Every finding on record at Five Points Healthcare of Nc LLC

An unannounced, on-site recertification survey was conducted 03/21/22 to 03/24/22. No deficiencies to the Emergency Preparedness program were identified.-MHB

An unannounced, onsite recertification and follow up survey was conducted 03/21/22 to 03/24/22. Standard level deficiencies to the Medicare Conditions of Participation were identified. -MHB

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review and staff interview, the agency, failed to add a new medication to the Plan of Care for 1 of 13 clinical records reviewed (Patient #1) and failed to obtain weight parameters for 1 of 2 patients (Patient #2) with heart failure. Findings included: Policy titled Physicians Orders – Verbal Orders, revised March 2018, was received from the agency director on 03/24/22 at 3:41 PM. This policy revealed, “Drugs and treatments are administered by the Agency staff only as ordered by a physician…Verbal orders are put in writing and signed and dated by the RN (registered nurse) or qualified therapists responsible for furnishing or supervising care” and “…the original order is documented and authenticated by the licensed staff and submitted to the Agency within three (3) business days after receipt(s)…” Patient #1 was admitted to the agency on 01/20/22 with diagnoses including post-viral fatigue syndrome, hypoxemia (low blood oxygen level), post COVID-19 condition, chronic obstructive pulmonary (lung) disease, atherosclerotic heart disease (heart disease caused by build-up in the arteries of the heart), hypertensive chronic kidney disease (kidney disease caused by high blood pressure), Type 2 diabetes, osteoarthritis, bladder cancer, and atrial fibrillation (abnormal heart rhythm). Plan of Care from 01/20/22 to 03/20/22 revealed orders for physical therapy 1 time per week for 1 week, 2 times per week for 1 week, and 1 time per week for 7 weeks. Medications included on the same Plan of Care included the following: Aspirin 81 milligrams daily Atorvastatin 10 milligrams one time daily Metoprolol tartrate 100 milligrams two times daily Metoprolol tartrate 50 milligrams one time daily Multivitamin tablet one time daily Vitamin C 500 milligrams daily Vitamin D3 25 micrograms Two capsules daily Xarelto 7.5 milligrams daily Zinc 50 milligrams daily Employee #14, physical therapy assistant, visited Patient #1 on 02/03/22. This visit note revealed, “…Patient began Amiodarone 100 mg (milligrams) once daily effective 1/31/2022, but did begin [sic] until 2/3/2022 due to the medication not being in stock…” There was no evidence that this medication was added to Patient #1’s plan of care at the time of survey. In an interview on 03/23/22, Employee #1, the agency director, stated that the system that the agency uses for electronic documentation does not allow a physical therapy assistant to make updates to the patient’s medication list. Employee #1 stated that in Patient #1’s case, any updates to the patient’s medication list would need to be added by the supervising physical therapist. In an interview on 03/24/22 at approximately 12:00 PM, Employee #14, the physical therapy assistant, stated that she verbally updated Employee #2, the supervising physical therapist, regarding Patient #1 starting Amiodarone as a new medication on 02/03/22. Employee #14 stated, “…we usually communicate over the phone…I would call him to satisfy regulations…” In an interview on 03/24/22 at approximately 12:30 PM, Employee #2 stated, “Typically the PTAs (physical therapy assistants) are very good as far as notifying me if there is an update in medication. There is a good chance that I may not have put it in. I will be honest, every now and then, I may forget to put it in. To be honest, I do remember [Employee #14] mentioning that (Patient #1 starting Amiodarone on 02/03/22) to me as well.” 2. Patient #2 was admitted to the agency on 02/07/22 with diagnoses including hypertensive heart disease with heart failure, acute on chronic diastolic congestive heart failure (heart disease affecting the pumping action of the heart), muscle weakness, chronic obstructive pulmonary (lung) disease, and atrial fibrillation (abnormal heart rhythm). Plan of Care from 02/07/22 to 04/07/22 revealed orders for skilled nursing 1 time per week for 4 weeks and 2 PRN (as needed) for falls or infection, physical therapy 1 time per week for 1 week and 2 times per week for 2 weeks, and occupational therapy 1 time per week for 1 week and re-evaluation the week of 02/27/22. Orders of disciplines and treatments included, “Occupational therapist to evaluate for OT services and develop plan of care for physician signature to include physical and psychosocial test results, establishment of a plan of treatment, rehabilitation goals, and evaluating the home environment for accessibility and safety and recommending modification. Therapist may perform O2 (oxygen) saturation level at evaluation visit and PRN for signs and/or symptoms of possible respiratory complications or with O2 use. Medical condition requiring skilled therapy for services include weakness.” The following parameters were documented for licensed professional to report vital signs: Temperature less than 95 or greater than 101; pulse less than 50 or greater than 100; respirations less than 12 or greater than 24; systolic (top number) blood pressure less than 90 or greater than 180; diastolic (bottom number) blood pressure less than 50 or greater than 90; fasting blood sugar less than 70 or greater than 300; random blood sugar less than 60 or greater than 400; pain greater than 7 (on a 0 to 10 scale); oxygen saturation less than 90. There was no evidence of weight parameters to report to the physician. Employee #13, an occupational therapy assistant, visited Patient #2 on 03/14/22. Vital signs taken during this visit included temperature, pulse, respirations, blood pressure, and weight. In an interview on 03/24/22 at approximately 11:30 AM, Employee #1, the agency director, confirmed that there were no reportable weight parameters and stated, “We will make sure to have that moving forward.”

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and staff interview, the agency provided wound care without an order for 1 of 5 patients (Patient #8) with wounds. Findings included: Policy titled Physicians Orders – Verbal Orders, revised March 2018, was received from the agency director on 03/24/22 at 3:41 PM. This policy revealed, “Drugs and treatments are administered by the Agency staff only as ordered by a physician…” Patient #8 was admitted to the agency on 04/03/19 with diagnoses including Parkinson’s (a progressive movement disorder) disease, osteoarthritis of the right knee, osteoarthritis of the right shoulder, chronic pain syndrome, and hypertension. Plan of Care from 07/21/21 to 09/18/21 included orders for physical therapy 1 time per week for 8 weeks and home health aide 1 time per week for 8 weeks. Employee #9, home health aide, conducted a visit on 08/03/21 and documented “Open wounds on buttocks, redness under breast…Blood pressure elevated 190/104. I reported to [Employee #8, supervising physical therapist] and [Employee #1, agency director].” On 08/31/21 the agency obtained an order for skilled nursing to evaluate and treat. On 09/01/21, Employee #4, registered nurse, conducted a skilled nursing visit. This visit note revealed documentation of a Stage II wound (partial thickness skin loss of first and/or second layer of skin) of the right buttock measuring 0.8 centimeters length by 0.3 centimeters width by 0.1 centimeters depth with the treatment documented as “Cleansed with soap and water. Alginate dressing applied to wound bed. Covered with foam dressing.” This visit note also revealed documentation of a Stage II wound to the left buttock measuring 2.0 centimeters length by 1.3 centimeters width by 0.1 centimeters depth with the treatment documented as, “Cleansed with soap and water. Applied alginate dressing to wound bed. Covered with bordered foam.” There was no evidence in the clinical record of a physician’s order for the wound care treatments performed on 09/01/21. In an interview on 03/23/22 at approximately 4:10 PM, Employee #1, the agency director, confirmed that there was no evidence in the clinical record of a physician’s order for the wound care treatments performed on 09/01/21 and stated, “Normally the nurse would write a plan of care addendum that the physician would sign as an update to the plan of care.”

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and staff interview, the agency failed to document coordination of care regarding a new wound for 1 of 5 patients (Patient #4) with wounds, failed to notify a physician that a patient was not monitoring her blood glucose levels for 1 of 5 patients (Patient #5) with diabetes, and failed to notify the physician of vital signs outside of parameters for 1 of 13 clinical records (Patient #8) reviewed. Findings included: Policy titled Coordination of Patient Care, revised March 2019, was received from the agency director on 03/24/22 at 3:41 PM. This policy revealed, “The Agency must: Assure communication with all physicians involved in the plan of care…Agency staff members regularly communicate to ensure their efforts are coordinated effectively and ultimately support the objectives outlined in the plan of care...”. This policy also revealed, “…Staff provides the physician with patient information on an ongoing basis regarding: Current condition and changes in condition…Outcomes of care and service…Changes in the environment and/or caregiver support…Results of relevant laboratory services” and “Coordination of agency’s internal resources includes…assuring all involved staff members are aware…” 1. Patient #4 was admitted to the agency on 02/01/22 with diagnoses including non-pressure, chronic ulcer (abdominal wound), Type 2 diabetes, chronic obstructive pulmonary (lung) disease, hypertension, and atrial fibrillation (abnormal heart rhythm). Skilled nursing services were ordered 2 times per week for 4 weeks, 1 time per week for 5 weeks, and 3 PRN (as needed) for falls, infection, or disease process exacerbation. Employee #7, licensed practical nurse, visited Patient #4 on 03/11/22 and documented, “…Pleasant mood but complains of pain in top buttock area. SN (skilled nurse) noted reddened area and small opening. Cleaned and covered with bordered foam. SN encouraged patient to stay off area and increase protein intake. Physician notified. Left voice message.” There was no evidence in the clinical record of documentation that Employee #7 notified the registered nurse case manager of this new wound. Employee #5, the registered nurse case manager, visited Patient #4 on 03/16/22. There was no documentation regarding a wound to Patient #4’s buttocks in this visit note. In an interview on 03/23/22 at 4:23 PM, Employee #1, the agency director, confirmed that there was no documentation in the clinical record regarding a buttocks wound after the 03/11/22 skilled nursing visit. In an interview on 03/23/22 at 5:10 PM, Employee #7 stated, “I did not get a follow up call (from the physician after leaving a message regarding the wound) but I did report that to the case manager.” When asked if there was documentation regarding reporting the wound to the case manager, Employee #7 stated, “No…I don’t recall.” 2. Patient #5 was admitted to the agency on 01/30/22 with diagnoses including COVID-19, orthostatic hypotension (low blood pressure related to changes in position), hypertensive chronic kidney disease (kidney disease related to high blood pressure), Type 2 diabetes mellitus, atrial fibrillation (an abnormal heart rhythm), pulmonary hypertension (a type of high blood pressure affecting the arteries of the lungs and right side of the heart), and obstructive sleep apnea (a sleep disorder where breathing is interrupted multiple times during sleep). Plan of Care from 01/30/22 to 03/30/22 revealed orders for skilled nursing 2 times per week for 1 week, 1 time per week for 8 weeks and 2 PRN (as needed) for falls, disease exacerbation, and infection; physical therapy 1 time per week for 1 week, 2 times per week for 3 weeks, and 1 time per week for 5 weeks; occupational therapy 1 time per week for 1 week; and home health aide services effective 02/06/22 at 1 time per week for 8 weeks. Skilled nursing discipline orders included, “…Skilled nurse to assess/evaluate co-morbid conditions including DM (diabetes mellitus), a-fib (atrial fibrillation) and other conditions that present themselves during the course of this episode to identify changes and intervene to minimize complications.” Employee #7, licensed practical nurse, conducted a skilled nursing visit on 02/02/22. This visit note revealed, “…Patient stated that she has not been checking her BS (blood sugar) due to being out of strips but that she plans to pick up more.” Employee #12, registered nurse case manager, conducted a skilled nursing visit on 02/09/22. This visit note revealed, “…How frequent are blood sugars checked? Usually 3 times daily but out of strips…hasn’t checked blood sugar since got [sic] out of the hospital over a week ago…” Employee #7 conducted a skilled nursing visit on 02/17/22. This visit note revealed, “…Patient is out of strips and has not been to Walmart to get more…” Employee #12 conducted a skilled nursing visit on 02/23/22. There was no evidence that Patient #5’s blood glucose level was addressed during this visit. Employee #7 conducted a skilled nursing visit on 03/03/22. There was no evidence that Patient #5’s blood glucose level was addressed during this visit. Employee #7 conducted a skilled nursing visit on 03/16/22. There was no evidence that Patient #5’s blood glucose level was addressed during this visit. There was no evidence in the clinical record that the physician was notified regarding Patient #5 not checking her blood glucose level. In an interview 03/23/22 at approximately 5:05 PM, when asked if Patient #5 had any strips to check her blood glucose level, Employee #7, licensed practical nurse, stated, “No, from my last visit, which I think was last week…her response every time is that she hasn’t gotten around to go and get them.” When asked if the physician would typically be notified regarding this type of noncompliance, Employee #7 stated, “Yes, it is something that I typically do, but I just hadn’t…I was trying to give her a chance to get them.” In an interview on 03/23/22 at approximately 5:10 PM, Employee #1, agency director, stated, “The expectation is that they (clinicians) communicate it to the physician and/or one of us (clinical manager or agency director)…All of that coordination would be documented.” In an interview on 03/24/22 at approximately 12:00 PM, Employee #12, the registered nurse case manager, stated, “My information regarding that would be in the record…I have not seen her recently.” Employee #12 stated that she did not have any additional recollection because she had not visited the patient recently. Employee #1 was also present during this interview and stated that Employee #12 had not visited Patient #5 recently. 3. Patient #8 was admitted to the agency on 04/03/19 with diagnoses including Parkinson’s disease (a progressive movement disorder), osteoarthritis of the right knee, osteoarthritis of the right shoulder, chronic pain syndrome, and hypertension. Plan of Care from 07/21/21 to 09/18/21 included orders for physical therapy 1 time per week for 8 weeks and home health aide 1 time per week for 8 weeks. The following parameters were documented to report vital signs to the physician: Temperature less than 96 or greater than 100; pulse less than 60 or greater than 100; respirations less than 12 or greater than 32; systolic (top number) blood pressure less than 90 or greater than 160; diastolic (bottom number) blood pressure less than 60 or greater than 100; oxygen saturation less than 90. Employee #9, home health aide, conducted a visit on 08/03/21 and documented “Open wounds on buttocks, redness under breast…Blood pressure elevated 190/104. I reported to [Employee #8, supervising physical therapist] and [Employee #1, agency director].” There was no additional documentation in the clinical record regarding Patient #8’s elevated blood pressure that occurred on 08/03/21. In an interview on 03/23/22 at approximately 4:00 PM, Employee #1, agency director, confirmed that there was no evidence in the clinical record regarding Patient #8’s elevated blood pressure on 08/03/21. Employee #1 stated, “We have notes about what was done for the skin, but not the blood pressure.”