Every finding on record at Banner Health

A recertification survey was completed on 9/2/21. Two deficiencies were cited.

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: 2. The clinical record for Patient #13 was reviewed on 8/31/21. Review of the plan of care for the certification period of 11/2/20 to 12/31/20, and 1/1/21 to 3/1/21 revealed a start of care date of 9/3/20; diagnoses included pregnancy with a history of preterm labor. Plan of care orders included SN services once a week for nine weeks for the certification period of 11/2/20 to 12/30/20 and once a week for three weeks for the certification period of 1/1/21 to 3/1/21 for supervision of pregnancy and providing weekly makena auto injections. a) The agency failed to ensure the individualized plan of care included all medications and treatments for Patient #13. Review of the Plan of Care dated 11/2/20 to 12/31/20 revealed the following medications; makena 275 MG/1.1 ML subcutaneous auto-injector to be administered weekly, and prenatal vitamins plus low iron 27 MG iron 1-MG tablet for 1 tablet daily. Review of the SN visit notes from 11/25/20 revealed that RN #7 noted in the narrative that Patient #13 was started on Amoxicillin 875 mg twice a day for seven days due to a urinary tract infection as well as being placed on a Zoloft 50 MG 1/2 tablet at bedtime for 7 days and then increased to 1 tablet at bedtime for anxiety and depression. Review of the Plan of Care, dated 1/1/21 to 3/1/21, revealed that the medication list for Patient #13 was not updated. The medications listed were the following; makena 275 MG/1.1 ML subcutaneous auto-injector to be administered weekly, and prenatal vitamins plus low iron 27 MG iron 1-MG tablet for 1 tablet daily. In contrast to the above RN #7 noted on all SN visits from 11/25/21 to the discharge date of 1/21/21 that Patient #13 continued to take a Zoloft tablet at bedtime. Further review of the medication list for Patient #13 also did not include the Amoxicillin or the Zoloft medications. During interview on 9/1/21 at 1:36 p.m., RN #7 stated since this incident happened a year ago she did not have a good memory of it. She stated that if the medications were not added on the medication list then she may have forgotten to add them. She went on to state this may have been an oversight. During interview on 9/2/21 at 8:49 a.m., the director stated these events occurred when the staff were still learning the new tablets that were provided to the staff. She went on to state she also believes it was an oversight on the RNs side. Based on interview, and record review, the agency failed to ensure the individualized Plan of Care included complete orders for interventions, treatments, or medications in 1 of 7 patients receiving wound care (Patient #5) and 1 of 5 discharged patient records (Patient #13). Findings include: AGENCY POLICY: According to the agency policy titled, "Home Health- Plan of Care," dated 12/18/18 (in pertinent parts): "B. The plan of care describes the patient needs, problems related to care/services provided, changes in condition, problems or needs associated with the family support system, and goals based on assessment of needs. The plan describes the specific services to be provided and action to be taken including type, frequency, and duration of care/services. C. The Plan of Care includes: 7. Treatments the patient is receiving from a source other than home health; 8. Medications and herbal supplements reported by the patient or the patient's representative and the dose, route of administration, and schedule for administration of each medication or herbal supplement." 1. The clinical record for Patient #5 was reviewed on 9/1/21. Review of the plan of care for the certification period of 8/13/21 to 10/11/21 revealed a start of care date of 8/13/21; diagnoses included sepsis (an infection in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death), stomach cancer, abdominal surgical wound, and atrial fibrillation (an irregular heart rate). Plan of care orders included skilled nursing (SN) services once a week for one week, twice a week for two weeks, four times a week for one week, and once a week for one week for wound care, coagulation draws, and medicine reconciliation, physical therapy (PT) service one time for evaluation and treatment if needed, and occupational therapy (OT) services twice a week for three weeks for range of motion, functional and strength training, and a home exercise program. a) The agency failed to ensure the individualized plan of care included complete orders for interventions and treatments for Patient #5. Review of the Plan of Care dated 8/13/21 to 10/11/21 revealed orders for "Skilled Nurse to perform/teach wound care to incision/suture site located at abdominal midline: 1) cleanse with NS (normal saline) or wound cleanser 2) pat dry 3) pack wound with Aquacel AG or Iodoform 4) cover with ABD (abdominal dressing) 5) cover ABD with bordered foam or secure ABD with tape using clean/aseptic technique. Change dressing BID (twice a day) and PRN (as needed)." Further review of the Plan of Care revealed the SN visit frequencies were once a week for one week, three times a week for two weeks, twice a week for five weeks, four times a week for one week, and once a week for one week. There was no evidence the SN was scheduled to provide services twice a day every day for dressing changes to Patient #5's wound. Review of the RN OASIS Admission dated 8/13/21, showed the registered nurse (RN #9) documented in the narrative section of the note, "Patient spouse instructed on proper wound care, written instructions given as well for reference. Patient spouse to change dressing BID while RN services are not scheduled for visits." However, there was no documentation on the Plan of Care that Patient #5's spouse would be providing wound care when the SN was scheduled for a visit. During an interview on 9/2/21 at 8:46 a.m., RN #10 stated Patient #5's dressing changes were every day and Patient #10's spouse was educated on performing the dressing change because agency staff was unable to provide wound care services daily. She further stated she was pretty sure the admitting SN had documented the spouse would perform dressing changes when agency staff was not scheduled in Patient #5's clinical record, however, she was not sure if this was documented on the Plan of Care. During an interview on 9/2/21 at 9:20 a.m., the agency Director stated new orders for the dressing change for Patient #5 had been received that week and the nurse had included orders for the patient's spouse to perform the dressing changes when agency staff was not scheduled for visits. However, she did note it was not documented on the Plan of Care.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to provide services and treatments only as ordered by the physician for 1 of 17 patient records reviewed (Patient #14). Findings include: AGENCY POLICY According to the agency policy titled, "Home Health - Physicians orders", dated 3/3/21 (in pertinent parts). "A. Banner Home Care staff will communicate with physicians to assure maximum interpretation and processing of diagnostic and therapeutic orders relative to patient care and to provide for their implementation and coordination. B. Banner Home Care provides care, treatment, and services according of the most recent Order. C. Orders are obtained from a physician or other licensed independent practitioner according to law and regulation and professional standards of practice before providing care." 1. The clinical record for Patient #14 was reviewed on 9/1/21. Review of the plan of care for the certification period of 7/13/20 to 9/10/20 revealed a start of care date of 7/13/20; diagnoses included atrial fibrillation (an irregular heart rate), chronic kidney disease, peripheral polyneuropathy (multiple areas of nerve pain), anemia (low blood iron levels), ischemic heart disease (death of heart muscle tissue), pacemaker implantation and myocardial infarctions (heart attacks) in 2012 and 2014. Plan of care orders included skilled nursing (SN) one time the first week, then once every six weeks if needed for observation and assessment of disease processes, physical therapy (PT) two times the first week, then four times a week for four weeks to establish or upgrade a home exercise program, therapeutic exercises, gait and balance training and use of adaptive equipment. a) The agency failed to ensure SN services were completed only as ordered by the physician. Review of the Client Coordination Note dated 7/13/20 revealed Registered Nurse (RN) #11 documented. "Patient had a CBD lotion on hand that was recommended for him. SN used gloves and helped apply some of the lotion to the patient. SN suggested they also ask the physical therapist to help apply the lotion." Review of the Client Medication Report dated 7/13/20 revealed no evidence of CBD lotion on the patient's medication list. Further review of the clinical record revealed no evidence of a physician order for the SN to administer CBD lotion to the patient. During an interview 9/1/21 at 2:45 p.m. RN #11, stated she attempted to enter the CBD lotion into the medical record but because there was no actual dosage she did not know how to do it. She stated she never called the physician for clarification nor her superiors for assistance. On 9/2/21 at 8:37 a.m. Director #1 and Senior Clinical Manager #2 stated the RN should have called the physician for clarification and employees can enter medications under the unlisted category. They are then reviewed and approved by management.