Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 017027	(X3) Date Survey Completed 07/14/2022
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 7/14/22, Decatur Morgan Homecare was found to be in substantial compliance with the standards 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 medical records (MR), observations, policy and procedure, and interviews with staff, it was determined the agency failed to update the patients medication profile, and review the profile in order to identify any potential adverse effects. This affected four of seven Home Visits (HV) conducted, including HV # 2, HV # 3, HV # 6, and HV # 4, and had the potential to affect all persons served by the agency. Findings include: Agency Policy: Monitoring Medications Policy number: 10.008 Revised date: 05/01/19 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... Procedure: 1. The discipline responsible for the drug regimen review will: ...b. Review all medications including over the counter medications, vitamins, herbs, and herbal products, creams and topical ointments... to identify issues such as: ...iv. Drug allergies; ...vii. Duplicate drug therapy; ...2. All clinicians participating in the patient's care are responsible to assist with the maintenance of accurate patient medication information throughout the episode of care... a. Through a collaborative process the care team will: i. Compare medications patient is currently taking with medications ordered for the patient in order to identify and resolve discrepancies. 2. HV # 3 was admitted to the agency on 6/25/22 with diagnoses including Encounter for Changes or Removal of Nonsurgical Wound Dressing and Type 2 Diabetes with Diabetic Peripheral Angiopathy without Gangrene. Review of the HHC and POC dated 6/25/22 to 8/23/22 revealed an order for SN one time a week for one week, two times a week for eight weeks and 1 time a week for 1 week. A HV was conducted 7/12/22 at 2:42 PM to observe care provided by EI # 5, License Practical Nurse (LPN). During the HV, HV # 3's medications were compared to the ML provided to the surveyor on 7/12/22 by the agency. The following discrepancies were observed: a. Lunesta 3 mg take one tablet at bedtime, with fill date of 6/22/22 was observed with HV # 3's medications and was not on the ML. The patient stated, he/she has been taking at night as ordered, since medication filled. b. Oxybutynin ER 10 mg take one tablet two times a day, with fill date of 6/9/22 was observed with HV # 3's medications and was not on the ML. The patient stated, he/she has been taking almost a year. c. Bydureon Bcise 2 mg/0.85 ml (milliliters) Subcutaneous (SQ) Auto-Injector, inject 2 mg SQ every seven days, with fill date of 6/9/22 was observed with HV # 3's medications and was not on the ML. Patient stated, he/she gives self shot in abdomen every Wednesday for almost a year. An interview was conducted on 7/14/22 at 11:45 AM with EI # 1, who confirmed the medications had not been reconciled per agency's policy. 3. HV # 6 was admitted to the agency on 1/12/22 with diagnoses including Spinal Stenosis, Lumbosacral Region and Anxiety Disorder, Unspecified. Review of the HHC and POC dated 7/11/22 to 9/8/22 revealed an order for Physical Therapy (PT) one time a week for four weeks. A HV was conducted 7/12/22 at 12:00 PM to observe care provided by EI # 6, License Physical Therapy Assistant (LPTA). EI # 7, Patient Care Manager (PCM) was also present during visit. During the HV, HV # 6's medications were compared to the ML provided to the surveyor on 7/12/22 by the agency. The following discrepancies were observed: a. Linzess 290 mcg capsule, take one capsule every AM was observed on ML. HV # 6 stated, he/she stopped that medication about three months ago. b. Tizanidine 4 mg tablet, take one tablet daily was listed on ML. The instructions on the bottle read take as needed. HV # 6 stated, he/she is taking medication as written on bottle. c. MetaMucil 25 mg, over the counter (OTC), individual packets was observed with HV # 6 medications and not on ML. HV # 6 stated, he/she has been taking medication as needed for about four and one half years. An interview was conducted on 7/14/22 at 11:09 AM with EI # 1, who confirmed the medications had not been reconciled per agency's policy. 4. HV # 4 was admitted to the agency on 5/17/22 with diagnoses including Infection/Inflammation Reaction Due To Internal Right Hip Prosthesis and Essential Primary Hypertension. Review of the HHC and POC dated 5/17/22 to 7/15/22 revealed an ordered SN visit frequency of one time a week for nine weeks. A HV was conducted on 7/13/22 at 10:22 AM to observe care provided by EI # 2, Registered Nurse (RN). EI # 1, Executive Director (ED) was also present. During the HV a comparison was made between the ML provided by the agency on 7/12/22, and medications observed in the home. The following discrepancies were observed: a. Benadryl 25 mg capsule, one capsule at bedtime was on the ML. The patient stated for the last six months to a year, he/she had only taken the Benadryl as needed for itching, and took two capsules, not one. b. Ferrous Sulfate 324 mg (65 mg iron) delayed release tablet, one tablet daily was on the ML. The patient stated he/she had stopped taking the iron supplement at least three weeks ago when he/she started receiving the intravenous (IV) antibiotics. c. The following medications were observed in the home, and not on the ML: - Over the counter (OTC) Pepto Bismol chew tabs. The patient stated he/she has taken the Pepto Bismol for a couple of years, whenever spicy food eaten. - OTC Lactaid 9000 unit capsules. The patient stated he/she has taken the lactaid for four to six years, whenever eating ice cream. - Bottle of Lorazepam 0.5 mg tabs with fill date 6/11/22. The patient stated he/she has been taking lorazepam for thirty two years, and used to take them every day, but currently takes as needed. - Bottle of Ibuprofen 800 mg with fill date 11/13/19, take one tab three times daily as needed. The patient stated he/she takes the ibuprofen as needed. - Bottle of Timolol 0.5 % eye drops, with fill date 3/4/22. The patient stated he/she currently places one drop in each eye two times daily. -Bottle of Dorzolamide 22.3/6.8 mg eye drops, with fill date 3/4/22. The patient stated he/she currently places one drop in each eye two times daily. -Ondansetron 4 mg tablets with fill date 4/9/21. The patient stated he/she takes the tablets as needed for nausea. Further review of the ML revealed Clonidine HCL (hydrogen chloride) 0.1 mg tablet, take as needed for high BP (blood pressure) as an active medication. Review of the drug allergies also on the ML had Clonidine listed as an allergy. In an interview conducted 7/14/22 at 11:22 AM, EI # 1 confirmed the agency failed to update the patient's medication profile per policy, and review all the medications the patient was currently using in order to identify any potential adverse effects. 1. HV # 2 was admitted to the agency on 6/29/22 with diagnoses including Crohn's Disease, Unspecified, Without Complications, and Essential (Primary) Hypertension. Review of the Home Health Certification (HHC) and Plan of Care (POC), dated 6/29/22 to 8/27/22, revealed a Skilled Nurse (SN) frequency of one time a week for 9 weeks., and a PT (Physical Therapist) ordered frequency of two times a week for one week. An additional order was observed for PT, dated 7/4/22, for one time a week for one week, then two times a week for four weeks. A HV was conducted on 7/12/22 to observe services provided by Employee Identifier (EI) # 3, MSW (Medical Social Worker). EI # 1, Executive Director, was also present during the visit. Prior to the HV, the surveyor received a copy of the current Medicine List (ML) dated 7/12/22. The ML was compared to the medications in the home, and the following discrepancies were observed: a. Dicyclomine 20 mg (milligrams) tablet (tab), one tab three times daily was on the ML. The bottle in the home read two times daily, and date filled was 2/4/22. The patient confirmed the dose, and stated, "I take them as needed." b. Losartan 100 mg tab, one tab daily, was on the ML. The bottle in the home read Losartan 25 mg, one tab daily. Date filled was 2/9/22. c. Ondansetron 8 mg tab, one tab every eight hours as needed was on the ML. The bottle in home read twice daily as needed and date filled was 12/19/19. The patient confirmed she/he used this bottle currently. d. Vitamin C 1,000 mg tab, one tab daily was on the ML. The bottle in the home read 250 mg and HV # 2 stated she/he takes two daily, for the past six weeks. e. Effexor ER (Extended Release) 75 mg tab, one every morning and two every evening. Date filled was 7/5/18. The patient stated she/he takes them when she/he needs them, and is currently taking one tab twice a day. g. Acyclovir 800 mg tab, one tab twice daily prn was in the home, and not on the ML. Date filled was 6/14/19. HV # 2 stated she/he used the medication for herpes flare ups. h. Budesomide 3 mg tab, one tab three times a day prn, was in the home and not on the ML. Date filled was 6/20/19. HV # 2 stated she/he used the medication for Crohn's disease flare ups. The discrepancies were confirmed onsite with EI # 1, who was present on the HV.
G0578	Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on review of medical records (MR), policy and procedure, and interviews, it was determined the agency failed to ensure staff followed physician orders for performing wound care. This affected two of six active records reviewed with patients with wounds, which included MR # 1, and MR # 3, and had the potential to affect all patients with wounds, served by the agency. Findings include: Agency Policy: Plan of Care Policy number: 2.1.007 Revised Date: 12/01/21 Purpose: ...To ensure that physician... orders are followed. Policy: Each patient has an individualized Plan of Care (POC) developed in consultation with the patient, physician... and staff that integrates comprehensive assessment findings to address patient problems, needs, and goals... Procedure: ...2. The POC includes: ...f. Medications and treatments. ...n. All patient care orders. ...7. Medications, treatments, and interventions are provided by qualified agency staff as ordered by the physician... 1. MR # 1 was admitted to the agency on 6/1/22 with diagnoses including Pressure Ulcer of Right Buttock, Stage 2 (two), and Hypertensive Heart and Chronic Kidney Disease with Heart Failure... Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 6/1/22 tp 7/30/22 revealed a SN (Skilled Nurse) frequency of one time a week for one week, two times a week for one week, and one time a week for seven weeks. Review of the MR revealed a new physician's order dated 6/8/22 with the following wound care: "# 12 low buttock rt (right) PU (Pressure Ulcer) II (Stage two)- Apply Mepilex border twice weekly and as needed. Goal: Wound to show signs of healing within seven to 10 days." Review of the SN Visit note dated 6/9/22 revealed the nurse documented the following wound care to wound # 12: "Cleansed with wound cleanser and gauze, patted dry with gauze, applied barrier cream to periwound. Covered with foam dressing using clean technique..." The new order did not include instructions to clean the wound with wound cleanser, or apply barrier cream to periwound. Review of the SN Visit Note dated 6/23/22 revealed the SN documented the following wound care to wound # 12: "Applied Mepilex border. Cleansed with wound cleanser and gauze, patted dry with gauze, applied barrier cream to periwound. Covered with foam dressing using clean technique..." The order did not include instructions to clean the wound with wound cleanser, or apply barrier cream to periwound. Review of the MR revealed the following new wound care order dated 6/30/22: "# 12 Low buttock rt PU II - Apply Medihoney to wound bed then cover with Mepilex border twice weekly and as needed. Goal: Wound to show signs of healing within seven - 10 days." Review of the SN Visit Note dated 7/5/22 revealed the SN documented the following wound care to wound # 12: "Applied Mepilex border. Cleansed with wound cleanser and gauze, patted dry with gauze, applied barrier cream to periwound. Covered with foam dressing using clean technique..." The SN failed to apply Medihoney to wound bed as ordered. Review of the SN Visit Note dated 7/11/22 revealed the SN documented the following wound care to wound # 12: Cleansed with wound cleanser and gauze, patted dry with gauze, applied barrier cream to periwound. Covered with foam dressing using clean technique..." The SN failed to apply Medihoney to wound bed as ordered. An interview was conducted on 7/14/22 at 10:52 AM with Employee Identifier (EI) # 1, Executive Director, who confirmed staff failed to perform wound care as ordered. 2. MR # 3 was admitted to the agency on 6/20/22 with diagnoses including Type 2 Diabetes Mellitus with Other Specified Complications, and Other Acute Osteomyelitis, Left Ankle and Foot. Review of the HHC and POC dated 6/20/22 to 8/18/22 revealed a SN frequency of three times a week for eight weeks, then two times a week for one week. Review of the MR revealed the following new wound care order dated 6/28/22, "Skilled nurse to cleanse wound # 3 left lateral foot with wound cleanser. Prepare periwound area with transparent drape. Fill entire cavity with foam. Cover with transparent drape and apply tubing. Apply negative pressure device at 125 mm/Hg (millimeters of Mercury) continuous. Wrap with rolled gauze and elastic bandage. Dressing to be changed every Mon (Monday), Wed (Wednesday), Fri (Friday). Skilled Nurse to cleanse wound # 2 left lateral foot and wound # 1 left proximal foot with wound cleaneser (cleanser). Pat dry with gauze. Apply wet to dry dressing and abd (abdominal) pad. Wrap with rolled gauze." Review of the SN Visit Note dated 7/4/22 revealed the nurse documented the following care for wound # 2: "Cleansed with wound cleanser and gauze. Patted dry with gauze. Prepared periwound area with transparent drape. Filled entire cavity with foam. Covered with transparent drape and applied tubing. Applied negative pressure device at 125 mm/Hg continuous. Tolerated well with no complaints." The SN failed to perform the correct wound care to wound # 2, as ordered. Further review of the SN Visit Note dated 7/4/22 revealed the nurse documented the following care for wound # 3: "Cleansed wound with wound cleanser. Prepared periwound area with transparent drape. Filled entire cavity with foam. Covered with transparent drape and applied tubing. Applied negative pressure device at 125 mm/Hg continuous. Wrapped with rolled gauze and elastic bandage. Cleansed with wound cleanser and gauze. Patted dry with gauze. Applied wet to dry dressing and abd pad. Wrapped with rolled gauze. Secured with ace wrap. Tolerated well." The surveyor was unable to determine if the wound care performed on wound # 3 was performed as ordered. An interview was conducted on 7/14/22 at 11:59 AM with EI # 1, who confirmed staff failed to perform wound care as ordered.
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 or allowed practitioner. This ELEMENT is not met as evidenced by: Based on medical record (MR) review, policy and procedure, and interview, it was determined the home health agency failed to obtain a physician order prior to administering a medication. This deficient practice affected one of twelve active records reviewed, including Home Visit (HV) # 4, and had the potential to affect all patients served by the agency. Finding include: Agency Policy: Physician Orders Policy Number: 2.1.008 Revision Date: 11/01/21 Purpose: To outline the process of receiving and documenting physician or authorized practitioner orders. Policy: No medications, treatments, diagnostic studies or therapeutics will be administered without the order of a qualified physician or authorized practitioner, ...and that order be reduced to writing and signed/dated by the ordering physician. Procedure: ...10. Services are provided according to the most recent orders updating the patient's plan of care (POC). 11. In addition to the minimum requirement for medications the following applies: ...b. Resumption of Care (ROC) orders: should contain ALL of the medications the patient is taking status post discharge from the hospital. The blanket reinstatement of previous orders...is not an acceptable practice to the organization. c. Standing orders: Not applicable in Home health. All orders must be part of the POC. 1. HV # 4 was admitted to the agency on 5/17/22 with diagnoses including Infection/Inflammation Reaction Due To Internal Right Hip Prosthesis and Essential Primary Hypertension. Review of the ROC orders upon discharge from the hospital dated 6/17/22 revealed an ordered Skilled Nurse (SN) visit frequency of one time a week for five weeks, effective 6/12/22, which included orders for the SN to perform lab draws from a Peripherally Inserted Central Catheter (PICC) vascular access device every Monday beginning 6/20/22. Further review of the ROC orders revealed the SN was to flush the PICC line with ten milliliters (ml) of Normal Saline (NS) prior to specimen draw, discard ten ml of blood, then flush with ten ml of NS after the specimen draw. Review of the SN Visit Note Report Narrative dated 7/4/22 revealed the SN documented, "Patient has new PICC Line to right upper arm." "Patient reports that one port is blocked." "SN aspirated several times then was able to slowly flush with heparin." Review of the ROC medication orders revealed no order for heparin. The SN administered the heparin without a physician's order. In an interview conducted 7/14/22 at 11:22 AM, Employee Identifier (EI) # 1, Executive Director confirmed there was no order to administer heparin, and the SN should have contacted the physician to obtain a heparin order before administering.
G0590	Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on review of the agency On-Call Log, medical records (MR), agency policy and procedure, and interviews, it was determined the agency failed to notify the physician for the following: 1. Blood glucose results outside of ordered parameters, including one critical blood glucose lab value. 2. New symptoms and Emergent Care received by the patient. 3. Increase in wound measurements. 4. Weight gain outside of ordered parameters. This affected an unsampled patient, and 4 of 12 active records reviewed, including Home Visit (HV) # 1, HV # 2, MR # 1, and MR # 3, and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Coordination of Care, From Admit Through Discharge Policy Number: 2.1.017 Revision Date: 8/1/19 Purpose: To establish processes and criteria so that the coordination of patient care will be optimal from admit through discharge. Policy: The agency provides care and services within an integrated continuum of care system. This is accomplished by: - Identifying patient needs through assessment and communication with other health care providers. Procedure: ...4. Coordination of care with physician: At admission, throughout care, and at discharge, coordination of services is promoted through routine communication with the patient's physician. a. When changes occur in the patient's condition... d. When results of laboratory and other tests become available... 1. A review of the agency's On-Call Log was conducted on 7/13/22 at 3:45 PM which revealed an entry dated 6/28/22 for a call received from (unnamed) hospital lab to report a critical lab glucose of 26. The agency on-call entry documented the lab was, "registered into the system at (unnamed) hospital at 4:41 PM today." Further review of the entry revealed documentation that Employee Identifier (EI) # 10, RN (Registered Nurse) attempted to call the patient on 6/28/22 with no answer. The surveyor asked if any other follow-up was done to ensure the patient status? A copy of a Client Coordination Note Report dated 6/30/22 was provided by the agency to the surveyor which revealed EI # 11, LPN (Licensed Practical Nurse) made a phone call to the patient two days later. In an interview conducted 7/14/22 at 12:20 PM, EI # 1, Executive Director, stated the agency should have notified the physician of the critical lab value when received, and called the patient's emergency contact when unable to reach the patient by phone on 6/28/22, and did not. 2. HV # 1 was admitted to the agency on 6/16/22 with diagnoses including Fracture Superior Rim of Right Pelvis Subsequent for Fracture with Routine Healing and Hypertensive Chronic Kidney Disease with Stage Five Chronic Kidney Disease or End Stage Renal Disease. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 6/16/2022 to 8/14/2022 revealed SN visits once a week for nine weeks and ... Licensed Professional to report vital signs falling outside the following established parameters...FBS ( Fasting Blood Sugar ) less than 60 greater than 250, RBS ( Random Blood Sugar ) less than 70 greater than 300... Review of the SN visit note narrative dated 6/16/22 revealed RBS of 319. There was no documentation the physician was notified of RBS greater than 300. An interview was conducted on 7/14/22 with EI # 1 Executive Director, at 10:46 AM who confirmed there was no documentation the physician was notified of RBS of 319 which was outside the established parameters. 3. HV # 2 was admitted to the agency on 6/29/22 with diagnoses including Crohn's Disease, Unspecified, Without Complications, and Essential (Primary) Hypertension. Review of the HHC and POC dated 6/29/22 to 8/27/22 revealed an order for SN one time a week for nine weeks, PT (Physical Therapist) one time a week for one week. Review of the MR revealed a Client Coordination Note Report dated 7/6/22, note type: "Emergent Care Notification: ...nausea, vomiting, and abdominal pain... patient checked for UTI (Urinary Tract Infection) which was negative. Given IV (Intravenous) fluids and discharged home with 2 (two) prescriptions." There was no documentation the physician was notified of the patient's new symptoms and emergent care. An interview was conducted on 7/14/22 at 11:14 AM with EI # 1, who confirmed staff failed to notify the physician of the patient's new symptoms. 4. MR # 1 was admitted to the agency on 6/1/22 with diagnoses including Pressure Ulcer of Right Buttock, Stage Two, Hypertensive Heart and Chronic Kidney Disease with Heart Failure... Review of the HHC and POC dated 6/1/22 to 7/30/22 revealed an order for the SN to obtain weight every visit and notify RN/ MD (Medical Doctor) of weight gain or loss of five lbs (pounds) within seven days, and orders for wound care for wound # 12 Low buttock, right pressure ulcer, stage two. Review of the SN Visit Note dated 6/9/22 revealed the patient's wound # 12: Low buttock, right pressure ulcer, stage two, measured Length x (times) Width x Depth was 1 cm (centimeter) x 1 cm x 0.1 cm. Review of the SN Visit Note dated 6/14/22 revealed the SN documented wound # 12 measured 2 cm x 2 cm x 0 (zero) cm, which was an increase of one cm in length and one cm in width, and a decrease in depth of 0.1 cm. There was no documentation the SN notified the MD of the increase in wound size. Review of 3 SN Visit Notes dated 6/6/22, 6/9/22, and 6/14 revealed the patient weighed 252 lbs, 251 lbs, and 252 lbs respectively. Review of the SN Visit Note dated 6/23/22 revealed the SN documented the patient weighed 254 lbs. Review of the SN Visit Note dated 6/27/22 revealed the SN documented the patient weighed 249 lbs, which was a loss of five pounds in four days. There was no documentation the SN notified the MD of the patient's weight loss. An interview was conducted on 7/14/22 at 10:52 AM with EI # 1, who confirmed staff failed to notify the MD of changes in the patients wound size and weight loss. 5. MR # 3 was admitted to the agency on 6/20/22 with diagnoses including Type 2 Diabetes Mellitus with Other Specified Complications, and Other Acute Osteomyelitis, Left Ankle and Foot. Review of the HHC and POC dated 6/20/22 to 8/18/22 revealed a SN frequency of three times a week for eight weeks, then two times a week for one week. Orders for the SN included wound care to be performed Monday, Wednesday, and Friday, including application of Negative Pressure Wound Therapy. Review of the SN Visit Note dated 7/4/22 revealed the nurse documented wound # 2 lat (lateral) ant (anterior) edge of foot, lt (left) measured length x width x depth (cm) (centimeters): 2.5 x 4 x 0.5, an increase from 1.5 x 1.5 x 0.2 on 7/1/22, which was an increase of 1.0 cm in length, 2.5 cm in width, and 0.3 cm in depth. The nurse also documented the wound had Exudate type: Purulent; Exudate amount: Moderate; and Odor: Faint. There was no documentation the SN reported the changes in the wound to the physician. An interview was conducted on 7/14/22 at 11:59 AM with EI # 1, who confirmed staff failed to notify the physician of changes in the patient's wound.
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 review of medical records, policy and procedure, and interviews, it was determined the agency failed to meet the needs of all patients needing assistance with activities of daily living, including bathing, grooming, and dressing. This affected 2 of 12 active records reviewed, including HV # 2, and HV # 4, and had the potential to affect all patients. Findings include: Agency Policy: Patient Assessment, Initial and Reassessment Policy number: 2.1.002 Revised date: 3/1/22 Policy: All patient admitted to the agency will receive an initial assessment... Procedure: 1. Upon admission and reassessments, the qualified clinician performs the following assessment activities and collects the following data: a. Current health status, psychosocial, functional, and cognitive status. ...d. Medical, nursing, rehabilitative... needs. ...3. The initial assessment determines whether or not the patient meets home health eligibility and patient needs can be met safely in the home setting; the type of care and services to be provided; and the need, scope, and intensity of additional assessments... 4. Additional assessment needs are determined by patient acuity, as well as any of the following: a. Functional status: i. This takes into account...level of self-care, assistance needed... mobility... 2. HV # 4 was admitted to the agency on 5/17/22 with diagnoses including Infection/Inflammation Reaction Due To Internal Right Hip Prosthesis and Essential Primary Hypertension. Review of the HHC and POC dated 5/17/22 to 7/15/22 revealed an ordered SN visit frequency of one time a week for nine weeks, and a PT visit frequency of one time a week for five weeks. Review of the RN OASIS Admission Note dated 5/17/22 revealed the RN documented the patient lived alone, had occasional/short term assistance available at his/her residence, and was at risk for falling. Review of the Functional Assessment documented by the RN revealed the following: a. HV # 4 had an amputated lower left leg. b. Needed help with grooming. c. Needed help to put on upper body clothing. d. Needed help to put on undergarments, slacks, socks or nylons, and shoes. e. Required the presence of another person throughout the bath for assistance or supervision. f. Needed assistance/supervision by another person to safely transfer on and off the toilet or bedside commode. g. Needed help to maintain toileting hygiene and/or adjust clothing. Review of the OASIS Admission Skilled Nurse (SN) Narrative revealed the SN documented HV # 4 was, "Currently very week (weak) from infection." "Have friend help him/her occationally (occasionally)." Review of the HHC and POC dated 5/17/22 to 7/15/22 revealed no orders for assistance with activities of daily living. An interview was conducted on 7/14/22 at 11:22 AM with EI # 1, who confirmed staff failed to ensure the POC addressed the needs of HV # 4 for assistance with activities of daily living. An Entrance Conference interview was conducted on 7/12/22 at 8:15 AM with Employee Identifier (EI) # 1, Executive Director, who stated the agency currently had no Home Health Aides (HHA). The surveyor asked EI # 1 how patient needs were met if someone needed HHA services. EI # 1 stated an OT (Occupational Therapist) consult would be made and if needed, an order for a COTA (Certified Occupational Therapy Assistant) to assist and train the patient in safely bathing would be requested. 1. HV # 2 was admitted to the agency on 6/29/22 with diagnoses including Crohn's Disease, Unspecified, without Complications, and Essential (Primary) Hypertension. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 6/29/22 to 8/27/22 revealed an order for SN (Skilled Nurse) one time a week for nine weeks, PT (Physical Therapist) one time a week for one week, and MSW (Medical Social Worker) one time a week for one week. Review of the RN (Registered Nurse) OASIS (Outcome and Assessment Information Set) Admission note dated 6/29/22, revealed the RN documented the patient lived alone, with occasional/ short-term assistance, lack of caregiver support, ...and was at risk for falling. Further review of the OASIS Admission note revealed the following "Functional" assessment findings: "...decreased strength, gait abnormality...unsteadiness, walking difficulty ...someone must assist the patient to groom self ...someone must help the patient put on upper body clothing ...someone must help patient put on undergarments, slacks, socks or nylons, and shoes ...able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision ...able to walk only with the supervision or assistance of another person at all times..." Review of the HHC and POC dated 6/29/22 to 8/27/22 revealed no orders for assistance with activities of daily living. An interview was conducted on 7/14/22 at 11:14 AM with EI # 1, who confirmed staff failed to ensure the POC addressed the needs of MR # 3 for assistance with activities of daily living.
G0716	Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on review of medical records (MR), policy and procedure, and interview, it was determined the agency failed to document wound care with NPWT (Negative Pressure Wound Therapy) per policy. This affected one of one patients receiving NPWT, and did affect MR # 3. Findings Include: Agency Policy: Negative Pressure Wound Therapy Agency Policy number: 2.2.007 Revised date: 01/01/20 Purpose: To promote wound healing and establish competency assessment guidelines when utilizing negative pressure wound therapy. Policy: Prior to the first independent visit for NPWT and annually thereafter, the clinician will: Review the Negative Pressure Wound Therapy policy and procedure... Procedure: 1. Obtain orders from physician for: ...g. type of foam/ sponge/ filler. ...4. The clinician will document the number of foam/ sponge pieces placed in the wound bed and the number of foam/ sponge/ filler pieces removed from the wound. 1. MR # 3 was admitted to the agency on 6/20/22 with diagnoses including Type 2 Diabetes Mellitus with Other Specified Complications, and Other Acute Osteomyelitis, Left Ankle and Foot. Review of the Home Health Certification and Plan of Care dated 6/20/22 to 8/18/22 revealed a SN (Skilled Nurse) frequency of three times a week for eight weeks, then two times a week for one week, and the following order: "SN to cleanse wounds to left foot with wound cleanser, prepare periwound area with transparent drape. Fill entire cavities with foam. Cover with transparent drape and apply tubing. Apply negative pressure device at 125 mm/ Hg (millimeters of mercury) continuous..." Review of the RN (Registered Nurse) OASIS (Observation and Assessment Information Set) Admission note dated 6/20/22 revealed the following documentation for Wound # 2: Lat (lateral) Ant (Anterior) edge of foot, lt (left), diab (diabetic) ulcer, Wound # 3: Lat lt ant edge of foot, left, and Wound # 1: Lt prox (proximal) plantar, lt: "Cleansed wound with wound cleanser, prepared periwound area with transparent drape, filled entire cavities with foam. Covered with transparent drape and applied tubing. Applied negative pressure device at 125 mm/ Hg continuous. Instructed patient/ caregiver on troubleshooting techniques and canister changes; Instructed on signs/ symptoms of wound infection. Patient tolerated well with minimal discomfort." There was no documentation of how many pieces of foam were placed in the wound cavities, per policy. Review of the SN Visit Note dated 6/28/22 revealed the following documentation of wound care for Wound # 3: "Cleansed wound with wound cleanser, prepared periwound area with transparent drape, filled entire cavitiy with foam. Covered with transparent drape and applied tubing. Applied negative pressure device at 125 mm/ Hg continuous. Wrapped with rolled gauze and elastic bandage. Patient tolerated well with minimal discomfort." There was no documentation of how many pieces of foam were removed from the wound, or how many pieces of foam were place in the wound, per policy. An interview was conducted on 7/14/22 at 11:59 AM with Employee Identifier # 1, Executive Director, who confirmed staff failed to document NPWT dressing change per policy.