Every finding on record at Hrs of Nebraska, Inc.

A complaint investigation was completed on 3/7/24. One or more of the allegations reported are verified and deficiencies were cited that are related to the allegations being investigated. The agency census was 225. Two condition level deficiencies were identified during the survey which include: G700- Skilled Professional Services G1008- Clinical Records.

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: Deficiencies cited at G706, G710, and G718 G706 Based on record review, policy and procedure review, and staff interview the skilled nurses (SN) failed to identify the presence of a suprapubic catheter/stoma (an opening in the abdomen to the bladder with a tube inserted to allow for the drainage of urine) during the recertification comprehensive assessment, and during the ongoing assessments conducted after 11/22/23 through 1/22/24 for one (Patient #4) (P4) of one patient records reviewed with suprapubic catheters. The total sample size was 5. The census was 225. G710 Based on record review, policy and procedure review, and staff interview, the agency staff failed to follow physician orders as written on the patient’s plan of care for one (Patient #4) (P4) of five records reviewed. The census was 225. G718 Based on record review, policy and procedure review, and staff interview, the agency failed to coordinate with all treating physicians for one (Patient # 4) (P4) of five patient records reviewed to identify changes in patient status and to ensure the patient’s plan of care is current and accurate. The census was 225

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on record review, policy and procedure review, and staff interview the skilled nurses (SN) failed to identify the presence of a suprapubic catheter/stoma (an opening in the abdomen to the bladder with a tube inserted to allow for the drainage of urine) during the recertification comprehensive assessment, and during the ongoing assessments conducted after 11/22/23 through 1/22/24 for one (Patient #4) (P4) of one patient records reviewed with suprapubic catheters. The total sample size was 5. The census was 225. Findings are: A. Review of the agency policy, "Care Planning, Coordination and Assessment Process", revised 9/15/23, revealed: 1. The comprehensive assessment was to include a head-to-toe assessment of the patient’s physical needs. 2. The content of comprehensive/ reassessments is delineated on each discipline specific assessment/reassessment form or electronic medical record format. 3. The policy failed to identify what the expectation was regarding conducting comprehensive assessments/reassessments, as well as ongoing assessments. B. Review of P4’s clinical record revealed: 1. Admitted to the home health agency on 9/15/23. 2. The Home Health Certification and Plan of Care for the certification period of: a. 9/15/23 through 11/13/23 included orders for SN, one time per week for six weeks, then one time every two weeks for two weeks, then one time per week for one week for assessment and evaluation of patient comorbid conditions, as well as to change foley catheter 1 time monthly and as needed (PRN); b. 11/14/23 through 1/12/24 included orders for SN, two times per week for one week, then one time per week for eight weeks, for assessment and evaluation of patient comorbid conditions, as well as to change foley catheter 1 time monthly and as needed (PRN); and c. 1/13/24 through 3/12/24, included orders for SN, one time per week for two weeks, then one time every two weeks for six weeks, then one time per week for one week, for assessment and evaluation of patient comorbid conditions, as well as to change foley catheter 1 time monthly and as needed (PRN). 3. Client Coordination Note dated 11/9/23 identified P4 was scheduled to have a suprapubic catheter placed on 11/20/23. 4. SN Visit Note Report (documentation of the SN assessment and evaluation) dated 11/21/23. The Licensed Practical Nurse (LPN)-F documented there were no remarkable findings with indwelling catheter inspection. This assessment showed no documentation of P4 having a suprapubic catheter. 5. SN Visit Note Report dated 12/5/23. LPN-F documented there were no remarkable findings with indwelling catheter inspection. This assessment showed no documentation of P4 having a suprapubic catheter. 6. SN Visit Note Report dated 12/18/23. Registered Nurse (RN)-D documented there were no remarkable findings with indwelling catheter inspection. This assessment showed no documentation of P4 having a suprapubic catheter. 7. SN Visit Note Report dated 1/1/24. LPN-G documented there was no bleeding noted at foley catheter insertion site. This assessment showed no documentation of P4 having a suprapubic catheter. 8. SN Recertification Assessment Visit Note Report dated 1/8/24. RN-D documented the foley catheter was changed during this visit. This assessment showed no documentation of P4 having a suprapubic catheter. 9. PRN SN Visit Note Report dated 1/15/24. LPN-G documented indwelling catheter was replaced after the patient pulled the previous catheter out. This assessment showed no documentation of P4 having a suprapubic catheter. 10. SN Visit Note Report dated 1/22/24. LPN-F documented indwelling catheter inspection completed. This assessment showed no documentation of P4 having a suprapubic catheter. 11. Urology Surgery Operative Note dated 11/22/23 for P4, received by the home health agency on 1/26/24. The note indicated that P4 had a suprapubic catheter placed on 11/22/23. The patient was to follow up in one month for an exchange of the suprapubic catheter tube. 12. Urology Visit Progress Note dated 12/21/23 for P4, received by the home health agency on 1/26/24. The note indicated that P4 had a suprapubic catheter tube exchanged on 12/21/23. The progress note included orders to continue every 30- day catheter changes at facility (patient lived at an assisted living facility). C. During an interview on 3/5/24 at 2:30 PM, LPN-F confirmed: 1. A suprapubic catheter/stoma was not identified during [gender] SN visits and assessments conducted with P4 after 11/22/23 through 1/22/24. 2. [gender] was not aware of a suprapubic catheter placed for P4 after 11/22/23. 3. The ALF staff notified LPN-F "a couple of days after" [gender] 1/22/24 SN visit (actual date not recalled during the interview), to inform the LPN that P4 had a suprapubic catheter, but now has an indwelling catheter in place. D. During an interview on 3/5/24 at 3:10 PM, LPN-G confirmed: 1. A suprapubic catheter/stoma was not identified during [gender] SN visits and assessments conducted with P4 after 11/22/23 through 1/22/24. 2. [gender] was not aware of a suprapubic catheter placed for P4 after 11/22/23. E. During an interview on 3/5/24 at 4:00 PM, RN-D confirmed: 1. A suprapubic catheter/stoma was not identified during [gender] SN visits and assessments conducted with P4 after 11/22/23 through 1/22/24. 2. [gender] was not aware of a suprapubic catheter placed for P4 after 11/22/23. 3. During the recertification assessment completed on 1/8/24, an indwelling foley catheter was in place and was replaced with another indwelling foley catheter. F. During an interview on 3/6/24 at 3:30 PM, the Administrator and the Territory Clinical Manager confirmed: 1. The SNs completing ongoing assessments and reassessments after 11/22/23 through 1/22/24 failed to identify the presence of a suprapubic catheter/stoma for P4. 2. All SN assessments/reassessments are expected to include a visualization of the patient’s body to identify changes that may not have been reported to the nurse by the patient and/or the patient’s caregiver.

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, policy and procedure review, and staff interview, the agency staff failed to follow physician orders as written on the patient’s plan of care for one (Patient #4) (P4) of five records reviewed. The census was 225. Findings are: A. Review of the agency policy titled, "Care Planning, Coordination and Assessment Process", revised 9/15/23, revealed the plan of care is ordered by the physician and included the types of services to be provided, treatments to be provided, and how often the visits were to be provided. B. Review of the agency policy titled, "Plan of Care", revised 9/15/23 revealed: 1. Changes or modifications to the plan of care may be made only with the approval of the attending physician or allowed practitioner. 2. Any revisions to the plan of care due to a change in patient health status must be communicated to the patient/representative and all physicians issuing orders for the plan of care. 3. The clinician was to notify the physician for modifications to the plan of care which includes, but is not limited to, when a significant change occurs in patient condition, inability to carry out a prescribed treatment, and the inability to perform an ordered visit. C. Review of P4’s clinical record revealed: 1. The Home Health Certification and Plan of Care for the certification period of 9/15/23 through 11/13/23 included orders for Skilled Nurse (SN) to change foley catheter with an 18 French (F) 10 cubic centimeters (cc) (catheter size and balloon size) coude (a type of catheter with a tip designed to maneuver around obstructions or blockages in the urethra) once monthly and as needed (PRN) when dislodged, leaking, occluded, painful, or with signs and symptoms (s/s) of a urinary tract infection (UTI). 2. The Home Health Certification and Plan of Care for the certification period of 11/14/23 through 1/12/24 included orders for SN to change foley catheter with an 18 French 30 cc once monthly and as needed (PRN) when dislodged, leaking, occluded, painful catheter. 3. PRN SN Visit Note Report (documentation of the assessment completed by the SN) dated 10/19/23. The SN documented the patient’s indwelling catheter came out and was replaced with a 16 F catheter. 4. PRN SN Visit Note Report dated 10/31/23. The SN documented the patient’s indwelling catheter became clogged and was replaced with a 20 F 30 cc catheter. 5. The clinical record lacked documentation that a monthly catheter change occurred in November or December 2023 (last documented catheter change was 10/31/23). 6. The clinical record lacked documentation the physician was notified of the missed catheter changes for November and December 2023. 7. The clinical record lacked documentation of an order to change the size of the catheter inserted on 10/19/23 or 10/31/23. D. During an interview on 3/6/24 at 3:30 PM, the Administrator and the Territory Clinical Manager confirmed for P4: 1. The clinical record lacked documentation that a monthly catheter change occurred in November or December 2023 (last documented catheter change was 10/31/23). 2. The clinical record lacked documentation the physician was notified of the missed catheter changes for November and December 2023. 3. The clinical record lacked documentation of an order to change the size of the catheter inserted on 10/19/23 or 10/31/23. 4. The SNs who conducted the visits on 10/19/23 and 10/31/23 and the SNs that conducted visits in November and December of 2023 failed to follow the physician's orders on the plan of care for changing the patient’s catheter.

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, policy and procedure review, and staff interview, the agency failed to coordinate with all treating physicians for one (Patient # 4) (P4) of five patient records reviewed to identify changes in patient status and to ensure the patient’s plan of care is current and accurate. The census was 225. Findings are: A. Review of the agency policy titled, "Care Planning, Coordination and Assessment Process", revised 9/15/23, revealed: 1. The case manager or primary clinician was to be responsible for facilitating communication about the patient status changes among all assigned disciplines, the patient, the physician or allowed practitioner, clinical supervisor, and facility staff to ensure services are not duplicated and to minimize the potential for missed or conflicting services. 2. Staff involved in patient care are to communicate changes and care coordination activities to the case manager or clinical supervisor in a timely manner. 3. Documentation of care coordination activities are to be included in the clinical record on a communication note, case conference summary, or clinical note. B. Review of P4’s clinical record revealed: 1. P4 was admitted to the home health agency on 9/15/23. 2. The Home Health Certification and Plan of Care for the certification period of: a. 9/15/23 through 11/13/23 included orders for Skilled Nurse (SN), one time per week for six weeks, then one time every two weeks for two weeks, then one time per week for one week for assessment and evaluation of patient comorbid conditions, as well as to change foley catheter 1 time monthly and as needed (PRN); b. 11/14/23 through 1/12/24 included orders for SN, two times per week for one week, then one time per week for eight weeks, for assessment and evaluation of patient comorbid conditions, as well as to change foley catheter 1 time monthly and as needed (PRN); and c. 1/13/24 through 3/12/24, included orders for SN, one time per week for two weeks, then one time every two weeks for six weeks, then one time per week for one week, for assessment and evaluation of patient comorbid conditions, as well as to change foley catheter 1 time monthly and as needed (PRN). 3. SN Visit Note Report (documentation of the SN assessment) dated 10/19/23. Licensed Practical Nurse (LPN)-F documented the patient was sent to the emergency department (ED) due to bleeding from penis. 4. The clinical record lacked documentation to indicate follow-up coordination was conducted or information received from the patient's ED visit on 10/19/23. 5. SN Visit Note Report dated 10/31/23. The Registered Nurse (RN)-D documented the patient was sent to the ED last night due to pulling out the foley catheter. 6. The clinical record lacked documentation to indicate follow-up coordination was conducted or information received from the patient's ED visit on 10/30/23. 7. Client Coordination Note dated 11/9/23 identified P4 was scheduled to have a suprapubic catheter placed on 11/20/23. 8. SN Visit Note Report dated 11/21/23 (one day after planned suprapubic catheter placement). LPN-F documented there were no remarkable findings with indwelling catheter inspection. 9. The clinical record lacked documentation to indicate follow-up coordination was conducted with P4's urologist to determine why the suprapubic catheter was not placed as planned on 11/20/23 or to see if the suprapubic catheter placement had been rescheduled. 10. Urology Surgery Operative Note dated 11/22/23 for P4, received by the home health agency on 1/26/24 (65 days after the procedure). The note indicated that P4 had a suprapubic catheter placed on 11/22/23. The patient was to follow up in one month for an exchange of the suprapubic catheter tube. 11. Urology Visit Progress Note dated 12/21/23 for P4, received by the home health agency on 1/26/24 (36 days after the procedure). The note indicated that P4 had a suprapubic catheter tube exchanged on 12/21/23. The progress note included orders to continue every 30- day catheter changes at facility (patient lived at an assisted living facility). 12. The clinical record lacked documentation to indicate staff was aware of the suprapubic catheter placement completed on 11/22/23 or the suprapubic catheter tube exchange on 12/21/23. C. During an interview on 3/6/24 at 3:30 PM, the Administrator and the Territory Clinical Manager confirmed: 1. The clinical record lacked documentation to indicate follow-up coordination was conducted or information received from the P4's ED visit on 10/19/23. 2. The clinical record lacked documentation to indicate follow-up coordination was conducted or information received from the P4's ED visit on 10/30/23. 3. The clinical record lacked documentation to indicate follow-up coordination was conducted with P4's urologist to determine why the suprapubic catheter was not placed as planned on 11/20/23 or to see if the suprapubic catheter placement had been rescheduled. 4. The case manager and clinical supervisor failed to follow the agency’s policy and procedure to be responsible for facilitating communication about the P4's status changes after ED visits on 10/19/23 and 10/30/23, and when the procedure planned on 11/20/23 did not occur.

Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This CONDITION is not met as evidenced by: Based or record review, policy and procedure review, and staff interview, the genitourinary (refers to the urinary and genital organs) assessments documented in the clinical record for four (Patient 1, 2, 3, and 4) (P1, P2, P3, and P4) of four patients with catheters failed to provide accurate information regarding the type of catheter utilized by the patient, and the Electronic Medical Record (EMR) system failed to differentiate the catheter types (indwelling, a catheter inserted usually through the urethra, and suprapubic, a catheter inserted through an opening in the abdomen directly to the bladder) and provide a means for staff to document the type of catheter the patient had. The total sample size was 5. The census was 225. Findings are: A. Review of the agency policy and procedure titled, "Documenting in the Electronic Medical Record", effective 4/1/22 revealed: 1. All entries in the EMR must be patient and visit specific and contain the actual data collected by the provider based on the care and services provided on the day of service. 2. EMR quality and integrity shall be maintained by adhering to identified standards in entering complete, concise, accurate, and updated information that produces a clear and valuable medical record. B. Review of the Assessment Form Viewer Report (a printed view of the EMR Skilled Nursing Assessment Form) revealed the genitourinary assessment, on page 38 and 39, failed to allow staff, completing the assessment form, to differentiate and identify the type of catheter the patient had. C. Review of P1's clinical record revealed: 1. The Home Health Certification and Plan of Care (POC) for the certification period of 2/6/24 through 4/5/24 revealed the patient had an indwelling catheter. The POC included orders for Skilled Nurse (SN) one time per week. 2. The weekly SN Visit Note Reports (documentation of the SN assessment) from 2/6/24 through 3/5/24 showed documentation on the genitourinary assessment that P1 had an indwelling/suprapubic catheter. The assessment failed to clearly state the actual type of catheter the patient had in place. D. Review of P2's clinical record revealed: 1. The POC for the certification period of 11/26/23 through 1/24/24 and 1/25/24 through 3/24/24 revealed P2 had an indwelling catheter. The POC included orders for SN one time per week for each of the certification periods. 2. The weekly SN Visit Note Reports from 12/31/23 through 3/5/24 showed documentation on the genitourinary assessment that P2 had an indwelling/suprapubic catheter. The assessment failed to clearly state the actual type of catheter the patient had in place. E. Review of P3's clinical record revealed: 1. The POC for the certification period of 12/28/23 through 2/5/24 and 2/6/24 through 4/25/24 revealed P3 had an indwelling catheter. The POC included orders for SN one time per week for one week, then one time every three weeks for six weeks for each certification period. 2. The weekly SN Visit Note Reports from 12/31/23 through 3/5/24 showed documentation on the genitourinary assessment that P3 had an indwelling/suprapubic catheter. The assessment failed to clearly state the actual type of catheter the patient had in place. F. Review of P4's clinical record revealed: 1. The Home Health Certification and Plan of Care for the certification period of: a. 9/15/23 through 11/13/23 included orders for SN, one time per week for six weeks, then one time every two weeks for two weeks, then one time per week for one week for assessment and evaluation of patient comorbid conditions, as well as to change foley catheter 1 time monthly and as needed (PRN); b. 11/14/23 through 1/12/24 included orders for SN, two times per week for one week, then one time per week for eight weeks, for assessment and evaluation of patient comorbid conditions, as well as to change foley catheter 1 time monthly and as needed (PRN); and c. 1/13/24 through 3/12/24, included orders for SN, one time per week for two weeks, then one time every two weeks for six weeks, then one time per week for one week, for assessment and evaluation of patient comorbid conditions, as well as to change foley catheter 1 time monthly and as needed (PRN). 2. The weekly SN Visit Note Reports from 9/15/23 through 1/22/24 showed documentation on the genitourinary assessment that P4 had an indwelling/suprapubic catheter. The assessment failed to clearly state the actual type of catheter the patient had in place. 3. Urology Surgery Operative Note dated 11/22/23 for P4, received by the home health agency on 1/26/24 (65 days after the procedure). The note indicated P4 had a suprapubic catheter placed on 11/22/23. The patient was to follow-up in one month for an exchange of the suprapubic catheter tube. 4. Urology Visit Progress Note dated 12/21/23 for P4, received by the home health agency on 1/26/24 (36 days after the procedure). The note indicated P4 had a suprapubic catheter tube exchanged on 12/21/23. 5. The clinical record lacked documentation until 2/6/24, of a change in the SN assessment documentation to show the patient had a suprapubic catheter in place. G. During an interview on 3/7/24 at 10:45 AM, the Administrator confirmed: 1. The genitourinary assessment documentation did not accurately reflect the type of catheter utilized by P1, P2, P3, and P4. 2. The EMR system used by the agency did not allow the SN to select and accurately document the type of catheter the agency patients have in place.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on record review, policy and procedure review, and staff interview, the agency failed to obtain in a timely manner, information to include in the clinical record of assessment completed during emergency department visits and procedures completed by a physician providing orders for the plan of care for one (Patient #4) (P4) of five patient records reviewed. The census was 225. Findings are: A. Review of the agency policy, "Clinical Patient Care Records, Timeliness, and Corrections", revised 9/18/23, revealed: 1. The agency policy requires the patient’s medical record is current, detailed, and consistent with medical and professional standards of care, and documentation associated with patient care is submitted timely. 2. Relevant medical information shall be obtained for all patients accepted for care. B. Review of P4’s clinical record revealed: 1. Skilled Nurse (SN) Visit Note Report (documentation of the SN assessment) dated 10/19/23. The SN documented the patient was sent to the emergency department (ED) due to bleeding from penis. 2. The clinical record lacked documentation to indicate the agency obtained ED notes regarding P4's ED visit on 10/19/23. 3. SN Visit Note Report dated 10/31/23. The Registered Nurse (RN) documented the patient was sent to the ED last night (10/30/23) due to pulling out the foley catheter. 4. The clinical record lacked documentation to indicate the agency obtained ED notes regarding P4's ED visit on 10/30/23. 5. Client Coordination Note dated 11/9/23 identified P4 was scheduled to have a suprapubic catheter placed on 11/20/23. 6. Urology Surgery Operative Note dated 11/22/23 for P4, received by the home health agency on 1/26/24 (65 days after the procedure). The note indicated P4 had a suprapubic catheter placed on 11/22/23. The patient was to follow up in one month for an exchange of the suprapubic catheter tube. 7. Urology Visit Progress Note dated 12/21/23 for P4, received by the home health agency on 1/26/24 (36 days after the procedure). The note indicated P4 had a suprapubic catheter tube exchanged on 12/21/23. C. During an interview on 3/7/24 at 10:45 AM, the Administrator confirmed the agency failed to obtain in a timely manner, all relevant medical information regarding P4’s care and services, including visit notes from ED visits on 10/19/23 and 10/30/23, and procedure notes from P4's urologist for procedures completed on 11/22/23 and 12/21/23.