Texas Family Choice 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 record review and interview, the agency failed to ensure all patients received home health services as ordered in the individualized POC. One (Discharged Patient #1) of 1 patient record was reviewed for wound care. The SN applied a different cleanser to the wound than was ordered by the physician. This failure potentially placed the patient at risk of infection and a decline in the patients’ wound status. FINDINGS: Patient #1: Review of the record revealed a POC dated 04/17/2021-06/15/2021 with a SOC date 08/20/2020. The POC listed the diagnoses diabetes and a wound to the left heel. The physician ordered SN visits once a week for nine weeks and wound care every visit. The wound care included, “cleanse wound with NS ….” A SN visit note dated 06/09/2021 completed by the AA/DON included, “… Patient visited wound clinic on yesterday received new orders for wound care… SN cleansed wound with betadine ….” A SN visit note date 06/11/2021 completed by the AA/DON included, “… Patient visited wound clinic 06/10/21 received new orders for wound care… SN cleansed wound with betadine….” Review of the entire patient record did not reveal any physician orders received that included cleansing the wound with Betadine. Patient #1 was discharged from the agency 06/15/2021. In an interview with the Administrator and the AA/DON on 02/09/2024 at 10:20 AM, the surveyor reviewed the findings and asked if the agency had any additional documentation or physician orders for Patient #1’s record. The Administrator stated all the documentation for the patients had been uploaded into the EHR system, no additional documentation was retained in paper charts. The surveyor asked the AA/DON why she did not follow the physician order and cleanse the wound with normal saline during the SN visits 06/09/2021 and 06/11/2021. AA/DON stated she didn’t remember using the betadine and stated, “but if that’s what I wrote….” The surveyor asked if there was a physician’s order for cleansing the patients’ wound with betadine. AA/DON stated she didn’t remember. She stated the wound healed up. Agency Policy, dated 01/13/2018, quoted in part, “PLAN OF CARE, TX.6, … PROCEDURE: … III. Each patient/client must receive an individualized written plan of care, including any revisions or additions. The individual plan of care must specify the care and services necessary to meet the patient/client-specific needs as identified in the comprehensive assessment… A. The individualized plan of care must include the following: … 10. All medications and treatments; … IV. All patient/client care orders, including verbal orders, must be recorded in the plan of care…. VIII. Drugs, services, and treatments are administered only as ordered by a physician….””

“Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure proper written notice was provided in advance of terminating care for 1 (Patients #1) of 1 patient who was discharged with “Goals Met.” The agency failed to provide the patient with the CMS form titled, “Notice of Medicare Non-Coverage.” Failure to provide notice of discharge potentially prevented the patient from adequately planning for health care needs after discharge from the agency. FINDINGS INCLUDE: Patient #1: Review of the record revealed a discharge summary dated 06/15/2021 completed by the Alternate Administrator/DON. The summary listed the reason for discharge, “Goals met.” A review of the entire clinical record did not contain a written notification of discharge. During an interview with the Administrator and the AA/DON on 02/09/2024 at 10:20 AM, the surveyor reviewed the findings and asked if the agency had any additional discharge documentation for Patient #1. The Administrator stated all the documentation for the patients had been uploaded into the EHR system, no additional documentation was retained in paper charts. The surveyor asked why the agency did not provide the Medicare written discharge notice at least two days in advance of discharge to Patient #1. The AA/DON stated she made the visit and did the (discharge) assessment but she did not remember if she took a (discharge) paper with her to the visit. The Administrator stated the agency nurses took the discharge paperwork with them when they did the discharges with the patients. The Administrator reviewed the patient record in the EHR system and stated she did not see any discharge notices and did not know what happened to it. Agency policy, dated 08/08/2020, quoted in part, “PATIENT/CLIENT TRANSFER AND DISCHARGE NOTICES, PE.6, … PURPOSE: To provide guidance on completion of the required transfer and discharge notices. POLICY: … II. The Agency will provide notice to eligible patients/clients of their right to expedited determinations when their period of covered care ends. III. The Agency will deliver the Notice of Medicare Non-Coverage… to the patient/client… at least two (2) calendar days before Medicare covered services end or the second to last day of service if care is not provided daily… PROCEDURE: … S. The Agency will retain a copy of all completed NOMNC’s given to patients/clients in their records….””

“Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on record review and interviews, the agency failed to ensure effective coordination of care between the agency and the physician for 1 (Patient #4) of 1 client who reported a change in condition and was discharged. This failure potentially placed the patient at risk of a decline in health status and risk of falls when interventions were not implemented. FINDINGS INCLUDE: Patient #4: Record review revealed a POC dated 01/10/2021-03/10/2021 with a SOC date 11/11/2020. The POC included, “… Risk for Hospitalization: History of falls (2 or more falls – or any fall with an injury – in the past 12 months) …” A comprehensive reassessment was completed on 01/09/2021, by the RN, former Employee A. On page 16, RN A documented, “… Gait continues to be unsteady. Now uses a cane for ambulation when inside the house at times. This is a change from last benefit period….” A SN visit note written on 01/13/2021, by RN A included, “… Comment: No falls since last visit. Patient states that she has been losing her balance more easily lately….” A comprehensive discharge assessment was completed on 02/10/2021, by the AA/DON and included, “… DISCHARGE INSTRUCTIONS: Patient requested discharged to physician caregiver and self. Patient did not give a reason….” Review of the entire client’s record revealed no documented coordination of care with the patient’s physician regarding a change in condition prior to discharge. During an interview with the Administrator and AA/DON on 02/09/2024 at 10:20 AM, the surveyor reviewed the findings and asked if the agency had any documentation of coordination of care with the physician regarding a change in condition for Patient #4. The Administrator stated all the documentation for the patients had been uploaded into the EHR system, no additional documentation was retained in paper charts. The surveyor asked the AA/DON why the agency did not notify the physician of a change in condition or the patient using a cane to assist with ambulation. AA/DON stated, “I don’t know, I don’t remember, changes were usually reported to the physician.” The Administrator reviewed the EHR for Patient #4 and stated, “oversight, nothing is in here (the EHR system).” Agency policy, dated 01/13/2018, quoted in part, “MONITORING PATIENT CARE/COORDINATION OF CARE, TX.8, PURPOSE: To ensure coordination of patient/client care and treatment. POLICY: 1. The Agency will monitor, evaluate, and report to the patient’s/client’s physician regarding the patient’s/client’s progress toward achieving goals established on the plan of care…. III. Agency staff are expected to contact the Agency to report patient/client needs and changes. This will be documented on a communication note and will serve as coordination of care….””