Every finding on record at Home Caregivers Partnership, LLC

Based on a recertification survey conducted 1/3/2022 through 1/5/2022, it was determined that Canyon Home Care was found in compliance with the Conditions of Participation for Emergency Preparedness; 42 CFR (Code of Federal Regulations) 484.22 and 484.102. No deficiencies were cited in the area of Emergency Preparedness.

Completion of the comprehensive assessment CFR(s): 484.55(b) Standard: Completion of the comprehensive assessment. This STANDARD is not met as evidenced by: Based on interview and record review, it was determined the home health agency (HHA) did not complete a comprehensive assessment for 2 of 17 sampled patients who were on a waiver service and received hands-on-care from a registered nurse (RN). (Patient identifiers: 4 and 5.) Findings include: 1. Patient 4 was admitted to the HHA to set up weekly medications as directed by a waiver program. The date of admission and a diagnosis for admission were not documented. A registered nurse documented obtaining patient 4's vital signs on 11/10/2021 and 12/8/2021. A comprehensive assessment was not documented in patient 4's medical record. 2. Patient 5 was admitted to the HHA to set up weekly medications and administer a monthly injection as directed by the waiver program. The date of admission and diagnosis for admission were not documented. The waiver order had that a nurse was to give an intramuscular injection of Abilify every 28 days. The RN documented that vital signs were obtained on 11/10/2021, 11/17/2021 and 12/8/2021. The RN administered Abilify on 11/26/2021 and 12/23/2021. A comprehensive assessment was not documented in patient 5's medical record. On 1/4/2022 at 11:24 AM, an email correspondence was sent to the branch director (BD) related to the missing comprehensive assessment. The BD responded at 2:01 PM and stated, "...we were under the impression with (the name of the waiver program) that the patient did not need a comprehensive assessment or recertification visits. We set these charts up as a non skilled chart instead of a skilled chart. We would love to get some clarification on how we should be setting these charts up."

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on interview and record review, it was determined the home health agency (HHA) did not ensure all patient medications had been reviewed as part of the comprehensive assessment and updated on the patients' medication profile for 2 of 17 sampled patients. (Patient identifiers: 7 and 8.) Findings include: 1. Patient 7 was admitted to the HHA on 12/17/2021 with diagnoses including hypertension, paroxysmal atrial fibrillation, chronic pain and cellulitis of the left upper arm. Patient 7's medical record was reviewed on 1/4/2022. The medication profile for patient 7 was reviewed. The admitting registered nurse (RN) did not document that patient 7 was to take an antibiotic after being discharged from the hospital on 12/17/2021. On 12/21/2021 at 9:33 AM, a nurse documented a visit note for 12/20/2021. The RN documented, "He states that he went to the hospital on Saturday (12/18/2021) and they gave him a new antibiotic and increased his other antibiotic. Wound on his arm is not getting better. I called and made an appointment with his PCP (primary care physician) for tomorrow. He agreed to go to the appointment. I filled his med box for one week and let him know the ones that needed to be refilled. …" Despite filling patient 7's medication box, the RN did not document the antibiotic, dosage or frequency. On 12/21/2021, the PCP documented , "...Cellulitis of left upper extremity. …Was prescribed Bactrim and Keflex for what appears to be 10-day course." There was no further documentation available for review to indicate what antibiotic patient 7 was prescribed. On 12/29/2021, a RN documented in a visit note, "Pt (patient) complains of rash and asks that I apply muriprocin (sic) on it." The medication profile was not updated to include the use of the antibiotics and the mupirocin. On 1/4/2022 at 9:07 AM, an email correspondence was sent to the agency branch director (BD) related to the medication profile not being updated. The BD was also asked to provide documentation of the hospital discharge summary and the emergency department documentation from the visit that occurred on 12/18/2021. The BD responded on 1/4/2022 at 10:56 AM and stated that the hospital records were requested and had not been received. The BD further stated, "We discussed this (the medications) with the nurse and she is updating them now. We will do another training for all of our nurses on updating medications." 2. Patient 8 was admitted to the HHA on 11/5/2021 and readmitted to the HHA on 11/21/2021 with diagnoses which included status post stroke, sepsis due to streptococcus, metabolic encephalopathy, hypertensive kidney disease and mechanical aortic valve replacement. Patient 8's medical record was reviewed on 1/5/2022. The hospital discharge instructions, dated 11/5/2021, indicated that patient 8 was to take warfarin (a medication used to treat/prevent blood clots from forming) 10 mg (milligrams) 1 tablet on Thursday/Sunday and 1/2 tablet Monday/Tuesday/Wednesday/Friday/Saturday. There was no order as to when a prothrombin time/international ratio (INR) was to be drawn to monitor the effectiveness of the warfarin. Patient 8 was also to take Lantus 100 units/ml (milliliter) 18 units subcutaneously every morning. The admitting RN documented the warfarin and Lantus orders on the medication profile. Patient 8 was seen on 11/15/2021. The RN documented, "...BG (blood glucose) continue (sic) to be elevated. Family is communicating log (sic) with pharmacist who is making adjustments to insulin. They report he is currently on 28 units (Lantus)…" The medication profile was not updated to include the new dosage of Lantus. Patient 8 was seen on 11/22/2021. The RN documented an INR greater than 4. A venipuncture was order and returned at 3.9. The anticoagulation clinic (ACC) was contacted and a new order was received to hold the warfarin on 11/22/2021 then give 5 mg on 11/23/2021. An additional order was given to recheck the INR on 11/24/2021. The medication profile was not updated to include the new warfarin order. Patient 8 was seen on 11/24/2021. The RN documented an INR of 3.7. The ACC was contacted and a new order was received to hold the warfarin on 11/24/2021 then administer 5 mg on 11/25/2021; 10 mg on 11/26/2021; 5 mg on 11/27/2021; and 10 mg on 11/28/2021. An additional order was given to recheck the INR on 11/29/2021. The medication profile was not updated to include the new warfarin order. Patient 8 was seen on 11/29/2021. The RN documented an INR of 3.2. The ACC was contacted and a new order was received to administer warfarin 5 mg daily. The medication profile was not updated to include the new warfarin order. Patient 8 was seen on 12/6/2021. The RN documented an INR of 2.5. The ACC was contacted and an order was received to continue warfarin 5 mg daily. The medication profile was not updated. On 1/5/2022 at 7:43 AM, an email correspondence was sent to the BD related to the Lantus and warfarin orders not being updated on the medication profile. The BD responded at 9:26 AM and stated the clinician was not aware of having to update the medication profile when medication changes occur.

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based on interview and record review, it was determined the home health agency (HHA) did not complete and send a transfer summary that included all necessary medical information pertaining to the patient's current course of illness and treatment preferences to the receiving facility or health care practitioner to ensure that safe and effective transition of care for 1 of 17 sampled patients. (Patient identifier: 8). Findings include: Patient 8 was admitted to the HHA on 11/5/2021 with diagnoses which included sepsis due to streptococcus, metabolic encephalopathy, hypertensive kidney disease and mechanical aortic valve replacement. Patient 8's medical record was reviewed on 1/5/2022. A registered nurse (RN) documented in a discharge OASIS (outcome and assessment information set), dated 11/17/2021, "Received notice from (patient 8's) daughter (name redacted) that she was having difficulty getting (patient 8) to wake up or respond. Photos sent which show left sided weakness. Advised that (patient 8) get to the hospital ASAP (as soon as possible). He was transported to the ED (emergency department) and admitted to (name of the hospital) for stroke. PCP (primary care physician) notified." There was no documentation in patient 8's medical record that a transfer summary was completed and sent to the receiving facility. On 1/4/2022 at 7:43 AM, an email correspondence to sent to the branch director (BD) related to the missing transfer summary. The BD responded at 9:26 AM and stated, "Unfortunately this was not put in there, we will make sure that we follow up with our staff and remind them that it is a requirement."

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on interview and record review it was determined that each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry for 2 of 17 sampled patients. Specifically, a plan of care was not developed for two patients receiving care as directed by a waiver program. (Patient identifiers: 4 and 5). Findings include: 1. Patient 4 was admitted to the HHA to set up weekly medications as directed by a waiver program. The date of admission and a diagnosis for admission were not documented. A registered nurse documented that vital signs were obtained on 11/10/2021 and 12/8/2021. A plan of care signed by a physician was not located in patient 4's medical record. 2. Patient 5 was admitted to the HHA to set up weekly medications and administer a monthly injection as directed by the waiver program. The date of admission and diagnosis for admission were not documented. The waiver order had that a nurse was to give an intramuscular injection of Abilify every 28 days. The RN documented that vital signs were obtained on 11/10/2021, 11/17/2021 and 12/8/2021. The RN administered Abilify on 11/26/2021 and 12/23/2021. A plan of care signed by a physician was not located in patient 5's medical record. On 1/4/2022 at 11:24 AM, an email correspondence was sent to the BD related to the missing physician orders and plan of care. The BD responded at 2:01 PM and stated, "...we were under the impression with (the name of the waiver program) that the patient did not need an comprehensive assessment or recertification visits. We set these charts up as a non skilled chart instead of a skilled chart. We would love to get some clarification on how we should be setting these charts up."

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 interview and record review, it was determined the home health agency did not develop an individualized plan of care that included 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 for 2 of 17 sample patients. Specifically, supplies required to care for peripherally inserted central catheters and venipuncture supplies were not documented on the plan of care. (Patient identifiers: 1 and 8.) Findings include: 1. Patient 1 was admitted to the HHA on 11/25/2021 with diagnoses which included a surgical site infection, osteomyelitis and abscess of the right lower leg. Patient 1's medical record was reviewed on 1/4/2022. The admission orders had that patient 1 was to receive Ceftriaxone Sodium 2 g (grams)/50 ml (milliliters) in an iso-osomotic dextrose intravenous solution; inject 2 grams intravenous once a day for 45 days. Patient 1 had a peripherally inserted central catheter (PICC). A CBC (complete blood count) with differential, CMP (complete metabolic profile), ESR (erythrocyte sedimentation rate) and C-Reactive Protein (CRP) were to be obtained weekly. The plan of care did not include the use of the PICC supplies, dressing change supplies for care of the PICC or the venipuncture supplies. On 1/3/22 at 1:39 PM, an email correspondence to sent to the branch director (BD) related to the PICC care, dressing change and venipuncture supplies. The BD responded at 2:36 PM and documented, "This was not added to the Plan of Care so clinician is working on that now." 2. Patient 8 was admitted to the HHA on 11/5/2021 and readmitted to the HHA on 11/21/2021 with diagnoses which included status post stroke, sepsis due to streptococcus, metabolic encephalopathy, hypertensive kidney disease and mechanical aortic valve replacement. Patient 8's medical record was reviewed on 1/5/2022. The admission order included the administration of Ceftriaxone 2 g/50 ml inject 2 gm via the PICC line once a day in the evening for 9 day. A CBC, CMP, ESR and CRP was to be obtained weekly. A PT (prothrombin time)/INR (international ratio) was to be obtained as ordered. The plan of care did not include the use of the PICC supplies, dressing change supplies for care of the PICC or the venipuncture supplies. On 1/4/2022 at 7:43 AM, an email correspondence was sent to the BD related to the PICC line, dressing changes and venipuncture supplies. The BD responded at 9:26 AM and documented, "We do not supply line care items for PICC. They are supplied by the infusion pharmacy. Do you still want them listed under supplies? If so, we will definitely start doing that."

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 interview and record review, it was determined the home health agency (HHA) did not ensure that drugs, services, and treatments were administered only as ordered by a physician for 1 of 17 sample patient. Specifically, an antipsychotic was administered intramuscularly without a physician's order. (Patient identifier: 5.) Findings include: Patient 5 was admitted to the HHA to set up weekly medications and administer a monthly injection as directed by the waiver program. The date of admission and diagnosis for admission were not documented. The waiver directions had that a nurse was to give an intramuscular injection of Abilify every 28 days. A registered nurse documented Abilify Maintena 400 mg (milligrams) intramuscularly was administered on 11/26/2021 and 12/23/2021. A physician's order to administer the Abilify was not located in patient 5's medical record. On 1/4/2022 at 11:24 AM, an email correspondence was sent to the branch director (BD) related to the missing physician orders and plan of care. The BD responded at 2:01 PM and stated, "...we were under the impression with (the name of the waiver program) that the patient did not need an comprehensive assessment or recertification visits. We set these charts up as a non skilled chart instead of a skilled chart. We would love to get some clarification on how we should be setting these charts up."

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 interview and record review, it was determined the home health agency (HHA) did not ensure the integration of services, whether 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 for 1 of 17 sampled patients. Specifically, the HHA did not ensure physician notification of abnormal laboratory values. (Patient identifier: 8.) Findings include: Patient 8 was admitted to the HHA on 11/5/2021 and readmitted to the HHA on 11/21/2021 with diagnoses which included status post stroke, sepsis due to streptococcus, metabolic encephalopathy, hypertensive kidney disease and mechanical aortic valve replacement. Patient 8's medical record was reviewed on 1/5/2022. a. On 11/15/2021, a registered nurse (RN) documented a complete blood count (CBC), complete metabolic profile (CMP), erythrocyte sedimentation rate (ESR) and a C-Reactive Protein (CRP) was obtained. The RN also documented that a blood culture was to be obtained as ordered the patient 8's primary care physician (PCP). The RN further documented, "Contacted lab and are unable to obtain blood culture bottles. Family notified." There was no documentation the RN contacted the PCP or other measures implemented to ensure the blood cultures were obtained. The following abnormal values were documented: Chloride 97 mmol/L (millimole per liter) (normal value 102-111); Glucose 357 mg/dL (milligrams per deciliter) (normal value 65-99); BUN 34 mg/dL (normal value of 8-20); Creatinine 1.59 mg/dL (normal value 0.77-1.35); Creatinine GFR 38 mL/min/1.73 sq m (milliliter per minute per 1.73 square meter) (normal value greater than 60); CRP 2.2 mg/dL (normal value 0.0-1.0); WBC (white blood cells) K/ul (cubic milliliter) (normal value 3.6-10.6); MCHC 31.4 g/dL (normal value 32.0-36.0); Neutrophils 85.0% (normal value 42.0-72.0); Lymphocytes 7.3% (normal value 18.0-45.0); Neutrophils, Absolute 9.6 K/uL (normal value 1.8-6.8); and Lymphs, Absolute 0.8 K/uL (normal value 1.2-3.4). The laboratory company documented, "Faxed to number requested on 11/15/21 at 2115 (9:15 PM)". There was no documentation from the RN which indicated patient 8's PCP received the labs or whether new orders related to the abnormal labs were to be implemented. Note: Patient 8 was admitted to the hospital on 11/17/2021 after displaying left sided facial drooping. b. A CBC and CMP was obtained on 11/22/2021. The following abnormal values were obtained: Sodium 136 mmol/L (normal value 137-146); Potassium 5.5 mmol/L (normal value 3.5-5.0); Glucose 574; BUN 35; Creatinine 1.46; Creatinine GFR 42; Total Protein 5.9 g/dL (normal value 6.0-8.4); Albumin 3.2 g/dL (normal value 3.5-5.21); WBC 11.4; RBC (Red blood cells) 4.23 M/ul (microliters) (normal value 4.50-5.9); Hemoglobin 12.6 g/dL (normal value 13.5-17.5); Hematocrit 39.5% (normal value 41.0-53.0); MCHC 31.0; Neutrophils 81; Lymphocytes 7.2; Neutrophils Absolute 9.2; Lymphs, Absolute 0.8; and Monocytes, Absolute 1.2 K/uL (normal value 0.2-0.9). The lab company documented the results were faxed to two different numbers on 11/22/2021 at 5:32 PM. There was no documentation from the RN which indicated patient 8's PCP received the labs or whether new orders related to the abnormal labs were to be implemented. c. On 11/26/2021, the RN documented that a BMP (basic metabolic profile) was obtained as recommended the patient 8's pharmacist. There was no documentation in patient 8's medical record of what the laboratory values were and whether new orders were recommended. d. A CBC and CMP were obtained on 11/29/2021. The following abnormal values were documented: glucose 318; BUN 33; Creatinine 1.50; Creatinine GRF 41; Total Protein 5.7; Albumin 2.0; RBC 3.96; Hemoglobin 11.7; Hematocrit 37.3; MCHC 31.4; Lymphocytes 15.2; and Lymphs, Absolute 1.0. The laboratory company documented, "Faxed to number requested on 11/30/21 at 0553 (5:53 AM)." There was no documentation from the RN which indicated patient 8's PCP received the labs or whether new orders related to the abnormal labs were to be implemented. e. A CBC, CMP, ESR and CRP were obtained on 12/6/2021. The following abnormal values were documented: Glucose 338; BUN 27; Creatinine GRF 47; Protein, Total 5.7; Albumin 3.2; RBC 4.02; Hemoglobin 11.8; Hematocrit 37.9; MCHC 31.1; RDW SD 49.2 fL (fluid liters); Neutrophils 80.9; Lymphocytes 9.8; and Lymphs, Absolute 0.8. The laboratory company documented, "Faxed as requested on 12/06/21 at 2103 (9:03 PM)." There was no documentation from the RN which indicated patient 8's PCP received the labs or whether new orders related to the abnormal labs were to be implemented. f. A CBC, CMP, ESR and CRP were obtained on 12/13/2021. The following abnormal values were documented: Glucose 197; BUN 30; Creatinine 1.59; Creatinine GFR 38; Protein, Total 5.7; Albumin 3.1; CRP 1.4; RBC 3.97; Hemoglobin 11.8; Hematocrit 37.7; MCHC 31.3; RDW SD 51.0; Neutrophils 74.4; Lymphocytes 11.8; Lymphs, Absolute 0.8; and ESR 30 mm/h (millimeters per hour) (normal value 0-20). The laboratory company documented, "Faxed to number requested on 12/13/21 at 2332 (11:32 PM)." There was no documentation from the RN which indicated patient 8's PCP received the labs or whether new orders related to the abnormal labs were to be implemented. On 1/4/2022 at 9:07 AM, an email correspondence was sent to the agency branch director (BD) related to the abnormal laboratory values and whether patient 8's PCP was notified. At 9:26 AM, the BD responded with, "The lab requisition states that they were sent to the physician and we did receive orders from the MD (medical doctor) if changes were needed." The BD was unable to provide documented evidence that the HHA contact the PCP with the abnormal laboratory values and did not document follow up phones calls if needed. Additionally, the BD did not provide documented evidence of any new orders received related to the abnormal laboratory values.