University of TN Medical Center Home Health Serv

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: This CONDITION is not met as evidenced by: Based on agency policy review, medical record review and interview, the agency failed to provide wound care as ordered by a physician (G580), failed to promptly alert physician of need to change the plan of care (G590), failed to coordinate care delivery with the caregiver (G608), and failed to ensure patient/caregiver received education and training (G610). The cumulative effect of these systemic practices resulted in the agency’s inability to ensure that the patients’ nursing needs would be met.”

“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 policy review, medical record review and interview, the agency failed to follow physician orders for 2 patients (#6, #10) of 10 patients reviewed. The findings include: Review of the policy titled “Physician Orders,” revised 10/2023, revealed “...Services are provided according to the most recent orders...” Patient #6 was admitted to the agency on 3/24/2021 with diagnoses including Stage 2 Pressure Ulcer of Left Heel and Paraplegia. Record review of the of Patient #6’s Home Health Certification and Plan of Care dated 3/8/2024-5/6/2024, revealed a physician’s order for wound care to the left lateral foot. The Skilled Nurse (SN) was to cleanse the area with saline, pat dry with gauze, apply Zinc Barrier cream (a cream that helps to seal out moisture) to peri wound (around the wound) skin, apply Calcium Alginate with Silver (absorbent dressing) to wound bed, cover with gauze, wrap with rolled gauze and secure with tape. The SN may use Silicone Bordered Foam dressing (absorbent dressing) to secure in place if needed. The frequency of the wound care was ordered every Wednesday. Record review of the SN notes dated 3/19/2024 and 4/2/2024 revealed the dressing to the left lateral foot was completed on Tuesdays and had not been completed on Wednesday as ordered by the physician. During an interview on 4/10/2023 at 12:30 PM, the Executive Director and Clinical Manager confirmed the wound care dressing changes were not provided on Wednesday’s as ordered by the physician. Patient #10 was admitted to the agency on 4/23/2023 with diagnoses including Type 2 Diabetes Mellitus and Stage 2 Pressure Ulcer of Sacral Region. Record review of Home Health Certification and Plan of Care dated 4/23/2023 to 6/21/2023 revealed a physician’s order for SN to perform wound care dressing changes 3 x week. The wound care consisted of SN cleansing the wound with wound cleanser or normal saline, apply Santyl (used to remove damaged tissue from ulcers), covered with Silvercel (absorbs fluid) to wound bed, covered with border dressing. Record review of SN note dated 4/26/2023 revealed the Santyl was not available in the home. Wound care had been provided but the Santyl was unavailable and had not been applied as ordered by the physician. Record review of SN note dated 4/28/2023 revealed the Santyl was not available in the home. The patient stated he cannot afford it. Wound care had been provided but the Santyl was unavailable and had not been applied as ordered by the physician. During an interview on 4/10/2023 at 1:00 PM, the Executive Director and Clinical Manager confirmed the wound care dressing changes were not provided as ordered by the physician.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on policy, medical record review and interview, the agency failed to obtain orders to change wound care for 2 patients (#6 and #10) of 10 patients reviewed. The findings include: Review of the agency’s policy titled “Plan of Care,” revised 12/2021 revealed “...Medications, treatments, and interventions are provided by qualified agency staff as ordered by the physician or authorized practitioner. Alterations to the POC (plan of care) are made only with the physician/authorized practitioner’s approval...” Patient #6 was admitted to the agency on 3/24/2021 with diagnoses including Stage 2 Pressure Ulcer of Left Heel and Paraplegia. Record review of the of Patient #6’s Home Health Certification and Plan of Care dated 3/8/2024 to 5/6/2024 revealed a physician’s order for wound care to the left lateral foot. The Skilled Nurse (SN) was to cleanse the area with saline, pat dry with gauze, apply Zinc Barrier cream (helps seals out wetness) to peri wound (area around the wound) skin, apply Calcium Alginate with Silver (absorbent dressing) to wound bed, cover with gauze, wrap with rolled gauze and secure with Tape. The SN may use Silicone Bordered Foam dressing (absorbent dressing) to secure in place if needed. The frequency of the wound care was ordered every Wednesday. Record review of the SN notes dated 3/19/2024 and 4/2/2024, revealed the dressing to the left lateral foot was completed on Tuesday and had not been completed on Wednesday as ordered by the physician. Continued review revealed no documentation the physician was notified of the change of wound care from Wednesday to Tuesday. During an interview on 4/10/2024 at 12:30 PM, the Executive Director confirmed the physician was not notified of the change in wound care orders and new orders had not been obtained. Patient #10 was admitted to the agency on 4/23/2023 with diagnoses including Type 2 Diabetes Mellitus and Stage 2 Pressure Ulcer of Sacral Region. Record review of the of Patient #10’s Home Health Certification and Plan of Care dated 4/23/2023 to 6/21/2023 revealed a physician’s order for SN to perform wound care dressing changes 3 x week. The wound care consisted of SN cleansing the wound with wound cleanser or normal saline, apply Santyl (used to remove damaged tissue from ulcers), covered with Silvercel (absorbs fluid) to wound bed, covered with border dressing. Record review of SN note dated 4/26/2023 revealed the Santyl was not available in the home. Wound care provided as ordered except for the Santyl. Continued review revealed no documentation the physician was notified the patient did not have Santyl in the home. Record review of SN note dated 4/28/2023 revealed the Santyl was not available in the home. The patient stated he cannot afford it. Wound care provided as ordered except for the Santyl. Continued review revealed no documentation the physician was notified the patient did not have Santyl in the home. During an interview on 4/10/2024 at 1:00 PM, the Executive Director confirmed the wound care orders were not followed for Patient #6 and Patient #10. Further interview confirmed no documentation no documentation the physician was notified of the change from Wednesday to Tuesday for the wound care. s were not changed as ordered by the physician.”

“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 agency policy review, medical record review and interview the agency failed to coordinate care delivery with the patient’s caregiver for 1 patient (#10) of 10 patients reviewed. The findings include: Review of agency’s policy titled “Patient Assessment, Initial and Reassessment,” revised on 3/2022 revealed “...Upon admission...the qualified clinician performs the following assessment and collects the following data...Primary caregiver support and willingness and ability to provide care...” Patient #10 was admitted to the agency on 4/23/2023 with diagnoses of Type 2 Diabetes Mellitus and Stage 2 Pressure Ulcer of Sacral Region. Record review of the Patient #10’s Home Health Certification and Plan of Care dated 4/23/2023 to 6/21/2023, revealed the Skilled Nurse (SN) was to provide instructions on Diabetes Type 2. Continued review revealed goals for the caregiver included “...Caregiver will understand and demonstrate compliance with treatment regimen for Diabetes...Caregiver will demonstrate knowledge of Diabetic medication types, action, possible side effects, use, administration and proper storage...” Further review revealed the physician ordered the SN or caregiver to perform blood glucose testing 4 times a day and as needed until patient’s therapeutic glucose range was between 70mg/dl to 150mg/dl (milligrams per deciliter). Continued review revealed the physician ordered a sliding scale of Lispro (insulin). If the glucose level was 70-150mg/dl - 0 units; 151-200mg/dl - 2 units; 201-250mg/dl - 4 units; 251-300mg/dl - 6 units; 301-350mg/dl - 10 units; 351-400mg/dl - 11 units; greater than 401mg/dl - 14 units and notify physician. Record review of the hospital discharge summary dated 4/22/2023, revealed the patient was discharged with Insulin-dependent Diabetes Mellitus. Continued review revealed on 4/6/2023 (date he was admitted to the hospital) he had an elevated glucose reading of 1300mg/dl (normal was between 70 - 150mg/dl). Continued review revealed the doctor who signed the home health orders assumed the patient’s care in the hospital on 4/17/2023. The physician was working towards sending the patient to a nursing facility. The patient came to the conclusion that he did not want to go to the nursing facility and wanted to be discharged home with his sister (caregiver). The physician telephoned the caregiver and informed her of his concerns that the patient’s care would exceed what she would be able to provide at home. The physician had concerned the patient would be at high risk for readmission if he is discharged home. The hospital arranged home health. Further review revealed the physician contacted the caregiver by phone and explained everything the patient would need, and she voiced understanding. Continued review revealed the glucose readings had been “okay” - running a “little bit on the higher side”, but the physician “prefer” him to be high rather than low during his hospital stay. Further review revealed the glucose reading on 4/22/2023 was 164 mg/dl. Record review of a SN note dated 4/23/2023, revealed the caregiver obtained the glucose reading using the patient’s glucometer. The glucose reading was 537mg/dl. Continued review revealed the patient had not obtained the insulin at that time due to a “mix-up” at the pharmacy. Further review revealed the caregiver was instructed to obtain glucose readings 4 times a day and insulin administration. The caregiver stated she had used a glucometer and administered insulin before. The caregiver was instructed to recheck glucose reading in 1/2 to 1 hour and if unable to “get BS (blood sugar) down to call the “on call” nurse. Continued review revealed the physician was notified and no documentation if the physician responded to the lack of insulin with the elevated glucose reading. The SN was unable to assess the caregiver’s ability to administer sliding scale insulin during the start of care visit. No documentation the SN assess the caregiver’s ability to administer the correct dosage of sliding scale insulin. No documentation the caregiver was instructed to keep a log of glucose readings and insulin administration for the nurse to review. No documentation the SN assessed the patient’s glucose level following the reading of 537mg/dl during skilled nurse visit on 4/23/2023. Medical record review of a social worker note dated 4/26/23 revealed the patient had obtained the insulin but not any of his other medications due to no prescription coverage. Record review of a SN note dated 4/26/2023 revealed {per the caregiver} had obtained the insulin and administered the insulin and obtained glucose readings as ordered. Further review revealed no documentation of the glucose readings or the amount of insulin administered since the last SN visit. Continued review revealed no documentation the caregiver was assessed on the ability to administer sliding scale insulin. No documentation the physician was notified by the SN of the patient’s inability to obtain the medications ordered by the physician other than the insulin. No documentation the caregiver had kept a log of glucose readings or amount of insulin administered and the caregiver was not instructed to keep this log for the nurse to review during this visit. Record review of a SN note dated 4/28/2023 revealed the caregiver was leaving the home to go the emergency department. Continued review revealed a “neighbor” would “watch” the patient while his sister is at the emergency department. The occupational therapist was in the home and stated the caregiver obtained the glucose reading of 505mg/dl. Sliding scale was administered (no documentation of the amount or who administered the insulin) and the physician was notified. The glucose was rechecked with the reading of 478mg/dl and the patient was diaphoretic (increased sweating). The patient informed the SN that a primary care physician had been obtained and he was scheduled to go “next week”. The SN called the agency and reported the findings of elevated glucose reading and patient was diaphoretic. The SN was told to call 911 and transport the patient to the hospital due to Hyperglycemia with symptoms. Record review of hospital history and physical dated 6/27/2023, revealed the patient was seen by home health on 4/28/2023, Hyperglycemic with blood sugar greater than 600. The glucose level at the emergency room was 303. Further review revealed the patient’s caregiver is “very ill” with Congestive Heart Failure. The patient was discharged to a nursing facility. During an interview on 4/10/2024 at 1:00 PM, the Executive Director and Clinical Manager confirmed the SN had not coordinated care with the caregiver. Further interview confirmed the SN had not instructed the caregiver on keeping a glucose log to document amount of insulin administered, had not assessed the caregiver’s ability to administer the sliding scale insulin, and the SN had not monitored the blood sugars or amount of insulin administered.”

“Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This Element is not met as evidenced by: Based on medical policy review, record review and interview, the agency failed to ensure the caregiver received ongoing education and training regarding monitoring of the patient’s glucose levels and administration of insulin for 1 patient (#10) of 3 patients reviewed with Diabetes Mellitus. The findings included: Review of agency’s policy titled, “Patient Assessment, Initial and Reassessment,” revised on 3/2022 revealed “...Upon admission...the qualified clinician performs the following assessment and collects the following data...Primary caregiver support and willingness and ability to provide care...” Patient #10 was admitted to the agency on 4/23/2023 with diagnoses of Type 2 Diabetes Mellitus and Stage 2 Pressure Ulcer of Sacral Region. Medical record review of the patients Home Health Certification and Plan of Care dated 4/23/2023 to 6/21/2023 revealed the Skilled Nurse (SN) was to provide instructions on Diabetes Type 2. Continued review revealed goals for the caregiver included “...Caregiver will understand and demonstrate compliance with treatment regimen for Diabetes...Caregiver will demonstrate knowledge of Diabetic medication types, action, possible side effects, use, administration and proper storage...” Further review revealed the physician ordered the SN or caregiver to perform blood glucose testing 4 times a day and as needed until patient’s therapeutic glucose range was between 70mg/dl to 150mg/dl (milligrams per deciliter). Continued review revealed the physician ordered a sliding scale of Lispro (insulin). If the glucose level was 70-150mg/dl - 0 units; 151-200mg/dl - 2 units; 201-250mg/dl - 4 units; 251-300mg/dl - 6 units; 301-350mg/dl - 10 units; 351-400mg/dl - 11 units; greater than 401mg/dl - 14 units and notify physician. Medical record review of the hospital discharge summary dated 4/22/2023 revealed the patient was discharged with Insulin-dependent Diabetes Mellitus with episodes of Hypoglycemia and Hyperglycemia (glucose range 104-342). Further review revealed on 4/6/2023 the patient was brought into the emergency department (ED) by ambulance. He had an elevated blood sugar reading at home. He recently moved to the area from New Mexico. The patient’s glucose reading was 1300mg/dl in the emergency department (normal was between 70 - 150mg/dl). Continued review revealed the doctor who signed the home health orders assumed the patient’s care in the hospital on 4/17/2023. The physician was working towards sending the patient to a nursing facility. The patient came to the conclusion that he did not want to go to the nursing facility and wanted to be discharged home with his sister (caregiver). The physician telephoned the caregiver and informed her of his concerns that the patient’s care would exceed what she would be able to provide at home. The physician had concerned the patient would be at high risk for readmission if he is discharged home. The hospital arranged home health. Further review revealed the physician contacted the caregiver by phone and explained everything the patient would need, and she voiced understanding. Continued review revealed the glucose readings had been “okay” - running a “little bit on the higher side”, but the physician “prefer” him to be high rather than low during his hospital stay. Further review revealed the glucose reading on 4/22/2023 was 164 mg/dl. Medical record review of a SN note dated 4/23/2023 revealed the caregiver obtained the glucose reading using the patient’s glucometer. The glucose reading was 537mg/dl. Continued review revealed the patient had not obtained the insulin at that time due to a “mix-up” at the pharmacy. Further review revealed the caregiver was instructed to obtain glucose readings 4 times a day and insulin administration. The caregiver stated she had used a glucometer and administered insulin before. The caregiver was instructed to recheck glucose reading in 1/2 to 1 hour and if unable to “get BS (blood sugar) down to call the “on call” nurse. Continued review revealed the physician was notified and no documentation if the physician responded to the lack of insulin with the elevated glucose reading. The SN was unable to assess the caregiver’s ability to administer sliding scale insulin during the start of care visit. Further review revealed no documentation the caregiver was instructed on keeping a glucose log and amount of insulin administered. Medical record review of a SN note dated 4/26/2023 revealed {per the caregiver} had obtained the insulin and administered the insulin and obtained glucose readings as ordered. Further review revealed no documentation of the glucose readings or the amount of insulin administered since the last SN visit. Continued review revealed no documentation the caregiver was assessed on the ability to administer sliding scale insulin. Medical record review of a social worker note dated 4/26/23 revealed the patient had not obtained his medications except for the insulin due to no prescription coverage. The social worker was working on finding the patient a primary care physician. The physician who ordered home health would only sign orders for 2 weeks. Medical record review of a SN note dated 4/28/2023 revealed the caregiver was leaving the home to go the emergency department. Continued review revealed a “neighbor” would “watch” the patient while his sister is at the emergency department. The occupational therapist was in the home and stated the caregiver obtained the glucose reading of 505mg/dl. Sliding scale was administered (no documentation of the amount) and the physician was notified. The glucose was rechecked with the reading of 478mg/dl and the patient was diaphoretic (increased sweating). The patient informed the SN that a primary care physician had been obtained and he was scheduled to go “next week”. The SN called the agency and reported the findings of elevated glucose reading and patient was diaphoretic. The SN was told to call 911 and transport the patient to the hospital due to Hyperglycemia with symptoms. Medical record review of hospital history and physical dated 6/27/2023 revealed the patient was seen by home health on 4/28/2023, Hyperglycemic with blood sugar greater than 600. The glucose level at the emergency room was 303. Continued review revealed the patient stated he had been diabetic for 20 plus years and had previously been able to keep his glucose under control. Further review revealed the patient’s caregiver is “very ill” with Congestive Heart Failure. The patient was discharged to a nursing facility. During an interview on 4/10/2024 at 1:00 PM, the Executive Director and Clinical Manager revealed the hospital physician would only sign orders for 2 weeks. Further interview confirmed the SN did not assess the caregiver’s ability to administer the sliding scale insulin and the SN did not monitor the blood sugars or amount of insulin given. Continued interview confirmed the caregiver was not instructed to keep a glucose log with amount of insulin administered for the nurse to review.”

“Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This Element is not met as evidenced by: Based on agency policy review, medical record review and interview, the agency failed to assess caregiver’s education on Diabetes and administration of Insulin for 1 patient (#10) of 10 patients reviewed. The findings included: Review of agency’s policy titled “Patient Assessment, Initial and Reassessment,” revised on 3/2022 revealed “...Upon admission...the qualified clinician performs the following assessment and collects the following data...Primary caregiver support and willingness and ability to provide care...” Patient #10 was admitted to the agency on 4/23/2023 with diagnoses of Type 2 Diabetes Mellitus and Stage 2 Pressure Ulcer of Sacral Region. Record review of the patients Home Health Certification and Plan of Care dated 4/23/2023 to 6/21/2023 revealed the Skilled Nurse (SN) was to provide instructions on Diabetes Type 2. Continued review revealed goals for the caregiver included “...Caregiver will understand and demonstrate compliance with treatment regimen for Diabetes...Caregiver will demonstrate knowledge of Diabetic medication types, action, possible side effects, use, administration and proper storage...” Further review revealed the physician ordered the SN or caregiver to perform blood glucose testing 4 times a day and as needed until patient’s therapeutic glucose range was between 70mg/dl to 150mg/dl (milligrams per deciliter). Continued review revealed the physician ordered a sliding scale of Lispro (insulin). If the glucose level was 70-150mg/dl - 0 units; 151-200mg/dl - 2 units; 201-250mg/dl - 4 units; 251-300mg/dl - 6 units; 301-350mg/dl - 10 units; 351-400mg/dl - 11 units; greater than 401mg/dl - 14 units and notify physician. Medical record review of a SN note dated 4/23/2023 revealed the caregiver obtained the glucose reading using the patient’s glucometer. The glucose reading was 537mg/dl. Continued review revealed the patient had not obtained the insulin at that time due to a “mix-up” at the pharmacy. Further review revealed the caregiver was instructed to obtain glucose readings 4 times a day and insulin administration. The caregiver stated she had used a glucometer and administered insulin before. The caregiver was instructed to recheck glucose reading in 1/2 to 1 hour and if unable to “get BS (blood sugar) down to call the “on call” nurse. The SN was unable to assess the caregiver’s ability to administer sliding scale insulin during the start of care visit. Further review revealed no documentation the caregiver was instructed on keeping a glucose log and amount of insulin administered. Medical record review of a SN note dated 4/26/2023 revealed {per the caregiver} had obtained the insulin and administered the insulin and obtained glucose readings as ordered. Further review revealed no documentation of the glucose readings or the amount of insulin administered since the last SN visit. Continued review revealed no documentation the caregiver was assessed on the ability to administer sliding scale insulin. Further review revealed no documentation the caregiver was instructed to keep a glucose log with the amount of insulin administered. Medical record review of a SN note dated 4/28/2023 revealed the caregiver was leaving the home to go the emergency department. Continued review revealed a “neighbor” would “watch” the patient while his sister is at the emergency department. The occupational therapist was in the home and stated the caregiver obtained the glucose reading of 505mg/dl. Sliding scale was administered (no documentation of the amount) and the physician was notified. The glucose was rechecked with the reading of 478mg/dl and the patient was diaphoretic (increased sweating). The patient informed the SN that a primary care physician had been obtained and he was scheduled to go “next week”. The SN called the agency and reported the findings of elevated glucose reading and patient was diaphoretic. The SN was told to call 911 and transport the patient to the hospital due to Hyperglycemia with symptoms. Medical record review of hospital history and physical dated 6/27/2023 revealed the patient was seen by home health on 4/28/2023, Hyperglycemic with blood sugar greater than 600. The glucose level at the emergency room was 303. Further review revealed the patient’s caregiver is “very ill” with Congestive Heart Failure. The patient was discharged to a nursing facility. During an interview on 4/10/2024 at 1:00 PM, the Executive Director and Clinical Manager confirmed the SN did not assess the caregiver’s ability to administer the sliding scale insulin and the SN did not instruct the caregiver to keep a glucose log with the amount of insulin administered. .”