DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		 (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER		 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
151518 A. BUILDING __________
B. WING ______________ 		02/10/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
DEACONESS VNA 611 HARRIETT STREET, EVANSVILLE, IN, 47734
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE

 TITLE

 (X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID
PREFIX
TAG		 SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
L0549      
38262 Based on observation, record review, and interview, the agency failed to ensure the plan of care included a treatment order for 1 of 2 home visit observations. (Patient 2) Findings include: A revised 11/22/19 policy titled Hospice Plan of Care was provided by the CHI Manager Area Director B on 2/8/21 at 1:45 p.m. The policy indicated, but was not limited to, "Hospice services are furnished in accordance with a written Plan of Care (POC) ... " A revised 7/8/15 policy titled Medication Administration was provided by the CHI Manager Area Director B on 2/8/21 at 1:45. The policy indicated, but was not limited to, "All nurses may administer medications by ... transdermal, topical ... when following physician orders." During a home visit on 2/9/21 at 10:30 a.m. RN (registered nurse) C was observed assessing patient 2's abdominal folds and under both breast for redness. RN C indicated Interdry (anti-microbial moisture wicking) dressing was in place to patient 2's abdominal folds and under right breast. RN C cut Interdry dressing and placed the dressing under patient 2's left breast. RN C indicated the family changes the dressings when the nurse was not there. The complete clinical record for patient 2 was reviewed on 2/9/21, start of care date 7/16/20 for the election period 1/12/21 to 3/12/21. A review of the updated plan of care failed to evidence a treatment order for Interdry dressing. A review of the electronic medical record failed to evidence a physician order for Interdry dressing. During an interview on 2/10/21 at 9:00 a.m. the Administrator agreed there should have been an order for Interdry.
L0578      
38262 Based on observation, record review, and interview, the agency failed to follow agency policy regarding bag technique for 1 of 2 home visit observations (Patient 2); and failed to screen visitors for Covid-19 upon entry to the agency for 2 of 3 survey visit dates. Findings include: 1. A 2/14/17 policy titled Bag Technique was provided by the CHI Manager Area Director B on 2/8/21 at 1:45 p.m. The policy indicated, but was not limited to, " ... keep the bag closed during the visit ... " 2. A 10/23/20 policy titled Pandemic Regulatory Guidance was provided by the CHI Manager Area Director B on 2/8/21 at 4:05 p.m. The policy indicated, but was not limited to, "Visitor restriction are to follow recommended infection control guidance from the CDC and State Health Departments." 3. A 10/24/19 policy titled Infection Control Surveillance was provided by the CHI Manager Area Director B on 2/8/21 at 4:05 p.m. The policy indicated, but was not limited to, "2. The Company takes reasonable efforts to protect the patient and the associate from infectious and communicable disease". 4. During a home visit on 2/9/21 at 10:30 a.m. RN (registered nurse) C was observed removing vital sign equipment from his/her supply bag. RN C failed to zip the bag closed before providing patient care. 5. Upon entering the agency's office, no Covid-19 (virus) screening process including temperature checks, symptom check or questions about travel was conducted for either of the State Health Surveyors on 2 of 3 days (2/8/21, 2/9/21). 6. During an interview on 2/9/21 at 12:40 p.m. the Administrator was asked if the agency had a Covid-19 screening process for those entering the agency. The Administrator stated the agency followed the same policy the hospital did and the hospital was currently taking visitor's temperatures and asking questions about travel and Covid exposure.