Stillwater Medical at Home

“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 and interview, the agency failed to ensure development of an episodic Plan of Care after a comprehensive OASIS assessment for two (Patients #5 and #6) of 10 patients. Findings: Patient #5 A review of the clinical record showed no documentation of physician orders (episodic POC) for POC episode period of 01/30/24 to 03/29/24. Documentation showed no physician notification of the conducted comprehensive OASIS assessment (ROC) on 02/14/24 and documented no physician orders for SN services. On 03/27/24 at 1:26 p.m., Staff A stated patient #5 did not have an updated POC (physician orders for SN services) other than an order for SN visit frequency for the episode period of 01/30/24 to 03/29/24 from the 02/14/24 ROC date. Patient #6 A review of the clinical record showed no documentation of physician orders (episodic POC) for POC episode period of 03/16/24 to 05/14/24. Documentation showed no physician notification of the conducted comprehensive OASIS assessment (SOC) on 03/16/24 and documented no physician orders. On 03/27/24 at 1:30 p.m., Staff A stated 1. Patient #6 did not have a POC (physician orders) for the episode period of 03/16/24 to 05/14/24 and; 2. There must have been a ‘glitch’ in the software program.”

“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. weight reporting parameters for one (Patient #2) of 10 patients. 2. blood sugar reporting parameters for one (Patient #3) of 10 patients and; 3. SN catheter treatment/interventions or last changed/treatment due date related to suprapubic urinary catheter management for one (Patient #8) of 10 patients. Findings: Patient #2 A review of the POC dated 02/19/24 to 04/18/24 showed orders for SN and PT to conduct assessment of patient weight every visit. Documentation showed no physician weight reporting parameters on the POC. Documentation showed SN visits were conducted on 02/27/24, 03/07/24 and on 03/19/24; PT visits were conducted on 02/23/24, 02/27/24, 03/01/24, 03/06/24, 03/12/24 and on 03/18/24. Documentation showed no patient weight monitoring was conducted. Documentation showed no patient/caregiver refusal of SN and PT assessment of the patient’s weight during the visits, no physician notifications and no change in orders. On 03/27/24 at 1:15 p.m., Staff A stated the POC for patient #2 should have included physician weight reporting parameters. Patient #3 A review of the POC dated 03/10/24 to 05/08/24 showed orders for SN to conduct assessment and monitoring of patient blood sugar every visit. Documentation showed no physician blood sugar reporting parameters on the POC. Documentation showed SN visits were conducted on 03/11/24, 03/13/24, 03/15/24, 03/18/24, 03/20/24, 03/22/24 and on 03/25/24 and showed no patient blood sugar monitoring was conducted. Documentation showed no patient/caregiver refusal of SN assessment and monitoring of the patient’s blood sugar during the SN visits, no physician notifications and no change in orders. On 03/27/24 at 1:22 p.m., Staff A stated the POC for patient #3 should have included physician blood sugar reporting parameters. Patient #8 A review of the POC dated 01/30/24 to 03/29/24 showed orders for SN to perform monthly suprapubic catheter changes using a 16 French catheter. POC documentation showed no catheter treatment intervention last changed or monthly change due date. Documentation showed no physician notification and no changes in orders. On 03/27/24 at 1:34 p.m., Staff A stated the POC for patient #8 should have included catheter treatment interventions last changed or monthly change due date related to suprapubic urinary catheter management.”

“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 agency failed to ensure a physician order for OT to evaluate and treat with lymphedema therapy were a part of the patient’s plan of care for one (Patient #5) of 10 patients. Findings: Patient #5 A review of the POC dated 01/30/24 to 03/29/24 showed a faxed physician’s order dated 03/15/24 attached to the clinical record for OT to evaluate and treat for lymphedema treatment intervention. Documentation showed no order transcription into the clinical record and showed no OT evaluation was conducted. Documentation showed no patient/caregiver refusal of OT evaluation and treatment, no physician notification and no changes in orders. On 03/27/24 at 1:26 p.m., Staff A stated the POC for patient #5 showed no physician order transcription into the clinical record, no physician notification and no changes in orders.”

“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 weight assessments of one (Patients #2) of 10 patients; SN conducted blood sugar assessments of one (Patients #3) of 10 patients and; OT evaluation was conducted for one (Patient #5) of 10 patients. Findings: Patient #2 A review of the POC dated 02/19/24 to 04/18/24 showed orders for SN and PT to conduct assessment of patient weight every visit. Documentation showed SN visits were conducted on 02/27/24, 03/07/24 and on 03/19/24; PT visits were conducted on 02/23/24, 02/27/24, 03/01/24, 03/06/24, 03/12/24 and on 03/18/24. Documentation showed no assessment of the patient’s weight was conducted. Documentation showed no patient/caregiver refusal of SN and PT assessment of the patient’s weight during the visits, no physician notifications and no change in orders. On 03/27/24 at 1:15 p.m., Staff A stated the SN and PT should have been conducted assessment of the patient’s weight every visit as ordered by the physician. Patient #3 A review of the POC dated 03/10/24 to 05/08/24 showed orders for SN to conduct assessment and monitoring of patient blood sugar every visit. Documentation showed SN visits were conducted on 03/11/24, 03/13/24, 03/15/24, 03/18/24, 03/20/24, 03/22/24 and on 03/25/24 and showed no patient blood sugar monitoring was conducted. Documentation showed no patient/caregiver refusal of SN assessment and monitoring of the patient’s blood sugar during the SN visits, no physician notifications and no change in orders. On 03/27/24 at 1:22 p.m., Staff A stated the SN should have been conducted assessment and monitoring of the patient’s blood sugar every visit as ordered by the physician. Patient #5 A review of the POC dated 01/30/24 to 03/29/24 showed a faxed physician’s order dated 03/15/24 attached to the clinical record for OT to evaluate and treat for lymphedema treatment intervention. Documentation showed no OT evaluation was conducted. Documentation showed no patient/caregiver refusal of OT evaluation and treatment, no physician notification and no changes in orders. On 03/27/24 at 1:26 p.m., Staff A stated the clinical record for patient #5 showed no OT evaluation, no physician notification and no changes in orders.”

“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 interview, the agency failed to ensure a completed transfer/discharge summary was provided for one (Patient #8) of 10 patients. Findings: Patient #8 A review of the clinical record documented discharged to inpatient nursing home services on 02/18/24. Documentation showed no discharge summary was provided to the inpatient nursing home service provider. On 03/27/24 at 1:35 p.m., Staff A stated no discharge summary was sent to the receiving inpatient nursing home service providers for patients #8.”