Every finding on record at Summitwest Care

A recertification survey was completed on 4/7/22. Two deficiencies were cited.

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure each patient's status was comprehensively assessed during the last five days of every 60-day certification period for 1 of 2 pediatric patients reviewed who were on service for more than 60 days (Patient #8). Findings include: 1. The clinical record for Patient #8 was reviewed on 4/6/22. The plan of care for the certification period dated 2/20/22 to 4/20/22, revealed a start of care date of 3/7/08; diagnoses included Lennox-Gastaut syndrome (a seizure disorder), endocrine disorder, dependence of supplemental oxygen, gastrostomy, urinary retention and a disorder of the kidney and ureter. Plan of care orders included skilled nurse (SN) visits once every 60 days for clinical assessment, medication reconciliation, recertification of the parent program, care plan review, delegation of the gastrostomy tube (GT) feeding task to the parent certified nurse aide (CNA) and the supervision of CNA skills and performance. Plan of care orders also included CNA visits, three times per day to assist with activities of daily living (ADLs), range of motion exercises, meal preparation, light housekeeping and “special procedures”. Additional CNA orders also included the delegated nursing task of GT feedings. a) Record review revealed the agency failed to ensure pediatric Patient #8 received a comprehensive assessment during the last five days of each 60-day certification period. A review of comprehensive assessment documentation showed registered nurse (RN) #8 completed the comprehensive assessment on 2/22/22, 2 days after the new certification period had begun. Further review of a communication note completed by RN #8 on 2/22/22 showed the recertification assessment was late because Patient #8 was sick and the delay was requested by the parent, however there was no evidence the patient’s physician had been contacted to approve the delayed recertification. During an interview on 4/7/22 at 8:30 a.m., RN #8 acknowledged the recertification assessment was completed late and stated it was originally scheduled prior to the end of the certification period, however the parent had requested to reschedule the SN visit. RN #8 also stated she believed she had contacted the physician regarding Patient #8’s status to obtain orders for the delayed recertification assessment because it was standard practice for her to routinely communicate with the patient's physician when a change occurred, however she was unable to recall what date she had contacted Patient #8’s physician or if she had documented the communication. Additional requests were made for any documentation of communication with Patient #8’s physician regarding the need for the delayed recertification assessment, however no further documentation was provided prior to survey exit on 4/7/22.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to record all patient care orders in the plan of care for 1 of 2 pediatric patients reviewed (Patient #8). Findings include: AGENCY POLICY According to the agency policy number 1-003 titled, “Physician Participation in Plan of Care”, (Revised 10/21) (in pertinent part) “A physician will direct the care of every home health care patient admitted for service…The care will be provided in compliance with the therapeutic and diagnostic orders and accepted standards of practice.” The policy further noted, “When services are provided on the basis of a physician's verbal orders, a registered nurse or other qualified practitioner responsible for furnishing or supervising the ordered services in accordance with state law shall document the orders in the patient's clinical record, and sign, date, and time the orders.” 1. The clinical record for Patient #8 was reviewed on 4/6/22. The plan of care for the certification period dated 2/20/22 to 4/20/22, revealed a start of care date of 3/7/08; diagnoses included Lennox-Gastaut syndrome (a seizure disorder), endocrine disorder, dependence of supplemental oxygen, gastrostomy, urinary retention and a disorder of the kidney and ureter. Plan of care orders included skilled nurse (SN) visits once every 60 days for clinical assessment, medication reconciliation, recertification of the parent program, care plan review, delegation of the gastrostomy tube (GT) feeding task to the parent certified nurse aide (CNA) and the supervision of CNA skills and performance. Plan of care orders also included CNA visits, three times per day to assist with activities of daily living (ADLs), range of motion exercises, meal preparation, light housekeeping and “special procedures”. Additional CNA orders also included the delegated nursing task of GT feedings. No other details regarding the GT feedings or “special procedures” had been included in the plan of care. a) Clinical record review revealed the agency failed to confirm and obtain gastrostomy tube (GT) feeding orders from the physician to be integrated into Patient #8’s plan of care. Specifically, the plan of care orders did not include the frequency, rate, duration or type of dietary formula to be run as part of the GT feeding delegated task. Record review revealed RN #8 had developed three different ‘Aide Care Plan(s)’ on 10/21/21, one for each CNA visit, morning, afternoon and evening. All three care plans were also reviewed again by RN #8 on 2/22/22. Each CNA care plan included a description that noted “Delegated Tasks J [GT] tube feeds per MD [Medical Doctor]/Nutritionist order and instructions”. No other specific task instructions or detail regarding the GT feeds had been included in any of the three care plans. During an interview on 4/6/22 at 12:24 p.m., the parent CNA (Employee #5) stated she was also the mother of Patient #8 and the patient's primary caregiver since birth. When asked to describe the procedure for the GT feeds, Employee #5 stated she would mix the dietary formula, fill the feeding bag and program the feeding pump per the delegation instructions provided by RN #8. The parent CNA also stated the GT feeds would run continuously at a rate of 158 milliliters per hour, for 17 hours, through the night. When asked to clarify how she knew the type of dietary formula, frequency, rate and duration of the GT feeds to provide to Patient #8, the parent CNA stated she would always follow the instructions that were provided to her by the patient’s physician or dietician. She was unaware if the GT feed instructions provided to her by the dietician had been shared with the home health agency or if RN #8 had contacted the patient's physician of record to obtain the correct orders and updated the plan of care. On 4/6/22 at approximately 3:45 p.m., the director of quality and compliance (Employee #7) provided a photocopy of a visit summary from Patient #8's registered dietitian, dated 12/22/21. Employee #7 stated this was a copy of the visit summary that was provided to the parent CNA by Patient #8's dietician during the 12/22/21 visit and that it provided the specific detailed instructions on how Patient #8's GT feeds were supposed to be given. Employee #7 stated these were the orders the parent CNA #5 was using as referenced in the aide care plan(s) that had been created by RN #8. Employee #7 stated an agency RN had not contacted Patient #8's physician of record to obtain adequate and specific GT feeding orders because the parent CNA had provided them with a copy of the visit summary. During the interview, both the agency administrator and Employee #7 acknowledged it was not customary to accept orders from a parent CNA and that an agency RN should have contacted the physician of record to obtain orders for the GT feeds and then should have updated the plan of care accordingly. b) Clinical record review revealed the agency failed to obtain complete and specific simple dressing change orders from the physician, to be integrated into Patient #8’s plan of care. Review of the three “Aide Care Plan(s)” created by RN #8 on 10/21/21, revealed in a section titled “special procedures”, the CNA was to perform simple dressing changes by placing clean gauze around the gastrostomy tube. During an interview on 4/6/22 at 12:24 p.m., when asked to describe the procedure for the simple dressing changes, the parent CNA (Employee #5) stated she would clean the GT area with water and place a clean 4 x 4 split gauze around the GT site at least three times per day and sometimes more. On 4/6/22 at approximately 3:45 p.m., a request was made for the simple dressing change orders the parent CNA was performing as directed in each of the aide care plans. The director of quality and compliance (Employee #7) stated the “special procedures” task on Patient #8's plan of care was also the simple dressing change order. Employee #7 also stated the plan of care used to have the specific directions for the simple dressing changes, however somehow the directions had been removed. Employee #7 acknowledged the plan of care should have contained detailed orders for the simple dressing changes. Employee #7 contacted patient #8's physician, obtained specific dressing change orders and updated the patient's plan of care prior to survey exit.