Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 017027	(X3) Date Survey Completed 09/26/2018
Name of Provider or Supplier Hga Homecare, Llc	Street Address, City, State 2050 Beltline Rd Sw, Decatur, 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 the recertification survey conducted on 9/26/18, Decatur Morgan Homecare was in substantial compliance with the Centers for Medicare and Medicaid Services requirements for Emergency Preparedness.
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 current and accurate for all patient medications. This affected 2 of 7 home visit (HV) records reviewed, including HV # 1 and # 4 and had the potential to negatively affect all patients admitted to this agency. Findings include: Policy: Monitoring Medications Policy Number: 10.008 Revised Date: 02/01/2018 Purpose: To provide a process to ensure continuous monitoring of medications in the patient's home. 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. ...The therapist will participate by monitoring and reporting any identified medication issues or non-compliance to the Patient Care Manager. ...The physician is contacted immediately if any discrepancies between agency information and patient medications are found. Procedure: ...a. Compare medication list obtained from the facility from which the patient was transferred and/or physician orders to actual medications patient is taking. b. Review all medications including over the counter medications...to identify issues such as: i. Potential adverse effects and drug reactions iii. Significant side effects; v. Contraindicated medications... **** 1. HV # 1 was admitted to the agency 8/18/18 with diagnoses including Dizziness and Giddiness, Other Pancytopenia, Atherosclerotic Heart Disease, Old Myocardial Infarction, Personal History of Nicotine Dependency and History of Falling. A home visit was completed on 9/24/18 at 11:30 AM with Employee Identifier (EI) # 4, COTA (Certified Occupational Therapy Assistant). EI # 1, Executive Director (ED) was present during the visit. The CMR provided to the surveyor prior to the visit was compared with the medication found in the home and reviewed with the patient during the home visit. B12 1000 micrograms 1 tablet by mouth daily was found in the home and reported by the patient in use for the last 10 days. The B12 was not documented on the current CMR. Eye Allergy Relief drops were documented on the CMR and not found in the home. During an interview on 9/26/18 at 9:35 AM, EI # 3, Performance Improvement Coordinator confirmed the aforementioned findings. 2. HV # 4 was admitted to the agency on 8/26/18 with diagnoses including Cellulitis of Right Lower Limb, Type II Diabetes Mellitus with Diabetic Chronic Kidney Disease. A HV was conducted on 9/24/18 at 2:27 PM with EI # 5, Registered Nurse to observe PICC (Peripherally Inserted Central Catheter) care and laboratory draw from the PICC. During the HV, the patient's medications were reviewed with the patient using the CMR provided to the surveyor by the agency and medication bottles In the home. The following medications were on the CMR with an incorrect dosage or administration frequency: Fluconazole 100 mg (milligram) 1 spray daily was documented on the CMR. Fluconazole 200 mg 1 spray daily was documented on the medication bottle and confirmed by the patient. The date the medication was changed was 8/26/18. Clonidine HCL (Hydrochloride) 0.1 mg 1 tablet 3 times a day was on the CMR. Clonidine HCL 0.1 mg take 1 tablet PRN (as needed) 3 times a day for a SBP (Systolic Blood Pressure) medication bottle dated 9/13/18. Niacin 1000 mg take 1 tablet daily was on the CMR. Niacin 500 mg 2 tablets daily was documented on the medication bottle. Novolog Flexpen U (unit) - 100 Insulin Aspart Subcutaneous 5 units 3 times a day was on CMR. Novolog Flexpen U- 100 Insulin Aspart Subcutaneous 18 Units to start, then according to the sliding scale 3 times a day was on the medication package. The patient confirmed the Novolog dosage was changed about 4 weeks ago. The following medication was found in the home and not documented on the CMR: Vibativ 1000 mg in 250 ml (milliters) of Normal Saline IV (Intravenously). The start date was 1 1/2 weeks ago according to patient and caregiver. On 9/24/18 at 3:20 PM, the surveyor interviewed the patient and caregiver regarding the medications and asked if the nurses check the patient's medications every week? The patient stated "No, that is why I wanted to know why you are checking them. No one ever asks for the pill bottles." An interview was conducted on 9/24/18 at 3:30 PM with EI # 1, ED who confirmed the above mentioned findings.
G0580	Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician. This ELEMENT is not met as evidenced by: Based on review of medical records (MR), agency policies and procedures, observations and interviews with the staff it was determined the agency failed to ensure: 1. The staff completed PICC (Peripherally Inserted Central Catheter) dressing changes and extension tubing changes per physician orders. 2. Wound care was completed per physician orders. This affected 3 of 4 MR's reviewed with PICC's and 2 of 12 MR's with wounds and did affect Home Visit (HV) # 4 and MR's # 5, # 7, # 1, and # 3. This had the potential to negatively affect all patients served by the agency. Finding include: Policy: Dressing Change Procedure for Central Venous, Midline, And Peripherally Inserted Central Catheters. Policy Number: 10.027 Revised Date: 10/01/16 Purpose: To keep insertion sites clean, stabilize catheter and minimize the risk of infection. Procedure: 4. Place moisture proof pad under patient's arm. 5. To remove old dressing, lift edge of dressing beginning at catheter hub and gently pull dressing perpendicular to the skin toward the insertion site. Remove catheter securement device and Chlorhexidine-impregnated sponge... 8. Inspect catheter, catheter exit site, and surrounding skin and patient's arm, chest and neck area. d. Measure external length of catheter from the insertion site to the catheter hub... 9. Cleanse the site with Chlorhexidine (preferred) in a back and forth motion for at least 30 seconds... 11. Consider application of a Chlorhexidine-impregnated sponge to the site... 12. Secure the catheter in place. The use of sutureless stabilization device is preferred to tape and sutures. ** Policy: Blood Sampling Via Peripheral or Central Venous Access Route. Policy Number: 10.010 Revised Date: 7/1/10 Purpose: To provide a standard as a guide for licensed nurses performing venipuncture and/or blood sampling for the purpose of laboratory analysis. Policy: It is not recommended to draw blood for therapeutic blood level from the same lumen in which the medication has been administered. Procedure: 1. Obtain physician's order 3. Perform sampling according to LHC (Louisiana Health Care) adopted clinical skills guidelines. ** Policy: Physician Order Policy Number: 2.1.008 Revised Date: 6/1/18 Purpose: To outline the process of receiving and documenting physician orders. Policy: No medications, treatments, diagnostic studies or therapeutics will be administered without the order of a qualified physician, or as designated by State Practice Acts and that order be reduced to writing and signed/dated by the ordering physician. Procedure: 9. Services are provided according to the most recent orders updating the patient's Plan of Care. 10. Orders containing medication must be entered into the software system or written legibly in ink and at a minimum include: a. Name of medication, dose, dilution, frequency, route, rate of infusion. g. Signature/date of physician. 1. HV # 4 was admitted to the agency on 8/26/18 with diagnoses of Cellulitis of Right Lower Limb, Type II Diabetes Mellitus with Diabetic Chronic Kidney Disease. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 8/26/18 revealed the following order for PICC line dressing change and lab (laboratory) draws: Skilled nurse (SN) to perform site care for infusion access device Hickman to right chest wall with clear occlusive dressing changes once a week and PRN (as needed) for loose or soiled dressing. Using sterile technique cleanse site with Chlorhexadine, apply Biosite, cover with clear occlusive dressing. Injection cap change once a week and with each Lab draw and PRN for contamination or malfunction... SN to flush with 10 ml (milliters) of Normal Saline (NS) prior to specimen draw. Discard 10 ml of blood, flush with 20 ml of NS and 5 ml of Heparin after specimen draw... Review of the SN visit notes dated 8/28/18 and 9/3/18 revealed the nurse performed a lab draw. The nurse failed to document withdrawal and discard of 10 ml of blood. The SN documented the PICC was flushed with 10 ml of Normal Saline and not the 20 ml NS as ordered. Review of the SN visit notes dated 9/10/18 and 9/17/18 revealed the nurse flushed the PICC with 10 ml of Normal Saline after completion of the lab draw and not 20 ml NS as ordered. A home visit was conducted on 9/24/18 at 2:27 PM with EI # 5, Registered Nurse, to observe PICC care. After sanitizing hands EI # 5 obtained the supplies to perform the dressing change to the PICC line. EI # 5 obtained a PICC line dressing kit and read the list of supplies. EI # 5 opened the package and determined the Biopatch (Biosite) required for the dressing change was not in the kit. EI # 5 searched through all supplies to find there was not a Biopatch in the kit provided. EI # 5 then phoned the IV (intravenous) supplier, spoke with the pharmacist and requested the supplies from the IV supply company. EI # 5 stated the dressing could be changed without the Biopatch and new supplies would be sent. While completing the dressing change EI # 5 realized there were no stat locks in the supplies. EI # 5 called the IV supplier and ordered more stat locks. The pharmacist again stated to leave the existing stat lock in place. During PICC site care, EI # 5 cleaned the PICC site with 2 Betadine swabs and not the Chlorhexadine as ordered. During the home visit, EI # 5 failed to contact the physician to inform him/her the dressing change to the PICC line was not changed per his/her orders. EI # 5 failed to receive new physician orders for PICC care provided on 9/24/18 during the HV. An interview was conducted on 9/24/18 at 3:30 PM and on 9/26/18 at 9:40 AM with EI # 1 who confirmed the above mentioned findings. 2. MR # 5 was admitted to the agency on 5/25/18 and recertified for continued care on 7/24/18 to 9/21/18 with diagnosis of Type II Diabetes Mellitus With Other Specified Complications. Review of the HHC and POC dated 7/24/18 revealed the following physician orders: Skilled Nurse (SN) to obtain IV (intravenous) access via PICC line using 10 ml syringe and aseptic technique. SN to change PICC line dressing weekly and PRN contamination/malfunction...Perform IV site care using sterile and aseptic technique. Flush IV access with 5-10 ml of Normal Saline (NS) before and after connection/disconnection and with 20 ml after lab draw to clear line. Flush catheter with Heparin 10 U (unit)/ml (5 ml)... Review of the 8/12/18, 8/17/18, 8/24/18 and 9/7/18 nurse visit notes revealed the nurse flushed the PICC line with 10 ml of NS after the lab draw and not 20 ml of NS as ordered. An interview was conducted 9/26/18 at 9:50 AM with EI 2, Clinical Director, who confirmed the above mentioned findings. 3. MR # 7 was admitted to the agency 9/11/18 with diagnoses including Urinary Tract Infection, Site Not Specified and Encounter for Adjustment and Management of VAD (Vascular Access Device). Record review of the HHC and POC dated 9/11/18 to 11/9/18 contained physician orders for Skill Nurse to visit 2 times a week for 1 week then weekly for 8 weeks. The SN orders included to draw lab every Monday starting 9/17/18 and to flush with 10 ml NS prior specimen draw. Discard 10 ml blood, flush with 20 ml NS and 5 ml of heparin (no strength ) after specimen draw. SN to perform site care for infusion device to right upper arm inner arm double lumen PICC line weekly and prn. Change injection cap once a week with each lab draw and prn for problems and extension tube change once a week and prn. Further review of the 9/11/18 HHC and POC medications revealed orders for Heparin 5 ml as directed after last saline per SASH (saline, antibiotic, saline, heparin) protocol. Review of the 9/11/18 RN Admission Visit Note Report and IV (intravenous therapy) Reference documentation revealed the PICC line was flushed with 10 cc NS. There was no documentation the Heparin 5 ml flush was administered after IV antibiotic administration as ordered. Review of the 9/14/18 RN Visit Note Report and IV Reference documentation revealed the PICC line was flushed with 10 cc NS. There was no documentation the Heparin 5 ml flush was administered after PICC site care and cap changes. There was no documentation the weekly extension set change was completed. Review of the 9/17/18 RN Visit Note Report and IV Reference documentation revealed PICC site care was performed and injection caps were changed. There was no documentation the PICC line was flushed with 10 cc NS and Heparin 5 ml flush as ordered. Review of the 9/24/18 RN Visit Note Report and IV Reference documentation revealed the PICC line was flushed with 10 cc NS. There was no documentation Heparin 5 ml flush was administered after PICC site care and cap changes. In an interview on 9/26/18 at 9:35 AM, EI # 3, Performance Improvement Coordinator, confirmed the aforementioned findings. 4. MR # 1 was admitted to the agency on 5/9/18 with diagnoses including Encounter for Surgical Aftercare Following Surgery on the Circulatory System and Encounter for Orthopedic Aftercare Following Surgical Amputation. Review of the Visit Note Report dated 5/9/18 revealed narrative documentation of "Patient has an open lesion to right foot in the area of an amputated right great toe" and patient "instructed on wet to dry dressing to right great toe." Review of the Visit Note Report dated 5/18/18 revealed narrative documentation of "wound care to R (right) Great Toe completed." Further review of the Visit Note Report dated 5/18/18 revealed no documenation of what wound care had been completed. Review of the HHC and POC dated 5/9/18 to 7/7/18 and physician orders dated 5/9/18 through 5/18/18 contained no documentation of physician orders for wound care to the right great toe. An interview was conducted on 9/26/18 at 10:35 AM with EI # 1 who confirmed the previous finding. 5. MR # 3 was admitted to the agency on 6/8/18 with diagnoses including Unspecified Fracture of Upper End of Right Humerus, Subsequent Encounter for Fracture with Routine Healing. Review of the HHC and POC dated 6/8/18 through 8/6/18 revealed a physician order for " Skilled nurse to provide/instruct/reinforce to client/caregiver wound care to wound # 2 Anterior Right Shoulder closed Surgical Incision as follows: ...cleanse daily starting 6/9/18 with antibacterial soap and water, pat dry with cloth, cover with gauze and secure with tape..." Review of the Visit Note Report dated 6/17/18 revealed documentation of wound care to wound # 2 as "Removed dressing for assessment. Replaced with dry gauze, secure with tape..." The 6/17/18 Visit Note Report revealed no documentation of how wound # 2 was cleansed and dried prior to the dry gauze application. An interview was conducted on 9/26/18 at 10:21 AM with EI # 1, who confirmed the previous findings.
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'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 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 review of medical records (MR) and interview with agency staff it was determined the agency failed to obtain and/or document verbal orders from the physician for all care provided for 2 of 17 records reviewed. This affected MR # 2 and # 4 and had the potential to negatively affect all patients receiving home health services. Findings include: 1. MR # 2 was admitted to the agency 2/9/18 with diagnoses including Traumatic Pneumothorax, Subsequent Encounter, Repeated Falls and Multiple Fractures of Ribs. Medical record review included a SN (skill nurse) Visit Note Report dated 3/16/18 which contained genitourinary system assessment documentation for dysuria and incontinence. The nurse documented obtained UA (urinalysis) via straight cath (catherization) due to dysuria. There was no physician's order documented for the SN to perform straight cath for UA collection. During an interview on 9/26/18 at 9:35 AM, Employee Identifier (EI) # 3, Performance Improvement Coordinator confirmed the aforementioned finding. 2. MR # 4 was admitted to the agency on 3/9/18 with diagnoses including Type 2 Diabetes Mellitus with Foot Ulcer and Non-Pressure Chronic Ulcer of Right Heel and Midfoot with Unspecified Severity. Review of the SN Visit Note Report dated 3/9/18 revealed narrative documentation of the Right Lateral Heel as "Spoke with (physician) and received for Doxycycline and wound culture..." Incomplete documentation in the MR, should say order for Doxycycline and wound culture. Review of the Visit Note Report dated 3/13/18 revealed narrative documentation of "C&S (culture and sensitivity) done and (physician identified) changed ABX (antibiotic) to Levofloxacin..." Record review of the physician verbal orders dated 3/9/18 through 3/13/18 revealed no documentation of a verbal order for the Culture of the Right Lateral Heel or the Doxycycline. The staff failed to document a complete physicians' order for wound culture to the Right Lateral Heel and Doxycycline in the medical record. An interview was conducted on 9/26/18 at 11:34 AM with EI # 1, Executive Director, 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 medical record (MR) review and interview with the staff it was determined the agency failed to ensure the physician was notified of changes in the patient's condition in 4 of 17 sampled records affecting home visit (HV) # 1 and # 4, MR # 1 and # 4 and had the potential to affect all patients served by the agency. Findings include: 1. HV # 1 was admitted to the agency 8/18/18 with diagnoses including Dizziness and Giddiness, Other Pancytopenia, Atherosclerotic Heart Disease, Old Myocardial Infarction, Personal History of Nicotine Dependency and History of Falling. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 8/18/18 to 10/16/18 included orders for the licensed professional to report vital signs falling outside parameters for temp (temperature) > 101, pulse 125, resp (respirations) (greater than) 26, systolic BP (blood pressure) 165, diastolic BP 90, pain > 6, O2 SAT(oxygen saturation) 350..." Review of the Visit Note Report dated 5/9/18 revealed the random FBS was "373" and the 5/9/18 narrative documentation revealed the "Patient has an open lesion to right foot in the area of an amputated right great toe" and the patient was "instructed on wet to dry dressing to right great toe." There was no documentation the physician was notified of FBS outside of ordered parameters or of the open lesion to the area of the right great toe. Review of the Visit Note Report dated 5/16/18 revealed the measurements of wound # 6 documented as "Length x (by) Width x Depth (CM) (centimeters) 4.5 x 0.5 x 0" and wound # 7 as "3 x 2 x 1." Review of the Visit Note Report dated 5/23/18 revealed wound # 6 measurements were documented as "5.5 x 0.1 x 0" and wound # 7 as "7 x 10 x 0.2." Further review of the Visit Note Report dated 5/23/18 revealed no documentation the physician was notified wound # 6 had increased length of 1 cm and wound # 7 had an increased length of 1.5 cm, an increased width of 9.9 cm and an increased depth of 0.1 cm. Review of the Vital Signs Report dated 6/13/18 revealed documentation the random FBS as "396." There was no documentation the physician was notified of FBS outside of ordered parameters. An interview was conducted on 9/26/18 at 10:35 AM with EI # 1, who confirmed the previous findings. 4. MR # 4 was admitted to the agency on 3/9/18 with diagnoses including Type 2 Diabetes Mellitus with Foot Ulcer and Non-Pressure Chronic Ulcer of Right Heel and Midfoot with Unspecified Severity. Review of the Physician Order form dated 3/21/18 revealed order for wound # 2 Right Foot, "Caregiver to cleanse Right Foot Ulcer with Vashe (brand of wound cleanser) and gauze, pat dry with gauze, apply Medihoney (wound treatment) to wound bed. Cover with gauze and rolled gauze. Secure with tape. Change daily..." Review of the Visit Note Report dated 3/23/18 revealed documentation the necrotic tissue amount to wound # 2 was "None". Review of the Visit Note Report dated 3/27/18 revealed documentation the necrotic tissue amount to wound # 2 was "50-<(less than)75%". There was no documentation the physician was notified wound # 2 had developed necrotic tissue. An interview was conducted on 9/26/18 at 11:34 AM with EI # 1, who confirmed the above finding.
G0606	Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on medical record (MR) reviews, agency policies and procedure and interviews, it was determined the agency staff failed to ensure all initial evaluations were completed to meet patient needs and according to agency policy. This included physical therapy (PT), occupational therapy (OT), speech therapy (ST) and Medical Social Services (MSW) services and affected HV's # 1 and # 2, MR's # 2, # 10, # 1, which was 5 of 11 records reviewed with therapy and MSW services ordered. This had the potential to affect all patients who received therapy and MSW services. Findings include: Policy Number: 2.1.002 Subject: Patient Assessment, Initial and Reassessment Revised Date: 02/01/18 ...Policy: All patients admitted to the agency will receive an initial assessment...the assessing clinician may obtain input from...other healthcare personnel... Procedure: c. Physical Therapist, Speech Therapist, Occupational Therapist, Medical Social Worker...may make initial evaluations of the patient status to determine the need for specific therapists. This initial discipline specific evaluation)s) will occur within 5 days from the referral or sooner if medically necessary... 7. Patient/caregiver will be notified of any changes in the Plan of Care, including notification in changes in services and frequency of visits. Documentation of such communication shall be evident in the medical record... ** Policy Number: 2.1.017 Subject: Coordination of care, From Admit thorough Discharge Revision Date: 01/01/18 Policy: ...provides care and services within an integrated continuum of care system...by: Identifying patient needs through assessment and communication with other health care providers Procedure: 3. During time of referral transfer, or discharge... a. Patients are referred to alternative agencies when the patient requires services that unable to be met by the agency and/or for continuing care needs. 4. Coordination of care with physician... b. When changes occur in caregiver support or the environment that affect patient treatment ...Coordination of care among disciplines: c. Appropriate, timely communication with the patient, caregivers, and staff involved in then patient's care regarding patient needs, goals, and care... d. Completed visit notes submitted...within 24 hours of visit... 7. Coordination of care with patient and caregiver: Written information obtained from the plan of care will be provided to the patient and caregiver outlining: a. Visit schedule including frequency of visits by agency staff... d. Pertinent instructions related to the patient's care and treatments...specific to the patient's needs ** 1. HV # 1 was admitted to the agency 8/18/18 with diagnoses including Dizziness and Giddiness, Other Pancytopenia, Personal History of Nicotine Dependency and History of Falling. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 8/18/18 to 10/16/18 included a physician's verbal order dated 8/28/18 for MSW to make a visit to assess community resources. Further review revealed a physician's order dated 8/31/18 to omit order for MSW Week of 8/26/18. MSW to EVAL (evaluation) week of 9/2/18. Review of the MSW documentation dated 9/4/18 revealed an add-on evaluation visit was completed 7 days after the initial MSW eval order was obtained. There was no documentation the MSW attempted to complete an evaluation visit within the 5 day period and no documentation the MSW communicated with HV # 2 regarding delay in services. In an interview on 9/26/18 at 9:35 AM, Employee Identifier (EI) # 3, Performance Improvement Coordinator confirmed the aforementioned findings. 2. HV # 2 was admitted to the agency 9/1/18 with diagnoses including Sepsis due to Escherichia Coli, Bacteremia and History of Falling. Review of the HHC and POC dated 9/1/18 to 10/30/18 included a physician's verbal order dated 9/6/18 for MSW to eval for any services to assist patient with ADL (activities of daily living). Record review revealed a physician's order dated 9/7/1818 to reschedule MSW eval scheduled for week of 9/3/18 to 9/10/18 due to unable to schedule time with patient. There was no documentation the MSW attempted to schedule an eval visit with the patient. Review of the record revealed a physician's order dated 9/11/18 to reschedule MSW eval to week of 9/17/18 due to scheduling conflict. There was no documentation the MSW attempted to schedule an eval visit with the patient. On 9/18/18, which was 12 days after the initial MSW eval order dated 9/6/18, the MSW completed an add-on evaluation visit. There was no documentation the MSW attempted evaluation visits within the 5 day period and no documentation the MSW communicated with HV # 2 regarding the delay in services. In an interview conducted on 9/26/18 at 10:10 AM, EI # 1, Executive Director confirmed the above findings. 3. MR # 2 was admitted to the agency 2/9/18 with diagnoses including Traumatic Pneumothorax, Subsequent Encounter, Repeated Falls and Multiple Fractures of Ribs. Review of the HHC and POC dated 2/9/18 to 4/9/18 revealed physician orders for OT (evaluation) effective 02/18/18 1 WK (week) 1 (one visit for one week). Record review included documentation the OT Add-on Evaluation was completed on 2/21/18 which was 12 days after the start of care visit identified need for OT services. There was no documentation why the OT evaluation was scheduled 9 days after the start of care and not within 5 days per agency policy. There was no documentation the OT attempted to schedule the OT eval, the patient/caregiver refused the care and no documentation the delay on OT services was agreed upon by the patient/caregiver. During an interview on 9/26/18 at 9:35 AM, EI # 3, confirmed the aforementioned finding. 4. MR # 10 was admitted to the agency 9/7/18 with diagnoses including Hemiplegia Following Cerebral Infarct Affecting Left Nondominant Side and History of Falling. Review of the HHC and POC dated 9/7/18 to 11/5/18 included physician orders PT 1 WK 1 effective 9/16/18. There was no documentation why the PT evaluation was effective 9 days after the admission and no documentation the delay in PT services was reviewed with the patient/caregiver and agreed upon. Further review of the 9/7/18 HHC and POC revealed orders for Speech Therapy to evaluate/assess and develop speech therapy (ST) plan of care that will be approved by the physician prior to implementation. Record review revealed MR # 10 had a fall in the home on 9/12/18. Medical record review revealed a physician verbal order dated 9/13/18 with the following order description documented: ST eval to be moved to week of 9/23/18, message left at physicians office. There was no documentation the patient/caregiver was notified and agreed to the ST eval delay. The PT Add-On Evaluation was completed 9/18/18, 11 days after the start of care comprehensive assessment was completed and identified MR # 10's need for PT services. As of the record review date of 9/24/18 and 16 days after the comprehensive assessment identified MR # 10's need for ST services, there was no documentation ST had completed the evaluation. In an interview conducted on 9/26/18 at 11:30 AM, EI # 2, Clinical Director, confirmed the staff failed to document therapy service delays were agreed upon by the patient/caregiver and the staff failed to complete therapy evaluations per agency policy. 5. MR # 1 was admitted to the agency 5/9/18 with diagnoses including Encounter for Surgical Aftercare Following Surgery on the Circulatory System and Encounter for Orthopedic Aftercare Following Surgical Amputation. Review of the HHC and POC dated 5/9/18 to 7/7/18 revealed a physician's order for "Occupational Therapy (OT) to Evaluate/Assess and Develop OT Plan of Care..." with a frequency of "OT effective 5/13/18 1w1 (once a week for one week)". Review of the Client Coordination Note Report dated 5/18/18 revealed OT documentation of, "PCM (Patient Care Manager) - see patient next week for OT evaluation. No answer." Review of the Client Coordination Note Report dated 5/23/18 revealed OT documentation of, "Missed visit on 5/18/18, Reason no answer door/phone..." Further record review revealed no documentation the OT attempted an eval visit within the 5 days period or communicated with MR # 1 regarding delay in OT services. Review of the physician's order dated 5/18/18 revealed physician's order for "patient to be evaluated by OT week of 5/20/18. Frequency 1w1..." Record review revealed no documentation the OT attempted an eval visit or communicated with MR # 1 regarding delay in services from 5/20/18 to 6/6/18. Review of the physician's order dated 6/7/18 revealed the following physician's order, "Omit OT evaluation at patient request..." An interview was conducted on 9/26/18 at 10:33 AM with EI # 1, Executive Director, who confirmed the aforementioned finding.
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 review of agency policies, Centers for Disease Control (CDC) Guidelines, observations and interviews, it was determined the agency staff failed to follow their policies and CDC guidelines for hand hygiene, bedbath and equipment cleaning in 2 of 7 home visits (HV) completed. This affected HV's # 4 and # 7 and had the potential to negatively affect all patients admitted to this agency. Findings include: Policy: Hand Hygiene - CDC (Centers for Disease Control) Guidelines Last Updated: November 5, 2015 1. Rational For Hand Hygiene: Potential risks of transmission of microorganisms to patients. Potential risks of health-care workers colonization or infection caused by organisms acquired from the patient. Contact with the patient's intact skin (e.g., taking pulse or blood pressure, performing physical examinations, lifting the patient in bed). Contact with environmental surfaces in the immediate vicinity of patients. After glove removal. 2.. Recommendations: Indications For handwashing and hand antisepsis: A. When hands are visibly dirty or contaminated. C. Decontaminate hands before having direct contact with patients. F. Decontaminate hands after contact with patient's intact skin (e.g., taking pulse or blood pressure, performing physical examinations, lifting the patient in bed). H. Decontaminate hands if moving from a contaminated - body site to a clean - body site during patient care. I. Decontaminate hands after contact with inanimate objects ( including medical equipment) in the immediate vicinity of the patient. J. Decontaminate hands after removing gloves. **** Policy: Clinical Skills Bathing: Bed Bath Date: August 2018 "Complete or Partial Bed Bath 16. Provide pernieal care. Perform perineal care during the daily bath...For a male patient, cleanse around the penis...For a female patient, cleanse the outer and inner labia. Cleanse, rinse, and dry the area throughly..." 1. HV # 4 was admitted to the agency on 8/26/18 with diagnoses of Cellulitis of Right Lower Limb, Type II Diabetes Mellitus with Diabetic Chronic Kidney Disease. A home visit was conducted on 9/24/18 at 2:27 PM with Employee Identifier (EI) # 5, Registered Nurse, to observe PICC (Peripherally Inserted Central Catheter) care. After EI # 5 collected the ordered labs, labeled and placed tubes in the bio hazard bag, EI # 5 removed gloves and sanitized hands. EI # 5 changed the port on the PICC line, removed gloves and sanitized hands then documented on the computer tablet. After completing the documentation, EI # 5 donned gloves without first completing hand hygiene. During the PICC dressing change, EI # 5 removed supplies from the barrier causing the hand sanitizer bottle to fall on the floor. EI # 5 removed glove, used a different bottle of hand sanitizer to sanitize hands, then retrieved the hand sanitizer bottle from the floor and placed the sanitizer on the barrier with the PICC dressing supplies. After the PICC dressing change was complete, EI # 5 used the bottle of hand sanitizer which was on the floor to sanitize hands. EI # 5 did not clean the bottle or lid prior to placing on barrier and before using to sanitize hands. An interview was conducted on 9/24/18 at 3:30 PM with EI # 1 who confirmed the above mentioned findings. 2. HV # 7 was admitted to the agency on 9/22/18 with diagnoses including Pressure Ulcer of Sacral Region, Unspecified Stage. A HV was conducted on 9/26/18 at 8:36 AM with EI # 7, Home Health Aide (HHA) for the observation of a bed bath. After taking HV # 7's blood pressure and temperature, EI # 7 removed a personal cell phone from his/her uniform pocket and touched the cell phone screen for several minutes. EI # 7 checked HV # 7's pulse rate using the cell phone to time the pulse. EI # 7 failed to clean cell phone or perform hand hygiene after touching contaminated equipment. EI # 7 placed cell phone on a barrier with the used blood pressure cuff, stethoscope, and thermometer. EI # 7 cleaned blood pressure cuff, stethoscope, and thermometer with wipe and replaced equipment in the nursing bag. EI # 7 then obtained the cell phone from barrier and placed in uniform right pocket. EI # 7 failed to clean cell phone prior to placement in uniform pocket. EI # 7 obtained bath supplies and bathed the patient's arms, chest, legs, and left side of back. EI # 7 then removed patient's diaper, washed the pubic area and inguinal groin areas and turned patient to the left side. EI # 7 washed the right buttock and outer labia, then turned HV # 7 onto his/her back and assisted the patient with placement of a new diaper. EI # 7 failed to clean inner labia and left buttock during the bed bath. An interview was conducted on 9/26/18 at 10:30 AM with EI # 1, who confirmed staff failed to clean all equipment used during the visit and follow the agency bed bath procedure.
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 agency policy, medical records (MR), and interviews, it was determined the agency failed to ensure: 1. Wound reassessments were conducted at least weekly and included measurements. 2. Documentation of the wound vac (Negative Pressure Wound Therapy, NPWT) dressing change to included the number of foam pieces removed and applied to wound. This affected 4 of 12 records reviewed with wounds including MR # 10, # 5, # 1 and # 4 and had the potential to affect all patients admitted to the agency with wounds. Findings include: Policy: Wound Assessment, Documentation, and Photography Policy Number: 2.2.0001 Revised: 9/1/17 "Purpose: To ensure the accurate and consistent assessment and documentation of wounds Policy: Upon initial visit and subsequently as indicated below, all wounds will be assessed with appropriate documentation within the medical record. ...Unless otherwise ordered by the physician, the Registered Nurse (RN) will assess wounds at least: Weekly for patient receiving negative pressure wound therapy, receiving daily wound care performed by the agency, have an infected wound, or have stage IV (4) pressure injury... ...The assessment includes measurement of the length, width and depth, undermining and tunneling, wound bed description, wound edges, exposed tissue types, drainage and the condition of the periwound. At each dressing change, the clinician should record the wound bed description, wound edges, exposed tissue types, drainage and the condition of the periwound..." *** Policy: Negative Pressure Wound Therapy (NPWT) Policy Number: 2.2.007 Revised Date: 9/1/17 Purpose: To promote wound healing and establish competency assessment guidelines when utilizing negative pressure wound therapy. Procedure: 2. Perform procedure utilizing LHC adopted clinical guidelines. 3. The dressing will be labeled with the date and time of application, clinician's initials, and number of foam/sponge pieces placed in the wound. 4. The clinician will document the number of foam/sponge pieces placed in the wound bed and the number of foam/sponge pieces removed from the wound bed. ** 1. MR # 10 was admitted to the agency 9/7/18 with diagnoses including Hemiplegia Following Cerebral Infarct Affecting Left Nondominant Side and History of Falling. Record review revealed a physician order dated 9/12/18 for a Registered Nurse (RN) visit for followup up after a fall with injury and daily wound care to wound # 1 left great (Toe) superficial trauma and wound # 2 left patellar superficial trauma, clean with soap and water, dry and apply triple antibiotic ointment, leave open to air. The 9/12/18 RN Visit documentation revealed wound # 1 measured 1.5 cm (centimeters) length (L) x (by) 1 cm width (W) x 0.1 cm depth (D) and wound # 2 measured 2 cm L x 1.5 cm W x 0.1 cm D. Review of the weekly nurse visit dated 9/19/18 revealed wound assessments were completed but the nurse failed to document wound measurements for wounds # 1 and wound # 2. In an interview conducted on 9/26/18 at 11:30 AM, Employee Identifier (EI) # 2, Clinical Director confirmed there were no wound measurements documented the week of 9/12/18. 2. MR # 5 was admitted to the agency on 5/25/18 and recertified for continued care on 7/24/18 to 9/21/18 and with diagnoses of Type II Diabetes Mellitus With Other Specified Complications and Other Acute Osteomyelitis, Right Ankle and Foot. Review of the physician order dated 7/30/18 the patient was receiving wound care to the right ankle and foot using the wound vac as ordered: Remove old dressing with number of pieces of foam removed, cleanse wound with Saf Clens or Normal Saline and gauze, using window pane technique, apply black foam to wound bed noting number of foam applied, apply wound vac at negative 125 mmHg (millimeters of mercury) continuous setting 3 times per week. Review of the skilled nurse visits (SN) for the week of 8/12/18 to 8/18/18 and the week of 8/26/18 to 9/1/18 revealed no wound measurements documentation. Review of the SN visit note dated 8/15/18 revealed the nurse failed to document the number of foam pieces removed, the color foam removed and how many pieces of foam were applied. An interview was conducted on 9/26/18 at 9:50 AM with EI # 2, Clinical Director, who confirmed the above mentioned findings. 3. MR # 1 was admitted to the agency 5/9/18 with diagnoses including Encounter for Surgical Aftercare Following Surgery on the Circulatory System and Encounter for Orthopedic Aftercare Following Surgical Amputation. Review of the Physician Order form dated 5/16/18 revealed the following order "clean R (right) heel with NS (normal saline) and gauze, pat dry with gauze, apply wet to dry dressing. cover with rolled gauze, secure with tape. Dressing to be changed daily." Review of the Visit Note Report dated 5/16/18 revealed narrative documentation of "Patient has a new wound to back of R Heel. Measurement not done..." Review of the Visit Note Report dated 5/18/18 revealed narrative documentation of "Patient has wound on R Heel 3 x 3 x 0 applying wet to dry dressing, wrapping with rolled gauze secured with tape." The Visit Note Reports(s) dated 5/16/18 and 5/18/18 revealed no wound assessment documentation for the R Heel wound bed description, presence or absence of undermining and tunneling, wound edges, exposed tissue types, drainage or condition of the periwound tissue. An interview was conducted on 9/26/18 at 10:35 AM, with EI # 1, Executive Director who confirmed the previous findings. 4. MR # 4 was admitted to the agency on 3/9/18 with diagnoses including Type 2 Diabetes Mellitus with Foot Ulcer and Non-Pressure Chronic Ulcer of Right Heel and Midfoot with Unspecified Severity. Review of the Client Coordination Note Report dated 3/18/18 revealed documentation of "...Caregiver called. Patient has been off of Aricept for 1 week due to interaction... She/He is weak and shaking and keeps sliding out of wheelchair. There is no one in the home capable of taking care of patient..." Review of the Physician Order form dated 3/21/18 revealed an order to "Cleanse Stage I PU (pressure ulcer) to left buttock with soap and water, pat dry, apply Calazime Daily and prn (as needed) with each incontinent episode." Review of the Visit Note Report dated 3/21/18 revealed narrative documentation of "Patient has new stage I PU to buttock..." Further review of the Visit Note Report dated 3/21/18 revealed no documentation of the left buttock wound bed description, measurements of the wound, if undermining and tunneling were present, wound edges, exposed tissue types, drainage of wound, condition of the periwound, or if wound care was provided. Review of the Visit Note Report dated 3/23/18 revealed narrative documentation of "CG (caregiver) did wound care and demonstrated correctly." Further review of the Visit Note Report dated 3/23/18 revealed no documentation of the left buttock wound bed description, measurements of the wound, if undermining and tunneling were present, wound edges, exposed tissue types, drainage of wound, condition of the periwound, or what wound care was provided by the caregiver. An interview was conducted on 9/26/18 at 11:34 AM with EI # 1, who confirmed the previous findings.
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 review medical records (MR) and interviews, it was determined the agency staff failed to follow the physician's plan of care which included: 1. Oxygen saturation monitoring as ordered. 2. Completion of nurse visit as ordered. This affected 3 of 17 MR's reviewed, including MR # 10, # 4 and Home Visit (HV) # 1 and had the potential to negatively affect all patients admitted to this agency. Findings include: 1. MR # 10 was admitted to the agency 9/7/18 with diagnoses including Hemiplegia Following Cerebral Infarct Affecting Left Nondominant Side and History of Falling. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 9/7/18 to 11/5/18 revealed orders for the skill nurse to obtain O2 SAT (oxygen saturation) on room air via pulse oximeter every SNV (skill nurse visit). Review of the 9/7/18 Registered Nurse (RN) Admission visit note report failed to contain documentation the O2 SAT monitoring was completed on admission as ordered in the POC. Review of the 9/12/18 RN Visit failed to reveal documentation the nurse completed O2 SAT monitoring as ordered in the POC. During an interview conducted on 9/26/18 at 11:30 AM, Employee Identifier (EI) # 2, Clinical Director confirmed the findings above. 2. HV # 1 was admitted to the agency 8/18/18 with diagnoses including Dizziness and Giddiness, Other Pancytopenia, Personal History of Nicotine Dependency and History of Falling. Review of the HHC and POC dated 8/18/18 to 10/16/18 contained orders for the skill nurse to obtain O2 SAT on room air via oximeter on admission and with decline in respiratory status. Review of the 8/18/18 RN Admission visit note report failed to contain documentation the O2 SAT monitoring was completed as ordered in the POC. In an interview on 9/26/18 at 9:35 AM, EI # 3, Performance Improvement Coordinator confirmed the aforementioned finding. 3. MR # 4 was admitted to the agency on 3/9/18 with diagnoses including Type 2 Diabetes Mellitus with Foot Ulcer and Non-Pressure Chronic Ulcer of Right Heel and Midfoot with Unspecified Severity. Review of the physician order dated 3/19/18 revealed order for "SN (skilled nurse) to make visit 3/20/18 to assess wound and instruct on changed wound care..." Review of all the Visit Note Report(s) dated 3/20/18 revealed no documentation a SN visit was made on 3/20/18 as ordered. An interview was conducted on 9/26/18 at 11:34 AM with EI # 1, Executive Director, who confirmed a SN visit was not made on 3/20/18 as ordered by the physician.
G1014	Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on review agency policy and procedure, medical records (MR), and interview it was determined the staff failed to prepare clinical note documentation that included all interventions and services provided to meet patient needs. This affected Home Visits (HV) # 1 and # 2, which was 2 of 7 HV's conducted and had the potential to affect all patients admitted to the agency. Findings include: Policy Number: 2.1.017 Subject: Coordination of care, From Admit thorough Discharge Revision Date: 01/01/18 Policy: ...provides care and services within an integrated continuum of care system...by: Identifying patient needs through assessment and communication with other health care providers Procedure: 3. During time of referral, transfer, or discharge... a. Patients are referred to alternative agencies when the patient requires services that unable to be met by the agency and/or for continuing care needs. ...b. When changes occur in caregiver support or the environment that affect patient treatment c. Appropriate, timely communication with the patient, caregivers...involved in the patient's care regarding patient needs. goals, and care... 6. Coordination of services with other organizations and community: When the patient receives services from other organizations and/or individuals care is coordinated to ensure that patient's needs are met...without duplication of services... 7. Coordination of care with patient and caregiver: Written information obtained from the plan of care will be provided to the patient and caregiver... d. Pertinent instructions related to the patient's care and treatments...specific to the patient's needs... **** 1. HV # 1 was admitted to the agency 8/18/18 with diagnoses including Dizziness and Giddiness, Other Pancytopenia, Personal History of Nicotine Dependency and History of Falling. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 8/18/18 to 10/16/18 included a physician's verbal order dated 8/28/18 for MSW to make a visit to assess community resources. Further review revealed another physician's order dated 8/31/18 to omit order for MSW Week of 8/26/18. MSW to EVAL (evaluation) week of 9/2/18. The add-on evaluation MSW visit dated 9/4/18 was completed 7 days after the initial MSW eval order obtained and revealed HV # 1 has no caregiver, lives alone in a cluttered soiled living area, cannot physically do laundry, housekeeping, prepare meals consistently, requested assistance in accessing provider/homemaker services, worries about having a heart attack and being at home alone and grieves for deceased spouse who passed away less than 3 months ago. The MSW documentation dated 9/4/18 revealed community services needed were meals on wheels and volunteer services. The MSW documented care coordination occurred with the patient for community resources and documented "instructed the patient regarding support networks available in the community, including meals on wheels and homemaker services. " There was no documentation the MSW notified or communicated with any outside community resources including meals on wheels, volunteer and homemaker services which were identified as patient needs. In an interview conducted on 9/26/18 at 9:35 AM, Employee Identifier (EI) # 3, Performance Improvement Coordinator confirmed the aforementioned findings. 2. HV # 2 was admitted to the agency 9/1/18 with diagnoses including Sepsis due to Escherichia Coli, Bacteremia and History of Falling. Record review of the HHC and POC dated 9/1/18 to 10/30/18 included a physician's verbal order dated 9/6/18 for MSW to eval for any services to assist patient with ADL (activities of daily living). On 9/18/18, which was 12 days after the initial MSW eval order dated 9/6/18, the MSW completed an add-on evaluation visit. The 9/18/18 MSW documentation revealed HV # 2 has no caregiver, lives alone in a cluttered soiled living area, no willing or able caregiver to access food, cannot physically do housekeeping, prepare meals. HV # 2 requested assistance in accessing provider/homemaker services and was interested in meals on wheels. The 9/18/18 MSW documentation revealed community services needed were meals on wheels, volunteer services and charitable organizations. The MSW documented care coordination occurred with the patient, discussed community resources, provided the community resource list and instructed the patient regarding support networks available in the community, including meals on wheels and homemaker services. The MSW documented in a Client Coordination Note Report dated 9/18/18 no follow-up needed at this time. There was no documentation the MSW notified or communicated with any outside community resources, meals on wheels, volunteer and charitable organizations for assistance in meeting the patient's identified needs. In an interview on 9/26/18 at 10:10 AM, EI # 1, Executive Director confirmed the above findings.
G1022	Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the 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) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on review of agency policy, medical record (MR) and staff interview, it was determined the staff failed to complete and send a transfer summary for unplanned inpatient transfers per agency policy. This affected 1 of 3 transfer records reviewed which included MR # 2 and had the potential to affect all patients admitted to the agency. Findings include: Policy Number: 2.1.004 Subject: Patient Discharge/Transfer Revision Date: 03/01/18 Purpose: To ensure continuity of care when a patient is...transferred... Procedure... 14. A Transfer Summary is sent to the primary care physician and the facility to which the patient is transferred within 2 business days..or becoming aware of unplanned transfer. This form includes agency name, transfer date...patient's condition, summary of care treatment, services provided to the patient, the patient's progress towards goals...advance directives...diagnoses, current list of medications... 1. MR # 2 was admitted to the agency on 2/9/18 with diagnoses including Traumatic Pneumothorax, Subsequent Encounter, Repeated Falls and Multiple Fractures of Ribs. Medical record review revealed a Client Coordination Note Report dated 2/23/18 with documentation the patient was admitted to the local inpatient hospital on 2/22/18 for a fall/possible pneumothorax. There was no documentation agency staff completed a transfer summary to facility to which the patient is transferred within 2 business days per policy. In an interview conducted on 9/26/18 at 9:35 AM, Employee Identifier # 3, Performance Improvement Coordinator, confirmed the aforementioned finding.