Every finding on record at University Health Systems Home Health and Hospice

An unannounced complaint investigation was conducted on 04/03/2023-04/04/2023. Deficiencies to the Medicare Conditions of Participation were identified.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on agency policy, record review, and staff interviews the agency failed to include current physician’s orders in the plan of care for 1 of 2 patients with urinary catheters. (Patient #1). Findings included: A policy, Skills: Urinary Catheter: Indwelling (Foley) Catheter Care (Home Health Care) was provided by the agency administrator on 04/04/23. The policy stated, “Verify the practitioner’s order…” Patient #1 was admitted on 07/09/2021 with diagnoses of neuromuscular disfunction of the bladder (lack of bladder control due to spinal cord injury), retention of urine and a personal history of urinary tract infections. The plan of care (POC) of 12/31/2022-02/28/2023 included orders for skilled nurse (SN) visits 2 times a week for 9 weeks and 3 visits as needed. The POC included, “Change catheter [PRN, Start: 10/15/2021] [SN to Preform foley catheter change every 30 days and as needed for malfunction using 16/18F catheter with 10mL balloon. ENSURE PATIENT HAS STAT – LOCK TO SECURE. C SUPRAPUBIC CATHETER LAST CHANGE 08/26/22 BY UROLOGY. CATHETER IS SUTURED IN PLACE. CATHETER TO BE CHANGED BY UROLOGY UNTIL FUTHER NOTICE.]” There was no evidence in the POC of an order for the SN to change the catheter. The SN visit of 01/06/23 included evidence that nurse #5 changed the indwelling suprapubic (a tube that enters the urinary bladder through the wall of the abdomen) catheter. Nurse #5 was not available for interview. The SN visits of 01/18/2023 and 02/16/2023 included evidence that SN #4 changed the indwelling suprapubic catheter. An interview was conducted on 04/03/23 at approximately 4:15 P.M. with SN #4. SN #4 stated that she was “unable to recall if there was an order (to change the catheter).” An interview was conducted on 04/03/23 with clinical manager #2. Clinical Manger #2 stated, “Typical ways to update a POC, they push the old order down and put the new order on top. They did that and didn’t put in an effective date.”