Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 017009 (X3) Date Survey Completed 04/26/2018
Name of Provider or Supplier Eh Health Home Health Of Birmingham, Llc Street Address, City, State 1 Chase Corporate Drive, Suite 210 A, Hoover, 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)
G0578 Conformance with physician orders
CFR(s): 484.60(b)

Standard: Conformance with physician orders.


This STANDARD is not met as evidenced by:
Based on observation, agency's policy and procedure, medical record (MR) reviews and staff interviews, it was determined the staff failed to follow physician's order for:



1. Wound care on 5 of 5 patients with wounds including MR # 1, # 2, # 3, # 4 and # 4



2. Enteral Feedings on 1 of 1 patient with enteral feedings including MR # 4 orders for physician ordered visits including MR # 1, # 3, # 4, and # 5.



3. Discipline's visit frequencies on 4 of 5 physician's ordered visits including MR # 1, # 3, # 4 and # 5.



This deficient practice has the potential to negatively affect all patients treated by the agency.



Findings include:



Policy: Monitoring Patient's Response/ Reporting to Physician

Policy No. HH 2-015

Revised: 11/2017



Purpose



To provide guidelines for monitoring the patient's response to care, and for reporting to the patient's physician.



Procedure



F. When there is a problem implementing the plan of care. This includes any service, frequency, and treatment.





1. MR # 1 was admitted to home health on 9/9/17 with the diagnoses including Abnormal Microbiologic Findings in Specimen from Respiratory Organ/ Thorax, Methicillin Resistant Staphylococcus Infection Causing Disease Elsewhere Classified and Pressure Ulcer Sacral Region, Stage IV.



Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 9/9/17 to 11/7/17 revealed the following wound care orders: Stage III Mid Sacral, cleanse with dermal wound cleanser (DWC) or Saline, pat dry with gauze, may apply protective skin barrier wipe, apply Santyl to wound bed and lightly pack wound bed and undermined areas with Dakins moistened gauze, cover with abdominal pad (ABD), secure with paper tape. Provide Wound care at a frequency of: Skilled Nurse (SN) 1x (time) x 1 wk (week), 4 x wk x 1wk, 2x wk x 3 wks.



Review of the SN visit notes 4/24/18 revealed the SN missed one visit week of 9/10/17. Further review of the MR revealed a communication note dated 9/28/17 of a missed SN visit without the actual date the missed visit happened.



An interview conducted on 4/26/18 at 8:30 AM with Employee Identifier (EI) # 1 Branch Manager (BM) who confirmed the above mentioned findings.



2. MR # 2 was admitted to home health on 9/30/17 with the diagnoses including Sepsis, Unspecified Organism, Pressure Ulcer on Left Heel, Stage II, Pressure Ulcer on Right Heel, Stage II and Pressure Ulcer on Other Site, Stage 2.



Review of the HHC and POC dated 9/30/17 to 11/28/17 revealed the following wound care orders: #1 Left Heel, cleanse with DWC, pat dry with gauze, applied skin protective barrier wipe, apply Aquacel AG (silver impregnated dressing), cover with ABD pad, apply Kerlix and secure with tape. # 2 Pressure Ulcer (PU) Left Proximal Dorsum, cleanse with DWC, part dry with gauze, apply skin protective barrier wipe, apply Mepilex AQ, cover with Kerlix, secure with tape. # 3 Stage II, PU, Right Heel, cleanse with DWC, pat dry with gauze, apply protective skin barrier wipe, apply Mepilex AQ, cover with Kerlix, secure with tape.

Wound care to be provided at a frequency of: SN 3 x week.



Review of the SN SOC (Start of Care) visit note on 4/24/18 dated 9/30/17 4/24/18 revealed the following documentation: Wound labeled # 6 Left Proximal Dorsum and # 9 Stage III PU Left heel was cleansed with saline or DWC, pat dry with gauze, apply protective skin barrier wipe, applied Medihoney, and covered with Petroleum or Xeroform gauze, covered with Mepilex border, secured with rolled gauze and Coban; # 3 was Mid- Sacral Stage II PU and was "cleansed with DWC, pat dry with gauze, applied protective skin barrier wipe, applied Xeroform and bordered with Mepilex", # 8 Right Heel, Unstageable, there was no wound care provided, SN documented "observed and assessed for signs and symptoms of infection, Left open to air.

Review of the HHC and POC revealed there was no wound care ordered for the wound # 8 in the Mid Sacral area.



Further review of the SN SOC note 9/30/17 on 4/24/18 revealed the SN provided wrong physician orders to # 6 Left Proximal Dorsum and # 9 Left Heel. There was no order to apply Medihoney and cover wounds with petroleum or xeroform gauze with Mepilex border and secure with rolled gauze and Coban.



Further review of SN SOC note 9/30/17 on 4/24/18 revealed the SN provided wound care to # 3 Mid Sacral area # 8 Right Heel. There was no documentation of a Physican order (MD) found for # 3 Mid Sacral area # 8 Right Heel.



Review of the SN visit notes 4/24/18 revealed the SN documented on 10/6/17 the following " SN visit moved tomorrow due to awaiting for a new wound care supplies to be delivered". There was no documented visit made until 4 days later on 10/10/17 when wound care was provided.



An interview was conducted on 4/26/18 at 9:30 AM with EI # 1 who confirmed the staff failed to perform wound care as scheduled.



3, MR # 3 was admitted to home health on 11/6/17 with the diagnoses including Pressure Ulcer Of sacral Region, Stage IV and Myelodysplastic Syndrome, Unspecified.



Review of the HHC and POC dated 11/6/17 to 1/4/18 Revealed the following wound care orders: Stage IV Pressure Injury of Coccyx, cleanse with Saline or wound cleanser, pat dry with gauze, apply Santyl to wound bed, apply saline moistened gauze, cover with dry gauze followed with Mepilex foam dressing. May apply protective skin barrier wipe to periwound skin at a frequency of daily and measure at a minimum of weekly.



Review of the SN visit note 11/14/17 on 4/24/18 revealed no documentation wound on Sacral area and (R) Proximal Arm was measured according to the physician's POC.



Review of the Resumption of Care (ROC) 11/30/17 revealed the following wound care orders: cleanse wound Stage IV Pressure Injury to Coccyx with saline or wound cleanser, pat dry with gauze, apply Santyl (if not available substitute Hydrogel until Santyl is available) to wound bed, apply Saline moistened gauze, cover with dry gauze followed by Mepilex Foam dressing. May apply skin protective barrier to periwound skin. Wound care daily and agency to measure weekly.



Review of the SN visit notes dated 12/12/17 and 12/19/17 on 4/24/18 revealed no documentation wound on the Sacral Area and (R) Proximal Arm was measured according to the physician's ROC.



Review of the HHC and POC dated 11/6/17 to 1/4/17 revealed the Home Health Aide (HHA) to 1x for 1 wk, 2x for 3 wks and 1x for 4 wks.



Review of the MR visit notes 4/25/18 revealed there was 1 missed visit week of SOC (11/6/17). There was no documentation the physician was notified.



An interview was conducted on 4/24/18 at 8:45 AM with EI # 1 who confirmed the aforementioned findings.



4. MR # 4 was admitted to home health on 12/4/17 with the diagnoses including Pressure Ulcer of Right Buttock, Stage III and Hypertensive Chronic Kidney Disease, Stage I - IV.



Review of the HHC and POC dated 12/4/17 to 2/1/18 revealed the following wound orders: SN to apply Negative Pressure Wound Therapy (NPWT) to Right Upper Buttock and a frequency of 3 times a week. Cleanse/ Irrigate (R) Buttock with dermal wound cleanser/ saline, apply skin protective barrier to peri-wound skin. Cut the black Granufoam to fit the size and shape of the wound, place the foam into the wound cavity, picture frame the wound edges with transparent dressing, cover the sponge with transparent dressing. choose location on the dressing to apply trac pad, cut a hole thru the transparent dressing exposing the foam, apply the trac pad to the cut home and seal onto the dressing, connect trac pad tube to the canister and set the therapy setting to 125 millimeter of mercury (mm/Hg).



Review of the SN visit note 12/12/17 on 4/25/18 revealed documentation of the presence of tunneling on the coccyx measuring 2.5 cm. There was no documentation the physician was notified.



Review of the HHC and POC dated 12/4/17 to 2/1/18 revealed the disciplines visit frequencies: SN 4x for 1 wk, 3x for 7 wks and 1x for 1 wk.; Home Health Aide (HHA) effective 12/10/17 at 2x for 3 wks and 1x for 3 wks; Physical Therapy (PT) 2x for 3 wks, 1x for 1 wk, 2x for 4 wks and 1x for 1 wk.; Occupational Therapy (OT) 2x for 4 wks.



Review of the SN visit notes 4/25/18 revealed 1 missed visit week of 12/31/17. There was no documentation the physician was notified.



Review of the HHA visit notes 4/25/18 revealed 1 missed visit week of 12/17/17 and 2 missed visits week of 12/24/17. There was no documentation the physician was notified.



Review of the PT visit notes 4/25/18 revealed 1 missed visit week of 12/4/17 and 1 missed visit week of 12/17/17. There was no documentation the physician was notified.



Review of the OT visit notes 4/25/18 revealed 1 missed visit week of 12/17/17 Further review of the OT notes revealed no visits (2) were made week of 12/24/17.



In an interview conducted on 4/26/18 at 8:30 AM with EI # 1 who confirmed the staff failed to follow agency's policy and procedures.



5. MR # 5 was admitted to home health on 11/17/17 with the diagnoses including Pressure Ulcer of Left Hip, Stage III and Pressure Ulcer of Sacral region, Stage II.



Review of the HHC and POC dated 11/17/17 to 2/25/18 revealed the SN visit frequencies was 3 x for 4 wks, 2 x for 3 wks and 1 x for 2 wks.



Review of the MR (medical record) visit notes 4/25/18 revealed there were 2 missed visits the week of SOC (11/17/17) and 1 missed SN visit week of 11/24/17. There was no documentation the physician was notified.



An interview was conducted on 4/26/18 at 9:15 AM with EI # 1 who confirmed the above mentioned findings.