Every finding on record at Brownfield Home Health LLC

A Recertification Survey entrance conference was conducted on 02/01/21, with the alternate administrator/supervising nurse, Employee B, at 9:17 a.m. Census: L&C - 18 LHH - 27 PAS - 23 An exit conference was conducted on 02/03/21, with the administrator, Employee A, and the alternate administrator/supervising nurse, Employee B, at 1:28 p.m. 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 the receipt of the Statement of Deficiencies. Acronyms/Definitions: 1.) Heart Failure/Congestive Heart Failure/CHF - a condition in which the heart cannot pump effectively which can result in buildup of fluid in the body's tissues, including the lungs, and can result in difficulty breathing. Increase in weight can indicate an exacerbation or worsening of the heart failure/fluid buildup. 2.) v/s - vital signs 3.) Q - every 4.) MD - medical doctor 5.) AM - morning 6.) SOB/SHOB - short of breath 7.) Lasix - generic name Furosemide - a medication used to remove excess fluid from the body resulting from medical conditions such as CHF or heart failure. 8.) BID - twice a day 9.) mg - milligram(s) 10.) Tab - tablet(s) 11.) CTA - clear to auscultation (listening with a stethoscope). 12.) Chronic Systolic (congestive) Heart Failure - a type of heart failure in which the left ventricle (chamber of the heart) is unable to pump effectively in order to circulate blood to the tissues. 13.) SN - skilled nurse 14.) Pt./pt. - patient 15.) ml - milliliter(s) 16.) IM - intramuscular - the medication is injected into a muscle via a needle. 17.) dx - diagnosis 18.) s/sx - signs and symptoms 19.) POC - plan of care

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on interview and record review, the skilled nurse failed to provide services ordered by the physician or allowed practitioner as indicated in the plan of care for 3 of 9 (Patient #4, Patient #8, and Patient #9) patients reviewed who were receiving skilled nursing services from agency staff in that: The skilled nurse failed to ensure weights were obtained/assessed as ordered by the physician for Patient #4, Patient #8, and Patient #9; and The skilled nurse failed to ensure Vitamin B 12 injections were administered as ordered by the physician for Patient #4. The failure to ensure orders were followed as written could place patients at risk of receiving substandard quality of care and deterioration in condition. The findings included: Patient #9: Review of a plan of care, for the certification period of 12/01/20 - 01/29/21, indicated the patient had a diagnosis of heart failure and indicated the agency was to provide skilled nurse visits once a week for nine weeks. The plan of care also indicated the skilled nurse was to "Assess v/s and all systems Q visit. Report v/s outside parameters associated with clinical signs and symptoms to MD ... weight gain or loss of 5 pounds in one week if able to weigh safely." Review of a skilled nurse visit, dated 12/15/20, the only skilled nurse visit conducted during this week, did not include documentation regarding the patient's current weight. Review of a communication note, dated 12/18/20, indicated, "Patient daughter called this AM stating Pt. had another episode last night where patient was SOB and having some chest discomfort ... Pt daughter said this episode seemed to last longer and seemed to be more intense this time ... Pt daughter also stated that Pt went to see a new cardiologist yesterday regarding a new dx of CHF and had labs drawn ..." Review of a physical therapy visit note, dated 12/21/20, indicated, "States she saw a new cardiologist last week and she told pt. to take Lasix ... Daughter states they resumed 20 mg Lasix BID ... since that visit ..." Review of a skilled nurse's note, dated 12/22/20, the only skilled nurse visit conducted during this week, indicated, "Her daughter states that Lasix was prescribed 20 mg BID but patient is now taking 20 mg 1/2 tab BID." There was no documentation regarding the patient's current weight. Review of a skilled nurse's note, dated 12/29/20, the only skilled nurse visit conducted during this week, indicated, "Patient states ... still gets SOB with exertion and has to rest frequently." There was no documentation regarding the patient's current weight. Review of a skilled nurse's note, dated 01/05/21, the only skilled nurse visit conducted during this week, indicated, "------------ (name of Patient #9's physician) ... increased Lasix 40 mg to 1&1/2 Tabs (60 mg) BID." There was no documentation regarding the patient's current weight. Review of a skilled nurse's note, dated 01/14/21, the only skilled nurse visit conducted during this week, indicated, "Patient lungs CTA but are significantly diminished. No SHOB to note at rest, however confirmed that often experiencing SHOB upon exertion." There was no documentation regarding the patient's current weight. Review of a skilled nurse's note, dated 01/21/20, the only skilled nurse visit conducted during this week, included no documentation regarding the patient's current weight. There was no documentation in any of the above referenced skilled nurse's notes to indicate the patient was unsafe to weigh. Patient #4: Review of a plan of care, for the certification period of 12/11/20 - 02/08/21, indicated the patient had a diagnosis of CHF and was to receive Furosemide 20 mg twice a day. The plan of care further indicated the agency was to provide skilled nurse visits once a week for eight weeks and indicated the skilled nurse was to "Assess v/s and all systems Q visit. Report v/s outside parameters associated with clinical signs and symptoms to MD ... weight gain or loss of 5 pounds in one week ... Primary reason for Home Health Care ... CHF ... Patient is home bound due to SOB with minimal exertion, weakness and poor endurance related to ... Chronic Systolic (congestive) heart failure ... SN required for observation and assessment of pt.'s unstable condition of cardiac ... conditions ... SN to assess, monitor, evaluate, and instruct pt./caregiver on heart failure disease process, signs and symptoms, management of heart failure, checking daily weights ..." Review of a skilled nurse's note, dated 01/12/21, the only skilled nurse visit conducted this week, did not include documentation regarding the patient's current weight. Review of a skilled nurse's note, dated 01/19/21, the only skilled nurse visit conducted this week, did not include documentation regarding the patient's current weight. The note further indicated, "SN received phone call ... notifyin (sic) SN provider stating Pt is SOB, has a "cough" ..." Review of the plan of care, for the certification period of 12/11/20 - 02/08/21, also indicated Patient #4 had a diagnosis of deficiency of specified B group vitamins and indicated, "SN to administer Vitamin B 12 2 ml IM Q month." Review of the skilled nurse's notes, for the time period of 12/11/20 - 02/01/21, included no documentation to indicate the skilled nurse had administered the Vitamin B 12 injection for the months of December 2020 or January 2021. Patient #8: Review of a plan of care, for the certification period of 12/15/20 - 02/12/21, indicated the patient had a diagnosis of CHF and was to receive Lasix 40 mg daily. The plan of care also indicated the agency was to provide skilled nurse visits once a week for nine weeks. The plan of care further indicated, "Patient is home bound due to weakness, poor endurance, SOB with moderate exertion related to ... CHF ..." and indicated the skilled nurse was to "Assess v/s and all systems Q visit. Report v/s outside parameters associated with clinical signs and symptoms to MD ... weight gain or loss of 5 pounds in one week ... SN required for observation and assessment of pt.'s unstable condition of cardiac ... conditions." Review of skilled nurse visits, dated 12/21/20, 12/28/20, 01/05/21, 01/12/21, and 01/19/21, the only skilled nurse visits conducted during these weeks, did not include documentation regarding the patient's current weight. During an interview conducted on 02/03/21 at 12:27 p.m., the alternate administrator/supervising nurse, Employee B, said the weights were not obtained/assessed by the skilled nurse for Patients #4, 8, and 9 and the B12 injections were not administered by the skilled nurse for Patient #4 for the months of December 2020 and January 2021. Review of the agency's policy and procedure manual indicated the agency had adopted a policy titled, "Care Planning," dated June 1991, last revised, March 2020, which indicated, "It is the policy of this Agency to provide individualized, planned, appropriate care, treatment, and/or service based on the patient's/client's needs ... The care planning process will include the following ... Implementation of the planned care or services by appropriate clinicians and/or the patient/family."