Every finding on record at Primestar Home Health of Central Texas Inc

An Entrance Conference was conducted on 2/6/2023 at 10:05 a.m. with the Administrative Assistant and by telephone, the Administrator. The agency representatives were informed that the purpose of the visit was a recertification survey. The agency census was: Austin: L&CHHS - 31 An Exit conference was conducted on 2/8/2023 at 4:20 p.m. with the Administrator, Administrative Assistant and Corporate HR Director. 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 receiving the Statement of Deficiencies. Abbreviations: L&CHHS- Licensed and Certified Home Health Services POC- Plan of Care IV- Intravenous, administered into a vein SN- Skilled Nurse LR- Lactated Ringers- a mixture of sodium chloride, sodium lactate, potassium chloride and calcium chloride in water. Use for replacing fluids and electrolytes. L- Liter (100 milliliters) RN- Registered 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, interview and observation, the agency failed to ensure that the Plan of Care (POC) for one of one patient receiving IV therapy (Patient #3), contained documentation that was specific to caregiver’s assistance with therapy and education related to administration of IV fluids by unlicensed caregivers. This failure has the potential that the physician may not be aware of the degree of assistance provided by the patient’s caregivers involving administration of IV therapy and may not be aware of the education provided to caregivers to complete this care. Findings: 1. Review of the clinical record of patient # 3 revealed a POC dated 1/13/2023 to 3/13/2023. The POC read in part: “Start of Care Date: 1/18/2022. Diagnosis: Dehydration. Medications: Lactated Ringers Intravenous 2000ml 3 times a week. Heparin Sodium Lock Flush Intravenous 100 unit/ml 5 ml IV push as final flush and as needed for implanted port maintenance. Sodium Chloride Injection 0.9 %5-10 ml flush as needed before and after medication administration. Orders and Treatments: SN (Skilled nursing) 1w1, 3w8, 1w1 (three times a week for one week, then three times a week for 8 weeks, then 1 time a week for one week.) SN to administer IV 2 L (Liters) LR (Lactated Ringers) at rate of 500ml-1 L (Liter) per hour via port every M, W, F (Monday, Wednesday, Friday.) 2. During a home visit with patient #3 on 2/8/2023 at 10:00 am, RN #2 stated during the visit he accessed the port, hung the IV and set the infusion rate. RN #2 stated the IV ran for approximately an hour, then the family or caregiver had been trained to stop the IV and de-access the port. The family and caregiver both verified that they had been trained by agency nursing staff to disconnect the IV, and also to monitor for any problems with infusion. 3. During an interview with the Administrator on 2/8/2023 at 1:30 p.m. the POC for Patient #3 was reviewed. The Administrator verified that the POC did not document family/ caregiver assisting with IV therapy and did not document teaching for family/ caregiver in regard to IV therapy. 4. Review of the agency policy and Procedure Manual revealed a policy entitled “Plan of Care” revised 9/2022. The policy read in part: “The attending physician certifies the need for home health care services and establishes a Plan of Care (POC) which includes Patient and Caregiver education, Patient specific goals, any additional interventions the HHA want to include.” 5. During an interview with Administrative Assistant on 2/23/2023 at 10:30 a.m. this surveyor questioned the payor source for patient #3. The Administrative Assistant stated patient #3's care was funded by a Medicare Advantage Plan, which meets criteria for L&CHHS. The patient roster provided to this surveyor on 2/6/2023 listed the payor source for patient #3 as a Medicare Advantage Plan.