Mountain Regional Personal Care Services 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 review of clinical records and interview, it was determined the agency’s staff failed to ensure home health services were provided according to the patient’s individualized plan of care for one (1) of four (4) patient’s in the survey sample (Clinical Record for Patient #9). 1. The clinical record for patient #9 was reviewed for the period of April 17, 2024 to June 15, 2024. The patient’s plan of care contained orders as follows: Skilled nurse to instruct patient or caregiver to weigh daily and record. Notify the home health nurse/physician if patient gains five (5) pounds within one (1) week. The clinical record failed to contain documentation that the nurse assessed the patient’s weight on the above plan of care order. On October 03, 2024 at 12 PM, the Medical Facilities Inspector (MFI) conducted an interview with Staff Member #2. Staff Member #2 revealed the skilled nurse documented education on heart failure but failed to assess or instruct the patient or caregiver to record daily weights.”

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on a review of clinical records, it was determined the agency failed to ensure patients were informed about and consented to the frequency of proposed visits in advance of starting care for five (5) of (17) patients in the survey sample (Clinical Record, Patient #’s: 4, 9, 11, 14, and 16). Findings: The informed consent signed at the time of admission and prior to services being provided for Patient #4, with a start of care date of August 30, 2024, failed to contain documentation of the frequency of Skilled Nursing services the patient would be receiving. The informed consent signed at the time of admission and prior to services being provided for Patient #9, with a start of care date of April 17, 2024. failed to contain documentation of the frequency of Skilled Nursing services the patient would be receiving. The informed consent signed at the time of admission and prior to services being provided for Patient #11, with a start of care date of February 23, 2024, failed to contain documentation of the frequency of Skilled Nursing services the patient would be receiving. The informed consent signed at the time of admission and prior to services being provided for Patient #14, with a start of care date of September 05, 2024, failed to contain documentation of the frequency of Skilled Nursing services the patient would be receiving. The informed consent signed at the time of admission and prior to services being provided for Patient #16, with a start of care date of August 20, 2024, failed to contain documentation of the frequency of Skilled Nursing services the patient would be receiving. The informed consents failed to ensure patients were informed about and consented to the frequency of proposed Skilled Nursing service visits. On October 03, 2024 at 9:30 AM, the Medical Facilities Inspector (MFI) conducted an interview with Staff Member #2. Staff Member #2 revealed some of the Skilled Nurses are new and missed that piece on the patient’s consents.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on clinical record review and interview, it was determined the agency failed to ensure accurate and complete medication lists were documented in one (1) of one (1) clinical record with a PICC line (catheter inserted through a peripheral vein to deliver medications) reviewed in the survey sample (Clinical Record for Patient #4). 1.The clinical record for Patient #4 was reviewed for the period of August 30, 2024 to October 28, 2024. The plan of care contained skilled nursing to obtain blood specimens every week and IV administration of antibiotics as prescribed via PICC line. The plan of care also instructed the skilled nurse to use the SASH (procedure for flushing a PICC line with Saline then administer medication, flush again with Saline and lastly Heparin) for the PICC infusions to keep the line patent. On October 03, 2024 at 8:45 AM, the Medical Facilities Inspector (MFI) conducted an interview with Staff Member #2. Staff Member #2 revealed the skilled nurse is new and the reviewer for the plan of care missed the PICC medications of Heparin and Saline with the dosages on the patient’s medication list. The medication list was reviewed and did not contain the above medications flushed through the PICC.”