Every finding on record at Nhrmc Home Care

An onsite, unannounced recertification survey was conducted 07/18/22-07/20/22. No deficiencies to the emergency preparedness program were identified. -MHB

An onsite, unannounced recertification survey was conducted 07/18/22-07/20/22. Standard-level deficiencies to the Medicare Conditions of Participation were identified. -MHB

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 policy review, clinical record review, and staff interview, the agency failed to notify the physician regarding an inability to obtain weights for 1 of 3 patients with heart failure (Patient #3) and failed to notify the physician regarding weights outside of ordered parameters for 1 of 3 patients with heart failure (Patient #14). Findings include: Policy titled Coordination of Service PC-11 was received from the Director of Specialty Services on 07/20/22 at 1:56 PM. This policy revealed, “The primary nurse and/or case manager are responsible for communication with all disciplines, external agencies and organizations involved in providing health and supportive services to the assigned patients…Coordination activities include but are not limited to…telephone communication, verbal report and/or written summaries to patient’s physician…” 1. Patient #3 was admitted to the agency on 06/29/22 with diagnoses including hypertensive heart and chronic kidney disease with heart failure (weakening of the heart related to high blood pressure and kidney disease) and acute on chronic systolic heart failure (a rapid onset of heart failure related symptoms in a person with a long-term heart failure diagnosis). Plan of Care from 06/29/22 to 08/27/22 revealed orders for skilled nursing 2 times per week for 3 weeks, 1 time per week for 6 weeks and 3 visits as needed. Skilled nursing orders included congestive heart failure instructions, “…instruct patient, caregiver…to weigh daily and record…notify SN (skilled nurse)/MD (medical doctor) if weight increase of 3 pounds in 24 hours or 5 pounds in one week…” Employee #4, a registered nurse, conducted a skilled nursing start of care visit on 06/29/22. This visit note revealed, “…per daughter…patient is not able to weigh daily as she is not steady enough to weigh…” Employee #5, a registered nurse, conducted a skilled nursing visit on 07/07/22. There was no evidence of a documented weight from this visit. At the time of survey, there was no evidence that the physician was notified that Patient #3 was not able to weigh. In an interview on 07/20/22 at approximately 11:35 AM, Employee #3, RN supervisor, stated, “I don’t see any documentation that they [Employees #4 and #5] notified the physician when they were unable to weigh…the expectation if unable to weigh would be that they notify the physician…” 2. Patient #14 was admitted to the agency on 05/08/21 with diagnoses including chronic diastolic heart failure and chronic obstructive pulmonary disease (a lung condition that leads to airflow blockage). Plan of Care from 05/08/21 to 07/06/21 revealed orders for skilled nursing 1 visit every day for 1 day, 3 visits every week for 1 week, 2 visits every week for 3 weeks, 1 visit every week for 5 weeks, and 4 visits as needed. Skilled nursing orders included congestive heart failure instructions, “…instruct patient, caregiver…to weigh daily and record…notify SN (skilled nurse)/MD (medical doctor) if weight increase of 3 pounds in 24 hours or 5 pounds in one week…” Clinical record review revealed a telehealth call dated 06/02/21 at 2:44 PM. This telehealth call documented that Employee #2, registered nurse case manager, was notified that Patient #14 had a 4-pound weight gain overnight. There was no evidence that Employee #2 contacted Patient #14 to follow-up regarding this weight gain on 06/02/21. There was also no evidence that Employee #2 notified the physician of the reported weight gain. There was a documented skilled nursing missed visit dated 06/04/21 and the next documented skilled nursing visit was conducted on 06/11/21. A telehealth call from 06/17/21 at 12:00 PM revealed, “This RN (registered nurse) notified [Employee #2] of patient’s 3 lbs (pounds) weight gain, over the past 24 hours, on telehealth. Weight yesterday 222 lbs and increased to 225.5 lbs today. [Employee #2] is going to plan to make an SN (skilled nursing) visit to assess pt (patient)…” There was no evidence that a skilled nursing visit was conducted on 06/17/21. There was no evidence that Employee #2 contacted Patient #14 to follow-up regarding the reported weight gain. There was no evidence that Employee #2 notified the physician of the reported weight gain. There was a documented skilled nursing missed visit dated 06/18/21 and the next documented skilled nursing visit was conducted on 06/21/21. A telehealth call from 06/23/21 at 11:28 AM revealed, “Pt (patient) contacted due to HR (heart rate) 136 [average heart rate range is 60-100 beats per minute] and wt (weight) concern 230.5 lbs, gradual inc (increase) over last several days. Pt states, ‘I am not doing well, the way it is going I might be back in the hospital by the end of the week.’ Pt instructed that this RN will contact HHCM (home health case manager, Employee #2) with concerns”. A documented telehealth call from 11:33 AM, revealed “HHCM contacted due to pt wt and HR concern today. HHCM states she will schedule a PRN (as-needed) visit to evaluate pt status and update pt MD (medical doctor) …” There was no evidence that a skilled nursing visit was conducted on 06/23/21. There was no evidence that Employee #2 contacted Patient #14 on 06/23/21 to follow-up regarding this elevated heart rate, weight gain or the patient’s report that he was “not doing well”. There was no evidence that Employee #2 notified the physician of the reported elevated heart rate and weight gain on 06/23/21. The next documented skilled nursing visit was conducted on 06/24/21. In an interview on 07/20/22 at approximately 2:00 PM, Employee #3, RN Supervisor, stated, “I would expect them to make a PRN visit the same day to assess the patient and follow-up with the doctor…” when asked about the expectation of clinicians when a patient has documented weights that fall outside of the ordered parameters.