Home Health Care Professionals

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on review of agency policies and procedures and clinical records, and based on interview with the office manager (Employee #10) and the assistant administrator/clinical supervisor (Employee #11), the agency failed to ensure documentation of care coordination (case conference) was included in the clinical record for two (2) of two (2) patients for whom therapy staff identified a change in patient status/condition. (Patients #2 and #9) FINDING INCLUDE: On January 12, 2024 at approximately 3:57 PM, review of agency policy 1-004, titled “Care/Service Coordination”, revealed the following under “Procedure”: 4. Care coordination will include, but not be limited to...E. Timely documentation of coordination of care activities... 6. Organization personnel will communicate changes in a timely manner via telephone, one-on-one meetings, case conferences and home visits. Documentation of all communications will be included in the clinical record on a communication note, case conference summary or clinical note. Documentation will include the date and time of the communication, individuals involved in the communication, information discussed and the outcome of the communication. Patient #2 (Discharge): On January 9, 2024 at approximately 12:17 PM, review of the clinical record revealed the primary diagnosis was traumatic subdural hematoma (bleeding in the space between the skull and the brain) without loss of consciousness and that home health services included skilled nursing (SN) and physical therapy (PT) as documented on the “Home Health Certification and Plan of Care” for the initial certification period of 08/08/2023 through 10/04/2023. Review of therapy visit information revealed that on 08/31/2023 the PT (Employee #12) documented that assessment findings revealed the patient was in a “down mood”. Review of discharge summary documentation revealed the patient expired at home on 09/04/2023. There was no documentation in the clinical record which provided evidence the PT notified the SN of the change in patient mood on 08/31/2023. Patient #9 (Discharge): On January 11, 2024 at approximately 2:29 PM, review of the clinical record revealed the primary diagnosis was type-2 diabetes with ketoacidosis (complication of diabetes) without coma and that home health services included SN and PT as documented on the “Home Health Certification and Plan of Care” for the initial certification period of 07/29/2023 through 09/26//2023. Review of the missed visit note dated August 4, 2023 revealed the PT (Employee #7) documented that the patient cancelled the PT visit due to suffering from diarrhea since that morning. Review of transfer assessment documentation revealed the patient was transferred to the hospital on 08/06/2023 due to diabetic related issues. There was no documentation in the clinical record which provided evidence the PT notified the SN of the patient’s complaint of vomiting on 08/04/2023. During interview conducted on January 11, 2024 at approximately 4:55 PM, the assistant administrator/clinical supervisor reported therapy staff communicate patient changes via the Slack texting system but that older texts cannot be accessed for review. The office manager and the assistant administrator/clinical supervisor confirmed documentation was not maintained in the clinical record which provided evidence the above referenced PT’s had notified the SN of the change in patient status/condition for the above identified patients.”

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on review of agency policies and procedures and clinical records, and based on interview with the office manager (Employee #10) and the assistant administrator/clinical supervisor (Employee #11), the agency failed to ensure skilled nursing (SN) assessments were performed as per the physician orders included on the “Home Health Certification and Plan of Care” for two (2) of ten (10) patients. (Patients #8 and #9) FINDING INCLUDE: On January 12, 2024 at approximately 3:55 PM, review of agency policy 6-022 , titled “Clinical/Service Data Collection”, revealed the following under “Procedure”: 1. A clinical service record will be initiated and maintained for each patient receiving care or services according to organization policies found in this manual and will include at a minimum...I. Current patient status.. . Patient #8: On January 11, 2024 at approximately 1:47 PM, review of the clinical record revealed the primary diagnosis is type-2 diabetes mellitus with foot ulcer and that SN is to assess the patient’s diabetic status and management as documented on the “Home Health Certification and Plan of Care” for the recertification period of 12/13/2023 through 02/10/2024. Review of clinical record revealed blood glucose (sugar) readings ranged between 228 and 235 as documented in the “Skilled Nursing Visit Assessment” note for four (4) of five (5) SN visits performed between 12/15/2023 and 01/08/2024. Review of SN documentation failed to reveal the licensed practical nurse (LPN-Employee #6) assessed the patient’s blood glucose reading on 01/02/2024. Patient #9 (Discharge): On January 11, 2024 at approximately 2:29 PM, review of the clinical record revealed the primary diagnosis was type-2 diabetes with ketoacidosis (complication of diabetes) without coma and that SN was to complete ongoing monitoring and assessment of blood glucose readings as documented on the “Home Health Certification and Plan of Care” for the initial certification period of 07/29/2023 through 09/26//2023. There was no documentation the “Start of Care Comprehensive Assessment” which provided evidence the registered nurse (RN-Employee #13) assessed the patient’s blood glucose reading on 07/29/2023. Review of transfer assessment documentation revealed the patient was transferred to the hospital on 08/06/2023 due to diabetic related issues. During interview conducted on January 11, 2024 at approximately 4:55 PM, the office manager and the assistant administrator confirmed documentation was not maintained in the clinical record which provided evidence the above referenced SN staff had assessed the blood glucose readings on the aforementioned dates for the above identified patients.”