Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 017024	(X3) Date Survey Completed 10/21/2021
Name of Provider or Supplier Southeast Alabama Homecare, Llc	Street Address, City, State 3813 Ross Clark Circle, Suite 300, Dothan, AL
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.

(X4) ID Prefix Tag	Summary Statement of Deficiencies (Each deficiency should be preceded by full regulatory or LSC identifying information)
E0000	Based on review of the agency Emergency Preparedness Plan and interview it was determined Southeast Alabama Homecare was in substantial compliance with 484.102 Conditions of Participation: Emergency Preparedness.
G0000	A recertification survey was conducted on 10/21/21 with standard deficiencies cited.
G0536	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 review of agency policy and procedure, observations, medical record (MR) review and interviews with the staff, it was determined the agency failed to ensure staff updated and maintained an accurate medication profile for each patient per the agency policy. This affected 4 of 6 Home Visits (HV), including HV # 6, # 3, HV # 2, HV # 5, and had the potential to affect all patients served by the agency. Findings include: Agency policy: Monitoring Medications Policy Number: 10.008 Revised Date: 5/1/19 Policy: A drug regimen review will be performed on all patients in conjunction with all comprehensive assessments. Additionally, all clinicians will participate in medication review and reconciliation throughout the episode. For patients receiving skilled nursing and therapy services, the skilled nurse is responsible for medication review and reconciliation throughout the episode. The therapist will participate by monitoring and reporting any identified issues or non-compliance to the Patient Care Manager. For patients receiving only therapy services, the therapist is responsible to facilitate drug regimen review and medication reconciliation throughout the episode. Procedure: 1. The discipline responsible for the drug regimen review will: a. Compare medication list obtained from the facility from which the patient was transferred and/or physician order to actual medications patient is taking. b. Review all medications including over the counter (OTC) medications, vitamins, herbs and herbal products, creams, and topical ointments. 2. All clinicians participating in their patient’s care are responsible to assist with the maintenance of accurate patient medication information throughout their episode of care. a. Through a collaborative process the care team will: i. Compare medications patient is currently taking with medications ordered for the patient in order to identify and resolve discrepancies. 4. HV # 5 was admitted to the agency on 1/4/2019 with diagnosis including Neuromuscular Dysfunction of Bladder, Unspecified and Encounter for Attention to Cystostomy. A HV was conducted 10/19/21 at 11:10 AM with EI # 8, Home Health Aide, to observe care provided. The surveyor was accompanied on the HV by EI # 6, RN. During the visit, the medications in the home were compared to the current MP provided by the agency and the following discrepancies were found and verified by the patient and EI # 6 RN: a. Calcium Carb-Vit (Vitamin) D3-Minerals 600 mg, 200 unit tablet, dose one tablet daily listed on the MP but per the patient, was discontinued about one year ago. b. Collagen Plus Vitamin C 125 mg - 740 mg capsule, dose three capsules daily listed on the MP but per the patient, was discontinued about one year ago. c. Cranberry Concentrate 500 mg capsule, dose 1 capsule daily listed on the MP but per the patient, was discontinued about one year ago. d. Evista 60 mg tablet, dose 1 tablet daily listed on the MP but per the patient, was discontinued about one year ago. e. Advil 200 mg tablets found in the home but not on the MP. Per the patient, takes two tablets daily as needed for about a year. f. BHI Diarrhea tablets found in the home but not on the MP. Directions on the bottle state one tablet every 4 to 6 hours as needed. Per the patient takes two tablets after the second loose stool as needed and has taken this medication, for "a long time". EI # 6 confirmed during the home visit the MP was not accurate. 3. HV # 2 was admitted to the agency 9/17/21 with a diagnosis of Unspecified Rotator Cuff Tear/Rupture of Left Shoulder-Not Trauma. A home visit was conducted 10/19/21 at 12:00 PM with EI # 3, Occupational Therapist, to observe treatment provided to the patient and medication reconciliation. The medications in the home were compared to the current MP provided by the agency and the following discrepancies were found. The medications were in the home and not on the Medication Profile and verified by the patient and wife: a. Sotalol HCL (Hydrochloride) 80 mg one by mouth daily-wife states has been on this medication for at least one year. b. Magnesium Oxide 400 mg by mouth Bid (twice) states has been on this medication since April 2021. c. Bumetanide 2 mg by mouth daily PRN (as needed) Has been taking since April 2021. d. Spironolactone 25 mg by mouth daily. Has been taking since April 2021. e. Senna 8.6 mg 1 by mouth daily PRN. Has been taking since September 7, 2021 f. Tylenol Extra Strength 1 tablet, 500 mg every 4 to 6 hours PRN. Has been taking for a couple weeks per wife. The following medication was on the Medication Profile and the patient’s wife stated he quit taking 6 months ago: Furosemide 40 mg 1 tablet by mouth daily. An interview was conducted on 10/21/21 at 11:00 AM with EI # 1 who confirmed the Medication Profile should have been verified and updated. 2. HV # 3 was admitted on 9/22/21 with diagnoses including Urinary Tract Infection, Pseudomonas, and Unspecified Escherichia Coli. A HV was conducted on 10/20/21 at 8:32 AM to observe care provided by EI # 4, RN (Registered Nurse). The medications in the home were compared to the Medication Profile provided by the Agency and the following discrepancies were found and verified with EI # 4 and HV # 3. a. Atorvastatin 80 mg one tablet daily was listed on the Medication Profile. Instructions on the medication bottle in the home filled on 9/2/21 was for ½ tablet daily. HV # 2 confirmed he/she has been taking ½ tablet daily since the prescription change. b. Glipizide 10 mg, 2 tablets 2 times daily was listed on the Medication Profile. Instructions on the bottle filled 8/25/21 was for 1 tablet 2 times daily. HV # 3 stated he/she has been taking the 1 tablet twice a day for a month or so. In an interview conducted on 10/21/21 at 11:10 AM, EI # 1, Executive Director, confirmed the Medication Profile had not been updated per agency policy. 1. HV # 6 was admitted to the agency 9/21/21 with diagnoses including Paraplegia and Essential Hypertension. A HV was conducted 10/19/21 at 12:30 PM with Employee Identifier (EI) # 7, Licensed Practical Nurse, to observe wound care and medication reconciliation. The medications in the home were compared to the current Medication Profile (MP) provided by the agency and the following discrepancies were found and verified by the patient and EI # 7: a. Gabapentin 300 mg (milligrams) 2 times per day with a date of 8/30/21 on the bottle was in the home. The MP profile had 3 times per day. The patient stated he/she had been taking 2 a day for a "long time." b. Niacin 1000 mg OTC 1 time per day was in the home and not listed on the MP. The patient stated the doctor had put him/her on that "over a year ago for cholesterol." EI # 7 confirmed during the home visit the MP was not accurate.
G0574	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 and procedure, review of medical records (MR) and interview with staff it was determined the agency failed to ensure the plan of care wound care orders included the frequency of dressing changes. This affected 2 of 6 records reviewed with wound care including Home Visit (HV) # 6, MR # 9 and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Physician Orders Policy Number: 2.1.008 Revised Date: 02/01/20 Policy: No medications, treatments...will be administered without the order of a qualified physician... Procedure: 10. Services are provided according to the most recent orders updating the patient's Plan of Care. 1. HV # 6 was admitted to the agency 9/21/21 with diagnoses including Paraplegia and Essential Hypertension. Review of the physician's order dated 9/27/21 revealed the skilled nurse (SN) was to visit 1 time per week to perform wound care and instruct the wound care procedure to the patient / caregiver. Wound care to the left lateral foot was ordered as follows: clean with normal saline, pat dry, apply Medihoney, cover with foam dressing using clean technique. The order failed to include how often the dressing was to be changed. A HV observation was conducted 10/19/21 at 12:30 PM to observe Employee Identifier (EI) # 7, Licensed Practical Nurse, perform wound care. During the visit the surveyor asked how often the dressing was changed and the patient and nurse stated every day, performed by the paid caregiver. An interview conducted 10/21/21 at 4:15 PM with EI # 5, Clinical Manager, confirmed the wound care order failed to include how often the dressing was to be changed. 2. MR # 9 was admitted to the agency 11/17/21 and recertified on 1/16/21 with diagnoses including Pressure Ulcer of Sacral Region Stage 2 and Pressure Ulcer of Left Buttock Stage 2. Review of the Plan of Care dated 1/16/21 revealed wound care to wound # 5, left buttock, and wound # 8. right inner buttock: clean with normal saline and gauze pads, pat dry, apply skin prep to periwound, then hydrocolloid. The order failed to include how often the dressing was to be changed. An interview conducted 10/20/21 at 4:00 PM with EI # 1, Executive Director, confirmed the order failed to include how often the dressing was to be changed.
G0584	Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on agency policy, medical record (MR) review and interview with staff it was determined the agency failed to ensure physician verbal orders were signed by the physician within 30 days. This affected 1 of 5 discharged records reviewed including MR # 10 and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Physician Orders Policy Number: 2.1.008 Revised Date: 02/01/20 Policy: No medications, treatments...will be administered without the order of a qualified physician...and that order...signed/dated by the ordering physician. 4. The Plan of Care (POC), telephone and/or verbal orders must be signed by the physician...30 days. 1. MR # 10 was admitted to the agency 3/6/21 with diagnoses including Chronic Pain Syndrome and Low Back Pain and recertified for care 5/5/21 to 7/3/21. MR # 10 was discharged goals met on 7/1/21. Review of the MR revealed the following verbal physician orders were not signed and dated by the physician: a. Physical Therapy (PT) Add On Discipline dated 6/18/21 which included the Plan of Care and visit frequency. b. Occupational Therapy (OT) Add On Discipline dated 6/21/21 which included the Plan of Care and visit frequency. c. Skilled Nurse order dated 6/17/21 which included nurse visit frequency, PT and OT evaluation. An interview conducted 10/20/21 at 4:12 PM with Employee Identifier # 1, Executive Director, confirmed the physician orders were not signed within 30 days as directed in the agency policy.
G0590	Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on agency policy and procedure, medical record (MR) review and interviews it was determined the agency failed to notify the physician of deterioration of wounds affecting 1 of 6 records with wounds including MR # 7. This had the potential to affect all patients with wounds served by the agency. Findings include Agency Policy: Coordination of Care From Admit Through Discharge Policy Number: 2.1.017 Revised Date: 8/1/19 Purpose: To establish processes and criteria so that the coordination of patient care will be optimal from admit through discharge. Procedure: 4. Coordination of care with physician: a. When changes occur in the patient's condition or response to treatment. 1. MR # 7 was admitted to the agency 9/29/21 with diagnoses including Chronic Ulcer Left Foot and Type 2 Diabetes Mellitus. Review of the Home Health Certification and Plan of Care dated 9/29/21 revealed the skilled nurse (SN) was to visit 1 time the first week then 2 times per week. SN to perform and instruct patient/caregiver in the wound care procedure to wounds # 13 - right pretibial venous stasis ulcer, # 18 - left foot mid-dorsum pressure ulcer (PU) stage 2, # 19 left heel PU stage 2, # 20 - right great toe PU stage 1, and # 21 - right heel PU stage 2. Perform twice weekly: cleanse with Vashe (wound cleanser), pat dry, apply silver sulfadiazine cream to wound bed, cover with xeroform gauze, wrap with roll gauze and Coban (a compression wrap) using clean technique. Review of the MR revealed the following changes in wound status: Wound # 13 venous stasis ulcer 9/29/21: scant amount of serosanguinous exudate - deteriorated to small amount of purulent drainage on 10/19/21 and measured 6 cm (centimeters) length (L), by 6 cm width (W), by 0.25 cm depth (D). This was the first measurement of Wound # 13 documented. There was no documentation the physician was notified of the change in exudate or the size of the wound. Wound # 18 left foot PU 9/29/21: moderate amount of purulent exudate with moderate odor measured 2 cm by 8.5 cm by 0.3 cm. continued to have purulent exudate on 10/6/21, 10/8/21, and 10/15/21. There was no documentation the physician was notified of the purulent exudate. Wound # 19 left heel PU 9/29/21: small amount of serosanguinous exudate with moderate odor, measured 5 cm by 5 cm by 0.2 cm - deteriorated to purulent exudate, small amount on 10/19/21. There was no documentation the physician was notified of the purulent exudate. An interview conducted 10/20/21 at 4:20 PM with Employee Identifier (EI) # 1, Executive Director, confirmed there was no documentation the physician was notified of the changes in wound status.
G0608	Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on review of the Medical Records (MR) and agency policy and procedure the agency staff failed to ensure care was coordinated with the physician regarding patient's blood sugar monitoring and swallowing difficulty. This deficient practice affected 3 of 17 MR's reviewed, including MR # 2, MR # 4, MR # 8 and has the potential to affect all the patient's served by the agency. Findings include: Agency Policy: Coordination of Care, from Admit Through Discharge Policy Number: 2.1.017 Revised Date: 8/1/19 Purpose: To establish processes and criteria so that the coordination of patient care will be optimal from admit through discharge. Procedure: ...4. Coordination of care with physician: At admission, throughout care, and at discharge, coordination of services is promoted through routine communication with the patient's Physician..." 3. MR # 8 was admitted to the agency on 8/28/21 with diagnosis including Aftercare Following Surgery For Neoplasm and Malignant Neoplasm of Overlapping Sites of Right Female Breast. Review of the HHC and POC dated 8/28/21 to 10/26/21 revealed orders for PT (Physical Therapy) effective 8/29/21 1WK1 (once per week times one week). PT to evaluate/assess and develop PT plan of care that will be approved by the physician prior to implementation. Review of the PT VNR dated 8/31/21 revealed evaluation for PT completed and care coordinated with physician with plans for PT visits 1W4 focusing on endurance training, BLE (Bilateral Lower Extremity) strengthening, fall prevention, gait training and HEP (Home Exercise Program) Training. Further review of the medical record revealed no PT physician orders were written for 1W4, no plan of care written and no visits were completed after the initial PT evaluation. An interview conducted on 10/20/21 at 3:45 PM with EI # 5, Clinical Manager confirmed the PT did not complete the plan of care and orders for PT as discussed with the physician on 8/31/21 and MR # 8 did not receive PT as planned. 1. MR # 2 was admitted to the agency on 9/3/21 with a diagnosis of Type 2 Diabetes Mellitus Without Complications. Review of the Home Health Certification (HHC) and Plan of Care (POC) revealed a physician order for "skilled nurse (SN) to instruct on Diabetes to include...management..." with a once a week SN frequency. Review of the SN admission note dated 9/3/21 revealed documentation of "...is not currently ordered to check (his/her) blood sugar and just has A1C's (lab test) checked at (Physician identified) twice yearly..." There was no documentation the SN coordinated with the physician about the patient not monitoring Diabetic Blood Sugars in the home and determine if the physician wanted to order blood sugar monitoring. Review of 7 of 7 SN visit note reports (VNR) between the next SN visit date of 9/7/21 through 10/19/21 revealed no documentation the SN coordinated with the physician about the patient not monitoring Diabetic Blood Sugars in the home and determine if the physician wanted to order blood sugar monitoring. An interview was conducted on 10/21/21 at 10:57 AM with Employee Identifier (EI) # 1, Registered Nurse Executive Director, who confirmed there was no documentation the agency staff coordinated with the physician about the patient not monitoring Diabetic Blood Sugars in the home and determine if the physician wanted to order blood sugar monitoring. 2. MR # 4 was admitted to the agency on 5/22/21 with diagnoses including, Unspecified Asthma, Uncomplicated and Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. Review of the SN VNR dated 6/9/21 revealed documentation of "patient not swallowing well. Has to do a barium swallow study on Friday" with a weight documented as 248 lbs (pounds). Review of the MR from 6/9/21 through 7/20/21 revealed no documentation of a follow up with the physician on the results of the barium swallow study nor coordination of care about the patient not swallowing well and need for Speech Therapy (ST). Review of the SN VNR dated 7/14/21 revealed documentation of "Patient reports low appetite and weight loss noted. Patient also reports that (her/his) CBG (Blood Sugar) monitor reads HI (High) instead of giving a number....MD (Medical Doctor) notified of...weight loss, CBGs..." There was no documentation of a physician return call to the SN and no documentation the SN attempted to follow up with the physician after not receiving a return call. An interview was conducted on 10/21/21 at 10:49 AM with EI # 1 who confirmed there was no documentation of the above coordination of care with the physician.
G0684	Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on review of personnel files, agency policy and interview with staff it was determined the agency failed to provide Hepatitis B vaccine when requested. This affected 1 of 3 personnel files reviewed including Employee Identifier (EI) # 7, Licensed Practical Nurse (LPN) and had the potential to affect all staff at risk for exposure to blood- borne pathogens. Findings include: Agency Policy: Staff Screening, New Hire and Annual Policy Number: 6.002 Revised Date: 09/01/21 Purpose: To establish a process to ensure appropriate staff screening prior to hire and annually thereafter. Procedure: H. Staff at Risk for Exposure to Blood-Borne Pathogens...are offered the series of Hepatitis B Vaccines, which is documented on the Hepatitis B Vaccine Consent Form... EI # 7, LPN, was hired 3/2/21. Review of the personnel file revealed EI # 7 signed the Hepatitis B Vaccination Consent form on 9/20/21. There was no documentation the Hepatitis B Vaccine series had been provided An interview conducted 10/20/21 at 4:00 PM with EI # 1, Executive Director, confirmed the Hepatitis B Vaccine had not been started for EI # 7.
G0714	Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on agency policy and procedure, medical record (MR) review and interviews it was determined the agency failed to ensure patients / caregivers were provided education and/or a return demonstration was obtained to ensure competency of: 1. Wound care. 2. New Medication. 3. Nebulizer use. 4. Oxygen Safety 5. Pressure Ulcer Prevention This affected 5 of 17 records including Home Visit (HV) # 6, MR # 7, MR # 4, MR # 6, HV # 5, and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Patient Education Policy Number: 3.001 Revised Date: 11/01/17 Purpose: To describe patient and/or caregiver interactions designed to promote and maximize patient health and safety. Policy: The agency plans, supports, and coordinates patient and caregiver education designed to promote optimal patient health and safety... Procedure: ...3. The patient and caregiver receive ongoing information specific to the identified needs... ...b. Patient/caregiver plan of care responsibilities ...4. The patient and caregiver receive ongoing safety information specific to the identified needs... a. Basic home safety within the patient information admit packet, including: v. Home Oxygen Safety... 5. Patients and caregivers receive...information on equipment safety specific to the identified needs...Including: a. medical gases: i. Storage of medical gases in a stable, protected area ii. Protection from heat extremes iii. Response to accidents and emergencies. b. Medical equipment: i. Purpose, operating instructions, troubleshooting, and correct use of supplies/accessories... 6. ...On medication education to include: a. Dosage, route, duration. b. Description, purpose, expected actions. c. Potential side effects, contraindications, avoidance of interactions, reactions to report. ...e. Appropriate mixing...storage, safeguards against contamination. f. Self-administration and monitoring techniques ...k. High alert medications... 7. Using the progress/visit note, the clinician documents the level of patient/caregiver comprehension, patient/caregiver return demonstration of skill(s) taught, compliance and any follow-up with team members... 5. HV # 5 was admitted to the agency on 1/4/2019 with diagnosis including Neuromuscular Dysfunction of Bladder, Unspecified ad Encounter for Attention to Cystostomy. Review of the Physician Order dated 8/22/21 revealed wound care to wound # 4 right buttocks and wound # 5 left buttocks as follows: Cleanse with saline and gauze, pat dry with gauze, apply hydrocolloid dressing using clean technique. Change weekly and PRN (as needed) soiling or dislodgement. Review of all VNRs by the nurse dated 8/22/21, 8/26/21 and 9/2/21 revealed no documentation of teaching wound care with a return demonstration by the caregiver. Further review of the VNR by the nurse dated 9/2/21 revealed, "wound care not provided:" (for wound # 4 and wound # 5) "Caregiver completed care." An interview conducted on 10/20/21 at 3:45 PM with EI # 5 confirmed there was no documentation of teaching wound care with a return demonstration by the caregiver prior to the caregiver providing the wound care. 4. MR # 6 was admitted on 5/27/21 and recertified from 7/26/21 to 9/23/21 with diagnoses including Pressure Ulcer of Other site, Stage 1, Diffuse Large B-Cell Lymphoma, and Neoplasm Related Pain. Review of the HHC and POC dated 5/27/21 revealed orders for the “Skilled Nurse to provide skilled teaching to prevent pressure ulcers, instruct on factors that contribute to skin breakdown, areas prone to breakdown and principles of skin care.” Review of the VNR, Braden Risk Assessment, dated 5/27/21 revealed the Braden Score was 15 indicating the patient was at risk for developing pressure ulcers. Further review of the POC dated 5/27/21 revealed orders for SN frequency of 1 wk 9 (1 x week x 9 weeks). Review of the SN VNR from week 1 through week 9 revealed no documentation of patient or caregiver teaching to prevent pressure ulcers. Review of the SN VNR dated 6/3/21 revealed the nurse documented MR # 6 had only one wound which was a Stage 1 Pressure Ulcer (PU) to the Mid-Perineum measuring 1 cm (centimeter) in length (L) x 1 cm width (W), and 1 cm depth (D). Review of the SN VNR dated 7/24/21 revealed the nurse documented the patient had wound # 1 Mid-Perineum PU Stage 1 measuring 4.2 L x 2.5 W x 0.2 D, wound # 2 Right lower buttock, unstageable PU measuring 0.9 L x 0.8 W x 0.1 D, and wound # 3 Left lower buttock, unstageable PU, measuring 3.0 L x 1 W x 0.2 D. In an interview conducted on 10/21/21 at 11:25 AM EI # 1, Executive Director, confirmed there was no documentation of patient or caregiver teaching of measures to prevent pressure injuries. 3. MR # 4 was admitted to the agency on 5/22/21 with diagnoses including, Unspecified Asthma, Uncomplicated and Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 5/22/21 to 7/20/21 revealed physician orders for "SN for instruction of administration of inhalation therapy and care for equipment...SN to instruct on new...medications...high risk medications...SN to instruct patient/caregiver on administration of insulin including proper storage, preparation of medication, rotation of injection sites, and sharps disposal." The ordered SN frequency was once a week for 1 week, twice a week for 1 week, then once a week for 8 weeks. Review of the Client Medication Report (CMR) revealed documentation of Humalog Insulin 15 Units three times a day subcutaneous and Tresiba Flex touch 40 Units daily subcutaneous. Review of the 12 SN Visit Note Report (VNR) reports dated from 5/22/21 to 7/27/21 revealed documentation the patient was prescribed insulin. There was no documentation the patient or caregiver provided a return demonstration of the subcutaneous administration of the Humalog Insulin and the Tresiba Flex touch. Review of the Physician Order dated 5/27/21 revealed documentation of "new med (medication) found in home" and Ipratropium 0.5 mg (milligram) - Albuterol 3 mg/3 ml (milliters) nebulization solution 3 ml dose 4 times daily as needed. Review of the SN VNR dated 5/27/21 revealed documentation of the Ipratropium 0.5 mg - Albuterol 3 mg/3 ml nebulization solution being added to the patient CMR. There was no documentation the SN educated the patient and/or caregiver on the Ipratropium - Albuterol medication or how to administer the medication via nebulizer. Review of the 9 SN VNR from 6/2/21 to 7/27/21 revealed documentation the patient was on Oxygen 2 Liters/minute, which was documented as both continuously and intermittently. There was no documentation the patient and/or caregiver was provided education on Oxygen Storage, protection from heat, and response to accidents and emergencies. An interview was conducted on 10/21/21 at 10:49 AM with EI # 1 who confirmed there was no documentation of the patient and/or caregiver education received education on Ipratropium - Albuterol medication or how to administer the medication via nebulizer, Oxygen Storage, protection from heat, and response to accidents and emergencies or provided a return demonstration of the subcutaneous administration of the Humalog Insulin and the Tresiba Flex touch. 1. HV # 6 was admitted to the agency 9/21/21 with diagnoses including Paraplegia and Essential Hypertension. Review of the physician's order dated 9/27/21 revealed the skilled nurse (SN) was to visit 1 time per week to perform wound care and instruct the wound care procedure to the patient / caregiver. Wound care to the left lateral foot was ordered as follows: clean with normal saline, pat dry, apply Medihoney, cover with foam dressing using clean technique. The order failed to include how often the dressing was to be changed. A HV observation was conducted 10/19/21 at 12:30 PM to observe Employee Identifier (EI) # 7, Licensed Practical Nurse, perform wound care. During the visit the surveyor asked how often the dressing was changed and the patient and nurse stated every day, performed by the paid caregiver. Review of the MR revealed no documentation the paid caregiver was instructed in the wound care procedure and no documentation the SN observed a return demonstration of wound care to confirm competency in providing the care. An interview conducted 10/20/21 at 4:15 PM with EI # 5, Clinical Manager, confirmed there was no documentation the caregiver was instructed in the wound care procedure and no return demonstration was documented. 2. MR # 7 was admitted to the agency 9/29/21 with diagnoses including Chronic Ulcer Left Foot and Type 2 Diabetes Mellitus. Review of the Home Health Certification and Plan of Care dated 9/29/21 revealed the SN was to visit 1 time the first week then 2 times per week. SN to perform and instruct patient/caregiver in the wound care procedure to wounds # 13 - right pretibial venous stasis ulcer, # 18 - left foot mid-dorsum pressure ulcer (PU) stage 2, # 19 left heel PU stage 2, # 20 - right great toe PU stage 1, and # 21 - right heel PU stage 2. Perform twice weekly: cleanse with Vashe (wound cleanser), pat dry, apply silver sulfadiazine cream to wound bed, cover with xeroform gauze, wrap with roll gauze and Coban (a compression wrap) using clean technique. Review of the SN admission visit note dated 9/29/21 revealed multiple "copious draining wounds" to the lower extremities and the SN provided wound care as ordered. There was no documentation the SN instructed the patient or caregiver in the wound care procedure and no documentation a return demonstration was observed to verify competency in the wound care procedure which was ordered twice weekly. The next SN visit was 7 days later on 10/6/21. An interview conducted 10/20/21 at 4:20 PM with EI # 1, Executive Director, confirmed there was no documentation the patient or caregiver was instructed in the wound care procedure and no return demonstration was documented.
G0716	Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on review of medical records (MR) and staff interviews, it was determined the agency failed to document correctly in the clinical record. This deficient practice did affect Home Visit (HV) # 5 and had the potential to affect all patients served by the agency. Findings include: 1. HV # 5 was admitted to the agency on1/4/2019 with diagnosis including Neuromuscular Dysfunction of Bladder, Unspecified and Encounter for Attention to Cystostomy. Review of the Home Health Certification and Plan of Care dated 8/21/21 to 10/19/21 revealed orders for skilled nurse (SN) to insert 20 Fr (French) 10 cc (cubic centimeter) balloon suprapubic catheter using aseptic technique. Change every 4 weeks beginning week of 9/5/21 and PRN (as needed)... Further review of the Home Health Certification and Plan of Care dated 8/21/21 to 10/19/21 revealed orders for SN to administer bladder irrigation/instillation with sterile water, 60 cc every week and PRN using aseptic technique. Review of the Visit Note Report by the SN dated 8/21/21 revealed patient complains of leaking catheter....SN removed old catheter, inserted new 20 Fr Catheter using sterile technique.... There was no documentation of what size balloon was used or how much fluid was used to inflate the balloon and no documentation of urine return. Review of the Visit Note Reports by the SN dated 8/26/21, 9/2/21, 10/4/21, 10/15/21 and 10/18/21 revealed, "Administration of bladder instillation/irrigation", instillation of 50 ml (milliliters) of sterile water...." There was no documentation of why 60 cc of sterile water was not used for irrigation as ordered. Review of the Visit Note Report by the SN dated 9/16/21 revealed a Suprapubic Foley Catheter size 16 Fr was inserted on 8/21/21 and not a 20 Fr Catheter as stated in the 8/21/21 Visit Note Report. Review of the Visit Note Report by the SN dated 9/29/21 revealed a Suprapubic Foley Catheter size 22 was inserted on 9/22/21. Further review of the medical record from 8/21/21 to 10/19/21 revealed no SN visit documented for 9/22/21. An interview conducted on 10/20/21 at 3:45 PM with EI (Employee Identifier) # 5 Clinical Manager confirmed the documentation was inaccurate and unclear.
G0798	Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on review of agency policy and procedure, observation and staff interviews, it was determined the agency failed to ensure the plan of care developed for the Home Health Aide (HHA) was individualized to meet the needs of the patient. This deficient practice affected 1 of 7 medical records (MR) reviewed receiving Home Health Aides (HHA) services and did affect HV # 5 and had the potential to affect all patients receiving HHA services. Findings include: Agency Policy: Plan of Care (POC) Revised Date: 1/1/21 Purpose: To assure an appropriate POC is developed and revised in a timely manner for each patient. To ensure that physician's orders are followed. Policy: Each patient has an individualized POC developed in consultation with the patient...to address specific services being provided. Procedure: 14. An aide POC will be developed by the Registered Nurse (RN) or other appropriate skilled professional...that is familiar with the patient if aide services have been ordered. 1. HV # 5 was admitted to the agency on 1/4/2019 with diagnosis including Neuromuscular Dysfunction of Bladder, Unspecified and Encounter for Attention to Cystostomy. Review of the Home Health Certification and Plan of Care dated 8/21/21 to 10/19/21 revealed the patient is "chair bound with weakness, contracture to right hand and foot drop to right foot." Review of the Aide Care Plan Report dated 8/21/21 included an (Activities of Daily Living) assignment of, "Stand-by assistance with ambulation every visit." A HV was conducted on 10/19/21 at 11:10 AM to observe EI (Employee Identifier) # 8 provide care for HV # 5. During the visit, the patient remained in a chair and the aide was observed providing a chair bath for the patient. An interview conducted on 10/20/21 at 3:45 PM with EI # 5, Clinical Director confirmed, the patient is unable to stand and ambulate and the aide POC was not updated to meet the needs of the patient.
G0800	Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on review of medical records (MR), observation and staff interviews, it was determined the agency failed to ensure the Home Health Aide (HHA) notified the nurse when he/she was not able to follow the Plan of Care (POC). This deficient practice affected 1 of 7 MRs reviewed receiving HHA services and did affect HV # 5 and had the potential to affect all patients receiving HHA services. Findings include: 1. HV # 5 was admitted to the agency on 1/4/2019 with diagnosis including Neuromuscular Dysfunction of Bladder, Unspecified and Encounter for Attention to Cystostomy. Review of the Aide Care Plan Report dated 8/21/21 included the following Activities of Daily Living (ADL) assignments: Stand-by assistance with ambulation: every visit Bathing (Chair): every visit Review of 17 Visit Note Reports by the Aide dated from 8/24/21 to 10/18/21 revealed documentation by the Aide, "Stand-by assistance with ambulation completed." A HV was conducted on 10/19/21 at 11:10 AM to observe Employee Identifier (EI) # 8, HHA perform care. During the visit the patient remained in his/her chair and the aide was observed providing a chair bath, but did not provide stand-by assistance with ambulation. Review of the Visit Note Report completed by EI # 8, HHA included the following documentation: Service: "Stand-by assistance with ambulation completed." An interview conducted on 10/20/21 at 3:45 PM with EI # 5 Clinical Manager confirmed, the patient is unable to stand and ambulate and the aide documented incorrectly on the Visit Note Reports.
G0966	Assure patient needs are continually assessed CFR(s): 484.105(c)(4) Assuring that patient needs are continually assessed, and This ELEMENT is not met as evidenced by: Based on agency policy, review of on-call message documentation, medical records (MR) and interviews it was determined the agency failed to ensure staff assessed the after hours needs of the patient and responded within 30 minutes of the call as directed in agency policy. This affected 3 un-sampled patients including Un-sampled Patient (UP) # 1, UP # 2 and UP # 3 and had the potential to affect all patients served by the agency. Findings include: Agency Policy: On-Call Process (To Include During and After Hours Care) Policy Number: 5.008 Revised Date: 03/01/19 Purpose: To establish guidelines to promote continuity of care. Procedure: 4. The respective answering service will contact the on-call clinician immediately after the patient related call is received. The total response time from patient/caregiver call to patient/caregiver contact by clinician will be no longer than 30 minutes... 5. Clinicians will document responses and outcomes of appropriate call on the On-Call Event Coordination note. 6. Clinicians will submit the On-Call Event Coordination Note and any supporting patient documentation by the next business day... Review of a random sampling of 5 on-call events revealed the following: 1. UP # 1 caregiver called the answering service on 9/25/21 at 10:28 AM with message "retaining water/extreme tightness both legs." UP # 1 called the answering service three more times, 10:57 AM, 11:21 AM and 11:58 AM. There was no documentation the on-call nurse contacted the patient / caregiver. A visit was conducted by the Licensed Practical Nurse (LPN) on 9/25/21 at 1:31 PM, 3 hours and 3 minutes later, which revealed Blood Pressure (BP) 94/78, Pulse 133 and weight 229.2 pounds. UP # 1 was transported the the Emergency Room (ER) via ambulance. UP # 1 caregiver called the answering service on 10/3/21 at 6:06 PM with message "wound vac (Vacuum Assisted Closure) message/blockage." There was no documentation the on-call nurse contacted the patient / caregiver. A visit was conducted the following day (10/4/21) at 9:46 AM, 15 hours and 40 minutes later. An interview conducted 10/20/21 at 12:18 PM with Employee Identifier (EI) # 5, Clinical Manager, confirmed there was no documentation the on-call nurse contacted the patient / caregiver as directed in agency policy. 2. UP # 2 contacted the answering service 9/19/21 at 12:03 AM with message "tightness/numbness/pressure in legs/ requested nurse assistance." There was no documentation the on-call nurse contacted UP # 2. A visit was conducted 9/19/21 at 12:23 PM, 12 hours and 20 minutes later, by the LPN which revealed a 17 pound weight gain. The physician was contacted and recommended the patient go to the ER. An interview conducted 10/20/21 at 3:55 PM with EI # 1, Executive Director, confirmed there was no documentation the on-call nurse contacted the patient as directed in agency policy. 3. UP # 3 contacted the answering service 9/24/21 at 6:11 PM with message "wound vac will not stay on/tape tore patient skin/needs to be covered/needs supplies for wound vac/urgent request for nurse visit 9/24/21." There was no documentation the on-call nurse contacted UP # 3. A visit was conducted at 9:35 PM, 3 hours and 24 minutes later. An interview conducted 10/20/21 at 3:55 PM with EI # 1, Executive Director, confirmed there was no documentation the on-call nurse contacted the patient as directed in agency policy.