Elara Caring

“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 record review and interview, the agency failed to ensure a patient received home health services as ordered in the individualized POC in two of seventeen patient records reviewed (Patient 1 and 3) in that: In one of one record reviewed (Patient 1) where the patient had a urinary catheter [a hollow flexible tube that is used to continually drain urine from the bladder], urinary catheter orders were not followed. In one of one record reviewed (Patient 3) where the patient had pressure ulcers [localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction] and heart failure, wound care and heart failure orders were not followed. This failure placed patients at risk of complications and a decline in health status. Findings Include: Patient 1: Record review of the medical record included a POC dated 09/28/2023 to 11/26/2023 signed by RN A and RN B on 09/25/2023. The POC included a diagnosis of fitting and adjustment of urinary device [foley catheter: a flexible tube that is inserted through the urethra to help drain urine from the bladder. It is a type of indwelling catheter, meaning one that is kept in place so that urine is continuously drained from the bladder]. The POC read in part, “…skilled nurse for O/A, teaching and self-management related to heart failure…Weight to be obtained every nurse visit and weight gain of 2 lbs overnight or 5 lbs in 1 week to be reported to physician. If unable to weigh patient, skilled nurse to obtain measurement of calf in cm at each visit and report an increase of 1 cm to physician…skilled nurse for indwelling urinary catheter management. Foley catheter insertion with 18 Fr catheter with 10 ml balloon…” The record included a skilled nursing visit conducted on 10/05/2023 by LVN B that read in part,“…Genitourinary…catheter-indwelling…Pt had an indwelling foley catheter change during this visit foley cath changed using sterile technic (sic), 16 Fr foley inserted…Interventions provided…1…performed catheter change. 16Fr…” The record included a skilled nursing visit conducted on 11/02/2023 by LVN A that read in part,“…Genitourinary…catheter-indwelling…foley catheter changed using sterile technic 16 F catheter inserted…Interventions provided…2…performed catheter change. 16F…” LVN B was a former employee and not interviewed. During an interview with LVN A on 01/16/2024 at 4:27 PM, the surveyor asked why a 16 Fr urinary catheter was used instead of the ordered 18 Fr catheter. LVN A stated Patient 1’s catheter was leaking and an 18 Fr catheter was not available so a 16 Fr was inserted instead. During an interview with the Alt Adm/DON on 01/17/2024 at 1:07 PM, the surveyor asked why LVN A and B used a 16 Fr urinary catheter instead of the ordered 18 Fr catheter. The Alt Adm/DON stated the LVN’s should have called and received an order from the doctor to use a 16 Fr catheter. The Alt Adm/DON stated the agency had educated the nurses on the issue and it was included in an action plan in the agency’s 2nd quarter QAPI documents. Patient 3: Record review of the medical record included a POC dated 09/25/2023 to 11/23/2023 signed by RN B and RN D on 09/23/2023. The POC included a diagnosis of Stage 4 pressure ulcer to left and right buttock [the most serious pressure ulcers with a high infection risk that extend into deep tissues, including muscle, tendons, and ligaments. In more severe cases, they can extend as far down as the cartilage or bone], heart failure, incomplete quadriplegia [weakness or paralysis of all four limbs], complete paraplegia [a type of paralysis that affects both legs], absence of the left leg below the knee and tracheostomy [a hole surgeons make through the front of the neck and into the windpipe to help with breathing when the usual route for breathing is somehow blocked or reduced]. The POC read in part, “…Skilled nurse to assess patient’s skin integrity and instruct patient/caregiver on measures to prevent pressure ulcers. Wound care order…(Monday, Wednesday and Friday & as needed if dislodged, saturated or soiled) take down outer foam dressing and do not disturb inner gauze & tapes for the whole weekclean (sic) peri-wound [skin around the wound that has been affected by the wound] site with saline, pat drycover (sic) with a new foam dressing left…wound care order (Monday, Wednesday and Friday & as needed if dislodged, saturated or soiled) take down old dressingclean (sic) site with wound wash, pat dryapply (sic) Mupirocin [used to treat skin infections] & Gentamycin [used to treat skin infections] ointments to wound bedcover (sic) with hydrofera [a foam wound care dressing] & a foam dressingsecure (sic) with silicone tapes…CG to perform wound care on non skilled nursing days…skilled nurse for O/A…related to heart failure…weight to be obtained and weight gain of 2 lbs overnight or 5 lbs in 1 week to be reported to physician. If unable to weigh patient, skilled nurse to obtain measurement of in (sic) cm at each visit and report an increase of 1 cm to physician…” The record included a physician order dated 10/02/2023 that read in part, “…New wound care order received…bilateral sacral wound care order (Monday, Wednesday and Friday as well as needed when dislodged, saturated or soiled) Take down old dressing clean site with wound wash, pat dry soak wound bed with wound wash, pat dry soak wound bed with gauzes saturated with Dakin solution [used to prevent and treat skin and tissue infections that could result from pressure sores] cover with collagen saturated with Dakin solution and a foam dressing secure with silicone tapes…” The record included a physician order dated 10/16/2023 that read in part, “…New wound care order received…bilateral sacral wound care order (Monday, Wednesday and Friday as well as needed when dislodged, saturated or soiled) Take down old dressing clean site with wound wash, pat dry apply Mupirocin and Gentamycin ointments cover with Prisma [absorbs drainage] and a foam dressing secure with silicone tapes…” The record included a physician order dated 10/23/2023 that read in part, “…Order is to be followed as below bilateral sacral wound care order (Monday, Wednesday and Friday) as well as needed when dislodged, saturated or soiled) Take down old dressing clean site with wound wash & pat dry apply Mupirocin and Gentamycin ointments cover with Prisma and a foam dressing Patient (sic) the macerated area [occurs when the skin is exposed to moisture for a prolonged period of time] with betadine [used on the skin to treat or prevent skin infection] secure with silicone tapes…” The record included a physician order dated 11/13/2023 that read in part, “…bilateral sacral wound care order (Monday, Wednesday and Friday) as well as needed when dislodged, saturated or soiled) Take down old dressing clean site with wound wash & pat dry apply Mupirocin and Gentamycin ointments cover with Promogram prisma matric AG silver [a sterile freeze-dried dressing] and a foam dressing paint the macerated area with betadine secure with silicone tapes…” The record included eight skilled nursing visits conducted by LVN A on 09/29/2023, 10/02/2023, 10/09/2023, 10/16/2023, 10/23/2023, 10/30/2023, 11/06/2023, and 11/13/2023. The eight visit notes did not include weights or measurements in cm. During an interview with LVN A on 01/16/2024 at 4:32 PM, the surveyor asked why weights or measurements were not obtained on any of the eight visits as ordered on the POC. LVN A stated she did not see the order on the POC. During an interview with the Alt Adm/DON on 01/17/2023 at 1:18 PM, the surveyor asked why weights or measurements were not obtained on visits made by LVN A as ordered on the POC. The Alt Adm/DON stated the agency implemented an action plan for following the POC. The record included a skilled nursing visit conducted on 11/20/2023 by RN C. The visit note did not include a weight or measurement in cm. The visit note included documentation of three wounds: Wound labeled #2: Stage 4 pressure ulcer right buttock; Wound labeled #12: Stage 4 pressure ulcer to left buttock and Wound labeled #13: Stage 3 pressure ulcer [involves the full thickness of the skin and may extend into the subcutaneous tissue layer] to right buttock. The visit note read in part, “…wound #2…wound care not provided: caregiver completed care… wound #12…wound care not provided: caregiver completed care… wound #13…wound care not provided: caregiver completed care……Narrative…wound care completed by spouse…” During an interview with RN C on 01/16/2023 at 4:44 PM, the surveyor asked why wound care was not done for the three wounds on the 11/20/2023 visit. RN C stated because Patient 3’s husband had already done the wound care. During an interview with the Alt Adm/DON on 01/17/2023 at 1:24 PM, the surveyor asked why RN C did not do wound care for the three wounds. The Alt Adm/DON stated Patient 3’s husband did wound care on the days an agency nurse was not there. QAPI documents given to the surveyor included pages that were unreadable and did not print correctly. Permission was granted to the agency to submit documentation after the exit conference of the actions they took in their QAPI meetings to correct the identified problems. During an interview with the Adm/ADON and Alt Adm/DON on 01/23/2023 at 2:33 PM, the Adm/ADON stated the agency provided extensive education with clinicians and action plans included in QAPI reports had been developed to correct deficient practices, including following the POC. In emails with the Adm/ADON on 01/18/2024, the Adm/ADON reported QAPI for the 2nd Quarter 2023 was reviewed and action plans initiated with employees on 09/21/2023. The Adm/ADON reported QAPI for the 3rd Quarter 2023 was reviewed and action plans initiated with employees on 12/18/2023. The Adm/ADON reported items on the QAPI reports with a threshold of 80% or less had an action plan initiated that included resources for staff education. The Adm/ADON reported an action plan for the POC/485 had been implemented for the 2nd and 3rd Quarter 2023 due to a threshold of less than 80%. 2nd Quarter QAPI: Record review of the 2nd Quarter 2023 (April, May, June) agency QAPI documents read in part, “… POC/485… Are interventions related to skilled procedures (e.g., wound care…) present in the order(s) and provided as ordered...” The threshold for POC/485 interventions was 30% out of 100%; therefore, a POC/485 action plan was initiated. The QAPI documents included an In-Service/Education Program dated 09/21/2023 presented by the Alt Adm/DON that read in part, “… Type of in-service… meeting/case conference… Program material presented… Wound Care… documentation… QAPI review of 2nd quarter…” Attendees included on the in-service record included RN A, RN C and LVN A. The agency initiated a 2nd quarter action plan due to 30% out of 100% threshold for POC/485 interventions. The 2nd quarter action plan for the POC/485 was initiated with staff on 09/21/2023 but was not followed by LVN B on the 10/05/2023 nursing visit and LVN A on the 11/02/2023 nursing visit for Patient 1. The action plan was not followed by LVN A at nursing visits on 09/29/2023, 10/02/2023, 10/09/2023, 10/16/2023, 10/23/2023, 10/30/2023, 11/06/2023, and 11/13/2023 and by RN C at the nursing visit on 11/20/2023 for Patient 3. 3rd Quarter QAPI: Record review of the 3rd Quarter 2023 (July, August, September) agency QAPI documents included Patient 3’s medical record was reviewed as part of the quarterly audit. The review included information for Patient 3’s prior certification period dated 05/28/2023-07/26/2023. The QAPI documents for Patient 3 read in part, “… POC/485… Are all interventions that are ordered on the plan of care provided as ordered… Patient is bedbound, unable to weigh. Left BKA. Not sure if left calf is available to measure. CHF interventions on POC document measure each calf every SNV and notify MD if calf measurement increases in size by 1 cm. 5/28 SOC = no calf measurement documented… 6/2, 6/3, 6/5, 6/9, 6/13, 6/19, 6/26, 7/6, 7/10, 7/17 SNV = no calf measurements documented… 7/24/2023 recert [an RN visit required for continuous home health after an initial 60 day episode of care] = no calf measurement documented… If unable to measure calf then documentation should be on the record as to the reason calf measurements not obtained every SNV… Specific wound care/frequency should be added to the POC to ensure wound care performed as orders, prevention of complications/hospitalizations…” The threshold for POC/485 interventions related to POC/485 was 70% out of 100%; therefore, a POC/485 action plan was initiated. The QAPI documents included an In-Service/Education Program Record dated 11/01/2023 presented by the Alt Adm/DON that read in part, “… Type of in-service… meeting/case conference… Program material presented… Quality Education Presentation Quarter QAPI review – resources provided…” Attendees included on the in-service record included RN C and LVN A. The agency initiated a 3rd Quarter 2023 action plan due to a continued threshold below 80% for POC/485 interventions. The threshold was 70% out of 100%. During an interview with the Alt Adm/DON on 01/17/2023 at 1:24 PM, the surveyor asked why issues identified in action plans had continued from quarter to quarter. The Alt Adm/DON stated the agency had done extensive education and training with newly hired nurses and documentation had improved. Agency policy titled SHH.075 Plan of Care with an effective date of 09/09/2020 read in part, “1. Policy Overview… Planning for care is a dynamic process that addresses the care, treatment and services to be provided. 2. Purpose: To provide guidelines for agency staff to develop a plan of care individualized to meet specific identified needs… Procedures… 7. Orders for services shall include the specific procedures and modalities to be used and the amount, frequency, and duration… 12. Professional staff shall promptly alert the physician or allowed practitioner to any changes that suggest a need to alter the Plan of Care. 13. Verbal/telephone orders shall be obtained from the client’s physician or allowed practitioner for changes in the Plan of Care…” Agency policy titled SHH.073 Physician Orders with an effective date of 06/21/2021 read in part, “1. Purpose… To document verification that orders for services have been obtained from the physician or allowed practitioner. To assure accurate and complete orders are obtained and verified… 2. Policy: All medications, treatments and services provided to clients must be ordered by a physician or allowed practitioner…” Agency policy titled SHH.028 Clinical Manager with an effective date of 11/12/2020 read in part, “… Policy… 3. The Clinical Manager(s) (Director of Nurses in Louisiana) must provide oversight of all client care services and personnel. Oversight must include the following… e. Assuring the development, implementation and updates of the individualized plan of care…””