Chilex Home Care Services Inc.

“Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This Element is not met as evidenced by: Based on record review, and interview, the agency failed to coordinate service with the group home to meet the patient-specific needs in 4 (Patient #1, 2, 3, and 4) of 5 active patient’s records reviewed with home visits (Patient #1, 2, and 3), and 1 (Patient # 6) of 2 discharged patient records reviewed who resided in group homes. This failure placed clients at risk of agency staff being unaware of any specific treatments or services required by the group home to further progress to meet the health goals of the patient. This failure could have resulted in a decline in the clients’ health status from missing or duplicated services. Findings include: The number of patients were taken from the list of current active and discharged patient’s list provided by the AA on 06/03/2024 at 2.30 pm. Record Review: Patient # 1: Review of the clinical record contained a POC with a Start of Care (SOC) date of 5/16/20215, and a certification period from 3/29/2024 thru 5/27/2024. The POC revealed Patient #1 had the following diagnosis: Contracture left hand, Severe Intellectual disability, Age-related osteoporosis (a bone disease) without current pathological fracture, Muscle wasting and atrophy, Encounter for attention to gastrostomy (surgical opening into the stomach from the abdominal wall) and Mixed incontinence. The physician’s orders included instructions for the skilled nurse (SN) to visit the client once a week for nine weeks and for the SN to change the dressing to the Percutaneous Endoscopic Gastrostomy (PEG) (tube is passed surgically into stomach through the abdominal wall, to provide feeding/medications when oral intake is not adequate or difficulty in swallowing.) tube site every visit. The POC failed to designate whether the Identifier C caregiver or the agency would be responsible for changing the PEG tube dressing and monitor vital signs and report abnormal readings to the physician. Further review the entire clinical record with a SOC 5/16/2015, did not include any evidence or documentation that indicated the agency had coordinated with the Identifier C management, or Identifier C staff under what circumstances the Identifier C #1 needed to notify the agency. Patient # 2: Review of the clinical record contained a POC for a certification period from 02/21/2024 thru 04/20/2024. The POC revealed Patient #2 had the following diagnosis: Pressure ulcer of right heel stage 3 (full-thickness loss of skin that extends to the subcutaneous tissue), Pressure ulcer of left heel -unstageable (wound covered by dead or dying tissue), profound Intellectual disabilities, Developmental disorder of speech and language, muscle weakness and mixed incontinence. The physician’s orders included instructions for the SN to visit the client once a week for nine weeks and for the SN to change the dressing to the right heel ulcer every visit. Further review the entire clinical record with a SOC 09/04/2021, the POC did not include any evidence or documentation that indicated the agency had coordinated with the Identifier C management, or Identifier C staff regarding who would be responsible for providing the wound care or under what circumstances the Identifier C #2 needed to notify the agency. Patient # 3: Review of the clinical record contained a POC for a certification period from 03/31/2024 thru 05/29/2024. The POC revealed Patient #3 had the following diagnosis: pressure ulcer to sacral region- stage 3 (full-thickness loss of skin that extends to the subcutaneous tissue), Unspecified osteoarthritis, Unspecified intellectual disabilities, Muscle wasting and atrophy, Developmental disorder of speech and language, and mixed incontinence. The physician’s orders included instructions for the SN to visit the client once a week for nine weeks and for the SN to change the dressing to the sacral area ulcer each visit. Patient’s record included wound care order dated 5/15/2024 “Home Health Nurse to change dressing 3X/week”. The POC did not include any information about the Identifier C #3’s responsibilities and wound care services provider’s responsibilities were regarding changing sacral and coccyx pressure ulcer dressings. Further review of the entire clinical record with a SOC 12/02/2023, did not include any evidence or documentation that indicated the agency had coordinated with the Identifier C management, or Identifier C staff regarding wound care and under what circumstances the Identifier C #3 needed to notify the agency. Patient # 4: Review of the clinical record contained a POC for a certification period from 03/14/2024 thru 05/12/2024. The POC revealed Patient #4 had the following diagnosis: Dysphagia (difficulty swallowing), Idiopathic epilepsy (seizure disorder with no known cause) and epileptic syndrome with seizures, Unsteadiness on feet, Moderate intellectual disabilities, Gastro-esophageal reflux disease without esophagitis, and mixed incontinence. The physician’s orders included instructions for the SN to visit the client once a week for nine weeks and for the SN to monitor health status and vital signs each visit. The POC did not include any documentation stating what care and tasks the Identifier C #4 would be responsible for regarding dysphagia precautions and seizure precautions. Further review the entire clinical record with a SOC 05/01/2015, did not include any evidence or documentation that indicated the agency had coordinated with the Identifier C management or Identifier C staff regarding care and under what circumstances the Identifier C #4 needed to notify the agency. Patient # 6: Review of the inactive clinical record contained a POC for a certification period from 03/11/2024 – 05/09/2024. The POC revealed Patient #6 lived in Identifier C #4 had the following diagnosis: Type 2 diabetes mellites, Cerebral Palsy, Venous insufficiency, Chronic venous hypertension with inflammation of bilateral lower extremity, localized swelling, mass and lump bilateral lower limb, and Hyperlipidemia. The physician’s orders included instructions for the SN to visit the client once a week for nine weeks and for the SN to monitor health status, vital signs and blood sugar monitoring each visit. The clinical record indicated patient was transferred to hospital and discharged from agency on 05/09/2024. The POC did not include any documentation stating what care and tasks the Identifier C # 4 would be responsible for. The entire clinical record with a SOC 11/17/2022, did not include any evidence or documentation that indicated the agency had coordinated with the Identifier C management, or Identifier C staff regarding under what circumstances the Identifier C #4 needed to notify the agency. Home visits were conducted for Patients # 1, 2, and 3. Patient # 1, 2, and 3 were non-verbal and with intellectual disabilities and they resided in three different group homes. On 6/04/2024 at approximately 4.30 pm a home visit was conducted at Identifier C #1 where Patient #1 resided. On 6/04/2024 at approximately 5.15 pm a home visit was conducted at Identifier C #3 where Patient #3 resided. On 6/05/2024 at approximately 10.30 am a home visit was conducted at Identifier C #2 where Patient #2 resided. The Patients # 4 and 6 resided in Identifier C # 4. During an interview with ADM/DON on 6/05/2024 at approximately 1:20 PM, the surveyor asked the ADM why the agency did not enforce their policy to ensure the clinical record included coordination of care with the Identifier C where patient’s 1, 2, 3, 4, and 6 resided. The ADM stated that she didn’t know it was needed. She added that she had the address of the group homes and contact information of the owner of the Identifier C but did not realize the information had to also be included in the patient’s records. The surveyor asked how you know what services the Identifier C homes were providing if it wasn’t written in the POC. The ADM/ DON said she knows the Identifier C homes were providing all the services patient needed. The surveyor asked how she would know she weren’t duplicating a service. The ADM did not answer. The surveyor asked for the documentation of Patient #3’s wound care dressing change three times a week, when SN visit was only once a week. The ADM/DON stated she did not document wound care dressing change was done by wound care nurse from the wound care services office twice a week. The ADM added that she called Identifier C management over the phone, but it was not documented. The surveyor asked who was responsible for the coordination of care with the group home where the patients resided. The ADM said she was taking responsibility of not doing it. The ADM/DON and AA did not dispute the survey findings and did not provide any additional evidence to explain the findings. Review of agency policy titled: “MONITORING PATIENT CARE/COORDINATION OF CARE, TX. 8”, of the Administrative Policy Manual revised on 06/01/06, read in part: “PURPOSE: To ensure coordination of patient care/treatment. POLICY: Agency will collaborate with other organizations providing services (i.e., medical equipment, other home health agencies, out-patient clinics, etc.) ... PROCEDURE: ... 4. When other organizations are involved in the patient’s care, Agency staff members notify them of significant changes in the patient’s overall care. This communication is documented in the medical record. 5. Agency staff are expected to contact the agency to inform of patient needs and changes. This will be documented on a communication note and will serve as coordination of care.” Review of agency policy titled:” PLAN OF CARE, TX.6”, of the Administrative Policy Manual revised on 03/16/04, read in part: “PURPOSE: To ensure that care provided is appropriately planned in a timely manner to meet the patient’s specific needs and problems. POLICY: Agency will utilize data/information gathered during patient assessments in the care planning process …… patient’s problems and/or needs. PROCEDURE: … 2. An RN is responsible for coordinating the plan of care when multi-disciplines are involved, or when more than one agency is involved, …. Identify responsibilities.”