Brema Healthcare Inc.

“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 reviews and interviews, the Agency failed to make sure that the patients were receiving the care that was ordered in their plan of care in 4 of 13 current patient’s records reviewed. Citing Patient # 1, Patient #4, Patient #10 and Patient # 11. This failure could result in the patient not having adequate care and could lead to negative patient outcomes. Findings: Patient #1 Review of Patient #1’s EMR revealed a plan of care with a certification period of 11/13/2024 - 1/11/2025. Review of this plan of care revealed orders that read, in part, “...Notify physician of...Diastolic blood pressure greater than 90 or less than 60...” Further review of Patient #1’s EMR revealed a nursing noted dated 11/26/2024. This note was signed by RN A. This note revealed a blood pressure of 151/92. Nowhere in this nurse’s note was it indicated that the physician was notified of the elevated diastolic blood pressure. Further review of Patient #1’s EMR revealed a nursing note dated 11/29/2024. This note was signed by RN A. This note revealed a blood pressure of 148/98. Nowhere in this nurse’s note was it indicated that the physician had been notified of the elevated diastolic blood pressure. Patient #4 Review of Patient #4’s EMR revealed a plan of care with a certification period of 10/26/2024 - 12/24/2024. Review of this plan of care revealed orders that read, in part, “...Notify physician of pulse greater than 100 or less than 60...” Further review of Patient #4’s EMR revealed a nursing note dated 11/8/2024. This note was signed by LVN A. The note revealed a pulse of 55 beats per minute. Nowhere in this nurse’s note was it indicated that the physician had been notified of the low pulse. Patient #10 Review of Patient #10’s EMR revealed a plan of care with a certification period of 11/5/2024 - 1/3/2025. Further review of Patient #10’s EMR revealed orders that read, in part, “...Notify physician of diastolic blood pressure greater than 90 or less than 60...” Further review of Patient #10’s EMR revealed a nursing note dated 11/14/2024. The note was signed by LVN A. The note revealed a blood pressure of 92/55. Nowhere in the nurse’s note was it indicated that the physician had been notified of the low blood pressure. Patient #11 Review of Patient #11’s EMR revealed a plan of care with a certification period of 11/8/2024 - 1/6/2025. Further review of Patient #11’s EMR revealed orders that read, in part, “ Notify physician of diastolic blood pressure greater than 90 or less than 60...” Further review of Patient #11’s EMR revealed a nurses note dated 11/21/2024. The note was signed by LVN A. The note revealed a blood pressure of 117/57. Nowhere in the nurse’s note was it indicated that the physician had been notified of the low blood pressure. A telephone interview was conducted with LVN A on 12/16/2024 at approximately 1:50 p.m. The surveyor inquired as to why the physician had not been notified regarding the vital signs of Patient #4, Patient #10 and Patient #11 that were out of the bounds of the parameters as the physician had ordered. LVN A inquired if the surveyor was allowed to call and ask these questions. LVN A then stated, “...I usually call the doctor and put it in a communication note. I forgot to document it but he was notified...” On 12/16/2024 at approximately 1:35 p.m. a telephone call was made to RN A at 219-276-XXXX. There was no answer and the call went to voice mail. The surveyor requested that RN A call her back at 817-614-XXXX. RN A did not return the surveyor’s call by the end of the survey. An interview was conducted with the Director of Nursing and with the Administrator on 12/16/2024 at approximately 1:20 p.m. The above findings were reviewed. The surveyor inquired as to why RN A and LVN A did not follow the plan of care by notifying the physician of the vital signs that were out bounds of the parameters as ordered by the physician. The Director of Nursing stated, “...We do have a QA Company. QA should notify the nurse...” The surveyor inquired if this was something the Director of Nursing should be following. The Director of Nursing stated, “Yes. But I don’t see anything unless the nurse tells me...” The surveyor inquired as to whose responsibility it is to make sure the nurses are following the plan of care. The Director of Nursing stated, “...Mine...” Review of the policy titled “Responsibilities of the Clinical Manager – Addendum, LD.30-TX Page 1 of 1, HCL Last Reviewed: 041423” read, in part, “...Policy The Supervising Nurse, appointed by the Administrator, is responsible for the daily direction of patient/client care and participates in activities relevant to professional services furnished. Procedure A. The responsibilities of the Supervising Nurse include but are not limited to: 2. Ensuring that a patient’s/client’s Plan of Care or care plan is executed as written...””

“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 record reviews, interviews and home visits, the agency failed to ensure that patients were provided with a visit schedule in 5 of 5 home visits conducted. Citing Patient #1, Patient #3, Patient #4, Patient #7 and Patient #18 This failure could prevent the patient and personnel from being aware of the patient’s schedule and could cause scheduling conflicts and missed visits leading to poor patient outcomes. Findings: Patient #1 Review of the EMR for Patient #1 revealed a plan of care with a certification period of 11/13/2024 - 1/11/2025. Further review of the plan of care revealed orders for the Skilled Nurse to visit 1 time a week for 9 weeks, Home Health Aide to visit 3 times a week for 9 weeks, Physical Therapy to evaluate and treat and Occupational Therapy to evaluate and treat. A home visit was conducted with Patient #1 on 12/12/2024. During the visit, the surveyor reviewed Patient #1’s admission packet. There was no dated or filled out visit schedule in the admission packet and there was no dated or filled out visit schedule anywhere in the patient’s immediate surroundings. An interview was conducted with Family Member #1 on 12/12/2024 at approximately 9:45 a.m. The surveyor inquired if the agency ever filled out a visit schedule. Family Member #1 stated “No.” The surveyor inquired how Family Member #1 knew when agency staff were going to visit. Family Member #1 stated “... They call the night before...” Patient #3 Review of the EMR for Patient #3 revealed a plan of care with a certification period of 11/21/2024 - 1/19/2025. Further review of the plan of care revealed orders for the Skilled Nurse to visit 1 time per week for 9 weeks and for Physical Therapy to evaluate and treat. A home visit was conducted with Patient #3 on 12/12/2024. During the visit, the surveyor reviewed Patient #3’s admission packet. There was no dated or filled out visit schedule in the admission packet and there was no dated or filled out visit schedule anywhere in the patient’s immediate surroundings. An interview was conducted with Patient #3 on 12/12/2024 at approximately 10:45 a.m. The surveyor inquired if the agency ever filled out a visit schedule. Patient #3 stated “No.” The surveyor inquired how Patient #3 knew when agency staff were going to visit. Patient #3 stated “... They contact me the night before...” Patient #4 Review of the EMR for Patient #4 revealed a plan of care with a certification period of 10/26/2024 - 12/24/2024. Further review of the plan of care revealed orders for the Skilled Nurse to visit 1 time per week for 9 weeks and for Physical Therapy to evaluate and treat. A home visit was conducted with Patient #4 on 12/13/2024. During the visit, the surveyor reviewed Patient #4’s admission packet. There was no dated or filled out visit schedule in the admission packet and there was no dated or filled out visit schedule anywhere in the patient’s immediate surroundings. An interview was conducted with Family Member #2 on 12/13/2024 at approximately 12:15 p.m. The surveyor inquired how Family Member #2 knew when agency staff were going to visit. Family Member #2 stated, “...Physical Therapy and the nurses would text me...” Patient #7 Review of the EMR for Patient #7 revealed a plan of care with a certification period of 11/8/2024 - 1/6/2025. Further review of the plan of care revealed orders for the Skilled Nurse to visit 1 time per week for 9 weeks, Physical Therapy to evaluate and treat and Occupational Therapy to evaluate and treat. A home visit was conducted with Patient #7 on 12/13/2024. During the visit, the surveyor reviewed Patient #7’s admission packet. There was no dated or filled out visit schedule in the admission packet and there was no dated or filled out visit schedule anywhere in the patient’s immediate surroundings. An interview was conducted with Patient #7 on 12/12/2024 at approximately 10:50 a.m. The surveyor inquired how Patient #7 knew when agency staff were going to visit. Patient #7 stated, “...They call me...” Patient #18 Review of the EMR for Patient #18 revealed a plan of care with a certification period of 11/5/2024 - 1/3/2025. Further review of the plan of care revealed orders for the Skilled Nurse to visit 2 time per week for 9 weeks. A home visit was conducted with Patient #18 on 12/12/2024. During the visit, the surveyor reviewed Patient #18’s admission packet. There was no dated or filled out visit schedule in the admission packet and there was no dated or filled out visit schedule anywhere in the patient’s immediate surroundings. An interview was conducted with Patient #18 and Family Member #3 on 12/12/2024 at approximately 12:00 p.m. The surveyor inquired how Patient #18 knew when agency staff were going to visit. Family Member #3 stated “...generally they just call...” An interview was conducted with the agency Administrator on 12/16/2024 at approximately 1:45 p.m. The surveyor inquired as to why there were no 9 day planners completed and placed in patient’s homes. The Administrator stated, “...We didn’t know...” The surveyor inquired as to whose responsibility it was to know and to make sure the 9 day planners were completed and placed in the patient’s homes. The Administrator stated, “...It’s mine...” Review of the policy titled “Implementing Care and Treatment, PC.40, Page 2 of 4, Last Reviewed 080120” , read, in part, “...VI. Written information to the patient/client. A. The Agency must provide the patient/client and caregiver with a copy of written instructions outlining: 1. Visit schedule, including frequency of visits by agency personnel and personnel acting on behalf of the agency.”