Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 017027	(X3) Date Survey Completed 09/26/2018
Name of Provider or Supplier Hga Homecare, Llc	Street Address, City, State 2050 Beltline Rd Sw, Decatur, AL
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.

(X4) ID Prefix Tag

Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)

G0580

Only as ordered by a physician
CFR(s): 484.60(b)(1)

Drugs, services, and treatments are administered only as ordered by a physician.

This ELEMENT is not met as evidenced by:
Based on review of medical records (MR), agency policies and procedures, observations and interviews with the staff it was determined the agency failed to ensure:

1. The staff completed PICC (Peripherally Inserted Central Catheter) dressing changes and extension tubing changes per physician orders.

2. Wound care was completed per physician orders.

This affected 3 of 4 MR's reviewed with PICC's and 2 of 12 MR's with wounds and did affect Home Visit (HV) # 4 and MR's # 5, # 7, # 1, and # 3. This had the potential to negatively affect all patients served by the agency.

Finding include:

Policy: Dressing Change Procedure for Central Venous, Midline, And Peripherally Inserted Central Catheters.

Policy Number: 10.027

Revised Date: 10/01/16

Purpose:

To keep insertion sites clean, stabilize catheter and minimize the risk of infection.

Procedure:

4. Place moisture proof pad under patient's arm.

5. To remove old dressing, lift edge of dressing beginning at catheter hub and gently pull dressing perpendicular to the skin toward the insertion site. Remove catheter securement device and Chlorhexidine-impregnated sponge...

8. Inspect catheter, catheter exit site, and surrounding skin and patient's arm, chest and neck area.

d. Measure external length of catheter from the insertion site to the catheter hub...

9. Cleanse the site with Chlorhexidine (preferred) in a back and forth motion for at least 30 seconds...

11. Consider application of a Chlorhexidine-impregnated sponge to the site...

12. Secure the catheter in place. The use of sutureless stabilization device is preferred to tape and sutures.

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Policy: Blood Sampling Via Peripheral or Central Venous Access Route.

Policy Number: 10.010

Revised Date: 7/1/10

Purpose:

To provide a standard as a guide for licensed nurses performing venipuncture and/or blood sampling for the purpose of laboratory analysis.

Policy:

It is not recommended to draw blood for therapeutic blood level from the same lumen in which the medication has been administered.

Procedure:

1. Obtain physician's order

3. Perform sampling according to LHC (Louisiana Health Care) adopted clinical skills guidelines.

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Policy: Physician Order

Policy Number: 2.1.008

Revised Date: 6/1/18

Purpose:

To outline the process of receiving and documenting physician orders.

Policy:

No medications, treatments, diagnostic studies or therapeutics will be administered without the order of a qualified physician, or as designated by State Practice Acts and that order be reduced to writing and signed/dated by the ordering physician.

Procedure:

9. Services are provided according to the most recent orders updating the patient's Plan of Care.

10. Orders containing medication must be entered into the software system or written legibly in ink and at a minimum include:

a. Name of medication, dose, dilution, frequency, route, rate of infusion.

g. Signature/date of physician.

1. HV # 4 was admitted to the agency on 8/26/18 with diagnoses of Cellulitis of Right Lower Limb, Type II Diabetes Mellitus with Diabetic Chronic Kidney Disease.

Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 8/26/18 revealed the following order for PICC line dressing change and lab (laboratory) draws:

Skilled nurse (SN) to perform site care for infusion access device Hickman to right chest wall with clear occlusive dressing changes once a week and PRN (as needed) for loose or soiled dressing. Using sterile technique cleanse site with Chlorhexadine, apply Biosite, cover with clear occlusive dressing. Injection cap change once a week and with each Lab draw and PRN for contamination or malfunction...

SN to flush with 10 ml (milliters) of Normal Saline (NS) prior to specimen draw. Discard 10 ml of blood, flush with 20 ml of NS and 5 ml of Heparin after specimen draw...

Review of the SN visit notes dated 8/28/18 and 9/3/18 revealed the nurse performed a lab draw. The nurse failed to document withdrawal and discard of 10 ml of blood. The SN documented the PICC was flushed with 10 ml of Normal Saline and not the 20 ml NS as ordered.

Review of the SN visit notes dated 9/10/18 and 9/17/18 revealed the nurse flushed the PICC with 10 ml of Normal Saline after completion of the lab draw and not 20 ml NS as ordered.

A home visit was conducted on 9/24/18 at 2:27 PM with EI # 5, Registered Nurse, to observe PICC care.

After sanitizing hands EI # 5 obtained the supplies to perform the dressing change to the PICC line. EI # 5 obtained a PICC line dressing kit and read the list of supplies. EI # 5 opened the package and determined the Biopatch (Biosite) required for the dressing change was not in the kit.

EI # 5 searched through all supplies to find there was not a Biopatch in the kit provided. EI # 5 then phoned the IV (intravenous) supplier, spoke with the pharmacist and requested the supplies from the IV supply company. EI # 5 stated the dressing could be changed without the Biopatch and new supplies would be sent.

While completing the dressing change EI # 5 realized there were no stat locks in the supplies. EI # 5 called the IV supplier and ordered more stat locks. The pharmacist again stated to leave the existing stat lock in place.

During PICC site care, EI # 5 cleaned the PICC site with 2 Betadine swabs and not the Chlorhexadine as ordered.

During the home visit, EI # 5 failed to contact the physician to inform him/her the dressing change to the PICC line was not changed per his/her orders. EI # 5 failed to receive new physician orders for PICC care provided on 9/24/18 during the HV.

An interview was conducted on 9/24/18 at 3:30 PM and on 9/26/18 at 9:40 AM with EI # 1 who confirmed the above mentioned findings.

2. MR # 5 was admitted to the agency on 5/25/18 and recertified for continued care on 7/24/18 to 9/21/18 with diagnosis of Type II Diabetes Mellitus With Other Specified Complications.

Review of the HHC and POC dated 7/24/18 revealed the following physician orders:

Skilled Nurse (SN) to obtain IV (intravenous) access via PICC line using 10 ml syringe and aseptic technique. SN to change PICC line dressing weekly and PRN contamination/malfunction...Perform IV site care using sterile and aseptic technique. Flush IV access with 5-10 ml of Normal Saline (NS) before and after connection/disconnection and with 20 ml after lab draw to clear line. Flush catheter with Heparin 10 U (unit)/ml (5 ml)...

Review of the 8/12/18, 8/17/18, 8/24/18 and 9/7/18 nurse visit notes revealed the nurse flushed the PICC line with 10 ml of NS after the lab draw and not 20 ml of NS as ordered.

An interview was conducted 9/26/18 at 9:50 AM with EI 2, Clinical Director, who confirmed the above mentioned findings.

3. MR # 7 was admitted to the agency 9/11/18 with diagnoses including Urinary Tract Infection, Site Not Specified and Encounter for Adjustment and Management of VAD (Vascular Access Device).

Record review of the HHC and POC dated 9/11/18 to 11/9/18 contained physician orders for Skill Nurse to visit 2 times a week for 1 week then weekly for 8 weeks. The SN orders included to draw lab every Monday starting 9/17/18 and to flush with 10 ml NS prior specimen draw. Discard 10 ml blood, flush with 20 ml NS and 5 ml of heparin (no strength ) after specimen draw. SN to perform site care for infusion device to right upper arm inner arm double lumen PICC line weekly and prn. Change injection cap once a week with each lab draw and prn for problems and extension tube change once a week and prn.

Further review of the 9/11/18 HHC and POC medications revealed orders for Heparin 5 ml as directed after last saline per SASH (saline, antibiotic, saline, heparin) protocol.

Review of the 9/11/18 RN Admission Visit Note Report and IV (intravenous therapy) Reference documentation revealed the PICC line was flushed with 10 cc NS. There was no documentation the Heparin 5 ml flush was administered after IV antibiotic administration as ordered.

Review of the 9/14/18 RN Visit Note Report and IV Reference documentation revealed the PICC line was flushed with 10 cc NS. There was no documentation the Heparin 5 ml flush was administered after PICC site care and cap changes. There was no documentation the weekly extension set change was completed.

Review of the 9/17/18 RN Visit Note Report and IV Reference documentation revealed PICC site care was performed and injection caps were changed. There was no documentation the PICC line was flushed with 10 cc NS and Heparin 5 ml flush as ordered.

Review of the 9/24/18 RN Visit Note Report and IV Reference documentation revealed the PICC line was flushed with 10 cc NS. There was no documentation Heparin 5 ml flush was administered after PICC site care and cap changes.

In an interview on 9/26/18 at 9:35 AM, EI # 3, Performance Improvement Coordinator, confirmed the aforementioned findings.

4. MR # 1 was admitted to the agency on 5/9/18 with diagnoses including Encounter for Surgical Aftercare Following Surgery on the Circulatory System and Encounter for Orthopedic Aftercare Following Surgical Amputation.

Review of the Visit Note Report dated 5/9/18 revealed narrative documentation of "Patient has an open lesion to right foot in the area of an amputated right great toe" and patient "instructed on wet to dry dressing to right great toe."

Review of the Visit Note Report dated 5/18/18 revealed narrative documentation of "wound care to R (right) Great Toe completed."

Further review of the Visit Note Report dated 5/18/18 revealed no documenation of what wound care had been completed.

Review of the HHC and POC dated 5/9/18 to 7/7/18 and physician orders dated 5/9/18 through 5/18/18 contained no documentation of physician orders for wound care to the right great toe.

An interview was conducted on 9/26/18 at 10:35 AM with EI # 1 who confirmed the previous finding.

5. MR # 3 was admitted to the agency on 6/8/18 with diagnoses including Unspecified Fracture of Upper End of Right Humerus, Subsequent Encounter for Fracture with Routine Healing.

Review of the HHC and POC dated 6/8/18 through 8/6/18 revealed a physician order for " Skilled nurse to provide/instruct/reinforce to client/caregiver wound care to wound # 2 Anterior Right Shoulder closed Surgical Incision as follows: ...cleanse daily starting 6/9/18 with antibacterial soap and water, pat dry with cloth, cover with gauze and secure with tape..."

Review of the Visit Note Report dated 6/17/18 revealed documentation of wound care to wound # 2 as "Removed dressing for assessment. Replaced with dry gauze, secure with tape..."

The 6/17/18 Visit Note Report revealed no documentation of how wound # 2 was cleansed and dried prior to the dry gauze application.

An interview was conducted on 9/26/18 at 10:21 AM with EI # 1, who confirmed the previous findings.