Every finding on record at Northwest Wheeler County Health

An unannounced Federal recertification survey was completed at this agency on 6/16/2021. The agency was surveyed for compliance with 42 CFR Conditions of Participation for Home Health Agencies, Part 484. An entrance conference was held with the Administrator on 6/8/2021 at 11:44 AM. The purpose of the survey and the survey needs were explained. An opportunity was provided for questions, answers and comments. Definitions and abbreviations: CFR - Code of Federal Regulations cont - continue HHA - home health agency I/O - Intake/output - indicates the need for monitoring intake and output MD - Doctor of Medicine PC - Primary care - referring to primary care physician RN - registered nurse r/t - related to wkly - weekly

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 interview and medical record review, it was determined the agency failed to include measurable outcomes and goals identified by the HHA and the patient on the individualized plan of care for 5 of 5 current patient records reviewed (Patients #1-5). Findings: 1. Review of the "Home Health Certification and Plan of Care" for Patients #1-5 revealed that each patient had "safety" or "safety measures" identified as a need in the visit orders. Futher review of the medical record for Patients #1-5 revealed documentation failed to include an individualized, measurable outcome related to "safety." Patient #1: Review of the "Home Health Certification and Plan of Care," signed 4/21/21, revealed the RN was to "Monitor disease progress and any changes safety [sic]." Further review of the medical record included a "Skilled Nursing Visit Report," dated 6/7/21, that stated "Nursing Diagnosis (Problem): High fall risk r/t unsteady gait." Review of additional documentation provided as plan of care information revealed the documentation failed to include a measurable outcome or goal identified by the HHA or the patient related to safety that addressed fall risk. Patient #2: Review of the "Home Health Certification and Plan of Care," signed 4/27/21, revealed visit orders indicated "Safety" was an issue. Review of narrative documentation titled "487-Addendum to plan of care," undated, signed by the MD on 5/18/21, revealed "[His/Her] PC has ordered Home Health for [him/her] to monitor [his/her] medications and [his/her] safety. [Patient name] smokes one after the other in [his/her] back room that is attached to [his/her] kitchen, [family member] is worried about [him/her] starting a fire." Further review of the medical record included a "Skilled Nursing Visit Report," dated 6/8/21, that stated "Nursing Diagnosis (Problem): High fall risk r/t generalized weakness." Review of additional documentation provided as plan of care information revealed the documentation failed to include a measurable outcome or goal identified by the HHA or the patient related to safety that addressed either the smoking or fall risk issues. Patient #3: Review of the "Home Health Certification and Plan of Care," signed 4/15/21, revealed visit orders indicated "Safety" was an issue. Further review of the medical record included a "Skilled Nursing Visit Report," dated 6/9/21, that stated "High fall risk r/t generalized weakness." Review of additional documentation provided as plan of care information revealed the documentation failed to include a measurable outcome or goal identified by the HHA or the patient related to safety that addressed fall risk. Patients #4 and #5: Review of the medical record for these patients revealed similar findings. 2. Review of the "Home Health Certification and Plan of Care" for Patients #1-3 and #5 revealed that each patient had the need for "I/O" identified in the visit orders. Futher review of the medical record for Patients #1-3 and #5 revealed documentation failed to include an individualized, measurable outcome related to "I/O." Patient #1: Review of the "Home Health Certification and Plan of Care," signed 4/21/21, revealed visit orders indicated the need to "Monitor I/O." Review of a "Recertification/Follow-up Assessment," dated 4/21/21, revealed under "Nutritional Status" a nutritional risk assessment score of 3; a score of 3-5 indicates moderate risk. Review of documentation provided as plan of care information revealed the documentation failed to include a measurable outcome or goal identified by the HHA or the patient related to the need for monitoring I/O. Patient #2: Review of the "Home Health Certification and Plan of Care," signed 4/27/21, revealed visit orders indicated "Nutrition Management" and "I/O" were needed. Review of a "Recertification/Follow-up Assessment," dated 4/27/21, revealed under "Nutritional Status" a nutritional risk assessment score of 11; a score of 6 or more indicates high risk. Review of documentation provided as plan of care information revealed the documentation failed to include a measurable outcome or goal identified by the HHA or the patient related to monitoring I/O and nutritional status. Patient #3: Review of the "Home Health Certification and Plan of Care," signed 4/15/21, revealed visit orders indicated "Intake/Output" was needed. Review of narrative documentation titled "487 - Addendum to plan of Care [sic]," undated, signed by the MD on 5/18/21, revealed the patient was "a frail [man/woman] who has been discharged from the hospital. [He/She] was admitted with dehydration, malnutrition, and failure to thrive." Review of a "Recertification/Follow-up Assessment," dated 4/15/21, revealed under "Nutritional Status" a nutritional risk assessment score of 3; a score of 3-5 indicates moderate risk. Review of documentation provided as plan of care information revealed the documentation failed to include a measurable outcome or goal identified by the HHA or the patient related to monitoring I/O and nutritional status. Patient #5: Review of the "Home Health Certification and Plan of Care," signed 4/5/21, revealed visit orders indicated "I/O" was needed. Review of a "Comprehensive Adult Nursing Assessment," dated 3/31/2021, revealed under "Nutritional Status" a nutritional risk assessment score of 7; a score of 6 or more indicates high risk. Review of documentation provided as plan of care information revealed the documentation failed to include a measurable outcome or goal identified by the HHA or the patient related to monitoring I/O and nutritional status. During an interview with Employee #1 on 6/9/2021, beginning at 10:11 AM, preliminary information regarding the lack of individualized, measurable outcomes or goals identified by either the HHA or the patient was presented. Employee #1 acknowledged the finding. During the exit conference with Employee #1 on 6/16/2021, beginning at 1:00 PM, additional information regarding the lack of individualized, measurable outcomes or goals identified by either the HHA or the patient was presented with specific examples related to "safety." Employee #1 indicated that care conferences were routinely held and documentation from those meetings may contain the information needed. Additional information was provided on 6/16/2021. The additional information was reviewed and failed to provide documentation necessary to satisfy the regulation requirement.