Every finding on record at Preferred Home Health LP

A recertification and follow-up (W77611 exit 08/19/20) survey entrance conference was conducted on 02/27/23. Census: 185 Licensed & Certified - 185 Licensed Home Health - 0 The agency was in substantial compliance with 42 CRF Park 484.102, Emergency Preparedness Requirements for Home Health Agencies.

A recertification and follow-up (W77611 exit 08/19/20) survey entrance conference was conducted on 02/27/23. Census: 185 Licensed & Certified - 185 Licensed Home Health - 0 Acronyms used: ESRD - end stage renal disease mg - milligram POC – plan of care

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 observation, interview, and record review, the agency failed to ensure the plan of care contained patient specific interventions and safety measures to protect against injury for 3 of 17 patients reviewed for plans of care. (Patient #’s 2, 11, and 12) This failure could place patients at risk of injury to a dialysis access site, worsening heart failure, leading to complications and hospitalization. Findings included: Record review of Patient #2’s POC dated 01/07/23 to 03/07/23 indicated she was 76 years old with diagnoses including end stage renal disease (final stage of kidney failure). The POC indicated Patient #2 was ordered skilled nursing visits one time a week for 3 weeks, then 2 times a week for one week, then one time a week for 5 weeks. Skilled nursing orders included to perform a comprehensive assessment and evaluate the need for home health services and to educate on interventions to help reduce the patient from having an acute care hospitalization. The medication list indicated Patient #2 was prescribed Furosemide (diuretic) 20 mg 2 tablets every morning and one tablet every afternoon for edema (swelling caused by fluid buildup in the body). The POC did not include orders to assess the patient’s dialysis access site (access to reach the blood for dialysis) and it did not address the location, safety measures, or care interventions for the protection of the access site. The POC did not include order for daily weights/weight monitoring and did not include weight parameters to report to the physician when weight was outside the parameters. Record review of Patient #11’s POC dated 01/12/23 to 03/12/23 indicated she was 78 years old with diagnoses including hypertensive heart disease with heart failure (condition where the heart is unable to pump blood and oxygen efficiently through the body). The POC indicated Patient #11 was ordered skilled nursing visits once a week for 9 weeks. Skilled nursing orders included to provide teaching of heart failure self-management, daily weights, medication management, and tracking symptoms. The POC did not include weight parameters to report to the physician when weight was outside the parameters. Record review of Patient #12 POC dated 02/03/23 to 04/03/23 indicated he was 73 years old with diagnoses including acute congestive heart failure (condition where the heart is unable to pump blood and oxygen efficiently through the body) and chronic kidney disease. The POC indicated Patient #12 was ordered skilled nursing visits once a week for 10 weeks. Skilled nursing orders included to perform a comprehensive assessment and evaluate the need for home health services and to educate on interventions to help reduce the patient from having an acute care hospitalization. The POC did not include order for daily weights/weight monitoring and did not include weight parameters to report to the physician when weight was outside the parameters. During an observation and interview on 02/28/23 at 9:57 a.m., Patient #2 had a dialysis access site to her right inner elbow and swelling to both lower legs. Patient #2 said she had ESRD but was not getting dialysis (treatment that removes waste and toxins from blood). Patient #2 placed her left hand over the dialysis access site to feel for the thrill (vibration felt at dialysis access site) and said the dialysis access site was working but she was not able to use the site for dialysis. Patient #2 said she the dialysis access site was implanted months ago and it caused some veins in her right arm to collapse. She said needed to have some testing completed on her veins before she could begin dialysis. During an interview on 03/01/23 at 1:01 p.m. with the Administrator and Supervising Nurse, the Supervising Nurse said patients with a diagnosis of congestive heart failure should have orders on the POC for weight monitoring and weights during skilled nurse visits with parameters to report to the physician. The Supervising Nurse said if the patient was non-weight bearing, the POC should have orders to measure the leg circumference. The Administrator said the agency did not normally include weight orders for patients with kidney disease but they could add weight orders to Patient #2’s POC. The Supervising Nurse said a patient with a dialysis access site should have precautions and safety measures in the POC. The Supervising Nurse said during a case conference on 02/16/23, she addressed adding dialysis access site precautions and safety measures to patients’ POC that had a dialysis access site. The Supervising Nurse said dialysis access site safety measures and precautions had not been added to Patient #2’s POC. The Supervising Nurse said a care plan management specialist reviewed all the POCs. The Administrator and Supervising Nurse said the Supervising Nurse was ultimately responsible for making sure the POC included patient interventions, precautions, and safety measures to protect against injury. During an interview on 03/01/23 at 1:42 p.m., the Administrator said it was important to have orders for weights/weight monitoring with weight parameters on the POC for a patient with heart failure because without those interventions in place, the patient’s heart failure could worsen, leading to death. He said it was important to have dialysis access site precautions and safety measures on the POC for a patient with a dialysis access site because without those interventions, it placed the patient’s dialysis access site at risk for injury. Record review of https://www.kidney.org/atoz/content/hemoaccess#keeping-your-access-working accessed on 03/02/23 indicated “…an access that is not working well can decrease the amount of dialysis you receive… Check the blood flow several times each day by feeling for a vibration, also called a pulse or thrill. If you do not feel this, or if there is a change, call your doctor or your dialysis center. Do not wear tight clothes or jewelry on your access arm. Do not carry anything heavy or do anything that would put pressure on the access. Do not sleep with your head on the arm that has your access. Do not let anyone use a blood pressure cuff on your access arm. Do not let anyone draw blood from your access arm…” Record review of https://www.kidney.org/atoz/content/dry-weight accessed on 03/02/23 indicated “...your normal weight without any extra fluid in your body is called dry weight. Extra fluid can be dangerous and cause extra strain on your body, including your heart and lungs…keep track of your daily weight…” Record review of https://www.heart.org/en/health-topics/heart-failure/warning-signs-of-heart-failure/managing-heart-failure-symptoms accessed on 03/02/23 accessed indicated “...heart failure requires that you, your family, and any caregivers pay close attention to any changes in your symptoms…daily weight…many people are first alerts to worsening heart failure when they notice a weight gain of more than two or three pounds in a 24-hour period or more than five pounds in a week. It’s a good idea to track your weight and check in with your doctor if you notice sudden changes…” Record review of the agency’s Service Delivery Physician’s Role policy dated 11/11/22 indicated the “…plan of care…that supports the patient’s medical, nursing, and psychosocial needs in the home setting and serves as the basis of care delivery. The plan includes…safety measures to protect against injury…all necessary interventions to address the underlying risk factors…and any other appropriate items…”

Assure implementation of plan of care CFR(s): 484.105(c)(5) Assuring the development, implementation, and updates of the individualized plan of care. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the Clinical Manager did not assure the development, implementation, and updates of the individualized plan of care for 3 of 17 patients reviewed for plans of care. (Patient #’s 2, 11, and 12) The Clinical Manager failed to ensure Patient #’s 2, 11, and 12 POC contained patient specific interventions and safety measures to protect against injury. This failure could place patients at risk of injury to a dialysis access site, worsening heart failure, leading to complications and hospitalization. Findings included: Record review of Patient #2’s POC dated 01/07/23 to 03/07/23 indicated she was 76 years old with diagnoses including end stage renal disease (final stage of kidney failure). The POC indicated Patient #2 was ordered skilled nursing visits one time a week for 3 weeks, then 2 times a week for one week, then one time a week for 5 weeks. Skilled nursing orders included to perform a comprehensive assessment and evaluate the need for home health services and to educate on interventions to help reduce the patient from having an acute care hospitalization. The medication list indicated Patient #2 was prescribed Furosemide (diuretic) 20 mg 2 tablets every morning and one tablet every afternoon for edema (swelling caused by fluid buildup in the body). The POC did not include orders to assess the patient’s dialysis access site (access to reach the blood for dialysis) and it did not address the location, safety measures, or care interventions for the protection of the access site. The POC did not include order for daily weights/weight monitoring and did not include weight parameters to report to the physician when weight was outside the parameters. Record review of Patient #11’s POC dated 01/12/23 to 03/12/23 indicated she was 78 years old with diagnoses including hypertensive heart disease with heart failure (condition where the heart is unable to pump blood and oxygen efficiently through the body). The POC indicated Patient #11 was ordered skilled nursing visits once a week for 9 weeks. Skilled nursing orders included to provide teaching of heart failure self-management, daily weights, medication management, and tracking symptoms. The POC did not include weight parameters to report to the physician when weight was outside the parameters. Record review of Patient #12 POC dated 02/03/23 to 04/03/23 indicated he was 73 years old with diagnoses including acute congestive heart failure (condition where the heart is unable to pump blood and oxygen efficiently through the body) and chronic kidney disease. The POC indicated Patient #12 was ordered skilled nursing visits once a week for 10 weeks. Skilled nursing orders included to perform a comprehensive assessment and evaluate the need for home health services and to educate on interventions to help reduce the patient from having an acute care hospitalization. The POC did not include order for daily weights/weight monitoring and did not include weight parameters to report to the physician when weight was outside the parameters. During an observation and interview on 02/28/23 at 9:57 a.m., Patient #2 had a dialysis access site to her right inner elbow and swelling to both lower legs. Patient #2 said she had ESRD but was not getting dialysis (treatment that removes waste and toxins from blood). Patient #2 placed her left hand over the dialysis access site to feel for the thrill (vibration felt at dialysis access site) and said the dialysis access site was working but she was not able to use the site for dialysis. Patient #2 said she the dialysis access site was implanted months ago and it caused some veins in her right arm to collapse. She said needed to have some testing completed on her veins before she could begin dialysis. During an interview on 03/01/23 at 1:01 p.m. with the Administrator and Supervising Nurse, the Supervising Nurse said patients with a diagnosis of congestive heart failure should have orders on the POC for weight monitoring and weights during skilled nurse visits with parameters to report to the physician. The Supervising Nurse said if the patient was non-weight bearing, the POC should have orders to measure the leg circumference. The Administrator said the agency did not normally include weight orders for patients with kidney disease but they could add weight orders to Patient #2’s POC. The Supervising Nurse said a patient with a dialysis access site should have precautions and safety measures in the POC. The Supervising Nurse said during a case conference on 02/16/23, she addressed adding dialysis access site precautions and safety measures to patients’ POC that had a dialysis access site. The Supervising Nurse said dialysis access site safety measures and precautions had not been added to Patient #2’s POC. The Supervising Nurse said a care plan management specialist reviewed all the POCs. The Administrator and Supervising Nurse said the Supervising Nurse was ultimately responsible for making sure the POC included patient interventions, precautions, and safety measures to protect against injury. During an interview on 03/01/23 at 1:42 p.m., the Administrator said it was important to have orders for weights/weight monitoring with weight parameters on the POC for a patient with heart failure because without those interventions in place, the patient’s heart failure could worsen, leading to death. He said it was important to have dialysis access site precautions and safety measures on the POC for a patient with a dialysis access site because without those interventions, it placed the patient’s dialysis access site at risk for injury. Record review of https://www.kidney.org/atoz/content/hemoaccess#keeping-your-access-working accessed on 03/02/23 indicated “…an access that is not working well can decrease the amount of dialysis you receive… Check the blood flow several times each day by feeling for a vibration, also called a pulse or thrill. If you do not feel this, or if there is a change, call your doctor or your dialysis center. Do not wear tight clothes or jewelry on your access arm. Do not carry anything heavy or do anything that would put pressure on the access. Do not sleep with your head on the arm that has your access. Do not let anyone use a blood pressure cuff on your access arm. Do not let anyone draw blood from your access arm…” Record review of https://www.kidney.org/atoz/content/dry-weight accessed on 03/02/23 indicated “...your normal weight without any extra fluid in your body is called dry weight. Extra fluid can be dangerous and cause extra strain on your body, including your heart and lungs…keep track of your daily weight…” Record review of https://www.heart.org/en/health-topics/heart-failure/warning-signs-of-heart-failure/managing-heart-failure-symptoms accessed on 03/02/23 indicated “...heart failure requires that you, your family, and any caregivers pay close attention to any changes in your symptoms…daily weight…many people are first alerts to worsening heart failure when they notice a weight gain of more than two or three pounds in a 24-hour period or more than five pounds in a week. It’s a good idea to track your weight and check in with your doctor if you notice sudden changes…” Record review of the agency’s Service Delivery Physician’s Role policy dated 11/11/22 indicated the “…plan of care…that supports the patient’s medical, nursing, and psychosocial needs in the home setting and serves as the basis of care delivery. The plan includes…safety measures to protect against injury…all necessary interventions to address the underlying risk factors…and any other appropriate items…” Record review of the agency’s Branch Director Clinical Manager policy dated 01/23/23 indicated “…the Branch Director confirms care delivery meets the needs of the patients and follows professional practice standards. The Branch Director…observes, supervises, counsels and disciplines staff effectively. Monitors compliance with…applicable Federal, State and local laws…professional standards and principles…established policies and procedures…the plan of care…”