Choice Health at Home - Antlers

“Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: Based on document review and interview, the Agency failed to maintain an emergency preparedness plan that was reviewed and updated at least every 2 years based on facility-based and community-based risk assessment, utilizing an all-hazards approach.* A review of the Agency Emergency Preparedness documents revealed a hazard risk assessment was completed 11/10/20. Further review of the documents failed to provide evidence of an updated risk assessment for the years 2022 or 2023. On 12/13/23 at 11:45 AM, the Director of Clinical Services stated the Agency failed to update the Agency hazard risk assessment as required.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on record review and interview, the RN failed to conduct the initial assessment visit within 48 hours of referral or on the physician ordered Start of Care date for one (#2) of seven (#1- #7) records reviewed. Patient #2 A review of the POC for Patient #2 for certification period 10/31/23 to 12/29/23 revealed a referral to the agency was received on 10/23/23. SN Visit Note documentation indicated the initial RN assessment visit was conduct on 10/31/23 (8 days later). Further review of the record failed to provide documentation as to the reason for the delayed assessment. On 12/13/23 at 11:45 AM, the Case Manger stated the admission of Pt#2 to the agency was delayed and confirmed the reason for the delay was not documented in the clinical record.”

“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 Skilled Nurse staff failed to conduct 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 for two (#4 and #6) of seven (#1- #7) records reviewed. Patient #4 A review of the POC for Patient #4 for certification period 11/30/23 to 01/29/23 revealed a primary diagnosis of Malignant Neoplasm of the Colon and orders for Skilled Nurse to instruct on colostomy care. Review of documentation in the Clinical Intake note, SOC Assessment and SN Visit Note of 12/7/23 indicated Pt #4 was currently receiving Chemotherapy treatments at a clinic every other week. Further review of the “Client Medication Report” failed to provide evidence the SN staff had included or reviewed any Chemotherapy medications Pt #4 was currently receiving. Patient #6 A review of the POC for Patient #6 for certification period 08/30/23 to 10/28/23 revealed a primary diagnosis of Aftercare following Surgery Neoplasm. Review of documentation in the SN Visit Notes indicated Pt#6 was receiving Chemotherapy treatments and experienced side effects and pain. Further review of the “Client Medication Report” failed to provide evidence the SN staff had included or reviewed any Chemotherapy medications Pt #6 was currently receiving. On 12/13/23 at 11:45 AM, the Director of Clinical Services stated the SN staff failed to include and conduct a review of the Chemotherapy medications Patients #4 and #6 were currently taking.”

“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 provide an individualized POC based on the patient’s assessed needs for three (#2, #4 and #5) of seven (#1- #7) records reviewed. Patient #2 A review of the POC for Patient #2 for certification period 10/31/23 to 12/29/23 revealed a primary diagnosis of Spondylosis and orders for “Licensed Professional to report vital signs outside the following established parameters ... FBS (Fasting Blood Sugar) 250 and RBS (Random Blood Sugar) 300...”. Further review of the record failed to identify any diagnosis, interventions, goals, DME equipment or SN assessment specific to Diabetes Mellitus. On 12/13/23 at 10:30 AM, during a home observation visit Patient #2 stated she does not have diabetes and does not check her blood sugar. Patient #4 A review of the POC for Patient #4 for certification period 11/30/23 to 01/29/23 revealed a primary diagnosis of Malignant Neoplasm of the Colon and orders for “Licensed Professional to report vital signs outside the following established parameters ... FBS (Fasting Blood Sugar) 250 and RBS (Random Blood Sugar) 300...”. Further review of the record failed to identify any diagnosis, interventions, goals, DME equipment or SN assessment specific to Diabetes Mellitus. Patient #5 A review of the POC for Patient #5 for certification period 10/21/23 to 12/19/23 revealed a primary diagnosis of Chronic Kidney Disease with Heart Failure and orders for “Licensed Professional to report vital signs outside the following established parameters ... FBS (Fasting Blood Sugar) 250 and RBS (Random Blood Sugar) 300...”. Further review of the record failed to identify any diagnosis, interventions, goals, DME equipment or SN assessment specific to Diabetes Mellitus. On 12/13/23 at 11:45 AM, the Director of Clinical Services stated the POCs were not individualized as blood sugar parameters were not based on assessed needs for Patients #2, #4 and #5.”

“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 and interview, the Agency failed to provide a completed transfer summary within 2 business days of a planned transfer or within 2 business days of becoming aware of an unplanned transfer for one (#6) of seven (#1- #7) records reviewed. Patient #6 A review of the POC for Patient #6 for certification period 08/30/23 to 10/28/23 revealed a primary diagnosis of Aftercare following Surgery Neoplasm. Review of documentation in the SN Visit Notes indicated Pt#6 was receiving Chemotherapy treatments and experienced side effects and pain. Further review of SN Visit Notes indicated Pt #6 was hospitalized and a Discharge/Transfer Report was completed on 10/28/23. There was no evidence in the record a successful transmission of discharge information was provided to the facility as required. On 12/13/23 at 11:45 AM, the Director of Clinical Services stated there was no evidence the Discharge/Transfer Report was provided to the facility as required for Patient #6.”