Every finding on record at Johnston Health Services Corporation

An unannounced on-site complaint investigation was conducted on 07/22/2024-07/23/2024. Standard level deficiencies to the Medicare Conditions of Participation were identified.

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on agency policy, complaint interview, and staff interviews the agency failed to document the existence and resolution of a complaint for 1 of 1 patient that made a complaint. (patient #1) Finding included: A policy Complaints & Grievances (Patient) (revised 08/2022) was received on 07/22/2024 at 4:07 P.M. from the Vice President of Patient Care Services. The policy stated, “Complaints that are resolved at the bedside by staff present may be documented on the [agency name] Complaint Form and sent to the Risk Management Office.” An interview conducted with the complainant on 07/22/2024 at 10:15 A.M. revealed that the complainant called the agency on 06/20/2024 to complain about supplies. The complainant stated that she spoke to [staff name, customer service representative]. The complainant stated that the customer service representative was unable to provide any information related to supplies. The complainant stated that [staff name, clinical manager] called her back. The complainant stated that a complaint related to supplies and the customer service representative was voiced. Patient #1 was admitted on 06/18/2024 with a diagnosis of aftercare following GI (gastrointestinal) surgery. The plan of care for 06/18/2024-08/16/2024 included order for skilled nurse visits 3 times a week for 9 weeks and 8 PRN (as needed). A clinical record review was conducted on 07/22/2024 at approximately 11:00 A.M. There was no evidence in the clinical record of a complaint or resolution. On 07/22/2024 at approximately 11:00 A.M. the Vice President of Patient Care Services stated, “There are no complaints for hospice or home health [documented on the complaint log].” An interview was conducted on 07/22/2024 at approximately 2:00 P.M. with the customer service representative #7. The customer service representative stated, “She [complainant] was very straight forward, she wanted to know about ostomy supplies. She wanted the supplies right then because they had used the last one. She spoke with my manager [clinical manager’s name]. Yes [she was complaining].” An interview was conducted on 07/22/2024 at approximately 2:25 P.M. with the clinical manager. The clinical manager stated, “She [complainant] had spoken with [customer service representative’s name]. [Customer Service Representative’s name] could not answer her questions. She was concerned that [customer service representative’s name] didn’t know who to forward the questions to. Originally, she complained about the ostomy supplies… I confirmed that the supplies were on the way. [customer service representative’s name] has been trained.” An interview was conducted on 07/22/24 at approximately 2:05 P.M. with the Director of Quality Programs. The Director of Quality Programs stated, “If it’s [complaint] not resolved they should document it and report it to the director of corporate compliance. It should be documented in the clinical record [if resolved].”

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews the agency failed to notify the physician of a patient’s needs that indicated that the plan of care should be changed for 1 of 3 patients monitoring blood sugars. (patient #2) Findings included: A policy, Interdisciplinary Care Coordination/Communication (revised 10/2023) was received on 07/23/2024 at 9:15 A.M. from the clinical manager. The policy stated, “Team will ensure communication occurs with physician or allowed practitioner for coordination of care.” Patient #2 was admitted on 07/07/2024 with diagnoses of encounter for surgical aftercare following surgery on the digestive system and type 2 diabetes mellitus (condition with difficulty controlling blood sugar) with hyperglycemia (high blood sugars). The plan of care (POC) for 07/07/2024-09/04/2024 included orders for skilled nurse (SN) visits 2 times a week for 1 week, 2 times a week for 2 weeks, 1 times a week for 1 week, 3 PRN (as needed) visits, and SN to notify MD (medical doctor) if blood glucose (sugar) is outside the following parameters 300 mg/dL x 3 consecutive readings or if patient is symptomatic. For the register nurse (RN) visit of 07/07/2024 RN #4 stated, “Patient hasn’t [sic] checked blood sugar since being home. States he rarely checks it.” There was no evidence in the clinical record of the MD being notified. For the RN visit of 07/11/2024 RN #6 stated, “Patient states he is unable to test blood sugar at this time because current home glucometer is not working properly.” There was no evidence in the clinical record of the MD being notified. For the RN visit of 07/16/2024 RN #6 stated, “Patient states his home glucometer is not working there fore [sic] he is not able to check his blood sugar.” There was no evidence in the clinical record of the MD being notified. An interview was conducted on 07/23/2024 at 9:03 A.M. with RN #6. RN #6 stated, “I did not [notify the doctor.] Yes [normally notify the doctor].” An interview was conducted on 07/23/2024 at 9:15 A.M. with RN #4. RN #4 stated, “No mam, I didn’t [notify the doctor], Yes I would [normally call the doctor.]” An interview was conducted on 07/23/2024 at 9:06 A.M. with the clinical manager. The clinical manager stated, “My expectation would be to notify the physician.”