Every finding on record at Well Care Home Health of the Triangle, Inc.

An unannounced, onsite complaint investigation was conducted 08/25/22. Standard-level deficiencies to the Medicare Conditions of Participation were identified. The complaint that the agency failed to coordinate patient care was substantiated.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and staff interview, the agency failed to record a physician’s verbal order for blood work 1 of 3 clinical records reviewed (Patient #3). Findings include: The following polices were received from the agency’s Clinical Manager on 08/25/22 at 11:50 AM. Policy PC-29 titled Coordination of Care and originated 02/2020 revealed, “…Care coordination will include but not be limited to…(e) Timely documentation of coordination of care activities…(j) Integrate orders from all physicians…involved in the plan of care so that all services and interventions are coordinated…” Policy PC-09 titled Ongoing Assessments and originated 02/2020 revealed, “…6. Based on the findings of the reassessment, additional orders will be generated and forwarded to the physician…for signature(s)…” Patient #3 was admitted to the agency on 02/17/21 with documented diagnoses including cerebral palsy, benign prostatic hyperplasia (an enlarged prostate gland), retention of urine, epilepsy (a disorder in the brain that leads to seizure activity) and encounter for fitting and adjustment of urinary device. Certification periods reviewed were from the Plans of Care 06/12/22 to 08/10/22 and 08/11/22 to 10/09/22. Plan of Care 06/12/22 to 08/10/22 revealed orders for skilled nursing effective 06/19/22 1 time per week for 1 week, 1 time every 2 weeks for 6 weeks, 1 time per week for 1 week and 2 PRN (as needed) nurse visits for catheter complications, signs and symptoms of UTI (urinary tract infection), change in condition, and PRN lab draw. Plan of Care 08/11/22 to 10/09/22 revealed orders for skilled nursing 1 time per week for 1 week, 1 time every 2 weeks for 2 weeks, 1 time per week for 2 weeks, 1 time every 2 weeks for 2 weeks, 1 time per week for 2 weeks, and 2 PRN nurse visits for change in condition, catheter complications, fall, signs and symptoms of infection, and medical complications. Employee #4, a licensed practical nurse, conducted a skilled nursing visit on 07/05/22. This visit note revealed, “…seizure activity lasting one min (minute) as per caregiver Thursday…call placed to Dr (doctor) [name of physician] spoke to medical assist [sic] reported seizuer [sic] reordered [sic] spoke with his nurse [name of nurse] to obtain blood work for. [sic] Lab work for TSH (test used to assess the level of thyroid stimulating hormone) and free T4 (test used to assess the functioning of the thyroid gland) insulin (test used to measure the level of insulin in the blood) ACTH (test used to assess the functioning of the adrenal gland) thriod [sic] cortisol (test used to measure the level of cortisol hormone in the body) by July 21…” At the time of survey, there was no evidence of a documented order for this blood work in the clinical record, there was no evidence in the clinical record that the blood work discussed during the 07/05/22 skilled nursing visit was ever obtained and there was no additional documentation in the clinical record regarding any further collaboration with the physician and/or his representative regarding the blood work discussed during the 07/05/22 skilled nursing visit. In an interview on 08/25/22 at 4:25 PM, Employee #2, Performance Improvement Coordinator, stated, “…I don’t see any documentation. It was not transcribed to an order…” When asked the expectation of an employee receiving this type of information verbally from a physician practice, Employee #2 stated, “That they would write an order.”

An unannounced onsite complaint investigation was conducted on 07/21/21. The complaint was substantiated. A deficiency to the Medicare Conditions of Participation was identified. ABH

Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient's discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner's issuing orders for the HHA plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any). This ELEMENT is not met as evidenced by: Based on agency policy and procedure, clinical record review, and staff interview the agency failed to communicate changes related to discharge for 1 of 3 patients with a catheter (#1). Findings included: A policy, “Provision of Care, Treatment, & Services”, revised 07/2018 was received from the Performance Improvement Coordinator on 07/21/21 at 1:37 p.m. The policy stated, “revisions/changes to the plan of care are documented in the clinical notes, through additional orders and the plan of care update form”. Patient #1 had a SOC (start of care) of 05/23/2020 and included diagnoses of encounter for fitting and adjustment of urinary device, other retention of urine, spina bifida (birth defect in which there is incomplete closing of the spine), and history of falling. Plan of care for 03/19/21 to 05/17/21 included orders for skilled nursing visits as follows: 3 times a week for 1 week, 1 every 5 weeks for 5 weeks, and 1 every 3 weeks for 3 weeks. Skilled nurse for insertion of 18 french silicone catheter maintenance with 5 cc(cubic centimeter) balloon, change every month and prn(as needed) dislodgement or stoppage, and obtain urine specimen as indicated. Review of skilled nursing missed visit for 05/14/21 revealed patient requested to be seen on 05/17/21. A discharge oasis was completed on 05/17/21 without a skilled nursing visit. Further review of the record revealed a coordination note completed by the scheduler on 05/20/21 noted ______ (Doctor office) called in for the patient and states patient has left multiple messages about her catheter to be changed and no one came Monday. No other documentation was noted to be in the record regarding discharging the patient. Staff Interview with the Performance Improvement Coordinator and Clinical Manager on 7/21/21 at 1:20 p.m. confirmed that no documentation of the patient requesting discharge is in the record.