Ascension at Home

“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 record review and interview, the agency failed to enforce a written policy regarding coordination of services to ensure the effective exchange of information, reporting, and coordination of care with all service providers involved in the care of a client, including physicians, contracted health care professionals and other agencies in that Client #1 was discharged from the hospital on 6/5/26 with newly placed feeding tube and did not have supplies or tube feedings available at the home, and the agency failed to properly coordinate care with Dietician and Physician to ensure necessary supplies and feedings were provided of Client’s plan of care for 1 of 5 Clients (Client #1). This failure placed Client at risk of dehydration which resulted in hospitalization 6/16/26. Review of Client #1 clinical records included age 69 years old with diagnosis of malignant neoplasm of tonsillar fossa, head, face, and neck with recent feeding tube placement for nutritional feedings. Client #1 plan of care dated 6/4/26 referral for home health services for skilled nursing for 1 time per week for 1 week, followed by 2 times per week for 1 week, 4 times per week for 1 week, 2 times per week for 2 weeks, finally 1 time per week for 5 weeks. The visits were to provide education and nutritional care following Client feeding tube placement. Start of care date 6/5/26 included registered dietician to assess nutritional needs related to the client’s illness and need for care, as well as monitoring of response to treatment and care adjustments. Review of coordination notes by RN A dated 6/5/26 revealed start of care home visit concern for fluid overload to lower extremities with Client #1 and recommendations from agency RN for client to go the hospital for further evaluation. Record review revealed Client refused hospital evaluation. Further record review revealed Client has orders for tube feedings and education for newly placed feeding tube, however, client does not have supplies or tube feedings available in the home. Following the home visit coordination notes dated 6/5/26 included email sent to Dietician for plan of care to include tube feedings for Client #1. Review of coordination notes by RN A dated 6/9/26 revealed home visit with Client #1 received chemotherapy on previous day and lab work was improving. During the home visit the client RN A attempted to contact pharmacy about tube feedings the Client has not received. Documentation revealed nurse left voicemails and escalated the issue to her manager to ensure timely resolution. RN A documented concern of delay in Client receiving nutritional support, which placed Client at risk for dehydration and malnutrition. Review of coordination notes by RN A dated 6/10/26 revealed follow-up phone call regarding status of Client nutritional formula order. Client #1 reported that he successfully completed the intake process with the pharmacy and expected delivery of tube feedings are expected to the following day. Documentation revealed Client #1 had doctor appointment on this day, so RN A instructed Client to monitor the delivery of the tube feedings and notify agency if there were any concerns to contact agency office. Additional documentation for RN A on 6/10/26 revealed notification to agency Supervising Nurse that Client must be seen later this week to follow up on missing Client tube feedings. Coordination notes revealed nutritional referral was placed for care and supplies previous week, on Tuesday. During the visit on 6/10/26 instructions and education provided to Client for water flush information and how to ensure hydration to client. Review of coordination notes by Dietician dated 6/11/26 revealed nutritional tube feedings for Client #1 with water flush instructions before and after. Review of coordination notes by LVN A dated 6/12/26 revealed home visit with Client #1 to provide education and assist with tube feedings for new feeding tube placement, however, Client has not received feedings to his home. Record review revealed minimum oral intake due to dysphagia and pain with swallowing. Education provided in reference to tube feedings, upon receipt to Client home, to include times and amount due at each feeding. Assessment documentation revealed Client is stable, however, remains deconditioned with fatigue due to impaired swallowing and no nutritional intakes with tube feedings via feeding tube. Review of coordination notes by RN A dated 6/16/26 revealed client went to ED due to change in status. Additional documentation coordination notes from Texas Oncology Dr. office revealed concern client experienced delay in enteral nutrition feedings and supplies and Client reported low urine output, feeling unwell. Documentation revealed concern for dehydration and nutritional compromise, which resulted in Client assessment in doctor office with recommendation for Client to go to the ED for further evaluation. Plan of care for agency services were placed on hold. Interview with RN A/Case Manager 9/15/26 at 6:45 PM via telephone in reference to intake #1113612 with Client #1. Asked RN A/Case Manager if she could provide details on Client visit and information on his tube feeding supplies. RN A/Case Manager stated Client had feeding tube placed at hospital on 6/5/26. She stated he was admitted to home health on 6/5/26 but did not have any feeding orders and Client #1 was sent home from new feeding tube placement without any nutritional supplements from hospital. Asked her if Client would generally discharge home with supplies, which she stated was case by case for each Client, based on if they were still able to have oral intake or not which she stated the Client was unable to take anything orally. RN A/Case Manager stated she contacted the agency on 6/5/26 (time unknown) for plan of care approval, so she requested the dietician referral be placed for the tube feedings at that time. RN A/Case Manager stated during the visit on 6/5/26 she felt the Client was not appropriate to stay at home, which she stated she called the Client physician office to notify him of the concern with his swelling in lower extremities and how she needed Client’s plan of care needed to be placed for his feedings due to no feedings were available for the Client at the time of her assessment. Triage nurse assessed Client with RN A/Case Manager on the phone on 6/5/26 (time unknown) and recommendations for ED evaluation, but Client refused. She stated she had communication with her Director of Clinical Services following the start of care home visit on 6/5/26 (time unknown), explaining the situation was not optimal due to Client status and no access to feedings in the home, but agency staff stated they would follow-up on dietician orders for his feedings. RN A/Case Manager stated on the next home visit on 6/9/26 she stated the feedings had not been delivered to Client home, so she tried to contact the pharmacy directly on 6/9/26 (time unknown), however, was unable to speak with someone. She stated the representative with the pharmacy had attempted to contact the Client, but they were unable to reach them via telephone. RN A/Case Manager stated she requested they call Client while she is in the home, which she stated the telephone did not ring so when the pharmacy called RN A/Case Manager back, she advised the phone did not ring. Upon review, the Client phone number was not correct with the pharmacy, so correction was made to this information. Verification was made with Client and pharmacy, and it was stated that the tube feedings would arrive within 48 hours to Client home. RN A/Case Manager stated Client was receiving IV hydration during chemotherapy visits, as well as education had been provided to Client and caregiver on water flushes during the day via feeding tube with medications. RN A/Case Manager stated Client was not taking anything by mouth, so she was concerned about his hydration status. She stated she was asked why Ensure had not been provided to the Client, which she stated she wasn’t a physician and did not have the orders to offer this to the Client. RN A/Case Manager was concerned about the care Client #1 received by Oncologist, due to Client being seen weekly by this physician. She also stated she did not believe the agency staff helped her facilitate Client’s plan of care, ultimately, she felt the Client was not taken care of and she stated she did all she was able to do in assisting him but she thought administration with agency was ‘too busy’. Interview with Administrator/Supervising Nurse during the date’s services were provided to Client #1, on 9/16/26 at 9:45 AM via telephone in reference to intake #1113612. Asked Administrator about Client #1 and services ordered on plan of care. Administrator stated she had recently assumed the current position, which was as of 6/29/26, prior to this she was the Supervising Nurse. Asked Administrator if the agency had a dietician to provide services, she stated they have one that does assist when needed but does not happen often. Asked Administrator what the process was in reference to the dietician services. She stated the dietician will receive a consultation and she reviews the record to make recommendations then can provide all teaching via telephone (because she is not within the local area, remote worker out of state, does telehealth). Asked Administrator, she was aware of the situation with Client #1 and failure to follow the plan of care to include the tube feedings. She stated she had been made aware of what was happening with Client #1 and even when RN A/Case Manager escalated the concern on 6/10/26 (time unknown) about how many days had passed and the Client did not receive their feedings at home. Administrator admitted to having ‘red flags’ about the care being provided by the agency with this Client and they should have contacted the physician and done more to assist in providing his care. Asked Administrator if she was aware of the notification of Client’s physician due to Client being unable to receive feedings, she stated she did not believe the notification had been made due to the Client being seen daily by the Oncologist. Asked Administrator about the dietician and her responsibilities for providing orders for Client tube feedings, which she stated when the dietician was notified of the Client not receiving feedings the dietician did not realize the Client had no access to tube feedings instead assumed this was ongoing services and he had tube feedings in the home already. Administrator stated the same day the orders were placed by the dietician on 6/11/26 the pharmacy had processed the Client’s referral, and it was supposed to be sent out to the Client within a day or two following, approximately 6/12-6/13. Asked Administrator who was responsible for providing orders to include tube feedings, she stated generally the Oncologist would place these orders and the agency provides the education and assistance for tube feedings for the Client in the home. Asked Administrator why no notification had been made to the physician/Oncologist, which stated the nurse did not report missing feeds, so that was why this did not occur. Asked Administrator if agency had policy in reference to missing services for tube feedings, etc., which she stated she could not recall a policy that addressed this concern. Review of policy titled “Care Coordination and Case Manager” dated 12/23/24 revealed ‘the case manager ensures all care provided under arrangement is delineated in the client’s plan of care and that care coordination is an ongoing, collaborative process focused on safe, effective, timely, and client-specific care.’”