Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 017037	(X3) Date Survey Completed 11/21/2019
Name of Provider or Supplier Alabama Homecare Of Montgomery, Llc	Street Address, City, State 400 South Union Street Suite 285, Montgomery, 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 11/19/19 to 11/21/19, the agency was found to be in substantial compliance with the Conditions of Participation for Emergency Preparedness.
G0000	A recertification survey was conducted on 11/19/19 to 11/21/19 and standard level deficiencies were cited.
G0536	A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on review of the policy and procedure, observations and interviews, it was determined the agency failed to ensure medication reconciliation was performed. This deficient practice affected 5 of 17 medical records (MR) reviewed including Home Visit (HV) # 1, HV # 3, HV # 7, MR # 4, MR # 1, and had the potential to affect all patients served by the agency. Findings include: Policy: Monitoring Medications Policy Number: 10.008 Revised date: 05/01/19 Policy: A drug regimen 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. Procedure: 1. The discipline responsible for the drug regimen review will: a. Compare medication list obtained from the facility from which the patient was transferred and/ or physician orders to actual medications patient is taking. b. Review all medications including over the counter (OTC) medications, vitamins, herbs and herbal products, creams, and topical ointments, and medical marijuana (in states where legalized), to identify issues as: vii. Duplicate drug therapy ix. Dosage errors; and x. Drug omissions 6. Notify the physician of any of the above identified issues/ discrepancies. Collaborate with the Patient Care Manager and ensure that supportive documentation is evident in the medical record. 1. HV # 1 was admitted on 8/25/19 with diagnoses including Hypertensive Heart Disease With Heart Failure and Chronic Systolic (Congestive) Heart Disease. A home visit was conducted on 11/19/19 at 11:30 AM with Employee Identifier (EI) # 11, Registered Nurse (RN) to observe RN assess and perform intravenous (IV) infusion. The following medications were observed in home, reconciled as current by the patient, and not listed on the agency Client Medication Report(CMR) provided by the agency on 11/19/19 at 1:30 PM. 1. Magnesium Oxide 1 tablet three times a day started 8/25/19 2. Protonix 40 (milligram) mg. 1 tablet daily started 10/10/19 3. Hydralazine 10 mg tablet three times a day. Medication not listed on the agency printed CMR provided. The following medication observed in the home had from the CMR: 1. Torsemide 120 mg 6 tablets two times a day as written in the CMR. 2. Torsemide 120 mg mg 4 tablets two times a day with meals, as written on the medicine bottle found at home. The discrepancy found was the difference between the number of tablets written on the CMR from the number of tablets written on the patient's medication bottle An interview was conducted on 11/20/19 at 8:30 AM with Employee Identifier (EI) # 1, Adminstrator who confirmed the above mentioned findings. 2. HV # 3 was admitted on 11/11/19 with diagnoses including Hypertensive Chronic Kidney Disease (CKD), Type 2 Diabetes Mellitus (DM), and Rheumatic Mitral Insufficiency. A home visit was conducted on 11/19/19 at 12:05 PM with EI # 9, Physical Therapy Assistant (PTA). The surveyor was accompanied by EI # 10, RN/Patient Care Manager (PCM). The following medications were observed in home, reconciled as current by the patient, and not listed on the agency CMR provided by the agency on 11/19/19 at 11:45 AM: 1. Labetalol 200 MG tablets- Take 4 tablets (tabs) by mouth every 12 hours. Fill date 11/9/19. 2. Hydralazine 100 MG tabs- Take one tablet (tab) by mouth every 8 hours. Fill date 11/9/19. Skilled Nurse (SN) visits were made 11/11/19, 11/14/19, and 11/18/19. The following medication was observed at the home but with a different dosage from what was reviewed on the CMR: 1. Isosorbide mononitrate 20 MG tabs- Take one tab by mouth daily was listed on the CMR. Isosorbide mononitrate 30 MG ER tabs- Take one tab by mouth every morning was observed in the home. Fill date 11/9/19. An interview was conducted on 11/19/19 at 12:30 PM with EI # 10 at the time of the home visit, who confirmed the above findings 3. HV # 7 was admitted on 11/18/19 with diagnoses including Right Quadrant Pain, Salpingitis and Oophoritis, and Sepsis. A home visit was conducted on 11/20/19 at 8:43 AM with Employee Identifier (EI) # 8, Licensed Practical Nurse (LPN) to assess and perform wound care with use of a Wound Vacuum-Assisted Closure (VAC). The surveyor was accompanied by EI # 3, RN/Clinical Director. The following medications were observed in home, reconciled as current by the patient, and not listed on the agency CMR provided by the agency 11/19/19 at 8:10 AM: 1. Fluconazole 150 MG tablet-take one tablet (tab) by mouth every 72 hours. Fill date 11/15/19. 2. Loratadine 10 MG- take one tab daily as needed in a 24 hour period (as directed). Patient confirmed he/she was taking the medication prior to admission to agency. The following medication was observed at the home but had a different dosage amount to be given compared to the dosage amount on the CMR: 1. Oxycodone-Acetaminophen Oral 10-325 MG 1 tab every 6 hours as needed. Oxycodone-Acetaminophen Oral 10-325 MG- Take 2 tablets by mouth every 6 hours as needed was observed in the home. Fill date 11/15/19. Patient SN visit was made 11/18/19. An interview was conducted on 11/20/19 at 11:10 AM with EI # 3, who confirmed the above findings. 4. MR # 4 was admitted to the agency 4/25/19 with diagnoses including Pilonidal Cyst With Abscess, Essential Hypertension, Type 2 Diabetes Mellitus With Diabetic Neuropathy Unspecified, and Hyperparathyroidism Unspecified. Review of the medical record revealed MR # 4 was transferred to an inpatient facility on 5/6/19 due to elevated blood sugar, diabetes out of control. Review of the facility discharge (d/c) instructions dated 5/8/19 and review of the resumption of care (ROC) order dated 5/9/19 revealed the following discrepancies: a. Sensipar 60 mg oral tablet (tab), 1 tab by mouth once daily was listed as a new medication on the facility d/c instructions and was listed on the ROC order with a start date of 5/9/19. Cinacalcet 60 mg 1 tablet daily was also listed on the ROC order with a start date of 4/2/19. This is the same medication and both were listed as current medications. The SN failed to review medications for duplication. b. Tresiba FlexTouch 200 units/ml (milliliter) subcutaneous 22 units once daily was listed on the facility d/c instructions and was not listed on the ROC order. c. NovoLog 100 units/ml sliding scale before meals, max (maximum) 10 units/day was listed on the facility d/c instructions and was not updated on the ROC order. An interview conducted on 11/21/19 at 1:40 PM with EI # 1 confirmed the patient was not taking the Tresiba as ordered and the Novolog had not been updated on the ROC order. 5. MR # 1 was admitted to the agency 8/30/19 with diagnoses including Other Symptoms and Signs Involving the Musculoskeletal System and Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. MR # 1 was discharged from the hospital on 8/29/19. Review of the Home Health Certification and Plan of Care dated 8/30/19 to 10/28/19 revealed one (1) medication - aspirin 81 mg one daily. Review of the physician's order dated 9/3/19 for RX Rec (prescription reconciliation) revealed 22 medications added to the patient's medication list. The order was not sent to the physician for signature. The agency failed to provide a current and complete medication list to the physician. Review of the MR revealed a Transfer Inpatient Facility dated 9/4/19 revealed the patient was hospitalized on 9/1/19. Further review revealed MR # 1 was discharged home on 9/14/19. Review of the hospital discharge orders and the agency Resumption of Care (ROC) orders dated 9/15/19 revealed the following discrepancies: a. Dexamethasone 1 mg tablet - 2 tabs oral every day for 4 days start 9/14/19 and end on 9/18/19 was listed on the hospital discharge order and not on the agency ROC order. b. Dexamethasone 1 mg tablet - 1 tabs oral every day for 4 days start 9/18/19 and then dc (discontinue). Resume 5 mg of prednisone daily was listed on the hospital discharge and not on the ROC order. c. Prednisone 5 mg 1 daily was on the ROC order with a start date 9/3/19 (patient was admitted to the hospital on 9/1/19) and not a start date of 9/23/19 after the dexamethasone would be completed as listed on the hospital discharge order. Review of the Client Medication Report printed 11/19/19 revealed the following duplications: a. Enzalutamide 40 mg 1 tab daily start 9/3/19 and Xandi 40 mg 4 tabs daily start 9/15/19. This is the same medication and both are listed as current. b. Zofran 8 mg 1 tabs 3 times daily start 9/3/19 and Zofran 10 mg 2 tabs 4 times daily with a start date of 9/4/19. The SN failed to assess for duplicate therapy. An interview conducted on 11/21/19 at 11:20 AM with EI # 2 confirmed the above 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 records (MR), agency policies and procedures, and interviews with agency staff, it was determined the agency failed to ensure: 1. The physician was promptly notified of blood clots in foley bag, edema to genital area after removal of a foley prior to attempt to reinsert a new foley catheter. 2. The physician was promptly notified of the patients pain above established parameters. 3. The physician was promptly notified of a significant increase in wound size. This deficient practice affecting 3 of 17 records reviewed including MR # 5, Home Visit (HV) # 6, MR # 7, and had the potential to negatively affect all patients served by the home health agency. Findings Include: Policy: Coordination Of Care, From Admit Through Discharge Policy Number: 2.1.017 Revised Date: 8/1/19 Purpose: To establish processes and criteria so that the coordination of patient care will be optimal from admit through discharge. 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 ... ...Coordinating patient care among various disciplines to ensure that services are continuous and coordinated from admission through discharge ... Procedure: ...4. Coordination of care with physician: At admission, throughout care, and at discharge, coordination or services is promoted through routine communication with the patient's physician: a. When changes occur in the patient's condition or response to treatment ... 1. MR # 5 was admitted to the agency on 4/8/19 and discharged on 5/8/19. Admitting diagnoses included Chronic Obstructive Pulmonary Disease (COPD) with Acute Exacerbation, Acute Diastolic Congestive Heart Failure (CHF), and Chronic Atrial Fibrillation. Review of the Client Coordination Note dated 4/11/19 revealed the agency received a phone call from the patient's wife stating "no urine draining in catheter bag since 0400 (4:00 AM) and he is hurting really bad ..." Review of the Visit Note Report from the PRN visit made by the SN on 4/11/19, documentation revealed " ...Blood clots in new urine bag ..." There was no documentation the physician was notified of the patient not having urinary output, patient's increased pain and blood clots in the Foley drainage bag. Review of the Visit Note Report from the PRN visit made by the SN on 5/4/19 at 2:05 PM revealed "...Thick yellow grayish urine in foley bag ...SN call ambulance to have patient sent to ER ..." Further review of the Visit Note Report of a PRN visit made by the SN on 5/4/19 at 3:24 PM revealed " ...urine in tube cloudy and strong odor noted ...attempted to insert new foley catheter. Foley would not advance into the bladder. Strong resistance met and was not going to force the foley. Advised patient and wife to go to ER (emergency room) for treatment." There was no documentation the physician was notified of the patient's discolored and foul-smelling urine in foley drainage bag and the SN's inability to insert a new foley prior to the SN notifying the ambulance for transport to the ER. An interview was conducted on 11/21/19 at 2:02 PM with Employee Identifier (EI) # 2, Performance Improvement Coordinator, who confirmed the above findings. 2. HV # 6 was admitted to the agency on 10/15/19 with diagnosis including Gout, Atherosclerotic Heart Disease, Chronic Kidney Disease, Congestive Heart Failure, and Pressure Ulcer of Sacral Region. Review of the Home Health Certification and Plan of Care (POC) dated 10/15/19 to 12/13/19 revealed the physician ordered "when vital signs are obtained by licensed professional to report vital signs falling outside the following established parameters:...Pain greater than 6". Review of Occupational Therapy (OT) Visit Note Report dated 11/4/19 revealed the OT documented the patient pain scale of 7. There was no documentation the physician was notified of HV # 6's pain scale of 7. An interview was conducted on 11/21/19 at 11:10 AM with EI # 1, Executive Director who confirmed the above findings. 3. MR # 7 was admitted to the agency on 2/4/18 and recertified for home care 10/17/19 to 12/15/19 with diagnoses including Pressure Ulcer of Sacral Region, Chronic Kidney Disease, and Congestive Heart Failure. Review of the SN Visit Note Report dated 11/1/19 revealed wound # 1 coccyx stage IV pressure ulcer measurements Length 7 cm (centimeters) x Width 11 cm x Depth 3 cm. Review of SN Visit Note Report dated 11/4/19 revealed wound # 1 coccyx stage IV pressure ulcer measurements Length 10 cm x Width 6 cm x Depth 3 cm. There was no documentation the physician was notified of the increased wound length by 3 cm. An interview was conducted on 11/21/19 at 10:50 AM with EI # 2, Performance Improvement Coordinator who confirmed the above findings.
G0610	Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on review of medical records (MR) and interview with staff it was determined the agency failed to ensure instruction and teaching was provided to the patient/caregiver as ordered in the Plan of Care. This deficient practice affected 1 of 17 MRs reviewed including MR # 4, and had the potential to affect all patients served by this agency. Findings include: 1. MR # 4 was admitted to the agency 4/25/19 with diagnoses including Pilonidal Cyst With Abscess, Essential Hypertension, Type 2 Diabetes Mellitus With Diabetic Neuropathy Unspecified, and Hyperparathyroidism Unspecified. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 4/25/19 revealed orders for the skilled nurse (SN) to instruct: a. On diabetes to include disease process, signs and symptoms of exacerbation, complications and management. b. New and changed medication, those with assessed knowledge deficit, high risk medications and any applicable drug interactions. c. Patient/caregiver in measures to improve home safety and reduce fall risk. Review of the SN admission visit dated 4/25/19 revealed the patient and caregiver had knowledge base deficits of: technical procedures; pathophysiology of disease; signs and symptoms to report; home safety/emergency procedures; and medications. Further review of the SN note dated 4/25/19 revealed the patient was at risk for falling and "instructed on fall prevention". There was no documentation what patient-specific instructions were provided. Review of the Client Coordination Note dated 4/29/19 revealed the note type as "clinically significant medication issue". The form instructed to "briefly describe the medication issue and follow up" and this section was blank. There was no documentation in the MR what the medication issue was and what follow up was completed. Review of the SN visit notes dated 4/30/19 and 5/3/19 revealed no documentation of instructions provided regarding diabetes management including blood sugar testing, signs and symptoms of exacerbation, and complications. There was no documentation of instructions on high risk medications for diabetes - Januvia, Metformin, and Novolog insulin. Review of the MR revealed MR # 4 was admitted to the hospital on 5/6/19 for diabetes out of control/hyperglycemia. Review of the discharge summary dated 5/8/19 revealed medication changes to include Novolog insulin sliding scale before meals max (maximum) 10 units per day and Tresiba Flexpen 22 units once daily. Review of the SN Resumption of Care visit note dated 5/9/19 revealed the patient's random blood sugar was 248. The narrative note documentation revealed the visit was for wound care and additional teaching on medications, and new medication changed noted. There was no documentation the SN instructed on the Novolog and Tresiba insulin. Review of the physician's order dated 5/23/19 revealed the SN to visit for post fall follow up. Review of the SN visit note dated 5/23/19 revealed the patient fell at the physician's office. There was no documentation the SN provided instructions for fall prevention and safety. An interview conducted on 11/21/19 at 1:40 PM with Employee Identifier (EI) # 1, Executive Director, confirmed the above 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 interview with staff it was determined that the agency failed to follow policy and accepted standards of practice for wound care. This affected 1 of 4 Home Visits (HV) with wounds including HV # 5 and had the potential to affect all patients served by this agency. Findings include: Policy: Wound Assessment, Documentation, and Photography Policy Number: 2.2.001 Revised: 9/1/17 ...Procedure:... 2. Perform wound care according to LHC adopted clinical skills guidelines and physician orders... Policy: Wound Care Best Practice: Dressing Change Competency Checklist Revised: 6/4/19 ...Wound Cleansing: 1. Adequately cleanse wound with either saline or wound spray 2. Blot dry with gauze 3. Remove and discard gloves and perform hand hygiene... 1. HV # 5 was admitted to the agency on 11/5/19 with diagnoses including Type 2 Diabetes Mellitus, Chronic Ulcer of Left Lower Leg, Chronic Ulcer of Right Lower Leg, and Essential (Primary) Hypertension. A HV was conducted on 11/20/19 at 8:35 AM to observe wound care provided by EI (Employee Identifier) # 5, LPN (Licensed Practical Nurse). EI # 10, RN (Registered Nurse), PCM (Patient Care Manager) accompanied the surveyor on the HV. EI # 5 removed the dressing from HV # 5 left leg and sprayed wound cleanser to the wounds and surrounding area of leg. EI # 5 then, with a single 4 x 4 gauze, wiped the wound and leg to dry returning several times to center of wound after wiping the surrounding skin. EI # 5 then removed the dressing from HV # 5 right leg and sprayed wound cleanser to the wounds and surrounding area of leg. EI # 5 then, with a single 4 x 4 gauze, wiped the wound and leg to dry returning several times to center of wound after wiping the surrounding skin. An interview on 11/20/19 at 9:40 AM with EI # 10, RN, PCM, who also observed the wound care, confirmed EI # 5 who confirmed the above observation. An interview was conducted on 11/21/19 at 10:40 AM with EI # 1, RN, Executive Director who confirmed the above findings.
G0714	Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on Medical Record (MR) review and interview with staff it was determined the agency failed to provide education to the patient and or caregiver for infection control and prevention for patients with wounds. This deficient practice affected 1 of 4 home visit patients with wounds including HV # 5 and had the potential to affect all patients served by this agency. Findings include: 1. HV # 5 was admitted to the agency on 11/5/19 with diagnoses including Type 2 Diabetes Mellitus, Chronic Ulcer of Left Lower Leg, Chronic Ulcer of Right Lower Leg, and Essential (Primary) Hypertension. Review of the Home Health Certification and Plan of Care (POC) dated 11/5/19 to 1/3/19 revealed physician ordered Skilled Nurse (SN) 3 wk 9 (3 times a week for 9 weeks) to change dressing to wounds on left and right pretibial area and "to instruct client/caregiver regarding infection control measures." Review of the SN Visit Note Reports on 11/5/19, 11/7/19, 11/9/19, 11/11/19, 11/13/19, and 11/16/19 revealed no documentation of patient or caregiver education on infection prevention. An interview was conducted on 11/21/19 at 10:40 AM with EI # 1, Executive Director, who confirmed the above findings.