Every finding on record at Cox Hps of the Ozarks, Inc.

A complaint investigation (71578) was completed on 10/04/2022 at the home health provider. The agency had 451 current patients. 403 current patients at the parent office in Springfield, 18 current patients at the branch office in Joplin, and 30 current patients at the branch office in West Plains. The complaint was not substantiated. None of the allegations reported were verified, but deficiencies were observed and cited in other areas that are not related to the original allegations being investigated. However, because the findings were standard level only, the provider remains in substantial compliance with the Medicare Condition of Participation for home health agencies.

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 policy review, clinical record review, and interview, the agency failed to ensure that services ordered by the physician were provided as indicated in the plan of care in two (Records/Patients #1 and #3) of three records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency’s policy titled, “Patient Refusal of All or Part of Care,” revised 06/29/2022 showed, “if the patient declines any visits, discipline(s), any procedures, or refuses any medications, the clinician will inform the patient of any consequences they may expect, notify the physician, and document that refusal in the medical record.” Review of the agency’s policy titled, “Interdisciplinary Team Approach,” revised 08/24/2022 showed, in part: - Direct care clinicians are obligated to promptly initiate direct telephone contact with the appropriate physician of any patient who; * Shows signs and symptoms that their condition is possibly deteriorating; and * Lacks orders or there are concerns regarding appropriateness of orders. Review of the agency’s policy titled, “Coordination of Care,” revised 08/17/2022, showed, in part: - The essential components of professional coordination of home care, treatment and services include but are not limited to the following; * Assessing and planning for the required services as ordered by the attending physician; and * Providing care, treatment and services according to the most recent orders, verbal or written. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to the agency on 05/03/2022 with a primary diagnosis of encounter for fitting and adjustment of urinary device (management of a urinary catheter) and additional diagnoses of diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), hypertensive chronic kidney disease (high blood pressure caused by the narrowing of the arteries that carry blood to the kidneys), and prostate cancer. The patient resides in his/her own home with his/her spouse. Review of the plans of care (POC), dated 07/02/2022 through 08/30/2022 and 08/31/2022 through 10/29/2022, showed: - A physician’s order for a home health aide (HHA) for bathing one time a week for nine weeks beginning 07/02/2022; - A physician’s order for physical therapy effective 07/29/2022 one time a week for one week, then two times a week for four weeks; and - An entry that stated that visits may be omitted for physician appointments, hospitalizations or patient refusals. Review of the HHA visit notes, with dates ranging from 06/28/2022 through 10/03/2022, showed a missed visit for the week of 07/02/2022 through 07/08/2022. Review of the document titled, “Case Communication, Service Order Note,” dated 07/05/2022 showed “omit home health aide visit for 07/06/2022, per patient request.” The agency failed to document any attempt to reschedule the visit and failed to notify the physician of the missed visit. Review of the physical therapy (PT) visit notes, with dates ranging from 07/29/2022 to 08/24/2022, showed a missed visit for the week of 08/20/2022 through 08/26/2022. Review of the document titled, “Case Communication Report,” dated 08/22/2022 showed the patient canceled the PT visit. The agency failed to document any attempt to reschedule the visit and failed to notify the physician of the missed visit. During an interview on 10/04/2022 at 11:00 AM, the administrator stated that, if there was a missed visit, physician notification and documentation was the expectation. He/she would expect the clinician to attempt to reschedule the visit with the patient. If they could not get the visit rescheduled he/she would expect the clinician to document the attempt to reschedule the visit and to notify the physician. During an interview with the administrator and the quality resource specialist on 10/04/2022 at 1:50 PM, the administrator stated that all the patient POCs state that visits may be omitted for physician appointments, hospitalizations or patient refusals. Both stated that they thought this entry in the POC excused the need to call the physician every time an ordered visit was missed. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to the agency on 07/21/2022 with a primary diagnosis of dehiscence (a separation of a previously closed wound/incision due to failure of proper wound healing) of a right leg below the knee amputation. The patient had additional diagnoses of diabetes mellitus and congestive heart failure (a chronic condition in which the heart doesn’t pump blood as well as it should). He/she received ongoing treatment at a wound care clinic and lived in his/her own home with his/her significant other. Review of the POC, dated 07/21/2022 through 09/18/2022 showed: - A physician’s order for skilled nursing (SN) to visit one time a week for one week, then two times a week for four weeks, then one time a week for two weeks; - A physician’s order for PT to visit one time a week for one week and then two times a week for eight weeks; and - An entry that stated that visits may be omitted for physician appointments, hospitalizations or patient refusals. Review of the physician’s order, dated 09/12/2022, showed that SN will visit one time a week for six weeks starting 09/19/2022. Review of SN visit notes, with dates ranging from 07/26/2022 to 09/29/2022, showed: - A missed visit for the following weeks: * 07/23/2022 through 07/29/2022 (only one of two visits were made); * 08/06/2022 through 08/12/2022 (only one of two visits were made); * 08/13/2022 through 08/19/2022 (only one of two visits were made); * 09/17/2022 through 09/24/2022 (zero of one visit was made); - The agency failed to document any attempts to reschedule the visits or the reason for the missed visits; and - The agency failed to notify the physician of the missed visits. Review of a wound clinic physician’s order, dated 08/10/2022, showed: - The order start date was to be 08/11/2022; - Return appointment on 08/15/2022 for wound vacuum placement; - Home health to see on Thursday for wound vacuum change; and - The order did not reduce the frequency of the agency’s SN visits. Review of the PT notes, with dates ranging from 07/22/2022 to 08/05/2022, showed: - No visits were documented for the week of 07/23/2022 through 07/29/2022 (two visits were ordered); - One missed visit for the week of 07/30/2022 through 08/05/2022 (only one of two visits were made); - The missed visits were documented as refusals; and - The agency failed to notify the physician of the missed visits. Review of document titled, “Case Communication Report,” dated 08/08/2022, showed: - Written in the subject heading: PT partial discharge; - A note that stated that the physical therapy assistant contacted the patient to schedule PT services for the week and the patient reported he/she does not require PT services at this time. The physician was notified of the patient’s refusal of future services; and - The agency failed to obtain an order to discharge the patient from PT services. During an interview on 10/04/2022 at 11:00 AM, the administrator stated that, if there was a missed visit, physician notification and documentation was the expectation. He/she would expect the clinician to attempt to reschedule the visit with the patient. If they could not get the visit rescheduled, he/she would expect the clinician to document the attempt to reschedule and to notify the physician. He/she thought the physician’s order from the wound clinic meant the frequency of the SN visits were reduced to once a week (on Thursdays). He/she stated that they should have clarified the order and clearly written the order to reduce the SN visit frequency to one time a week. He/she was not able to find an order to discharge the patient from physical therapy. He/she was unaware an order was needed. During an interview with the administrator and the quality resource specialist on 10/04/2022 at 1:50 PM, the administrator stated that all the patient POCs state that visits may be omitted for physician appointments, hospitalizations or patient refusals. Both stated that they thought this entry in the POC excused the need to call the physician every time an ordered visit was missed.