Every finding on record at Bear Lake Memorial Hospital Home Health

A Medicare recertification survey of your agency, including Emergency Preparedness, was conducted from 2/06/23 to 2/09/23. The agency was found in compliance for the regulations found in Appendix Z of the State Operations Manual.

The following deficiencies were cited during the recertification survey of your agency, conducted from 2/06/23 to 2/09/23. Abbreviations used in this report include: EMS - Emergency Medical Services ER - Emergency Room HHA - Home Health Agency POC - Plan of Care PT - Physical Therapy RN - Registered Nurse SN - Skilled Nursing

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on record review and staff interview, it was determined the HHA failed to ensure the comprehensive assessment was updated after a decline in health status for 1 of 7 patients (Patient#1) whose record was reviewed. This resulted in an incomplete assessment of the patient. Findings included: Patient #1 was a 50 year old male who was admitted to the HHA on 3/18/22 with a primary diagnosis of burn of second degree of right thigh. Additional diagnoses included paraplegia, depression, and history of falls. He received SN, PT, and aide services. His record for the certification periods 11/13/22 to 1/11/23 and 1/12/23 to 3/12/23 were reviewed. Patient #1's record included a nursing note dated 12/13/22 which stated, "Family reports that patient has been exhibiting signs of increased harmful behavior over the weekend. Patient has been screaming and yelling while threatening to harm himself and his family. He has been cutting his arms, and he did throw a knife at his mother ... Family reports police were been [sic] called ... Ambulance was called and patient was transported to ER for evaluation. Patient was found to have been combining multiple medications that were interacting with each other ... Home Health to hold all visits until psych eval [psychiatric evaluation] can be completed to ensure safety of staff." Patient #1's record included a note from an ER visit on 12/13/22. The note stated, "Patient presents to the emergency department via EMS with a complaint of 'anger issues' ... There have been multiple episodes over the last several weeks where patient has threatened multiple family members with knives ... Patient states this all started since he took him off of his medications and put him on Suboxone ... His family reports that it round [sic] 9 or 10 at night he starts to become agitated this is after he takes 3 mg [milligrams] of Xanax and a Suboxone and that starting around 10 PM patient begins to become paranoid aggressive, easily agitated and that is when he threatens them with knives." The note later stated, "Spoke with patient's son and mother ... that I am concerned that some of his symptoms are related to his medications and how he is currently taking them. Explained that these combination of medications could cause a psychosis with hallucinations and agitation. Patient agreed to allow both of his sons to go in and search his room for any and all medications and to help administer them. " Patient #1's record included a recertification order, dated 1/10/23 signed by the nurse which stated, "The patient had developed psychosis, delusions, hallucinations, self harming, suicidal ideation, and aggressive behavior towards family ... The patient's family have started managing medications for the patient and giving the patient a medication box one day at a time to prevent any unintentional or intentional misuse. The patient is now stable." Patient #1's comprehensive assessment was reviewed. It did not mention Patient #1's recent ER visit for the psychiatric issues, medication issues, or encounters with law enforcement for threats to his family. The RN director was interviewed on 2/08/23 beginning at 9:26 AM and Patient #1's record was reviewed in her presence. She confirmed the comprehensive assessment was not updated and stated this was because his doctor did not give him any new diagnoses. She agreed the comprehensive assessment should have been updated to include the recent psychiatric issues with Patient #1. The HHA failed to ensure the comprehensive assessment was updated after a major decline in health status for Patient #1.

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: Based on record review and staff interview, it was determined the HHA failed to ensure a patient's POC included all pertinent diagnoses and mental status for 1 of 7 patients (Patient #1) whose records were reviewed. This resulted in an incomplete POC that had the potential to interfere with patient care. Findings included: Patient #1 was a 50 year old male who was admitted to the HHA on 3/18/22 with a primary diagnosis of burn of second degree of right thigh. Additional diagnoses included paraplegia, depression, and history of falls. He received SN, PT, and aide services. His record for the certification periods 11/13/22 to 1/11/23 and 1/12/23 to 3/12/23 were reviewed. Patient #1's record included a nursing note dated 12/13/22 which stated, "Family reports that patient has been exhibiting signs of increased harmful behavior over the weekend. Patient has been screaming and yelling while threatening to harm himself and his family. He has been cutting his arms, and he did throw a knife at his mother ... Family reports police were been [sic] called ... Ambulance was called and patient was transported to ER for evaluation. Patient was found to have been combining multiple medications that were interacting with each other ... Home Health to hold all visits until psych eval can be completed to ensure safety of staff." Patient #1's record included a note from an ER visit on 12/13/22. The note stated, "Patient presents to the emergency department via EMS with a complaint of 'anger issues' ... There have been multiple episodes over the last several weeks where patient has threatened multiple family members with knives ... Patient states this all started since he took him off of his medications and put him on Suboxone ... His family reports that it round [sic] 9 or 10 at night he starts to become agitated this is after he takes 3 mg of Xanax and a Suboxone and that starting around 10 PM patient begins to become paranoid aggressive, easily agitated and that is when he threatens them with knives." The note later stated, "Spoke with patient's son and mother ... that I am concerned that some of his symptoms are related to his medications and how he is currently taking them. Explained that these combination of medications could cause a psychosis with hallucinations and agitation. Patient agreed to allow both of his sons to go in and search his room for any and all medications and to help administer them. " Patient #1's record included a recertification order, dated 1/10/23 signed by the nurse which stated, "The patient had developed psychosis, delusions, hallucinations, self harming, suicidal ideation, and aggressive behavior towards family ... The patient's family have started managing medications for the patient and giving the patient a medication box one day at a time to prevent any unintentional or intentional misuse. The patient is now stable." Patient #1's POC for the certification period 1/12/23 to 3/12/23 was reviewed. The POC did not include any SN interventions to assess Patient #1's mental and psychiatric well-being after his ER visit and encounters with law enforcement. The RN Director was interviewed on 2/08/23 at 9:26 AM and Patient #1's record was reviewed in her presence. She confirmed there was no mental health or psychiatric interventions on Patient #1's POC after his encounters in the ER and with law enforcement. She agreed the POC should have been updated to reflect this. The HHA failed to ensure Patient #1's POC included all pertinent diagnoses and mental status

Participate in HHA-sponsored in-service CFR(s): 484.75(b)(9) Participation in HHA-sponsored in-service training. This ELEMENT is not met as evidenced by: Based on personnel file review and staff interview it was determined the HHA failed to ensure that clinical staff were appropriately oriented and trained for 1 of 5 staff whose personnel files were reviewed (Staff A). This caused a lack of oversight to personnel providing clinical services for the HHA. Findings included: Personnel files for staff were reviewed. Staff A's personnel file did not include documented orientation and competencies. The RN Director was interviewed on 2/09/23, beginning at 8:15 AM, and Staff A's personnel file was reviewed in her presence. She confirmed that Staff A was hired approximately three weeks prior and was seeing home health patients independently. Additionally, the RN Director confirmed that no documentation of orientation, oversight, and competencies were done prior to Staff A visiting patients independently. The HHA failed to ensure that all clinical staff were in-serviced to orientation and competencies upon hire. klj