Every finding on record at Optimal Home Care Inc

A recertification survey in conjunction with a COVID 19 survey was completed on 7/8/21. Three deficiencies were 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 interview, and record review, the agency failed to ensure the individualized plan of care included complete orders for interventions or treatments, in 3 of 3 patients receiving Foley (urinary) catheter care (Patients #2, #5 and #14). Findings include: AGENCY POLICY: According to the agency policy titled, "PLAN OF CARE," dated 1/19/21 (in pertinent parts): PURPOSE: 4. To provide detailed clinical information for all primary care provider [sic] involved in case management. "3. THE INDIVIDUALIZED PLAN OF CARE MUST INCLUDE: 3.10 All medications and treatments." 1. The clinical record for Patient #2 was reviewed on 7/6/2021. The Plan of Care for the certification periods dated 4/27/2021 to 6/25/2021 and 6/26/2021 to 8/24/2021 revealed a start of care date of 4/27/2021; diagnoses included breakdown (mechanical) of indwelling urethral catheter, bladder neck obstruction, and other disorders of the bladder and retention of urine. Plan of Care orders include physical therapy (PT) two times a week for three weeks, for strengthening, balance and gait training; and skilled nursing (SN) services every four weeks for Foley catheter changes and as needed (PRN) for malfunction-obstruction, or clogging. a) The agency failed to provide complete Foley (urinary) catheter orders on the plan of care. Review of the plan of care dated 4/27/21 to 6/25/21 revealed orders for Foley catheter care reading, "Change Foley catheter every four weeks. Change Foley catheter as needed for malfunction-obstruction, clogging. Examine and secure tubing at each nursing visit." However, the catheter care orders did not include the size of the catheter to be used, what size balloon, and how to secure it. Review of the Plan of Care dated 6/26/21 to 8/24/21 revealed orders for Foley catheter care reading "Optimal HHRN (home health registered nurse) for routine catheter care - flush PRN (as needed), change catheter every four weeks and as needed for catheter malfunction" and "Optimal clinician will be responsible for monthly catheter care Fr (french size) 18, 10 cc" However, the Plan of Care orders for catheter care failed to include the type of solution to be used when flushing the catheter, the amount of solution to use when flushing and did not indicate if the 10 cc was the balloon size or an amount of solution. Review of the Physician Orders dated 4/27/21 to 6/25/21 and 6/26/21 to 8/24/21 revealed no evidence the physician ordered any additional orders for catheter care during the time periods stated. Review of a supplemental order dated 6/17/21 showed, "flush -prn (as needed)," and to "change the catheter every four weeks." However this order did not contain the size or type of catheter, and the type or amount of solution used to flush the catheter. During an interview on 7/8/21 at 12:02 p.m. Licensed Practical Nurse (LPN #8) stated that the catheter orders were found on the Plan of Care under interventions. However, no evidence of complete catheter orders were included on the Plan of Care. During an interview on 7/8/21 at 12:30 p.m., Employee #7 stated Foley catheter orders should always include insertion date, catheter size, balloon size, how often to change the catheter, and flush orders including whether to flush with normal saline or sterile water, how much to flush with and how often to flush. However, none of these were included in the catheter orders for Patient #2. 2. The clinical record for Patient #14 was reviewed on 7/7/21. The Plan of Care for the certification periods dated 12/20/20 to 2/17/21 and 2/18/21 to 4/18/21 revealed a start of care date of 12/20/20; diagnosis included chronic kidney disease, urinary device fitting and adjustment, polyneuropathy, and restless let syndrome. Plan of Care orders included SN services once a month for three months for urinary catheter changes, PT services once a week for four weeks for balance, gait, and endurance training, and occupational therapy (OT) services once a week for four weeks and then once a week for three weeks for muscle re-education and home safety interventions. a) The agency failed to ensure the patient's plan of care included complete orders for Foley (urinary) catheter care. Review of the plan of care dated 12/20/20 to 2/17/20 revealed orders for Foley catheter care reading, "Foley irrigation. Catheter change every month with 10 mL (milliliters) normal saline. Catheter care." However, the catheter care orders did not include the size of the catheter to be used, orders for catheter flushes with the type of flush, amount of flush to use, or how often to flush, and the order, "Catheter change every month with 10 mL," did not specify if the 10mL is the catheter balloon fill size or whether this is for flushing the catheter. Review of the plan of care dated 2/18/21 to 4/18/21 revealed orders for Foley catheter care reading, "Catheter change every month with 10mL normal saline utilizing sterile technique. Foley irrigation. PRN (as needed) Catheter care up to 4 visits during episode." However, the catheter care orders did not include the size of the catheter to be used, orders for catheter flushes with the type of flush, amount of flush to use, or how often to flush, and the order, "Catheter change every month with 10 mL," did not specify if the 10mL is the catheter balloon fill size or whether this is for flushing the catheter. Review of the Physician Orders dated 12/20/20 to 2/17/21 and 2/18/21 to 4/18/21 revealed no evidence the physician ordered any additional orders for catheter care during the time periods stated. Review of the Communication Notes dated 12/20/20 to 4/18/21 revealed no evidence the SN attempted to clarify the physician orders for catheter care to include balloon size, catheter size, or flushes. 3. The clinical record for Patient #5 was reviewed on 7/7/21. The Plan of Care for the certification period dated 5/23/21 to 7/21/21 revealed a start of care date of 1/29/20; diagnosis included neuromuscular dysfunction of the bladder, fitting and adjustment of a urinary device, and hemiplegia (weakness or paralysis of one side of the body). Plan of Care orders included SN services three times a week for nine weeks for catheter care, vital signs, and anticoagulant monitoring, certified nursing assistant (CNA) services three times a week for nine weeks for personal cares, ambulation, transfer, and mobility assistance, and PT services once a week for eight weeks for balance, gait, strengthening, and endurance training. a) The agency failed to ensure the patient's plan of care included complete orders for Foley catheter care. Review of the Plan of Care dated 5/23/21 to 7/21/21 revealed order for catheter care that stated, "Irrigate 3 x week (three times a week) due to chronic UTI (urinary tract infection) 50-60 ml. Catheter change every month with 16fr (french- size) catheter." However, the Plan of Care orders for catheter care failed to include the catheter balloon size or the type of solution to be used when flushing the catheter. During an interview on 7/8/21 at 12:30 p.m., Employee #7 stated Foley catheter orders should always include insertion date, catheter size, balloon size, how often to change the catheter, and flush orders including whether to flush with normal saline or sterile water, how much to flush with and how often to flush. However, none of these were included in the catheter orders for Patient #14.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to provide services and treatments only as ordered by the physician for 2 of 2 patients reviewed who were receiving Coumadin (anticoagulant) monitoring (Patients #5 and #12). Findings include: AGENCY POLICY According to the agency policy titled, "PRIMARY CARE PROVIDER ORDERS," dated 1/19/21 (in pertinent parts): "PROCEDURE: 1. MEDICATIONS OR TREATMENTS - administered by a home health clinicians [sic] only as ordered by authorized primary care provider within the scope of his/her state license, certification or registration." 1. The clinical record for Patient #12 was reviewed on 7/7/21. The Plan of Care for the certification periods dated 3/25/21 to 5/23/21 and 5/24/21 to 7/22/21 revealed a start of care date of 3/25/21; diagnoses included chronic heart failure, peripheral vascular disease, and hypertensive heart disease. Plan of Care orders included skilled nursing (SN) services once a week for one week and then once a week for eight weeks for monitoring of anticoagulant use, and physical therapy (PT) services once a week for one week and then twice a week for four weeks for balance and gait training. a) The agency failed to obtain physician's orders for anticoagulant monitoring. Review of the Skilled Visit Notes dated 4/29/21, 5/7/21, 5/20/21, and 6/22/21 revealed the SN had drawn a PT/INR (anticoagulant monitoring level) level during each of these visits. Review of the Physician Orders for the certification periods of 3/21/21 to 5/23/21 and 5/24/21 to 7/22/21 revealed no evidence of physician orders to draw PT/INR levels on 4/29/21, 5/7/21, 5/20/21, and 6/22/21. Review of the Physician Orders dated 3/30/21 revealed the physician had ordered a PT/INR draw for 4/19/21. Review of the SN schedule for the week dated 4/18/21 to 4/24/21 revealed no evidence the SN had drawn a PT/INR for that week. However, the physician order dated 3/30/21 stated the SN was to draw the PT/INR on 4/19/21. During an interview on 7/8/21 at 11:40 a.m., RN #9 stated she had input some orders for the PT/INR for Patient #12, but she didn't remember if she input the orders for the above dates because she was very busy with many patients. She stated Patient #12 had received a new monitoring machine and was told by the company responsible for the machine that PT/INRs had to be done once a week in order for the patient to use that particular machine. She further stated she had not received an order from the physician for weekly PT/INR monitoring because the company that owned the machine had told her to monitor the patient weekly. During an interview on 7/8/21 at 12:15 p.m., Employee #7 stated Patient #12 had started with their new machine in either March or April of 2021 (three months prior to the survey) and stated the SN probably had forgotten to request orders for PT/INR monitoring for the patient. She further stated the SN would enter late orders to correct the documentation in the patient record. 2. The clinical record for Patient #5 was reviewed on 7/7/21. The Plan of Care for the certification period dated 5/23/21 to 7/21/21 revealed a start of care date of 1/29/20; diagnosis included neuromuscular dysfunction of the bladder, fitting and adjustment of a urinary device, and hemiplegia (weakness or paralysis of one side of the body). Plan of Care orders included SN services three times a week for nine weeks for catheter care, vital signs, and anticoagulant monitoring, certified nursing assistant (CNA) services three times a week for nine weeks for personal cares, ambulation, transfer, and mobility assistance, and PT services once a week for eight weeks for balance, gait, strengthening, and endurance training. a) The agency failed to obtain physician's orders for anticoagulant monitoring. Review of Physician Orders dated 5/24/21 revealed the physician had ordered a PT/INR draw on 5/28/21, however there was no evidence in Patient #5's record that the SN performed a PT/INR draw during that visit. During an interview on 7/8/21 at 12:34 p.m., RN #10 stated the physician may order an exact date for a PT/INR draw but that was not always a 'hard' date for the draw. He stated the lab draws were always completed, even if they weren't on the date the physician ordered. He further stated the physician usually ordered lab draws for 'the week' instead of a specific date.

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 have evidence of communication with the physician for lab results for 1 of 3 records reviewed for patients receiving blood glucose monitoring (Patient #9), and 1 of 2 records reviewed for patients receiving anticoagulant monitoring (Patient #12). Findings include: AGENCY POLICY According to the agency policy titled "Primary Care Provider Notification," dated 1/21/21 (in pertinent parts): "PROCEDURE: 1. The primary care provider will be notified of but not limited to the following: 1.6 As ordered. 2. DOCUMENTATION GUIDELINES: Document the following in the patient's clinical chart: 2.1 Any communication with the primary care provider." 1. The clinical record for Patient #9 was reviewed on 7/6/21. The Plan of Care for the certification periods dated 3/25/21 to 5/23/21 and 5/24/21 to 7/22/21 revealed a start of care date of 3/25/21; diagnoses included type two diabetes, paranoid schizophrenia, and hypertension. Plan of Care orders included skilled nursing (SN) services once a day, seven days per week for daily glucose monitoring and insulin administration. a) The agency failed to ensure the physician was notified of blood glucose monitoring that was outside of physician ordered parameters. Review of the Plan of Care orders dated 3/25/21 to 5/23/21 revealed the physician orders, "Notify physician of blood sugar over 300 or under 70 mg/dL (deciliter)." Review of the Skilled Visit Notes dated 4/3, 4/4, 4/6, 4/9, 4/10, 4/11, 4/14, 4/16, 4/17, 4/18, 4/20, 4/21, 4/23, 4/24, 4/28, 5/1, 5/2, 5/7, 5/8, 5/10, and 5/12/21 revealed Patient #9 had blood glucose levels over 300 mg/dL. Review of the Skilled Visit Notes for the dates above revealed no evidence of the SN notifying the physician of the high blood glucose levels during the SN visits. Review of the Communication Note dated 4/12/21 revealed the SN reported the high blood sugar levels from 4/9/21 and 4/10/21 on this date (2 and 3 days later, respectively). Further review of the Communication Notes showed on 5/3/21 the SN reported high blood sugar levels for 5/1/21 and 5/2/21 (2 and 3 days later), on 5/14/21 the SN reported the high blood glucose level from 5/12/21 (2 days later), and on 5/25/21 the SN reported the high blood glucose levels from 4/23/21 and 4/24/21 (31 and 32 days later, respectively). During an interview on 7/8/21 at 12:03 p.m., Licensed practical nurse (LPN #18) stated the agency process was to notify the physician and the case manager when blood glucose monitoring was outside of physician parameters. She further stated she had documented multiple times in the patient record under coordination notes when she notified the physician of high blood glucose numbers for Patient #9, however, record review showed multiple instances of no physician communication documentation for the patient's blood glucose monitoring. During an interview on 7/8/21 at 12:20 p.m., Employee #7 stated the agency policy was to notify the physician or nurse practitioner at the end of a patient visit when there are lab results outside of physician parameters. She further stated the blood glucose results were always documented in the log in the patient's home, and these were scanned into the record as the SN completed each page. However, this was not made available to the state agency (SA) prior to the survey exit. 2. The clinical record for Patient #12 was reviewed on 7/7/21. The Plan of Care for the certification periods dated 3/25/21 to 5/23/21 and 5/24/21 to 7/22/21 revealed a start of care date of 3/25/21; diagnosis included chronic heart failure, peripheral vascular disease, and hypertensive heart disease. Plan of Care orders included SN services once a week for one week and then once a week for eight weeks for monitoring of anticoagulant use, and physical therapy (PT) services once a week for one week and then twice a week for four weeks for balance and gait training. a) The agency failed to ensure the physician was notified of anticoagulant monitoring that was outside of physician ordered parameters. Review of the Plan of Care orders for the certification period dated 5/24/21 to 7/22/21 revealed physician orders for, "SN to check INR [international normalized ratio] as directed by physician. Results called to physician." Review of the Skilled Visit Note dated 7/1/21 revealed Patient #12 had a PT [Prothrombin time]/INR of 3.9 (higher than the normal therapeutic range). However, there was no evidence the SN notified the physician of Patient #12's results until the next PT/INR draw on 7/6/21. During an interview on 7/8/21 at 11:40 a.m., RN #9 stated her first step after she received the results for the PT/INR for the patient was to call the physician's office and notify them of the results. She further stated Patient #12 had a PT/INR machine that automatically transmitted the results to the machine's company, who then contacted the physician with the results. However, there was no evidence of documentation in the patient records to show whether the machine had transmitted the data or not, and there was no evidence of physician's orders to show the physician had received the results and adjusted Patient #12's medications accordingly.