All Saints Home Health Care Inc — Every Inspection Finding on Record

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 record review and interview, the agency failed to ensure the POC included types of services, supplies and equipment; pertinent activity orders; nutritional requirements; medications and treatments; safety measures and education and training for 6 of 6 active patients (1, 2, 3, 4, 5 and 6) whose records were reviewed. Patients 1, 2, 3, 4, 5 and 6’s POCs did not include orders for the SN to flush and draw blood from the PICC line; start a peripheral IV; how to infuse the IV medication(s); the infusion rate; the type of dressing change and safety measures for PICC line/peripheral IV lines; safety measures for wound care; safety measures for post cerebrovascular disease; a complete medication list; the types of services, supplies and equipment required and patient specific interventions and education. These failures could place the agency's active patients receiving LCHH services at risk of injury, infection and deteriorating health status. Findings Include: Anaphylactic: A severe, potentially life-threatening allergic reaction. It can occur within seconds or minutes of exposure to something you're allergic to, such as peanuts or bee stings. Resource: https://www.mayoclinic.org/diseases-conditions/anaphylaxis/symptoms-causes/syc-20351468 Anaphylactic Kit: A kit containing medications needed to treat a severe allergic reaction. Resource: https://findanyanswer.com/what-does-an-anaphylaxis-kit-contain Anticoagulants: Medications that prevent the blood from clotting as quickly or as effectively as normal. Resource: https://patient.info/heart-health/anticoagulants Biopatch: Evidenced-based dressing choice for reducing local infections, catheter-related blood stream infections and skin colonization of microorganisms with central venous and arterial catheters Resource: https://www.devinemedical.com/Protective-Disks-with-CHG-Dressing-p/j-j4151h.htm Cerebrovascular Disease: A vascular disease of the cerebral circulation. Arteries supplying oxygen to the brain are affected resulting in one of a number of cerebrovascular diseases. Most commonly this is a stroke. Resource: https://en.wikipedia.org/wiki/Cerebrovascular_disease Chloraprep: Used to clean the skin to prevent infection. Resource: www.drugs.com/mtm/chloraprep-one-step.html Elastomeric: A device that infuses medication once the tubing is unclamped. Built with an elastic balloon inside a very tough outer cover, the device pushes intravenous medication through tubing and a filter that is attached to the reservoir. Resource: https://www.infuserveamerica.com/104/elastomeric-pumps Ertapenem: An antibiotic that is used to treat severe infections caused by bacteria in the skin, lungs, stomach, pelvis, and urinary tract.. Ertapenem is also used to prevent infection in people having certain types of surgery. Resource: https://www.drugs.com/mtm/ertapenem.html Hemiparesis: Muscular weakness or partial paralysis restricted to one side of the body. Resource: https://www.merriam-webster.com/medical/hemiparesis Hemiplegia: Total or partial paralysis of one side of the body that results from disease of or injury to the motor centers of the brain. Resource: https://www.merriam-webster.com/dictionary/hemiplegia Heparin: An anticoagulant injection used to decrease the clotting ability of the blood and help prevent harmful clots from forming in blood vessels. Resource: https://www.mayoclinic.org/drugs-supplements/heparin-intravenous-route-subcutaneous-route/description/drg-20068726 CMS IV Services: What are the home infusion therapy plan of care requirements: Plan of Care Content - The plan of care must prescribe the type, amount, and duration of the home infusion therapy services (including monitoring) that are to be furnished. The plan of care would also include the specific medication, the prescribed dosage and frequency as well as the professional services to be utilized for treatment. The ordering physician must sign and date the plan of care upon any changes to the plan of care. Resource: https://www.cms.gov/files/document/home-infusion-therapy-services-benefit-beginning-2021-frequently-asked-questions.pdf Levemir: a man-made form of insulin that is injected under the skin. Insulin works by lowering levels of glucose (sugar) in the blood. Resource: https://www.drugs.com/levemir.html Milrinone: A medication indicated for cardiac support in patients with acute heart failure, pulmonary hypertension, or chronic heart failure. Its use is primarily in the perioperative and ICU settings, although it also has utility for outpatient therapy in select patient populations. Resource: https://www.ncbi.nlm.nih.gov/books/NBK532943/ Peripheral IV: A catheter (small, flexible tube) placed into a peripheral vein for IV therapy such as medication fluids. Resource: en.wikipedia.org/wiki/Peripheral_venous_catheter PICC Line: An acronym for a Peripherally Inserted Central Catheter, and it is a long IV line. It is usually inserted in a smaller vein in the upper arm (peripheral) and terminates in a larger vein in the chest near the heart (central). “Catheter” is just another name for “tube”. PICC lines can have 1-3 lumens, which allow medications to be attached and flow through the line. Additionally, blood draws for lab purposes can also be extracted from the line. Also known as vascular access device. Resource: https://infusionsolutionsinc.com/what-is-a-picc-line Patient 1: Record review of the EMR included a POC dated 08/27/2021 to 10/25/2021 that included a diagnosis of Systolic and Diastolic (congestive) heart failure, long term (current) use of anticoagulants and Encounter for adjustment and management of vascular access device. The POC included an order for the SN to visit the patient one time a week for nine weeks. The POC included medications: Heparin Injection IV as Needed/prn, Milrinone Injection IV continuous and Sodium Chlorine Injection IV as Needed/prn. The POC read in part, “…Allergies…Calamine lotion, Sulfa antibiotics…Pt is currently on IV medication; Milrinone 0.5mcg/kg/min continuous IV infusion through double lumen PICC line. Pt will require skilled nursing services for IV medication administration… SN to obtain v/s Q visit and notify physician of…Systolic BP greater than…160 or less than…90…Diastolic BP greater than…100…or less than…50…” The POC did not include: the location of the PICC line, safety measures for the PICC line, orders and frequency for the nurse to flush the PICC line with IV medications, how the IV medication was to be infused (IV pump, etc), a complete medication list to include medications used to treat adverse reactions to the IV medications and frequency of administration, instructions to educate the patient/caregiver on measures to take if an adverse reaction to the IV medication occurred, the type(s) of medication allergens including the types of reactions to the allergens, IV supplies and equipment and bleeding safety precautions for the blood thinner medication. According to, The Mayo Clinic, After PICC line insertion, don't lift heavy objects and don't have BP readings taken on the affected arm, avoided jarring activities with your arm, such as throwing a ball, avoid submerging the PICC line in water, such as might happen with swimming or using a hot tub, check the area daily for signs of infection, cover a PICC line when showering, as the area shouldn't get wet. Resource: https://www.mayoclinic.org/tests-procedures/picc-line/about/pac-20468748 PICC Line: An acronym for a Peripherally Inserted Central Catheter, and it is a long IV line. It is usually inserted in a smaller vein in the upper arm (peripheral) and terminates in a larger vein in the chest near the heart (central). “Catheter” is just another name for “tube”. PICC lines can have 1-3 lumens, which allow medications to be attached and flow through the line. Also known as vascular access device. Resource: https://infusionsolutionsinc.com/what-is-a-picc-line According to “https://medlineplus.gov/ency/patientinstructions/000159.htm”, A PICC line needs to be flushed after every use to keep the catheter clean. It also prevents blood clots from blocking the catheter. According to https://www.mayoclinic.org/drugs-supplements/warfarin-oral-route/precautions/drg-20070945”, safety precautions while taking Coumadin include: Be careful when using a regular toothbrush, dental floss, or toothpick; be careful not to cut yourself when you are using sharp objects, such as a safety razor or fingernail or toenail cutters; avoid contact sports or other situations where bruising or injury could occur; check with your doctor right away if you notice any unusual bleeding or bruising, black, tarry stools, blood in the urine or stools, or pinpoint red spots on your skin. The record included a verbal order on an unknown company letterhead. The order was dated 06/23/2021 and titled, "Verbal Order/Changes”. The order read in part, “…Patient requires External Infusion Pump Daily…Pump Supplies per Bag of Infusion Drug Daily…IV Catheter Supplies Weekly…” The verbal order was not signed by the ordering physician. The verbal order was not part of the agency's individualized POC. The record included a verbal order on an unknown company letterhead. The order was dated 06/23/2021 and titled, "Verbal Order/Changes”. The order read in part, “…Milrinone IV continuous infusion at a rate of 0.5 mcg/kg/min…24 hour period…Infuse at 6.6 ML/hour via volumetric pump…charge pump via wall outlet for 4-6 hours daily…” The verbal order was not signed by the ordering physician. The verbal order was not part of the agency's individualized POC. An SN visit was conducted by Adm/DON on 09/20/2021. The BP was taken on the R upper extremity. The PICC line was located on the R upper extremity. During an interview with the Adm/DON on 11/18/2021 at approximately 12:30 PM, the surveyor presented the above findings of why the POC did not include a complete medication list to include medications used to treat adverse reactions to the IV medications with the frequency of administration. The Adm/DON stated the IV infusion company that supplied the medication, Identifier ZZ, does not usually send anaphylactic kits to the homes unless the patient is receiving IV antibiotics. The surveyor presented the above findings of why the POC did not include instructions to educate the patient/caregiver on measures to take if an adverse reaction to the IV medication occurred. The Adm/DON stated teaching done by the nurses was included in the nursing OASIS assessments for some of the patients but the information is not included on the POC’s because normally, the patient understands the information. The Adm/DON stated these agency failures were not likely to cause a problem since the agency normally instructs the patients on these issues. The Adm/DON stated he instructed the patient to call him immediately if an allergic reaction occurred and he would then tell the patient what to do. The surveyor asked what the impact might be if an allergic reaction was so severe the patient did not have time to call the Adm/DON for instructions. The Adm/DON stated most of the patients knew how to administer the anaphylactic medications. During an interview with the Adm/DON on 11/18/2021 at approximately 12:35 PM, the surveyor reviewed the agency policy IVT.1 and presented the above findings of why the POC did not include the type(s) of medication allergens to include the type of reaction(s) to Calamine lotion and Sulfa Antibiotics, as listed as allergies on the POC. The Adm/DON stated he did not know the types of reactions to medication allergens was included in the agency policy or that it should have been included on the POC. The surveyor presented the above findings of why the POC did not include the location of the PICC line and safety measures for the PICC line to include no lifting of heavy objects; no BP readings taken on the affected arm; avoided jarring activities with your arm, such as throwing a ball; avoid submerging the PICC line in water; and checking the area daily for signs of infection and covering the PICC line when showering, as the area shouldn't get wet. The Adm/DON stated the information was not included on the POC but the patients were taught these things during nursing visits. The surveyor asked what the impact might be due to these failures. The Adm/DON stated the POC for Patient 1 read in part, “…SN to assess IV line for complications, patency, and signs and symptoms of adverse medication or ineffective IV line response each visit.” During an interview with the Adm/DON on 11/18/2021 at approximately 12:46 PM, the surveyor presented the above findings of why the POC Section labeled, “DME and Supplies” did not include all IV supplies and equipment and/or IV dressing change supplies. The Adm/DON stated because the Infusion Company, Identifier ZZ, supplied those things and it didn’t come from the agency. The Adm/DON stated the agency’s failure to include all IV and dressing change supplies on the POC would not affect the patients since all the supplies needed were in the home. During an interview with the Adm/DON on 11/18/2021 at approximately 12:30 PM, the surveyor presented the above findings of why the POC did not include the frequency for the nurse to flush the PICC line lumens with IV medications. The Adm/DON stated the PICC line had two lumens and both lumens were flushed every 24 hours. The Adm/DON stated the family was taught to flush the lumens every 24 hours. The surveyor asked why the orders were not on the POC. The Adm/DON stated they were on the order the agency received from the infusion provided, Identifier ZZ. The surveyor presented the above findings of why the POC did not include how the IV medication was to be infused. The Adm/DON reviewed the EMR and stated the information was included on the order from Identifier ZZ and there was no way for the agency to add the IV medication was to be infused using an IV pump because there was nowhere in the agency’s EMR system to add that information. The surveyor presented the above findings of why the POC did not include bleeding safety precautions due to the patient taking the blood thinner, Coumadin. The Adm/DON stated the information was missed by the agency. The Adm/DON stated the agency’s failure to add this information to the POC would not affect the patient because the agency had already instructed the patient on what to do. The Adm/DON stated the wife of the patient was a nurse and she also knew what to do. During an interview with the Adm/DON on 11/18/2021 at approximately 1:45 PM, the surveyor presented the above findings of the two verbal orders dated 06/23/2021 on an unknown company letterhead and asked who the documents were from since the name was not included at the top of the pages. The Adm/DON stated the orders were from [Identifier ZZ], who supplied all IV medications and supplies. The Adm/DON stated the agency dealt with [Identifier ZZ] but the agency did not deal directly with the ordering physician. The Adm/DON stated the physician sent the orders/information to [Identifier ZZ] and [Identifier ZZ] sent it to the agency. The surveyor asked if the physician signed orders from [Identifier ZZ]. The Adm/DON stated no, the agency did not have the orders signed, but [Identifier ZZ] probably did. The surveyor asked why the two verbal orders had not been signed by the doctor. The Adm/DON stated he didn’t realize they needed to be. During an interview with the Adm/DON on 11/18/2021 at approximately 12:54 PM, the surveyor presented the above findings of why the BP was taken on the R side, the same side the PICC line was located, during the SN visit conducted on 09/20/2021. The Adm/DON stated he was the nurse that conducted the visits and he mis-charted. Patient 2: Record review of the EMR included a POC dated 09/05/2021 to 11/03/2021 that included a diagnosis of combined Systolic and Diastolic Heart Failure and Encounter for adjustment and management of vascular access device. The POC included an order for the SN to visit the patient two times a week for nine weeks. The POC included medications: Sodium Chlorine Injection as ordered, Heparin Injection as ordered and Milrinone injection continuous. The POC read in part, “…Pt is currently on IV medication…Pt will require skilled nursing services for IV medication administration… SN to obtain v/s Q visit and notify physician of…Systolic BP greater than…160 or less than…90…Diastolic BP greater than…100…or less than…50…” The POC did not include the location of the PICC line, safety measures for the PICC line, the number of PICC line lumens, orders and frequency for the nurse to flush the PICC line with IV medications, how the IV medication was to be infused (IV pump, etc), a complete medication list to include medications used to treat adverse reactions to the IV medications and frequency of administration, instructions to educate the patient/caregiver on measures to take if an adverse reaction to the IV medication occurred, and IV supplies and equipment. The record included a verbal order on an infusion company letterhead, Identifier ZZ, dated 05/07/2021 and titled, "Verbal Order/Changes”. The order read in part, “…Admit to [Identifier ZZ] for the provision of IV pharmaceutical services [Identifier YY] to provide skilled nursing…PICC line care and maintenance per agency’s policy/procedure. Biopatch to catheter exit site. Change patch/dressing and stabilization device every 5-7 days and as needed, per agency’s policy/procedure…Administer Milirone IV continuous infusion at a rate of 0.125 mcg/kg/min…24 hour period…Infuse at 1.4 ML/hour…via volumetric pump…charge pump via wall outlet for 4-6 hours daily… Sodium chloride 0.9% IV 5-10 mL IV push as flush as needed for catheter care maintenance…Heparin…5 ml IV push as needed for catheter maintenance. Flush unused lumen daily for catheter maintenance…Initiate standing orders for peripheral IV start as needed…Pt/caregiver may be trained on all pertinent aspects of care…including infusion, pump management, catheter care…Patient requires External Infusion Pump Daily…Pump Supplies…IV catheter supplies…” The verbal order was not signed by the ordering physician. The verbal order was not part of the agency's individualized POC. SN visits were conducted by Adm/DON on 09/16/2021, 09/27/2021, 10/14/2021, 10/18/2021, 10/21/2021 and 10/25/2021. The BP was taken on the R upper extremity. The PICC line was located on the R upper extremity. During an interview with the Adm/DON on 11/18/2021 at approximately 12:35 PM, the surveyor presented the above finding of why the POC did not include the location of the PICC line and safety measures for the PICC line. The Adm/DON stated it was the same answer given for Patient 1 in an earlier interview. The surveyor reviewed the answer for Patient 1 and asked if the answer was the information was not included on the POC but the patients were taught these things during nursing visits. The Adm/DON stated yes. During an interview with the Adm/DON on 11/18/2021 at approximately 1:03 PM, the surveyor presented the above findings of why the POC did not include the number of PICC line lumens and the frequency for the nurse to flush the PICC line with IV medications. The Adm/DON stated it was the same answer given for Patient 1 in an earlier interview. The surveyor reviewed the answer for Patient 1 and asked if the answer was the PICC line had two lumens, both lumens were flushed every 24 hours and the family was taught to flush the lumens every 24 hours. The Adm/DON stated yes. The surveyor asked why the orders were not on the POC. The Adm/DON stated they were on the order received from the infusion provider, Identifier ZZ. The surveyor presented the above findings of why the POC did not include how the IV medication was to be infused. The Adm/DON reviewed the EMR record and stated the information was not on the POC but it was supposed to be. During an interview with the Adm/DON on 11/18/2021 at approximately 12:30 PM, the surveyor presented the above findings of why the POC did not include a complete medication list to include medications used to treat adverse reactions to the IV medications with the frequency of administration. The Adm/DON stated it was the same answer given for Patient 1 in an earlier interview. The surveyor reviewed the answer for Patient 1 and asked if the answer was the IV infusion company that supplied the medication, Identifier ZZ, does not usually send anaphylactic kits to the homes unless the patient is receiving IV antibiotics. The surveyor presented the above findings of why the POC did not include instructions to educate the patient/caregiver on measures to take if an adverse reaction to the IV medication occurred. The Adm/DON stated it was the same answer given for Patient 1 in an earlier interview. The surveyor reviewed the answer for Patient 1 and asked if the answer was teaching done by the nurses was included in the nursing OASIS assessments for some of the patients but the information is not included on the POC’s because normally, the patient understands the information. The Adm/DON stated yes. During an interview with the Adm/DON on 11/18/2021 at approximately 12:46 PM, the surveyor presented the above findings of why the POC Section labeled, “DME and Supplies” did not include all IV supplies and equipment and/or IV dressing change supplies. The Adm/DON stated it was the same answer given for Patient 1 in an earlier interview. The surveyor reviewed the answer for Patient 1 and asked if the answer was because the Infusion Company, Identifier ZZ, supplied those things and it didn’t come from the agency. The Adm/DON stated yes. During an interview with the Adm/DON on 11/18/2021 at approximately 1:45 PM, the surveyor presented the above findings of the verbal order on an unknown company letterhead and asked who the documents were from since the name was not included at the top of the pages. The Adm/DON stated the orders were from [Identifier ZZ], who supplied all IV medications and supplies. The Adm/DON stated the agency dealt with [Identifier ZZ] but the agency did not deal directly with the ordering physician. The Adm/DON stated the physician sent the orders/information to [Identifier ZZ] and [Identifier ZZ] sent it to the agency. The surveyor asked if the physician signed orders from [Identifier ZZ]. The Adm/DON stated no, the agency did not have the orders signed, but [Identifier ZZ] probably did. The surveyor asked why the two verbal orders had not been signed by the doctor. The Adm/DON stated he didn’t realize they needed to be. The Adm/DON stated the agency’s failure to add all information to the POC would not affect the patient since he had already instructed her what to do. Patient 3: Record review of the EMR included a POC dated 08/26/2021 to 10/24/2021 that included a of diagnosis Inflammatory polyarthropathy, Rheumatoid Arthritis and Encounter for adjustment and management of vascular access device. The POC read in part, “…admitted to home health services for administration and management of IV…Patient is currently on i/v Remicaid (sic) 280 mg gm…Medication…Sodium Chloride…Injection…Heparin…Injection…Remicade 100MG/10ML 280MG/250ML Injection…Intravenous…Allergies…Amoxicillin, Cipro, Sulfa Antibiotics… Skilled Nursing 1Wk1, Q2WKS, 6 WKS, 8WKS…SN to administer IV medications Remicade 280mg as ordered in medication profile…SN to access peripheral line every 3 days as needed using aseptic technique…SN will perform IV site dressing changes as well as cap changes weekly as ordered…” The POC did not include orders for the nurse to start a peripheral IV line, safety measures for the IV line, the rate of infusion for the IV medication, a complete medication list to include medications used to treat adverse reactions to the IV medications, instructions to educate the patient/caregiver on measures to take if an adverse reaction to the IV medication occurred, the type(s) of medication allergens including the types of reactions to the allergens, IV supplies and equipment, the type of dressing change for the SN to perform when changing the IV site dressing, nutritional requirements and IV supplies and equipment. The record included a verbal order on an infusion company letterhead, Identifier ZZ, dated 07/30/2021 and titled, "Verbal Order/Changes”. The order read in part, “…PERIPHERAL IV CARE GUIDELINES…HH nurse to assess peripheral IV site with each SNV…Teach patient/caregiver to assess IV site with each infusion, or at least twice daily…Report temperature >100..redness, tenderness, swelling, any drainage…IV site to be restarted by HH nurse as needed upon presentation of these symptoms…Indwelling peripheral IV site must be dressed with transparent dressing to facilitate monitoring of site…” The verbal order was not signed by the ordering physician. The verbal order was not part of the agency's individualized POC. The record included a verbal order on an infusion company letterhead, Identifier ZZ, dated 07/30/2021 and titled, "Verbal Order/Changes”. The order read in part, “…Admit to [Identifier ZZ] for the provision of IV pharmaceutical services [Identifier YY] to provide skilled nursing…Peripheral line care and maintenance per agency's policy/procedure… Sodium chloride 0.9% IV 1-5 mL IV push as flush before and after medication administration…Heparin (100 U/mL) IV 1-3 mL IV push as final flush after medication administration…Pre-medicate 30 minutes before start of infusion with…Acetaminophen 650 MG orally…Diphenhydramine 50 MG orally…Remicade IV (5 mg/kg) 280 MG (250 mL 0.9% NaCl)… at weeks 0, 2, and 6 then every 8 weeks through 7/30/2022 at the following rates: 50 mL/hr over 15 minutes (12.5 mL) if no reaction then increase to 100 mL/hr over 15 minutes (25 mL) if no reaction then increase to 150 mL/hr over 15 minutes (37.5 mL) if no reaction then increase to 200 mL/hr over 15 minutes (50 mL) if no reaction then infuse the remaining volume 125 mL over 60 minutes. Total time 2 hours…If infusion reactions: mild to moderate (flushing, headache, nausea tightness in chest, chills, itchy skin, abdominal pain) stop infusion for 30 min, if symptoms resolve, consider restarting infusion at the following rates: 2 mL/hr over 15 minutes (0.5 mL) if no reaction then increase to 5 mL/hr over 15 minutes (1.25 mL) if no reaction then increase to 10 mL/hr over 15 minutes (2.5 mL) if no reaction then increase to 20 mL/hr over 15 minutes (5 mL) if no reaction then increase to 40 mL/hr over 15 minutes (10 mL) if no reaction then increase to 80 mL/hr over 15 minutes (20 mL) if no reaction then increase to 150 mL/hr over 30 minutes (75 mL) if no reaction then increase to 200 mL/hr over 30 minutes (100 mL) or remaining volume over 1 hour… If infusion reaction: severe - O2 saturation 150 and hypotension), drop in systolic of 20 mmHG. STOP the infusion. Administer diphenhydramine 25-50 mg orally Administer epinephrine 1:10,000 0.3 mg IV… Monitoring parameters: Document vital signs…at baseline, every 30 min during the infusion, and 30 min post infusion Notify MD if: decrease in systolic blood pressure by 20 mmHG or increase in heart rate > 25 BPM over baseline or patient experiences fever, chills, rigors, headache, respiratory changes, symptoms of mucosal edema, dizziness or rash… Anaphylactic precautions…Diphenhydramine 25mg orally…Epinephrine 1:10,000 0.3 mg IM x 2…” The verbal order was not signed by the ordering physician. The verbal order was not part of the agency's individualized POC. Diphenhydramine and Epinephrine were not included on the POC. The record included a verbal order on an infusion company letterhead, Identifier ZZ, dated 07/30/2021 and titled, "Verbal Order/Changes”. The order read in part, “…FOR LOCALIZED ALLERGIC REACTION (LOCALIZED ERYTHEMA (reddened skin), URTICARIA (hives), PRURITIS (itching), WHEAL REACTION (swelling, dilation of blood vessels),NO RESPIRATORY OR CARDIAC INVOLVEMENT: Stop drug infusion. Administer DIPHENHYDRAMINE 25-50 MG orally. Contact physician for further orders. Observe closely for signs/symptoms of respiratory/cardiac distress…FOR ANAPHYLACTIC REACTION: TREATMENT OF GENERALIZED ALLERGIC REACTION (GENERALIZED URTICARIA AND/OR PRURITIS WITH RESPIRATORY DISTRESS AND/OR CARDIAC INVOLVEMENT: Stop infusion. CALL 911. Initiate CPR as appropriate. Nurse or trained caregiver to administer EPINEPHRINE 1:1000 0.3 ML IM. Contact physician. Administer 2ND dose of EPI in 10 minutes if symptoms not noticeably improved…” The verbal order was not signed by the ordering physician. The verbal order was not part of the agency's individualized POC. Diphenhydramine and Epinephrine were not included on the POC. The record included an SN visit note conducted on 09/09/2021 by the Adm/DON that read in part, “…Using aseptic technique, SN started peripheral access line to the left lower arm. flushed peripheral line with 10ml of saline, pre medications administered; acetaminophen 500 mg, diphenhydramine 50 mg. SN administered Remicade 280 mg over 2 hours, flushed with 10 ml of sodium chloride followed with 3 ml of heparin…” The POC did not include orders for the nurse to start a peripheral IV line. Acetaminophen, Diphenhydramine and Epinephrine were not included on the POC. During an interview with the Adm/DON on 11/18/2021 at approximately 1:15 PM, the surveyor presented the above findings of why the POC for Patient 3 did not include orders for the nurse to start a peripheral IV line. The Adm/DON reviewed the EMR and stated he found an order. The order was described above on Identifier ZZ’s letterhead. The surveyor asked if a peripheral IV was started on the three visits conducted in the episode on 8/26/2021, 09/09/2021 and 10/21/2021. The Adm/DON stated, “yes”, he started a peripheral IV on all three visits. The surveyor presented the above findings and asked why the POC did not include safety measures for the peripheral IV line. The Adm/DON stated the agency taught that during SN visits but it was not included on the POC. The surveyor presented the above findings of why the POC for Patient 3 did not include the rate of infusion for the IV medication and how the IV medication was to be infused. The Adm/DON reviewed the POC and stated that information was not specified. The surveyor presented the above findings of why the POC did not include a complete medication list to include medications used to treat adverse reactions to the IV medications with the frequency of administration (Acetaminophen, Diphenhydramine and Epinephrine) and instructions to educate the patient/caregiver on measures to take if an adverse reaction to the IV medication occurred. The Adm/DON stated that was a good question and it is must have been because the medications were single doses. During an interview with the Adm/DON on 11/18/2021 at approximately 12:35 PM, the surveyor presented the above findings of why the POC did not include the type(s) of medication allergens to include the type of reaction(s) to Amoxicillin, Cipro and Sulfa Antibiotics, as listed as allergies on the POC. The Adm/DON stated it was the same answer given for Patient 1 in an earlier interview. The surveyor reviewed the answer for Patient 1 and asked if the answer was the Adm/DON did not know the types of reactions to medication allergens was included in the agency policy or that it should have been included on the POC. The Adm/DON stated yes. The surveyor presented the above findings of why the POC for Patient 3 did not include the type of dressing change for the SN to perform when changing the IV site dressing and nutritional requirements. The Adm/DON stated it was just an omission. During an interview with the Adm/DON on 11/18/2021 at approximately 12:46 PM, the surveyor presented the above findings of why the POC Section labeled, “DME and Supplies” did not include all IV supplies and equipment and/or IV dressing change supplies. The Adm/DON stated it was the same answer given for Patient 1 in an earlier interview. The surveyor reviewed the answer for Patient 1 and asked if the answer was because the Infusion Company, Identifier ZZ, supplied those things and it didn’t come from the agency. The Adm/DON stated yes. The Adm/DON stated the agency’s failure to add all information to the POC would not affect the patient since he had already instructed her what to do with everything involving her IV infusion. Patient 4: Record review of the EMR included a POC dated 10/11/2021 to 12/09/2021 that included a diagnosis of Encounter for change or removal of surgical wound dressing, chronic osteomyelitis of the right ankle and foot and Type 2 Diabetes. The POC read in part, “…Medication…Levemir…injection…Subcutaneous daily at bedtime…the patient has amputated 4th and 5th metatarsal on the right foot…SN may perform glucometer check every visit and report to MD if FBS >300250 During an interview with the Adm/DON on 11/18/2021 at approximately 1:32 PM, the surveyor presented the above findings of why the POC did not include safety measures for the wound and wound care and diabetic supplies. The Adm/DON stated the nurses taught safety measures for the wound but it was not included on the POC. The Adm/DON stated Patient 4 is a VA patient so the agency doesn’t supply the wound care supplies, but the VA does. The Adm/DON stated Adm/DON checks the patients blood sugar every time he made a visit but he uses the patient’s diabetic supplies. The Adm/DON stated he did not think the patient would be impacted by the agency’s failures. Patient 5: Record review of the EMR included a POC dated 09/21/2021 to 11/19/2021 that included a diagnosis of Hemiplegia and Hemiparesis following other cerebrovascular disease affecting left dominant side, muscle weakness and difficulty walking. The POC included an order for the SN to visit the patient one time a week for nine weeks and for PT to evaluate and treat. The POC read in part, “…Home Bound status…Residual weakness…SN to assess all body systems each visit and notify MD of…Systolic BP greater than…160 or less than…90…Diastolic BP greater than…90…or less than…60…” The POC did not include safety measures to ensure no BP’s were taken or blood draws performed on the left arm affected by the Cerebrovascular Disease. An PT evaluation visit conducted was conducted on 09/24/2021 by PT. The BP was taken on the left arm. The left arm was affected by the Cerebrovascular Disease. During an interview with the Adm/DON on 11/18/2021 at approximately 1:38 PM, the surveyor presented the above findings why the POC did not include safety measures to ensure no BP’s or blood draws were performed on the left arm affected by the Cerebrovascular Disease and why PT took a BP reading on the left arm on 09/24/2021. The Adm/DON stated it was an omission. Patient 6: Record review of the EMR included a POC dated 09/11/2021 to 11/09/2021 that included a diagnosis of Diverticulitis of intestine and large intestine and Long-Term use of antibiotics. The POC included an order for the SN to visit the patient one time a week for nine weeks. The POC included medications: Ertapenam 1G/11 GM injection IV every 24 hours; Sodium Chloride injection, intravascular before and after IV medication and Heparin injection, Intravenous after NS flush. The POC read in part, “…admitted to home health services for administration and management of IV…Patient is currently on i/v ERTAPENEM 1 GM every 24 hours through PICC line… SN will perform IV Site dressing changes…weekly as ordered…” The POC did not include the location of the PICC line, safety measures for the PICC line, the number of PICC line lumens, the rate of infusion for the IV medication, how the IV medication were to be infused, orders and frequency for the nurse to flush the PICC line with IV medications, orders for the SN to draw blood from the PICC line, a complete medication list to include medications used to treat adverse reactions to the IV medications and frequency of administration, instructions to educate the patient/caregiver on measures to take if an adverse reaction to the IV medication occurred, the type of dressing change for the SN to perform when changing the PICC line site dressing and IV supplies and equipment. The record included a letter dated 09/10/2021 from Identifier ZZ addressed to MD that read in part, “…RE: [Identifier 6]…Our staff is providing this patient with your prescribed therapy. We have enclosed some forms and documents with this letter that require your review and signature…” The order was not signed by the ordering physician. The order was not part of the agency's individualized POC. The forms included orders on an infusion company letterhead, Identifier ZZ, dated 09/08/2021. The orders read in part, “…Admit to [Identifier ZZ] for the provision of IV pharmaceutical services…[Identifier YY] to provide nursing…PICC line care and maintenance per agency’s policy/procedure. Biopatch to catheter exit site. Change patch/dressing every 5-7 days and as needed per agency’s policy/procedure…Ertapenem 1 gm (100 ml) IV over 30 minutes every 24 hours via elastomeric device X 10 days…Sodium Chloride…5-10 ML IV push as flush before and after medication administration… Heparin…5 ML IV push as flush after medication administration and as needed for catheter maintenance. Flush unused lumen twice daily with 5 ML…” The forms included orders on an infusion company letterhead, Identifier ZZ, dated 09/08/2021. The order read in part, “…FOR LOCALIZED ALLERGIC REACTION (LOCALIZED ERYTHEMA, URTICARIA, PRURITIS, WHEAL REACTION, NO RESPIRATORY OR CARDIAC INVOLVEMENT): Stop drug infusion. Administer DIPHENHYDRAMINE 25-50 MG orally. Contact physician for further orders. Observe closely for signs/symptoms of respiratory/cardiac distress…FOR ANAPHYLACTIC REACTION: TREATMENT OF GENERALIZED ALLERGIC REACTION (GENERALIZED URTICARIA AND/OR PRURITIS WITH RESPIRATORY DISTRESS AND/OR CARDIAC INVOLVEMENT: Stop infusion. CALL 911. Initiate CPR as appropriate. Nurse or trained caregiver to administer EPINEPHRINE 1:1000 0.3 ML IM. Contact physician. Administer 2ND dose of EPI in 10 minutes if symptoms not noticeably improved…” The order was not signed by the ordering physician. The order was not part of the agency's individualized POC. Diphenhydramine and Epinephrine were not included on the POC. SN visits were conducted on 09/18/2021, 09/25/2021, 10/02/2021 and 10/09/2021, 10/16/2021, 10/20/2021, 10/27/2021 and 11/03/2021 by LVN that read in part, “…SN performed PICC line site dressing change using a sterile technique with Chloraprep using back and forth scrubbing motion, applied Biopatch, and covered with a transparent adhesive dressing. The POC did not include orders for the type of dressing change for the SN to perform. SN visits were conducted on 09/18/2021, 09/25/2021, 10/02/2021 by LVN that read in part, “…Using aseptic technique, SN obtained blood for lab via PICC line, cleansed with Alcohol Pads, flushed PICC line flushed line with 20ml normal saline and 5ml heparin at dressing change. The POC did not include orders for the SN to draw blood from the PICC line. SN visits were conducted by Adm/DON on 09/11/2021 and 11/09/2021 and LVN on 09/25/2021, 10/02/2021, 10/16/2021 and 11/03/2021. The BP was taken on the left upper extremity. The PICC line was located on the left upper extremity. During an interview with the Adm/DON on 11/18/2021 at approximately 12:35 PM, the surveyor presented the above finding of why the POC did not include the location of the PICC line and safety measures for the PICC line. The Adm/DON stated it was the same answer given for Patient 1 in an earlier interview. The surveyor reviewed the answer for Patient 1 and asked if the answer was the information was not included on the POC but the patients were taught these things during nursing visits. The Adm/DON stated yes. During an interview with the Adm/DON on 11/18/2021 at approximately 1:41 PM, the surveyor presented the above findings of why the BP was taken on the left upper extremity where the PICC line was located on 09/11/2021, 09/25/2021, 10/02/2021, 10/16/2021, 11/03/2021 and 11/09/2021. The Adm/DON stated the BP’s must have been mis-charted. The surveyor presented the above findings of why the POC did not include the number of PICC line lumens and orders and frequency for the nurse to flush the PICC line with IV medications. The Adm/DON stated the PICC line had two lumens on the left upper extremity and the information should have been included on the POC but it was an omission. The surveyor presented the above findings of why the POC did not include the rate of infusion for the IV medication and how the IV medication was to be infused (IV pump, etc) . The Adm/DON stated the medication was infused through a ball infusion and did not require a pump but the information was not included on the POC. The surveyor asked why this information was not included on the POC. The Adm/DON stated the POC didn’t specifically indicate that information. The surveyor presented the above findings of why the POC did not include orders for the SN to draw blood from the PICC line. The Adm/DON stated initially there were no orders for blood draws until the doctor office called the agency and ordered it. The surveyor asked if the agency wrote a verbal order after the blood draw order was received from the doctor. The Adm/DON reviewed the EMR and stated he could not find an order. The surveyor asked why LVN did not document what labs were drawn. The Adm/DON reviewed the EMR and asked the Alt Adm, who was in the next room, if LVN drew blood from the PICC line. The Adm/DON left and went in the room where the Alt Adm was located and returned to the interview room and stated LVN only drew blood from the PICC line on the first documented lab draw visit, but not on the other visits. The surveyor asked why LVN documented lab draws when they were not done. The Adm/DON stated the information on the lab draw carried over from the first note to all other notes and the information should not have been included on any note except the first one. The surveyor presented the above findings of why the POC did not include the type of dressing change for the SN to perform when changing the PICC line dressing. The Adm/DON reviewed the EMR and stated the orders were not included. The surveyor asked how LVN knew what dressing change to perform without orders. The Adm/DON stated LVN had been doing this for a long time and he worked with her at another agency where LVN performed all aspects of IV infusion and care, therefore, he knew she was knowledgeable. During an interview with the Adm/DON on 11/18/2021 at approximately 12:30 PM, the surveyor presented the above findings of why the POC did not include a complete medication list to include medications used to treat adverse reactions to the IV medications with the frequency of administration. The Adm/DON stated it was the same answer given for Patient 1 in an earlier interview. The surveyor reviewed the answer for Patient 1 and asked if the answer was the IV infusion company that supplied the medication, Identifier ZZ, does not usually send anaphylactic kits to the homes unless the patient is receiving IV antibiotics. The surveyor presented the above findings of why the POC did not include instructions to educate the patient/caregiver on measures to take if an adverse reaction to the IV medication occurred. The Adm/DON stated it was the same answer given for Patient 1 in an earlier interview. The surveyor reviewed the answer for Patient 1 and asked if the answer was teaching done by the nurses was included in the nursing OASIS assessments for some of the patients but the information is not included on the POC’s because normally, the patient understands the information. The Adm/DON stated yes. During an interview with the Adm/DON on 11/18/2021 at approximately 12:46 PM, the surveyor presented the above findings of why the POC Section labeled, “DME and Supplies” did not include all IV supplies and equipment and/or IV dressing change supplies. The Adm/DON stated it was the same answer given for Patient 1 in an earlier interview. The surveyor reviewed the answer for Patient 1 and asked if the answer was because the Infusion Company, Identifier ZZ, supplied those things and it didn’t come from the agency. The Adm/DON stated yes. The Adm/DON stated the agency’s failure to add all information to the POC would not affect the patient because the nurses knew not to take the BP on the same side the PICC line was located and LVN knew what to do with IV’s. Agency Policy titled, "PLAN OF CARE PC.8" with a revision date of 11/01/2020, read in part, “…PURPOSE To ensure that care provided is appropriately planned…to meet the patient’s/client’s specific needs and problems…POLICY I. The Agency will use data/information gathered during patient/client assessments in the care planning process which involves the identification of patient/client…actions and interventions that will resolve or alleviate the patient’s/client’s problems and/or needs…PROCEDURE I. The appropriate licensed professional staff member…is responsible for developing the plan of care…III. Each patient/client must receive an individualized written plan of care…The individualized plan of care must specify the care and services necessary to meet the patient/client specific-needs…A. The individualized plan of care must include the following…safety measures to protect against injury…patient/client-specific interventions and education…” Agency policy titled, “Assessment for Home Infusion Therapy IVT.1” with a revision date of 06/01/2019 read in part, “…PROCEDURE…III. The patient’s/client’s allergy history will be assessed and the allergens and types of reactions will be documented. Previous adverse reactions to drugs or history of allergies will aide in identifying a high risk patient/client. IV. Medications are to be checked for adverse reaction possibilities, cross allergies, side effects, contraindicated medications and drug interactions. A nurse who is present during when an adverse drug reaction occurs will follow the Adverse Drug Reaction policy/procedure…” Agency policy titled, “General Policies for Administration of Intravenous Solutions and Medications IVT.3” with a revision date of 01/13/2018 read in part, “…PURPOSE To provide guidelines for intravenous/infusion therapy, define medications and/or medication classes that the qualified infusion nurse may administer, and to ensure safe and appropriate administration of intravenous fluids and medications. POLICY The Agency provides intravenous therapy per physician’s orders and the Agency administration policy…” Agency policy titled, “Adverse Drug Reactions IVT.4” with a revision date of 01/13/2018 read in part, “…PURPOSE To establish guidelines for infusion nurses in response to adverse drug reactions during administration of home infusion therapy, and to ensure optimal care and patient/client safety. POLICY I. The infusion nurse will react in an efficient and timely manner if an adverse drug reaction occurs in the home. PROCEDURE I. The Agency will obtain a written order and medications will be in the home for treatment of an adverse reaction prior to administering infusion therapy. II. The patient/client and/or caregiver will be instructed in the management of adverse reactions that may occur when the nurse is not present. Instructions may include but not be limited to how to stop the infusion, medications to be administered and how to administer them, to call 911 if necessary and if trained in CPR, and to notify the physician and the Agency of the reaction and the patient’s/client’s condition. III. If a non-life threatening, non-acute systemic reaction…occurs during a nursing visit, the nurse will…C. Administer the medications orders for the reaction…D. Call an ambulance or instruct the caregiver to do so…E. Ensure the patient’s/client’s airway is open. F. Start CPR if needed…” Agency Policy titled, "ORDERS FOR CARE PC.7" with a revision date of 11/01/2020, read in part, "PURPOSE To ensure patient/client care is provided in accordance with a physician…order and federal and state laws and regulations…POLICY A. The Agency will obtain orders and provide care in accordance with orders…The order will be signed and dated with the date of receipt by the registered nurse…responsible for furnishing or supervising the ordered services…PROCEDURE…I. All orders are kept current and renewed or updated as appropriate…V. The original order is sent/faxed to the physician…and a copy is retained in the patient’s/client’s medical record…IX. Agency staff will verify upon return of an order that the orders is complete, accurate, signed with the date of the orders…XI. When it is received by the Agency, the signed order replaces the copy in the patient’s /client’s medical record…XIV. Verbal orders must be authenticated and dated by the physician…Physician…signatures are obtained on the Plan of Care and supplemental verbal orders within sixty (60) days…Plans of Care should be signed within 30 days and verbal orders should be signed within 14 calendar days…” Agency Policy titled, "PLAN OF CARE PC.8" with a revision date of 11/01/2020, read in part, “…PURPOSE To ensure that care provided is appropriately planned in a timely manner to meet the patient’s/client’s specific needs and problems. Orders will be retuned signed within sixty (60) days…III. Each patient/client must receive an individualized written plan of care, including any revisions or additions…The individualized written plan of care must specify the care sand services necessary to meet the patient/client-specific needs…A. The individualized plan of care must include the following: 3. The types of services, supplies, and equipment required…9. Nutritional requirements; 10. All medications and treatments; 11. Safety measures to protect against injury; 13. Patient/client and caregiver educations and training to facilitate timely discharge; 14. Patient/client specific interventions and educations…IV. All patient/client care orders, including verbal orders, must be recorded in the plan of care…VIII. Drugs, services, and treatments are administered only as ordered by a physician…” Agency Policy titled, "MEDICATION ADMINISTRATION PC.16" with a revision date of 08/01/2020, read in part, “…PURPOSE To ensure competent and safe medication administration to patient/clients and maintenance of a current patient/client medication list. POLICY Agency staff will administer and document drugs…according to…clinical policies and procedures…PROCEDURE I. A written physician…order is obtained for medication administration. II. Written physician…orders specify: C. Medication dose. III. Agency staff will transcribe written physician…medication orders as soon as possible after they are received. These orders will be signed by the physician…within sixty (60) days…XII…Medications to treat allergic and/or severe adverse reactions will be present in the home during the administration. If an allergic or other adverse drug reaction occurs, the administering nurse will administer the medication(s) ordered for the allergic reaction…” Agency Policy titled, "MEDICATION LIST AND MONITORING PC.17" with a revision date of 08/01/2020, read in part, “PURPOSE To outline a process for ongoing medication monitoring. POLICY I. An agency RN will be responsible for coordinating the efforts of monitoring the medication regimen by compiling assessment data through a collaborative effort of all Agency staff involved in the patient’s/client’s care. A medication profile/list will be maintained on all patients/clients. II. Medication monitoring will include appropriate date/information to develop an accurate patient/client medication and a current, complete medication profile. This date will be available to all Agency staff involved in the patient/client care. PROCEDURE I. The agency will maintain a current, accurate list of all prescription and over-the-counter…medication taken by the patient/client (Medication Profile)…”

Every finding on record at All Saints Home Health Care Inc

Survey of November 18, 2021