Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 017037	(X3) Date Survey Completed 05/11/2023
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 5/11/23, Baptist Home Health was found to be in substantial compliance with the Conditions of Participation for Emergency Preparedness.
G0000	A recertification survey was conducted on 5/9/23 to 5/11/23 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 observations, agency policy and procedure, medical record (MR) review, and interviews, it was determined the agency failed to ensure the medications were reconciled and all current medications were listed on the Client Medication Report (CMR). This deficient practice affected three of seven home visits (HV) including HV # 5, HV # 2, and HV # 6, and had the potential to affect all patients admitted to this agency. Findings include: Agency policy: Monitoring of Medications Policy number: 10.008 Revised: 05/01/19 Policy: A drug regimen review will be performed on all patients in conjuction with all comprehensive assessments. Additionally, all clinicians will participate in medication review and reconciliation throughout the episode... 2. All clinicians participating in the patient's care are responsible to assist with the maintenance of accurate medication information... i. Compare medications patient is currently taking with medications ordered for the patient... 2. HV # 2 was admitted to the agency on 5/3/22 and recertified for care 4/28/23 to 6/26/23 with diagnoses including Encounter for Orthopedic Aftercare Following Surgical Amputation and Type Two Diabetes with Diabetic Peripheral Angiopathy without Gangrene. Review of the HHC and POC dated 4/28/23 revealed orders for SN visits two times a week for eight weeks. A HV was conducted on 5/9/23 at 12:42 PM to observe care provided by EI # 3, Licensed Practical Nurse (LPN). During the HV, the patient's home medications were compared to the CMR dated 4/28/23. The following discrepancies were observed: Aspirin 81 mg, take one tablet daily, date filled 4/18/23 was observed in the home but not listed on the CMR. The patient stated," I have taken that on and off for several years now." An interview was conducted on 5/11/23 at 12:22 PM with EI # 1, who confirmed the medications had not been reconciled per agency policy. 3. HV # 6 was admitted to the agency on 5/4/23 with diagnoses including Heart Failure, Unspecified and Acute Kidney Failure, Unspecified. Review of the HHC and POC dated 5/4/23 revealed orders for SN visits one time a week for one week, two times a week for two weeks and one time a week for four weeks. PT visits two times a week for four weeks effective 5/7/23. Medical Social Worker (MSW) one time a week for one week. A HV was conducted on 5/9/23 at 2:00 PM to observe care provided by EI # 7, MSW. During the HV, the patient's home medications were compared to the CMR dated 5/8/23. The following medications were observed in the home but not listed on the CMR: a. Tylenol 325 mg as needed (PRN) every 4-6 hours. The patient stated, "I only take this when I have a little ache or pain. I have taken that for several months now." b. Iron tablets with Vitamin C 100/250 mg tablet, one per day, date filled 3/14/23. The patient stated, "I have taken this for quite a while now, for several years." c. Latanoprost Ophthalmic Solution 125 mg/2.5 ml one drop/day each eye. The patient stated, "I have been on those drops since my hospital stay in the last two months." d. Centrum Silver Multivitamin one per day. The patient stated," I have been on those vitamins for years." e. Refresh Tears lubricant eye drops artificial tears 1-2 drops prn. The patient stated, "I only need those every now and again but have had them for several months." f. Trelegy Ellipta inhale one puff by inhalation every day at the same time daily last filled 5/28/21. The patient stated, "I have been on that for a couple of years now to help me breathe but I don't need it very often." g. Entresto 49 mg one tablet per day was observed in the home, Entresto 24 mg take one daily was listed on the CMR. An interview was conducted on 5/11/23 at 10:23 AM with EI # 1 who confirmed the medications had not been reconciled per agency policy. 1. HV # 5 was admitted on 4/20/23 with diagnoses including Hypertensive Heart Disease, Heart Failure, and Post Procedure Hematoma of Skin. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 4/20/23 revealed orders for Skilled Nurse (SN) one visit per week for one week then two visits per week for three weeks, Physical Therapy (PT) one visit per week for one week the two visits per week for three weeks, and Occupational Therapy (OT) one visit per week for four weeks. A HV was conducted on 5/9/23 at 12:50 PM to observe care provided by Employee Identifier (EI) # 6, PT. During the HV the patient's home medications were compared to the CMR dated 5/9/23, the following discrepancies were observed: Furosemide 40 mg (milligrams) take one tablet daily and Klor-Con 8 meq (milliequivalents) take one tablet daily were listed on the CMR. HV # 5 stated he/she was only taking the the Furosemide and the Klor-Con as needed for swelling and the last dose was three weeks earlier. An interview was conducted on 5/9/23 at 3:45 PM with EI # 1, Executive Director, who confirmed the medications had not been reconciled per agency policy.
G0574	Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on review of medical records (MR), agency policy and staff interviews, it was determined the agency failed to provide an individualized plan of care (POC). This deficient practice affected one of 17 MR reviewed and had the potential to affect all patients admitted to the agency. Findings include: Agency Policy: Plan of Care Policy number: 2.1.007 Date revised 12/01/21 Purpose: To assure an appropriate plan of care is developed and revised in a timely manner for each patient. To ensure that physician's/authorized practitioner's orders are followed. Policy: Each patient has an individualized POC developed in consultation with the patient, physician or authorized practitioner and staff that integrates comprehensive assessment findings to address patient problems, needs and goals as well as to address specific services being provided. Procedure: 1. A POC is developed for all patients and updated... 2. The POC includes ...e. Nutritional requirements f. Medications and treatments... i. Patient specific interventions and education... n. all patient care orders... 3. The qualified clinician develops and revises the POC under the direction of the physician or authorized practitioner. The POC is established prior tp providing services. 1. MR # 3 was admitted to the agency on 4/18/23 with admitting diagnoses including Chronic Obstructive Pulmonary Disease, Unspecified and Acute and Chronic Respiratory Failure with Hypoxia. Review of the Home Health Certification (HHC) and POC dated 4/18/23 revealed orders for skilled nurse (SN) visits two times a week for one week and one time a week for six weeks. The SN visit note report (VNR) dated 4/18/23 under the heading Nutrition- Nutritional approaches: check all of the nutritional approaches that apply- Feeding Tube- Percutaneous Endoscopic Gastrostomy (PEG). Further review of the SN VNR dated 4/18/23 revealed the SN documented in the narrative section - "The patient was recently hospitalized at ...Rehab Hospital from 3/17/23 to 3/22/23 for strengthening and PEG care... Patient has a PEG Tube that is clamped but SN needs specified orders to perform PEG management." Further review of the HHC and POC dated 4/18/23 revealed no documentation of a PEG Tube or physician's orders for care of a PEG Tube in the POC. An interview was conducted on 5/11/23 at 10:42 AM with EI # 1, Executive Director, who confirmed the agency failed to provide an individualized POC.
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 the review of medical records (MR), agency policy and procedure and staff interviews it was determined the agency staff failed to follow physician orders for visit frequency. This deficient practice did affect two of seventeen MRs reviewed, including Home Visit (HV) # 4 and MR # 7 and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Plan of Care (POC) Policy Number: 2.1.007 Revised Date: 12/1/21 Purpose: ...To ensure that physician/ (or) authorized practitioner's orders are followed. Policy: Each patient has an individualized POC developed in consultation with the...physician or authorized practitioner... to address specific services being provided. Procedure: ...2. The POC includes: ...b. Types, frequency, and duration of services required 1. HV # 4 was admitted to the agency on 4/12/23 with diagnoses including Multiple Sclerosis and Anemia, Unspecified. Review of Home Health Certification (HHC) and POC dated 4/12/23 to 6/10/23 revealed an Occupational Therapy (OT) frequency of once a week for one week, then twice weekly for three weeks, then once a week for one week, and a Medical Social Worker (MSW) frequency of once a week for one week effective 4/16/23. Review of the OT notes for the week of 4/16/23 revealed missed visits on 4/19/23 and 4/20/23. There was no documentation the OT attempted to reschedule the visits in conformance with the physician ordered frequency of twice a week. Review of the MSW notes for the week of 4/16/23 revealed a missed visit on 4/20/23. There was no documentation the MSW attempted to reschedule the visit in conformance with the physician ordered frequency of once a week. Review of the OT notes for the week of 4/30/23 revealed an OT visit was performed on 5/5/23. There was no documentation the OT attempted a second visit in conformance with the physician ordered frequency of twice a week. An interview was conducted on 5/11/23 at 10:54 AM with Employee Identifier (EI) # 1, Executive Director, who confirmed the agency staff failed to follow physician orders for visit frequency. 2. MR # 7 was admitted to the agency on 12/19/22 with diagnoses including Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1 Through Stage 4 Chronic Kidney Disease, or Unspecified Chronic Kidney Disease, Unspecified Systolic (Congestive Heart Failure) and Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. Review of the HHC and POC dated 12/19/22 to 2/16/23 revealed an order for a Physical Therapy (PT) frequency of once a week for one week, then twice weekly for three weeks, then once weekly for one week. Review of the PT notes for the week of 12/25/22 revealed a missed visit on 12/30/22. There was no documentation the PT attempted to reschedule the visit in conformance with the physician ordered frequency of twice a week. Review of the PT notes for the week of 1/8/23 revealed a missed visit on 1/12/23. There was no documentation the PT attempted to reschedule the visit in conformance with the physician ordered frequency of twice a week. An interview was conducted on 5/11/23 at 10:57 AM with EI # 1 who confirmed the agency staff failed to follow physician orders for visit frequency.
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 review of medical records (MR), agency policy, and interviews, it was determined the agency failed to ensure all treatments were ordered by the physician. This deficient practice affected two of six MR's reviewed of patients with wounds including MR # 8 and MR # 3, and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: Physician Orders Policy number: 2.1.008 Revised: 4/01/23 ...Policy: No medications, treatments, diagnostic studies or therapies will be administered without the order of a qualified physician... 2. MR # 3 was admitted to the agency 4/18/23 with admitting diagnoses Chronic Obstructive Pulmonary Disease, Unspecified and Acute and Chronic Respiratory Failure with Hypoxia. Review of the HHC and POC dated 4/18/23 revealed the orders for SN visits two times a week for one week and one time a week for six weeks. Review of the the SN Visit Note Report (VNR) dated 4/18/23 in the narrative- "Patient has a PEG Tube that is clamped but SN needs specified orders to perform PEG management." The SN VNR dated 4/24/23 revealed under heading Integumentary- PEG Tube site." Educated patient's son on cleaning the PEG Tube site and returned demonstration." In the narrative-" SN educated the patient and son on cleaning around the PEG Tube site. Using Saline solution, a q-tip and gauze to pat dry, apply a split gauze under the plastic ring and tape around the gauze to hold it in place. Dressing changes twice a day." Further review of the HHC and POC and Physician's orders dated 4/18/23 revealed no documentation of orders for the PEG Tube. An interview was conducted on 5/11/23 at 10:42 AM with EI # 1, who confirmed the agency failed to ensure all treatments were ordered by the physician. 1. MR # 8 was admitted on 6/16/22 and recertified for home care from 10/14/22 to 12/12/22 with diagnoses including Non Pressure Chronic Ulcer of Left Lower Leg, Essential (Primary) Hypertension, and Paroxysmal Atrial Fibrillation. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 10/14/22 revealed orders for SN (Skilled Nurse) one visit per week for eight weeks. Review of the SN Visit Note dated 11/23/22 revealed the SN documented a new Stage II pressure ulcer to the left distal lateral posterior calf measuring 0.6 cm (centimeters) length x 0.3 cm width x 0.1 cm depth with scant serosanguous exudate. Further review of the SN Visit Note dated 11/23/22 revealed the SN documented the new wound was cleansed with wound cleanser and gauze, patted dry, petroleum gauze applied, covered with ABD (abdominal) pad and Kerlix, and secured with tape. Review of the physician orders revealed no documentation of wound care orders for the pressure ulcer. An interview was conducted on 5/11/23 at 10:00 AM with Employee Identifier (EI) # 1, Executive Director, who confirmed there were no physician orders for the wound care that was provided to the new pressure ulcer.
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 medical records (MR), agency policy and procedure, hospital report and staff interviews, it was determined the agency failed to ensure the physician was promptly notified of changes in the patient's condition or needs. This deficient practice affected six of 17 MR's reviewed, including MR # 8, Home Visit (HV) # 5, MR # 3, MR # 10, HV # 3, MR # 9 and MR # 7, and had the potential to negatively affect all patients admitted to this agency. Findings include: Agency Policy: Coordination of Care, from Admit Through Discharge Policy number: 2.1.017 Revised: 04/01/23 ...Policy: The agency provides care and services within an integrated continuum of care system... Identifying patient needs through assessment and communication with other health care providers... Procedure: ...4. Coordination of care with physician:... a. When changes occur in the patient's condition or response to treatment... b. When changes occur in caregiver support or the environment that affect patient treatment. ...e. When there is a need to change the patient's plan of care. 6. MR # 9 was admitted to the agency on 7/29/22 with diagnoses including Hypertensive Heart Disease without Heart Failure, Paroxysmal Atrial Fibrillation and Type 2 Diabetes Mellitus without Complications. Review of the HHC and POC dated 7/29/22 to 9/26/22 revealed an order for Physical Therapy (PT) to instruct patient on management of Diabetes. Review of the Physical Therapy (PT) Visit Note dated 7/29/22 revealed the patient does not have a glucometer and believes he/she is not a Diabetic. Further review of the PT Visit Note dated 7/29/22 revealed the patient's home "...is cluttered and unsanitary with dog urine/feces on floor..." and the patient's spouse was having difficulty caring for the patient. There was no documentation the physician was notified of the patient not having a glucometer in the home, home condition and difficulty of caregiver in caring for patient. Review of the PT Visit Note dated 8/2/22 revealed the patient was found laying on the sofa in his/her own urine and feces and reported he/she had been that way for a week. The fire department was called to assist in transferring the patient to a hospital bed. Further review of the PT Visit Note dated 8/2/22 revealed the home had a strong odor due to multiple small dogs were in the home with animal feces and urine throughout the house. The PT felt it was unsafe to breathe the air in the home and the caregiver was unable to provide adequate care for the patient. There was no documentation the physician was notified of the patient condition, the caregiver being unable to provide adequate care for the patient and the home condition. Review of the PT Visit Note dated 8/4/22 revealed the patient was found in the same unsanitary conditions as the visit on 8/2/22 with the bed saturated and the PT felt the home was unsanitary and is not suitable for habitation. There was no documentation the physician was notified of the patient condition and the home condition. An interview was conducted on 5/11/23 at 9:50 AM with EI # 1 who confirmed the PT failed to notify the physician of the patients condition and home environment. 7. MR # 7 was admitted to the agency on 12/19/22 with diagnoses including Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1 Through Stage 4 Chronic Kidney Disease, or Unspecified Chronic Kidney Disease, Unspecified Systolic (Congestive Heart Failure) and Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. Review of the HHC and POC dated 12/19/22 to 2/16/23 revealed an order for the licensed professional to report a blood sugar below 60 mg/dL (milligrams per decilitre) or above 250 mg/dl. Review of the PT visit note dated 12/28/22 revealed a blood sugar of 316 mg/dL. There was no documentation the PT notified the physician of the blood sugar. Review of the PT visit note dated 1/6/23 revealed a blood sugar of 341 mg/dL, the patient's weight had increased by 14 pounds since the start of care on 12/19/22, 18 days, and the patient verbalized he/she had been noncompliant with fluid pills administration and monitoring blood glucose. There was no documentation the PT notified the physician of the blood sugar, weight gain and patient noncompliance. Review of the PT visit note dated 1/11/23 revealed a morning blood sugar of 426 mg/dL, a noon blood sugar of 406 mg/dL and the patient was noncompliant with diabetic medication administration. There was no documentation the PT notified the physician of the blood sugars and the patient noncompliance. Review of the PT visit note dated 1/17/23 revealed a blood sugar of HI during the visit and the patient was not complaint with monitoring blood sugar and administration of medications. There was no documentation the PT notified the physician of the blood sugar and the patient noncompliance. Review of the PT visit note dated 1/18/23 revealed no documentation of a blood sugar and assessment of patient compliance with diabetic management and medication administration. Review of the hospitalization report dated 1/23/23 revealed the patient was hospitalized with a blood sugar of 821 mg/dL. An interview was conducted on 5/11/23 at 10:57 AM with EI # 1 who confirmed there was no documentation the PT notified the physician of the patient's blood sugars, weight gain and noncompliance. 5. HV # 3 was admitted to the agency on 4/6/23 with admitting diagnoses of Encounter for Surgical Aftercare Following Surgery on the Digestive System and Essential (Primary) Hypertension. Review of the HHC and POC dated 4/6/23 revealed the SN was to visit one time a week for one week, then two times a week for one week, and one time a week for two weeks. The SN to perform/instruct/ reinforce patient and caregiver procedure of wound care to wound # 1 anterior-abdominal right lower quadrant - surgical incision daily and as needed for soiled or dislodged dressings. Cleanse with soap and water and gauze. Rinse well and pat dry with gauze. Cover with bordered gauze using clean technique... Review of the RN (Registered Nurse) Add On Evaluation dated 4/7/23 revealed wound # 1 measured 1 cm in length x 0.1 cm in width x 0 cm in depth. Review of the SN visit note dated 4/11/23 revealed wound # 1 measurements as 0.1cm in length x 6.2 cm in width x 0 cm in depth. Review of the 4/11/23 SN visit note revealed no documentation the physician was notified of the increase of the width of wound # 1 from 0.1 cm to 6.2 cm. An interview was conducted on 5/11/23 at 10:23 AM with EI # 1 who confirmed the documentation of the wound was incorrect and the nurse did not document the physician was notified. 3. MR # 3 was admitted on 4/18/23 with admitting diagnoses including Chronic Obstructive Pulmonary Disease and Acute and Chronic Respiratory Failure with Hypoxia. Review of the HHC and POC dated 4/18/23 revealed orders for SN visits two times a week for one week then one time a week for six weeks. Physical Therapy (PT) one time a week for one week then two times a week for four weeks. Occupational Therapy (OT) effective 4/23/23 one time a week for one week. Further review of the HHC and POC dated 4/18/23 revealed Licensed Professional to report vital signs outside of the following parameters: Pain greater than six out of ten. Review of the PT visit note dated 4/20/23 revealed the patient reported pain eight out of ten. There is no documentation the physician was notified of pain outside the parameters. Review of the OT visit note dated 5/2/23 revealed the patient reported pain eight out of ten. There is no documentation the physician was notified of pain outside of parameters. An interview was conducted on 5/11/23 at 1042 with EI # 1, who confirmed there was no documentation physician was notified of pain outside of parameters. 4. MR # 10 was admitted to the agency on 3/8/23 with admitting diagnoses including Cellulitis of Left Upper Limb and Type Two Diabetes Mellitus with Diabetic Polyneuropathy. Review of the HHC and POC dated 3/8/23 revealed Occupational Therapy (OT) visits one time a week for one week effective 3/12/23. Further review of the HHC and POC dated 4/18/23 revealed Licensed Professional to report vital signs outside of the following parameters: Pain greater than six out of ten. Review of the OT visit note dated 3/17/23 revealed the patient reported pain of seven out of ten. There is no documentation the physician was notified of pain outside of parameters. An interview was conducted on 5/11/23 at 9:57 AM with EI # 1, who confirmed there was no documentation physician was notified of pain outside of parameters. 1. MR # 8 was admitted on 6/16/22 and recertified for home care from 10/14/22 to 12/12/22 with diagnoses including Non Pressure Chronic Ulcer of Left Lower Leg, Essential (Primary) Hypertension, and Paroxysmal Atrial Fibrillation. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 10/14/22 revealed orders for SN (Skilled Nurse) one visit per week for eight weeks. Review of the SN Visit Note dated 11/23/22 revealed the SN documented the presence of wound # 6, Stage II pressure ulcer to the distal lateral left posterior distal calf, onset date 11/23/22. The wound measurements were 0.6 cm (centimeters) length x 0.3 cm width x 0.1 cm depth with scant serosanguous exudate. Further review of the SN Visit Note dated 11/23/22 revealed no documentation the physician was notified of the new pressure ulcer. An interview was conducted on 5/11/23 at 10:00 AM with Employee Identifier (EI) # 1, Executive Director, who confirmed there was no documentation the physician was notified of the new wound. 2. HV # 5 was admitted on 4/20/23 with diagnoses including Hypertensive Heart Disease, Heart Failure, and Post Procedure Hematoma of the Skin. Review of the HHC and POC dated 4/20/23 revealed orders for SN one visit a week for one week then two visits a week for three weeks. Review of the Physician Order dated 4/24/23 revealed orders for the SN to perform/instruct/reinforce patient/caregiver procedure of wound care to wound # 1 left subclavian surgical incision. Review of the SN Visit Note dated 4/27/23 revealed the SN documented wound # 1 measurements were 1 cm length, 2 cm width, and 0.2 cm depth. Review of the SN Visit Note dated 5/2/23 revealed the SN documented wound # 1 wound measurements were 5.8 cm length x 0.1 cm width x 0 cm depth. There was no documentation the physician was notified of the increase in wound size. Review of the SN Visit Note dated 5/4/23 revealed the SN documented wound # 1 wound measurements were 3.7 cm length x 0.1 cm width x 0 cm depth. An interview was conducted on 5/11/23 at 10:30 AM with EI # 1 who confirmed there was no documentation the physician was notified of the increase in wound size.
G0608	Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on medical record (MR) review, agency policy, and interviews, it was determined the agency failed to ensure care was coordinated with the physician in relation to new medications and with outside agency at the time of discharge. This deficient practice affected one of four discharge records reviewed including MR # 8, and had the potential to affect all patients admitted to this agency. Findings include: Agency policy: Coordination of Care from Admit through Discharge Policy number: 2.1.017 Revised: 4/1/23 ...Policy: The agency provides care and services within an integrated continuum of care system... 4. Coordination of care with physician: At admission, thoughout care, and at discharge, coordination of services is promoted through routine communication with the patient's physician: a. when changes occur in the patients condition or response to treatment... 5. Coordination of care among disciplines: ... c...Significant changes in the patient's condition (... new or worsening symptoms, new or changed orders, or vital signs not within physician ordered parameters)... 6. Coordination of services with other organizations and community: When the patient receives services from other organizations and/or individual's care is coordinated to ensure that patient's needs are met efficiently... b. Communication with other health care providers when there are significant changes in patient care and/or condition... 1. MR # 8 was admitted on 6/16/22 and recertified for home care from 10/14/22 to 12/12/22 with diagnoses including Non Pressure Chronic Ulcer of Left Lower Leg, Essential (Primary) Hypertension, and Paroxysmal Atrial Fibrillation. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 10/14/22 revealed orders for SN (Skilled Nurse) one visit per week for eight weeks. Review of the SN Visit note dated 10/26/22 revealed the SN documented the caregiver (cg) stated MR # 8 was treated for UTI (Urinary Tract Infection) two weeks earlier and the physician had called in an antibiotic. Further review of the HHC and POC dated 10/14/22 revealed no documentation of the new antibiotic. There was no documentation the physician was contacted to verify the new medication and no documentation the new medication was added to the CMR. Review of the RN (Registered Nurse) Discharge from Agency note dated 12/8/22 revealed the nurse documented the patient felt like his/her goals set on admission were not met. The nurse documented the Patient Care Manager would have to assess the care plan and patient's progress to see if he/she qualified for more visits and someone from the office would contact him/her. There was no documentation the agency office contacted MR # 8 about the discharge plans and possible recertification. An interview was conducted on 5/11/23 at 10:00 AM with Employee Identifier (EI) # 1, Executive Director, who confirmed there was no documentation the physician was contacted to confirm the new medication and no documentation the office contacted the patient to discuss recertification.
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, agency policy and procedure and interviews with the staff it was determined the staff failed to follow the agency policy for hand hygiene, complete bed bath and glove change. This deficient practice affected two of five Home Visits (HV), including HV # 7 and HV # 4 and had the potential to negatively affect all patients served by the agency. Findings include: Agency Policy: Hand Hygiene Policy Number: 8.004 Revised Date: 5/1/19 Policy: Staff are required to perform hand hygiene prior to, at specified time points during, and following patient contact. Hand Hygiene will be performed using soap and water or an alcohol-based hand sanitizer. Procedure: 1. Staff performs hand hygiene by handwashing with soap and water or using an alcohol-based hand sanitizer: a. before direct contact with patients. ...d. if moving from a contaminated body site to a clean body site during patient care. e. after contact wit inanimate objects (including medical equipment...) in the immediate vicinity of the patient. f. before and after removal of personal protective equipment (PPE). g. at the conclusion of the visit after contact with a patient's intact skin, (e.g., when taking vital signs and lifting a patient.) 8. Other Aspects of Hand Hygiene: c. Change gloves during patient care if moving from a contaminated body site to a clean body site. Point of Care - Complete or Partial Bed Bath: ...16.Perform Hand hygiene and don gloves. ...27.Wash the patient's face... 28. Wash the patient's upper extremities and trunk. Change bath water when moving from one body part to the next... 29. Wash the patient's hands and nails... 30. Change the water and check the temperature of the bath water. Bathwater should be changed when moving from one body part to the next. 31. Wash the patient's abdomen... 32. Change the bathwater, being mindful of water temperature. 33. Wash the patient's lower extremities... 34. Change the bath water before perineal care... 35. Provide perineal care while the patient is in supine position... 36. Change the bath water after perineal care... 37. Remove gloves, perform hand hygiene, and don clean gloves. 38. Wash the patient's back. a. Assist patient to a prone or side-lying positing... b. ...wash, rinse and dry the patient's back from neck to the buttocks with long, firm strokes. c. Use a clean washcloth mitt for cleansing the buttocks and anus to prevent contamination of the bathwater. d. Cleanse the buttocks and anus...Cleanse, rinse and dry the area thoroughly... ...40. Remove gloves, perform hand hygiene, and don clean gloves. ...51. Discard or store supplies, remove PPE and perform hand hygiene... Agency Policy: Cleaning of Re-Useable Equipment. Policy Number: 8.006 Revised Date: 6/1/22 Policy: Equipment used for more than one patient is cleaned between each patient use. Definitions: 1. Low-Level disinfection - destroys most bacteria, fungi and some viruses...Examples include at least 70% isopropyl alcohol/ethyl alcohol... Procedure: 6. a. The hand-held computer device (i.e. tablet or Smartphone) should be wiped down with a low-level disinfectant at the beginning and end of each visit.... 2. HV # 4 was admitted to the agency on 4/12/23 with diagnoses including Multiple Sclerosis and Anemia, Unspecified. Review of Home Health Certification (HHC) and POC dated 4/12/23 to 6/10/23 revealed an Occupational Therapy (OT) frequency of once a week for one week, then twice weekly for three weeks, then once a week for one week. A HV was conducted on 5/9/23 at 2:10 PM with EI # 5, OT, to observe care. During the HV, EI # 5 failed to perform hand hygiene prior to donning gloves once and after removing gloves once. An interview was conducted on 5/9/23 at 3:44 PM with EI # 1, who confirmed the agency staff failed to follow the agency policy by not performing hand hygiene prior to donning gloves and after removing gloves. 1. HV # 7 was admitted to the agency on 4/27/23 with admitting diagnoses of Hemiplegia Following Cerebral Vascular Accident Right Dominant Side, and Aphasia Following Cerebral Infarction. An observation was conducted on 5/9/23 at 5:15 PM with Employee Identifier (EI) # 8, Home Health Aide (HHA), to observe care provided during a bed bath. EI # 8 sanitized hands, placed barrier on table and placed HHA bag on barrier. EI # 8 sanitized hands and donned clean gloves and removed equipment from the HHA bag. EI # 8 took HV # 7's vital signs (VS) and placed the equipment on the barrier. With the same gloves, EI # 8 cleaned the blood pressure cuff, stethoscope and the Oxygen saturation monitor and placed on clean side of barrier, removed gloves and sanitized hands and donned clean gloves. EI # 8 bathed and dried HV # 7's face and the upper body. EI # 8 then performed perineal care and bathed the patient's legs. The patient rolled on his/her right side and EI # 8 bathed the patient's back, buttocks and legs. Once complete HV # 7 asked if EI # 8 was going to wash his/her right side of back and legs. EI # 8 told the patient he/she did but the patient rolled on the left side and with the same gloves, water and wash cloths bathed the patient's right side. While on the left side the son applied a dressing to the coccyx area. EI # 8 used the same wash cloths, water and gloves for the entire bath. HV # 7 then asked EI # 8 if he/she was going to shave him/her. EI # 8 removed gloves and donned clean gloves and failed to sanitize hands prior to donning clean gloves and shaved the patient. EI # 8 removed gloves and did not sanitize hands and pulled an ink pen from the scrub pocket and documented in the patient's folder and replaced the pen back into the pocket. EI # 8 picked up the barriers from the table and placed in a bag and documented on the tablet. HV # 7 asked to have his/her hair combed. EI # 8 placed the HHA bag on the table without a barrier, donned clean gloves and did not sanitize hands prior to donning the gloves and combed the patient's hair. EI # 8 removed gloves, did not sanitize hands, placed the gloves in the trash bag and documented on tablet. Upon exiting the home EI # 8 used the hand sanitizer at the patient's front door. EI # 8 failed to clean the tablet prior to exiting the home. An interview was conduced on 5/9/23 at 4:00 PM with EI # 1, Executive Director, who confirmed the HHA failed to change the bath water during the bath, failed to sanitize hands when removing gloves, failed to use multiple wash cloths during the bath and failed to clean tablet prior to exiting the home.
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 the review of medical records (MR), agency policy and procedure, hospitalization report and staff interviews it was determined the agency staff failed to obtain a return demonstration of the administration of insulin to ensure the patient and/or caregiver was competent. This did affect one of eight MR's reviewed with a diagnosis of Diabetes, including MR # 7, and had the potential to affect all patient's with Diabetes served by the agency. Findings include: Agency Policy: Patient Education Policy Number: 3.001 Revised Date: 11/1/17 Purpose: To describe patient and/or caregiver interactions designed to promote and maximize patient health and safety. Policy: The agency plans, supports, and coordinates patient and caregiver education designed to promote optimal patient health and safety... Procedure: ...7. Using the progress/visit note, the clinician documents...patient/caregiver return demonstration... 1. MR # 7 was admitted to the agency on 12/19/22 with diagnoses including, Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1 Through Stage 4 Chronic Kidney Disease, or Unspecified Chronic Kidney Disease, Unspecified Systolic (Congestive Heart Failure) and Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. Review of the HHC and POC dated 12/19/22 to 2/16/23 revealed an order for a Physical Therapy (PT) frequency of once a week for one week, then twice weekly for three weeks, then once weekly for four weeks and for the PT to instruct the patient on management of Diabetes. Review of the Client Medication Report revealed the patient was prescribed Humalog 100 Units/ml (milliliter) 10 Units three times daily in addition to a sliding scale, sliding scale not documented, and Insulin Glargine 100 Units/ml 30 Units daily. Review of the 17 visit notes dated 12/19/22 to 1/23/23 revealed no documentation the patient and/or caregiver provided a return demonstration of insulin administration to ensure competency. Review of the hospitalization report dated 1/23/23 revealed the patient was hospitalized with a blood sugar of 821. An interview was conducted on 5/11/23 at 10:57 AM with EI # 1, Executive Director, who confirmed there was no documentation the patient and/or caregiver provided a return demonstration of insulin administration to ensure competency.
G0802	Duties of a HH aide CFR(s): 484.80(g)(3) The duties of a home health aide include: (i) The provision of hands-on personal care; (ii) The performance of simple procedures as an extension of therapy or nursing services; (iii) Assistance in ambulation or exercises; and (iv) Assistance in administering medications ordinarily self-administered. This ELEMENT is not met as evidenced by: Based on review of medical records (MR), agency Train Aide's Guide to Home Visits and interviews with the staff it was determined the Home Health Aide (HHA) failed to follow the aide plan of care for documentation of the the patient's last BM (bowel movement). This affected two of three patients receiving HHA services and did affect Home Visit (HV) # 7 and MR # 1 and had the potential to negatively affect all patients receiving HHA services. Findings include: Agency Train: An Aide's Guide to Home Visits Number: None Date: 2016 This checklist is a guide to assist the Home Health Aide in all the necessary steps to completing the HHA visit. HHA Aide Checklist: Indicate each ADL (Activity of Daily Living) or IADL (Instrumental Activities of Daily Living) Tasks, input/output, precautions and other special instructions as complete or incomplete. Aide Care Plan Job Aid: Registered Nurses, Physical Therapists, Occupational Therapists and Speech Therapists will use this job aide as a guide in developing a Home Health Aide (HHA) care plan when a HHS is indicated and the physician has ordered the services. The HHA will only perform duties which they have been deemed competent to perform by a Registered Nurse or Therapist. The HHA plan of care is a comprehensive plan directing the HHA on specific personal care and services to provide during the patient visit... Intake and Output: Intake and output monitoring captures data to ensure the patient is receiving the required/ordered amount of fluids, and to record Urinary and/or Bowel output and elimination information. Date of Last BM 2. MR # 1 was admitted to the agency 4/19/23 with admitting diagnoses including Other Osteoporosis with Current Pathological Fracture, Left Femur, Subsequent Encounter for Fracture with Routine Healing and Age Related Osteoporosis with Current Pathological Fracture, Left Forearm, Subsequent Encounter for Fracture with Routine Healing. Review of the HHC and POC dated 4/19/23 revealed orders the HHA was to visit two times per week for two weeks effective 4/23/23. Review of the Aide Care Plan Report revealed the following under Intake/Output: Date of last BM every visit. Review of the Aide Visit Note Report dated 5/2/23 revealed under category Intake/Output EI # 8 documented Y for yes and failed to document the date of the last bowel movement per the Aide Care Plan Report. An interview was conducted on 5/11/23 at 10:20 AM with EI # 1, who confirmed the aide failed to follow the Aide Plan of Care and document the date of the last bowel movement. 1. HV # 7 was admitted to the agency on 4/27/23 with admitting diagnoses of Hemiplegia Following Cerebral Vascular Accident Right Dominant Side, and Aphasia Following Cerebral Infarction. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 4/27/23 revealed the Home Health Aide (HHA) was to visit 2 times a week for 3 weeks beginning on 4/30/23. Review of the Aide Care Plan Report revealed the following under Intake/Output: Date of Last BM (Bowel Movement) every visit. Review of the Aide Visit Note Reports dated 5/4/23 and 5/9/23 revealed under category: intake/output, Employee Identifier (EI) # 8, Home Health Aide, documented "Y" for yes and failed to document the date of the last bowel movement per the Aide Care Plan Report. An interview was conducted on 5/11/23 at 10:47 AM with EI # 1, Executive Director, who confirmed the aide failed to follow the Aide Plan of Care and document the date of the last bowel movement.