Relief Home Healthcare Services Inc.

“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, record reviews and interviews, the agency failed to ensure the patients’ plan of care was complete and included all required elements for 1 (Patient 3) of 1 patient who had received a kidney transplant and whose AV shunt remained in the left arm. The POC did not include instructions for the SN to avoid blood draws and BP readings from the left arm. This failure potentially placed the patient at risk of infection, blood clotting and damage to the AV shunt and surrounding tissue when the SN did not have instructions to avoid the patients’ left arm for blood draws and BP checks. FINDINGS INCLUDE: Lippincott Procedures- Hemodialysis access care, home care, revised 2020, “ … the access site should be assessed for swelling, change in color or temperature, drainage, auscultated (listen with a stethoscope) for the presence of a bruit (a “whooshing” sound) and palpated (felt) for a thrill (vibration sensation). Never measure the patient’s blood pressure on the extremity with the AV access. …” Nurseslabs.com/hemodialysis-nursing-care-plans, April 30, 2024, “… 1. Promoting Safety and Preventing Injury Risk, … 8. Avoid trauma to shunt. … Avoid taking BP or drawing blood samples in the shunt extremity. …” Patient #3: Record review revealed a POC dated 01/06/2025-03/06/2025 with a SOC 11/07/2024, electronically signed by the RN A on 01/04/2025. The POC included the following diagnoses: Chronic kidney disease/ESRD (condition where the kidneys can no longer filter toxins or remove excess water from the blood) and DM-2 (condition where the pancreas has trouble controlling blood sugar). Physician orders included, “… SN frequency once a week for nine weeks … post kidney transplant ... SN to assess AV shunt for patency and function every visit. Report complications to physician. …” Review of the record did not reveal any additional physician orders for a SN to avoid blood draws and BP checks from the patient’s left arm where the AV shunt access site was located. The POC did not include instructions for the SN to avoid blood draws and BP checks from the left arm for Patient #3. A Comprehensive assessment, dated 01/03/2025, completed by RN A, included, “… INTEGUMENTARY STATUS, … Comments: PATIENT SHE [sic] STILL HAVE AV SHUNT TO HER LEFT ARM, SAID HER KIDNEY DR /HOSPITAL LEFT IN PLACE EVEN AFTER HER KIDNEY TRANSPLANT. … Admission Summary … POST KIDNENY [SIC] TRANSPLANT- 06/17/2024. …” During a home visit interview with Patient #3 on 04/03/2025 at 1:00 PM, the surveyor asked about the care and services received by the agency and staff nurses. Patient #3 stated the Nurse (Administrator, LVN) visited once a week and the RN visited about every 6-8 weeks. Patient #3 stated, “they check my blood sugar and vital signs (including BP), check my feet and skin and the (AV) shunt.” The surveyor asked about the AV shunt site, the kidney transplant and if she had any problems or complications. Patient #3 stated she had the kidney transplant in June 2024 and developed a blood clot in her groin area in September 2024. She had been in and out of the hospital many times. She stated the transplant doctor told her they would keep the A/V shunt in her left arm at this time and she wasn’t sure when they planned to remove it. She stated she had a PICC line (soft tube inserted in the vein, used to deliver medications and other treatments) in the hospital and briefly at home for antibiotics and lab work draws, but it was removed “a while ago.” In an interview with the Administrator/LVN A on 04/08/2025 at 2:35 PM, the surveyor reviewed the findings and the POC. The surveyor asked why the POC did not include instructions for the SN to avoid using the patient’s left arm blood draws and BP checks. The Administrator/LVN A stated, “I do check for the bruit (whooshing sound) and thrill (vibration sensation) with a stethoscope (used to listen to internal sounds), but it should have been on the POC to not do lab draws or BP checks from the left arm.” The surveyor asked how this problem could affect the patient. The Administrator/LVN A stated, “the labs or BP checks could be done on the left side (arm) without knowing and they (SN) could get a wrong BP reading or damage the shunt.” In a phone interview with the Administrator/LVN A and RN A on speaker, on 04/08/2025 at 3:30 PM, the surveyor reviewed the findings and the POC. The surveyor asked why the POC did not include instructions for the SN to avoid the left arm for blood draws and BP checks. RN A stated, “I don’t think I put it on there, if it’s not there. The patient said it was to be removed, that’s why it wasn’t included.” The Administrator/LVN A stated the patient did not mention removal of the AV shunt during her weekly visits. Agency policy, quoted in part, “C 580 PLAN OF CARE/REVIEW/REVISION, POLICY, … The individualized plan of care will specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, … services will be furnished in accordance with accepted standards of practice. PURPOSE: To provide guidelines for agency staff to develop a plan of care individualized to meet specific identified needs. … SPECIAL INSTRUCTIONS: … 3. The individualized plan of care will include the following: … (xiv) Patient-specific interventions and education; …””

“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, record review and interviews, the agency failed to provide the patient and caregiver with written information outlining medication instructions to include: the medication name, dosage and frequency and which medications would be administered by the HHA personnel for 3 (Patients # 1, 2 and 3) of 3 patients whose home folders were reviewed during home visits. This failure potentially placed the patients at risk of missed, incorrect or contraindicated medication management when the patient self-administered their medications. FINDINGS INCLUDE: Patient #1: Record review revealed a POC dated 02/02/2025-04/02/2025 with a SOC date 02/08/2024. The POC included the following diagnoses: UTI (infection in the kidneys, bladder or uretha); Muscle weakness; High blood pressure and history of respiratory failure with pneumonia (lung infection with fluid). Physician orders included, “… SN frequency once a week for nine weeks. …” Review of the record revealed no evidence that medication instructions had been provided to Patient #1. During a home visit interview with Patient #1 and her family member/caregiver, Identifier B on 04/03/2025 at 12:15 PM, the surveyor reviewed the patients’ home folder that was given to the patient by the agency and asked if anything had been removed or placed in another location. Patient #1 stated, “it’s all there.” The surveyor reviewed the documents in the home folder and asked if the nurse who visited had given the patient a medication list with directions about her medications. Identifier B stated he knew what (medications) she (Patient #1) took and that there was no written list and the patient recently took antibiotics for a UTI. Identifier B stated, “I set up her (patient’s) medications and order the refills. The nurse checks the meds (medications) when she comes weekly.” Patient #2: Record review revealed a POC dated 01/23/2025-03/24/2025 with a SOC 10/02/2023. The POC included the following diagnoses: UTI; Seizures (sudden, temporary disruptions of normal brain activity, potentially causing changes in behavior, movement or awareness) and severe intellectual disabilities. Physician orders included, “… SN frequency once a week for nine weeks. …” Review of the record revealed no evidence that medication instructions had been provided to Patient #2. During a home visit interview with Patient #2 and her family member/caregiver, Identifier C on 04/03/2025 at 11:00 AM, the surveyor reviewed the patients’ home folder that was given to the patient by the agency and asked if anything had been removed or placed in another location. Identifier C stated the patient was non-verbal, except for noises and that she could answer for the patient. Identifier C stated, “everything is in there (the home folder).” The surveyor reviewed the documents in the home folder and asked if the agency nurse had given the patient/Identifier C a medication list with directions about the patients’ medications. Identifier C stated she knew the meds (medications) and gave the patient all her medications because the patient had trouble swallowing certain things. All the medications were crushed and the vitamins were given with yogurt. Identifier C stated the nurse visited weekly and checked the meds if needed. Patient #3: Record review revealed a POC dated 01/06/2025-03/06/2025 with a SOC 11/07/2024. The POC included the following diagnoses: Chronic kidney disease/ESRD (condition where the kidneys can no longer filter toxins or remove excess water from the blood) and DM-2 (condition where the pancreas has trouble controlling blood sugar). Physician orders included, “… SN frequency once a week for nine weeks … post kidney transplant ... .” Review of the record revealed no evidence that medication instructions had been provided to Patient #3. During a home visit interview with Patient #3 on 04/03/2025 at 1:00 PM, the surveyor reviewed the patients’ home folder that was given to the patient by the agency and asked if anything had been removed or placed in another location. Patient #3 stated, “it’s all in there.” The surveyor reviewed the documents in the home folder and asked if the nurse who visited had given the patient a medication list with directions about her medications. Patient #3 stated, “I have a med (medication) list from the doctor, but not from the nurse.” Patient #3 showed the surveyor the printed medication list from the doctor. The surveyor asked if patient used a medication reminder for the week or self- administered her medications directly from the bottle. Patient #3 stated the SN helped her set up a weekly reminder med (medication) box. In an interview with the Administrator/LVN on 04/08/2025 at 2:35 PM, the surveyor reviewed the findings and asked why Patient’s #1, #2 and #3 were not given a list or written information of their medications. The Administrator/LVN stated, “I have my med (medication) list that I carry with me when I make home visits to the patient’s.” The surveyor asked why the patients weren’t provided a medication list by an agency nurse. The Administrator/LVN stated, “I don’t know, I have mine that I take to the patients’ home when I do home visits.” The surveyor asked if the Administrator/LVN was aware the patients were supposed to be provided a written list of medications from the agency. The Administrator/LVN stated she was not aware. The surveyor asked what could happen if the patients didn’t have a written medication list. The Administrator/LVN stated, “they may not know what they have on their bottles or what they’re taking.””