023. Review of the Referral for Services dated 07/01/2023 revealed the patient was referred to the agency on 07/01/2023 and the patient’s daughter requested the agency start of care occur on 07/03/2023. Review of the Physical Therapy Outcome and Assessment Information Set Start of Care revealed the initial assessment was completed on 07/07/2023, six (6) days after the patient was referred to the agency for services. Review of the clinical record lacks documentation of a delay of services and physician notification after the 07/03/2023 start of care request. During interview on 05/01/2024 at 09:10 AM, the Physical Therapist stated the patient’s daughter requested the start of care be delayed from the 07/03/2023 to 07/07/2023 but failed to be documented and the physician was not notified of the delay until 07/07/2023.”

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on review of clinical records and interviews with staff, for one (1) of eighteen (18) patient records (Patient #12), the agency failed to ensure that a comprehensive assessment consistent with the patient’s needs was performed within five (5) calendar days after the start of care. Failure to ensure a comprehensive assessment is complete and accurate has the potential for unmet patient needs and possible negative outcomes. The agency failed to ensure that a comprehensive assessment consistent with the patient’s needs was performed within five (5) calendar days after the Start of Care as evidenced by the following: Patient #12 – This 72-year-old therapy-only patient with diagnoses of spinal stenosis, acute bilateral lower back pains, and paroxysmal atrial fibrillation was admitted to the home care agency on 04/05/2024. Review of the Home Care Referral dated 04/03/2024 revealed the patient was to be evaluated for Physical Therapy, Occupational Therapy, Home Health Aide and Social work services. Review of the Home Health Certification and Plan of Care for 04/05/2024 to 06/03/2024 revealed an order for Social Work for long term planning. Review of the clinical record revealed the Social Worker initiated contact with the patient on 04/16/2024, ten (10) days after the start of care. During interview on 05/02/2024 at 10:53 AM, the Social Worker stated she had contacted the patient who requested the visit at a later date but failed to document this.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on review of patient care records and interview with agency staff for one (1) of eighteen (18) patient records (Patient #5), the agency failed to ensure the initial comprehensive assessment was of sufficient scope to identify patient needs. Failure to ensure the initial comprehensive assessment is complete and accurate has the potential for unmet patient needs and possible negative outcomes. The agency failed to ensure the initial comprehensive assessment was of sufficient scope to identify patient needs as evidenced by: Patient #5 – This 64-year-old patient with the diagnoses of malignant neoplasm of cardia, secondary malignant neoplasm of bone, and secondary and unspecified malignant neoplasm of lymph node was admitted to the home care agency on 03/30/2024. Review of the Home Health Plan of Cate dated 03/30/2024 revealed the following: - Wound care: drain. - Caregiver to perform drain care to abdomen daily and as needed if soiled or not intact to consist of: remove old dressing, cleanse with normal saline, pat dry, apply gauze dressing, secure with tape. - Intervention: Skilled observation and assessment of wound. Review of the Skilled Nurse Outcome and Assessment Information Set Start of Care dated 03/30/2024 revealed the Registered Nurse documented “Caregiver instructed on drain care, able to redemonstrate without issue.” Review of the Skilled Nurse Outcome and Assessment Information Set Start of Care dated 03/30/2024 lacks documented evidence of an assessment of the drain site. During interview on 05/02/2024 at 10:40 AM, the Registered Nurse stated she did assess the site during the dressing change but did not document the assessment in the visit note.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on clinical record review and interview with agency staff for two (2) of ten (10) therapy-only patients (Patient #’s:12 and 13), the clinical records lack documented evidence of a complete review of all medications the patient currently uses to identify any potential adverse effects, drug reactions, or concerns. Failure to conduct a complete medication review and to ensure the medication regime is appropriate has the potential for the patient harm. The agency failed to ensure a complete review of all medications the patient currently uses to identify any potential adverse effects, drug reactions, or concerns as evidenced by the following: Patient #12 – This 72-year-old therapy only patient with diagnoses of spinal stenosis, acute bilateral lower back pains, and paroxysmal atrial fibrillation was admitted to the home care agency on 04/05/2024. Review of the facility referral to the agency dated 04/05/2024 revealed an order for artificial tears one percent instill 1(one) drop in both eyes every 6 (six) hours as needed for dry eyes. Review of the Home Health Plan of Care for 04/05/2024 to 06/03/2024 revealed an order for artificial tears ophthalmic solution 1 (one) drop into both eyes 4(four) times daily as needed for dry eyes. Review of the clinical record lacks documented evidence of clarification of the artificial tears ophthalmic solution dosing. The Physical Therapist failed to identify and reconcile the medication discrepancy identified in the referral for services and the Plan of Care. During interview on 05/02/2024 at 11:20 AM, the Physical Therapist stated she picked the wrong dose from the medication pick list by error and did not clarify the dosing discrepancy with the physician but should have contacted the physician regarding the identified discrepancy. The agency failed to ensure a complete review of all medications the patient currently uses to identify any potential adverse effects, drug reactions, or concerns as evidenced by the following: Patient #13 – This 66-year-old therapy only patient with diagnoses that include broken internal right knee prosthesis, mechanical loosening of internal left knee prosthetic joint and essential hypertension was admitted to the home care agency on 03/24/2023. Review of the facility After Visit Summary dated 03/23/2023 revealed the patient was discharged from the facility on the following medications: - gabapentin 300 milligrams by mouth three (3) times a day; and - methotrexate 2.5 milligram tablet, take one (1) time per week, three (3) pills every wednesday morning and three (3) pills every wednesday evening. Review of the Home Health Plan of Care from 03/24/2023 to 05/22/2023 lacks medication orders for gabapentin and methotrexate. Review of the clinical record lacks documentation of acknowledgement and clarification of the identified medication discrepancies. During interview on 05/01/2024 at 10:40 AM, the Physical Therapist stated the identified medications failed to get ordered on the plan of care due to her failure to enter their corresponding start dates.”

“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 review of observational home visit, clinical records and staff interviews for five (5) of eighteen (18) patients (Patient #’s: 5, 10, 13, 15 and 16) the agency failed to develop individualized plans of care that are complete and accurate and address the total needs of the patients. Failure to ensure that a comprehensive individualized plan of care is developed has the potential for unmet patient needs. The agency failed to develop individualized plans of care that are complete and accurate and address the total needs of the patients as evidenced by: HV Patient #10- This 86- year-old patient with the diagnoses of venous insufficiency (chronic)(peripheral), non-pressure chronic ulcer part of right lower leg with unspecified severity, and essential (primary) hypertension was admitted to the home care agency on 04/19/2024. Review of Home Health Plan of Care dated 04/19/2024 revealed the following orders for wound care: Skilled nurse, patient, and caregiver to perform dressing change to right pretibial venous ulcer wound. Effective date 04/19/2024. Dressing change to consist of: - Utilizing clean technique. - Remove old dressing and discard. - Cleanse with normal saline. - Pat dry. - Apply xerforom to wound bed. - Cover with bordered foam. - Change wound dressing three (3) times weekly and as needed if integrity of dressing is compromised. During an observational home visit on 05/01/2024 at 01:15 PM the patient was observed wearing a tubigrip the over wound bandage. During interview on 05/02/2024 at 10:26 AM, the Registered Nurse stated the tubigrip was not ordered, but should have been. The plan of care is incomplete. The agency failed to develop individualized plans of care that are complete and accurate and address the total needs of the patients as evidenced by: Patient #5 – This 64-year-old patient with the diagnoses of malignant neoplasm of cardia, secondary malignant neoplasm of bone, and secondary and unspecified malignant neoplasm of lymph node was admitted to the home care agency on 03/30/2024. Review of the Home Health Plan of Care dated 03/30/2024 revealed the patient receives outpatient chemotherapy but lacks documentation regarding what medication is being given while at chemotherapy. The plan of care is incomplete. During interview on 05/02/2024 at 10:40 AM, the Registered Nurse stated the medication was not listed on the after-visit summary and she did not call the physician to find out what medication was being given. Patient #15 – This 68-year-old therapy-only patient with the diagnoses of fracture of unspecified part of neck of left femur, unspecified fall, and urine retention was admitted to the home care agency on 07/26/2023 and discharged on 08/10/2023. Review of the Physical Therapy Outcome and Assessment Information Set Start of Care dated 07/26/2023 revealed the Physical Therapist documented “history of chronic urinary retention – foley catheter intact – patient states has to make appointment with urologist for catheter removal once able to ambulate independently to the bathroom. Review of the Home Health Plan of Care dated 07/26/2023 lacks an order for a foley catheter. The plan of care is incomplete. During interview on 05/02/2024 at 09:34 AM, the Physical Therapist stated there is no order for the foley, it was an oversight. The agency failed to develop individualized plans of care that are complete and accurate and address the total needs of the patients as evidenced by the following: Patient #13 – This 66-year-old therapy only patient with diagnoses that include broken internal right knee prosthesis, mechanical loosening of internal left knee prosthetic joint and essential hypertension was admitted to the home care agency on 03/24/2023. A.) Review of the Physical Therapy Outcome and Assessment Information Set Start of Care dated 03/24/2023 revealed the Physical Therapist documented the patient’s diabetes is managed with diet, an oral hypoglycemic medication and is independent with blood glucose testing. Review of the Home Health Plan of Care from 03/24/2023 to 05/22/2023 lacks an order for diabetic supplies. During interview on 05/01/2024 at 10:44 AM, the Physical Therapist stated it was an oversight that the diabetic supplies were left off the plan of care. B.) Review of the Physical Therapy Outcome and Assessment Information Set Start of Care dated 03/24/2023 revealed the Physical Therapist documented the patient was unable to get to and from the toilet but was able to use a bedside commode. Review of the Home Health Plan of Care from 03/24/2023 to 05/22/2023 lacks an order for the bedside commode being used by the patient. During interview on 05/01/2024 at 10:46 AM, the Physical Therapist stated it was an oversight the bedside commode was not included on the plan of care.”

“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 observational home visit, review of clinical records and interviews with agency staff, three (3) of eighteen (18) patients (Patient #’s: 5, 6 and 13), the agency failed to ensure drugs and treatments are administered in accordance with physician orders. Failure to administer drugs and treatments without a physician’s order has the potential to result in poor quality of care. The agency failed to ensure drugs and treatments are administered in accordance with physician orders as evidenced by: HV Patient #6 - This 61-year-old patient with the diagnoses of encounter for change or removal of nonsurgical wound dressing, necrotizing fasciitis, and type II diabetes mellitus with diabetic neuropathy, unspecified was admitted to the home care agency on 03/13/2024. A.) Review of the Home Health Plan of Care dated 04/29/2024 revealed the following orders for negative pressure wound therapy: skilled nurse to perform dressing change to right groin fourniers wound. Effective date 03/22/2024. Dressing change consist of: Utilizing clean technique. Remove old dressing and discard. Cleanse with normal saline. Pat dry as appropriate. Apply skin protectant to peri-wound. Apply anasept gel to slough areas. Apply dressing from negative pressure wound therapy kit to wound using black foam. Set therapy cycle on negative pressure wound therapy pump to continuous. Set pressure on negative pressure wound therapy pump 125 millimeters of mercury. Change dressing three (3) times weekly and as needed if integrity of dressing is compromised. During an observational home visit on 04/29/2024 at 04:10 PM, the Registered Nurse used wound cleanser to cleanse the patient’s wound. During interview on 05/02/2024 at 12:12 PM, the Registered Nurse she misread the wound care order and used wound cleanser instead of normal saline as ordered. B.) During an observational home visit on 04/29/2024 at 04:13 PM, the Registered Nurse failed to apply anasept to slough areas of wound. During interview on 05/02/2024 at 12:15 PM, the Registered Nurse stated she was unable to recall if she applied anasept to wound bed as ordered. The agency failed to ensure drugs and treatments are administered in accordance with physician orders as evidenced by: Patient #5 – This 64-year-old patient with the diagnoses of malignant neoplasm of cardia, secondary malignant neoplasm of bone, and secondary and unspecified malignant neoplasm of lymph node was admitted to the home care agency on 03/30/2024. Review of the Home Health Plan of Care dated 03/30/2024 revealed the following orders for Skilled Nursing: 1 (one) visit every week for 1 (one) week, 3 (three) visits as needed for wound complications, 3 (three) visits every week for 4 (four) weeks. Review of the clinical record from 04/07/2024 to 04/13/2024 revealed the Skilled Nurse completed two (2) home visits, one (1) less than what is ordered. During interview on 05/02/2024 at 10:50 AM, the Vice President of Patient Services stated the Registered Nurse did not meet the ordered frequency and there is no documentation to state why. The agency failed to ensure drugs and treatments are administered in accordance with physician orders as evidenced by the following: Patient #13 – This 66-year-old therapy only patient with diagnoses that include broken internal right knee prosthesis, mechanical loosening of internal left knee prosthetic joint and essential hypertension was admitted to the home care agency on 03/24/2023. A.) Review of the Home Health Plan of Care from 03/24/2023 to 05/22/2023 revealed an order to assess the patient’s vital signs and notify the Physician/ Physician Assistant/Nurse Practitioner if the systolic blood pressure is 90 millimeters of mercury or less or 180 millimeters of mercury or greater and/ or diastolic blood pressure is 60 millimeters of mercury or less or 110 millimeters of mercury or greater. Review of the Physical Therapy Home Visit Note dated 04/04/2023 lacks documentation of a blood pressure being obtained or the patient refusing an assessment of the blood pressure. During interview on 05/01/2024 at 09:53 AM, the Physical Therapist states the patients blood pressure was obtained but is unable to explain why it did not get documented in the identified assessment. B.) Review of the Home Health Plan of Care from 03/24/2023 to 05/22/2023 revealed a medication order for tramadol 50 milligrams, one (1) tablet by mouth every six (6) hours for seven (7) days, end date 03/30/2023. Review of the Physical Therapy Home Visit Notes dated 04/01/2023, 04/03/2023, 04/04/2023, 04/06/2023 and the Physical Therapy Outcome and Assessment Information Set Discharge dated 04/10/2023 revealed the Physical Therapist documented the following pain relief comments: acceptable relief with rest, repositioning, cryotherapy, acetaminophen and tramadol as needed. Review of the clinical record lacks an order for tramadol after it was discontinued 03/30/2023. During interview on 05/01/2024 at 09:42 AM, the Vice President of Patient Services stated upon review of the electronic medical record, the patient had an as needed order for tramadol initiated on 03/23/2023 but it failed to be added to the agency plan of care.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on review of clinical records and interviews with agency staff for one (1) of eighteen (18) patients (Patients #17), the agency failed to coordinate care delivery and ensure patient needs are addressed. Failure to coordinate care delivery has the potential for negative patient outcomes. The agency failed to coordinate care as evidenced by the following: Patient #17 - This 69-year-old therapy-only patient with the diagnoses of spondylolisthesis, lumbar stenosis, and lumbar ligamentum flavum hypertrophy was admitted to the agency on 09/06/2023 and discharged on 09/22/2023. This patient was identified on the Potentially Avoidable Event Patient Listing Report for Development of Urinary Tract Infection. Review of the Home Health Plan of Care dated 09/06/2023 revealed the following orders for pain management: Instruct patient/caregiver pain management techniques such as immobilization, rest/activity, massage, avoiding stress, medications. Instruct in pharmacologic and non-pharmacologic pain management techniques. Review of the Home Health Visit Note dated 09/08/2023 revealed the Physical Therapist documented that the patient’s ordered oxycodone-acetaminophen (Percocet) 7.5-325 milligrams tablets ended on 09/07/2023. Additionally, on that date the patient reports feeling “lousy”, having chills, a low-grade fever and increased pain. The Physical Therapist documented that the physician’s office was contacted, and the Physical Therapist spoke with an agent of the physician, but received no new orders. Review of clinical record from 09/08/2023 to 09/13/2024 lacks documented evidence the Physical Therapist followed up with the physician and the patient to ensure the patient had appropriate pain management, the physician was aware of the patient’s symptoms and to ensure the patient was safe. Review of the Home Health Visit Note dated 09/14/2023 revealed the Physical Therapist documented the patient continued to have pain, the patient was afebrile, and the patient’s husband reported that the physician ordered hydrocodone-acetaminophen (Norco). During interview on 05/02/2024 at 09:24 AM, the Physical Therapist stated there was no further communication with the physician but upon next visit 09/14/2024 there was new pain medication in home.”

“Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This Element is not met as evidenced by: Based on observational home visit, review of clinical records, and staff interview, for one (1) of eighteen (18) patients (Patient #6), the agency failed to ensure the patient/caregiver receives appropriate education regarding the care and services identified in the plan of care. Failure to provide appropriate education has the potential to result in the patient receiving inadequate care and could result in patient harm. The agency failed to ensure the patient/caregiver receives appropriate education regarding the care and services identified in the plan of care as evidenced by: HV Patient #6 - This 61-year-old patient with the diagnoses of encounter for change or removal of nonsurgical wound dressing, necrotizing fasciitis, and type II diabetes mellitus with diabetic neuropathy, unspecified was admitted to the home care agency on 03/13/2024. Review of the Home Health Plan of Care dated 04/29/2024 revealed the following orders for interruption of negative pressure wound therapy: - If negative pressure wound therapy is off greater than two (2) hours, may apply a normal saline moistened gauze dressing; cover with gauze dressing, secure with tape until the negative pressure wound therapy can be restarted. Review of Supplemental Orders dated 04/09/2024 revealed the following: - Instruct patient/caregiver in disease process, pain management, signs/symptoms of infection, nutrition to promote wound healing, and wound care/dressing. - Patient/caregiver to perform wound care once taught. During an observational home visit on 04/29/2024 at 04:08 PM, the patient did not have negative pressure wound therapy and the wound was covered with a clear dressing. Review of the clinical record lacks documented evidence the caregiver received appropriate wound care education. The agency failed to ensure the caregiver was able to successfully re-demonstrate the ability to independently perform wound care for interruption of negative pressure wound therapy. During interview on 05/02/2024 at 12:17 PM, the Registered Nurse stated the nurse is expected to educate the caregiver and document that the caregiver was able to re-demonstrate wound care. The patient’s husband covered the wound with the incorrect dressing because he was not properly educated.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on review of clinical records and interviews with agency staff, for one (1) of eighteen (18) patients (Patient #’s: 6) receiving services, the agency failed to ensure clinicians prepare and document complete and accurate clinical and progress notes. Failure to prepare or document complete clinical and accurate progress notes has the potential for unmet patient needs The agency failed to prepare or document complete clinical and accurate progress notes as evidenced by the following: Patient # 6 – This 61-year-old patient with the diagnoses of encounter for change or removal of non-surgical wound dressing, necrotizing fasciitis, and Type 2 diabetes mellitus with diabetic neuropathy, unspecified, was admitted to the home care agency on 03/13/2021. A.) Review of the Home Health Plan of Care dated 03/13/2024 revealed the agency’s vital sign parameters are to notify the physician/Physician Assistant/Nurse Practitioner if pulse ox is less than 90 percent. Review of the Home Care Visit dated 03/27/2024 revealed the Physical Therapist documented the patient’s blood oxygen levels (SpO2) at 87 percent. Review of the clinical record lacks documented evidence of the Physical Therapist notifying the physician of blood oxygen level below 90 percent. During an interview on 05/02/2024 at 09:31 AM, the Physical Therapist stated the blood oxygen level was 97 percent and her documentation was an error. B.) Review of the Home Care Visit note dated 04/25/2024 revealed the Registered Nurse documented that the patient’s last bowel movement was on 04/26/2024. During an interview on 05/01/2024 at 03:31 PM, the Registered Nurse stated that the date of last bowel movement was entered incorrectly and should have been dated as the same day as her visit. She will add an amendment to the chart to correct.”

“Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This Element is not met as evidenced by: Based on review of clinical records and interviews with agency staff, for one (1) of eighteen (18) patients (Patient #’s: 17), the agency failed to ensure there was effective communication and follow-up with the physician involved in the patient’s plan of care. Failure to communicate with the physician involved in the patient’s care has the potential for unmet patient needs and negative outcomes. The agency failed to communicate with the physician involved in the patient’s care as evidence by the following: Patient #17 - This 69-year-old therapy-only patient with the diagnoses of spondylolisthesis, lumbar stenosis, and lumbar ligamentum flavum hypertrophy was admitted to the home care agency on 09/06/2023. This patient was identified on the Potentially Avoidable Event Patient Listing Report for Development of Urinary Tract Infection. A.) Review of the Home Health Visit Note dated 09/08/2023 revealed the Physical Therapist documented leaving a voicemail for the physician reporting the following: “feels lousy, chills, increased pain, low grade T (temperature), no BM (bowel movement).” Review of the Home Health Visit Note dated 09/08/2023 revealed the Physical Therapist documented that the patient’s next appointment with the physician is 09/11/2023. Review of the clinical record lacks documentation the Physical Therapist communicated with the physician regarding the increased pain or the lack of bowel movements after patient’s appointment with physician. During interview on 05/02/2024 at 09:31 AM the Physical Therapist stated he did not communicate with the physician regarding the increased pain or the lack of bowel movements. B.) Review of the Home Health Visit Note dated 09/14/2023 revealed the Physical Therapist documented the patient had continued complaints of pain and reported the physician was calling in a stronger prescription. Review of the Home Health Visit Note dated 09/14/2023 revealed the Physical Therapist documented the patient had had a visit with the surgeon and has an appointment to see the primary care provider the following week. Review of the Home Health Visit Note dated 09/20/2023 revealed the Physical Therapist documented the patient is on antibiotic for treatment of a urinary tract infection. Review of clinical record lacks documented evidence of communication between the Physical Therapist and the physician regarding the patient’s continued pain. During interview on 05/02/2024 at 09:31 AM the Physical Therapist stated he did not communicate with the physician regarding the patient’s continued pain.”