Every finding on record at Newton Healthcare Corporation

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site Recertification Survey (#616DC-H1) at the above-named Home Health Agency (HHA) from 11/06/23 to 11/13/23 resulted in a finding of no deficiency citations respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.102.

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site Recertification survey (# 616DC-H1) conducted at the above-named Home Health Agency (HHA) from 11/06/23 to 11/13/23 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.

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 interviews, record reviews, and policy review, the agency failed to include a diagnosis on the patient’s plan of care for 1 (Patient 9) of 10 sampled patients reviewed. The agency further failed to ensure all medications were reconciled on the plan of care for 1 (Patient 3) of 10 sampled patients reviewed. Findings Include: 1. Review of Patient 9’s “Home Health Certification and Plan of Care,” revealed the agency admitted Patient 9 on 03/21/23, with diagnoses that included non-pressure chronic ulcers of the left leg and foot. The Home Health Certification and Plan of Care revealed Patient 9’s medications included buspirone (a medication used to treat depression) 5 milligrams, two tables twice a day for depression. The Home Health Certification and Plan of Care did not indicate Patient 9 had a diagnosis of depression. During an interview on 11/09/23 at 9:00 AM, the Clinical Director (CD) confirmed Patient 9’s plan of care did not include a diagnosis of depression and stated the plan of care should include all the patient’s diagnoses. The CD stated the agency did not have a policy on including pertinent diagnoses on a patient’s plan of care. 2. Review of the agency’s policy titled “Medication Safety [agency name],” dated 09/25/23, revealed, “2.1.6 [Agency name] Home Care clinicians shall routinely assess for changes to the medications and reconcile the medications when there has been a change. 2.1.5.1 Changes shall be documented in the clinical record and communicated to the patient and/or caregiver.” Review of Patient 3’s “Home Health Certification and Plan of Care,” dated 10/23/23, revealed the agency admitted Patient 3 on 10/23/23, with diagnoses that included intestinal adhesions (bands of scar tissue that formed between the abdominal organs, mainly the small intestine that could block digestive function) and constipation. During an interview in Patient 3’s home on 11/07/23 at 8:35 AM, Patient 3 reported having problems with constipation. Registered Nurse (RN) 1 reviewed the patient’s current medications and stated the patient was ordered a stool softener which was not documented on the patient’s medication list. RN 1 reviewed the patient’s pill box and confirmed Patient 3 received a stool softener. RN 1 then added the stool softener to Patient 3’s medication list. During an interview on 11/07/23 at 10:35 AM, Patient 3’s Family Member (FM) stated that Patient 3 started the stool softener two weeks ago. During an interview on 11/08/23 at 9:45 AM, Licensed Practical Nurse (LPN) 3 stated that during Patient 3’s nursing visit on 11/03/23, Patient 3’s FM told her that Patient 3 started a stool softener. LPN 3 stated she added the stool softener to Patient 3’s pill box, however failed to add the medication to the patient’s plan of care. LPN 3 stated the agency policy was to review patients’ medications at each visit and to update the plan of care if new medications or changes to medications were identified. During an interview on 11/08/23 at 10:05 AM, the Clinical Director (CD) stated that the agency policy directed clinicians to assess for medication changes during each nursing visit and update the patient’s plan of care. The CD acknowledged the agency failed to follow their policy for medication reconciliation.

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 interview, record reviews, and policy review, the agency failed to provide social worker visits as ordered by the physician for 1 (Patient 1) of 10 sampled patients reviewed. This deficient practice has the potential to place patients at risk for unmet needs and services. Findings Include: Review of an undated agency policy titled, “Coordination of Care – Providers [facility name],” revealed, “Orders shall be integrated from all the providers involved in the plan of care to assure the coordination of all services and interventions provided to the patient.” Review of Patient 1’s “Home Health Certification and Plan of Care,” revealed the agency admitted Patient 1 on 09/08/23, with diagnoses that included chronic gastric (stomach) ulcer, post hemorrhagic (bleeding) anemia (low red blood cells), anxiety, depression, low income, and problems related to living alone. Review of Patient 1’s “Provider Communication,” dated 09/08/23, and signed by the skilled nurse, revealed Patient 1 was evaluated by a skilled nurse who requested a physician’s order for Patient 1 to be seen by the social worker for resource and financial assistance, twice a week for three weeks, and then once a week for five weeks. The Provider Communication revealed, the physician signed the order on 09/13/23. Review of Patient 1’s entire clinical record, revealed no documentation the agency provided social work services as ordered by the physician. During an interview on 11/08/23 at 3:00 PM, the Clinical Director (CD) confirmed Patient 1’s physician had ordered social work visits for Patient 1 and the agency had not provided the service. The CD stated the agency policy was to provide services as ordered by the patient’s physician and acknowledged the agency failed to follow their policy.