Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 017025 (X3) Date Survey Completed 06/28/2018
Name of Provider or Supplier Saad Enterprises, Inc. Street Address, City, State 1515 University Blvd, South, Mobile, 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 a validation survey conducted on 6/26/18 to 6/28/18, the agency was in substantial compliance with the Emergency Preparedness regulations
G0000 A recertification survey was conducted on 6/28/18 with standard deficiencies cited.
G0516 Skilled professional performs assessment
CFR(s): 484.55(a)(2)

When rehabilitation therapy service (speech language pathology, physical therapy, or occupational therapy) is the only service ordered by the physician who is responsible for the home health plan of care, and if the need for that service establishes program eligibility, the initial assessment visit may be made by the appropriate rehabilitation skilled professional.


This ELEMENT is not met as evidenced by:
Based on review of medical records (MR), agency policy and interviews with the staff it was determined the agency failed to ensure all admissions were completed within 48 hours of the referral date and/or documentation as to why the admission did not occur within the 48 hours of the referral date.



This affected 1 of 17 MR's reviewed and did affect MR # 9 and had the potential to negatively affect all patients served by the agency.



Findings include:



Policy: Oasis Based Admission and Resumption of Care Assessments

Last Review and Revision Date: 5/18



"Section 2: Policy



2.3 A Start of Care/Resumption of Care Form Utilizing OASIS, will be complete by an RN/PT within 48 hours of referral..."



*****



1. MR # 9 was admitted to the agency on 5/21/18 with a referral date of 5/16/18 and admitting diagnoses was Parkinson's Disease and Chronic Atrial Fibrillation.



Review of the Transitional Care Worksheet revealed the referral date was 5/16/18 and the admission date was 5/21/18.



Review of the Home Health Certification (HHC) and Plan of Care (POC) revealed an admission date of 5/21/18.



Review of the PT (Physical Therapy) Oasis Admission dated 5/21/18 revealed no documentation as to why the admission was completed 5 days after the referral date and not 48 hours per agency policy.



An interview was conducted on 6/28/18 at 10:35 AM with Employee Identifier # 1, Director of Nursing, who confirmed the above mentioned findings.





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, medical records (MR), observations and interviews, it was determined the agency failed to ensure the Client Medication Report (CMR) was accurate and reflected all current medications. This affected 6 of 17 records reviewed, including Home Visit(s) (HV) # 5, HV # 4, HV # 1, HV # 3, HV # 7, HV # 6 and had the potential to negatively affect all patients admitted to this agency.



Findings include:



Policy: Medication Profile Process

Date Reviewed: 4/2018



"Section 2: Policy



2.1 A Plan of Care with Medication Profile will be completed on every patient upon admission to the agency and verified with physician for accuracy. Skilled Nurse and Therapy will reconcile medications every visit and as needed for medication changes.



Section 5: Documentation



5.1 Documentation on the Plan of Care and Medication Profile must be clear, concise and accurate."



*****



1. HV # 5 was admitted to the agency on 5/25/18 with admitting diagnoses including Cervicalgia, and Type 2 Diabetes with Diabetic Neuropathy.



A HV was conducted on 6/27/18 at 8:45 AM to observe care provided by Employee Identifier (EI) # 6, Occupational Therapist (OT). EI # 11, RN (Registered Nurse) was also present on the HV.



During the HV, the medications in the home were compared to the CMR provided to the surveyor. The following discrepancy was observed:



Prorenal Oral 8 mg, one tablet daily, was listed on the CMR. HV # 5 stated that was incorrect, he/she took two tablets daily.



During an interview on 6/28/18 at 10:45 AM with EI # 1, Director of Nursing, the above findings were confirmed.



2. HV # 4 was admitted to the agency on 8/11/17 and recertified 6/7/18 to 8/5/18. Admitting diagnoses included Encounter for Fitting and Adjustment of Urinary Device, and Other Neuromuscular Dysfunction of Bladder.



A HV was conducted on 6/27/18 at 9:40 AM to observe care provided by EI # 5, Aide. EI # 11 was also present on the HV.



During the HV, the medications in the home were compared to the CMR dated 6/7/18 to 8/5/18 and provided to the surveyor. The following discrepancies were observed:



a). Clonazepam 0.5 mg, 1 tablet by mouth twice daily as needed for anxiety, was in the home and not on the CMR. The date filled was 5/3/18.



b). Clearlax 3350, as needed for constipation, was in the home and not on the CMR. The patient's caregiver stated that HV # 4 had "...used that for a long time."



c). Antifungal Powder, as needed to skin under the breasts, was in the home and not on the CMR. The date filled was 4/18/18.



During an interview conducted on 6/28/18 at 11:30 AM with EI # 9, RN, Supervisor, the above findings were confirmed.



3. HV # 1 was admitted to the agency on 1/31/18 and recertified for continued care on 5/31/18 to 7/29/18 with diagnoses including Hemiplegia Following Cerebral Infarction Affecting Left Nondominant Side, Essential Hypertension, Type 2 Diabetes and Long Term Use of Insulin.



A home visit was conducted on 6/26/18 at 1:20 PM to observe the Medical Social Worker, EI # 12. The surveyor compared medications found in the home with the CMR provided to the surveyor on 6/26/18.



Found in the home was Vancyclovir 1 gram orally daily, filled on 5/21/18. The Vancyclovir was not documented on the current CMR.



The patient reported Levimir U-100 dosage 55 U (units) every (Q) morning (AM) and 40 U Q PM (evening) in use greater than 1 month. The CMP documented Levemir U 100 20 units Q AM and 14 U Q PM.



During an interview conducted on 6/28/18 at 10:56 AM, EI # 1 confirmed the CMR was not accurate for the patients current medications.



4. HV # 3 was admitted to the agency on 8/22/16 and recertified for continued care on 6/13/18 to 8/11/18 with diagnoses including Pressure Ulcer of Sacral Region, Stage 4.



A home visit was conducted on 6/27/18 at 1:15 PM to observe the Licensed Practical Nurse, EI # 4, perform wound care. The surveyor compared medications found in the home with the CMR provided to the surveyor on 6/27/18.



Found in the home was Methadone 10 mg 3 tablets two times a day (BID), filled on 6/14/18. Methadone 10 mg 2 tablets BID was documented on the current CMR.



Documented on the CMR was Sodium Bicarbonate 650 mg oral 1 tablet BID and Vitamin B 12 oral 1,000 microgram 1 tablet daily. No Sodium Bicarbonate and Vitamin B 12 was found in the home and the caregiver confirmed the medications were not being taken.



In an interview conducted on 6/28/18 at 10:50 AM, EI # 9, Registered Nurse, Clinical Manager verified staff failed to maintain a current/updated CMR for HV # 3.



5. HV # 7 was admitted to the agency on 1/9/18 with a recertification date of 5/9/18 to 7/7/18 and admitting diagnoses of Parkinson's Disease and Dysphagia Unspecified.



A HV was conducted on 6/27/18 at 10:30 AM with EI # 8, Speech Therapist, to observe care provided.



During the HV the patient's medications were reviewed with the caregiver using the patient's medication bottles and the CMR provided to the surveyor by the agency.



The following medications were in the home and not listed on the CMR:



Celebrex 200 mg by mouth every 12 hours as needed bottle dated 4/21/11 when the prescription began.



Oxybutynin 5 mg/ml (milliters) 1 teaspoon twice a day bottle dated 6/19/18 the day perscription began.



The following medications were listed on the CMR and the patient was no longer taking:



Fesoterodine 8 mg 1 tablet daily discontinued 6/19/18

Nutren 2.0 feeding tube 0.08 gram - 2 kcal (kilocalorie's)/ml 3-4 cans daily discontinued 5/18.

Lisinopril 20 mg daily (bottle dosage was 10 mg) discontinued 5/18.



The following medication was listed on the CMR incorrectly according the the bottle directions:



Primidone 50 mg 1 tablet 2 times a day was on the CMR.

Bottle directions were written as Primidone 50 mg 1 - 3 tablets daily date started was unknown.



An interview was conducted on 6/27/18 at 1:30 PM with EI # 1 who confirmed the above mentioned findings.



6. HV # 6 was admitted to the agency on 6/7/18 with admitting diagnoses of Aftercare Following Joint Replacement Surgery and Essential Primary Hypertension.



A HV was conducted on 6/27/18 at 11:45 AM with EI # 7, Physical Therapist, to observe care provided.



During the HV the patient's medications were reviewed with the patient using the patient's medication bottles and the CMR provided to the surveyor by the agency.



The following medication was listed on the CMR and patient stated he/she was no longer taking the medications. The patient stated he/she stopped the medication 1 1/2 to 2 weeks ago.



Senokot 8.6 mg 1 tablet daily.



An interview was conducted on 6/28/18 at 10:55 AM with EI # 1 who confirmed the above mentioned findings.
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 may choose to include.


This ELEMENT is not met as evidenced by:
Based on review of medical records (MR), and interview, it was determined the agency failed to ensure the staff obtained and documented physician's orders for oxygen in 1 of 3 records reviewed with oxygen. This affected MR # 7 and had the potential to affect all patients admitted to the agency.



Findings include:



1. MR # 7 was admitted to the agency on 5/22/18 with diagnoses including Unspecified Diastolic Heart Failure and Chronic Obstructive Pulmonary Disease.



Review of the 5/22/18 Registered Nurse Admission Visit Note Report documentation revealed oxygen was in use. There was no documentation of the flow rate, frequency and administration device.



Review of the 5/22/18 to 7/20/18 Home Health Certification (HHC) and Plan of Care (POC) included durable medical equipment and medications, but failed to contain oxygen.



Record review revealed Nurse documentation on the 6/7/18 Visit Note Report, the patient uses oxygen as needed for dyspnea. The nurse documented on 6/14/18 that oxygen 1-2 liters via nasal cannula was in use. On 6/19/18, the nurse documented the patient has been using oxygen more frequently.



There was no documentation on the HHC/POC or physician orders for the use of oxygen, the rate of flow, frequency and administration device.



An interview was conducted on 6/28/18 at 11:57 AM with Employee Identifier (EI) # 9, Registered Nurse, Clinical Manager who confirmed the above findings.











G0576 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 review of medical records (MR) and interview with the staff it was determined the agency failed to ensure staff documented all physician orders and entered them into the patient medical record. This affected 1 of 2 unsampled patients reviewed from the agency's complaint log, and did affect Unsampled Patient #1, and had the potential to negatively affect all patients served by the agency.



Findings include:



1. Unsampled Patient # 1 was admitted to the agency on 12/27/17 with diagnoses including Encounter for Surgical Aftercare Following Surgery on the Circulatory System.



Review of the agency complaint log revealed the following documentation dated 1/10/18 at 3:56 PM: "The daughter of the patient, ... voiced a complaint that neither the nurse aides or nurses had taken proper care of her dad, resulting in the sore and infection that he now has on the end of his penis."



Review of the MR revealed an On Call Client Coordination Note dated 1/2/18. The SN documented: "...On call visit due to patient going to Urologist and having catheter removed with no output for over 8 hours. ...On Call MD (Medical Doctor) contacted regarding urine retention and orders received to reinsert catheter..."



A copy of the MD order to reinsert catheter was requested by the surveyor. Employee Identifier (EI) # 1, Director of Nursing, responded in an email dated 6/29/18 at 11:42 AM to the surveyor there was no order written for the catheter.
G0578 Conformance with physician orders
CFR(s): 484.60(b)

Standard: Conformance with physician orders.


This STANDARD is not met as evidenced by:
Based on, review of medical records (MR), review of agency policy and procedure, and staff interviews, it was determined the agency failed to ensure discipline visit frequencies were completed as ordered by the physician.



This affected MR # 2, 1 of 17 records reviewed and had the potential to affect all patients admitted to the agency.



Findings include:



Policy: Physician Notification and Physician Orders

Review and Revision Date: 01/14



"Purpose / Objective:

1.1 To ensure that the physician is notified of all changes in patient status and that all changes to the Plan of Care are addressed in a Physician Change Order.



1.2 To ensure that all disciplines follow all orders...



Procedure:



4.2 Reasons to obtain a New Order, or provider physician notification, will include but are not limited to the following:



d. Change in discipline frequency



4.3 Omission of a visit by any discipline will need a Missed Visit Notification Note in the Electronic Medical Record completed and Physician Notification will be faxed, mailed, or hand-delivered."



*****



2. MR # 2 was admitted to the agency on 5/26/17 with certification dates of 5/26/17 to 7/24/17 for diagnoses including Type 1 Diabetes Mellitus with Hyperglycemia.



Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 5/26/17 to 7/24/17, revealed Skilled Nurse (SN) order as "2 wk 2;1 wk 8" (twice a week for 2 weeks, once a week for 8 weeks)



Review of the Physician Verbal Order dated 5/26/17 revealed an order for SNV (Skilled Nurse Visit) 5/27/17 to assess blood sugar and call significant findings to MD (Medical Doctor).



Review of the Visit Note Reports revealed SNV for admission to agency on Friday 5/26/17.



Further review of the Visit Note Reports revealed no documentation of a SNV on Saturday 5/27/17.



Review of the MR revealed no documentation of a missed visit note or physician notification of the missed SN visit on 5/27/17.



An interview was conducted on 6/28/18 at 11:09 AM with Employee Identifier (EI) # 1, Director of Nursing, who confirmed the previous findings.
G0590 Promptly alert relevant physician of changes
CFR(s): 484.60(c)(1)

The HHA must promptly alert the relevant physician(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 review of medical record (MR), policy and procedure and interviews, it was determined the staff failed to notify the physician with changes in the patient condition. This affected MR # 7 and MR # 3, 2 of 17 records reviewed and had the potential to affect all patients admitted to the agency.



Findings include:



Policy: Physician Notification and Physician Orders

Review and Revision Date: 01/14



"Purpose / Objective:

1.1 To ensure that the physician is notified of all changes in patient status and that all changes...



Procedure:



4.2 Reasons to obtain a New Order, or provide physician notification, will include but are not limited to the following:



e. Change in patient status...

i. Any parameters outside those listed above.



Guidelines for Physician Notification:

7. Blood Glucose less than 70 or greater then 250...



13. Pain greater then 7..."



*****



1. MR # 7 was admitted to the agency on 5/22/18 with diagnoses including Unspecified Diastolic Heart Failure and Chronic Obstructive Pulmonary Disease.



Medical record review revealed a Nurse Visit Note Report dated 6/4/18 that included documentation of the presence of a red rash beneath the patients' breasts that resembled yeast. The nurse documented use powder and keep area dry.



Review of the Nurse Visit Note Report dated 6/14/18 contained documentation of trace bilateral lower extremity edema.



On 6/19/18, the nurse documented a moist red rash beneath breast, treating with corn starch and baby powder mix and 3 plus bilateral lower extremity edema.



There was no documentation the physician was notified regarding the worsening of the yeast-like rash and the increase in lower extremity edema.



An interview was conducted on 6/28/18 at 11:57 AM with Employee Identifier (EI) # 9, Registered Nurse, Clinical Manger, who confirmed the above findings.

2. MR # 3 was admitted to the agency on 11/16/17 with a recertification date of 1/15/18 to 3/15/18 with admitting diagnoses of Type 2 Diabetes Mellitus with Chronic Kidney Disease and Chronic Kidney Disease Stage 3 Moderate.



Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 1/15/18 revealed the following order:



Skilled nurse for observation and assessment of pain, effectiveness of pain management regimen and skilled teaching related to pain management. Skilled nurse (SN) to intervene with increased pain level to minimize complications.



Review of the Guidelines for Physician Notification form revealed Pain greater than 7.



Review of the Physical Therapy (PT) visit dated 1/16/18 revealed the patient reported a pain level of 8 out of 10 to the sternum. Further review revealed no documentation by PT of physician notification of pain greater then 7 and no documentation the skilled nurse was notified.



Review of the Occupational Therapist (OT) note dated 1/18/18 revealed the patient reported pain in the sternum. OT failed to document the pain scale or notify the nurse or physician.



Review of the SN visit dated 1/18/18 revealed the patient's random blood sugar was documented as 326. Further review of the SN note revealed the nurse documented "will notify MD" (medical doctor).



Review of the Client Coordination Notes with in the MR revealed no documentation the physician was notified of the increase in blood sugar.



An interview was conducted on 6/28/18 at 11:00 AM with EI # 1, Director of Nursing, who confirmed the above mentioned findings.
G0682 Infection Prevention
CFR(s): 484.70(a)

Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases.


This STANDARD is not met as evidenced by:
Based on observations, review of agency policies and procedures, and staff interviews, it was determined the agency failed to ensure the staff:



1. Performed hand hygiene as directed per the agency policy.



2. Performed routine catheter care and perineal care according to agency policy.



This affected 4 of 7 Home Visits (HV) conducted including, HV # 4, HV # 2, HV # 3, HV # 7 and had the potential to negatively affect all patients served by this agency.



Findings include:



Policy: Hand Washing Indications

Date Reviewed: 3/18



"Section 2: Policy



2.1 All employees will follow CDC (Centers for Disease Control and Prevention) hand washing recommendations for preventing nosocomial infections.



2.2 All employees involved in patient contact/care will sanitize hands with antimicrobial containing product before and after removing gloves/ gown.



Section 4: Procedure



4.1 Employees should sanitize their hands before and after performing invasive procedures.



4.3 Employees should always sanitize their hands before and after touching wounds.



4.4 Employees should sanitize their hands before and after situations during which microbial contamination of hands is likely to occur, especially those involving contact with mucous membranes, blood or bodily fluids, secretions, or excretions.



4.6 Employees should sanitize their hands before and after touching inanimate sources that are likely to be contaminated virulent or infectious microorganisms..."



*****



Instructions: How to Use Hand Sanitizer

From the Purell Website:



"As with all over-the-counter products, it is important to use PURELL® Hand Sanitizer products properly and according to the instructions on the label: wet hands thoroughly with product, and briskly rub hands together until dry..."



*****



Policy: Foley Catheter Care

Date Reviewed: 3/18



"Section 1: Purpose/Objective



1.1 To promote cleanliness.

1.2 To prevent infection.

1.3 To remove odors and secretions.



Section 2: Policy



...2.2 A Home Health Aide may perform this procedure after being qualified by an R.N. (Registered Nurse).



...Section 4: Procedure



...4.2 Gently separate the labia on the female patients... Observe the urinary meatus for sores, crusts, redness, swelling, discoloration or abnormal drainage. If present, report to supervisor.



4.3 Clean the area around the urinary meatus with soapy washcloth or spray with perineal cleaning solution. Clean downward and away from the urinary meatus. Use only one downward stroke at a time. Rinse and dry. Avoid pulling on the catheter..."



*****



Policy: Perineal Care: Female

Date Reviewed: 9/13



"...Section 2: Policy and Criteria



...2.2 A Home Health Aide may perform this procedure after being qualified by a supervisor.



...Section 4: Procedure



4.6 Ask the patient to bend her knees slightly and spread her legs.



4.7 Separate the labia with one hand and wash with the other, using gentle downward strokes from front to back of the perineum to prevent internal organisms from contaminating the urethra or vagina..."



*****



1. HV # 4 was admitted to the agency on 8/10/17 and recertified from 6/7/18 to 8/5/18. Admitting diagnoses included Encounter for Fitting and Adjustment of Urinary Device, and Other Neuromuscular Dysfunction of Bladder.



A HV was conducted on 6/27/18 at 9:40 AM to observe care provided by Employee Identifier (EI) # 5, Aide. EI # 11, RN, was also present on the HV.



Review of the Aide Care Plan Report dated 6/13/18, revealed orders including bathing (bed/bath), routine catheter care, and perineal care every visit.



EI # 5 donned gloves to check the patient's vital signs. After examining HV # 4's arm and adjusting clothing to perform a blood pressure check, EI # 5 re-entered her/his bag to retrieve supplies, with contaminated gloves.



Each time EI # 5 removed gloves and performed hand hygiene, she/he waved hands back and forth to "dry" hands.



During the bed bath EI # 5 failed to separate the labia and clean around the meatus and urinary catheter per policy guidelines.



After completing the bed bath and emptying the bath water, EI # 5 removed her/his gloves and failed to perform hand hygiene.



EI # 5 assisted HV # 4 into wheelchair and into den area lift chair.



EI # 5 returned to patient's bedroom and changed bed linens. She/he then removed gloves and reached in to patient's glove box, without first performing hand hygiene.



While gathering up supplies to exit, EI # 5 dropped her/his personal cell phone on the floor of the bedroom. EI # 5 picked the phone up off the floor and placed on computer tablet. EI # 5 failed to clean the phone or tablet before leaving the home.



During an interview conducted on 6/28/18 at 11:30 AM with EI # 9, RN, Supervisor, the above findings were confirmed.



2. HV # 2 was admitted to the agency on 6/16/18 with diagnosis including Encounter For Other Orthopedic Aftercare and Diabetes due to Underlying Condition without Complications.



Record review revealed resumption of care (ROC) order dated 6/23/18 with a physician's order for Skilled Nurse (SN) to perform blood sugar analysis every visit...



Further review of the ROC order dated 6/23/18 revealed SN to perform wound care to lower back dehisced surgical incision, as follows: Using aseptic technique and sterile supplies cleanse with sterile Normal Saline, Pat dry, Apply skin prep to surrounding intact skin and allow to dry. Window pane wound edges with Transparent Dressing as needed (prn), then apply: Black Foam to wound bed, cut to fit... Cover with Transparent Dressing, cut hole in Transparent Dressing over Foam and attach Trac Pad.



Review of the RN (Registered Nurse) Resumption of Care Visit Note Report dated 6/23/18 revealed wound # 4 Low Back, Medial, Surgical listed for wounds.



A HV was conducted on 6/27/18 to observe care provided by EI # 3, RN. The following is the care observed during the visit:



EI # 3 obtained patient vital signs with gloves donned then obtained blood sugar using the glucometer without changing gloves or performing hand hygiene prior to obtaining blood sugar.



EI # 3 then entered nursing bag with the contaminated gloves and obtained wipes to clean equipment used during visit. After equipment was cleaned and placed in nursing bag, EI # 3 then removed contaminated gloves and performed hand hygiene.



EI # 3 then donned gloves and performed an assessment of the patient's bilateral (both) feet. Following assessment of patient's bilateral feet EI # 3 then donned 3 pairs of gloves without removing the contaminated gloves used to assess patient's feet or performing hand hygiene.



EI # 3 then documented vital signs in patient home folder, reconciled patient medication bottles with CMR (Client Medication Report) , picked up nursing bag and placed on his/her shoulder, folded wound care scissors and bag containing clean gloves in a barrier, then picked up trash used at visit in gloved hands. EI # 3 then removed the outer pair of gloves folding trash inside gloves, and placed in the trash can.



EI # 3 failed to remove the other 3 pair of gloves or perform hand hygiene following touching inanimate sources or trash removal.



EI # 3 then picked up the folded barrier and moved barrier to edge of patient bed for wound care and obtained supplies for wound vac (Vacuum-assisted closure) dressing without removing gloves or performing hand hygiene.



EI # 3 then inspected outside of the wound vac machine and removed wound drainage canister from wound vac and placed in the trash. EI # 3 then removed outer pair of gloves and placed new wound drainage canister into the wound vac.



EI # 3 failed to remove the other 2 pair of gloves or perform hand hygiene following removal of wound drainage canister or prior to the placement of new drainage canister.



EI # 3 then applied 4 clean pair of gloves over the 2 pair that were already on his/her hands.



EI # 3 failed to remove other 2 pair of gloves or perform hand hygiene prior to donning clean gloves.



EI # 3 then opened top part of gauze pad packages and moistened gauze pads with wound cleanser inside of package. EI # 3 then placed moistened gauze pad packages on barrier and removed wound vac dressing on wound # 4 and placed in the trash.



EI # 3 then placed removed wound vac dressing and outer pair of gloves in the trash. Following placement of the dressing and outer pair of gloves in the trash, EI # 3 applied hand sanitizer to remaining 5 pair of gloves that were on EI # 3's hands.



EI # 3 failed to remove other 5 pair of gloves or perform hand hygiene to bare hands after removing wound vac dressing.



EI # 3 then cleaned wound # 4 with wound cleanser moistened gauze and patted dry. EI # 3 removed outer pair of gloves and applied hand sanitizer to remaining 4 pair of gloves.



EI # 3 failed to remove other 4 pair of gloves or perform hand hygiene to bare hands.



EI # 3 then talked with caregiver for several minutes, about what to do if wound vac malfunctioned or lost power. EI # 3 asked caregiver to obtain gauze and 2 separate bottles of Normal Saline from a second wound care supply bag. EI # 3 then began to verbally instruct caregiver on how to use Normal Saline to moisten gauze for a wet to dry dressing in case of wound vac malfunction or loss of power.



EI # 3 then applied 1 clean pair of gloves over the remaining 4 pair of gloves, and demonstrated to caregiver how to apply moistened gauze into wound bed.



EI # 3 failed to remove other 4 pair of gloves or perform hand hygiene prior to demonstration of wound care to caregiver or donning new pair of gloves.



EI # 3 then obtained and opened abdominal pad from sterile package and demonstrated how to place pad over incision. EI # 3 then replaced abdominal pad back into package and placed on patient bedside table.



EI # 3 failed to remove the contaminated abdominal pad used for the demonstration to ensure it was not used for patient wound care.



EI # 3 then removed Normal Saline moistened gauze from wound bed used in demonstration, placed in the trash, and then applied a new pair of gloves over the other 5 pair of gloves.



EI # 3 failed to remove other 5 pair of gloves or perform hand hygiene prior to donning new pair of gloves.



EI # 3 then continued with wound care by placement of the wound vac transparent dressing, black foam, and Trac Pad attachment. Following the Trac Pad attachment, EI # 3 then removed outer pair of gloves and applied hand sanitizer to other 4 pair of gloves that remained on EI # 3's hands.



EI # 3 failed to remove other 4 pair of gloves or perform hand hygiene to bare hands.



EI # 3 then applied transparent dressing on top of Trac Pad to secure.



An interview was conducted with EI # 1, Director of Nursing, EI # 2, Administrator, EI #9, RN Supervisor, and EI # 10, RN Supervisor on 6/28/18 at 11:38 AM who verified the previous was improper procedure.





3. HV # 3 was admitted to the agency on 8/22/16 and recertified for continued care on 6/13/18 to 8/11/18 with diagnoses including Pressure Ulcer of Sacral Region, Stage 4.



A home visit was conducted on 6/27/18 at 1:15 PM to observe Licensed Practical Nurse, EI # 4, perform wound care.



EI # 4 removed and discarded the old sacral wound dressing. EI # 4 failed to remove gloves, perform hand hygiene and don clean gloves after removal of the old (contaminated) dressing.



EI # 4 opened the wound cleanser, new gauze packets and measured the wound. EI # 4, then removed gloves, donned clean gloves, but failed to perform hand hygiene after glove removal.



EI # 4 labeled the wound measurer, placed the measurer on top of the wound and photographed the wound with wound measurer using the computer tablet camera. EI # 4 obtained a Q Tip, completed wound measurements and applied Dakins soaked gauze to the stage 4 sacral wound. EI # 4, then removed gloves and performed hand hygiene.



EI # 4 failed to remove gloves and perform hand hygiene after contact with inanimate equipment, the computer tablet for wound photography.



In an interview conducted on 6/27/18 at 3:07 PM, EI # 1, verified staff failed to follow facility infection control policy.



4. HV # 7 was admitted to the agency on 1/9/18 with a recertification date of 5/9/18 to 7/7/18 and admitting diagnoses of Parkinson's Disease and Dysphagia Unspecified.



A HV was conducted on 6/27/18 at 10:30 AM with EI # 8, Speech Therapist, to observe care provided.



During the HV after placing barriers and placing the nursing bag on the barrier, EI # 8 sanitized hands and removed all equipment from the bag and placed on the barrier. EI # 8 then sanitized hands and donned gloves and took the patient's vital signs. When complete EI # 8 removed gloves, sanitized hands and cleaned the stethoscope and placed around his/her neck. EI # 8 then donned gloves and failed to sanitize hands after cleaning of the stethoscope. EI # 8 fed patient and assessed swallowing. EI # 8 then prepared the neuromuscular unit with the same gloves on and place the electrodes on the patient's neck. EI # 8 then handed the patient the resistant breather for use and continued to wear the same gloves.



After the patient assessment and exercises were complete EI # 8 cleaned all the equipment and placed in the bag while wearing the same gloves. EI # 8 failed to remove gloves after cleaning equipment and sanitize hands prior to entering the bag.



EI # 8 then reviewed medications wearing the same gloves the equipment was cleaned with. Once the review of the medications was complete EI # 8 removed gloves and donned a clean pair of gloves without sanitizing hands and completed the visit.



An interview was conducted on 6/27/18 at 1:30 PM with EI # 1 who confirmed the above mentioned findings.
G0706 Interdisciplinary assessment of the patient
CFR(s): 484.75(b)(1)

Ongoing interdisciplinary assessment of the patient;


This ELEMENT is not met as evidenced by:
Based on review of medical records (MR), agency policy, and staff interview(s) it was determined the SN (Skilled Nurse) failed to follow the plan of care for wound assessment(s).



This affected 2 of 6 records reviewed with wounds, including MR # 5, MR # 1 and had the potential to affect all patients served by the agency.



Findings include:



Policy: Wound Care

Date Reviewed: 4/18



"Section 2: Policy



2.1 Wound measurements and photos are done on Admission, Recertification, on a Weekly basis, and prn" (as needed)."



*****



1. MR # 5 was admitted to agency on 10/1/17 with certification dates of 10/1/17 to 11/29/17 with diagnoses including, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side.



Review of the Physician Order dated 10/14/17 revealed order for Skilled Nurse (SN) to perform/teach wound care to right and left buttocks and coccyx, using aseptic technique and sterile supplies, as follows: Cleanse with wound cleanser, pat dry, and cover with Mepilex Border. CG (Caregiver) to perform daily in absence of SNV (Skilled Nurse Visit).



Review of the SN visit notes dated 10/16/17, 10/18/17, and 10/26/17 revealed no documentation of the wound care measurements.



Based on the previous, wound measurements were not documented for the weeks of 10/15/17 thru 10/21/17 or 10/22/17 thru 10/28/17.



An interview was conducted on 6/28/18 at 11:14 AM with EI (Employee Identifier) # 10, RN supervisor, who confirmed that SN had failed to document wound care measurements per agency policy.



2. MR # 1 was admitted to the agency on 3/24/17 with diagnoses including Bacteremia, Methicillin Resistant Staph Infection, Peripheral Vascular Disease and Acquired Absence of other Right Toes.



Record review revealed a resumption of care (ROC) order dated 4/25/17 with nurse visits ordered 3 times a week for assessment of the integumentary status to identify changes, intervene and wound care to be performed to the right heel and right foot every nurse visit.



Further record review revealed plan of care updates on 4/27/17 and 5/3/17 that included changes in wound care orders and nurse visits continued 3 times a week.



Review of the Nurse Visit Note Reports dated 4/25/17, 4/26/17 and 4/28/17 failed to include documentation the nurse re-assessed wounds to the right heel and right foot and documented wound measurements.



Review of the Nurse Visit Note Reports dated 5/8/17, 5/10/17 and 5/12/17 failed to include documentation the nurse re-assessed the right heel wound and documented weekly wound measurements.



In an interview conducted on 6/28/18 at 10:39 AM, EI # 1, Director of Nursing confirmed staff failed to complete and document weekly wound measurements.
G0710 Provide services in the plan of care
CFR(s): 484.75(b)(3)

Providing services that are ordered by the physician as indicated in the plan of care;


This ELEMENT is not met as evidenced by:
Based on observations, review of medical records (MR), review of agency policy, and staff interviews, it was determined the agency failed to ensure the staff:



1. Obtained weekly weights prescribed by the physician.



2. Performed wound care as prescribed by the physician.



3. Obtained blood sugar analysis each visit as prescribed by the physician.



This affected MR # 1, MR # 3, MR # 4, MR # 6 and Home Visit (HV) # 2, 5 of 17 records reviewed and had the potential to affect all patients served byt this agency.



Findings include:



Policy: Wound Care

Date Reviewed: 4/18



"Section 2: Policy



2.5 Wound care protocols are by physician orders."



Policy: Oasis Based Admission and Resumption of Care Assessments

Date Revised 5/18



"Section 1: Purpose/Objective



1.1 To implement and maintain a process that preserves a systematic and coordinated plan for the course of care for all patients/clients of the Agency.



Secton 4: Procedure



4.8 The weight and blood sugar log will be assessed every SNV (Skilled Nurse Visit) and document on SN Note, if applicable."



*****



1. MR # 1 was admitted to the agency on 3/24/17 with diagnoses including Bacteremia, Methicillin Resistant Staph Infection, Peripheral Vascular Disease and Acquired Absence of other Right Toes.



Record review revealed resumption of care (ROC) orders dated 4/25/17 with nurse visits ordered 3 times a week, patient to be weighed weekly, report weight gain of 5 lbs (pounds) in one week to the medical doctor.



Review of the Nurse Visit Note Reports dated 4/25/17, 4/26/17 and 4/28/17 failed to contain documentation weekly weights were obtained.



Review of the Nurse Visit Note Reports dated 5/8/17, 5/10/17 and 5/12/17 failed to contain documentation weekly weights were obtained.



Review of the Nurse Visit Note Reports dated 5/15/17, 5/17/17 and 5/19/17 failed to contain documentation weekly weights were obtained.



In an interview conducted on 6/28/18 at 10:39 AM, Employee Identifier (EI) # 1, Director of Nursing confirmed staff failed to document weekly weights the weeks of 4/23/17, 5/7/17 and 5/14/17 as ordered in the plan of care.

2. MR # 3 was admitted to the agency on 11/16/17 with a recertification date of 1/15/18 to 3/15/18 with admitting diagnoses of Type 2 Diabetes Mellitus with Chronic Kidney Disease and Chronic Kidney Disease Stage 3 Moderate.



Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 1/15/18 revealed the following order for wound care:



SN to perform wound care to anterior outer edge of right foot diabetic ulcer (#4) as follows: Using clean technique and sterile supplies, cleanse with wound cleanser or Normal Saline, pat dry, cover with foam border dressing...



Review of the physician order dated 1/18/18 at 4:19 PM revealed the following order: Skilled nurse to provide wound care to right lateral foot ulcer using aseptic technique and sterile supplies as follows: Cleanse with wound cleanser, pat dry, apply silver foam border. Change Monday / Thursday, PRN (as needed). Instruct caregiver to change between skilled nurse visits.



Review of the SNV dated 1/18/18 at 11:15 AM revealed the following wound documentation, "skilled nurse to provided wound care to ulceration on right outer foot using aseptic techniques and sterile supplies. Cleansed with wound cleanser or sterile saline, patted dry, covered with Mepilex Silver AG foam border gauze during SNV..."



Review of the nurse visit note revealed no documentation as to which solution the nurse cleaned the wound with and the skilled nurse also used Mepilex AG foam border gauze and the order stated border gauze not the Mepilex AG.



An interview was conducted on 6/28/18 at 11:00 AM with EI # 1 who confirmed the above mentioned findings.



3. MR # 4 was admitted to the agency on 4/13/18 and recertified from 6/12/17 to 8/10/17. Admitting diagnoses included Type 2 Diabetes Mellitus without complications and Essential (Primary) Hypertension.



Review of the HHC and POC revealed orders for the SN to perform blood sugar analysis every visit... SN to weigh patient each visit and report weight loss of 3 lbs (pounds) or more per month to MD (Medical Doctor).



Review of the SN Visit Note dated 6/16/17 revealed no documented blood sugar or weight.



Review of the SN Visit Notes dated 6/22/17, 6/28/17, 7/4/17, and 7/12/17 revealed no documented weight.



During an interview on 6/28/18 at 11:20 AM with EI # 10, RN, Supervisor, the above findings were confirmed.



4. MR # 6 was admitted to the agency on 6/5/18, diagnoses included Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation and Chronic Respiratory Failure with Hypoxia



Review of the HHC and POC dated 6/5/18 to 8/3/18, revealed a physician order for SN to weigh patient every SN visit and instruct patient to weigh every morning after first void and record on weight log.



Review of the Nurse Visit Note Report dated 6/8/18, revealed documentation in the narrative section of "Wt (weight) 2 days ago 125. No scales in home. Advised to obtain scales."



Further review of Nurse visit Note report dated 6/8/18 revealed no documentation that SN had documented a patient weight obtained at the SN visit.



Review of the Nurse Visit Note Report dated 6/15/18 failed to contain documentation of the patient's weight at visit or assessment of the patient's weight log.



During an interview conducted on 6/28/18 at 11:51 AM with EI # 10, RN Supervisor, the above findings were confirmed.



5. HV # 2 was admitted to the agency on 6/16/18 with diagnosis including Encounter For Other Orthopedic Aftercare and Diabetes due to Underlying Condition without Complications.



Record review revealed resumption of care (ROC) orders dated 6/23/18 with a physician's order for SN to perform blood sugar analysis every visit...



Further review of the ROC order dated 6/23/18 revealed SN to perform wound care to lower back dehisced surgical incision, as follows: Using aseptic technique and sterile supplies cleanse with sterile Normal Saline, Pat dry, Apply skin prep to surrounding intact skin and allow to dry. Window pane wound edges with Transparent Dressing as needed (prn), then apply: Black Foam to wound bed, cut to fit... Cover with Transparent Dressing, cut hole in Transparent Dressing over Foam and attach Trac Pad.



Review of the RN Resumption of Care Visit Note Report dated 6/23/18 revealed wound # 4 Low Back, Medial, Surgical listed for wounds.



Review of the MR revealed no documentation that physician was contacted to clarify the wound name or wound number.



An observation visit was conducted on 6/27/18 at 1:00 PM to observe wound care provided to HV # 2. The following wound care was observed during visit by surveyor:



EI # 3 moistened gauze pads with wound cleanser and cleansed wound # 4.



EI # 3 then cut wound vac transparent dressing into strips and applied to wound edges to form window pane.



EI # 3 failed to cleanse wound # 4 with Normal Saline or apply skin prep to surrounding intact skin and allow it to dry prior to application of transparent dressing window pane.



Review of the RN visit note report dated 6/27/18 revealed wound care documentation under narrative section as follows: Wound care to # 1 (incorrectly documented, should have been # 4) lower back dehisced surgical incision using aseptic technique and sterile supplies....Cleansed with wound cleanser and sterile gauze, patted dry, no skin prep needed at this time.



Review of the visit note report revealed no documentation that the physician was notified about use of wound cleanser to clean the wound instead of Normal Saline or skin prep not applied to surrounding intact skin.



An interview was conducted with EI # 1, Director of Nursing, on 6/28/18 at 12:30 AM for notification of the previous findings.
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 agency policy, medical record (MR) and interview, it was determined the agency staff failed to ensure medical record documentation was complete and included the specific wound care performed. This affected 1 of 6 records reviewed with wounds including MR # 1 and had the potential to affect all patients admitted to this agency.



Finding include:



Policy Title: Wound Documentation

Revised 8/13



"Section 2: Policy



2.1 Wound documentation should be clear using verbiage...universally accepted.



2.2 Wound documentation should be concise.



...2.4 Wound documentation should accurately reflect the actual status of the patient at the time of the procedure.



Section 5: Documentation



5.1 The documentation on the procedure performed for wound care should be incorporated in the notes to describe the wound care protocol...



5.3 Document the exact wound care procedure performed during the visit..."



1. MR # 1 was admitted to the agency on 3/24/17 with diagnoses including Bacteremia, Methicillin Resistant Staph Infection, Peripheral Vascular Disease and Acquired Absence of other Right Toes.



Record review revealed resumption of care (ROC) orders dated 4/25/17 to cleanse the right heel pressure ulcer with normal saline or wound cleanser, apply Aquacel, cover with foam dressing. Nurse visits were ordered 3 times a week for 4 weeks.



Review of the ROC Nurse Visit Reports dated 4/25/17 and 4/26/17 failed to reveal the specific cleansing solution used during wound care, whether wound cleanser or normal saline was used to the right heel for wound cleansing.



Physican orders dated 4/27/17 and 5/3/17 included cleanse right heel with wound cleanser or normal saline, pat dry, leave open to air.



Review of the Nurse Visit Reports dated 4/28/17, 5/1/17, 5/3/17, 5/5/17, 5/8/17, 5/10/17 and 5/12/17 failed to contain documentation for the specific cleansing solution, whether wound cleanser or normal saline was used to the right heel during wound care.



In an interview conducted on 6/28/18 at 10:39 AM, Employee Identifier (EI) # 1, Director of Nursing confirmed staff failed document the exact wound care procedure performed during nurse visits.
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; (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 agency guidelines, medical records (MR), and interviews with staff, it was determined the agency failed to ensure the home health aide followed the written plan of care and accurately documented the care provided.



This affected 3 of 6 records reviewed receiving home health aide services and did affect Home Visit (HV) # 4, HV # 5, and MR # 6 and had the potential to negatively affect all patients receiving home health aide care.



Findings include:



Guidelines for Physician Notification

Dated: 11/13/13



"...9. No BM (Bowel Movement) > (greater than) three days."



*****



1. HV # 4 was admitted to the agency on 8/10/17 and recertified from 6/7/18 to 8/5/18 with admitting diagnoses included Encounter for Fitting and Adjustment of Urinary Device, and Other Neuromuscular Dysfunction of Bladder.



Review of the Aide Care Plan Report dated 6/13/18 revealed orders for the aide to document the date of the last BM, every visit.



Review of the Aide Visit Note dated 6/20/18 revealed the aide answered "Y" (yes) to the question: "Date of Last BM." The aide failed to document the actual date of the last BM, and therefore unable to determine if it has been greater than three days.



During an interview conducted on 6/28/18 at 11:30 AM with Employee Identifier (EI) # 9, RN (Registered Nurse), Supervisor, the above findings were confirmed.



2. HV # 5 was admitted to the agency on 5/25/18 and recertified 5/25/18 to 7/23/18. Admitting diagnoses included Cervicalgia, and Type 2 Diabetes with Diabetic Neuropathy.



Review of the Aide Care Plan Report dated 5/25/18 revealed orders for the aide to document the date of the last BM, every visit.



Review of the Aide Visit Notes dated 6/7/18, 6/14/18, and 6/26/18 revealed the aide failed to document the date of the patient's last BM, and therefore unable to determine if it has been greater than three days.



An interview was conducted on 6/28/18 at 10:45 AM with EI # 1, Director of Nursing, who confirmed the above findings.



3. MR # 6 was admitted to the agency on 6/5/18 with certification dates from 6/5/18 through 8/3/18. Admitting diagnoses included Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation and Chronic Respiratory Failure with Hypoxia.



Review of the Aide Care Plan Report dated 6/5/18 revealed orders for the aide to document the date of the last BM, every visit.



Review of the Aide Visit Note dated 6/11/18 and 6/14/18 revealed the aide answered "Y" to the question: "Date of Last BM." The aide failed to document the actual date of the last BM, and therefore unable to determine if it has been greater than three days.



During an interview conducted on 6/28/18 at 11:51 AM with EI # 10, RN Supervisor, the above findings were confirmed.