Every finding on record at Via Christi Home Health Wichita, LLC

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site Recertification Survey (ASPEN #CDX011) at the above-named Home Health Agency (HHA) conducted from 01/24/2022 through 01/28/2022 resulted in a finding of no deficiency citations respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.22.

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site Recertification survey (ASPEN #CDXO11) conducted at the above-named Home Health Agency (HHA) from 01/24/22 through 01/28/22 resulted in a finding of substantial compliance respective to applicable Conditions of Participation (CoPs) under 42 CFR 484, Subpart A through C with the following standard-level deficiencies cited.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on interviews, record reviews, and policy reviews, it was determined that the agency failed to conduct an initial assessment visit within 48 hours after receiving a referral to provide services for one (Patient 3) of 17 patients reviewed. This failure had the potential for the patient to not receive needed assessments and home care services that could have negatively impacted Patient 3's health. Findings Include: Review of an agency policy titled, "Initial and Comprehensive Patient Assessments," created on 11/01/2011 and revised 12/01/2017, revealed that agency staff were to complete an initial patient assessment within 48 hours of receipt of a patient referral. Review of Patient 3's, "Home Health Certification and Plan of Care (POC)," dated 01/08/2022, indicated that Patient 3 was admitted to the agency on 01/08/2022, with diagnoses that included type 2 diabetes mellitus with diabetic chronic kidney disease (high levels of sugar in the blood that damages the kidneys) and a surgical wound on the right knee. During an interview conducted on 01/25/2022 at 10:00 AM, Patient 3 stated that there was a delay from the date of his discharge from a rehabilitation hospital and the date when the agency staff began providing services. Patient 3 further stated that the agency was suppose to provide wound care but he had to drive to a facility to receive the care during the time between discharge from the rehabilitation hospital on 12/29/2021 and the agency start of care (SOC - completion of an initial assessment) on 01/08/2022. Review of Patient 3's clinical record, "Discharge Summary," dated 12/29/2021, showed that Patient 3 was discharged from a rehabilitation hospital and referred to the agency on 12/29/2021 with orders to provide wound care three times per week. Review of Patient 3's clinical record, "POC," dated 01/08/2022, showed that Patient 3's SOC was on 01/08/2022. During an interview conducted on 01/28/2022 at 11:12 AM, the Direct Care Supervisor (DCS) stated that the agency policy was that a patient's SOC was to occur within 48 hours of receipt of physician orders for service, unless the physician indicated a particular SOC date. The DCS further stated that the agency was to notify the patient's physician if a patient's SOC was delayed past 48 hours. The agency was unable to provide documentation that the agency notified Patient 3's physician of the delay in SOC. The DCS confirmed that Patient 3's SOC occurred more than 48 hours after the agency's receipt of Patient 3's referral and acknowledged that the agency had not followed agency policy.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observations, interviews, record reviews, and policy reviews, it was determined that the agency failed to conduct a medication regimen review (a review of all patient medications completed at the time of admission or when a patient's medication changes) for one (Patient 3) of 17 patients reviewed. This failure resulted in insulin (a drug given to treat high blood sugar) not showing on Patient 3's Plan of Care (POC - a comprehensive plan that includes medications and interventions that guides the staff in providing patient care) and had the potential for the patient to not receive education and guidance on the use of the medication and become ill. Findings Include: Review of an agency policy titled, "Drug Regimen Review," created on 11/01/2011 and revised 06/30/2021, revealed that staff were to review and create a list of all of a patient's current medications when the patient was admitted to the agency, and that staff were to update the medication list as needed. Review of Patient 3's "Home Health Certification and Plan of Care (POC)," dated 01/08/2022, indicated that Patient 3 was admitted to the agency on 01/08/2022, with diagnoses that included type 2 diabetes mellitus with diabetic chronic kidney disease (high levels of sugar in the blood that damages the kidneys). During an observation conducted in Patient 3's home on 01/25/2022 at 10:00 AM, Registered Nurse (RN) A asked Patient 3 for his current insulin dosage. Review of Patient 3's "Discharge Summary," dated 12/29/2021, indicated that Patient 3 was discharged from a rehabilitation hospital and was referred to the agency with a diagnosis of type 2 diabetes mellitus, and that Patient 3 was taking insulin three times a day. Review of Patient 3's "POC," dated 01/08/2022, revealed a physician order that the agency nurses were to provide the patient teaching on insulin administration. Further review did not show insulin listed in Patient 3's medication list. Review of Patient 3's "Client Coordination Note Report," dated 01/15/2022, revealed that a nursing staff member noted that Patient 3's insulin was not listed on Patient 3's medication list. Review of Patient 3's "Home Health Updated Plan of Care Report (UPOC)," dated 01/28/2022, revealed a physician order that the agency nurses were to provide patient teaching on insulin administration. Further review did not show insulin listed in Patient 3's medication list. During an interview conducted on 01/28/2022 at 11:12 AM, the Executive Director (ED) confirmed that Patient 3's "POC," dated 01/08/2022, and Patient 3's "UPOC," dated 01/28/2022, did not show insulin listed in Patient 3's medication list. The ED stated that Patient 3's insulin should have been documented in Patient 3's medication list and acknowledged that the agency had not followed agency policy.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on interviews, record reviews, and policy reviews, it was determined that the agency failed to include a diagnosis for one (Patient 3) of 17 patients reviewed on his Plan of Care (POC - an individualized and comprehensive plan that includes diagnoses, medications, and interventions that guides the staff in providing patient care). This failure had the potential for Patient 3 to not receive staff education and services related to management of this health issue. Findings Include: Review of an agency policy titled, "Plan of Care, Certification and Recertification," created on 11/01/2011 and revised 08/30/2019, showed that every patient's POC should include all pertinent diagnoses. Review of Patient 3's "Home Health Certification and Plan of Care (POC)," dated 01/08/2022, indicated that Patient 3 was admitted to the agency on 01/08/2022, with diagnoses that included type 2 diabetes mellitus with diabetic chronic kidney disease (high levels of sugar in the blood that damages the kidneys) and a surgical wound on Patient 3's right knee. Further review showed that Patient 3 was taking Pantoprazole (a medication used to treat stomach problems) two times per day and Sucralfate (a medication used to treat or prevent ulcers in the intestines) four times per day and a physician order that the agency nurses were to assess and provide teaching and intervention for any stomach and intestine problems. Further review did not show any diagnoses related to stomach or intestinal issues. Review of Patient 3's "Home Health Updated Plan of Care Report (UPOC)," dated 01/28/2022, revealed that Patient 3 was taking Pantoprazole two times per day and Sucralfate four times per day and a physician order that the agency nurses were to assess and provide teaching and intervention for any stomach and intestine problems. Further review did not show any diagnoses related to stomach or intestinal issues. During an interview conducted on 01/28/2022 at 11:12 AM, the Executive Director (ED) confirmed that Patient 3's "POC," dated 01/08/2022, and Patient 3's "UPOC," dated 01/28/2022, did not show any diagnoses related to stomach or intestinal problems. The ED stated that Patient 3's POC should have included a diagnosis related to stomach or intestinal issues and acknowledged that the agency had not followed agency policy.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on interviews, record reviews, and policy reviews, it was determined that the agency failed to provide services as ordered by a physician for one (Patient 7) of 17 patients reviewed. This failure resulted in Patient 7 not receiving necessary services. Findings Include: Review of an agency policy titled, "Plan of Care, Certification and Recertification," created on 11/01/2011 and revised 08/30/2019, showed that patients were to receive care as ordered. Review of Patient 7's "Home Health Certification and Plan of Care (POC)," dated 12/29/2021, showed that Patient 7 was admitted to the agency on 12/29/2021, with diagnoses that included pressure ulcers (bed sores), heart failure, and depression. Further review showed that Patient 7 was to receive Home Health Aide (HA) services to help Patient 7 with hygiene and activities of daily living (activities that included bathing, grooming, and dressing). Review of Patient 7's "Client Schedule Report," dated 01/28/2021, did not indicate that Patient 7 received any HA services. During an interview conducted on 01/28/2022 at 10:21 AM, the Direct Care Supervisor (DCS) confirmed that Patient 7's "POC," dated 12/29/2021, and Patient 7's "UPOC," dated 01/28/2022, showed that Patient 7 was to receive HA services. The facility was unable to provide evidence that the agency provided HA services to Patient 7. The DCS acknowledged that the agency had not followed agency policy.