Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 017024	(X3) Date Survey Completed 12/29/2021
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)
G0000	A complaint survey was conducted on 12/27/21 to 12/29/21 with condition level deficiencies at 484.50 Condition: Patient Rights and related standard level deficiencies.
G0406	Patient rights CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on review of agency policy and procedure, Medical Record (MR), and interviews with staff, it was determined the agency staff failed to follow facility policy and procedure when discharging for cause including notification of the patient and caregiver a discharge for cause was being considered by the agency, make and document efforts to resolve problems presented by the patient's behavior and/or situation and provide contact information for other agencies and/or services available to the patient and/or caregiver. This had to potential to negatively affect all patient's served by the agency. Findings include: Refer to G 432, G 462, G 464, G 466, and G 468 for findings.
G0432	Make complaints to the HHA CFR(s): 484.50(c)(3) Make complaints to the HHA regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the HHA; This ELEMENT is not met as evidenced by: Based on review of agency policy and procedure and interviews with staff, it was determined the agency failed to follow their policy for complaint investigation and documentation of complaints, their investigation and follow-up through resolution. This affected 1 of 1 Medical Record (MR) reviewed with Intravenous (IV) administration and wound care who was discharged for cause. This affected MR # 1 and had the potential to affect all patients who are admitted to this home health agency. Findings include: Agency Policy: Grievance Procedure, Patient Complaints Policy Number: 1.007 Revised date: 11/1/21 Purpose: To establish a process for patient, caregivers...to communicate areas of concern in regard to patient care and services as well as an internal process to investigate, address findings and follow-up with the individual who initiated the concern. Policy ...The agency will investigate complaints made by the patient, legal representative, caregiver, and/or family... Procedure: 1. Staff receiving complaints either in person, by phone, or through the mail shall document the patient complaint. Agencies will document the complaint with the information system: the Executive Director or Clinical Director will receive an automated workflow regarding the complaint for follow-up. 2. The Executive Director or Clinical Director interviews the patient, family, and involved staff or other individuals and takes appropriate actions to resolve the issue. ...5. After the investigation and analysis is completed, but no later than 30 days after the complaint/grievance filing, the Executive Director or Clinical Director will follow-up with the patient and/or complainant and document within the information system... 6. Agencies can access the complaint report within the information system. Any supporting documentation regarding the complaint should be kept in a confidential file. 1. The surveyor was provided the agency complaint log on 12/28/21 by Employee Identifier (EI) # 1, Executive Director. Review of the agency complaint log on 12/29/21 revealed no documentation of a complaint related to MR # 1, a patient admitted to the agency on 7/31/21, recertified for continued care from 9/29/21 to 11/27/21, who had been receiving Intravenous infusion and wound care services from the agency and was discharged for cause on 10/24/21. An interview was conducted with EI # 1 who was asked if the agency had received a complaint involving MR # 1. EI # 1 stated, "I think the mother/father called and there was an email to return his/her call. Then it escalated. I think she/he would call continuously... I think (EI # 6, Office Manager) talked to him/her since I was out of the office. EI # 1 was asked if there was documentation of the call. EI # 1 stated, "No, I never talked to her/him." An interview was conducted with EI # 6 who was asked if the agency had received a complaint involving MR # 1. EI # 6 stated, "Yes...about discharge from service. I told her/him she/he would need to speak to (EI # 1 Identified), she/he was in the (another agency location identified), she/he was talking about she/he couldn't understand why we called DHR (Department of Human Resources). She/He talked to me about (agency nurse identified), she thought (agency nurse identified) was a friend, she told me about the drinking and she/he could only take a sip or two and would be intoxicated. She/He said she was going to call state. She/He called several times, that day was after the DHR complaint and she/he was mad. She/He was on her/his way to meet DHR at the house." EI # 6 was asked what happened with the complaint after then. EI # 6 stated, "I told her/him I would reach out to EI # 1 and let him/her know what the complaint was....I called EI # 1 and let him/her know everything that had been said on the call. EI # 6 was asked if the complainant verbalized she/he wanted to speak with EI # 1 during the call. EI # 6 stated, "yes." Due to the call not being documented there is no documentation of the date of the complainant's call. .
G0462	Before discharge for cause HHA must: CFR(s): 484.50(d)(5) The HHA determines, under a policy set by the HHA for the purpose of addressing discharge for cause that meets the requirements of paragraphs (d)(5)(i) through (d)(5)(iii) of this section, that the patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. The HHA must do the following before it discharges a patient for cause: This ELEMENT is not met as evidenced by: Based on review of agency policy and procedure, Medical Record (MR), and interviews with staff, it was determined the agency staff failed to follow facility policy and procedure when discharging for cause. This affected 1 of 1 MR's review with Intravenous (IV) administration and wound care who was discharged for cause. This affected MR # 1 and had the potential to affect all patients who are admitted to this home health agency.Findings include:Agency Policy: Patient Discharge/TransferPolicy Number: 2.1.004Revised date: 11/1/21 Purpose: To ensure continuity of care when a patient is discharged... Policy: 1. Any of the following reasons may be criteria for patient discharge or transfer: …e. Agency determines a discharge for cause is appropriate because patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or ability of the agency to operate effectively is seriously impaired... Procedure: ...7. In the event a discharge for cause (i.e. disruptive, abusive, or uncooperative behavior interfering with delivery of care) is being considered, the agency will: a. Advise patient, legal representative...responsible for care after discharge of possible discharge. The clinical record will reflect identification of the problems encountered, assessment of the situation...a plan to resolve issues and results of the plan implementation. In situations when staff are threatened or endangered, the agency can take immediate actions without taking measures to resolve the issue... 1. MR # 1 was admitted to the agency on 7/31/21, recertified for continued care from 9/29/21 to 11/27/21, with diagnoses including Pressure Ulcer of Sacral Region, Stage 4 and Encounter for Orthopedic Aftercare Following Surgical Amputation. Review of the MR revealed documentation the patient was receiving daily nursing visits from 10/17/21 through discharge date of 10/24/21 for daily IV antibiotic administration and wound care twice weekly. Further review of the MR revealed no documentation the patient and caregiver were notified of a possible upcoming discharge or a discharge for cause was being considered by the agency. Review of the Skilled Nurse (SN) Visit Note Report (VNR) dated 10/24/21 revealed documentation of "...upon arrival to home, patient immediately requests for RN (Registered Nurse) to go to the store and purchase cigarettes for her/him, with refusal patient began verbally abusing this nurse. Patient informed due to multiple episodes of cursing, verbal abuse and outbursts with nurse, medical and medication non-compliance and no available caregiver that patient would be discharged this date. Patient verbalized understanding. Patient refused vital sign assessment and further intervention education and requested nurse to leave residence and went to her/his room. Attempted to make contact with patients (parent identified) that lives out of town with no success..." Further review of the SN VNR dated 10/24/21 revealed documentation of "...Indicate other community service involved or needed: DHR...Is there an unstable caregiver or potential for an unstable caregiving situation? No...Indicate type of environmental safety barriers present in the home:...None..." Review of the Care Management sections revealed the patient did not require assistance with ADL's, medical procedures/treatments, assistance for supervision and safety and the patient did require assistance for medication administration which was documented as "...non-agency caregiver(s) currently provide assistance." Further review of the SN VNR dated 10/24/21 revealed no documentation of how the patient was verbally abusing the nurse and no documentation the agency staff felt threatened or endangered based on the nurse offering further assessment and intervention and the patient asking the nurse to leave while the patient went to her/his room. The patient's primary nurse was unavailable for interview due to sickness. An interview was conducted on Employee Identifier (EI) # 2, RN, on 12/29/21 at 9:10 AM, who performed a nursing visit 3 days prior to discharge of the patient. EI # 2 verbalized the agency was going to see the patient daily because the patient's primary nurse said there was some worry about the patient's cognitive ability to administer the IV antibiotics. EI # 2 stated, "She/He did try to get me to leave and go get her/him cigarettes. I do remember that. I told her/him no..." EI # 2 was asked what the patient's response was to the nurse refusing to obtain cigarettes for the patient. EI # 2 stated, "She said okay that was fine. I will get a friend to get them." EI # 2 was asked if the patient displayed any outburst, agitation or cursing during the visit. EI # 3 stated, "nothing of that nature." EI # 2 was asked is she/he was aware of any safety issues/concerns related to the patient and/or caregiver situation. EI # 2 stated, "She/He was safe with ADL's (Activities of Daily Living), there wasn't any acute mental issues. I think she/he had some occasional forgetfulness and that's what we were coming for, as reminders. There wasn't any significant altered mental status." An interview was conducted on 12/29/21 at 9:34 AM with EI # 3, RN, who performed a nursing visit 7 days prior to discharge of the patient. EI # 3 who verbalized PI # 1 "...acted okay. She/he was kind of forgetful, like when the medication was infusing, she/he would try to get up. I would say, 'hey, don't forget you have medicine infusing' and she/he would say oh ya I forgot and sit down but then she/he would do it again later..." EI # 3 was asked if the patient displayed any outburst, agitation or cursing during the visit. EI # 3 stated, "no, not with me." EI # 3 verbalized "I remember in her/his visit notes there was someone we could talk to, a cousin or aunt, someone since the mother/father lives so far away." An interview was conducted on 12/29/21 at 10:04 AM with EI # 4, Licensed Practical Nurse, who performed 2 visits within 2 weeks prior to the patient's discharge. EI # 4 verbalized the patient was a "...little unsteady" and verbalized at one of EI # 4's visit the patient fell. EI # 4 verbalized the patient was trying to feed the dogs and fell. EI # 4 verbalized the caregiver was notified and told EI # 4 she/he was on the way. EI # 4 was asked the patient displayed any outburst, agitation or cursing during the visit. EI # 4 stated, "no, just one time the (caregiver) was there and told her/him I was there and (MR # 1 identified) said just tell her/him I'm sick. I said (MR # 1 identified), I can hear you. She/He did a little cussing then but nothing out of the normal. She/He just didn't want to be seen that day. That's all." EI # 4 was asked if the cursing was directed at the staff member. EI # 4 state, "no, not at all." EI # 4 was asked if she/he recalled noticing any noncompliance from the patient. EI # 4 state, "no...she/he was always complaint when I was there." An interview was conducted on 12/29/21 at 11:05 AM with EI # 5, Occupational Therapist, who had been seeing the patient weekly until 10/20/21 when the patient was discharged for goals met. EI # 5 stated, "...she/he was very nice to me but a little wild..." EI # 5 explained the patient "there was always a giant bottle of alcohol there. She/He partied. She/He smoked but would say don't tell my (mother/father). You couldn't really tell if she/he was doing the things or not because she/he would say one time she/he did all of that and the next time would say she/he didn't. EI # 5 was asked about the bottle of alcohol and if the agency would discharge for the alcohol. EI # verbalized "it was one bottle, it was huge. As far as I could tell it was the same bottle...I wouldn't think so unless it was seriously interfering with the Plan of Care." EI # 5 was asked if the patient displayed any outburst, agitation or cursing during the visit. EI # 5 stated, "not while I was there. I mean she/he cursed when she/he talked but nothing like an outburst while I was there." EI # 5 was asked if the patient cussing was ever direct at the staff member or if the patient would become verbally abusive. EI # 5 stated, "no, with me she/he was always polite, she/he just cusses when she/he talks. It's just her/his language." EI # 5 was asked if the patient was noncompliant in anyway. EI # 5 stated, "I felt she/he wasn't doing exercises. She/He would say she/he was doing them and then also at time say...I'm not doing them. I think medication was a problem, she/he had a big set up but still think they were an issue." EI # 5 was asked about the patient's "set up". EI # 5 state, "they had a dining room table with medications in baggies with the times on them. We would come in the afternoon and she/he would just be woke up and hadn’t took her/his medications. She/He would go in there and take some. There was some confusion if she/he was taking the morning or afternoon, since she just woke up but I don't remember if I just was thinking that (talking about the agency confusion on which medication the patient was taking) or if we talked about it...I don't know that I would have gone and looked at what was taken or not taken..."EI # 5 was asked his/her if the patient was able to live alone. EI # 5 stated, "I don't know. I felt she was borderline, she was having...services before and felt it would be helpful for them to come back. I don't think she/he needed anyone there full time but someone checking on her/him." EI # 5 was asked about the caregiver's involvement with the patient. EI # 5 stated, "sometimes they were fighting, and she would be (MR # 1 identified) is going to do what (MR # 1 identified) is going to do but most of the time she was involved." In an interview on 12/29/21 at 1:42 PM with EI # 1, Executive Director and EI # 7, Performance Improvement Coordinator, verified there was no documentation of what verbal abuse occurred at the visit. EI # 1 and EI # 7 were asked was the patient's documented behavior to the extent that the delivery of care to the patient or the ability of the agency to operate effectively seriously impaired? EI # 1 stated, "I think it was just the nurse herself." EI # 7 stated, "if a patient started a verbal abuse towards me, I would not stay in the home but in addition to that I believe the nurse felt the patient needed more of a caregiver..." The surveyor asked if the agency administration had been contacted prior to the discharge about the patient's discharge. EI # 1 verbalized the nurse had not called prior to discharging the patient and EI # 1 was notified after the discharge had taken place. EI # 1 was asked per the agency policy/procedure if the agency administration were supposed to be notified prior to a discharge for cause. EI # 1 stated, "yes".
G0464	Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health 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) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: Based on review of agency policy and procedure, Medical Record (MR), and interviews with staff, it was determined the agency staff failed to notify the patient and caregiver a discharge for cause was being considered by the agency. This affected 1 of 1 MR's review with Intravenous (IV) administration and wound care who was discharged for cause. This affected MR # 1 and had the potential to affect all patients who are admitted to this home health agency. Findings include:Agency Policy: Patient Discharge/TransferPolicy Number: 2.1.004Revised date: 11/1/21 Purpose: To ensure continuity of care when a patient is discharged... Policy: 1. Any of the following reasons may be criteria for patient discharge or transfer: …e. Agency determines a discharge for cause is appropriate because patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or ability of the agency to operate effectively is seriously impaired... Procedure: ...7. In the event a discharge for cause (i.e. disruptive, abusive, or uncooperative behavior interfering with delivery of care) is being considered, the agency will: a. Advise patient, legal representative...responsible for care after discharge of possible discharge... In situations when staff are threatened or endangered, the agency can take immediate actions without taking measures to resolve the issue... 1. MR # 1 was admitted to the agency on 7/31/21, recertified for continued care from 9/29/21 to 11/27/21, with diagnoses including Pressure Ulcer of Sacral Region, Stage 4 and Encounter for Orthopedic Aftercare Following Surgical Amputation. Review of the Physician's order dated 10/17/21 revealed documentation the patient was to receive daily nursing visits daily IV antibiotic administration and wound care twice weekly. Review of the Skilled Nurse (SN) Visit Note Report (VNR) dated 10/24/21 revealed documentation of "...upon arrival to home, patient immediately requests for RN (Registered Nurse) to go to the store and purchase cigarettes for her/him, with refusal patient began verbally abusing this nurse. Patient informed due to multiple episodes of cursing, verbal abuse and outbursts with nurse, medical and medication non-compliance and no available caregiver that patient would be discharged this date. Patient verbalized understanding. Patient refused vital sign assessment and further intervention education and requested nurse to leave residence and went to her/his room. Attempted to make contact with patients (parent identified) that lives out of town with no success..." Further review of the SN VNR dated 10/24/21 revealed no documentation of how the patient was verbally abusing the nurse and no documentation the agency staff felt threatened or endangered based on the nurse offering further assessment and intervention and the patient asking the nurse to leave while the patient went to her/his room. Further review of the MR revealed no documentation the patient and caregiver were notified of a possible upcoming discharge or a discharge for cause was being considered by the agency prior to the patient's actual discharge. There was no documentation of another attempt to contact the patient's parent who is the caregiver of the patient and responsible for care following the discharge. In an interview on 12/29/21 at 1:42 PM with EI # 1, Executive Director and EI # 7, Performance Improvement Coordinator, verified there was no documentation of what verbal abuse occurred at the visit and no additional attempts to contact the patient caregiver were documented.
G0466	Make efforts to resolve the problem(s) CFR(s): 484.50(d)(5)(ii) (ii) Make efforts to resolve the problem(s) presented by the patient's behavior, the behavior of other persons in the patient's home, or situation; This ELEMENT is not met as evidenced by: Based on review of agency policy and procedure, Medical Record (MR), and interviews with staff, it was determined the agency staff failed to make efforts to resolve problems presented by the patient's behavior and/or situation. This affected 1 of 1 MR's review with Intravenous (IV) administration and wound care who was discharged for cause. This affected MR # 1 and had the potential to affect all patients who are admitted to this home health agency. Findings include:Agency Policy: Patient Discharge/TransferPolicy Number: 2.1.004Revised date: 11/1/21 Purpose: To ensure continuity of care when a patient is discharged... Policy: 1. Any of the following reasons may be criteria for patient discharge or transfer: …e. Agency determines a discharge for cause is appropriate because patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or ability of the agency to operate effectively is seriously impaired... Procedure: ...7. In the event a discharge for cause (i.e. disruptive, abusive, or uncooperative behavior interfering with delivery of care) is being considered, the agency will: b. Attempt to resolve problems(s) presented by patient's behavior or other individual's behavior in home or situation. ...d. Ensure the issue of concern and efforts to resolve problems is documented in the MR. The clinical record will reflect identification of the problems encountered, assessment of the situation...a plan to resolve issues and results of the plan implementation. In situations when staff are threatened or endangered, the agency can take immediate actions without taking measures to resolve the issue... 1. MR # 1 was admitted to the agency on 7/31/21, recertified for continued care from 9/29/21 to 11/27/21, with diagnoses including Pressure Ulcer of Sacral Region, Stage 4 and Encounter for Orthopedic Aftercare Following Surgical Amputation. Review of the Skilled Nurse (SN) Visit Note Report (VNR) dated 10/11/21 revealed the patient had fallen on 10/9/21, 10/11/21 and at the visit with the SN. The SN also documented the patient had just returned from a physician's appointment where the patient was found to be "severely impacted with stool" per caregiver. The SN also documented the patient's wound were found to have MRSA (Methicillin-Resistant Staphylococcus Aureus) and the patient had complained of nausea and vomiting. There was no documentation of how long the patient had been having the nausea and vomiting, how many occurrences of the vomiting the patient had, and the hydration status of the patient. Review of the SN VNR dated 10/12/21 revealed documentation of an Registered Nurse (RN) follow up due to patient fall and "...mother/father has a plan to have family keep medication oit (out) of home ane (and) come to administer multiple times daily as patient is not taking medications as ordered. She/He is becoming increasingly forgetful. Patient refuses to move in with mother/father althoigh (although) mother/father feels she/he is unsafe to live alone..." There was no documentation of how the patient was not taking the medication as ordered and the reason the parent felt the patient was unsafe to live alone. Review of the SN VNR dated 10/13/21 revealed documentation of "patient more alert and coherent today...called and spoke with...(IV infusion company identified)... was waiting to make sure patient would have help. Spoke with (agency Patient Care Manager identified)...stated we could cover assistance..." Review of the OT (Occupational Therapy) VNR dated 10/13/21 revealed documentation of "...required assistance to access pills from sandwich bag to take. Complains of some issues with swallowing pills and food the last week, requests SLP (Speech Therapist) evaluation." There was no documentation the caregiver was notified of the patient requiring assistance to access pills from sandwich bag and interventions/efforts by the agency to help resolve the required assistance to access pill in the sandwich bag(s). The was no documentation of the agency staff's interventions/efforts to resolve the issues found during the visit. Review of the physician order dated 10/13/21 revealed an order for a Speech Therapy (ST) evaluation due to "difficulty swallowing meds (medications) and food over the last week as well as increasing cognitive issues/confusion..." Review of the ST evaluation dated 10/20/21 revealed documentation the patient was alert and oriented with no abnormal neurologic, cognitive and behavioral problems identified. Further review of the ST evaluation dated 10/20/21 revealed documentation of "...complains of pills hanging in her/his throat when she/he swallows. Patient takes 8 to 10 pills at once. Educated patients on taking 1-2 at a time... no overt signs or symptoms of aspiration observed on soft solids and thin liquids...report no difficult (difficulty) with food...patients may benefit from GI (Gastrointestinal) consistency to rule out esophageal stricture..." Review of the SN VNR dated 10/22/21 revealed documentation of "patient reports fall...patient states (Neurologist Identified) changed her/his dosage of antiseizure medication, new medication not in home this date. This RN feels patient still isn't taking medications as ordered. She/He still has no one managing her/his medications as all medications are still in the home..." The nurse further documented the patient reported smoking and the caregiver verbalized the patient would be disowned if anymore cigarettes were bought, the patient attempts to call people to obtain cigarettes during the visit and "...patient asked this RN to go to the store to purchase...cigarettes. When RN refused...states she/he will ride...riding lawnmower to the store if that's what she/he has to do. Notified (MD office staff identified) of above and that patient would be discharged if when RN arrives tomorrow patient has cigarettes and tells RN she/he rode her/his lawn mower to town for them. Patient lives approx (approximately) 3-4 miles from closest store..." Further review of the SN VNR dated 10/22/21 revealed no documentation of when the antiseizure medication dosage was increased, attempts to find out what the medication dosage was increased too, an assessment of the medications to determine what medications the patient was or was not taking incorrectly, assessment of the reason the patient was taking the medication correctly, notification of the caregiver about nurses concern of the patient's medications being in the home and feeling the patient was not taking medications as ordered, the patient's fall and patient statement regarding riding the lawnmower to store for cigarettes with possibility of discharge if action occurred. The was no documentation of the agency staff's interventions/efforts to resolve the issues found during the visit. Review of the SN VNR dated 10/23/21 revealed documentation of "...patient requesting RN go and get her/him cigarettes at beginning and end of visit. Patient cursed at RN when...told...wound not. RN began infusion, assessed patient, returned to car for duration of infusion due to patient cursing at RN and returned to home to flush and disconnect. Patient states a friemd (friend) is going to pickup her/his new medications today..." There was no documentation the SN attempted to address the issue of cursing at the SN and asking agency staff to acquire cigarettes for them with the patient and/or caregiver to resolve the issue. Review of the SN VNR dated 10/24/21 revealed documentation of "...upon arrival to home, patient immediately requests for RN to go to the store and purchase cigarettes for her/him, with refusal patient began verbally abusing this nurse. Patient informed due to multiple episodes of cursing, verbal abuse and outbursts with nurse, medical and medication non-compliance and no available caregiver that patient would be discharged this date. Patient verbalized understanding. Patient refused vital sign assessment and further intervention education and requested nurse to leave residence and went to her/his room. Attempted to make contact with patients (parent identified) that lives out of town with no success..." Further review of the SN VNR dated 10/24/21 revealed documentation of "...Indicate other community service involved or needed: DHR...Is there an unstable caregiver or potential for an unstable caregiving situation? No...Indicate type of environmental safety barriers present in the home:...None..." Review of the Care Management sections revealed the patient did not require assistance with ADL's, medical procedures/treatments, assistance for supervision and safety and the patient did require assistance for medication administration which was documented as "...non-agency caregiver(s) currently provide assistance." Further review of the SN VNR dated 10/24/21 revealed no documentation of how the patient was verbally abusing the nurse and no documentation the agency staff felt threatened or endangered based on the nurse offering further assessment and intervention and the patient asking the nurse to leave while the patient went to her/his room. In an interview on 12/29/21 at 1:42 PM with Employee Identifier (EI) # 1, Executive Director and EI # 7, Performance Improvement Coordinator. The surveyor asked about the 10/11/21 SN visit and if there was an assessment performed for the amount of vomiting and/or hydration status of the patient. EI # 1 verbalized there was no documentation of the assessment because the patient had just returned from the GI physician's office. The surveyor asked about the 10/22/21 visit and if the SN had documented the reason she felt the patient was not taking the medication correctly. EI # 1 verbalized it was based on the medication being in the home and what was documented on 10/12/21 SN visit. The surveyor asked if the patient and/or caregiver had been notified of the possible discharge action documented on 10/22/21 if the patient rode the lawn mower to the store to obtain cigarettes. EI # 1 verbalized there was no documentation and according the the facility policy the patient and/or caregiver should have been notified. The surveyor asked about the 10/24/21 SN visit EI # 1 verified there was no documentation of what verbal abuse occurred at the visit. The surveyor asked asked was the patient's documented behavior to the extent that the delivery of care to the patient or the ability of the agency to operate effectively seriously impaired? EI # 1 stated, "I think it was just the nurse herself." EI # 7 stated, "if a patient started a verbal abuse towards me, I would not stay in the home but in addition to that I believe the nurse felt the patient needed more of a caregiver..." The surveyor asked if the agency administration had been contacted prior to the discharge about the patient's discharge. EI # 1 verbalized the nurse had not called prior to discharging the patient and EI # 1 was notified after the discharge had taken place. EI # 1 was asked per the agency policy/procedure if the agency administration were suppose to be notified prior to a discharge for cause. EI # 1 stated, "yes". EI # 1 and EI # 7 verified there was no further documentation of the agency's efforts to resolve the issues found then what is documented above.
G0468	Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This ELEMENT is not met as evidenced by: Based on review of agency policy and procedure, Medical Record (MR), and interviews with staff, it was determined the agency staff failed to provide contact information for other agencies and/or services available to the patient and/or caregiver. This affected 1 of 1 MR's review with Intravenous (IV) administration and wound care who was discharged for cause. This affected MR # 1 and had the potential to affect all patients who are admitted to this home health agency. Findings include:Agency Policy: Patient Discharge/TransferPolicy Number: 2.1.004Revised date: 11/1/21 Purpose: To ensure continuity of care when a patient is discharged... Policy: 1. Any of the following reasons may be criteria for patient discharge or transfer: …e. Agency determines a discharge for cause is appropriate because patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or ability of the agency to operate effectively is seriously impaired... Procedure: ...7. In the event a discharge for cause (i.e. disruptive, abusive, or uncooperative behavior interfering with delivery of care) is being considered, the agency will: ...c. Provide patient and legal representative (if any) contact information for other agencies. ...In situations when staff are threatened or endangered, the agency can take immediate actions without taking measures to resolve the issue... 1. MR # 1 was admitted to the agency on 7/31/21, recertified for continued care from 9/29/21 to 11/27/21, with diagnoses including Pressure Ulcer of Sacral Region, Stage 4 and Encounter for Orthopedic Aftercare Following Surgical Amputation. Review of the MR revealed documentation the patient was receiving daily nursing visits from 10/17/21 through discharge date of 10/24/21 for daily IV antibiotic administration and wound care twice weekly. Review of the Skilled Nurse (SN) Visit Note Report (VNR) dated 10/24/21 revealed documentation of "...upon arrival to home, patient immediately requests for RN (Registered Nurse) to go to the store and purchase cigarettes for her/him, with refusal patient began verbally abusing this nurse. Patient informed due to multiple episodes of cursing, verbal abuse and outbursts with nurse, medical and medication non-compliance and no available caregiver that patient would be discharged this date. Patient verbalized understanding. Patient refused vital sign assessment and further intervention education and requested nurse to leave residence and went to her/his room. Attempted to make contact with patients (parent identified) that lives out of town with no success..." Review of the SN VNR dated 10/24/21 and the MR revealed no documentation the patient and caregiver were provided contact information for other agencies and/or services available. In an interview on 12/29/21 at 1:42 PM with EI # 1, Executive Director and EI # 7, Performance Improvement Coordinator, verified there was no documentation the patient and/or caregiver were provided contact information for other agencies and/or services available.
G0578	Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on review of agency policy and procedure, Medical Record (MR), and interviews with staff, it was determined the agency staff failed to follow facility policy and procedure for the administration of Intravenous (IV) medications. This affected 2 of 2 MR's review with Intravenous (IV) administration. This affected MR # 1 and MR # 5 and had the potential to affect all patients who received IV administration by the agency.Findings include:Agency Policy: Administration of Medications and Fluids Through a Peripheral or Central Venous Access DevicePolicy Number:10.012Revised date: 5/1/18 Purpose: To administer medication or solutions safely through a peripheral IV or a central venous access device. ...Mid-Line catheters should be treated as peripheral IV catheters. PICC (Peripherally Inserted Central Catheter) should be treated as central venous access devices... Procedure: ...4. Document the following in the electronic health record...: a. Name of drug b. Dose ...d. Route of administration e. Duration of infusion f. Time administered and time disconnected 1. MR # 1 was admitted to the agency on 7/31/21, recertified for continued care from 9/29/21 to 11/27/21, with diagnoses including Pressure Ulcer of Sacral Region, Stage 4 and Encounter for Orthopedic Aftercare Following Surgical Amputation. Review of the Physician's order dated 10/17/21 revealed an order for Skilled Nurse (SN) to administer "Tygacil 50 mg (milligrams)/100 ml (milliliters) daily over 60 minutes vis (via) elastomeric kit..." Review of the SN Visit Note Report(s) (VNR) dated 10/17/21, 10/18/21 and 10/19/21 revealed documentation the SN administered an IV infusion via a peripheral line. There was no documentation of the name of the drug administered, dose of the drug administered, duration of the infusion and time the infusion was administered and disconnected. Review of the SN VNR dated 10/20/21, 10/21/21, 10/22/21 and 10/23/21 revealed documentation the SN administered an IV infusion via a mid- line. There was no documentation of the name of the drug administered, dose of the drug administered, duration of the infusion and time the infusion was administered and disconnected. In an interview conducted on 12/29/21 at 1:42 PM, Employee Identifier (EI) # 1, Executive Director, confirmed there was no documentation of the name of the drug administered, dose of the drug administered, duration of the infusion and time the infusion was administered and disconnected on the above dates. 2. MR # 5 was admitted to the agency on 11/24/21 with diagnoses including Sepsis, Unspecified Organism and Severe Sepsis with Septic Shock. Review of the Home Health Certification and Plan of Care dated 11/24/21 to 1/22/22 revealed an order for the SN to "...instruct patient/caregiver on administering the following medication Ancef 1 gram in 50 ml of Normal Saline every 8 hours x (times) 3 weeks beginning 11/24/21 via esometric ball..." Review of the SN Admission Note dated 11/24/21 revealed documentation of "SN instructed ...on how to administer IV antibiotics and he/she provides correct return demonstration as follows: ...connects antibiotics to port, unclamps to allow to flow. At end of procedure he/she correctly flushes..." There was no documentation name of the drug administered, dose of the drug administered, duration of the infusion and time the infusion was administered. In an interview conducted on 12/29/21 at 1:26 PM, EI # 1 confirmed there was no documentation of the name of the drug administered, dose of the drug administered, duration of the infusion and time the infusion was administered and disconnected on 11/24/21.