Every finding on record at Lhcg Clxvi, LLC D/B/A University Health Services, Inc

An onsite unannounced Recertification Survey and a COVID - 19 Staff Vaccination Survey were conducted at University HHA from 1/23/2023 to 1/26/2023. University HHA is in compliance with the Medicare COVID-19 Staff Vaccine requirements with 116 staff members fully vaccinated, and 4 religious exemptions approved. The facility is in compliance with the Conditions for Coverage (CFC) at 42 CFR PART 484.102.

An onsite unannounced Recertification Survey was conducted from 1/23/2023 - 1/26/2023. The facility is not in compliance with the Medicare Conditions at 42 CFR PART 484. The following standard level deficiencies were cited. Current census is 113.

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 observations, interviews, and record reviews, the home health agency failed to ensure the patient's plan of care included all medications and diagnoses for two of two applicable patients during home visits. (Patient #1 and #4) Findings: Patient #4 On 1/24/23, at 11:00 AM, a home visit was conducted with the registered nurse (RN #2) to Patient #4. Patient #4 has a medication bottle labeled, “Bisprol HCTZ (medication for high blood pressure)…” with a pharmacy fill date of 12/2/22. In a concurrent interview, RN #2 states the medication Bisprol HCTZ is not on Patient #4’s medication list. RN #2 states she last reconciled (compared the medications in the home to the plan of care medication list) Patient #4’s medications when Patient #4 was recertified (update to the comprehensive plan of care) for home health services which was on 12/26/22. Also, during the home visit to Patient# 4, RN #2 stated Patient #4 has a DVT (deep venous thrombosis – clot in a vein) in his/her left leg diagnosed by the physician prior to 12/13/22, which was when the medication for DVT (Eliquis) was prescribed. On 01/25/23, at 12:20 PM, Patient #4’s record was reviewed with the RN Executive Director (ED). Patient #4's record indicated she/he was admitted with diagnoses including pressure ulcer (wound caused by pressure) of right ankle, hypertension (high blood pressure), and peripheral vascular disease (poor circulation to the lower extremities). The RN ED confirms Patient #4 had Bisprol HCTZ ordered by the physician beginning 12/2/22. The RN ED confirms Patient #4’s comprehensive plan of care was updated on 12/26/22 and the medication Bisprol HCTZ was not on the medication list, and she/he states it should have been. The RN ED also confirms Patient #4’s diagnosis of DVT was not included in the comprehensive plan of care and states it should have been included. On 1/25/23, at 2:30 PM, the agency policy titled, “MONITORING MEDICATIONS,” revised 5/1/19 was reviewed. The policy indicated, “…A drug regimen review will be performed on all patients in conjunction with all comprehensive assessments…the skilled nurse is responsible for medication review and reconciliation throughout the episode…The discipline responsible for the drug regimen review will…Compare medication list…to actual medications patient is taking…” On 1/25/23, at 2:30 PM, the agency policy titled, “PLAN OF CARE,” revised 12/1/21 was reviewed. The policy indicated, “…The POC (plan of care) includes…Medications…Pertinent diagnosis(es)…” Patient #1 During home observation visit on 1/24/2023 between 11 AM and 11:48 AM, it was revealed discrepancies in the agency medication list and what the patient is taking in the home. Agency medication list reports patient taking Zyrtec 10 mg 1 tablet daily, patient reports only taking medication as needed. Agency medication list reports Chlorthalidone 25 mg tablet 1 tablet daily has been discontinued but patient reports taking the medication daily. Patient reports taking Baclofen 5 mg 1 tablet as needed for spasms, this is not part of the agency list. Interview on 1/24/2023 at 11:37 AM, Registered Nurse (RN) #1 verifies the findings.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on chart reviews and interview, the home health agency's staff failed to follow physician orders for reporting the patient's blood sugar, failed to chart an initial evaluation, and failed to change the patient's urinary catheter timely for 3 of 10 patient charts reviewed for care and services. (Patient #1, Patient #3, and Patient #5) Patient #3 On January 25, 2023 at 10:00 AM chart review reveals physician orders dated 3/12/2022 “Next cath change due week of 3/27/22”. Documented nursing visits on 3/22/22 and 3/24/22 show no urinary catheter change. Urinary catheter change documented on 4/19/22. Interview with the Executive Director on 1/26/23 at 10:00 AM reports "I will check that out" and verifies the finding. Patient #1 Chart review on 1/24/2023 at 2:45 PM reveals in orders for episode 12/24/2022 to 2/21/2023, “WHEN VITAL SIGNS ARE OBTAINED LICENSED PROFESSIONAL TO REPORT VITAL SIGNS FALLING OUTSIDE THE FOLLOWING ESTABLISHED PARAMENTER…FBS 300”. Physical Therapy (PT) visits are completed on 12/28/2022, 1/05/2023, 1/10/2023 and 1/17/2023 with no documentation of Fasting Blood Sugar (FBS) results. Registered Nurse (RN) visits are completed on 12/28/2022 and 1/24/2023 with no documentation of FBS results. Interview on 1/25/2023 at 11:46 AM, Executive Director reports “should have been recorded” and verifies the findings. Patient #5 Chart review on 1/24/2023 at 10:10 AM reveals, Patient #5 admitted on 11/26/2022. 485 reveals statement “PHYSICAL THERAPY TO EVALUATE/ASSESS AND DEVELOP PHYSICAL THERAPY PLAN OF CARE THAT WILL BE APPROVED BY THE PHYSICIAN PRIOR TO IMPLEMENTATION”. There is no documentation in the chart of an evaluation by physical therapy. Interview on 1/25/2023 at 11:46 AM, Executive Director reports “this should not have been on there” and verifies the finding.