Every finding on record at Avera at Home Marshall

On 1/10/22 and 1/11/22, an abbreviated on-site survey was conducted for a complaint investigation. Your agency was found to have not met the requirements at 42 CFR Part 484, requirements for Home Health Agencies. The following complaint was found to be unsubstantiated: H8144001C (21897) however deficiencies were cited as a result of the investigation at G590 and G592.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on interview and document review, the agency failed to notify the provider when a patient fall with injury occurred for 1 of 3 patients (P1) reviewed for falls. P1's plan of care (POC) for certification period 5/26/21 to 7/24/21, indicated her start of care (SOC) date was 4/1/2020. Diagnoses included chronic obstructive pulmonary disease (COPD), dizziness and giddiness, history of falls, depression, anxiety, and diabetes. The POC included orders for weekly skilled nurse visits (SNV) for various assessments and teaching, including assessment of pain and pain management, safety and fall prevention. A home health aide (HHA) was ordered two times per week for one week then three times weekly for eight weeks to assist with personal cares, including bathing, dressing, skin and hair care and assist with safe environment with ambulation. Occurrence Report dated 2/1/21, indicated P1 had fallen outside and sustained bruises to her hand and leg. A Case Conference Report dated 5/13/21, indicated P1 had reported a very recent fall and had a right hip x-ray with no fracture noted. The medical record lacked an agency Occurrence Report for this incident. SNV notes lacked evidence of assessment of this fall. A SNV report dated 5/24/21, indicated P1 had sustained a fall in the shower on 5/21/21, resulting in a compression fracture and severe pain. The medical record lacked an agency Occurrence Report for this incident. Review of P1's medical record lacked evidence of notification to the physician regarding her falls with injury and change in pain status. During a group interview with the agency's clinical manager (CM)-A, vice president of clinical (VP)-B, and quality assurance (QA)-C nurse on 1/11/22, at 2:32 p.m. QA-C stated staff would follow the agency's Physician Notification policy regarding notifying the primary physician following a patient fall and it would be an individual clinical decision whether to notify the physician. The agency does not fill out incident reports following every fall, it would depend on if the fall was witnessed or unwitnessed, if injury occurred and if the POC needed to be updated. If a patient fell, the nurse would assess and determine the need to communicate with the patient's primary provider and would look at the POC to see if updates were needed. It would depend on the nurse to see if the fall would require submission of an agency Occurrence Report for root cause analysis. Review of the agency's Incident Reporting policy dated 8/4/20, indicated when an incident occurred, staff would follow up with the patient, caregiver, and/or patient's physician, if indicated by the manager or designee. Review of the agency's Home Health Primary Care Provider Responsibility in Managing Patients dated 5/14/21, indicated the agency's responsibilities included providing the primary care provider and physicians with timely information regarding their patient's. Notification and contact would occur when there were changes in the patient's condition or environment, lack of achievement of goals, changes or lack of patient response to care, and changes needed regarding disease, treatments and medications. Staff were to provide information to assist with the continuity of care, including ongoing updates and phone consultation as needed.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on interview and document review, the agency failed to ensure the plan of care was revised to reflect current information from the patient's updated assessment and individualized to identify patient specific measurable outcomes and goals for 1 of 3 patients (P1) reviewed for plan of care. P1's plan of care (POC) for certification period 3/27/21 to 5/25/21, indicated her start of care (SOC) date was 4/1/2020. Diagnoses included chronic obstructive pulmonary disease (COPD), dizziness and giddiness, history of falls, depression, anxiety, and diabetes. The POC included orders for weekly skilled nurse visits (SNV) for various assessments and teaching, including assessment of pain and pain management, safety and fall prevention. A home health aide (HHA) was ordered 1 time weekly for eight weeks to assist with personal cares, including bathing, dressing, skin and hair care and assist with safe environment with ambulation. Review of SNV 5/10/21, and 5/17/21 indicated pain was assessed and P1 denied any pain concerns. SNV for recertification, dated 5/24/21, indicated P1 reported a fall on 5/21/21, while taking a shower. Registered nurse (RN)-A documented the HHA had reported the fall to her on 5/21/21 and she had recommended P1 go to the emergency room. P1 refused but did go to the emergency later that evening. P1 reported compression fracture in her back and reported uncontrolled back pain 9 out of 10 on 0 to 10 pain scale, indicating severe pain. SNV dated 6/1/21, indicated P1 continued to report back pain and rated her pain 7 out of 10 on a 0 to 10 pain scale. When interviewed on 1/11/22, at 10:38 a.m. RN-A stated she had received a call from the HHA on 5/21/21, that she had stepped out of the bathroom while giving P1 a shower to obtain a towel and P1 had fallen during the time she was not in the bathroom. She had recommended P1 go in to the emergency room to be evaluated but P1 had refused. P1 did eventually go in to be evaluated later that evening and was diagnosed with a compression fracture to her back. She could not remember if she had notified P1's primary physician of the fall, however, she did tell the HHA that P1 should not be left alone in the bathroom during a shower in the future. She could not recall if she updated P1's POC to reflect her new diagnosis, change in pain status or level of assistance needed in the shower. During telephone interview on 1/11/22, at 11:31 a.m. HHA-A stated if a patient needed assistance with a shower, she made sure she gathered all her supplies prior to assisting a patient and would never leave a patient requiring assist with a shower alone in the bathroom. The care plans we have are pretty generic. They do not indicate if a patient just needs help to transfer in and out of the shower, or partial or full assistance with the shower, or exactly how much help each patient needs. But that would not matter, she would stay in the bathroom when a patient showers, no matter what. Review of P1's POC dated 5/26/21 to 7/24/21. lacked changes to level of assistance needed for showering. P1's severe pain was not addressed, nor was compression fracture added to P1's diagnosis list. Review of P1's HHA assignment sheets dated 5/24/21, lacked changes to direct the HHA of and increase level of assistance required with showering or notification for P1's need for constant supervision in the shower or notation indicating P1 was not to be left unattended in the shower. Review of P1's Care Plan Summary for period 5/26/21 through 7/15/21, lacked changes to level of assistance needed with showers. The summary lacked updates to P1's pain management or prevention of falls to reflect the new diagnosis of compression fracture and severe pain P1 was experiencing. Review of P1's medical record lacked an Occurrence Report following her fall with major injury on 5/19/21. During a group interview with the agency's clinical manager (CM)-A, vice president of clinical (VP)-B, and quality assurance (QA)-C nurse on 1/11/22 at 2:32 p.m. QA-C stated when a HHA reports a fall the nurse would then go and assess the patient and determine if there was a need to communicate with the primary physician and she would look at the POC to see if changes were needed. The nurse would then identify the areas of risk on the POC and edit the POC with specific details. If changes were needed in something specific, like bathing, there would be specific text direction in the HHA POC. If changes occurred with a patient's pain or ability to perform tasks, she would consider the primary nurse would make specific directions in the care plan. The agency policy, Incident Reporting, dated 8/4/20, indicated an incident or adverse event included major fall with injury and an incident report was to be completed within 48 hours of the incident. The quality team would conduct a root cause analysis of the event as appropriate. The agency policy Development and Revision of the Service Plan dated 12/15/21, indicated each patient's service plan was reviewed by the registered nurse (RN) during each regular client monitoring visit at least every 90 days, whenever changes are needed to the services to be provided because of a change in the client's condition, after receipt of new or revised orders, and/or following an incident or a patient's return from a hospital or nursing home. If a review of the service plan indicates that the patient's service plan needs modification based on the patient's needs, or preferences, the RN would make the necessary changes.