Every finding on record at Southwest General Home Health LLC

EMERGENCY PREPAREDNESS SURVEY At the time of the emergency preparedness survey completed on 04/28/22. Southwest General Home Health, is in compliance with the provisions of 42 CFR Part 484.102 for Home Health Agencies.

Partial Extended Re-certification Survey The following deficiency is based on the partial extended re-certification survey completed on 04/28/221. Southwest General Home Health, 367253, is not in compliance with the requirements found at 42 CFR Part 484 Subparts B, C for Home Health Agencies. An entrance conference was held with administrative staff on 04/21/22 and an exit conference was conducted with administrative staff on 04/28/22.

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 medical record review, review of job descriptions for nursing visits, and staff interview, the agency failed to provide care per the plans of care for two (Patients#12 and Patient #13) of 10 active patients reviewed for compliance with the plan of care. The agency census was 316. Findings include: 1. Review of the medical record for Patient #12 revealed a start of care with the agency on 04/02/22. Diagnoses included bile duct fistula, diabetes mellitus type 2 with diabetic polyneuropathy, and history of protein-calorie malnutrition. The Medicare certification period under review was 04/02/22 through 05/031/22. The plan of care directed the patient to have skilled nursing (SN) visits twice per week for seven weeks and an additional three as needed visits for wound management or condition status changes. The plan of care directed the skilled nurse to management the patient’s diabetes by assessment, and performing/instructing the patient or caregiver on diabetic care including diet, exercise, activity, level and modification of sick day management, signs and symptoms of hyperglycemia and hypoglycemia. The plan of care directed staff to assess foot care and skin care and to monitor lower extremities for lesions. Review of the skilled nurse visit notes for Patient #12 dated 04/03/22, 04/05/22, 04/10/22, 0412/22, 04/15/22, 04/22/22 and 04/28/22 revealed the nurses failed to obtain a blood sugar check during the nursing visits. Additionally, the visit notes of 04/03/22, 04/05/22, 04/07/22, 04/12/22, 04/15/22, 04/22/22, and 04/28/22 failed to document the nurse had inspected the patient’s feet for diabetic lesions or performed diabetic education and instructions to the patient per the plan of care. 2. Review of the medical record for Patient #13 revealed a start of care with the agency on 01/23/21. Diagnoses included dehiscence of amputation stump, type 2 diabetes mellitus with diabetic peripheral angiopothy, and polyneuropathy. Review of the plan of care directed the patient to have SN visit once per week for nine weeks. The plan of care for the Medicare Certification Period of 03/19/22 through 05/17/22 directed the skilled nurse to provide for the management the patient’s diabetes by assessment. The plan of care directed staff to assess foot care and skin care and to monitor lower extremities for lesions. Review of the skilled nursing visit notes for a Patient #13 dated 03/21/22, 03/28/22, 04/05/22, 04/11, and 04/19/22 revealed the nurse had failed to perform blood sugar checks on the nursing visits but only recorded patient reported blood sugars. Additionally the nurses had failed to inspect the patient’s right foot for presence of diabetic lesions or reports of hypoglycemic or hyperglycemic episodes as directed by the plan of care. Review of the agency's job description titled "Home Health LPN," last modified 02/08/16, directed the licensed practical nurse (LPN) was to provide nursing care and prescribed treatments for patients in their home, according to the physician's plan of care as assessed and formulated by the registered nurse (RN), and document pertinent patient and caregiver teaching each visit relative to plan of care. Review of the agency’s job description titled “Home Health Case Manager Staff Nurse,” modified 02/08/16, directed the RN was a professional caregiver who planned, provided and coordinated patient care in collaboration with the patient; performed assessments, orders, clinical notes, missed visit notes, consents, discharge documentation; and home health aide (HHA) supervision was completed and available in the office within required timeframes. Interview on 04/28/22 at 9:47 AM, Staff A verified Patient #12 and Patient #13 did not have their plan of care followed on the SN visits.

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 medical record review, review of agency policy, and staff interviewed, the agency failed to obtain physical therapy (PT) evaluation as requested for one (Patient #13) of 10 active patients reviewed for coordination of care. The agency census was 316 Findings include: Review of the agency’s policy and procedure titled Coordination of Care with a most recent revision date of 02/2020 directed that agency services identified at a later time will be communicated to the physician and documented in the clinical record. The attending physician must be notified of new or changed orders received from other providers as early as necessary to address patient needs and no later than the next comprehensive assessment. Informing the attending physician of the services and identifying the services on the plan of care (if known). Review of the medical record for Patient #13 revealed a start of care with the agency on 01/23/21. Diagnoses included dehiscence of amputation stump, type 2 diabetes mellitus with diabetic peripheral angiopothy, and polyneuropathy. The plan of care directed the patient to have skilled nurse visit once per week for nine weeks. The plan of care for the Medicare Certification Period of 03/19/22 through 05/17/22. Review of the comprehensive Outcome Assessment and Information Set (OASIS) Assessment completed by the RN on 03/15/22 documented the patient had requested a Physical therapy (PT) evaluation for strengthening. Review of the agency documentation titled Patient Treatment Plan and Medications List, under Interventions, directed an additional discipline was ordered for a PT evaluation effective 03/18/22. The medical record revealed no evidence the request for the PT evaluation was ever communicated to the physician for an order, nor was there a referral to the physical therapist for the evaluation. Review of the agency’s policy titled "Coordination of Care," revised 02/2020, revealed the agency services identified at a later time will be communicated to the physician and documented in the clinical record. Interview on 04/28/22 at 9:47 AM, Staff A verified Patient #13 had not received his requested PT evaluation.