Home Care Solutions

“Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This Element is not met as evidenced by: Based on medical record review and interview the agency failed to follow the plan of care to monitor glucose levels for 1 patient (Patient #8) of 17 patients reviewed. The findings include: Record review revealed Patient #8 was admitted to the agency on 9/17/2024 with diagnoses including Type 2 Diabetes Mellitus and Acute Kidney Failure. Review of a Home Health Certification and Plan of Care (485) dated 9/17/2024 to 11/15/2024 revealed a physician’s order for Physical Therapy (PT) visits at 2 times a week for 3 weeks and then 1 time a week for 6 weeks. Continued review revealed a physician’s order for the PT to monitor the patient’s blood glucose levels. Further review revealed the patient/caregiver was to check the glucose levels daily and the therapeutic range was 70 to 200. Review of the PT notes from 9/17/2024 to 10/07/2024 revealed the glucose level was only obtained from the patient on admission (9/17/2024) and no documentation the glucose was monitored following admission. Review of an email dated 10/10/2024 from the Executive Director confirmed the physical therapist did not monitor the glucose levels following the admission and the plan of care had not been followed.”

“Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) The HHA must— (i) Investigate complaints made by a patient, the patient’s representative (if any), and the patient’s caregivers and family, including, but not limited to, the following topics: (A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; (B) Mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the HHA. This Element is not met as evidenced by: Based on the agency policy, medical record review, and interview the agency failed to investigate complaints made by 1 patient (Patient #13) of 3 patients reviewed. The findings include: Review of the agency’s policy titled “Grievance, Procedure, Patient Complaints” revised 11/01/2023 revealed “...The agency will investigate complaints made by the patient...” Record review revealed patient #13 was admitted to agency on 10/22/2022 with diagnoses including Nonsurgical Wound Dressing and Chronic Venous Hypertension with Ulcer of Left Lower Extremity. Record review of the Home Health Certification and Plan of Care (485) dated 2/14/2024 to 04/13/2024 revealed the physician ordered skilled nurse (SN) at 1 time a week for 1 week; 2 times a week for 7 weeks; and 1 time a week for 1 week. SN were to performed wound care 2 times a week (patient was seen by wound care clinic 1 time a week). Wound care performed was to the right lateral lower leg, right plantar great toe, right posterior lower leg, left anterior lower leg left posterior lower leg, right 3rd toe which included “cleanse with NS (normal saline), apply (a bacteria and fungi binding dressing) to wound bed. Apply two-layer compression wrap to BLE (bilateral lower extremities).” Record review of SN note dated 3/26/2024 revealed no documentation the patient requested discharge from the agency. Record review of SN note dated 3/28/2024 revealed a discharge OASIS was completed with no SN visit - data collection only. Review of the complaint log for March and April 2024 revealed no complaints or concerns were made to the agency regarding patient discharged. Review of a complaint dated 4/05/2024 revealed the last time the agency perform wound care was on 3/26/2024. Continued review revealed it had been 9 days since the wound care was provided. He contacted the Clinical Director A and was told he requested discharge on 3/26/2024. He denied requesting discharge from the agency. Continued review revealed he complained of being “uncomfortable” and had some pain because the wounds are not being treated. Review of a complaint dated 4/10/2024 revealed the last time the agency perform wound care was on 3/26/2024. Continued review revealed no one had performed wound care since his complaint on 4/05/2024. Further review revealed he denied requesting discharge as he has no one to provide wound care. Continued review revealed the patient complained of “great pain” and was unable to sleep at night. Further review revealed his right leg became infected and he has developed additional wounds. Continued review revealed he has contacted Clinical Director A with no resolution. Review of the complaint log from 1/1/2024 to 4/04/2024 revealed no complaints were made by the patient. Review of coordination note dated 10/09/2024 revealed the Clinical Director A stated he requested discharge on 3/26/2024. He was not happy that 2 of his nurses had resigned from the agency. Continued review revealed the Clinical Director A stated the patient had a “long history” of calling office while inebriated and then calling back later forgetting what he had originally stated. Patient’s discharge request aligned with the resignation of 2 nurses the patient had created a rapport with. Further review revealed he was admitted by another agency on 4/09/2024. During an interview on 10/09/2024 at 1:00 PM, the Executive Director revealed Clinical Director A did not investigate the patient’s complaints of no services for wound care due to the patient would not remember making complaints in the past. Further interview revealed the last time the patient was seen by the agency was on 3/26/2024 and a discharge OASIS was completed on 3/28/2024 with no nursing visit. During an interview on 10/09/2024 at 1:30 PM, the Executive Director confirmed the complaints/concerns called into the office by the patient had not been investigated by the agency. Download Form .”

“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 the agency policy, medical record review, and interview the agency failed to notify the physician of a discharge from the agency for 1 patient (Patient #13) of 3 discharged patients, and failed to notify the physician of 1 patient (Patient #15) reviewed for smoking with oxygen in use and a new wound of 17 patients reviewed. The findings include: Review of the agency policy titled, “Patient Discharge” revised 10/01/23 revealed “…Revisions to plan for patient’s discharge will be communicated to…patient...all physicians issuing orders, patient’s primary care practitioner or health care professional who will provide care and services to patient after discharge…notification to physician and measures taken to investigate refusal of services…” Record review revealed patient #13 was admitted to agency on 10/22/2022 with diagnoses including Nonsurgical Wound Dressing and Chronic Venous Hypertension with Ulcer of Left Lower Extremity. Medical record review of the Home Health Certification and Plan of Care (485) dated 2/14/2024 to 4/13/2024 revealed the physician ordered skilled nurse (SN) at 1 time a week for 1 week; 2 times a week for 7 weeks; and 1 time a week for 1 week. SN were to performed wound care 2 times a week (patient was seen by wound care clinic 1 time a week). Wound care performed was to the right lateral lower leg, right plantar great toe, right posterior lower leg, left anterior lower leg left posterior lower leg, right 3rd toe which included “...cleanse with NS [normal saline], apply [a bacteria and fungi binding dressing] to wound bed. Apply two-layer compression wrap to BLE [bilateral lower extremities]...” Medical record review of SN notes from 2/16/2024 to 3/26/2024 revealed wound care provided as ordered. Continued wound assessment revealed wounds have healed or has decreased in size. Medical record review of SN note dated 3/26/2024 revealed no documentation the patient requested discharge from the agency. Medical record review of a SN note dated 3/28/2024 revealed a discharge OASIS was completed with no SN visit - data collection only. Review of complaint dated 4/05/2024 and 4/10/2024 revealed the time the agency perform wound care on his wounds was on 3/26/2024. He contacted the Clinical Director A on both 4/05/2024 and 4/10/2024and was told he requested discharge on 3/28/2024. Continued review revealed he did not request discharge as he had no one to perform his wound care. Review of coordination note dated 10/09/2024 revealed the Clinical Director A stated he requested discharge on 3/26/2024. During an interview on 10/09/2024 at 1:00 PM, the Executive Director revealed Clinical Director A stated she had told the patient’s physician the patient had been discharge due to the patient’s request, however, did not document the conversation. Further interview revealed the Clinical Director A did not investigate the patient’s complaints of being discharge from the agency because he would make complaints and not remember them later. During an interview on 10/09/2024 at 1:30 PM, the Executive Director confirmed no documentation the physician was notified prior/after the patient’s discharge. Record review revealed Patient #15 was admitted to the agency on 05/18/2023 with diagnoses including Pneumonia, Nicotine Dependence – Cigarettes and Dependence on Oxygen. Review of the Home Oxygen Safety procedure dated 10/26/2016 revealed “…Presence of smoking materials…no smoking signs posted…knowledge of oxygen safety and its use…evidence of continued assessment of home oxygen safety…” Medical record review of the Home Health Certification and Plan of Care dated 5/18/2023 to 7/16/2023 (485) revealed a physician’s order for Oxygen at 2 Liters via nasal cannula. Continued review revealed the Oxygen was to be used to maintain Oxygen Saturations at 90% and above. Further review revealed the SN was to instruct oxygen management including administration, skin care, care of equipment and safety. Further review revealed the patient’s mental status was oriented and patient’s cognitive functioning was alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently. Medical record review of SN note dated 5/18/2023 (admission note) revealed the patient and caregiver were given instructions on oxygen use and safety. Further review revealed they understood the instructions. Medical record review of SN note dated 5/24/2023 revealed patient smoking a cigarette approximately 5 feet from the oxygen concentrator. Patient was instructed on oxygen safety and not to smoke with the oxygen concentrator in use. No documentation the patient’s physician was notified he was smoking with oxygen on. Medical record review of SN note dated 5/31/2023 revealed the patient continued to smoke cigarettes in the home. The patient was instructed on oxygen safety and not to smoke with oxygen concentrator in use. No documentation the physician was notified of patient smoking with oxygen concentrated in use. Medical record review of SN note dated 6/28/2023 revealed burns were noted to nostril, lip and back of left arm. The patient stated he was smoking while using oxygen and it caught fire. Patient requested a new concentrator and SN notified Durable Medical Equipment agency to provide a new concentrator. Education provided on the dangers of smoking around oxygen and proper use of fire extinguisher. No documentation the patient’s physician was notified of burns, smoking with oxygen on and need for wound care orders. Photo of wounds on left upper arm obtained. Medical record review of SN note dated 7/05/2023 revealed the patient continues to smoke with oxygen in use. Physician order obtained for wound care for the burns a wound care provided as ordered on this visit. Continued review revealed photo of wounds obtained. Medical record review of a physician’s order dated 7/05/2023 revealed “…Temporary Order: SN to perform and instruct wound care to burn on left upper arm as follows: Cleanse wound, pat dry with 4x4 gauze. Apply skin prep to periwound, apply a soft dressing that soaks up liquids easily, secure with Medipore tape (flexible tape). Do not use foam bandage to cover. Wound care to be completed 2 times a week…” Medical record review of a SN note dated 7/12/2023 revealed the patient was instructed on smoking with oxygen (patient not smoking on this visit). SN placed fire extinguisher at patient’s bedside. Left upper arm wound care provided. Wound measurements were 4 cm length x 2 width x 0.1 cm depth. Continued review revealed photo of wound obtained. Medical record review of a SN note dated 7/14/2023 revealed wound care was provided. Continued review revealed measurements of wound did not change from 7/12/2023. Further review revealed the wound had a small amount of serosanguinous drainage. Medical record review of a physician’s order dated 7/14/2023 revealed the wound care was to continue as ordered on 7/05/2023. Interview with the Executive Director on 10/11/2024 via email confirmed the patient’s physician was not notified of patient was smoking with oxygen in use on 5/24/2023, 5/31/2023 and 6/28/2023 and also did not notify physician of burns and need for wound care on 6/28/2023. Continued interview revealed the Executive Director confirmed wound care orders for the burns were not obtained until 7/05/2023 – a delay of 8 days. Download Form”