Great Plains Home Care

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure measurable progress of the performance improvement project being conducted for all 37 patients. A review of the agency’s documentation showed a performance improvement project implemented for hospitalizations related to falls for calendar years 2022 and 2023. Documents showed no methods and/or goals for measuring the progress achieved for the project. On 04/18/24 at 11:42 a.m., Staff A stated there was no documentation of the measurable progress achieved for the performance improvement project for calendar years 2022 and 2023.”

“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 and interview, the agency failed to ensure: 1. SN frequencies were followed as ordered for two (Patient #1 and 6) of seven patients; 2. SN notified the physician of diastolic blood pressure levels outside the ordered parameters for one (Patient #5) of seven patients; and 3. SN provided oxygen treatment as ordered for one (Patient #1) of seven patients. 1. Patient #1 A review of the POC dated 01/08/24 to 03/07/24 showed a SN frequency of once a week for one week (effective 1/8/24), once a week for one week (effective 2/5/24), and once a week for one week (effective 3/4/24). A review of a SN missed visit note dated 01/10/24 documented the reason for the missed visit as healthcare appointment, and no other visits documented for the week of 01/07/24 to 01/13/24. Documentation showed no refusal of visits or services from the patient or caregiver and no contact made with the patient or caregiver and no physician order for a change in services. Patient #6 A review of the POC dated 11/20/23 to 01/18/24 showed a SN frequency of one time a day for one day (effective 11/22/23), two times a week for two weeks (effective 11/27/23), and once a week for six weeks (effective 12/11/23). A review of clinical records showed one SN visit completed on 12/05/23 and no other visits or missed visits documented for the week of 12/03/23 to 12/09/23 (one of two visits). Documentation showed no refusal of visits or services from the patient or caregiver, no contact made with the patient or caregiver and no physician order for a change in services. 2. Patient #5 A review of the POC dated 02/24/24 to 04/23/24 showed an order for the physician to be notified of diastolic blood pressure less than 50. A review of the clinical records showed the following: A SN visit dated 02/29/24 showed a diastolic blood pressure reading of 42. Documents showed no physician notification for the diastolic blood pressure reading less than 50. A SN visit dated 03/06/24 showed a diastolic blood pressure reading of 40. Documents showed no physician notification for the diastolic blood pressure reading less than 50. 3. Patient #5 A review of the POC dated 02/24/24 to 04/23/24 showed an order for oxygen inhalation at 2 liters continuously. A review of a SN visit dated 03/12/24 showed the patient’s oxygen was increased to 3 liters. Documents showed no order for oxygen to be increased or a change in treatment by the physician. On 04/18/24 at 11:27 a.m., Staff A stated: 1. the SN frequencies for Patients #1 and 6 were not met as ordered by the physician; 2. there was no documentation of physician notification of the diastolic blood pressures being out of parameters for Patient #5; and 3. there was no order to increase the oxygen level or a change in treatment by the physician for Patient #5.”