Every finding on record at Integrity Home Care of Kansas, LLC

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site Recertification Survey (iQIES-5E42F-H1) at the above-named Home Health Agency from 11/01/22 to 11/03/22 resulted in a finding of no deficiency citations respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.22

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site Recertification Survey (iQIES-5E42F-H1) at the above-named Home Health Agency from 11/01/22 to 11/03/22 resulted in a finding of substantial compliance respective to applicable Condition of Participation (CoP) under 42 CFR 484, Subpart A through C with the following standard-level deficiencies cited.

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 document review, policy review, and interview, the Home Health Agency (HHA) failed to ensure services were integrated to assure the patient needs and factors that could affect treatment and care were coordinated by all disciplines for 3 (Patients 2, 4 and 7) of 10 patient records reviewed. Failure to coordinate identified factors that could affect treatment has the potential to place all patients at risk for unmet needs or delayed treatment goals. Findings Include: Review of a policy titled, "Case Management/Coordination of Care, dated 12/15/17," showed the Case Manager was a registered nurse or supervising therapist (Physical Therapy, Occupational Therapy, Speech Therapy) and the registered nurse would be the case manager for all patients receiving nursing services; a therapist would be assigned as a case manager for therapy only services. The policy showed the case manager would address all needs identified in the Plan of Care (POC); implementation of the therapy POC may be delegated to the therapy assistant. The policy showed the visiting clinician would: “Complete all assigned visits and communicate all pertinent clinical information to the Case Manager…all information relayed to the Case Manager must be documented in clinical record.” The visiting clinician will: “Provide quality care for home care patients by following guidelines determined by the Case Manager and Clinical Director; Be responsible for contacting physician when assessment reveals a change in condition or to request additional orders as needed to maintain patient status; Report of all physician contact must be given to the Case Manager as well as documented in the clinical record.” Patient 2 Review of Patient 2's medical record showed the patient was an 83 year who lived with her son in his home admitted for agency services on 09/26/22Patient reported a history of frequent falls and has a past medical history that includes multiple CVA’s (cerebral vascular accident-mini strokes) with right sided weakness, osteoarthritis and chronic pain. Patient 2’s "Home Health Certification and Plan of Care," (POC) for the Certification Dates of 09/26/22 through 11/24/22, showed an admitting diagnosis of Morbid (severe) Obesity. The POC showed the Skilled Nurse, the Occupational Therapist, and the Physical Therapist to report to Physician with increased pain level over 5 (numeric pain scale where 0 equals least pain and 10 equals most pain) to minimize complications. Review of Patient 2’s Visit Note Report-Physical Therapy Evaluation, completed by Staff B, Physical Therapist (PT), on 09/30/22 showed Patient 2 had a pain score of “6”. The note showed the patient’s reported goal for pain at “2.” There was no documentation to support the physical therapist coordinated care with the physician for patient’s pain level of 5 or greater, in compliance with the plan of care requirements. Review of Patient 2’s Visit Note Report, completed by Staff A, Registered Nurse, Case Manager (RN), on 10/06/22 showed Patient 2 had a pain score of “8” listed in Vital Signs section of the record The note showed the patient’s reported goal for pain at “4.” There was no documentation to support the RN coordinated with the physician to report the patient’s pain level of 5 or greater in compliance with the plan of care requirements. Review of Patient 2’s Visit Note Report, completed by Staff E, Certified Occupation Therapy Assistant (COTA), on 10/07/22 showed Patient 2 had a pain score of “7." The note showed the patient’s reported goal for pain at “0.” There was no documentation to support the COTA coordinated with the Therapy Case Manager to report the patient’s pain level of 5 or greater in compliance with the plan of care requirements. There was no documentation to support the Therapy Case Manager coordinated care with the physician to report the patient’s pain level of “7” in compliance with the Plan of Care. Review of Patient 2’s Visit Note Report, completed by Staff E, COTA on 10/13/22 showed Patient 2 had a pain score of “9.” The note showed the patient’s reported goal for pain at “0.” There was no documentation to support the COTA coordinated with the Therapy Case Manager to report the patient’s pain level of 5 or greater in compliance with the plan of care requirements. There was no documentation to support the Therapy Case Manager coordinated care with the physician to report the patient’s pain level of “9” in compliance with the Plan of Care. Review of Patient 2’s Visit Note Report, completed by Staff E, COTA on 10/21/22 showed Patient 2 had a pain score of “7.” The note showed the patient’s reported goal for pain at “0.” There was no documentation to support the COTA coordinated with the Therapy Case Manager to report the patient’s pain level of 5 or greater, in compliance with the plan of care requirements. There was no documentation to support the Therapy Case Manager coordinated care with the physician to report the patient’s pain level of “7” in compliance with the Plan of Care. Review of Patient 2’s Visit Note Report, completed by Staff E, COTA on 11/03/22 showed Patient 2 had a pain score of “6.” The note showed the patient’s reported goal for pain at “0.” There was no documentation to support the COTA coordinated with the Therapy Case Manager to report the patient’s pain level of 5 or greater in compliance with the plan of care requirements. There was no documentation to support the Therapy Case Manager coordinated care with the physician to report the patient’s pain level of “6” in compliance with the Plan of Care. Patient 4 Review of Patient 4's medical record showed the patient was a 76- year old who lived in her home, admitted for agency services on 08/25/22 Patient 4’s "Home Health Certification and Plan of Care," (POC) for the Certification Dates of 10/24/22 through 12/22/22, showed an admitting diagnosis of Unspecified Severe Protein-Calorie Malnutrition with a history of falls and Chronic Pain Syndrome. The POC showed a Physical Therapy frequency of visits of 1WK4 (one time a week for four weeks), an Occupational Therapy frequency of visits of 1WK4, 1Every2WK4, (one time a week for four weeks followed by 1 visit every two weeks for a total of 4 weeks) and Home Health Aide services with a visit frequency of 1WK8, (one time a week for 8 weeks). There were no pain levels (parameters) documented on the plan of care, for clinicians to report to the physician. Review of Patient 4’s Visit Note Report, completed by Staff E, COTA on 09/06/22 showed Patient 4 had a pain score of “8." The note showed the patient’s reported goal for pain at “0.” There was no documentation to support the COTA coordinated with the Therapy Case Manager to report the patient’s pain level of “8”. There was no documentation to support the Therapy Case Manager coordinated care with the physician to report the patient’s pain level of "8 in compliance with agency policy. Review of Patient 4’s Visit Note Report, completed by Staff E, COTA on 09/08/22 showed Patient 4 had a pain score of “8”. The note showed the patient’s reported goal for pain at “0.” There was no documentation to support the COTA coordinated with the Therapy Case Manager to report the patient’s pain level of “8.” There was no documentation to support the Therapy Case Manager coordinated care with the physician to report the patient’s pain level of “8” in compliance with agency policy. Review of Patient 4’s Visit Note Report, completed by Staff E, COTA on 09/16/22 showed Patient 4 had a pain score of “8.” The note showed the patient’s reported goal for pain at “0.” There was no documentation to support the COTA coordinated with the Therapy Case Manager to report the patient’s pain level of “8.” There was no documentation to support the Therapy Case Manager coordinated care with the physician to report the patient’s pain level of “8” in compliance with agency policy. Review of Patient 4’s Visit Note Report, completed by Staff E, COTA on 09/21/22 showed Patient 4 had a pain score of “8.” The note showed the patient’s reported goal for pain at “0.” There was no documentation to support the COTA coordinated with the Therapy Case Manager to report the patient’s pain level of “8.” There was no documentation to support the Therapy Case Manager coordinated care with the physician to report the patient’s pain level of “8” in compliance with agency policy. Patient 7 Review of Patient 7's medical record showed the patient was an 88-year old who lived alone in his apartment, admitted for agency services on 10/13/22 Patient 7’s "Home Health Certification and Plan of Care," (POC) for the Certification Dates of 10/13/22 through 12/11/22, showed an admitting diagnosis of Hemiplegia Following Cerebral Infarction (Right sided paralysis following a stroke) affecting the Right Dominant Side. The POC showed the Skilled Nurse, the Occupational Therapist, and the Physical Therapist to report to Physician with increased pain level over 5 to minimize complications. There were no pain levels (parameters) documented on the plan of care, for Speech Therapy to report to the physician. Review of Patient 7’s Visit Note Report, completed by Staff A, RN, Case Manager on 10/19/22 showed, “Pt observed lying in bed on side. Pt has a pain rated at 10 of 10.” There was no documentation to support the RN coordinated with the physician to report the patient’s pain level of 10 in compliance with the plan of care requirements. Review of Patient 7’s Visit Note Report, completed by Staff E, COTA on 10/20/22 showed Patient 7 had a pain score of “8.” The note showed the patient’s reported goal for pain at “0.” There was no documentation to support the COTA coordinated with the Therapy Case Manager to report the patient’s pain level of 5 or greater in compliance with the plan of care requirements. There was no documentation to support the Therapy Case Manager coordinated care with the physician to report the patient’s pain level of “8” in compliance with the Plan of Care. Review of Patient 7’s Visit Note Report, completed by Staff E, COTA on 10/24/22 showed Patient 7 had a pain score of “8.” The note showed the patient’s reported goal for pain at “0.” There was no documentation to support the COTA coordinated with the Therapy Case Manager to report the patient’s pain level of 5 or greater in compliance with the plan of care requirements. There was no documentation to support the Therapy Case Manager coordinated care with the physician to report the patient’s pain level of “8” in compliance with the Plan of Care. Review of Patient 7’s Visit Note Report-Speech Therapy (ST) Add-On Evaluation, completed by Staff F, Speech Therapist (ST), on 10/24/22 showed Patient 7 had a pain score of “10.” The note showed the patient’s reported goal for pain at “3.” There was no documentation to support the Speech Therapist coordinated care with the physician to report the patient’s pain level of “10” in compliance with agency policy. Review of Patient 7’s Visit Note Report-Physical Therapy Evaluation, completed by Staff D, Physical Therapist (PT), on 10/24/22 showed Patient 7 had a pain score of “6.” The note showed the patient’s reported goal for pain at “4.” There was no documentation to support the physical therapist coordinated care with the physician for patient’s pain level of 5 or greater in compliance with the plan of care requirements. Review of Patient 7’s Visit Note Report, completed by Staff G, Licensed Practical Nurse (LPN), on 10/26/22 showed Patient 7 had a pain score of “8” listed in Vital Signs section of the record The note showed the patient’s reported goal for pain at “0.” There was no documentation to support Staff A, RN, Case Manager coordinated care with the physician to report the patient’s pain level of 8, as reported by the LPN and in compliance with the plan of care requirements. During an interview on 11/03/22 at 10:50 AM, Staff D, Occupational Therapist (OT), confirmed that if there were no pain parameters documented on the plan of care the agency established level of pain for therapists to report to the physician was for a pain level of “7 or greater.” The surveyor inquired the responsibilities of the therapy assistants (COTA) in reporting of pain that is outside the parameter on the POC or greater than the established reporting level of 7. The OT confirmed the assistant (COTA) would call or email to notify the Occupational Therapy (Case Manager) and would not call the physician directly. Staff D, OT confirmed it was the responsibility of the professional therapist to contact the physician regarding pain or other assessment findings. During the same interview, that was conducted during the home visit with Patient 7, Staff D, OT confirmed Staff E, COTA had not reported elevated pain levels for Patient 7. During an interview on 11/03/22 at 4:05 PM, Staff H, RN Clinical Director confirmed that if the plan of care did not list specific parameters for reporting pain, that clinical staff should report pain levels 7 or greater to the physician and that communication should be documented in the patient’s clinical record.