Every finding on record at Jp and P Healthcare Agency Inc

Purpose of visit: Relicensure/Recertification/Complaint Survey Entrance: 12/12/2022 Agency Census: L&C 16 LHHS 0 PAS 42 Abbreviations: Notice of Medicare Non-Coverage (NOMNC) Plan Of Care (POC) New (N) Exacerbation (E) Hardware (HWR) Central Daylight Time (CDT) Abdominal (ABD) Q Visit (every visit) Start Of Care (SOC) Skilled Nurse (SN) Outcome and Assessment Information Set (OASIS) Physical Therapy/Occupational Therapy (POT/OT)

Purpose of visit: Relicensure/Recertification/Complaint Survey Entrance: 12/12/2022 Agency Census: L&C 16 LHHS 0 PAS 42 Abbreviations: Notice of Medicare Non-Coverage (NOMNC) Plan Of Care (POC) New (N) Exacerbation (E) Hardware (HWR) Central Daylight Time (CDT) Abdominal (ABD) Q Visit (every visit) Start Of Care (SOC) Skilled Nurse (SN) Outcome and Assessment Information Set (OASIS) Physical Therapy/Occupational Therapy (POT/OT)

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to respect the patient's right to receive proper written notice, in advance of terminating on-going care in three of three (Patients #3, 4 and 5) inactive patient records reviewed. The agency failed to provide the Centers for Medicare and Medicaid form titled "Notice of Medicare Non-Coverage". The failure could place the patients at risk of harm due to inadequate or inappropriate continuity of care in the patients' post-discharge needs and could prevent the patients from exercising the right to appeal the discharge decision, if desired. FINDINGS INCLUDED: Discharge patient list provided by the Office Assistant on 12/14/2022 reflected the following: Patient #3 Start of Care 02/20/2022 Discharge Date 12/06/2022 Reason of Discharge Goals Met Patient #4 Start of Care 10/13/2018 Discharge Date 11/20/2022 Reason of Discharge Goals Met Patient #5 Start of Care 02/01/2017 Discharge Date 07/04/2022 Reason of Discharge Goals Met Clinical Record #3: Record review12/14/2022 Record review of the chart for patient #3 revealed a POC with a SOC date of 02/20/2022. Patient #3's record included a discharge OASIS which revealed a discharge date of 12/06/2022. Patient #3's clinical record did not show that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on 12/06/2022. The record did not include a written Notice of Medicare Non-Coverage (NOMNC). Clinical Record #4: Record review12/14/2022 Record review of the chart for patient #4 revealed a POC with a SOC date of 10/13/2018. Patient #4's record included a discharge OASIS which revealed a discharge date of 11/20/2022. Patient #4's clinical record did not show that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on 11/20/2022. The record did not include a written Notice of Medicare Non-Coverage (NOMNC). Clinical Record #5: Record review12/14/2022 Record review of the chart for patient #5 revealed a POC with a SOC date of 02/01/2017. Patient #5's record included a discharge OASIS which revealed a discharge date of 07/04/2022. Patient #3's clinical record did not show that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on 07/04/2022. The record did not include a written Notice of Medicare Non-Coverage (NOMNC). During an interview with the Alternate Administrator/Director of Nursing on 12/15/2022 at approximately 12:40 p.m., the surveyor presented the above findings. The Alternate Administrator/Director of Nursing acknowledged that, the agency had not provided written notice of the intent to discharge with the NOMNC form no later than two days in advance of terminating on-going care for patients #3, 4 and 5. The Alternate Administrator/Director of Nursing replied, "It was an oversight." Review of agency policy, Rvd, 080120 quoted in part, "PATIENT/CLIENT TRANSFER AND DISCHARGE NOTICES PE.6 .... II. Notice of Medicare Non-Coverage (NOMNC) …. Agency staff will provide valid delivery notice (involves both delivery and completion) of the NOMNC to the patient/client (or their representative) when the end of all covered care is foreseen, even if the patient/client agrees with the discharge. B. At least two (2) calendar days before the Medicare covered services end…. The Agency will have the patient/client (or their representative) complete and sign the NOMC. The patient/client or representative should sign and date two copies, keep one, and return a copy to the Agency…. The Agency will retain a copy of all completed NOMNC’s….”

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 record reviews and interviews, the agency failed to ensure the plan of care (POC) included pertinent, complete, and accurate treatment orders for one (Client #1) of one record reviewed with a surgical wound. This failure put the patient at risk of infection, slow healing, negative outcomes of care and services provided. Findings Included Clinical Record #1: The record contained a POC for the certification period 08/26/2022 – 10/24/2022 with a start of care date 06/27/2022 dated and signed by the Assistant Director of Nursing on 08/26/2022. The POC contained the primary diagnoses of Encounter for other Orthopedic Aftercare (N) 10/13/2022. The POC read in part….”SN will clean L3-S1 Laminectomy with normal saline mix with betadine, soaked gauze with betadine solutions cover Laminectomy stitch area with gauze then secure with tape using aseptic technique weekly.” The record contained a discharge order from Hospital A electronically signed by Doctor A on 10/07/2022. The order read in part, “…Nursing, PT/OT eval, treat & progress as tolerated for L3-S1 HWR removal/exploration of fusion mass, re-instrumentation, and extension of fusion to pelvis, routine spine precautions……home safety eval…” There was no physician order in the record that addressed wound care. The record contained a Resumption of care dated 10/13/2022 and completed by the Assistant Director of Nursing. The Assistant Director of Nursing documented the dressing change was performed to the L3-S1 surgical site. There was no assessment of the L3-S3 surgical site. The record contained a Recertification dated 10/24/2022 and completed by the Assistant Director of Nursing. The Assistant Director of Nursing documented the dressing change was performed to the spine surgical site. There was no assessment of the spine surgical site. The record contained a POC for the certification period 10/25/2022– 12/23/2022 with a start of care date 06/27/2022 dated and signed by RN A on 10/25/2022. The POC contained the primary diagnoses of Encounter for other Orthopedic Aftercare (E) 10/24/2022. The POC read in part “,,,,,Skilled Nurse will clean recent spine surgery with solution mix solution, cover with ABD pad and secure with tape…Diabetic Wound Care: SN will clean spine surgery stitches apply betadine mix solution then cover with ABD pad and with tape Q visits.” There was no physician order in the record that addressed wound care. Interviews: In an interview with patient #1, on 12/14/2022 at approximately 2:11 p.m., the surveyor discussed the patient’s recent surgery. The surveyor asked who performed the dressing changes. The patient stated “No one is doing the wound care. The doctor told me not to remove the dressing and not to submerge in the bath or get it wet. When I made my follow-up visit the doctor removed the dressing. There were only stitches left it was all healed up, and he told me I didn’t have to do anything to the stitches”. The surveyor asked did the nurses perform wound care after the surgery? The patient stated, “No.” During an interview with the Alternate Administrator/Director of Nursing on 12/15/2022 at approximately 10:45 a.m., the surveyor presented the above findings. The Alternate Administrator/Director of Nursing acknowledged that, the agency failed to provide correct plan of cares for patient #1. The Alternate Administrator/Director of Nursing stated, “I can’t explain why the wound care orders were on the plan of care dated 08/26/2022 – 10/24/2022 considering the surgery was done on 10/7/22. There weren’t orders for wound care from the hospital, so that was a mistake on the RN’s part to put it on the assessment.” The surveyor asked for coordination of care between the surgeon, Doctor A, the homecare doctor, and the agency. The Alternate Administrator/Director of Nursing stated, “There was a lack of coordination of care.” The surveyor asked for wound care orders for the plan of care dated 10/25/2022– 12/23/2022. The Alternate Administrator/Director of Nursing stated, “There are no orders, it was an oversight. The plan of care wasn’t updated.” Review of agency policy, Rvd, 010111 quoted in part, "Plan of Care PC.8 .... Procedure…II. An RN is responsible for coordinating the plan of care when multiple disciplines are involved...to decrease the possibility of duplication or conflict and to identify problems. III. Each patient/client must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient/client specific needs…A. The individualized plan of care must include the following: ...10. All medications and treatments…. IV. All patient/client care orders, including verbal orders, must be recorded in the plan of care…. VIII. …. treatments are administered only as ordered by a physician…”

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to enforce its written policy regarding coordination of client services with other health services providers for 1 of 5 clients reviewed (#1) in that there was no documentation that the agency collaborated with all physicians involved in the plan of care. This failure could place the client at risk of receiving inadequate care and services and placed Patient #1 at risk of wound deterioration and infection. The findings included: Clinical Record #1: The record contained a POC for the certification period 08/26/2022 – 10/24/2022 with a start of care date 06/27/2022 dated and signed by the Assistant Director of Nursing on 08/26/2022. The POC contained the primary diagnoses of Encounter for other Orthopedic Aftercare (N) 10/13/2022. The POC read in part….”SN will clean L3-S1 Laminectomy with normal saline mix with betadine, soaked gauze with betadine solutions cover Laminectomy stitch area with gauze then secure with tape using aseptic technique weekly.” The record contained a discharge order from Hospital A electronically signed by Doctor A on 10/07/2022. The order read in part, “…Nursing, PT/OT eval, treat & progress as tolerated for L3-S1 HWR removal/exploration of fusion mass, re-instrumentation, and extension of fusion to pelvis, routine spine precautions……home safety eval…” There was no physician order in the record that addressed wound care. The record contained a Resumption of care dated 10/13/2022 and completed by the Assistant Director of Nursing. The Assistant Director of Nursing documented the dressing change was performed to the L3-S1 surgical site. There was no assessment of the L3-S3 surgical site. The record contained a Recertification dated 10/24/2022 and completed by the Assistant Director of Nursing. The Assistant Director of Nursing documented the dressing change was performed to the spine surgical site. There was no assessment of the spine surgical site. The record contained a POC for the certification period 10/25/2022– 12/23/2022 with a start of care date 06/27/2022 dated and signed by RN A on 10/25/2022. The POC contained the primary diagnoses of Encounter for other Orthopedic Aftercare (E) 10/24/2022. The POC read in part “,,,,,Skilled Nurse will clean recent spine surgery with solution mix solution, cover with ABD pad and secure with tape…Diabetic Wound Care: SN will clean spine surgery stitches apply betadine mix solution then cover with ABD pad and with tape Q visits.” There was no physician order in the record that addressed wound care. Interviews: In an interview with patient #1, on 12/14/2022 at approximately 2:11 p.m., the surveyor discussed the patient’s recent surgery. The surveyor asked who performed the dressing changes. The patient stated “No one is doing the wound care. After the surgery the doctor told me not to remove the dressing and not to submerge in the bath or get it wet. When I made my follow-up visit the doctor removed the dressing. There were only stitches left it was all healed up, and he told me I didn’t have to do anything to the stitches”. The surveyor asked did the nurses perform wound care after the surgery? The patient stated, “No.” During an interview with the Alternate Administrator/Director of Nursing on 12/15/2022 at approximately 10:45 a.m., the surveyor presented the above findings. The Alternate Administrator/Director of Nursing acknowledged that, the agency failed to provide correct plan of cares for patient #1. The Alternate Administrator/Director of Nursing stated, “I can’t explain why the wound care orders were on the plan of care dated 08/26/2022 – 10/24/2022 had surgical wound care orders when the surgery was done 10/7/22. There weren’t orders for wound care from the hospital, so that was a mistake on the RN’s part to put it on the assessment.” The surveyor asked for coordination of care between the surgeon, Doctor A, the homecare doctor, and the agency. The Alternate Administrator/Director of Nursing stated, “There was a lack of coordination of care.” The surveyor asked for wound care orders for the plan of care dated 10/25/2022– 12/23/2022. The Alternate Administrator/Director of Nursing stated, “There are no orders, it was an oversight. The plan of care wasn’t updated.” Review of agency policy, Rvd, 010111 quoted in part, " Monitoring Patient Care / Care Coordination PC.10….The Agency will: A. Ensure communication with all physicians and/or non-physician practitioners, involved in the plan of care ...Integrate orders from all physicians and/or non-physician practitioners, involved in the plan of care...to ensure the coordination of all services and interventions provided to the patient/client ...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."