Saint Francis Home Health

“Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure completion of a discharge summary for one (Patients #17) of 17 patients. Findings: Patient #17 A review of the clinical record showed the patient was discharged from agency on 01/26/25 for patient refusal of services. Documentation showed no discharge summary was completed. On 02/25/25 at 3:05 p.m., Staff G stated the agency did not complete a discharge summary for patient #17 because of a software system error.”

“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 record review and interview, the agency failed to ensure a medication profile was updated with current ordered medications for one (Patient #4) of 17 patients. Findings: Patient #4 A review of a POC dated 02/17/25 to 04/17/25 showed a start of care medication profile dated 02/17/25 by the admitting Physical Therapist. Documentation showed clindamycin (a systemic antibiotic) 300 mg every day with a start date of 07/31/24 and doxycycline 100 mg (a systemic antibiotic) every day with a start date of 07/31/24. Documentation showed no end date for the antibiotic regimen or indication for use and showed no follow up review with the residential facility, no physician notifications, and no change in orders. On 02/25/25 at 2:07 p.m., Staff G stated documentation showed no follow up review with the residential facility, and no physician notifications by the PT to verify continued use and/or indication for use.”

“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 and interview, the agency failed to ensure individualized patient POC included: 1. SN interventions for wound site management were removed from the POC at the time of recertification for continued services for one (Patients #2) of 17 patients. 2. SN intervention for assessment and instruction for management of pain showed no pain reporting parameters to report to the physician for 11 (Patients #2, 3, 6, 7, 9, 11, 12, 14, 15, 16 and #17) of 17 patients. 3. SN intervention for assessment, instruction and urinary catheter change every month did not identify a last changed or due date of intervention for two (Patients #5 and #10) of 17 patients. Findings: Patient #2 A review of the POC dated 02/01/25 to 04/01/25 showed orders for SN to assess and instruct the patient’s pain level every visit and showed orders for a healed wound site dated 07/03/24. SN visit notes documented the patient’s reported pain levels as 2/10 on 02/24/25. Documentation showed no pain reporting parameters to report to the physician, no physician notifications and no change in orders. On 02/25/25 at 1:50 p.m., Staff G stated: 1. The POC documentation identified no pain reporting parameters to report to the physician and; 2. The wound care from a healed wound site should have been removed from the POC at the time of the patient’s recertification for continued services. Patient #3 A review of the POC dated 01/04/25 to 03/04/25 showed orders for SN to assess and instruct the patient’s pain level every visit. SN visit notes documented the patient’s reported pain levels as 2/10 on 01/20/25. Documentation showed no pain reporting parameters to report to the physician, no physician notifications and no change in orders. On 02/25/25 at 2:05 p.m., Staff G stated the POC documentation identified no pain reporting parameters to report to the physician. Patient #5 A review of the POC dated 02/06/25 to 04/06/25 showed orders for SN to assess and instruct the patients’ health conditions and perform urinary intervention to change catheter 16 French /10 cubic centimeter every month. Documentation did not identify a last changed or due date of intervention and showed no physician notifications and no change in orders. On 02/25/25 at 2:10 p.m., Staff G stated the POC documentation identified no last changed or due date of intervention. Patient #6 A review of the POC dated 01/30/25 to 03/30/25 showed orders for SN to assess and instruct the patient’s pain level every visit. SN visit notes documented the patient’s reported pain levels as 5/10 on 02/06/25 and 6/10 on 02/14/25. Documentation showed no pain reporting parameters to report to the physician, no physician notifications and no change in orders. On 02/25/25 at 2:15 p.m., Staff G stated the POC documentation identified no pain reporting parameters to report to the physician. Patient #7 A review of the POC dated 01/23/25 to 03/23/25 showed orders for SN to assess and instruct the patient’s pain level every visit. SN visit notes documented the patient’s reported pain levels as 1/10 on 02/10/25. Documentation showed no pain reporting parameters to report to the physician, no physician notifications and no change in orders. On 02/25/25 at 2:20 p.m., Staff G stated the POC documentation identified no pain reporting parameters to report to the physician. Patient #9 A review of the POC dated 02/05/25 to 04/05/25 showed orders for SN to assess and instruct the patient’s pain level every visit. Documentation showed no pain reporting parameters to report to the physician, no physician notifications and no change in orders. On 02/25/25 at 2:25 p.m., Staff G stated the POC documentation identified no pain reporting parameters to report to the physician. Patient #10 A review of the POC dated 01/18/25 to 03/18/25 showed orders for SN to assess and instruct the patients’ health conditions and perform urinary intervention to change catheter 16 French /10 cubic centimeter every month. Documentation identified the due date of intervention as 11/20/23 (date from prior certification period) and showed no physician notifications and no change in orders. On 02/25/25 at 2:30 p.m., Staff G stated the POC documentation identified a prior due date of intervention and gave no last changed date. Patient #11 A review of the POC dated 01/23/25 to 03/23/25 showed orders for SN to assess and instruct the patient’s pain level every visit. Documentation showed no pain reporting parameters to report to the physician, no physician notifications and no change in orders. On 02/25/25 at 2:35 p.m., Staff G stated the POC documentation identified no pain reporting parameters to report to the physician. Patient #12 A review of the POC dated 01/16/25 to 03/16/25 showed orders for SN to assess and instruct the patient’s pain level every visit. SN visit notes documented the patient’s reported pain levels as 3/10 on 01/20/25, 3/10 on 01/23/25, 4/10 on 01/27/25, and 5/10 on 02/06/25. Documentation showed no pain reporting parameters to report to the physician, no physician notifications and no change in orders. On 02/25/25 at 2:20 p.m., Staff G stated the POC documentation identified no pain reporting parameters to report to the physician. Patient #14 A review of the POC dated 09/13/24 to 11/11/24 showed orders for SN to assess and instruct the patient’s pain level every visit. Documentation showed no pain reporting parameters to report to the physician, no physician notifications and no change in orders. On 02/25/25 at 2:50 p.m., Staff G stated the POC documentation identified no pain reporting parameters to report to the physician. Patient #15 A review of the POC dated 12/28/24 to 02/25/25 showed orders for SN to assess and instruct the patient’s pain level every visit. Documentation showed no pain reporting parameters to report to the physician, no physician notifications and no change in orders. On 02/25/25 at 2:55 p.m., Staff G stated the POC documentation identified no pain reporting parameters to report to the physician. Patient #16 A review of the POC dated 09/14/24 to 11/12/24 showed orders for SN to assess and instruct the patient’s pain level every visit. SN visit notes documented the patient’s reported pain levels as 7/10 on 09/17/24 and 5/10 on 10/02/24. Documentation showed no pain reporting parameters to report to the physician, no physician notifications and no change in orders. On 02/25/25 at 3:00 p.m., Staff G stated the POC documentation identified no pain reporting parameters to report to the physician. Patient #17 A review of the POC dated 01/26/25 to 03/26/25 showed orders for SN to assess and instruct the patient’s pain level every visit. Documentation showed no pain reporting parameters to report to the physician, no physician notifications and no change in orders. On 02/25/25 at 3:05 p.m., Staff G stated the POC documentation identified no pain reporting parameters to report to the physician.”

“Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure care was coordinated between the agency and physician for four (Patients #1, 6, 11 and #14) of 17 patients. Findings: Patient #1 A review of a plan of care dated 01/22/25 to 03/22/25 documented a primary diagnosis of non-pressure ulcer to the left lower extremity and showed a SN visit frequency and duration of two times a week for two weeks, then one time a week for seven weeks. Documentation showed patient refusal of wound site care visits on 02/19/25 and 02/21/25 showed the missed visit alerts were auto faxed to the physician with no follow up. Documentation showed no instruction for alternate caregivers to perform the wound site care interventions. The documentation showed no direct physician coordination of care communications as follow up to the patient’s refusals of SN visits and showed no changes in orders. On 02/25/25 at 1:45 p.m., Staff G stated the missed visit alerts for patient #1 that were auto faxed by the clinical record computer system should have had follow up coordination of care communications to ensure the physician was aware of the patient’s refusal of care. Patient #6 A review of a plan of care dated 01/30/25 to 03/30/25 documented a primary diagnosis of pressure ulcer to the left buttock and showed a SN visit frequency and duration of one time a week for one week, two times a week for three weeks, then one time a week for five weeks. A SN visit note dated 02/14/25 showed the patient complained of chest pain and EMS was called to the residence. After the EMS assessment the patient refused transport to a hospital emergency medicine department. Documentation showed a communication alert was auto faxed to the physician with no follow up. The documentation showed no direct physician coordination of care communications as follow up to the patient’s incidence of chest pain complaints and showed no changes in orders. On 02/25/25 at 2:15 p.m., Staff G stated the communication alert for patient #6 that was auto faxed by the clinical record computer system should have had follow up coordination of care communications to ensure the physician was aware of the patient’s change in condition. Patient #11 A review of a plan of care dated 01/23/25 to 03/23/25 documented a primary diagnosis of hypertensive heart disease with heart failure and showed a home health aide visit frequency and duration of one time a week for one week, two times a week for three weeks, then one time a week for five weeks. Documentation showed patient refusal of visits on 01/24/25, 01/31/25, 02/03/25, 02/06/25 and on 02/07/25 and showed the missed visit alerts were auto faxed to the physician with no follow up. The documentation showed no direct physician coordination of care communications as follow up to the patient’s refusals of home health aide visits and showed no changes in orders. On 02/25/25 at 2:35 p.m., Staff G stated the missed visit alerts for patient #11 that were auto faxed by the clinical record computer system should have had follow up coordination of care communications to ensure the physician was aware of the patient’s refusal of care. Patient #14 A review of a plan of care dated 09/13/24 to 11/11/24 documented a primary diagnosis of hypertension and showed a SN visit frequency and duration of one day one, then three times a week for three weeks. Documentation showed the patient was discharged to hospice care services on 10/04/24. Documentation showed no physician coordination of care communications prior to the patient’s discharge from home health services and showed no changes in orders. On 02/25/25 at 2:50 p.m., Staff G stated the SN should have had follow up coordination of care communications to ensure the physician was aware of the patient’s change in condition prior to discharge from home health services.”

“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 record review and interview, the agency failed to ensure: SN conducted urinary catheter change intervention as ordered by the physician for one (Patient #2) of 17 patients; SN reported to the physician blood pressure readings outside of reporting parameters for one (Patient #11) of 17 patients and; SN reported to the physician weight readings outside of reporting parameters for one (Patient #15) of 17 patients. Patient #2 A review of the POC dated 02/01/25 to 04/01/25 showed orders for SN to perform suprapubic urinary catheter change intervention using a 22 French / 30 cubic centimeter every month. Documentation showed during a SN visit conducted on 02/24/25, a 22 French / 5 cubic centimeter catheter over inflated to 10 cubic centimeter was used to perform the intervention. Documentation showed no physician notifications and no change in orders. On 02/25/25 at 1:50 p.m., Staff G stated the SN should have used the catheter as ordered in the plan of care by the physician. Patient #11 A review of the POC dated 01/23/25 to 03/23/25 showed orders for SN to conduct assessment and monitoring of patient blood pressure every visit and report to the physician reading outside of the 150 systolic reporting parameter. During SN visit conducted on 01/29/25 documentation showed a blood pressure reading of 160/62. Documentation showed no physician notifications and no change in orders. On 02/25/25 at 2:35 p.m., Staff G stated the SN should have notified the physician of the blood pressure reading as ordered on the POC. Patient #15 A review of the POC dated 12/28/24 to 02/25/25 showed orders for SN to conduct assessment and monitoring of patient weight every visit and report to the physician reading outside of the five-pound weight gain in one week reporting parameter. Documentation showed during SN visit conducted on 01/06/25 the patient’s weight was 68.5 kg and on 01/13/25 a weight of 70.8 kg (5.06-pound weight gain). Documentation showed no physician notifications and no change in orders. On 02/25/25 at 3:05 p.m., Staff G stated the SN should have notified the physician of the patient’s weight gain of 5.06 pounds in one week as ordered on the POC.”

“Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure clinical visit note documentation was completed for two (Patients #1 and #3) of 17 patients. Findings: Patient #1 A review of the POC dated 01/22/25 to 03/22/25 showed orders for SN to assess, instruct and monitor patients’ health conditions and perform wound site care each visit. SN visit notes dated 02/05/25 and 02/14/25 documented no patient response to the wound site care interventions. On 02/05/25 at 1:45 p.m., Staff G stated SN clinical visit notes for 02/05/25 and 02/14/25 documented no patient response to the interventions. Patient #3 A review of the POC dated 01/04/25 to 03/04/25 showed orders for SN to assess, instruct and monitor patients’ pain each visit. SN visit note dated 01/05/25 documented no pain severity level reported by the patient. On 02/05/25 at 2:05 p.m., Staff G stated SN clinical visit notes for 01/05/25 documented no pain severity level reported by the patient.”

“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 reviews and interviews, the agency failed to ensure completed transfer/discharge summaries were provided timely to receiving service providers for four (Patients #11, 14, 16 and #17) of 17 patients. Findings: Patient #11 A review of the clinical record showed the patient was transferred to in-patient hospital care on 02/14/25. Documentation showed a transfer summary, which was provided to the in-patient hospital service provider on 02/17/25 (3 days after the date of transfer). Patient #14 A review of the clinical record showed the patient was discharged to hospice care on 10/04/24. Documentation showed no discharge summary was provided to the hospice service provider, patient/caregiver or physician. Patient #16 A review of the clinical record showed the patient was transferred to in-patient hospital care on 10/09/24. Documentation showed a transfer summary, which was provided to the in-patient hospital service provider on 10/14/24 (5 days after the date of transfer). Patient #17 A review of the clinical record showed the patient was discharged from home health services on 01/26/25. Documentation showed a discharge summary was provided to the physician medical provider on 01/30/25 (4 days after the date of discharge). On 02/25/25 at 2:35 p.m. to 3:05 p.m., Staff G stated the transfer/discharge summaries for patients #11, 14, 16 and #17 were not provided to the receiving service providers timely.”