Every finding on record at Visiting Nurse Association of Johnson County

The #61483-C complaint investigation, conducted by the Department of Inspections and Appeals from 1/20/22 through 1/27/22, resulted in not substantiated of the complaint allegations and found the agency operating out of compliance with related standard level deficiencies under the Condition of Participation 42 CFR 484.60 Care Planning, Coordination and Quality of Care ( G572 and G574).

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 agency policy review, clinical record review and agency staff interview, the agency failed to follow a Plan of Care established and periodically reviewed by a physician or notify the physician of the need to vary frequency of visits or inability to perform treatments/services as originally ordered on the Plan for Care for 4 of 5 sampled patients (Patients #1, #2, #3, and #4). Failure to follow a Plan of Care established by a physician placed patients at risk of not receiving safe, individualized and consistent care designed to meet each patient's health care needs. Findings include: According to the agency policy, titled Plan of Care and dated 6/2020, a written and individualized Plan of Care is established for all patients and services provided are consistent with the Plan of Care. All physicians authorizing skilled, health maintenance, private duty, or outpatient plans of care are regularly informed of the patient's status and changes that may impact the plan of care. Written summary/progress notes reflecting current status, progress to goals, any changes or problems that occurred during the reporting period, and any missed visits or services not already reported, accompany each recertification plan. During agency staff interview on 1/25/22 at 1:20 PM, the Clinical Manager reported if the frequency of visits varies from the Plan of Care, notification is sent automatically electronically through the electronic health record system. 1. Patient #3 had a start of care date of 11/19/21. Clinical record review revealed the following: a. The Plan of Care, dated 11/19/21 to 1/17/22, included physician orders for skilled nursing visits 1 time every week for 8 weeks for medication set up, home care aide visits twice weekly for bathing assistance, and physical therapy visits twice weekly for strengthening. b. The skilled nursing visit notes, dated 12/14/21, 1/4, 1/11, and 1/17/22, lacked documentation the nurse provided weekly medication set up as ordered by the physician. Interview on 1/26/22 at 10:08 AM with Staff F, Registered Nurse (RN) reported the nurse set up patient's medications weekly and documented the medication set up in the visit note by documenting the dates the medications were filled through. The RN further reported another nurse set up the care plan interventions when they changed to the new system and not sure why the dates would not have been documented. c. A physical therapy missed visit note, dated 11/29,12/27 and 12/29/21, documented the visit was not made due to having no staff. The note lacked documentation of notification to the physician of the missed physical therapy visit. d. A home health aide missed visit note, dated 12/24/21 and 1/3/22, documented a missed visit. The note lacked documentation of notification to the physician of the missed visit. e. The physical therapy visit note, dated 1/20/22, documented only one physical therapy visit occurred the week of 1/17/22. A missed visit note, dated 1/18/22, documented the additional visit was not made due to scheduling conflict. The note lacked documentation of notification to the physician of the missed physical therapy visit. On 1/27/22, the agency provided documentation the 12/27/21, 12/29/21, 1/12/22 and 1/19/21, physical therapy visit notes and 12/24/21, 12/30/21, and 1/3/22 home care aide notes were sent to the physician by the electronic health care record vendor on 1/27/21. The clinical record lacked any documentation of physician notification for the variance in the tasks ordered on the Plan of Care. 2. Patient #1 had a start of care date of 5/14/2020. Clinical record review revealed the following: a. The Plans of Care, dated 11/5/21 to 1/3/22 and 1/4/22 to 3/4/22, included physician orders for skilled nursing visits 1 time every week for 8 weeks for medication set up and physical therapy visits twice weekly for gait training and establish a home exercise program. b. A physical therapy missed visit note, dated 11/24, 11/29, 12/12, 12/27 and 12/29/21 documented the visit was not made due to having no staff. The note lacked documentation of notification to the physician of the missed physical therapy visit. c. A physical therapy missed visit note, dated 12/22/21, documented the visit was not made due to scheduling conflict between the clinician and the patient. The note lacked documentation of notification to the physician of the missed physical therapy visit. d. A physical therapy missed visit note, dated 1/12/22, documented the visit was not made due patient refusal. The note lacked documentation of notification to the physician of the missed physical therapy visit. e. A physical therapy missed visit note, dated 1/19/22, documented the visit was not made due to facility being closed. The note lacked documentation of notification to the physician of the missed physical therapy visit. On 1/27/22, the agency provided documentation the 1/12/22 and 1/19/21, visit notes were sent to the physician by the electronic health care record vendor on 1/27/22. The Clinical Manager reported the EHR report to show when the previous notes were sent to the physician are not working and the company is working on this as well. The clinical record lacked any documentation of physician notification for the variance in the tasks ordered on the Plan of Care. 3. Patient #2 had a start of care date of 12/10/21. Clinical record review revealed the following: a. The Plan of Care, dated 12/10/21 to 2/7/22, included physician orders for skilled nursing visits 1 time every week for 8 weeks for medication set up and physical therapy visits twice weekly for strengthening. b. A physical therapy missed visit note, dated 12/21/21, documented the additional visit was not made due patient refusal. The note lacked documentation of notification to the physician of the missed physical therapy visit. c. The physical therapy missed visit notes, dated 12/28/21 and 12/30/21, documented the visits were not made due to having no staff. The notes lacked documentation of notification to the physician of the missed physical therapy visits. d. A physical therapy missed visit note, dated 1/18/22, documented the additional visit was not made due to scheduling conflict. The note lacked documentation of notification to the physician of the missed physical therapy visit. On 1/27/22, the agency provided documentation the 12/21/21, 12/28/21, 12/30/21, and 1/18/22, visit notes were sent to the physician by the electronic health care record vendor on 1/27/22. The Clinical Manager reported the EHR report to show when the previous notes were sent to the physician were not working and the company was working on this as well. e. The Plan of Care, dated 12/10/21 through 2/7/22, included orders for the skilled nurse to assess vital signs including blood pressure, and apical and radial pulses. f. The skilled nursing visit notes, dated 12/10/21, 12/14/21, 12/17/21, 12/21/21, 12/24/21, 12/28/21, 12/31/21, 1/4/22, 1/7/21, 1/11/22, 1/14/22, 1/18/22 and 1/21/22, lacked documentation of assessment of a radial pulse. Interview with physician's office on 1/27/21 at 9:30 AM, revealed the physician did want the agency to assess both apical and radial pulses. The physician's office also contacted the agency to inform them of this as well. The clinical record lacked any documentation of physician notification for the variance in the tasks ordered on the Plan of Care. 4. Patient #4 had a start of care date of 7/20/2020 and a discharge date of 11/22/21. Clinical record review revealed the following: a. The Plans of Care, dated 9/13/21 to 11/11/21 and 11/12/21 to 1/10/22, included physician orders for skilled nursing visits 2 times every week for 8 weeks and included weight parameters of 343 to 350 pounds. b. The skilled nursing visit notes, dated 10/1, 10/14, 10/15, 10/22, 10/28, 10/29, 11/1, 11/5, 11/12, 11/15, and 11/19 lacked documentation of assessment of the patient's weight. The clinical record lacked any documentation of physician notification for the variance in the tasks ordered on the Plan of Car The above findings were reviewed with the agency Administrator, Clinical Manager, and Chief Operations Officer. Agency staff provided no additional information prior to the end of the survey.

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 agency policy review, clinical record review, home visit observation and patient and staff interview, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including medications used by the patient for 1 of 1 sampled patients with surveyor home visit observation(Patient #1). Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services, medications and/or treatments according to assessed needs and physician orders. Findings include: According to agency policy, titled Plan of Care, dated 6/2020 the individualized plan of care is established for all patients and includes all medications. Patient #1 had a start of care date of 5/14/2020. Clinical record review, home visit observation and accompanying interviews revealed the following: a. The Plans of Care, dated 11/5/21 to 1/3/22 and 1/4/22 to 3/4/22, included orders for Cholecalciferol 25 micrograms (mcg) and instructed the patient to take 1 capsule daily in the morning (5000 international units). b. The Medication Profile, dated 1/24/22, included orders for Cholecalciferol 25 micrograms (mcg) and instructed the patient to take 1 capsule daily in the morning (5000 international units). During a home visit observation on 1/24/22 at 3:59 PM, with Staff C, Registered Nurse (RN), the nurse performed medication set up for the patient. The surveyor observed the bottle used by the RN to fill the patient's medication planner. The 1/2 full bottle was for Cholecalciferol 125 mcg per soft gel 5000 international units. The Plan of Care lacked the correct dosage of Cholecalciferol used by the patient. c. The Plans of Care, dated 11/5/21 to 1/3/22 and 1/4/22 to 3/4/22, included orders for Calcium Carbonate and Vitamin D with 500 mg of Calcium Carbonate and 5 mcg of Vitamin D and instructions to take 2 tablets daily. d. The Medication Profile, dated 1/24/22, included orders for Calcium Carbonate and Vitamin D with 500 mg of Calcium Carbonate and 5 mcg of Vitamin D and instructions to take 2 tablets daily. During the same home visit observation, the surveyor observed the bottle used to fill the patient's medication planner. The bottle was for 650 mg of Calcium Citral and 25 mcg (1000 international units) of Vitamin D. The nurse educated the patient's caregiver about buying the correct dosage over the counter and stated would notify physician or inaccuracies. The Plan of Care lacked the correct dosage of Citracal used by the patient. The above findings were reviewed with the agency Administrator, Clinical Manager, and Chief Operations Officer. Agency staff provided no additional information prior to the end of the survey.