Every finding on record at Canyon Home Care & Hospice LLC

The following deficiencies were cited during a Federal Medicare complaint investigation and COVID-19 focused infection control survey of your agency conducted on 4/12/21. Surveyors conducting the complaint investigation and infection control survey were: Brian Osborn, RN, HFS, Team Lead Molly Lorden, RN, BSN, HFS Acronyms used in this report include: ALF - Assisted Living Facility CMS - Centers for Medicare and Medicaid Services COVID-19 - Coronavirus Disease 2019 GAD - Generalized Anxiety Disorder HH - Home Health HHA - Home Health Agency IM - Intramuscular MD - Doctor of Medicine mg - milligram ml/mls - milliliters NP - Nurse Practitioner OT - Occupational Therapy PCP - Primary Care Physician POC - Plan of Care PT - Physical Therapy RNCM - Registered Nurse Case Manager SN - Skilled Nursing ST - Speech Therapy VO - Verbal Order VORB - Verbal Order Read Back

Patient rights CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on medical record review, patient rights information review, guardianship document review, policy review, and staff interview, it was determined the agency failed to ensure patient rights and agency discharge notification were discussed and promoted for patients with a court-appointed guardian. This resulted in patients' rights not being upheld. Findings include: 1. Refer to G-424, as it relates to the failure of the agency to promote patient rights for patients who had a court-appointed guardian. 2. Refer to G-442, as it relates to the failure of the agency to ensure patients were given written notification of discharge from services at least 2 days prior to the termination of home health services. The cumulative effect of these systemic issues impeded the ability of the agency to protect the rights of patients.

Exercise of rights CFR(s): 484.50(b)(1)(2)(3) Standard: Exercise of rights. (1) If a patient has been adjudged to lack legal capacity to make health care decisions as established by state law by a court of proper jurisdiction, the rights of the patient may be exercised by the person appointed by the state court to act on the patient's behalf. (2) If a state court has not adjudged a patient to lack legal capacity to make health care decisions as defined by state law, the patient's representative may exercise the patient's rights. (3) If a patient has been adjudged to lack legal capacity to make health care decisions under state law by a court of proper jurisdiction, the patient may exercise his or her rights to the extent allowed by court order. This STANDARD is not met as evidenced by: Based on medical record review, patient rights information review, guardianship documents, policy review, and staff interview, it was determined the agency failed to promote patient rights for 1 of 1 patient who had a court-appointed guardian (Patient #2), and whose record was reviewed. This resulted in a patient and their court-appointed guardian not being consulted, informed, or involved in their POC. Findings include: Patient #2 was a 60 year old female who was admitted to the agency on 12/16/20, with a primary diagnosis of ruptured disks. Additional diagnoses included GAD, failure to thrive, and psychosis. She received SN, PT, OT, and ST services. Her record, including the POC, for the certification period of 12/16/20 - 4/14/21, was reviewed. Patient #2 was discharged from the agency on 3/03/21. 1. Patient #2's court-appointed guardian was not consulted, informed, or involved in her POC. Patient #2's medical record included a POC, dated 12/30/21, signed by her physician, which stated, "[Patient #2] is currently living in an ALF in payette [sic] and has a guardian through the state that signs all her paperwork [sic] I received VO from her prior to seeing pt [sic] guardian is [name]." Patient #2's medical record did not include documentation of her legal petition and/or legal guardianship acceptance of appointment. It could not be determined what role Patient #2's court-appointed guardian played in her POC. Patient #2's medical record included admission consent forms, dated 12/18/21, signed by her court-appointed guardian. However, there was no further documentation Patient #2's court-appointed guardian was involved in her POC. It could not be determined what role Patient #2's court-appointed guardian played in her POC. Patient #2's RNCM was interviewed via telephone on 4/12/21, beginning at 1:19 PM, and Patient #2's medical record was reviewed. When asked if she had consulted, informed, or involved Patient #2's court-appointed guardian regarding her POC and treatment, the RNCM stated, "no." The RNCM stated she was unaware of who Patient #2's court-appointed guardian was and what the court-appointed guardian's role was. The Clinical Manager was interviewed on 4/12/21, beginning at 1:34 PM, and Patient #2's medical record was reviewed in her presence. She stated she was unaware of Patient #2's court-appointed guardian's involvement in her POC. The Administrator, Clinical Manager, and Director of Quality were interviewed together on 4/12/21, beginning at 2:16 PM, and Patient #2's medical record was reviewed in their presence. They confirmed they did not have a copy of Patient #2's guardianship paperwork, nor were they aware of what role the court-appointed guardian played in Patient #2's treatment. When asked if there was a policy or procedure which governed court-appointed guardians for patients and staff, the Director of Quality stated, "no." The Administrator, Clinical Manager, and Director of Quality confirmed Patient #2's court-appointed guardian was not consulted, informed, or involved in her POC. Patient #2's assigned Program Manager for the Idaho Board of Guardians was interviewed via phone, on 4/13/21, beginning at 10:20 AM. She stated the last time she was contacted by the HHA was to sign admission consents and that Patient #2 would receive a PT evaluation. The Program Manager stated she was not consulted, informed, or involved in Patient #2's POC. She stated she was unaware Patient #2 had been previously discharged from home health services. Patient #2's court-appointed guardian was not consulted, informed, or involved in her POC. 2. Patient #2 and her court-appointed guardian were not consulted, informed, or involved regarding her medication administration. Patient #2's "LETTERS OF GUARDIANSHIP AND CONSERVATORSHIP AND ACCEPTANCE OF APPOINTMENT," dated 3/26/21, signed by Clerk of the District Court of the Fourth Judicial District of the State of Idaho in and for the County of Ada, stated, "To the extent possible, [Patient #2] will be consulted regarding food choices and intake of food and medicine." This legal document was not followed. An agency policy "ADMINISTRATION OF PATIENT MEDICATIONS," reviewed 1/26/21, stated, "Patient/family/Primary Caregivers...Need to be educated regarding the purpose of the drug, expected action, dosage, potential side effects, and time frame of administration." This policy was not followed. Patient #2's medical record included an ST visit note, dated 12/26/21, signed by her speech therapist, which stated, "Patient also asking about B12 shot that she reports she was receiving monthly before." Patient #2's medical record included an ST visit note, dated 1/13/21, signed by her speech therapist, which stated, "PCP notified that patient continues to ask about B12 injection with PCP reporting back patient is taking oral B12." Patient #2's medical record included an ST visit note, dated 1/15/21, signed by her speech therapist, which stated, "Patient educated she was receiving vitamin B12 as an oral medication. Patient was not aware of this with written report left with ALF asking them to let patient know which of medications is the B12." Patient #2's medical record included a medication order, dated 1/20/21, signed by her FNP, which stated, "Please add on skilled nursing for monthly Haldol injections" and "Haldol deconate 50 mg/ml injection...inject 1.5 mls into muscle [every] 30 days". It could not be determined if Patient #2's court-appointed guardian was notified of the change in her POC. Patient #2's medical record included an SN visit note, dated 1/22/21, signed by her RNCM, which stated, "SN assessment added to pts care for the need of a [sic] IM injection of Haldol due to increased disruptive behaviors and order from [name] her PCP." Patient #2's medial record included a "Canyon Home Care & Hospice [ALF] Care Coordination Form, dated 1/22/21, signed by her RNCM, which documented IM Haldol administration. The Mayo Clinic website, accessed on 4/13/21, stated, "Haloperidol injection is used to treat schizophrenia. This medicine should not be used to treat behavior problems in older adult patients who have dementia-related psychosis." Patient #2's medical record did not include documentation she, or her court-appointed guardian, was informed of Haldol's expected action, dosage, potential side effects, and time frame of administration. The RNCM who administered Haldol to Patient #2 on 1/22/21 could not be interviewed due to the fact she resigned her position on 2/01/21. The RNCM who took over Patient #2's SN care after 2/01/21 was interviewed via phone on 4/12/21, beginning at 1:19 PM, and Patient #2's medical record was reviewed in her presence. When asked if she was familiar with Patient #2's IM Haldol administration, the RNCM stated, "yes." The RNCM stated Patient #2 received SN services specifically for IM Haldol injections every 30 days. She stated Patient #2 had received 2 IM Haldol injections to her knowledge: 1 administered by the previous RNCM and 1 administered by her. The RNCM stated she was unsure what date she administered Patient #2's IM Haldol injection, but she believed it was "7 days after 2/12/21." When asked if there was anything unusual about Patient #2's IM Haldol injection, the RNCM stated, "yes." She stated she was told by "ALF staff to not inform Patient #2 she was receiving IM Haldol due to the fact she would refuse the injection, but rather tell her it was a "vitamin shot." The RNCM stated she told Patient #2 she was injecting "Vitamin H," not Haldol. When asked why she was untruthful with Patient #2, the RNCM stated it was for the purpose of ensuring compliance. When asked if she involved Patient #2's court-appointed guardian in the decision to be untruthful with Patient #2's medication administration, the RNCM stated, "no." The RNCM confirmed she should have been truthful regarding Patient #2's medication administration. The Clinical Manager was interviewed on 4/12/21, beginning at 1:34 PM, and Patient #2's medical record was reviewed in her presence. She confirmed Patient #2's second IM Haldol injection and SN visit note were not documented by her RNCM. When asked if she was aware Patient #2's RNCM was untruthful regarding her medication administration, the Clinical Manager stated, "no." The Clinical Manager stated she was, however, aware Patient #2's ALF staff were being untruthful with her regarding her medication administration. When asked if the ALF staff's actions with Patient #2 were brought to the attention of agency administration, she stated, "no." When asked if the ALF staff's actions with Patient #2 were brought to the attention of Patient #2's court-appointed guardian, the Clinical Manager stated, "no." When asked if an incident report or ethics inquiry were documented for Patient #2, the Clinical Manager stated, "no." When asked if it was appropriate for Patient #2's RNCM to be untruthful regarding her medication administration, the Clinical Manager stated, "no." Finally, when asked if Patient #2's IM Haldol administration issues were discussed and/or documented during case conferences, the Clinical Manager stated, "no." The Director of Quality, Administrator, and Clinical Manager were interviewed together on 4/12/21, beginning at 2:16 PM, and Patient #2's medical record was reviewed in their presence. The Director of Quality and Administrator stated it was not appropriate for Patient #2's RNCM to be untruthful regarding her IM Haldol administration. The Director of Quality and Administrator confirmed Patient #2's court-appointed guardian was not informed of her medication administration issues. Patient #2's assigned Program Manager for the Idaho Board of Guardians was interviewed via phone, on 4/13/21, beginning at 10:20 AM. She stated she was not informed HHA staff were being untruthful with Patient #2's medication administration to ensure compliance. Patient #2 and her court-appointed guardian were not consulted, informed, or involved regarding her medication administration. 3. Patient #2 and her court-appointed guardian were not consulted, informed, or involved in advance of agency discharge. Agency patient rights information, included in all patient admission packets, stated, "Prior to a scheduled discharge, you and/or your family and physician will be notified of the discharge." These rights were not followed. Patient #2's medical record included a "Physician Communication," dated 3/02/21, signed by the Clinical Manager, which stated, "VORB from [name], NP to DC patient from HH services as he is no longer providing services. [sic] for this patient." Patient #2's medical record included an "Interdisciplinary Communication," dated 3/03/21, signed by her RNCM, which stated, "3/2/21 discharge note: Pt is being discharged per dr [sic] order. So a non visit discharge is done for HH services." Patient #2's medical record included a discharge OASIS note, dated 3/05/21, signed by her RNCM, which stated, "DISCHARGE REASON...CHANGE IN PAYOR...INSURANCE PROVIDER DENIAL...MD AGREEMENT." It is unclear why insurance provider denial was documented as the reason for discharge instead of the previous VO which stated Patient #2's NP was no longer providing services. It could not be determined if Patient #2 met her home health goals or if she needed additional home health services. Additionally, it was unclear why the HHA did not attempt to secure an alternate physician to manage Patient #2's home health needs, if appropriate. Patient #2's medical record did not include documentation her court-appointed guardian was notified of her agency discharge. Patient #2's RNCM was interviewed on 4/12/21, beginning at 1:19 PM, and Patient #2's medical record was reviewed in her presence. She stated Patient #2 was discharged because her NP was no longer following her care. The RNCM stated she was unsure why another physician was not secured to ensure continuity of home health care for Patient #2. Additionally, she confirmed Patient #2 and her court-appointed guardian were not notified of an agency discharge prior to her discharge date. The Director of Quality, Administrator, and Clinical Manager were interviewed together on 4/12/21, beginning at 2:16 PM, and Patient #2's medical record was reviewed in their presence. They confirmed it was unclear if Patient #2's goals were met prior to discharge. The Director of Quality stated it was unusual why another physician was not secured to ensure continuity of home health care for Patient #2. The Director of Quality, Administrator, and Clinical Manager confirmed Patient #2 and her court-appointed guardian were not notified of an agency discharge prior to her discharge date. Patient #2's assigned Program Manager for the Idaho Board of Guardians was interviewed via phone, on 4/13/21, beginning at 10:20 AM. She stated she had not been informed Patient #2 had been discharged from home health services. Additionally, the Program Manager stated she had not been informed the agency was considering discharging Patient #2 from home health services. Patient #2 and her court-appointed guardian were not consulted, informed, or involved in advance of agency discharge.

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on medical record review, CMS NOMNC instructions review, and staff interview, it was determined the agency failed to ensure patients were given written notification of discharge from services at least 2 days prior to the termination of home health services for 1 of 3 discharged patients (Patient #2) whose records were reviewed. This had the potential to interfere with patients' ability to appeal the agency's decision to terminate coverage for services. Findings include: The "CMS Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123" state, "A Medicare provider or health plan (Medicare Advantage plans and cost plans, collectively referred to as "plans") must deliver a completed copy of the Notice of Medicare Non-Coverage (NOMNC) to beneficiaries/enrollees receiving covered skilled nursing, home health (including psychiatric home health), comprehensive outpatient rehabilitation facility, and hospice services. The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily." These instructions were not followed. Patient #2 was a 60 year old female who was admitted to the agency on 12/16/20, with a primary diagnosis of ruptured disks. Additional diagnoses included GAD, failure to thrive, and psychosis. She received SN, PT, OT, and ST services. Her record, including the POC, for the certification period of 12/16/20 - 4/14/21, was reviewed. Patient #2 was discharged from the agency on 3/03/21. Patient #2's medical record did not include a NOMNC form signed by her or her court-appointed guardian. It was unclear if Patient #2 and her court-appointed guardian were given the information needed to appeal her agency discharge. The Director of Quality was interviewed on 4/12/21, beginning at 4:15 PM, and Patient #2's medical record was reviewed in her presence. She confirmed Patient #2's medical record did not include a NOMNC form signed by her or her court-appointed guardian. The agency failed to ensure Patient #2 and her court-appointed guardian were given written notification of discharge from services at least 2 days prior to the termination of home health services.