Every finding on record at Unitypoint at Home

The Department of Inspections and Appeals conducted a complaint survey, complaint # 47549-C from 10/19/21 through 10/26/21. The complaint survey identified the following allegations related to the Medicare Conditions of Participation: 42 CFR 484.60 Care Planning, Coordination of Services and Quality of Care was substantiated with a related standard level deficient practice (see G0608).

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 clinical record review, agency policy review, patient, family and staff interview, the agency failed to ensure agency staff coordinated the delivery of care to assure agency staff meet the individualized needs of patients for 3 of 4 sampled patients (Patients #1, #2 and #3) receiving home health aide services. The agency reported a current census of 230 patients at the time of the survey including 89 receiving home health aide services. Failure to ensure agency staff effectively coordinated the delivery of care increased the risk of the patients not receiving care to meet individualized patient needs. Findings include: Review of the agency policy, titled Care Planning Process, dated 1/2018, identified the Plan of Care (POC) will be based on the initial and on-going assessments completed by agency clinicians. Agency clinicians will develop a written, individualized POC in conjunction with the supervising physician, on all patients after the initial assessment, update the POC at least every 60 days and as indicated by changes in the patient situation. The clinical case manager is responsible for care planning for home health aide services. The registered nurse (RN) or therapy care manager is responsible for coordinating care. The POC will include medications and identify the dose, frequency and route of medications. The POC will include specific interventions to be completed by agency staff, patient problems and needs and treatments/orders. 1. Patient #1 had a start of care date of 10/30/19, went to the hospital on 9/29/21 for observation and later admitted to the hospital on 10/1/21. Review of the clinical record revealed the following: a. The POC, dated 8/20/21 to 10/18/21, identified a diagnosis of Parkinson's and included physician orders for skilled nursing services one time every two weeks and home health aide services 3 times per week. The POC included the following wound care orders: for the coccyx (buttock) wound, cleanse with mild soap and water, rinse with Normal Saline, dry area, apply triple antibiotic ointment around the wound, apply Aquacell (type of medicated gauze) to the wound bed and cover with Mepilex (type of wound dressing) 2 times per week; for the left ankle, the POC included a wound care order to the left ankle and for the nurse to teach the patient and caregiver wound care to include cleansing the wound with mild soap and water, rinse with Normal Saline, dry the area, apply antibacterial ointment to the wound bed and cover with Mepilex 2 times per week. The POC included written instructions for the home health aide to complete the following tasks: apply lotion, assist with bath or shower per patient's choice, perform hair care, shampoo the patient's hair and inspect the patient's skin for skins of pressure or irritation. b. The update to the comprehensive assessment completed at the time of recertification, dated 8/16/21, identified the patient needed assistance with dressing, grooming, bathing and ambulation. c. The home health aide visit notes, dated 9/2, 9/7, 9/9, 9/13, 9/14, 9/16, 9/20, 9/23, 9/27 and 9/28/21, included RN instructions for the home health aide to complete wound care on the coccyx and left ankle as follows: change dressing to coccyx and left ankle every visit, remove old dressing, apply triple antibiotic and Mepilex, interventions should be performed 2 times weekly. The visit notes included documentation by the home health aide which identified the home health aide completed wound care to the coccyx and left ankle. The instructions provided by the RN for the coccyx and left ankle wounds did not match the physician orders. The instructions did not include cleansing the wounds with mild soap and water and rinse with Normal Saline. The instructions for the coccyx did not include Aquacell to the wound bed and the instructions directed the home health aide to apply antibiotic to the wound rather than around the wound. The RN instructions to the home health aide for wound care included instructions for the home health to complete wound care every visit and then also instructions to perform the intervention 2 times per week. The POC included orders for home health aide services 3 times per week, but wound care by the nurse, patient or caregiver 2 times per week. d. The week of 9/12/21 included documentation of 3 home health aide visits, dated 9/13, 9/14 and 9/16/21. The home health aide documented he/she completed the task of wound care to the coccyx and left ankle each visit the week of 9/12/21. e. The home health aide visits, dated 9/13, 9/20 and 9/27/21, included documentation Staff D, Home Health Aide, completed the visits. f. The home health aide visits, dated 9/14, 9/16, 9/23 and 9/28/21, included documentation Staff C, Home Health Aide, completed the visits. On 10/21/21 at 8:35 AM, during an interview, Staff C, Home Health Aide, reported she cleaned both the coccyx and ankle wounds with soap and water, applied antibiotic ointment to the wounds and covered the wounds with Mepilex. The patient's caregiver/family was not present during her visits with the patient. On 10/21/21 at 8:37 AM, during an interview, Staff D, Home Health Aide, reported she did not know about having to do the coccyx wound. She reported the patient's family member took care of the coccyx wound. She explained the left ankle wound was the only wound care she had to complete. She applied antibiotic ointment and Mepilex to the left ankle wound. On 10/21/21 at 9:41 AM, during an interview, Staff F, RN, reported sometimes the patient's caregiver/family member would do the wound cares. She reported the caregiver/family member would pack the Aquacell gauze in the coccyx wound and the home health aide would just apply the antibiotic ointment and Mepilex to the wounds. She explained the Aquacell dressing was above the home health aides' abilities. Staff F, RN, was aware the patient's family member/caregiver was not typically present when the home health aides provided care to the patient. On 10/21/21 at 10:29 AM, during an interview, the patient's caregiver/family member reported she was typically not present when agency staff provided care to the patient. She reported one time recently being present when Staff D, Home Health Aide, provided cares to the patient, but she was unsure of the date. The caregiver/family member explained the caregiver/family member did the wound cares to the patient's coccyx, not the home health aides. Agency nursing staff failed to coordinate care with the home health aides and patient's caregiver. 2. Patient #2 had a start of care date of 12/21/18. Review of the clinical record revealed the following: a. The POCs, dated 8/7/21 to 10/5/21 and 10/6/21 to 12/4/21, identified a diagnosis of chronic pain and included physician orders for one skilled nursing visit every other week and home health aide services 2 times per week. The POCs included RN instructions to the home health aide to complete the following tasks: apply lotion per patient preference, assist with bath, dressing, shampoo, inspect the patient's skin and perform hair care. On 10/20/21 at 11:25 AM, during a home visit observation, Staff E, Home Health Aide, assisted the patient with personal cares. The patient requested Staff E, Home Health AIde, apply Aspercreme (a topical over the counter medication with 4 percent Lidocaine) to the patient's back. In an interview during the same home visit observation, the patient reported typically using Biofreeze or Icy Hot (types of topical pain relievers), but had been unable to find any at the store. Staff E, Home Health Aide, reported she had applied roll on Biofreeze and Icy Hot on the patient's back at previous visits. b. The POCs lacked any physician order for Biofreeze, Icy Hot or Aspercreme and lacked any RN instructions to the home health aide to apply these medications. On 10/21/21 at 8:54 AM, during an interview, Staff H, RN, reported she did add the Aspercreme to the patient's medication list on 10/20/21, after Staff E, Home Health Aide, contacted her and let her know she had applied this on the patient. Staff H, RN, explained when she did the patient's medication review with the update to the comprehensive assessment on 10/4/21, the patient did report using a generic topical pain reliever, but not as frequently. The patient only used it when the patient's back was hurting. Staff H, RN, was aware the home health aides had applied the topical pain relievers on the patient's back at other visits. The POCs failed to identify the patient used topical pain relievers as needed and failed to include RN instructions to the home health aide to apply topical pain relievers per the patient's request. 3. Patient #3 had a start of care date of 8/4/21 and transferred to inpatient hospital care on 8/27/21. Review of the clinical record revealed the following: a. The POC, dated 8/4/21 to 10/2/21, identified a diagnosis of chronic obstructive pulmonary disease and included orders for skilled nursing services one time per week and home health aide services one time per week (start date the week of 8/15/21). The POC included RN instructions to the home health aide to complete the following tasks: apply lotion per patient's preference, assist with bath/shower, shampoo, dressing, foot care (did not specify what the home health aide should do to complete the task of foot care) and inspect skin for signs of pressure or irritation. The POC included physician orders for Clotrimazole 1 percent cream apply topically 2 times per day to affected areas and Triamcinolone 0.1 percent apply topically 2 times daily as needed to affected areas. Neither medication identified where the affected areas were located. b. The initial comprehensive assessment, dated 8/4/21, included documentation Staff F, RN, completed the assessment. The assessment identified the patient required assistance with bathing and lower body dressing. c. The clinical record included documentation of 2 home health aide visits, dated 8/18 and 8/25/21, completed by Staff I, Home Health Aide. Staff I, Home Health Aide, documented she completed the assigned tasks. On 10/21/21 at 9:34 AM, during an interview, Staff I, Home Health Aide, reported she remembered providing care to the patient. She reported she had the Clotrimazole cream to the patients foot or feet, she could not remember if it was one or both feet that had a fungal infection. She remembered the patient told her the patient's physician prescribed the Clotrimazole for the patient's foot. Staff I, Home Health Aide, remembered applying lotion to the patient's lower legs, but could not remember if the lotion was Triamcinolone or some other over the counter lotion. On 10/21/21 at 9:48 AM, during an interview, Staff F, RN, could not remember where the patient's affected areas were located for the Clotrimazole and Triamcinolone creams. She explained if the patient needed the home health aide to assist with applying the medicated creams, a specific task should have been added to the home health aide assignment. She denied being aware the patient needed assistance with the application of the creams. On 10/21/21 at 10:21 AM, during an interview, Staff J, RN, confirmed she was the RN Case Manager for Patient #3. She was unsure of where the patient needed the medicated creams applied, but thought one of them might have been to the patient's legs. She was not aware the home health was applying any of the medicated creams and explained the aide assignment should have been more specific with the instructions for the home health aide if the patient needed this to be done. The Administrator and Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.