Every finding on record at Gilead Community Home Health Inc

A complaint investigation was conducted for complaint, Intake 465158/1Q102808 on 11/20/2023. The licensed and certified home health services census was 110. Acronyms/Abbreviations: Adm/DON-Administrator/Director of Nursing Alt Adm-Alternate Administrator ADON-Alternate Director of Nursing Clinical Mgr.-Clinical Manager Office Mgr.-Office Manager Registered Nurse (RN) Licensed Vocational Nurse (LVN) POC- Plan of Care SN/SNV- Skilled Nursing/Visit PT-Physical Therapy LCHHS-Licensed and Certified Home Health Services FSBS-Fingerstick Blood Sugar SOC-Start of Care

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 record review and interview the agency failed to ensure services were provided that were ordered by a physician as indicated in the plan of care in two (Patient # 3 and 4) of three patient records reviewed who received skilled nursing services, in that: the agency failed to ensure that FSBS was monitored and calf measurements were completed as indicated in the plan of care. The failure could place the patients’ health and safety at risk if the patients’ health care needs were not monitored and were not met. The failure could lead to unnecessary hospitalizations. Findings include: Patient # 3 Record review of Patient # 3’s LCHSS clinical record revealed a POC with a SOC date of 04/19/2022 and a treatment period of 10/11/2023 to 12/09/2023. Review of the POC revealed that it was dated 10/11/2023 and signed by RN A. The POC included a primary diagnosis of pressure ulcer (a wound caused by continuous pressure to the skin) to left heel and a secondary diagnosis of hypertensive heart disease with heart failure (heart condition that happens with long term poorly managed high blood pressure). The POC also included orders for SN visits one time per week for one week and three times per week for eight weeks and PT to evaluate and treat. Continued review of the POC revealed the following, on page five of seven: “…Patient unable to safely stand for weight. SN to assess for edema and report LE (lower limb) edema (swelling) [greater than] 2+ (mild swelling) to physician…SN to measure calves each visit and report to [medical doctor] greater than 2-5 [centimeters] increase in swelling…” Further review of Patient # 3’s record revealed a physician order dated 10/20/2023 and signed by ADON. The order read in part: “…Patient was hospitalized on 10/20/2023 due to [shortness of breath] …” The clinical record also included a “A post Hospital Order” dated 10/27/3023. Review of the post hospital order revealed that it included the order to measure Patient # 3’s calves during each visit. Continued review of Patient # 3’s record revealed SN visit notes dated as follows: 10/20/2023; 10/30/2023; 11/01/2023; and 11/06/23, 11/08/23, 11/10/23, 11/13/23, 11/15/23 and 12/17/2023. The SN notes were signed by RN B. Review of the SN notes did not reveal that RN B had measured Patient # 3’s calves at each visit. The record did not include any documentation of communication with Patient # 3’s physician (Identifier 100) why RN B did not measure Patient # 3’s calves at each visit (to monitoring for swelling) as indicated in the plan of care. Patient # 4 Record review of Patient # 4’s LCHSS clinical record revealed a POC with a SOC date of 12/15/2022 and a treatment period of 10/11/2023 to 12/09/2023. Review of the POC revealed that it was dated 10/09/2023 and signed by the ADON. The POC included a primary diagnosis of Type 2 diabetes mellitus (chronic elevated levels of sugar in the blood) with foot ulcer (wound) and a secondary diagnosis of hypertension (chronic high blood pressure). The POC also included orders for SN visits two times per week for one week and three times per week for eight weeks. Continued review of the POC revealed the following orders: on page three of six: “Notify physician of…Fasting blood sugar greater than… 200 or less than…60 Random blood sugar greater than…250 or less than…70” and on page four of six: “…Patient unable to safely stand for weight. SN to assess for edema and report LE (lower limb) edema (swelling) [greater than] 2+ (mild swelling) to physician…SN to measure calves each visit and report to [medical doctor] greater than 2-5 [centimeters] increase in swelling…” The record also included orders for wound care dated 10/26/2023 and 11/09/2023. Continued review of Patient # 4’s record revealed SN visit notes dated as follows: 10/16/2023; 10/20/2023; 10/23/23, 10/25/23, 10/27/23, and 10/30/2023; 11/01/2023; and 11/15/23 and 11/17/2023. The visit notes were signed by LVN A. Review of the visit notes revealed that there was no documentation of blood sugar measurements. The notes read in part on the addendum page, “Patient does not check [FSBS, fingerstick blood sugar].” Further review of the SN notes did not reveal that LVN A had notified Patient # 4’s physician (Identifier 200) that Patient # 4’s blood sugar levels were not being monitored (to report blood sugar levels that were out of the ordered parameters). Continued review of the SN notes did not reveal that LVN A had measured Patient # 4’s calves at each visit. The record did not include any documentation of communication with Patient # 4’s physician (Identifier 200) why LVN A did not measure Patient # 4’s calves at each visit (to monitoring for swelling) as indicated in the plan of care. During an interview with RN B on 11/22/2023 at 2:30 p.m. the surveyor discussed the findings and asked why the calf measurements for Patient # 3 had not been completed at each visit, as indicated in the plan of care. RN B stated that he usually checked for “edema, but I guess I overlooked that.” During an interview with LVN A on 11/22/2023 2:30 p.m. and follow-up telephone interview on 12/07/2023 at 8:49 a.m. the surveyor discussed the findings and asked why the calf measurements were not completed, as indicated in the plan of care. LVN A stated that he was never told about the calf measurements. The surveyor also asked why there was no communication, documentation of coordination of care with Client # 4’s physician (Identifier 200) about the FSBS not being monitored. He stated that he reported to the supervisor but that it was his fault that he did not follow up on the communication to the physician. During an interview with the Adm/DON on 11/28/2023 at 1:15 p.m. the surveyor discussed the findings and asked how the failure to provide care and services, as indicated in the plan of care the POC could adversely affect the patients. The Adm/DON replied, “It could affect their health and safety.” She stated that if there was an increase in the patients’ fluid levels and they were not assessed properly, it could lead to other complications; it could lead to unnecessary hospitalizations. Review of agency policy titled, “Monitoring Patient Care/Coordination of Care PC.45” last reviewed 080120 read in part: “Purpose [:] To ensure coordination of patient/client care and treatment…Procedure I. The Agency will: A. Assure effective communication with all physicians…involved in the plan of care. D. Coordinate care delivery to meet the patient’s/client’s needs, and involve the patient/client, representative, and caregiver…in the coordination of care activities…III. Agency staff are expected to contact the Agency to report patient/client needs and changes. This will be documented on a communication note and will serve as coordination of care. Review of agency policy titled, “Plan of Care PC.35” last reviewed 031723 red in part: “…Procedure…V. Each patient/client must receive the home health services that are written in an individualized plan of care that identifies patient/client-specific measurable outcomes and goals, and which is…signed by a Doctor of Medicine…” Review of Johns Hopkins Medicine website at https://www.hopkinsmedicine.org/health/conditions-and-diseases/congestive-heart-failure-prevention-treatment-and-research, on 12/07/2023 revealed the following: “…Congestive heart failure (also called heart failure) is a serious condition in which the heart doesn’t pump blood as efficiently as it should. Despite its name, heart failure doesn’t mean that the heart has literally failed or is about to stop working. Rather, it means that the heart muscle has become less able to contract over time or has a mechanical problem that limits its ability to fill with blood. As a result, it can’t keep up with the body’s demand, and blood returns to the heart faster than it can be pumped out—it becomes congested, or backed up. This pumping problem means that not enough oxygen-rich blood can get to the body’s other organs… There’s no cure for heart failure. Treatment aims to relieve symptoms and slow further damage… Here are some of the things you’ll want to do in addition to sticking to the lifestyle changes that can improve the health of a damaged heart: Monitor your symptoms. Heart failure worsens over time, so you need to be familiar with changes in your body. Some of these can be addressed with different medications. Weighing yourself daily is one of the easiest ways to track fluid retention, indicated by a sudden gain. Swelling in the legs and feet can also mean more fluid is accumulating…”

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure communication with all physicians related to the current plan of care in two (Patient # 3 and 4) of three Patient records reviewed who received skilled nursing services, in that: the agency failed to communicate with the physicians related to missed visits, compliance with recommended patient treatment, and/or treatment or care that was not provided. The failure could place the Patient’s health and safety at risk if the Patients’ health care needs were not met and at risk to not have physician supervision of the Patients’ health care services. Findings include: Patient # 3 Record review of Patient # 3’s LCHSS clinical record revealed a POC with a SOC date of 04/19/2022 and a treatment period of 10/11/2023 to 12/09/2023. Review of the POC revealed that it was dated 10/11/2023 and signed by RN A. The POC included a primary diagnosis of pressure ulcer (a wound caused by continuous pressure to the skin) to left heel and a secondary diagnosis of hypertensive heart disease with heart failure (heart condition that happens with long term poorly managed high blood pressure). The POC also included orders for SN visits one time per week for one week and three times per week for eight weeks and PT to evaluate and treat. Continued review of the POC revealed the following, on page five of seven: “…Patient unable to safely stand for weight. SN to assess for edema and report LE (lower limb) edema (swelling) [greater than] 2+ (mild swelling) to physician…SN to measure calves each visit and report to [medical doctor] greater than 2-5 [centimeters] increase in swelling…” Further review of Patient # 3’s record revealed a physician order dated 10/20/2023 and signed by ADON. The order read in part: “…Patient was hospitalized on 10/20/2023 due to [shortness of breath] …” The clinical record also included a “A post Hospital Order” dated 10/27/3023. Review of the post hospital order revealed that it included the order to measure Patient # 3’s calves during each visit. Continued review of Patient # 3’s record revealed SN visit notes dated as follows: 10/20/2023; 10/30/2023; 11/01/2023; and 11/06, 11/08/23, 11/10/23, 11/13/23, 11/15/23, and 11/17/2023. The SN notes were signed by RN B. Review of the SN notes did not reveal that RN B had measured Patient # 3’s calves at each visit. The record did not include any documentation of communication with Patient # 3’s physician (Identifier 100) why RN B did not measure Patient # 3’s calves at each visit (to monitoring for swelling) as indicated in the plan of care. Patient # 4 Record review of Patient # 4’s LCHSS clinical record revealed a POC with a SOC date of 12/15/2022 and a treatment period of 10/11/2023 to 12/09/2023. Review of the POC revealed that it was dated 10/09/2023 and signed by the ADON. The POC included a primary diagnosis of Type 2 diabetes mellitus (chronic elevated levels of sugar in the blood) with foot ulcer (wound) and a secondary diagnosis of hypertension (chronic high blood pressure). The POC also included orders for SN visits two times per week for one week and three times per week for eight weeks. Continued review of the POC revealed the following orders: on page three of six: “Notify physician of…Fasting blood sugar greater than… 200 or less than…60 Random blood sugar greater than…250 or less than…70” and on page four of six: “…Patient unable to safely stand for weight. SN to assess for edema and report LE (lower limb) edema (swelling) [greater than] 2+ (mild swelling) to physician…SN to measure calves each visit and report to [medical doctor] greater than 2-5 [centimeters] increase in swelling…” The record also included orders for wound care dated 10/26/2023 and 11/09/2023. Continued review of Patient # 4’s record revealed SN visit notes dated as follows: 10/16/2023; 10/20/2023; 10/23, 25, 27, and 30/2023; 11/01/2023; and 11/15 and 17/2023. The visit notes were signed by LVN A. Review of the visit notes revealed that there was no documentation of blood sugar measurements. The notes read in part on the addendum page, “Patient does not check [FSBS, fingerstick blood sugar].” Further review of the SN notes did not reveal that LVN A had notified Patient # 4’s physician (Identifier 200) that Patient # 4’s blood sugar levels were not being monitored (to report blood sugar levels that were out of the ordered parameters). Continued review of the SN notes did not reveal that LVN A had measured Patient # 4’s calves at each visit. The record did not include any documentation of communication with Patient # 4’s physician (Identifier 200) why LVN A did not measure Patient # 4’s calves at each visit (to monitoring for swelling) as indicated in the plan of care. Further review of Patient # 4’s record revealed missed visit notes signed by LVN A and dated as follows: 10/18/2023; 11/03/2023; 11/06/2023; 11/08/2023; and 11/10/2023. Review of the missed visit notes read in part: “MD notified: No…” The missed visit notes 11/03/2023; 11/06/2023; 11/08/2023; and 11/10/2023 listed the reason for the missed visit as, “patient cancelled appt stating he is taking his sister to MD today [or] taking his sister to all of her appts this week…” The missed visit not for 10/18/2023 listed the reason for the missed visit was the patient had “something important to do…” The record did not include any documentation of communication with Patient # 4’s physician (Identifier 200) of the missed visits. During an interview with RN B on 11/22/2023 at 2:30 p.m. the surveyor discussed the findings and asked why the calf measurements for Patient # 3 had not been completed at each visit, as indicated in the plan of care. RN B stated that he usually checks for “edema, but I guess I overlooked that.” During an interview with the Adm/DON on 11/28/2023 at 1:00 p.m. the surveyor discussed the findings and asked what the agency’s process were for coordinating care and services agency patients. The Adm/DON stated the managers oversee coordination of care/services and “they report up to me.” The surveyor asked to speak to Client # 3’s and 4’s clinical manager (ADON). The Adm/DON stated that the ADON was not available and that the ADON had just recently (former clinical manager, Clinical Mgr. A retired approximately a month ago) became the ADON. The Surveyor asked why there was no physician communication, coordination of care and documentation of the missed visits, FSBS not being monitored and/or the calf measurement not being completed for Patients # 3 and # 4. She stated that the clinical manager “should have been following up on that.” The surveyor asked how the failure could adversely affect the agency’s clients. She replied, “Basically their safety, in general.” During an interview with LVN A on 11/22/2023 2:30 p.m. and follow-up interview on 12/07/2023 8:49 a.m. the surveyor discussed the findings. The surveyor also asked why the calf measurements were not completed, as indicated in the plan of care. LVN A stated that he was never told about the calf measurements. The surveyor also asked why there was no communication, documentation of coordination of care with Client # 4’s physician (Identifier 200) about the missed visits, and FSBS not being monitored. He stated that he reported to the supervisor but that it was his fault that he did not follow up on the communication to the physician. Review of agency policy titled, “Monitoring Patient Care/Coordination of Care PC.45” last reviewed 080120 read in part: “Purpose [:] To ensure coordination of patient/client care and treatment…Procedure I. The Agency will: A. Assure effective communication with all physicians…involved in the plan of care. D. Coordinate care delivery to meet the patient’s/client’s needs, and involve the patient/client, representative, and caregiver…in the coordination of care activities…III. Agency staff are expected to contact the Agency to report patient/client needs and changes. This will be documented on a communication note and will serve as coordination of care. Review of agency policy titled, “Plan of Care PC.35” last reviewed 031723 red in part: “…Procedure…V. Each patient/client must receive the home health services that are written in an individualized plan of care that identifies patient/client-specific measurable outcomes and goals, and which is…signed by a Doctor of Medicine…” Review of Johns Hopkins Medicine website at https://www.hopkinsmedicine.org/health/conditions-and-diseases/congestive-heart-failure-prevention-treatment-and-research, on 12/07/2023 revealed the following: “…Congestive heart failure (also called heart failure) is a serious condition in which the heart doesn’t pump blood as efficiently as it should. Despite its name, heart failure doesn’t mean that the heart has literally failed or is about to stop working. Rather, it means that the heart muscle has become less able to contract over time or has a mechanical problem that limits its ability to fill with blood. As a result, it can’t keep up with the body’s demand, and blood returns to the heart faster than it can be pumped out—it becomes congested, or backed up. This pumping problem means that not enough oxygen-rich blood can get to the body’s other organs… There’s no cure for heart failure. Treatment aims to relieve symptoms and slow further damage… Here are some of the things you’ll want to do in addition to sticking to the lifestyle changes that can improve the health of a damaged heart: Monitor your symptoms. Heart failure worsens over time, so you need to be familiar with changes in your body. Some of these can be addressed with different medications. Weighing yourself daily is one of the easiest ways to track fluid retention, indicated by a sudden gain. Swelling in the legs and feet can also mean more fluid is accumulating…”

A complaint investigation was conducted for complaint, ACTS ID 1Q94036 on 12/02/0222. The licensed and certified home health services census was 119. A deficiency was cited. Acronyms/Abbreviations: Adm/DON-Administrator/Director of Nursing Alt Adm-Alternate Administrator V P Clinical Servs-Vice Present of Clinical Services Clinical Mgr.-Clinical Manager P A-Physician’s Assistant EHR- Electronic Health Record Registered Nurse (RN) POC- Plan of Care SN/SNV- Skilled Nursing/Visit PT-Physical Therapy OT-Occupational Therapy ST-Speech Therapy

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure that the patient received all home health services as outlined in the plan of care in one (Patient # 3) of one inactive record reviewed in which the patient had an order for speech therapy. This failures places patients at risk of a decline in health status from inaccurate or absent treatments and care services. FINDINGS INCLUDED: Patient Record Review # 3: Review of Patient # 3's EHR revealed a POC with a start of care date of 08/06/2022 for certification period of 08/06/2022 to 10/04/2022. The POC was electronically signed by the Clinical Mgr. and dated 08/06/2022. The POC contained a primary diagnosis of “Hemiplga following cerebral [infarction], without status epilepticus [A seizure that lasts longer than 5 minutes, or having more than 1 seizure within a 5-minute period, without returning to a normal level of consciousness between episodes]. ...” The POC also included orders for SN visits for one time per week for one week and two times per week for eight weeks; PT, OT, and ST to evaluate and treat. Further review of Patient # 3’s record revealed that there was no ST evaluation for the certification period of 08/06/2022 to 10/04/2022. Continued review of the record revealed that the ST evaluation was not completed until 11/15/2022. The agency failed to ensure that Patient # 3 received an ST evaluation as outlined in the plan of care for the certification period of 08/06/2022 to 10/04/2022. During an interview with the Clinical Mgr. and V P of Clinical Services on 12/01/2022 at approximately 2:15 p.m., the surveyor discussed the above findings and asked why Patient # 3 did not receive the ST evaluation as outlined in the plan of care. The V P of Clinical Services replied, “We were waiting on the insurance to approve the visit.” The surveyor also discussed how the failure to provide services as outlined in the plan of care could adversely affect Client # 3. The Clinical Mgr. replied, “It would have a negative impact.” Review of agency policy titled “RI.1 Patient Bill of Rights and Responsibilities/Rights of the Elderly” dated 070221 read in part: “…Rights of the Patient…A. The patient has the right to…5. Receive all services outlined in the plan of care…”