Every finding on record at Blue Mountain Hospital District

An unannounced Federal recertification survey was completed at this agency on 8/30/2022. The agency was surveyed for compliance with 42 CFR Conditions of Participation for Home Health Agencies, Part 484. An entrance conference was held with the Director on 8/22/2022 at 2:20 PM. The purpose of the survey and the survey needs were explained. An opportunity was provided for questions, answers and comments. Definitions and abbreviations: ACT - actuation CFR - Code of Federal Regulations eval - evaluate HFA - hydrofluoroalkane; the propellant used in some inhalers HR - Human Resources MCG - microgram MG - milligram prn - as needed PT - physical therapy RN - registered nurse tab - tablet

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 interview and medical record review, it was determined the agency failed to include patient-specific measurable outcomes and goals on the individualized plan of care that is signed by the physician for 2 of 5 active patient medical records reviewed (Patients #1 and #4). Findings: Patient #1: Review of the "Home Health Certification and Plan of Care," for the certification period from 8/14/2022 to 10/12/2022, revealed orders for PT once a week for one week, followed by two times a week for 6 weeks. Further review revealed PT was the primary discipline. Review of the "Goals and Outcomes" section of the document revealed that patient-specific measurable outcomes and goals for PT were not listed. The document was signed by the physician on 8/16/2022. During an interview with Employee #2 and Employee #3 on 8/23/2022 beginning at 2:00 PM, the above information was presented. Employee #2 searched the electronic medical record and determined that the Physical Therapist completed the recertification on 8/11/2022 and the electronic medical record contained PT goals but the goals were not "pushed through to the next episode" which would make them appear on the document being reviewed. Patient #4: Review of the "Home Health Certification and Plan of Care," for the certification period from 8/12/2022 to 10/10/2022, revealed orders for PT to "Eval and treat." Search of the electronic medical record by Employee #2 on 8/23/2022 revealed the Physical Therapist performed an evaluation on 8/9/2022; the PT planned to continue treatment and PT goals were established. Review of the "Goals and Outcomes" section of the document revealed that patient-specific measurable outcomes and goals for PT were not listed. The document was signed by the physician on 8/16/2022. During an interview with Employee #2 and Employee #3 on 8/23/2022 beginning at 2:00 PM, the Patient #4 findings were presented. Employee #2 determined that the PT goals were not "pushed through to the next episode." Further discussion of the findings with Employee #2 and Employee #3 revealed that both Physical Therapists were "travelers" who are not employed by the agency and "may not remember they need to push the goals through." Employee #2 also stated "Maybe it is a process error on my part, I really don't know, but I will look into it."

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 interview and medical record review, it was determined the agency failed to include complete medication orders on the individualized plan of care for 3 of 5 active patient medical records reviewed (Patients #1, #2 and #5). Findings: Patient #1: Review of "Medications" on the "Home Health Certification and Plan of Care," for the certification period from 8/14/2022 to 10/12/2022, revealed the order "Tylenol oral 325 MG 2 Tab(s) take prn." The order failed to include the reason for the medication and failed to provide complete instructions regarding frequency by not indicating how often the medication can be taken and/or a maximum daily dose. Patient #2: Review of "Medications" on the "Home Health Certification and Plan of Care," for the certification period from 7/25/2022 to 9/22/2022, revealed the order "Allegra-D Allergy & Congestion Oral 180-240 MG 1 Tab(s) 1 tablet prn for allergy symptoms." The order failed to provide complete instructions regarding frequency by not indicating how often the medication can be taken and/or a maximum daily dose. Patient #5: Review of "Medications" on the "Home Health Certification and Plan of Care," for the certification period from 6/27/2022 to 8/25/2022, revealed the order "Proventil HFA Inhalation 108 (90 Base) MCG/ACT 2 puffs As [sic] needed." The order failed to include the reason for the medication and failed to provide complete instructions regarding frequency by not indicating how often the medication can be taken and/or a maximum daily dose. During an interview with Employee #1 on 8/24/2022 beginning at 8:00 AM, the above findings were presented. Employee #1 acknowledged the findings.