Concho Valley Home Health Care

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure that each patient received the home health services that were written in an individualized plan of care for 1 of 9 (Patient #5) patients reviewed in that the agency failed to ensure LVN G inserted the size of urinary catheter (a medical tube inserted into the bladder to drain urine) ordered by the physician in the written plan of care for Patient #5 on 04/20/26, 04/30/26, and 05/14/26. This failure could result in increased risk of urinary tract infections (infections of the bladder and other urinary structures) and pain or discomfort to the patient. The findings included: Record review of the clinical record for Patient #5 included a plan of care, for the certification period of 04/17/26 – 06/15/26, which indicated the patient had a start of care date of 12/18/25 and diagnoses of BPH (a medical condition in which the prostate gland (a gland in the male reproductive system) is enlarged and can press on the urethra (tube leading from the bladder to the outside of the body) which can result in blockage of urine and difficulty urinating) and encounter for fitting and adjustment of a urinary device. The plan of care indicated that the patient was to receive skilled nurse visits twice a week for one week, then once a week for seven weeks beginning the week of 04/20/26. The plan of care indicated, “… SN to change 20 FR [A unit of measurement one French equals one-third of a millimeter or 0.33 mm] … [a brand of urinary catheter] … q [every] 2WEEKS and as needed …” There was no documentation to indicate the nurse was to insert an 18 French urinary catheter. Record review of a skilled nurse’s note, dated 04/20/26, signed by LVN G, indicated, “CATHETER CHANGE AS FOLLOWS … 18 FR FOLEY WAS INSERTED …” There was no documentation to indicate the physician had ordered for the nurse to insert an 18 French urinary catheter for Patient #5 on this date in the written plan of care. Record review of a skilled nurse’s note, dated 04/30/26, signed by LVN G, indicated, “CATHETER CHANGE AS FOLLOWS … 18 FR FOLEY WAS INSERTED …” There was no documentation to indicate the physician had ordered for the nurse to insert an 18 French urinary catheter for Patient #5 on this date in the written plan of care. Record review of a skilled nurse’s note, dated 05/14/26, signed by LVN G, indicated, “CATHETER CHANGE AS FOLLOWS … 18 FR FOLEY WAS INSERTED …” There was no documentation to indicate the physician had ordered for the nurse to insert an 18 French urinary catheter for Patient #5 on this date in the written plan of care. Record review of the clinical record for Patient #5, for the time-period of 04/17/26 – 06/15/26, did not include a physician’s order for the nurse to insert an 18 French urinary catheter. During an interview conducted on 06/18/26 at 1:00 p.m., with Patient #5, when asked the size of urinary catheter he was ordered to receive by the physician, Patient #5 said the size was a twenty (French) and said he had used a sixteen in the past but there were problems with it getting blocked and the physician had increased it to a twenty. Patient #5 said he had no issues with the catheter becoming blocked since the catheter was changed to a twenty. During an interview conducted on 06/18/26 at 3:48 p.m., the QAPI Coordinator confirmed she was designated as the agency’s QAPI Coordinator. When asked if she had reviewed the patients’ clinical records for concerns with skilled nurses providing urinary catheter changes in accordance with the size of urinary catheter ordered by the physician in the written plan of care and/or physician orders, the QAPI Coordinator said she was not currently checking for the nurses’ compliance with the physician’s orders/written plan of care regarding size of urinary catheter to be used. During an interview conducted on 06/18/26 at 4:32 p.m., LVN G said the agency changed Patient #5’s urinary catheter every other week and they utilized an 18 French urinary catheter for the patient. LVN G said the agency had to change the urinary catheter frequently because it would get “clogged” with stones (deposits of minerals and salts that can crystalize and form into stones in the bladder) and sediment (solid particles in urine). When asked what the patient’s plan of care and physician’s orders indicated regarding the size of urinary catheter to be used for Patient #5, LVN G said she thought that it said to utilize an 18 French urinary catheter. LVN G said the patient had previously used a 16 French catheter and there were issues with it becoming blocked and so they increased the size to an 18 French. When advised the plan of care and physician’s orders indicated the patient was to receive a 20 French urinary catheter, LVN G said the patient’s order must have been increased to a 20 French. When asked if the agency could provide any supply orders for the catheters for Patient #5 that would show what size urinary catheter was used for the patient, LVN G said she just used the supplies in the office and no catheters were delivered to the patient so there would be no delivery or supply orders or receipts to show what size was used. When asked if the catheters were kept in separate spaces in the agency’s supply area by size or if they were mixed together and if she would be able to tell what size she had used when pulling the supplies, LVN G said the catheters were kept in separate spaces by size and she was “pretty sure” she had utilized the 18 French urinary catheter for Patient #5 because she had not realized that the order had changed to a 20 French. LVN G said she thought it was her mistake. During an interview conducted on 06/19/26 at 1:16 p.m., with the Administrator, when asked the agency’s policy regarding provision of care according to the written plan of care, the Administrator said staff were expected to provide care in accordance with the written plan of care and the physician’s orders. The Administrator said she did not know what size of urinary catheter was ordered for Patient #5. The Administrator said if the written plan of care and/or the physician’s orders indicated a 20 French urinary catheter was to be used she would expect the nurses to use a 20 French urinary catheter. The Administrator said the nurse who made the visit when the urinary catheter was inserted would be responsible for ensuring the correct size of urinary catheter as ordered by the physician in the written plan of care/physician’s orders was inserted. The Administrator said the agency did not have urinary catheter supplies delivered to patients’ homes and instead used supplies maintained at the agency’s office. The Administrator said the agency’s supplies of urinary catheters were separated by size and the nurse would be able to determine which size was selected when selecting a urinary catheter for a patient. When asked if the agency had a process in place to monitor to ensure the correct size of urinary catheter as ordered by the physician was utilized, the Administrator said the skilled nurse’s notes were reviewed by the agency’s QAPI Coordinator after they were submitted by the nurse who made the visit and the agency could add monitoring for correct size of urinary catheter to the list of things the QAPI Coordinator reviewed the skilled nurse’s notes for during her review but the agency was not checking for this as of the time of the interview. The Administrator said if the size of urinary catheter ordered to be used by the physician was to change the order would be documented in the patient clinical record and there was no other place the order would be documented. The Administrator said the agency’s policies regarding provision of care in accordance with the written plan of care were not followed for Patient #5 in that the size of urinary catheter ordered by the physician was not utilized by LVN G. The Administrator said she did not know the reason the ordered size was not utilized. The Administrator said there were potential outcomes to patients related to this failure in that use of the incorrect size of urinary catheter could result in infections or pain. During an interview conducted on 06/19/26 at 1:27 p.m., with the Alternate Administrator/Supervising Nurse, when asked regarding the agency’s policy regarding provision of care in accordance with the written plan of care, the Alternate Administrator/Supervising Nurse said the expectation was that the staff would follow the written plan of care and the physician’s orders. The Alternate Administrator/Supervising Nurse said the agency emailed all staff when the physician’s orders for a patient changed to ensure all staff were aware of changes and the expectation was the staff would provide care in compliance with the most recent order. When asked the size of urinary catheter ordered by the physician to be used by the agency nurses for Patient #5, the Alternate Administrator/Supervising Nurse said Patient #5 started with use of a 16 French urinary catheter and the patient had a lot of sediment and the size was increased to an 18 French. The Alternate Administrator/Supervising Nurse said then the size was increased again to a 20 French due to the amount of sediment in the patient’s urine and concerns of the catheter becoming blocked. When asked what size of urinary catheter was ordered to be used for Patient #5 during the visits on 04/20/26, 04/30/26, and 05/14/26, the Alternate Administrator/Supervising Nurse said a 20 French. The Alternate Administrator/Supervising Nurse said the nurse who made the visit and inserted the urinary catheter was responsible for ensuring the ordered size was used and said that the size used should be documented in the skilled nurse’s notes. When asked if the agency had a process to monitor to ensure the plan of care/physician’s orders regarding size of urinary catheter were followed, the Alternate Administrator/Supervising Nurse said the QAPI Coordinator should be checking the skilled nurse’s notes to ensure the nurses were following the orders regarding the urinary catheters and should notify him if there were concerns so he could address them. When advised the QAPI Coordinator said she had not been checking the notes for size of urinary catheter used, the Alternate Administrator/Supervising Nurse said he assumed the QAPI Coordinator had been monitoring for this, but she might not have been doing so. The Alternate Administrator/Supervising Nurse said the nurse making the visit and inserting the urinary catheter was responsible for reviewing the plan of care/physician’s orders before the visit and for providing care in accordance with the plan of care/physician’s orders. The Alternate Administrator/Supervising Nurse said the size of urinary catheter ordered by the physician should be documented in the written plan of care and/or the physician’s orders and included in the patient’s clinical record and there was nowhere else a physician’s orders for urinary catheter size would be documented. The Alternate Administrator/Supervising Nurse said the agency’s policies regarding provision of care in accordance with the written plan of care were not followed for Patient #5 in that the incorrect size of urinary catheter was inserted by LVN G. The Alternate Administrator/Supervising Nurse said he did not know the reason the incorrect size was used. The Alternate Administrator/Supervising Nurse said the agency did not have urinary catheter supplies delivered to patients’ homes and kept a supply of urinary catheters in the agency’s office. The Alternate Administrator/Supervising Nurse said the urinary catheters were separated by size and the nurse selecting a urinary catheter to be used should be able to tell what size she had selected. The Alternate Administrator/Supervising Nurse said there was a potential outcome to the patient related to this failure in that if a smaller size of urinary catheter than ordered by the physician was utilized it could create a higher risk of infection due to increased sediment and crystals in Patient #5’s urine. Record review of an agency policy titled, “Plan of Care (POC),” dated 1Q/2008, indicated, “Each patient receiving skilled home health agency service will have a plan of care (POC) individualized to meet his/her needs. Each ordered discipline will provide services according to accepted professional standards and physician orders … Clinical services are implemented only in accordance with the POC …””