Every finding on record at Dallas County Medical Center Home Care, LLC

On 2/15/22 at 9:00 AM, an entrance conference was conducted with Agency Representatives. The Agency was informed the purpose of the visit was to conduct a Medicare Recertification survey for compliance with the Conditions of Participation for Home Health. On 2/18/22 at 1:15 PM an exit conference was conducted with Agency Representatives. Preliminary findings of the survey were discussed.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on Clinical Record review and staff interview, it was determined the Agency staff failed to monitor, record, and report circumferences for edema in 1 (#10) of 2 (#10 and #16) of 17 (#1 - #17) Clinical Records reviewed. This failed practice had the potential to affect the quality of care received by all patients currently on census, in that, there was a risk of adverse outcome, potential to affect the attainment of the patients individual goals and a risk of hospitalizations due to disease exacerbation. 1. Review of Clinical Record #10 revealed the following: A. Document titled "Home Health Certification and Plan of Care (POC)" dated 1/9/22 to 3/9/22 listed a primary diagnosis of Chronic Kidney disease with Heart Failure. The POC contained orders for the Skilled Nurse (SN) to provide instructions related to heart failure and possible complications of heart failure. The order included that If the Patient was unable to stand for the SN to observe for edema, notify MD if edema to lower extremities are greater than 2+ B. A document titled "Visit Note Report" dated 1/18/22, the Physical Therapist (PT) documented the Patient "complained of more SOB (shortness of breath) than normal with minimal exertion and increased fluid retention in abdomen on R (right) side." PT documented notified (named RN) at home health agency of changes. Named RN was scheduled to visit Patient on 1/18/22. C. A document titled "Visit Note Report dated 1/18/22, documentation by the SN shows the Patient had "non-pitting" edema to lower right and left extremities. The RN documented the Patient had a cough with sputum and was short of Breath at rest. There was no evidence the RN measured the circumference of the right and left extremities with the edema as ordered on the POC. D. A document titled "Visit Note Report dated 1/25/22, documentation by the SN shows the Patient is SOB and has non-pitting edema. There was no evidence circumferences were measured by the SN. E. A document titled "Visit Note Report" dated 1/31/22 showed documentation by the RN the Patient was transferred to the hospital on 1/28/21 due to "Heart Failure, fluid overload." 2. During an interview on 2/18/22 at 1:00 PM, Agency Representatives were provided an opportunity to present additional documentation. With no additional documentation presented, Agency Personnel #1 confirmed the Agency staff failure to measure Patient #10 circumferences as ordered. .

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on Clinical Record review and staff interview, the Licensed Practical Nurse (LPN) did not communicate with the Registered Nurse (RN) information regarding Patient status and health needs in 2 (#10 and #16) of 17 (#1 - #17) Clinical Records reviewed. The deficient practice identified, placed the patient at risk of adverse outcomes and hospitalization, in that patient specific data was not communicated timely to the RN for follow - up. 1. Review of Clinical Record #10 revealed the following: A. Document titled "Home Health Certification and Plan of Care", dated 1/9/22 to 3/9/22 showed a primary diagnosis of Hypertensive Heart Failure with orders for the Skilled Nurse (SN) to provide instructions of signs and symptoms of heart failure, measures to manage heart failure and possible complications of heart failure, to perform pulse oximetry with Oxygen on to monitor patient's respiratory status. B. Review of a document titled "Visit Note Report", dated 1/25/22 showed documentation by the Licensed Practical Nurse (LPN) that Patient #10 reported shortness of breath with minimal exertion and the Patient had non pitting edema to both right and left lower extremities. There was no evidence the LPN reported the findings to the Home Health Agency (HHA) RN. C. Review of a document titled "Visit Note Report" dated 1/31/22 showed Patient #10 was admitted to the hospital for heart failure and fluid overload. 2. Review of clinical record #16 revealed the following: A. Review of a document titled "Home Health Certification and Plan of Care", dated 10/26/21 to 12/24/21 showed a primary diagnosis of hypertensive heart disease with heart failure and included orders for the SN to provide instructions related to heart failure including measures to prevent heart failure, signs and symptoms of heart failure, measures to manage heart failure and possible complications of heart failure and to report to doctor a weight gain of 2 pounds overnight or 5 pounds over one week. B. Review of a document titled " Visit Note Report" dated 12/7/21 showed documentation by the LPN Patient #16 was short of breath with minimal exertion and was on Oxygen. Further documentation by the LPN showed Patient's pulse Ox (Oxygen) readings at 93% and Oxygen use at use at 2 liters. The LPN also documented the Patient "refused" to be weighed during the LPN visit . There was no evidence the LPN reported the Patient's refusal to weigh to the HHA RN for follow-up and possible change of the plan of care. C. Review of a document titled "Visit Note Report" dated 12/13/21 showed documentation by the RN that Patient #16 was transferred to the hospital due to heart failure and fluid overload. 2. During an interview on 2/18/22 at 1;00 PM, Agency Representatives were provided an opportunity to present additional documentation. With no additional documentation presented, Agency Personnel #1 confirmed the LPN's failure to communicate with the RN information regarding Patient status and health needs .