Every finding on record at Volunteers of America Home Health of Western Colo

A recertification survey and focused COVID-19 infection control survey was completed on 1/21/21. Three deficiencies were cited.

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 may choose to include. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the individualized plan of care in included medications and the frequency and duration of visits to be made in 2 of 6 patient's who received physical therapy (PT) services (Patient #4 and #8). Findings include: AGENCY POLICY According to the policy, Plan of Care, undated (in pertinent part): "4. The Plan of Care shall be completed in full to include: d. The frequency and duration of visits to be made; j. All medications and treatments. 5. Orders for therapy services shall include the specific procedures and modalities to be used and the amount, frequency, and duration." 1. The clinical record for Patient #4 was reviewed on 1/19/21. The Plan of Care for the certification period dated 1/13/21 to 3/31/21 revealed a start of care date of 1/13/21; diagnoses included right total knee replacement, osteoarthritis, Parkinson's Disease, history of diseases of the musculoskeletal system and connective tissue and long term use of opiate analgesic and aspirin. Plan of Care orders included PT services three times weekly for one week, five times weekly for one week and three times weekly for four weeks; skilled nursing (SN) services once weekly for one week and three times as needed (PRN); and certified nurse aide services twice weekly for five weeks. a) The agency failed to ensure the patient's plan of care included all medications and treatments. Clinical record review revealed Physical Therapist (PT #6) completed a start of care comprehensive assessment for Patient #4 on 1/13/21, pertaining to the certification period dated 1/13/21 to 3/31/21. Review of the assessment revealed PT #6 documented Patient #4 had long term current use of opiate analgesic and aspirin, Patient #6 was taking five or more medications and he had completed a Drug Regimen Review and found no issues. PT #6 further documented Patient #4 was unable to take medications unless administered by another person. Review of the plan of care for the certification period dated 1/13/21 to 3/31/21 failed to reveal medications, including dosages and frequency. During an interview during a home visit on 1/20/21 beginning at 11:00 a.m., PT #6 stated he had begun conducting start of care visits recently. He stated the plan of care was developed from the start of care assessment and the start of care assessment should include medications, prior medical history, assessments completed, goals, and the patient's support system. PT #6 then reviewed the plan of care for Patient #4 and confirmed medications were not included on the plan of care. He stated the electronic medical record (EMR) system had recently undergone an update and he was having trouble navigating it. He stated he had reviewed medications with Patient #4 at the start of care and completed a medication profile, but was unsure why it had not populated on the plan of care. During an interview on 1/20/21 at 1:06 p.m., the Director of Clinical Services (DCS) confirmed medications were missing from Patient #4's plan of care. 2. The clinical record for Patient #8 was reviewed on 1/20/21. The Plan of Care for the certification period dated 9/2/20 to 10/31/20 revealed a start of care date of 1/6/20; diagnoses included diabetes mellitus, hemiplegia, dystonia, sleep apnea, gastro-esophageal reflux disease, long term use of insulin and aspirin, dependance on supplemental oxygen, and history of nicotine dependence. Plan of Care orders included SN services once weekly for eight weeks and two times PRN. The Plan of Care for the certification period 11/1/20 to 12/30/20 included orders for SN services twice weekly for four weeks and four visits PRN. a) The agency failed to ensure the patient's plan of care included the frequency and duration of services for all disciplines. Clinical review of the Patient #8's plans of care for the certification periods dated 9/2/20 to 10/31/20 and 11/1/20 to 12/30/20 revealed a summary of PT orders and PT goals. However, the plans of care for the certification periods dated 9/2/20 to 10/31/20 and 11/1/20 to 12/30/20 failed to reveal PT frequency and duration orders. During an interview on 1/20/21 at 1:09 p.m., the DCS reviewed the plans of care for Patient #8 for the certification periods dated 9/2/20 to 10/31/20 and 11/1/20 to 12/30/20 and confirmed neither of them contained the PT frequency and duration of services. She stated it appeared the frequency and duration of PT did not get "pulled over" and it "didn't get noticed." 3. During an interview on 1/20/21 at 1:06 p.m., the DCS stated the agency had previously been reviewing all plans of care for approximately one year and found no issues. She stated the agency was no longer reviewing plans of care prior to being submitted to the physician for approval. However, she stated the agency was currently having issues with the EMR not "pulling things over" from the completed comprehensive assessments to the plans of care.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to provide services and treatments only as ordered by the physician for 1 of 1 patient records reviewed who required a resumption of care (Patient #6). Findings include: AGENCY POLICY According to the policy, Comprehensive Client Assessment, undated (in pertinent part): "Reassessments are conducted based on client needs, physician orders, professional judgement and/or OASIS or other regulatory requirement, and for any changes in the plan of care will be sent to the physician. According to the policy, Physician Orders, undated (in pertinent part): "All medication, treatments and services provided to clients must be ordered by a physician. The orders may be initiated via telephone or in writing and must be countersigned by the physician in a timely manner. All medications, treatments and services, that are part of the client's plan of care, must be ordered by the physician." 1. The clinical record for Patient #6 was reviewed on 1/19/21. The Plan of Care for the certification period 12/5/20 to 2/2/21 revealed a start of care date of 12/5/20; diagnoses included acute respiratory failure with hypoxia, bacterial pneumonia, chronic kidney disease, chronic obstructive pulmonary disease (COPD), kidney failure, severe sepsis, anemia, hypertension, atrial fibrillation, hypokalemia, long term use of aspirin, steroids and anticoagulants, need for drug monitoring, dependence on supplemental oxygen, history of nicotine dependence, pacemaker, and benign prostatic hyperplasia. Plan of Care orders included skilled nurse (SN) services once weekly for 10 weeks and three times as needed (PRN); Physical Therapy (PT) services three times weekly for one week and twice weekly for three weeks ending on 1/2/21. a) The agency failed to obtain physician's orders for SN services following a resumption of care (ROC) prior to the provision of services. Review of the clinical record for Patient #6 revealed Registered Nurse (RN #7) completed a transfer to inpatient summary on 12/31/20 following Patient #6's transfer to the hospital on 12/28/20. On 12/30/20, the agency received orders from the hospital to which Patient #6 had been transferred to "resume home health." Registered Nurse (RN #7) completed the resumption of care on 1/1/21 and conducted visits to Patient #6 on 1/4/21 and 1/8/21 and RN #8 conducted visits to Patient #6 on 1/9/21, 1/12/21 and 1/15/21. Further review of the record revealed RN #7 wrote an order which stated "Verbal consent given to resume SN and PT services via [Agency Name]." However, the record failed to show specific orders for SN services including frequency, duration and treatments to be provided following the ROC. During an interview on 1/20/21 at 1:24 p.m. the Director of Clinical Services (DCS) stated agency policy is for the RN to complete the ROC and to receive physician orders for services within 24 to 48 hours of the patient returning to home health services. She reviewed the clinical record for Patient #6, stated the agency should have received new SN orders, to include frequency, duration and treatments provided, following the ROC and confirmed RN #7 did not receive orders for SN services following the ROC.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure a registered nurse (RN) or other appropriate skilled professional familiar with the patient, the patient's plan of care and the written patient care instructions made an onsite visit to the patient's home no less frequently than every 14 days to conduct certified nurse aide (CNA) supervision for 1 of 1 active patient records reviewed receiving skilled care and CNA services (Patient #10). Findings include: AGENCY POLICY According to agency policy, "Home Health Aide Supervision", undated: "Agency shall provide Home Health Aide services under the direction and supervision of a Registered Professional Nurse/Therapist when personal care services are indicated and ordered by the physician. The frequency of supervision will be in response to Medicare regulation, agency policy and other state or federal requirements". 1. The clinical record for Patient #10 was reviewed on 1/20/21. The Plan of Care for the certification period dated 11/20/20 through 1/18/21 revealed a start of care 11/20/2020; diagnoses included unspecified displaced fracture of cervical vertebrae, sternum fracture, rib fractures, traumatic brain injury, atrial fibrillation, diabetes mellitus, ventricular premature depolarization, syncope, and history of falls. Plan of Care orders included Physical Therapy (PT) visits two times a week and Certified Nurse Aide (CNA) visits two times a week to provide assistance with personal care, balance, gait training and activities of daily living. a) The agency failed to ensure CNA supervisory visits were conducted every 14 days. Review of the plan of care for the certification period 11/20/20 to 1/18/21 showed Patient #10 was authorized to receive CNA services for assistance with showering, dressing and straightening the patient's room twice weekly and PT services twice weekly. Review of the visit notes for the time period dated 11/20/20 through 1/15/21 revealed Patient #10 received PT and CNA services twice weekly. Record review failed to reveal PT #6 conducted supervisory visits of the CNA every 14 days. Rather, PT #6 conducted supervisory visits on 11/23/20 and 12/18/20, a period of 26 days, and not again until 1/6/21, a period of 19 days. During an interview on 1/20/21 at 4:00 p.m., the Director of Clinical Services (DCS) stated there was no was no documentation for the CNA supervisory visits that should have been conducted between 11/23/20 through 1/6/21. She further stated she confirmed with CNA #4 and PT #6 CNA supervisory visits were not conducted every 14 days as required by agency policy and regulation.