Every finding on record at Pilot Point Home Health Inc

A Recertification Survey entrance conference was conducted on 09/28/2021 at 11:45 AM with the Adm and DON. Census: L&CHH: 44 LHH: 0 An exit conference was conducted on 10/05/2021 at 4:40 PM with the Adm, DON, LVN and OM. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. The agency was found in compliance with 42 CFR Part 484.22 Medicare Conditions of Participation and no deficiencies were cited.

A Recertification Survey entrance conference was conducted on 09/28/2021 at 11:45 AM with the Adm and DON. Census: L&CHH: 44 LHH: 0 An exit conference was conducted on 10/05/2021 at 4:40 PM with the Adm, DON, LVN and OM. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. Deficiencies cited at standard level. ABBREVIATIONS Adm - Administrator AM - ante meridiem AV - arteriovenous CFR - Code of Federal Regulations DON - Director of Nurses/Supervising Nurse EMR - electronic medical record IUC - indwelling urinary catheter L&CHH- Licensed and Certified Home Health LHH - Licensed Home Health LVN - Licensed Vocational Nurse OM - office manager PI - performance improvement PIP - Performance Improvement Project PM - post meridiem POC - plan of care QAPI- Quality Assurance Performance Improvement RN - registered nurse SN - skilled nurse

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 record review and interview, the agency failed to develop a POC that covered all required elements for all patients. In one (Patient 1) of one active record reviewed where the patient had an AV shunt and received services from a dialysis facility, the POC failed to include: safety measures for the renal dialysis access site to include the location of the AV shunt to ensure no blood pressures were taken from the arm where the shunt was located and orders for the SN to assess the AV shunt for bruit and thrill. In one (Patient 2) of one active record reviewed where the patient had an AV shunt, the POC failed to include safety measures for the renal dialysis access site to include the location of the AV shunt to ensure no blood pressures were taken from the arm where the shunt was located. In one (Patient 3) of one active record reviewed where the patient had an order for the SN to change the IUC, the POC failed to include the type of IUC, the size of the IUC and the volume of fluid to inflate the urinary catheter balloon. This failure resulted in patients being placed at risk of harm for the type of services needed for appropriate care, for receiving inadequate care, a decline in status and exacerbation of disease process. Findings Include: Definitions: "Dialysis arteriovenous fistula: A surgically created connection between an artery and vein in the arm of patients who need to undergo hemodialysis, a process in which blood is removed from the body, cleansed and then returned to the body." Resource: www.radiologyinfo.org Jan 2021 "A healthy AV fistula has: A bruit (a rumbling sound that you can hear) A thrill (a rumbling sensation that you can feel)..." Resource: www.azuravascularcare.com 10/18/2018 IUC: " ...the catheter is placed into the urethral meatus (opening), traverses the length of the urethra, and then enters the bladder ...the IUC is held in place by a balloon located at the tip of the catheter that is inflated once the catheter is in the bladder ....Catheters are made from various materials and coatings can be applied to the surface of the catheter to improve their biocompatibility, ease their insertion, and minimize infections. Catheter materials and coating can be significant factors when selecting an IUC as each have their advantages and disadvantages ..." Resource: https://abdominalkey.com/indwelling-transurethral-and-suprapubic-catheters/ Patient 1: Record review of the EMR included a POC for the certification period 07/07/2021 to 09/04/2021 electronically signed by RN A on 07/06/2021 that included a diagnosis of Hypertensive heart and chronic kidney disease with heart failure, Stage 5 chronic kidney disease and dependence on renal dialysis. The POC did not include safety measures for the renal dialysis access site to include the location of the AV shunt to ensure no blood pressures were taken from the arm where the shunt was located and orders for the SN to assess the AV access shunt for bruit and thrill. Patient 2: Record review of the EMR included a POC for the certification period 07/03/2021 to 08/31/2021 electronically signed by RN B on 06/28/2021 that included a diagnosis of hypertensive chronic kidney disease with stage 5 chronic kidney disease and AV fistula. The POC did not include safety measures for the renal dialysis access site to include the location of the AV shunt to ensure no blood pressures were taken from the arm where the shunt was located. During an interview with the Adm, DON, LVN and the OM on 10/05/2021 at approximately 11:00 AM, the surveyor presented the above findings of why the POC for Patient 1 did not include safety measures for the renal dialysis access site to include the location of the AV shunt to ensure no blood pressures were taken from the arm where the shunt was located and orders for the SN to assess the AV access shunt for bruit and thrill and why the POC for Patient 2 did not include safety measures for the renal dialysis access site to include the location of the AV shunt to ensure no blood pressures were taken from the arm where the shunt was located. The DON stated the agency used a template with their software and they needed to add that to the template. Patient 3: Record review of the EMR included a POC for the certification period 07/12/2021 to 09/09/2021 electronically signed by RN B on 07/07/2021 that included a diagnosis of neuromuscular dysfunction of bladder and encounter for fitting and adjustment of urinary device. The POC read in part, " ...Supplies ...Foley Catheter ...skilled nurse to change indwelling catheter monthly and prn using sterile technique ...patient has chronic indwelling catheter that was placed today by SN due (sic) patient pulled out ..." The POC did not include the type of IUC, the size of the IUC and the volume of fluid to inflate the urinary catheter balloon. During an interview with the Adm, DON, LVN and the OM on 10/05/2021 at approximately 11:15 AM, the surveyor presented the above findings of why the POC for Patient 3 did not include the type of IUC, the size of the IUC and the volume of fluid to inflate the urinary catheter balloon. The DON stated it was because the agency did not have the appropriate information on the template. Agency Policy titled, "PLAN OF CARE" read in part, "POLICY: Each patient receiving skilled home health agency service will have a plan of care (POC) individualized to meet his/her needs ...PURPOSE: To ensure quality care and adherence to regulatory requirements and standards of care ...PROCEDURE ...VII. The individualized POC must include the following ...all medications and treatments ...safety measures to protect against injury ...patient-specific interventions ..." Agency Policy titled, "CARE PLANNING PROCESS ..." read in part, " ...PURPOSE ...Each patient must receive an individualized written plan of care ...The individualized plan of care must specify the care and services necessary to meet the patient-specific need ...PROCEDURE ...V. The assessing clinician in collaboration with the responsible physician/practitioner creates the individualized plan of care (POC) that specifies the care and services necessary to meet the patient-specific needs ...including ...all medications and treatments ...patient-specific interventions ..."

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to conduct and document PIP(s) for the calendar years 2018, 2019 and 2020 that reflected the scope, complexity and past performance of the agency's services and operations. The failure could place the agency at risk to not improve and provide quality care and services to the agency's patients. FINDINGS INCLUDE: Record review of the agency's QAPI manual did not reveal any reports, reviews or documentation that indicated the agency had conducted PIP(s), per federal regulatory requirements, for the years 2018, 2019 and 2020. The manual contained a two-page form titled, "QAPI Performance Improvement Project (PIP)" that was blank and contained no agency information. During an interview with the Adm on 10/05/2021 at approximately 4:03 PM, the surveyor presented the above findings of what the agency's PIP had been for 2018, 2019 and 2020. The Adm stated that was something that had not been done. Agency policy titled, "QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT - TEXAS" read in part, " ...The Texas Agency will develop, implement and maintain an effective, ongoing Agency wide, data-driven QAPI program which adheres to ...Federal regulations...Performance Improvement Projects...The number and scope of distinct PI projects conducted annually must reflect the scope, complexity and past performance of the Agency's services and operations ..."