Spirit Homecare, Inc.

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on record review and interview, the facility failed to ensure an order for a patient to have nothing by mouth was included in the plan of care. This affected one (Patient #3) of three patients reviewed. The agency census was 296. Findings include: Record review for Patient #3 revealed a primary diagnosis of acute hypoxic respiratory failure. The diet/nutrition orders included bolus tube feedings every six hours through a percutaneous endoscopic gastrostomy (PEG) tube. The patient was ordered to have nothing by mouth (NPO) except tube feedings. The patient was also ordered to receive tracheostomy management per protocol. A tracheostomy had been placed on 09/13/23. A communication note on 01/08/24 revealed the agency received a call from another agency asking if the agency could take over care as they could no longer staff the patient. The Start of Care OASIS revealed an admission assessment was performed by a registered nurse on 01/08/24. The respiratory assessment noted the patient had dyspnea (difficult or labored breathing), tracheostomy, and oxygen use. Under feeding/eating, the registered nurse selected that the patient was unable to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy. The physician ordered plan of care for certification periods of 01/08/24 through 03/07/24 and 03/08/24 through 05/06/24 contained no physician order for Patient #3 to be NPO. During an interview on 04/16/24 at 3:07 PM, Staff A confirmed there should be a physician’s order for the patient to be NPO in the plan of care.”

“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 record review and interview, the facility failed to ensure a patient received education regarding smoking with the use of oxygen. This affected one (Patient #3) of three patients reviewed. The agency census was 296. Findings include: The medical record of Patient #3 revealed a primary diagnosis of acute hypoxic respiratory failure. The patient was also ordered to receive tracheostomy management per protocol. A tracheostomy had been placed on 09/13/23. Review of discharge orders also revealed that oxygen per nasal canula/tracheostomy at 2 liters/minute was ordered as needed. A communication note on 01/08/24 revealed the agency received a call from another agency asking if the agency could take over care as they could no longer staff the patient. The Start of Care OASIS revealed an admission assessment was performed by a registered nurse on 01/08/24. The respiratory assessment noted the patient had dyspnea (difficult or labored breathing), tracheostomy, and oxygen use. The oxygen risk assessment revealed that the patient was a smoker. The physician was notified of the elevated risk for oxygen safety. The physician ordered plan of care for the certification period of 01/08/24 through 03/07/24 revealed Patient #3 was admitted to the agency with diagnoses including acute respiratory failure with hypoxia, dysphagia (difficulty swallowing), alcohol dependence, esophageal obstruction, gastrostomy, and tracheostomy. The physician ordered the services of a nurse twice a week for two weeks, once a week for seven weeks, and three PRN visits for illness and medication changes. Among other tasks, the nurse was ordered to perform, tracheostomy care, patient/caregiver teaching on care of the stoma and trach, dressing changes, suctioning, patient/caregiver teaching on how to clean reusable medical equipment, and patient/caregiver teaching on self-management of oxygen therapy. A list of medications on the plan of care included oxygen 2 liters as needed. Durable medical equipment listed on the plan of care included oxygen. Skilled nurse visits were conducted by a staff licensed practical nurse (LPN) as ordered. Skilled nursing notes for each visit noted a respiratory assessment that included oxygen use intermittently per nasal cannula, and tracheostomy. The visit notes contained no documentation that any education provided to the patient about the dangers of smoking with oxygen use. The OASIS Recertification visit was performed on 03/05/24. Although this assessment was less comprehensive, the assessment noted the boxes for oxygen use and smoker were selected. It was further noted that the physician was notified of the elevated risk for oxygen safety. A communication note dated 03/08/24 stated the agency LPN spoke with the case manager for the patient’s Medicaid managed care plan. The case manager voiced concerns with Patient #3 smoking with oxygen. The note stated the LPN informed the case manager that the patient had not been observed smoking. During an interview on 04/17/24 at 11:30 AM, a care management supervisor for the patient’s Medicaid managed care plan reviewed the case manager’s notes and stated that the case manager visited the patient’s home on 02/21/24. The patient was observed smoking. The case manager also documented the agency LPN stated she was unaware the patient was smoking. During an interview on 04/16/24 at 3:07 PM, Staff A confirmed that the medical record lacked documentation the agency registered nurse conducting the OASIS assessments which noted the patient’s smoking with oxygen use notified the agency LPN conducting the weekly visits of the patient’s smoking. It was also confirmed that the medical record lacked documentation the patient was provided education on the dangers of smoking with oxygen use.”