1st Choice Home Health

“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 observation, interview and record review, the agency failed to ensure the plan of care contained patient specific interventions and education, and safety measures to protect against injury for 1 of 8 patients (Patient #s 8) records reviewed for plans of care, in that: Patient #8’s POC did not include bleeding safety precautions or teaching on signs and symptoms to report to the physician or SN while taking Eliquis (blood thinner). This failure could place patients at risk of not recognizing symptoms of bleeding, and not receiving proper care/instruction leading to complications and hospitalization. Findings included: Record review of Patient #8’s POC dated 11/10/24 to 01/08/25 indicated a SOC date of 09/11/24, and indicated she was 86 years old with diagnoses including hypertensive heart disease with heart failure (heart can’t pump blood well enough to meet your body’s needs), chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems), dementia (diseases that affect thinking, memory, and the ability to perform daily tasks), chronic atrial fibrillation (irregular heartbeat), aortic (valve) stenosis (thickening and narrowing of the valve between the heart’s main pumping chamber and the body’s main artery), and repeated falls. The POC indicated Patient #8 was ordered skilled nursing visits 1 time a week for 9 weeks. The POC medication list indicated Patient #8 took Eliquis (blood thinner) 5mg, one tablet by mouth, twice a day. The POC did not include bleeding safety precautions or teaching on signs and symptoms to report to the physician or SN. During an interview on 12/12/24 at 9:11 a.m., RN E said a POC/485 was updated every 60 days. She said if there was a significant change in condition, decline, or resumption of care the POC was updated with changes. She said if there was no decline it was updated at recertification. RN E said the POC was developed and updated by the RN who did the OASIS assessment. RN E said the RN Alternate Administrator reviewed the POCs. RN E said a patient on Aspirin, Plavix, or Eliquis should have bleeding precautions and teaching on soft toothbrushes, and electric razors. RN E said a potential negative outcome for bleeding precautions not on the POC would be no education and a bleeding issue with the patient. She said if a patient was on a blood thinner and hit their head, they should go to the emergency room for evaluation. During an interview on 12/12/24 at 10:07 a.m., LVN D said she did not do anything with the POC, the RN did. She said she knew to watch and teach for bruising if a patient was on a blood thinner such as Eliquis, Aspirin, or Plavix. During an interview on 12/12/24 at 11:41 a.m., RN G said POCs were updated with orders, changes, at recertification, or a change in health status. She said a POC for a patient on Eliquis should include bleeding precautions. She said a potential negative outcome would be if a patient fell, they would be at risk for bleeding and injury, or GI bleed. RN G said she saw Patient #8 and completed the last recertification. She said Patient #8 was on Eliquis and should have bleeding precautions on her 485/POC. During an interview on 12/12/24 at 1:32 p.m., the RN Administrator said the POC was developed by the RN who did the OASIS, and the RN Alternate Administrator reviewed them and sent them back for corrections. The RN Administrator said the RN Alternate Administrator reviewed all OASIS and 485/POC to make sure teaching and safety precautions were listed. She said a POC for a patient on Eliquis should have bleeding precautions. During an interview on 12/12/24 at 1:38 p.m., the RN Administrator said she reviewed Patient #8’s POC and did not see any teaching for bleeding precautions. The RN Administrator said she verified with RN Supervising Nurse C that Patient #8 did not have bleeding precautions on her POC/485. She said bleeding precautions would be under safety measures. She said it should be on the 485/POC for if a patient fell. During an interview on 12/12/24 at 1:40 p.m., RN Supervising Nurse C said bleeding precautions should be on the 485/POC because the SN should know the precautions and interventions to take for abnormal bleeding or falls if a patient hit their head. She said anticoagulant (bleeding) precautions should be under safety measures and should be the first one. During an interview on 12/12/24 at 1:43 p.m., the RN Administrator said for client on a blood thinner, bleeding precautions should be on the 485/POC, so the SNs were aware. During an interview on 12/12/24 at 2:00 p.m., the RN Alternate Administrator said she reviewed all 485s/POCs. She said the RN developed the POC and if a patient was on Eliquis, Aspirin, or Plavix, anticoagulant precautions was supposed to be marked under safety precautions. She said RN Supervising Nurse C told her she missed one. She said it was her (RN Alternate Administrator) job to check. She said if she got overwhelmed with the amount of POCs coming in, she may forget to check. Record review of a Plan of Care Policy dated 05/02/24 indicated “…III. Each patient/client must receive an individualized written plan of care… The individualized plan of care must specify the care and services necessary to meet the patient/client-specific needs… A. The individualized plan of care must include the following… 11. Safety measures to protect against injury… 14. Patient/client-specific interventions and education…” Review of Eliquis instructions dated 07/25/24 and accessed at https://www.drugs.com/eliquis.html on 12/12/24 indicated “...Eliquis is used to lower the risk of stroke or a blood clot… Eliquis increases your risk of severe or fatal bleeding, especially if you take certain medicines at the same time (including some over-the-counter medicines)… Call your doctor at once if you have signs of bleeding such as: swelling, pain, feeling very weak or dizzy, bleeding gums, nosebleeds, heavy menstrual periods or abnormal vaginal bleeding, blood in your urine, bloody or tarry stools, coughing up blood or vomit that looks like coffee grounds, or any bleeding that will not stop. Eliquis should be stopped 24-48 hours prior to any surgery, invasive procedure, or dental work. Tell your surgeon if you are taking Eliquis… Do not stop taking Eliquis unless your doctor tells you to. Stopping suddenly can increase your risk of blood clot or stroke…””

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on observation, interview, and record review the agency failed to provide the patient and caregiver with a copy of written instructions outlining the visit schedule including frequency of visits by home health staff in 4 of 4 patients (Patient #’s 1, 2, 3, & 4) home folders reviewed during home visits, in that: There was no written visit schedule in the home folders of Patient #1, #2, #3, & #4. This failure placed patients at risk of missed visits by staff when visits were not scheduled and conflicted with other appointments and the availability of the patients. Findings included: Record review of Patient #1’s POC dated 11/17/24 to 01/15/25 indicated a SOC date of 09/29/22, and indicated she was 69 years old with diagnoses including laceration without foreign body left knee, wedge compression fracture vertebra (the broken bone collapses and takes on a wedge shape), chronic kidney disease (kidneys are damaged and cannot filter blood as well as they should), congestive heart failure (heart can’t pump blood well enough to meet your body’s needs), pulmonary hypertension (blood pressure in the lungs is higher than normal), venous insufficiency (veins in the legs have trouble moving blood back to the heart), irritable bowel syndrome (causes abdominal pain and changes in bowel movements), chronic pain, peripheral vascular disease (narrowed blood vessels reduce blood flow to the limbs), and Cushing’s syndrome (body produces too much cortisol, a hormone that helps regulate blood sugar and blood pressure). The POC indicated Patient #1 was ordered skilled nursing visits 2 times a week for 4 weeks, then 1 time a week for 5 weeks. During a home visit observation on 12/12/24 at 8:30 a.m., the surveyor reviewed Patient #1’s home folder and the folder consisted of agency documents, a vital sign log, a medication profile dated 11/23/22, patient rights, and teachings. There was no visit schedule or POC in Patient #1’s home folder. During an interview on 12/12/24 at 8:45 a.m., RN E said the agency used to put a calendar in the patients’ home folders. She said the agency stopped putting the POCs in the home folder due to family would look at the POC and would see if a patient was incontinent (involuntary loss of urine or stool) and the family would say the patient was not incontinent, etc. She said she was not sure why the agency stopped putting the calendars in the home folders. Record review of Patient #2’s POC dated 11/15/24 to 01/13/25 indicated he was 64 years old with diagnoses including disruption of an external surgical wound and pressure ulcer of left heel, unstageable. The POC indicated Patient #2 was ordered skilled nursing visits 1 time a week for 1 week, then 3 times a week for 8 weeks, then 1 time a week for 1 week. During a home visit observation on 12/12/24 at 9:29 a.m., the surveyor reviewed Patient #2’s home folder and the folder consisted of agency documents, a vital sign log, patient rights, and teachings. There was no visit schedule or POC in Patient #2’s home folder. Record review of Patient #3’s POC dated 11/12/24 to 01/10/25 indicated a SOC date of 07/15/24, and indicated she was 97 years old with diagnoses including chronic kidney disease (kidneys are damaged and cannot filter blood as well as they should), heart failure (heart can’t pump blood well enough to meet your body’s needs), peripheral vascular disease (narrowed blood vessels reduce blood flow to the limbs), depression (loss of pleasure or interest in activities for long periods of time), chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems), anxiety (feeling of fear, dread, and uneasiness), and falling. The POC indicated Patient #3 was ordered skilled nursing visits 1 time a week for 9 weeks. During an interview on 12/12/24 at 10:07 a.m., LVN F said the home folders consisted of protocols for disposals, doctors, blood pressure goals, and a in/out log. She said a calendar was not in the home folder due to it was in the electronic medical record. LVN F said there was no POC in the home folders and the POC was in the electronic medical record. LVN F said she would tell the patient what their SN days were, or wound care was. She said she would tell the patient when their next visit was and if a visit was changed. During a home visit observation on 12/12/24 at 10:13 a.m., the surveyor reviewed Patient #3’s home folder and the folder consisted of agency documents, heart disease zone tool, a vital sign log, patient rights, and teachings. There was no visit schedule or POC in Patient #3’s home folder. Record review of Patient #4’s POC dated 11/29/24 to 01/27/25 indicated a SOC date of 11/29/24 and indicated she was 81 years old with diagnoses including type 2 diabetes mellitus (body either doesn’t produce enough insulin, or it resists insulin), essential (primary) hypertension (high blood pressure), paroxysmal vertigo (sudden, brief episode of dizziness or spinning that occurs when the head is moved in certain positions), fibromyalgia (widespread muscle pain and tenderness), and repeated falls. The POC indicated Patient #4 was ordered skilled nursing visits 2 times a week for 8 weeks, then 1 time a week for 1 week. Patient #4 was ordered physical therapy evaluate and treat. During a home visit observation on 06/19/24 at 1:03 p.m., the surveyor reviewed Patient #4’s home folder and the folder consisted of agency documents, a vital sign log, patient rights, and teachings. There was not a visit schedule or POC in Patient #4’s home folder. During an interview on 12/12/24 at 11:30 a.m., the RN Administrator said the agency quit putting the patients’ medication list and calendars in the home folders because the medications were always changing, and the clients would file them in their folder, and it would get to be too much. She said the agency quit putting the 485/POC in the folders because the patient or family would call about the diagnosis and say the patient didn’t have “that”, such as Alzheimer’s or arthritis, or say the patient wasn’t incontinent. She said it got to be too much, so the agency quit putting it in there. She said the agency didn’t put anything about treatments or services in the folders. She said the agency had the medication list and calendars in the electronic medical record. During an interview on 12/12/24 at 12:00 p.m., the RN Administrator said it was her fault the home folders did not have the required items because the forms wouldn’t make it in there. She said the agency would print them but the SNs didn’t come by the office very much since working in the field. She said if the SNs were working out of town they would not drive all the way to the office to get the forms. She said by the time the SN would come to the office the “stuff” had changed and the POC/medication list wouldn’t be good anymore. During an interview on 12/12/24 at 12:05 p.m., the RN Administrator said when the agency put the items in home folders the patients would ask why they had to have all those papers. Record review of an Implementing Care and Treatment policy dated 05/02/24 indicated “…VI. Written information to the patient/client. The Agency must provide to the patient/client and caregiver with a copy of written instructions outlining: 1. The visit schedule, including frequency of visits by Agency personnel and personnel acting on behalf of the Agency... 3. Any treatments to be administered by Agency personnel and personnel acting on behalf of the Agency, including therapy services. 4. Any other pertinent instruction related to the patient’s care and treatment that the Agency will provide, specific to the patient’s/client’s care needs…””

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on observation, interview, and record review the agency failed to provide the patient and caregiver with a copy of written instructions of the patient medication schedule / instructions for 4 of 4 patients (Patient #’s 1, 2, 3, & 4) reviewed for medication schedule, in that: There was no patient medication schedule or instructions, written in plain language, in the home folders of Patient #1, #2, #3, & #4. This failure could place patients at risk of medication errors or adverse reactions. Findings included: Record review of Patient #1’s POC dated 11/17/24 to 01/15/25 indicated a SOC date of 09/29/22, and indicated she was 69 years old with diagnoses including laceration without foreign body left knee, wedge compression fracture vertebra (the broken bone collapses and takes on a wedge shape), chronic kidney disease (kidneys are damaged and cannot filter blood as well as they should), congestive heart failure (heart can’t pump blood well enough to meet your body’s needs), pulmonary hypertension (blood pressure in the lungs is higher than normal), venous insufficiency (veins in the legs have trouble moving blood back to the heart), irritable bowel syndrome (causes abdominal pain and changes in bowel movements), chronic pain, peripheral vascular disease (narrowed blood vessels reduce blood flow to the limbs), and Cushing’s syndrome (body produces too much cortisol, a hormone that helps regulate blood sugar and blood pressure). The POC indicated Patient #1 was ordered skilled nursing visits 2 times a week for 4 weeks, then 1 time a week for 5 weeks. During a home visit observation on 12/12/24 at 8:30 a.m., the surveyor reviewed Patient #1’s home folder and the folder consisted of agency documents, a vital sign log, a medication profile dated 11/23/22, patient rights, and teachings. There was no updated medication list for Patient #1 in the home folder. During an interview on 12/12/24 at 8:45 a.m., RN E said the patients home folders included their medication list and was updated every recertification or every 60 days, and staff would put the updated list in the home folders. During an interview on 12/12/24 at 9:11 a.m., Patient #1 said she did not have an updated medication list from the agency. Record review of Patient #2’s POC dated 11/15/24 to 01/13/25 indicated he was 64 years old with diagnoses including disruption of an external surgical wound and pressure ulcer of left heel, unstageable. The POC indicated Patient #2 was ordered skilled nursing visits 1 time a week for 1 week, then 3 times a week for 8 weeks, then 1 time a week for 1 week. During a home visit observation and interview on 12/12/24 at 9:29 a.m., the surveyor reviewed Patient #2’s home folder and the folder consisted of agency documents, a vital sign log, patient rights, and teachings. There was no medication list for Patient #2 in the home folder. RN E said Patient #2 should have a medication list in his folder. Patient #2 said he only had a medication list from his pharmacy and the hospital, and he did not know what was in the home folder. Record review of Patient #3’s POC dated 11/12/24 to 01/10/25 indicated a SOC date of 07/15/24, and indicated she was 97 years old with diagnoses including chronic kidney disease (kidneys are damaged and cannot filter blood as well as they should), heart failure (heart can’t pump blood well enough to meet your body’s needs), peripheral vascular disease (narrowed blood vessels reduce blood flow to the limbs), depression (loss of pleasure or interest in activities for long periods of time), chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems), anxiety (feeling of fear, dread, and uneasiness), and falling. The POC indicated Patient #3 was ordered skilled nursing visits 1 time a week for 9 weeks. During an interview on 12/12/24 at 10:07 a.m., LVN F said the home folders consisted of protocols for disposals, doctors, blood pressure goals, and a in/out log. She said there were no medication sheets in the folder because they were updated all the time. She said the agency quit doing the medication list and had not done them in a while due to the staff had computers. LVN F said there was no POC in the home folders and the POC was in the electronic medical record. LVN F said she would tell the patient what their SN days were, or wound care was. She said she would tell the patient when their next visit was and if a visit was changed. During a home visit observation on 12/12/24 at 10:13 a.m., the surveyor reviewed Patient #3’s home folder and the folder consisted of agency documents, heart disease zone tool, a vital sign log, patient rights, and teachings. There was no medication list for Patient #3 in the home folder. Record review of Patient #4’s POC dated 11/29/24 to 01/27/25 indicated a SOC date of 11/29/24 and indicated she was 81 years old with diagnoses including type 2 diabetes mellitus (body either doesn’t produce enough insulin, or it resists insulin), essential (primary) hypertension (high blood pressure), paroxysmal vertigo (sudden, brief episode of dizziness or spinning that occurs when the head is moved in certain positions), fibromyalgia (widespread muscle pain and tenderness), and repeated falls. The POC indicated Patient #4 was ordered skilled nursing visits 2 times a week for 8 weeks, then 1 time a week for 1 week. Patient #4 was ordered physical therapy evaluate and treat. During a home visit observation on 06/19/24 at 1:03 p.m., the surveyor reviewed Patient #4’s home folder and the folder consisted of agency documents, a vital sign log, patient rights, and teachings. There was no medication list for Patient #4 in the home folder. During an interview on 12/12/24 at 11:30 a.m., the RN Administrator said the agency quit putting the patients’ medication list and calendars in the home folders because the medications were always changing, and the clients would file them in their folder, and it would get to be too much. She said the agency quit putting the 485/POC in the folders because the patient or family would call about the diagnosis and say the patient didn’t have “that”, such as Alzheimer’s or arthritis, or say the patient wasn’t incontinent. She said it got to be too much, so the agency quit putting it in there. She said the agency didn’t put anything about treatments or services in the folders. She said the agency had the medication list and calendars in the electronic medical record. During an interview on 12/12/24 at 11:41 a.m., RN G said in patients’ home folders the agency put the medication profile, especially if the SN were doing the patient’s medication box. During an interview on 12/12/24 at 12:00 p.m., the RN Administrator said it was her fault the home folders did not have the required items because the forms wouldn’t make it in there. She said the agency would print them but the SNs didn’t come by the office very much since working in the field. She said if the SNs were working out of town they would not drive all the way to the office to get the forms. She said by the time the SN would come to the office the “stuff” had changed and the POC/medication list wouldn’t be good anymore. During an interview on 12/12/24 at 12:05 p.m., the RN Administrator said when the agency put the items in home folders the patients would ask why they had to have all those papers. Record review of a Implementing Care and Treatment policy dated 05/02/24 indicated “…VI. Written information to the patient/client. The Agency must provide to the patient/client and caregiver with a copy of written instructions outlining… 2. Patient medication schedule/instructions, including: medication name, dosage, time of medication administration, frequency, and which medications will be administered by Agency personnel acting on behalf of the Agency. 3. Any treatments to be administered by Agency personnel and personnel acting on behalf of the Agency, including therapy services. 4. Any other pertinent instruction related to the patient’s care and treatment that the Agency will provide, specific to the patient’s/client’s care needs…””