Nurse Medical Home Healthcare LLC

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on record review, interview and policy review, the agency failed to ensure the physician was notified of missed visits and a change in the plan of care; failed to ensure the plan of care included the type of service to be provided, frequency and duration of all visits, medications, treatments, procedures, and treatment goals; failed to ensure all medications, treatments and services provided to the patient were ordered and signed by the physician; failed to ensure verbal orders were signed by the registered nurse when the verbal order was received and that the verbal order was signed by the physician; and failed to ensure the plan of care was reviewed and updated every 60 days by the physician. See G572, G574, G580, G584 and G588.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on record review, interview and policy review, the agency failed to ensure the physician was notified of missed visits and a change in the plan of care. This affected three (Patients #3, #5, and #6) of seven patient records reviewed. The census was 35. Findings include: 1. Review of the medical record for Patient #6 and physician’s plan of care dated 08/01/23 did not contain the frequency of occupational therapy (OT) visits. During an interview on 02/12/24 at 2:26 PM, Staff B stated the OT visited twice a week. Review of the medical record for Patient #6 and the OT visit sheets revealed a missed visit on 09/01/23 and no documented evidence the physician had been notified. Interview on 02/12/24 at 2:39 PM Staff B stated the contracted therapy notifies the physician and confirmed it was not documented. 2. Review of the medical record for Patient #3 and the most current physician’s plan of care dated 05/31/23 indicated the skilled nurse was to visit daily. Review of the skilled nurse visit sheets from 01/28/24 to 02/10/24 revealed the AM visit on 02/02/24 and the AM visit on 02/04/24 were missing and no missed visit reports were provided. During an interview on 02/12/24 at 4:00 PM Staff B stated the skilled nurse visited Patient #3 twice a day, seven days per week since 09/29/23. Staff B confirmed the physician had not been notified of the missed visits. 3. Review of the medical record for Patient #5 and physician’s plan of care dated 12/17/23 directed the home health aide (HHA) to provide care 35 hours per week. Review of the HHA visit sheets revealed the HHA did not provide 35 hours of care for the weeks of 12/17/23, 01/07/24 and 02/04/24. During an interview on 02/15/24 at 9:36 AM Staff B confirmed the HHA did not provide 35 hours each week. Staff B confirmed the physician had not been notified. Staff B stated they didn’t know they were supposed to notify the physician for the HHA missed visits. Staff B stated they only notify the case manager if the skilled nurse missed a visit. Review of the agency policy titled “C-580 Plan of Care” effective 2018, revealed home care services are furnished under the supervision and direction of the patient’s physician. The professional staff shall promptly alert the physician to any changes that suggest a need to alter the Plan of Care.”

“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 observation, record review and interview, the agency failed to ensure the medication profile was complete and updated to include all medications taken by the patient. This affected three (Patients #1, #2 and #3) of three patients reviewed with a home visit. The census was 35. Findings include: 1. Review of the medical record for Patient #1 revealed start of care was 08/07/18 and the last recertification assessment was 01/03/24. The skilled nurse visited two times a week. Review of the medication profile revealed Rosuvastatin Calcium 5 milligrams (mg) daily. On 02/13/24 at 11:00 AM., a visit was made to Patient #1’s home with Staff E in attendance. Review of the medications taken by Patient #1 revealed Rosuvastatin Calcium 10 mg daily. During interview on 02/13/14 at 11:25 AM., Staff E confirmed the dose of Rosuvastatin Calcium Patient #1 was not the same dose as what was on the medication profile. 2. Review of Patient #3’s medication profile revealed the patient was taking Baclofen 20 mg three times per day and D-Mannose 500 mg daily. On 02/13/14 at 9:30 AM, a visit was made to Patient #3’s home with Staff D in attendance. Review of the medications taken by Patient #3 revealed Baclofen 10 mg three times a day and D-Mannose 1000 mg daily which was not consistent with the medication profile. Patient #3 took additional medications not on the medication profile that included Macrodantin, Metoprolol, Oxybutine CL XL, Vitamin C, Rosuvastation Calcium, Restoril, Ferrasolfate, and cranberry capsules. During an interview on 02/13/14 at 9:42 AM, Patient #3 stated the had been taking Baclofen 30 mg dose for almost a year. During an interview on 02/13/24 at 10:24 AM., Staff D confirmed the medications in Patient #1’s home did not match what was on the agency’s medication profile. 3. Review of Patient #2’s medication profile revealed and folic acid 1000 mcg (micrograms) and Vitamin D 1000 IU (25 micrograms) daily. On 02/13/24 at 2:30 PM, a visit was made to Patient #2’s home with Staff C present. Review of the medications in Patient #2’s home revealed a multivitamin, a men’s multivitamin, lutein 20 mg daily, zinc 50 mcg daily, biotin 5000 mcg daily, B12 1000 mcg daily, Vitamin D3 5000 IU (125 mcg) daily, melatonin 5 mg at bedtime, docusate sodium 100 mg twice daily, ferrous sulfate 325 mg daily. and folic acid 800 mcg daily. During an interview on 02/13/24 at 3:14 PM, Staff C stated Patient #2 had been taking the vitamin B12 prior to coming to this agency. Staff C had taken care of Patient #2 prior to admission. Staff C confirmed these were over the counter medications and were not on the agency’s medication profile and confirmed duplicate medication therapy. Review of the agency policy titled “C-709 Medication Reconciliation” effective 2018, revealed on admission the admitting professional will document a complete list of all medications taken by the patient prior to admission. This will include all over the counter, prescribed, and as needed medications. The staff will review this medication list with the physician and confirm those medications that are to be continued or discontinued. When the patient is discharged from the inpatient setting, the medications will be reviewed, and the orders updated to reflect changes. Review of the agency policy titled “C-700 Medication Profile” effective 2018, revealed the medication profile will be reviewed and updated as needed to reflect current medications the patient is taking. The medication profile will identify possible ineffective drug therapy, duplicate drug therapy, adverse reactions, side effects, drug allergies and contraindicated medications. The medication profile will provide documentation of changes in the medication regime as they happen.”

“Within 48 hours of the patient’s return CFR(s): 484.55(d)(2) Within 48 hours of the patient’s return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This Element is not met as evidenced by: Based on record review, interview and policy review, the agency failed to ensure a resumption of care comprehensive assessment was completed within 48 hours of a hospital discharge. This affected two (Patients #3 and #8) of two patients admitted to the hospital. The census was 35. Findings include: 1. Review of the medical record for Patient #3 revealed the patient was hospitalized on 08/25/23 and 12/12/23. A resumption of care assessment was not completed after either hospitalization, upon resuming home health services. 2. Review of the medical record for Patient #8 revealed the patient was hospitalized and discharged on 01/22/24. A resumption of care assessment was not completed after the hospitalization, upon resuming home health services. During an interview on 02/14/24 at 10:20 AM, Staff B confirmed no resumption of care assessment was completed for either patient. Review of the agency policy titled “C-145 Comprehensive Patient Assessment” effective 2018, revealed if a patent is admitted to an inpatient facility for more than 24 hours for reasons other than diagnostic testing, a resumption of care assessment will be completed within 48 hours of discharge. The resumption of care assessment incorporates OASIS data, identifies changes in diagnosis and/or service needs.”

“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 record review, interview and policy review, the agency failed to ensure the plan of care included the type of service to be provided, frequency and duration of all visits, medications, treatments, procedures, and treatment goals. This affected five (Patients #2, #2, #4, #5, and #6) of seven patient records reviewed. The census was 35. Findings include: 1. Review of the medical record for Patient #6 and physician’s plan of care dated 08/01/23 did not reveal the frequency and duration of the Occupational Therapist (OT) visits or goals. The OT evaluation was completed on 06/09/23. Review of the OT visit sheets from 08/02/23 to 09/27/23 revealed the OT visited twice a week. During an interview on 02/12/24 at 2:08 PM, Staff B confirmed there was no frequency or duration of OT visits or OT goals. 2. Review of the medical record for Patient #3 and physician’s plan of care dated 05/31/23 (most current plan of care) did not reveal the duration of the skilled nurse visits, medications, treatments, procedures, or nursing goals. On 02/13/24 at 9:30 AM, a visit was made to Patient #3’s home with Licensed Practical Nurse Staff D present. During observations at the home visit, Staff D flushed Patient #3’s suprapubic catheter with vinegar and normal saline solution, changed the dressing around the catheter insertion site and applied antibiotic cream to the catheter insertion site. Staff D then changed dressings on Patient #3’s right thigh and right food. Staff D gave the patient a rectal suppository for bowel management. During an interview on 02/13/24 at 9:10 AM, Staff D stated the catheter should be flushed twice per day due to reoccurring urinary tract infections. Staff D also stated the skilled nurse visits twice a day and confirmed the plan of care did not contain the duration of the skilled nurse visits, medications, treatments, procedures, or nursing goals 3. Review of the medical record for Patient #2 and physician’s plan of care dated 01/15/24 did not reveal the duration of the skilled nurse visits or nursing and physical therapy (PT) goals. During an interview on 02/13/24 at 4:18 PM, Staff B confirmed there was no duration of skilled nursing visits or nursing or PT goals on the plan of care. 4. Review of the medical record for Patient #5 and physician’s plan of care dated 12/17/23 did not reveal the duration of the home health aide visits, or the goals for the skilled nurse or aide. During interview on 02/15/24 at 9:36 AM, Staff B confirmed the physician’s plan of care did not contain the duration of nurse or aide visits, or aide goals. 5. Review of the medical record for Patient #4 and unsigned physician’s plan of care dated 12/15/23 did not document what services were to be provided. Review of an unsigned verbal order dated 08/16/23 directed the home health aide to provide 10 hours of service per week. Review of the HHA visit sheets from 12/17/23 to 02/08/24 revealed the HHA did provide 10 hours of service a week for Patient #4. During interview on 02/15/24 at 9:46 AM, Staff B confirmed the plan of care did not provide what service was to be provided. Review of the agency policy titled “C-580 Plan of Care” effective 2018, revealed an individualized Plan of Care signed by a physician shall be required for each patient receiving home health and personal care services. The plan of care will include the type, frequency and duration of all visits/services, medications, treatments, procedures, and treatment goals.”

“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 record review, interview and policy review, the agency failed to ensure all medications, treatments and services provided to the patient were ordered and signed by the physician. This affected four (Patients #2, #3, #4 and #6) of seven patients reviewed. The census was 35. Findings include: 1. Review of the medical record for Patient #3 and physician’s plan of care dated 10/08/21 revealed start of care 10/08/21 with diagnoses Quadriplegia, paroxysmal atrial fibrillation, and Lupus. Interview on 02/12/24 at 3:04 PM Staff B stated Patient #3 was a current patient with skilled nursing going twice a day, seven days a week since 09/29/23. On 02/13/24 at 9:30 AM, a visit was made to Patient #3’s home with Licensed Practical Nurse Staff D present. During observations at the home visit, Staff D flushed Patient #3’s suprapubic catheter with vinegar and normal saline solution, changed the dressing around the catheter insertion site and applied antibiotic cream to the catheter insertion site. Staff D then changed dressings on Patient #3’s right thigh and right food. Staff D gave the patient a rectal suppository for bowel management. During an interview on 02/13/24 at 12:50 PM, Staff B stated there was no physician plan of care that had been signed by the physician since the start of care on 10/08/21. Staff B confirmed there were no signed orders for the visits and services provided. 2. Review of the medical record for Patient #6 and physician’s plan of care dated 08/01/23 did not reveal orders for Occupational Therapy (OT). The OT evaluation was completed on 06/09/23. Review of the OT visit sheets from 08/02/23 to 09/27/23 revealed the OT visited twice a week. During interview on 02/12/24 at 2:08 PM, Staff B confirmed there was no physician’s order for the OT visits from 08/02/23 to 09/27/23. 3. Review of the medical record for Patient #2 and physician’s plan of care dated 01/15/24 did not reveal orders for the Physical Therapy (PT) visits after the evaluation was done. The PT evaluation was completed on 01/16/24. The PT plan of care for two visits for one week and three visits for eight weeks were not signed by the physician. Review of the PT visit sheets revealed the PT provided services on 01/19/24 and 01/23/24. During an interview on 02/14/24 at 10:50 AM, Staff B confirmed there was no physician’s order for the PT visits. 4. Review of the medical record for Patient #4 and physician’s plan of care dated 12/15/23 did not reveal orders for the home health aide to provide services. Review of the home health aide sheets from 12/17/23 to 02/08/24 revealed the HHA provided ten hours of services per week to Patient #4. During an interview on 02/14/24 at 3:16 PM, Staff B confirmed there were no orders for the services provided. Review of the agency policy titled “C-635 Physician’s Orders” effective 2018, revealed all medications, treatments and services provided to the patient must be ordered by a physician and must be signed by the physician in a timely manner.”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on record review, interview and policy review, the agency failed to ensure verbal orders were signed by the registered nurse when the verbal order was received and failed to ensure the verbal order was signed by the physician. This affected two (Patients #4 and #5) of two verbal orders reviewed. The census was 35. Findings include: 1. Review of the medical record for Patient #4 revealed a verbal order dated 08/16/23 for home health aide service 10 hours per week for help with housework, shopping, and other needs. This order was signed by the registered nurse (RN) on 02/12/24. The order was not signed by the physician. 2. Review of the medical record for Patient #5 revealed a verbal order dated 12/17/23 for home health aide service seven days per week, five hours each day for personal care, housekeeping and meals and for the skilled nurse to visit three times a week for medication management and health evaluation. This order was signed by the registered nurse 02/12/24. The order was not signed by the physician. During an interview on 02/15/24 at 11:46 AM, Staff B confirmed these verbal orders were not signed when they were originally taken and were not signed by the physician Review of the agency policy titled “C-635 Physician’s Orders” effective 2018, revealed all medications, treatments and services provided to the patient must be ordered by a physician and must be countersigned by the physician in a timely manner. A system will be used by this agency to ensure the telephone orders are signed and dated by the physician and returned to the patient’s record within an appropriate time frame. This agency will implement a tracking system to assure timely response.”

“Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This Element is not met as evidenced by: Based on record review, interview and policy review, the agency failed to ensure the plan of care was reviewed and updated every 60 days by the physician. This affected three (Patients #3, #4 and #6) of seven records reviewed. The census was 35. Findings include: 1. Review of the medical record for Patient #3 and physician’s plan of care dated 10/08/21 revealed start of care 10/08/21 with diagnoses including quadriplegia, paroxysmal atrial fibrillation, and Lupus. During an interview on 02/12/24 at 3:04 PM, Staff B stated Patient #3 was a current patient with the skilled nursing visiting twice per day, seven days a week since 09/29/23. Staff B confirmed the physician plan of care had not been reviewed or updated by the physician since 10/08/21. 2. Review of the medical record for Patient #4 and physician’s plan of care dated 12/15/23 revealed start of care 08/17/23 with diagnoses of diabetes, high blood pressure and chronic obstructive pulmonary disease. During an interview on 02/14/24 at 4:33 PM, Staff B confirmed the physician’s plan of care had not been reviewed or updated by the physician since 08/17/23 3. Review of the medical record for Patient #6 and physician’s plan of care dated 08/01/23 revealed start of care date of 06/02/23 with diagnoses of multiple sclerosis, eczema and wounds on both legs. During an interview on 02/15/24 at 4:42 PM, Staff B confirmed the physician’s plan of care had not been reviewed or updated by the physician since 08/01/23 and Patient #6 was discharged 09/28/23. Review of the agency policy titled “C-580 Plan of Care” effective 2018, revealed the total Plan of Care shall be reviewed by the attending physician at least one time every sixty days.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(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 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 §484.80(g), must make an onsite visit to the patient’s home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This Element is not met as evidenced by: Based on record review, interview and policy review, the agency failed to ensure a supervisory visit to the home health aide was made every 14 days. This affected one (Patient #5) of one patient reviewed for skilled nurse and home health aide. The census was 35. Findings include: Review of the medical record for Patient #5 and physician’s plan of care dated 12/17/23 directed the skilled nurse to visit three times a week and the home health aide to provide 35 hours of services per week. Review of the skilled nurse visit sheets revealed no supervisory visits for the home health aide were completed between 01/03/24 to 02/14/24. During an interview on 02/15/24 at 11:07 AM, Staff B confirmed there were no supervisory visits between 01/03/24 and 02/14/24. Review of the agency policy titled “C-340 Home Health Aide Supervision” effective 2018, revealed when skilled services are being provided to the patient, a registered nurse must make a supervisory visit to the patient’s home at least every 14 days.”

“Non-skilled direct observation every 60 days CFR(s): 484.80(h)(2) If home health aide services are provided to a patient who is not receiving skilled nursing care, physical or occupational therapy, or speech-language pathology services, the registered nurse must make an on-site visit to the location where the patient is receiving care no less frequently than every 60 days in order to observe and assess each aide while he or she is performing care. This Element is not met as evidenced by: Based on record review, interview and policy review, the agency failed to ensure the registered nurse observed and assessed the aide every 60 days while they were performing care. This affected one (Patient #5) of one patient receiving home health aide services only. The census was 35. Findings include: Review of the medical record for Patient #4 and unsigned physician’s plan of care dated 12/15/23 did not contain what services were to be provided. Review of an unsigned verbal order dated 08/16/23 directed the home health aide to provide 10 hours of service per week. This was the only service provided. Review of the HHA visit sheet for the week of 12/10/23 revealed the HHA did not provide care to Patient #4 on 12/14/23. Review of the supervisory visit note documented the home health aide was present during a supervisory visit on 12/14/23. During an interview on 02/15/24 at 9:31 AM, Staff B confirmed the supervisor visit was done when the home health aide was not present on 12/14/23. Review of the agency policy titled “C-340 Home Health Aide Supervision” effective 2018, revealed the registered nurse will observe the HHA providing care to the patients, and to assess competency in basic skills as well as delegated nursing tasks. The supervisory visits of the HHA will occur every 60 days when the patient is receiving HHA services only. Each supervisory visit must occur when the HHA is providing patient care.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on record review, interview and policy review, the agency failed to ensure patient reassessments were done within 48 hours of a transfer to a hospital. This affected two(Patients #3 and #8) of two patients reviewed with admissions to a hospital. The census was 35. Findings include: 1. Review of the medical record for Patient #3 and hospital records revealed Patent #3 was admitted to a hospital on 12/12/23. There was no documented evidence that a transfer OASIS had been made. 2. Review of the medical record for Patient #8 and hospital records revealed Patient #8 was admitted to the hospital 01/19/24. There was no documented evidence that a transfer OASIS had been made. During an interview on 02/14/24 at 10:20 AM, Staff B confirmed there was no transfer OASIS when either patient was admitted to the hospital. Review of the agency policy titled “C-155 Patient Reassessment/Update of Comprehensive Assessment” effective 2018, revealed the Comprehensive Assessment will be updated and revised as often as the patient’s condition warrants due to major decline or improvement in health status. Reassessments must be done within 48 hours of (or knowledge of) a transfer.”