Every finding on record at Be Healthy at Home Inc

An Entrance Conference was conducted on 2/28/2023 at 8:45 a.m. with the Office Manager, Supervising Nurse, and by telephone the President and Administrator. The agency representatives were informed that the purpose of the visit was an investigation of complaint intake # 408254/ IQ96364. The agency census was: Austin/ Parent: L&CHHS- 385 LHHS- 3 PAS- 0 An Exit conference was conducted on 3/1/2023 at 4:47 p.m. with the Administrator, Supervising Nurse, and President. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of receiving the Statement of Deficiencies. Abbreviations: L&CHHS- Licensed and Certified Home Health Services LHHS- Licensed Home Health Services PAS-Personal Assistance Services SN- Skilled Nursing POC- Plan of Care MD- Physician IV- Intravenous, given through a vein Kmail- Agency internal email DPM- Doctor of Podiatry Medicine RNCM- Registered Nurse Case Manager SVN- Supervising Nurse/ Director of Nursing

Integrate all orders CFR(s): 484.60(d)(2) Integrate orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to integrate orders from all relevant physicians involved into the POC for one of five records (Patient #1) reviewed with patients receiving wound care. This failure resulted in an order received on 1/24/2023 not being processed for patient #1. This failure had the potential to contribute to wound deterioration and may have contributed to the amputation of the second toe. Findings: Review of the clinical record of patient #1 for the period of 1/15/2023 to 3/15/2023 revealed a POC which read in part: “Primary Diagnosis: Infection of amputation stump, left lower extremity. Other Diagnoses: Type 2 Diabetes Mellitus with foot ulcer, Non-pressure chronic ulcer right foot, fat layer exposed, Heart failure, Chronic Kidney Disease, Acquired absence of left foot. Orders and Treatments: SN (Skilled Nursing) 3w8, 2w1 (three times a week for 8 weeks, 2 times a week for one week). SN Interventions: SN to cleanse left foot wound with wound cleanser, pat dry, apply betadine to wound then place hydrafera blue to wound bed, cover with gauze and secure with kerlix and ace bandage. Wound care to be performed 3x week. SN to cleanse right foot and right 2nd toe wounds with wound cleanser, pat dry, apply betadine to both wounds, place gauze over wounds and secure with tape. Wound care to be performed 3x week.” Clinical records for podiatry visits for patient #1 were obtained from the DPM on 3/1/2023. Review of the records revealed a visit dated 1/24/2023 which read in part:” “New WCO (wound care order) sent to PAM HH.” The agency clinical record of patient #1 did not show an order from the physician for this date. The Administrator was questioned if additional orders were in the record that this surveyor could not see. The order was found in Focura. (Focura is a document management system where physicians can fax records.) During an interview with the Administrator at 2:55 p.m. on 3/1/2023, the Administrator stated orders faxed in by physicians go into Focura. The Administrative Assistant sends orders to Case Manager and cc’s SVN (in case the Case Manager is out on leave). Case Manager is responsible for processing the order and sending order to physician for review and signature. The Administrator stated the order dated 1/24/2023 “was not processed” by the RNCM. Order dated 1/24/2023, found in Focura read in part: “Orders: Apply silver alginate to all wounds and cover with Band aid 3 x week. An email dated 1/24/2023 provided by the Administrative Assistant revealed the order was sent to RNCM and SVN on 1/24/2023 at 11:00 a.m. An interview was conducted with RNCM on 3/1/2023 at 3:46 pm. RNCM was questioned if she remembered receiving an email with the order for 1/244/2023. RNCM stated that she was not at her computer (she was off on personal leave) and stated she could have overlooked the email. RNCM stated if the order was not in the record, she did not address it.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to integrate and coordinate patient services between all staff involved in providing/ scheduling care in one of five records (patient #1) reviewed receiving wound care. This failure had the potential that visits were not rescheduled as needed and could have possibly contributed to wound deterioration and amputation of second right toe. . Findings: Review of the clinical record of patient #1 for the period of 1/15/2023 to 3/15/2023 revealed a POC which read in part: “Primary Diagnosis: Infection of amputation stump, left lower extremity. Other Diagnoses: Type 2 Diabetes Mellitus with foot ulcer, Non-pressure chronic ulcer right foot, fat layer exposed, Heart failure, Chronic Kidney Disease, Acquired absence of left foot. Orders and Treatments: SN (Skilled Nursing) 3w8, 2w1 (three times a week for 8 weeks, 2 times a week for one week). SN Interventions: SN to cleanse left foot wound with wound cleanser, pat dry, apply betadine to wound then place hydrafera blue to wound bed, cover with gauze and secure with kerlix and ace bandage. Wound care to be performed 3x week. SN to cleanse right foot and right 2nd toe wounds with wound cleanser, pat dry, apply betadine to both wounds, place gauze over wounds and secure with tape. Wound care to be performed 3x week.” Further review of the clinical record revealed: For the week of 2/5/2023, SN was provided once (Wed, 2/8/23) and a missed visit note was noted on 2/7/2023 and 2/10/2023. The missed visit note dated 2/7/2023 read in part: “SN showed up to ALF and staff said pt. had been checked out by his brother. SN also went day before and pt. was leaving for dialysis when SN arrived. MD notified, yes, Supervisor notified, yes.” The missed visit note dated 2/10/2023 read in part: “Reason- Doctor/ clinic appointment, at dialysis. MD notified, yes, Supervisor notified, yes.” For the week of 2/12/2023, SN was provided once (Wed. 2/15/23) and a missed visit note was noted on 2/13/2023 and 2/17/2023. The missed visit note dated 2/13/2023 read in part: “Reason- Doctor/ clinic appointment, at dialysis. MD notified, yes, Supervisor notified, yes.” The missed visit note dated 2/17/23 read in part: “Front desk informed SN pt. currently at dialysis will return around 4:00 pm. SN was not able to arrive before 10 due to fasting lab draw in another pt. on this day. MD notified, yes, Supervisor notified, yes.” The clinical record contained an updated order dated 2/15/2023 which read in part: “SN frequency change effective 2/15/2023: 2w2, 3w1, 2w2. Patient goes to wound care every other Tuesday, plot SN visits on Tuesday, Thursday, Saturday. VO (verbal order) received from CMA with Dr.” The clinical record did not contain documentation that visits were plotted for Saturday 2/18/2023 or Tuesday 2/20/2023. For the week of 2/19/2023, SN was provided Wednesday 2/22/2023. Patient #1 was admitted to the hospital following dialysis on Wednesday 2/22/2023 for IV antibiotics and X-ray to determine the need for surgery per request of DPM. The clinical record contained a note dated 2/28/2023 and signed by LVN-A which read in part: “date of contact 2/21/2023 Attempted to go today since no visit yesterday and patient was not in facility again, patient is at podiatry appt.” During an interview with RNCM on 2/28/2023 at 12:50 pm, RNCM was questioned why visits were scheduled on Monday Wednesday and Fridays for patient #1 when it was known that he had dialysis on those days. RNCM stated they would arrange the schedule if a patient had requested visits on certain days or times and stated she did not know if this had been requested from patient #1. The RNCM was off on personal leave and stated she did not have access to the clinical record at this time. She stated she did make an error and did not process the order dated 2/15/2023 in a timely manner, and the frequency did not get changed. She was unsure if the order was ever sent into the scheduler. During an additional interview at 9:10 am on 3/1/2023, RNCM stated she did not notify scheduling of the order for Tues/ Thurs/ Sat visits. RNCM was questioned who plotted the days on the schedule as it was noted that several weeks were scheduled for Monday/ Wednesday/ Friday, and others for Tuesday/ Thursday/ Saturday. The RNCM stated the scheduler would plot them on the calendar, but nurses could change them as needed to accommodate for appointments or other occurrences. RNCM stated visits scheduled 3 times a week were usually plotted by the scheduler on Monday/ Wednesday/ Friday unless instructed differently. She further stated if the assigned nurse missed a visit, she could replot the visit for another day, and if a fill-in nurse missed a visit, she should contact the scheduler to replot the visit. An interview was conducted with LVN-B on 2/28/2023 at 4:42 pm. LVN-B stated she was filling in for the regular LVN-B on Friday 2/17/2023 and stated she did not see the note in the chart of patient #1 stating he had dialysis at 10:30 am on Monday/ Wednesday/ Friday until after she arrived for the visit. LVN-B stated she contacted the physician, RNCM and scheduler of the missed visit. An interview was conducted with LVN-A on 3/1/2023 at 10:10 a.m. LVN-A stated she did not change the frequency dates plotted on the calendar. LVN-A stated she knew that patient #1 had dialysis and she wouldl try to see him before he went if the visit was plotted on Monday/ Wednesday/ Friday. LVN-A stated if she was unable to see patent then she would put the visit on her schedule for the following day unless it was a Friday. LVN-A stated if she missed a visit on Friday, she would notify the RNCM to replot the visit for the weekend. LVN-A stated she was not sure what happened on 2/10/2023, as the RNCM was notified and RNCM and the scheduler should have replotted the visit. During an interview with Administrator on 3/1/2023 at 10:30 a.m., Administrator stated nurses should be notifying RNCM and scheduler when unable to complete a visit. During an interview with the SVN on 3/1/2023 at 2:40 p.m., SVN stated protocol was for staff to notify the Case Manager if unable to make visit, and the Case Manager notified the scheduler. An interview was conducted with the scheduler on 3/1/2023 at 10:38 a.m. Scheduler stated visits ordered three times a week are scheduled for Monday/ Wednesday/ Friday unless she is instructed otherwise. Scheduler stated if visits are missed, staff are supposed to let her and the RNCM know, so they can replot the visits. Scheduler stated she is notified either by a message or Kmail. Scheduler was asked if she could check her messages to see if she was notified about missed visits on 2/10/23, 2/13/23 or 2/17/23. After reviewing her messages and Kmail, scheduler stated she did not have any notification of missed visits for those days. Scheduler stated changes in orders are sent to her by the RNCM. Scheduler stated she did receive a message regarding the frequency change on 2/15/2023, but the request left off the request to plot on Tuesday/ Thursday/ Saturday. The Kmail received by the scheduler read “SN Frequency change effective 2/15/23: 2w2, 3w1, 2w2. Patient goes to wound care on Tuesday." This surveyor was provided a copy of document entitled “PAM Health at Home Scheduling Process.” The document read in part: “2. Case management and scheduling staff will process missed visits and reschedule patients daily. 3. Field staff will communicate needed frequency changes and missed visits to their case manager timely, so that changes to the care plan and rescheduling can take place appropriately.” During an interview with the Administrator on 3/1/2023 at 10:58 a.m., the Administrator stated the communication to the scheduler was not clear and left out the instructions to plot visits on Tuesday/ Thursday/ Saturday.