Every finding on record at Community Health Center of St. Mary's Healthcare & Nathan Littauer Hospital, Inc

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 clinical record review and staff interview the agency failed to ensure a complete Plan of Care (POC) was developed to meet the individualized needs of the patient in five of eighteen patient records (Patient # 2, 3, 4, 6 and 14). Failure to develop a comprehensive POC has the potential for unmet patient needs and places patients at risk for receiving incorrect and/or inappropriate care. Findings: Patient # 2 (start of care 07/28/2021) has diagnoses of Hypertensive Heart Disease with Heart Failure and Acute on Chronic Diastolic (Congestive) Heart Failure. The POC for certification period 07/28/2021 through 09/25/2021 contains an order for Levothyroxine 112 micrograms (mcg) tablet, one tablet oral once a day am. The order is incomplete as it lacks instructions to take the medication one half hour to one hour prior to consuming food. Patient # 3 (start of care 08/14/2021) has diagnoses of Encounter for other Orthopedic Aftercare and Lumbago with Sciatica, Right Side. The POC for certification period 08/14/2021 through 10/12/2021 contains order for: - Acetaminophen- Hydrocodone 5/325, one tablet oral every four hours as need (prn) pain. Take for pain greater than (>) five. . - Acetaminophen-Hydrocodone 10/325, one tablet oral every four hours prn pain. Take for pain > 5. - Tylenol 500 milligrams (mg) two tablets oral every eight hours prn pain. Take for pain > 5. The above orders require clarification of which medication is to be taken for pain > 5. Patient # 4 (start of care 04/26/2021) has diagnoses of Type II Diabetes Mellitus with Foot Ulcer and Non-pressure Chronic Ulcer of Right Heel/Midfoot with bone involvement without evidence of Necrosis. The POC for certification period 08/24/2021 though 10/22/2021 contains an order for Chlorthalidone 25, one tablet oral once a day. The order is incomplete as it lacks the complete dosage (i.e. mg, mcgs, grams, etc.). Patient # 6 (start of care 07/05/2021) has diagnoses of Encounter for Surgical Aftercare following surgery on the Digestive System and Dysphagia. The POC for certification period 07/05/2021 through 09/02/2021 contains orders for: - Levothyroxine 25 mcgs one tablet oral once a day. The order is incomplete as it lacks instructions to take the medication one half hour to one hour prior to consuming food. - Polyethylene Glycol 3350, 17 gram oral every twelve hours times five days. The order is incomplete as it lacks the form (i.e. tablet, liquid, powder, etc.). Patient # 14 (start of care 06/25/2021, discharged 08/22/2021) has diagnoses of Pressure Ulcer of Sacral Region, Stage 3 and Pressure Ulcer of Left Heel, Stage 3. The POC for certification period 06/25/2021 through 08/23/2021 states the patient is to check Complete Blood Glucose daily. The POC is incomplete as it lacks needle disposal precautions. The findings were confirmed on 08/24/2021 at 10:50 AM and 2:50 PM, 08/25/2021 at 11:00 AM and 08/26/2021 at 8:20 AM with the Director of Patient Services; no additional evidence was provided.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview evidence is lacking in one of eighteen patient records (Patient # 3) the physician was contacted regarding changes that alter or suggest the need to alter the Plan of Care (POC). Failure to consult with the physician when changes occur in the patient's condition has the potential for unmet patient needs and/or negative patient outcomes. Finding: Patient # 3 (start of care 08/14/2021) has diagnoses of Encounter for Orthopedic Aftercare and Lumbago with Sciatica, Right Side. The POC for certification period 08/14/2021 through 10/12/2021 states the physician is to be notified for weight gain of of 2 pounds (lbs.) in one day or 5 lbs. in one week. The record contains a Physical Therapist (PT) note (dated 08/16/2021) that documents the patient's weight as 198 lbs. The record also contains a PT note (dated 08/18/2021) that documents the patient's weight as 207 lbs., an increase of 9 pounds in 2 days. The record lacks any documented evidence the physician was notified. The record contains a Skilled Nurse note (dated 08/18/2021) that documents the patient's weight as 217 lbs., a increase of 19 lbs. The record lacks any documented evidence the physician was notified. The findings were confirmed on 08/24/2021 at 10:50 AM with the Director of Patient Services; no additional evidence was provided.