Every finding on record at Silver Spring Home Healthcare Services Inc

A complaint investigation survey entrance conference was conducted 06/10/2021 with the Alternate Administrator, Office Manager, PDN Case Manager, Director of Operations and Director of Nursing at 9:50 am. Census: L&CHHS: 9 LHHS: 55 PAS: 54 Complaint number - #282427 An exit conference was conducted on 06/14/2021 at 2:20 p.m., with the Administrator, Alternate Administrator, Director of Nursing, Director of Operations, Intake Coordinator and Order Tracker. The preliminary findings were discussed. The agency was given 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 were cited. Abbreviations used: DON - Director of Nursing PDN - Private Duty Nursing POC - Plan of Care CR - Clinical Record CKD - Chronic Kidney Disease SN - Skilled Nurse RN- Registered Nurse LVN - Licensed Vocational Nurse NP - Nurse Practitioner LCT - unclear abbreviation about someone at the Assisted Living Facility L&CHHS - Licensed and Certification Home Health Services LHHS - Licensed Home Health Services PAS - Personal Assistance Services

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient was informed in changes to care to be furnished for 1 of 3 patients (#2) whose records were reviewed, in that: Patient #2's POC included orders for SN 7 days per week for 9 weeks. The agency provided SN 5 days per week for 9 weeks and did not notify the patient that SN visits were decreased. Failure of the agency to ensure the patient was informed of care changes places all patients at risk of poor health outcomes. Findings include: Record review of Intake #276155 received on 5/4/2021 by HHSC Complaint and Incident Intake Department, read in part: " ... RESIDENT [#2] AT [Facility J]. THE AGENCY ADMINISTERS INSULIN TO CLIENT #2. THE AGENCY HAS NOT BEEN CONSISTENT WITH ADMINISTERING IT. THE COMPLAINANT KNOWS THE AGENCY DIDN'T GO ON 6/7/2021 AND A FEW DAYS IN MAY (6,11,18, AND 31). THE COMPLAINANT WAS ASKED IF THERE HAS BEEN ANY ADVERSE AFFECTS. ON 5/18/2021, CLIENT #2 WAS SENT TO THE HOSPITAL. CLIENT #2. BLOOD SUGAR LEVELS WERE MONITORED AND STABILIZED. CLIENT #2 WENT WITH SUGAR LEVELS OF 593. ..." Interview on 06/14/2021 at 1:25 p.m., with Identifier #102 at the facility, revealed that she usually checked the patient's blood sugar between 4:00 a.m. and 5:00 a.m.; Identifier #102 further stated that the facility staff are not allowed to administer insulin to the residents and so any day her blood sugar was high and the agency's nurse did not show up, she would call Identifier #100 to come to the facility to administer the insulin to the patient. Interview on 06/10/2021 at 9:30 a.m., with Identifier #100 revealed that the agency did not communicate any changes in the care plan to him, but that it was the Facility #200 that told him that the physician had to remove the weekend visits because the agency would not have staff to fill the weekend shift. Interview on 06/10/2021 at 1:15 p.m. with the DON, when asked why Patient #2 did not receive skilled visits on weekends. The DON stated that Patient #2 lives in an assisted living facility and that the facility got an order from the doctor to administer oral diabetic medications on Saturdays and Sundays. When asked if the agency communicated with Identifier #100 about these changes, the DON stated that the Facility was the patient's caregivers and the agency was in communication with the facility. The DON further stated that Identifier #100 was not available. Record review of POC for certification period 04/19/2021 to 06/15/2021 revealed a SOC date of 04/19/2021 and the principal diagnosis of type 2 diabetes mellitus. Orders for Discipline and Treatment included: SN frequency: 7W9 (7 visits a week for 9 weeks). Further review of the POC revealed SN to perform complete physical assessment each visit with emphasis on Type 2 Diabetes Mellitus with Hyperglycemia; SN to assess other co morbidities including CKD Stage 3, Anemia of Chronic Disease, HTN, Vascular Dementia without behavioral disturbances, Diastolic CHF, Diabetic Poly Neuropathy associated with type 2 diabetes mellitus and other conditions that present themselves during this episode of care. Record review revealed a "Home Health Certification and Plan of Care" order signed by MD #V on 05/12/2021 which read in part: "Admit [Patient #2] to Home Health Services 7 days a week for insulin administration and Blood Glucose monitoring, Teaching and Disease Management. ..." Record review of skilled nurse visits revealed that Patient #2 did not receive SN visits on Saturdays and Sundays. LVN E provided skilled visits from Monday to Thursday while RN D provided visits on Fridays. Further review of the CR revealed numerous missed visits by LVN E. There were no visits documented for Saturdays and Sundays. Further review of the CR revealed the following: a) 05/02/2021: Missed visit signed by RN #D read in part "MD #V gave order for LCT to give antidiabetic medication on weekends, Saturday and Sundays; b) 05/03/2021: Communication Note signed/dated by the Scheduler, Identifier #F read in part: "SN called the office to inform that the facility told her that they received orders to give oral medications on the weekend and she did not have to come anymore." Interview on 06/10/2021 at 1:15 p.m. with the DON, when asked why Patient #2 did not receive skilled visits on weekends (Saturdays and Sundays), the DON stated that Patient #2 lives in an Assisted Living Facility and that the facility got an order from the doctor to administer oral diabetic medications on Saturdays and Sundays. When asked if the agency received an order from the referring physician, MD #V to change the patient's care plan, the DON stated that it is the same doctor that prescribed the facility's medication and that Patient #2 had been taking the oral medications even before she was admitted to this agency. The DON further stated that the SN notified the agency that the facility's Medication Tech told her that the doctor replaced the weekend insulin dose with oral medications. Interview with MD #V on 06/11/2021 at 2:10 p.m., revealed that the agency informed him that they would not provide weekend services and that he had to go with the agency's terms since it was difficult to place the patient with other agencies. Interview on 06/11/2021 at 2:40 p.m., with MD #V's NP revealed that the agency had stated to her that they would not be able to come on weekends and that their weekday visits were not consistent. When asked if substituting insulin for oral diabetic medications for 2 of 7 days was adequate to ensure safety of Patient #2. The NP stated "Oral medications are not the same as insulin but that's what we had to work with. She is insulin dependent." In another interview with the DON, on 06/14/2021 at 2:00 PM, the DON denied that the agency communicated unavailability of staff to provide weekend care to Patient #2. The DON further stated that the weekend nurse was willing to provide the care but the MD's order to the facility made that impossible. Interview on 06/10/2021 at 1:15 p.m. with the DON, when asked why Patient #2 did not receive skilled visits on weekends. The DON stated that Patient #2 lives in an assisted living facility and that the facility got an order from the doctor to administer oral diabetic medications on Saturdays and Sundays. When asked if the agency communicated with Identifier #100 about these changes, the DON stated that the Facility was the patient's caregivers and the agency was in communication with the facility. The DON further stated that Identifier #100 was not available. Record review of agency policy titled "Plan of Care" read in part: " . . . PURPOSE ... B. The Agency will provide optimal care to achieve the goals and outcomes identified in the patient's plan of care for each patient ' s medical, nursing, and rehabilitative needs. ... PROCEDURE... H. Any revision to the plan of care due to a change in patient health status must be communicated to the patient, representative (if any), caregiver, and all physicians issuing orders for the patient plan of care. ..."

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure that each patient received home health services as written in an individualized plan of care (POC) for 1 of 3 patients (#2) whose records were reviewed, in that: 1) Patient #2's POC included orders for SN 7 days per week for 9 weeks. The agency provided SN 5 days per week for 9 weeks; and 2) Patient #2's POC included orders for SN to recognize and intervene to minimize complications. The SN failed to intervene to minimize complications to Patient #2. Patient #2 had an Emergency Room visits due to a hyperglycemic episode. Failure of the agency to ensure that patients POC was followed as written, placed the patient at risk of inadequate care and had the potential to health deterioration. Findings include: Record review of Intake #276155 received on 5/4/2021 by HHSC Complaint and Incident Intake Department, read in part: " ... RESIDENT [#2] AT [Facility J]. THE AGENCY ADMINISTERS INSULIN TO CLIENT #2. THE AGENCY HAS NOT BEEN CONSISTENT WITH ADMINISTERING IT. THE COMPLAINANT KNOWS THE AGENCY DIDN'T GO ON 6/7/2021 AND A FEW DAYS IN MAY (6,11,18, AND 31). THE COMPLAINANT WAS ASKED IF THERE HAS BEEN ANY ADVERSE AFFECTS. ON 5/18/2021, CLIENT #2 WAS SENT TO THE HOSPITAL. CLIENT #2. BLOOD SUGAR LEVELS WERE MONITORED AND STABILIZED. CLIENT #2 WENT WITH SUGAR LEVELS OF 593. ..." 1) Record review of POC for certification period 04/19/2021 to 06/15/2021 revealed a SOC date of 04/19/2021 and the principal diagnosis of type 2 diabetes mellitus. Orders for Discipline and Treatment included: SN frequency: 7W9 (7 visits a week for 9 weeks). Further review of the POC revealed SN to perform complete physical assessment each visit with emphasis on Type 2 Diabetes Mellitus with Hyperglycemia; SN to assess other co morbidities including CKD Stage 3, Anemia of Chronic Disease, HTN, Vascular Dementia without behavioral disturbances, Diastolic CHF, Diabetic Poly Neuropathy associated with type 2 diabetes mellitus and other conditions that present themselves during this episode of care.... SN to recognize and intervene to minimize complications, notify physician immediately of any potential problems that impede completion of patient recovery and desired goals.... SN to minimize/eliminate risk for hospitalization due to identified problems with medications polypharmacy, risk associated with name of high risk medications, requiring help with managing medications and noncompliance of medication management; ... Record review revealed a "Home Health Certification and Plan of Care" order signed by MD #V on 05/12/2021 which read in part: "Admit [Patient #2] to Home Health Services 7 days a week for insulin administration and Blood Glucose monitoring, Teaching and Disease Management. ..." Record review of skilled nurse visits revealed that Patient #2 did not receive SN visits on Saturdays and Sundays. LVN E provided skilled visits from Monday to Thursday while RN D provided visits on Fridays. Further review of the CR revealed numerous missed visits by LVN E. There were no visits documented for Saturdays and Sundays. Further review of the CR revealed the following: a) 05/02/2021: Missed visit signed by RN #D read in part "MD #V gave order for LCT to give antidiabetic medication on weekends, Saturday and Sundays; b) 05/03/2021: Communication Note signed/dated by the Scheduler, Identifier #F read in part: "SN called the office to inform that the facility told her that they received orders to give oral medications on the weekend and she did not have to come anymore." Record review showed no documentation that the agency received an order from Patient #2's physician to reduce the SN frequency. Interview on 06/10/2021 at 1:15 p.m. with the DON, when asked why Patient #2 did not receive skilled visits on weekends (Saturdays and Sundays), the DON stated that Patient #2 lives in an Assisted Living Facility and that the facility got an order from the doctor to administer oral diabetic medications on Saturdays and Sundays. When asked if the agency received an order from the referring physician, MD #V to change the patient's care plan, the DON stated that it is the same doctor that prescribed the facility's medication and that Patient #2 had been taking the oral medications even before she was admitted to this agency. The DON further stated that the SN notified the agency that the facility's Medication Tech told her that the doctor replaced the weekend insulin dose with oral medications. Interview with MD #V on 06/11/2021 at 2:10 p.m., revealed that the agency informed him that they would not provide weekend services and that he had to go with the agency's terms since it was difficult to place the patient with other agencies. Interview on 06/11/2021 at 2:40 p.m., with MD #V's NP revealed that the agency had stated to her that they would not be able to come on weekends and that their weekday visits were not consistent. When asked if substituting insulin for oral diabetic medications for 2 of 7 days was adequate to ensure safety of Patient #2. The NP stated "Oral medications are not the same as insulin but that's what we had to work with. She is insulin dependent." In another interview with the DON, on 06/14/2021 at 2:00 PM, the DON denied that the agency communicated unavailability of staff to provide weekend care to Patient #2. The DON further stated that the weekend nurse was willing to provide the care but the MD's order to the facility made that impossible. Interview on 06/10/2021 at 1:15 p.m. with the DON, when asked why Patient #2 did not receive skilled visits on weekends. The DON stated that Patient #2 lives in an assisted living facility and that the facility got an order from the doctor to administer oral diabetic medications on Saturdays and Sundays. When asked if the agency communicated with Identifier #100 about these changes, the DON stated that the Facility was the patient's caregivers and the agency was in communication with the facility. The DON further stated that Identifier #100 was not available. Interview on 06/14/2021 at 1:25 p.m., with Identifier #102 at the facility, revealed that she usually checked the patient's blood sugar between 4:00 a.m. and 5:00 a.m.; Identifier #102 further stated that the facility staff are not allowed to administer insulin to the residents and so any day her blood sugar was high and the agency's nurse did not show up, she would call Identifier #100 to come to the facility to administer the insulin to the patient. 2) Further review of the CR revealed a communication note signed by LVN #E on 05/06/2021 (Thursday) read in part: "Skilled nurse stopped at the patient's assisted living facility for regularly scheduled skilled nursing visit upon arrival skilled nurse was notified the patient was taken to the emergency room yesterday evening or last night due to a hyperglycemic episode." Record review did not include documentation of a SN follow up after the patient's ER visit and interventions to minimize the risk for further hospitalization. There was no communication from the agency to notify physician immediately of any potential problems that impede completion of patient recovery and desired goals. Record review of agency policy titled "Plan of Care" read in part: " . . . PURPOSE ... B. The Agency will provide optimal care to achieve the goals and outcomes identified in the patient's plan of care for each patient ' s medical, nursing, and rehabilitative needs. ... PROCEDURE ... E. Modifications to the plan of care are indicated by reassessments, patient condition/needs, changes in orders, and/or achievement of identified goals. F. The Agency must promptly alert the relevant physician(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. There will be supporting documentation in the discipline's progress notes or communication notes regarding contact with the physician. G. The plan of care may include orders for treatment or services incorporated from physicians other than the responsible physician. These orders are approved by the responsible physician as an updated plan of care. With a change in patient condition, the Agency should notify the responsible physician and the physician(s) associated with the relevant aspect of care. H. Any revision to the plan of care due to a change in patient health status must be communicated to the patient, representative (if any), caregiver, and all physicians issuing orders for the patient plan of care. ..."

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to coordinate care delivery to meet the patient's needs, and involve the patient representative and caregiver(s), in the coordination of care activities for 1 of 3 patients (#2), whose records were reviewed, in that: There was no documentation in Patient #2's CR to show coordination between the patient's representative and the agency regarding the changed medication administration and the agency's skilled visits. Findings Include: Record review of Intake #276155 received on 5/4/2021 by HHSC Complaint and Incident Intake Department, read in part: " ... RESIDENT [#2] AT [Facility #200]. THE AGENCY ADMINISTERS INSULIN TO CLIENT #2. THE AGENCY HAS NOT BEEN CONSISTENT WITH ADMINISTERING IT. THE COMPLAINANT KNOWS THE AGENCY DIDN'T GO ON 6/7/2021 AND A FEW DAYS IN MAY (6,11,18, AND 31). THE COMPLAINANT WAS ASKED IF THERE HAS BEEN ANY ADVERSE AFFECTS. ON 5/18/2021, CLIENT #2 WAS SENT TO THE HOSPITAL. CLIENT #2'S BLOOD SUGAR LEVELS WERE MONITORED AND STABILIZED. CLIENT #2 WENT WITH SUGAR LEVELS OF 593. ..." Record review of Patient #2's CR revealed a "Home Health Certification and Plan of Care" order signed by MD #V on 05/12/2021 read in part: "Admit [Patient #2] to Home Health Services 7 days a week for insulin administration and Blood Glucose monitoring, Teaching and Disease Management. ..." Further review of the CR revealed admission documents showing that Identifier #100 was listed as Patient #2's representative. Record review contained no documentation to show that the agency communicated with Identifier #100 regarding the change of schedule from 7 days per week to 5 days per week for skilled nursing to administer insulin. Record review revealed a POC for certification period 04/19/2021 to 06/15/2021 with a SOC date of 04/19/2021 and the principal diagnosis of type 2 diabetes mellitus. Orders for Discipline and Treatment included: SN frequency: 7W9 (7 visits a week for 9 weeks). Record review of the skilled nurse visits revealed that Patient #2 did not receive SN visits on Saturdays and Sundays. LVN #E provided skilled visits from Monday to Thursday while RN #D provided visits on Fridays. Further review of the CR revealed numerous missed visits by LVN #E. There were no SN visits documented for Saturdays and Sundays. Record review showed no documentation that the agency received an order from Patient #2's physician to reduce the SN frequency. Interview on 06/10/2021 at 9:30 a.m., with Identifier #100 revealed that the agency did not communicate any changes in the care plan to him, but that it was the Facility #200 that told him that the physician had to remove the weekend visits because the agency would not have staff to fill the weekend shift. Interview on 06/10/2021 at 1:15 p.m. with the DON, when asked why Patient #2 did not receive skilled visits on weekends. The DON stated that Patient #2 lives in an assisted living facility and that the facility got an order from the doctor to administer oral diabetic medications on Saturdays and Sundays. When asked if the agency communicated with Identifier #100 about these changes, the DON stated that the Facility was the patient's caregivers and the agency was in communication with the facility. The DON further stated that Identifier #100 was not available. Interview on 06/14/2021 at 1:25 p.m., with Identifier #102 at the facility, revealed that she usually checked the patient's blood sugar between 4:00 a.m. and 5:00 a.m.; Identifier #102 further stated that the facility staff are not allowed to administer insulin to the residents and so any day her blood sugar was high and the agency's nurse did not show up, she would call Identifier #100 to come to the facility to administer the insulin to the patient. Record review of agency policy titled "Monitoring Patient Care/Coordination of Care" read in part: " ... Agency will exchange information, report to and coordinate client services among ...B.3. The agency and a licensed facility, group home, foster home, or boarding home facility in which a client resides. ... C. Agency will communicate with family/caregivers as needed to ensure appropriate coordination of care for the client. " No additional information about coordination was provided at the exit conference on 06/14/2021 or within two business days after.