Every finding on record at Amedisys Home Health of Alabama, LLC

Based on the recertification survey conducted on 6/2/22, Amedisys Home Health Lakeshore of Birmingham was found to be in substantial compliance with the standards for Emergency Preparedness.

A recertification survey was conducted at Amedisys Home Health Lakeshore of Birmingham from 5/31/22 to 6/2/22 and standard level deficiencies were cited.

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on review of medical records (MR), agency policy and procedure and interviews with staff, it was determined the agency failed to provide a written Notice of Medicare Non-Coverage (NOMNC) form on 2 of 5 discharge medical records reviewed and did affect MR # 6 and MR # 10 and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Medicare Notice of Non-Coverage Policy Number: TX-007 Date Revised: 3/25/21 Purpose: Medicare beneficiaries...will receive a NOMNC at least 2 days prior to the discontinuation of services. Procedure: 1. The agency will issue the NOMNC to all Medicare beneficiaries no later than 2 days before the end of covered services or the second to last day of service if care is not being provided daily.... 4. At least 2 days prior to discharge or earlier, the clinician will notify the patient of the proposed date for end of service, and their right to appeal if they disagree with the discharge or termination of services. A NOMNC must be delivered even if the beneficiary agrees with the termination of services. 5. The clinician will review the NOMNC with the patient and explain their right to an appeal and the process to be followed if they choose to do so.... 1. MR # 6 was admitted to the agency on 11/4/14 and recertified for care from 11/27/21 to 1/25/22 with diagnoses including Encounter For Fitting and Adjustment of Urinary Device and Retention of Urine, Unspecified. Review of the Physician Order Dated 12/30/21 revealed, "Discharge due to insurance change first of year." Review of the Client Coordination Note Report by the LPN (Licensed Practical Nurse) dated 12/31/21 revealed, "Called patient to discuss ...Medicare Part A terming on 12/31/21. Review of the Visit Note Report (VNR) by the RN (Registered Nurse) dated 12/31/21 revealed, "Patient being discharged today due to insurance change."... Review of the NOMNC form dated 12/31/21 and signed by the patient 12/31/21 revealed the patient was notified that coverage of services would end on 12/31/21. There was no documentation the patient signed the NOMNC form 2 days prior to the discharge per policy. An interview conducted on 6/2/22 at 1:25 PM with Employee Identifier (EI) # 1 Director of Operations (DOO) confirmed the patient signed the NOMNC form the day of discharge and was not signed 2 days prior to discharge per policy. 2. MR # 10 was admitted to the agency on 12/10/21 and certified for care from 12/10/21 to 2/7/22 with diagnoses including Encounter for Other Orthopedic Aftercare and Spinal Stenosis, Lumbar Region Without Neurogenic Claudication. Review of the Physician Order dated 1/13/22 revealed, "Patient to be discharged due to insurance change." Review of the VNR by the Physical Therapist (PT) dated 1/13/22 revealed, "Discharge from Agency. Current payment source for home care, Medicare." Further review of the MR revealed there was no documentation a NOMNC form was reviewed and signed by the patient. An interview conducted on 6/2/22 at 1:25 PM with EI # 1 confirmed there was no signed NOMNC form signed by the patient per policy.

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 review of medical records (MR), agency policy and procedure, observation and interviews, it was determined the agency failed to ensure accuracy of the medication profile in 4 of 7 Home Visits (HV) including HV # 5, HV # 3, HV # 2, HV # 7, and had the potential to negatively affect all patients served by the agency. Agency Policy: Drug Regimen Review Policy Number: MA-002 Review date 01/2020 Purpose: To identify appropriateness, inconsistencies, and/or significant drug interactions in the patient's current medication regimen, as well as ensure the comprehensive list of medications are updated any time there is a medication change including dose changes, new medications, and any medications discontinued. Procedure: 1. The clinician completing the OASIS (Outcome and Assessment Information Set) Assessment must complete a comprehensive drug regimen review of all medications the patient is currently taking at the time of admission, recertification, resumption of care and with any major change in condition. The medication profile is completed by documenting all the patient's medications which includes: Medications on written prescriptions and medication bottles; Over the counter medications; Herbal products; Vitamins and supplements and Oxygen. 2. The clinician will question the patient and/or caregiver periodically regarding changes in medications including dosage changes, any new medications added or any medications discontinued. ( This inquiry will include over the counter medications ,herbal products, supplements and oxygen). The clinician will also ask the patient to periodically allow them to visualize all the medications the patient is currently taking. (Medications will be visualized minimally at Start of Care, Recertification/Follow-up, Recertification of Care and upon any medication change). The visualized medications are compared to the current medication profile to ensure accuracy of the medication profile... 4. When medication additions or changes are not received verbally from the physician but identified in the home by review of prescription bottle or written prescription for the physician: The clinician/therapist will document new or changed medication on the clinicians visit note. The medication change is then entered in the computer system... A new medication list is generated, printed and taken to patient's home as appropriate. 3. HV # 2 was admitted to the agency on 5/16/22 with diagnosis including Erosive (Osteo) Arthritis and Pain in the Right Shoulder. A HV was conducted 5/31/22 at 1:45 PM to observe care provided by EI # 9, Certified Occupational Therapy Assistant (COTA). During the HV visit, HV # 2’s medications were compared to the current Medication List (ML) provided to the surveyor on 5/31/22 by the agency. The following discrepancies were observed: Cetirizine 10 mg (milligrams) capsule take 1 capsule orally daily was listed on the ML and not observed with HV # 2 medications. The patient stated he/she has been taking Loratadine 10 mg daily for about two months for allergies instead. Loratadine 10 mg observed with HV # 2’s medications and not on the ML. Diclofenac 1 % Topical Gel, apply 3 centimeters to knees twice daily as needed, observed on the ML. Patient stated he/she did not have Diclofenac and was using Over-the-Counter (OTC) Salonpas Lidocaine Plus Patches instead for about two months because it’s cheaper to buy. Salonpas Lidocaine Plus Patches observed with HV # 2’s medications and not on the ML. A bottle of OTC Turmeric 1000 mg was observed with HV # 2 medications and not on the ML. The patient stated he/she had been taking one capsule every night for about 8 years. An interview was conducted on 6/2/22 at 1:35 PM with EI # 7, Registered Nurse (RN), DOO of North Alabama Region, who confirmed the medications had not been reconciled per agency's policy. 4. HV # 7 was admitted to the agency on 5/16/22 with diagnoses including disruption of traumatic injury wound repair, and laceration without foreign body, right thigh. Review of Home Health Certification and Plan of Care dated 5/16/22 revealed orders for the SN to visit 3 times per week for 9 weeks. A HV was conducted on 6/1/22 at 11:55 AM to observe wound care and medication review with EI # 5 RN, Case Manager. During the HV visit, HV # 7’s medications were compared to the current ML provided to the surveyor on 5/31/22 by the agency. The following discrepancies were observed: Fluoxetine 20 mg capsule take 3 capsules daily observed on HV # 7’s the ML. Patient stated he/she stopped those pills about 2 months ago and notified the primary doctor. Gabapentin 300 mg capsule take 1 capsule three times daily observed on HV # 7’s the ML. Patient stated he/she has been out of that medication for about one week and had no refills. Methocarbamol 500 mg tablet take 1 tablet three times daily observed on HV # 7’s the ML. Patient stated he/she has been out of that medication for about one week and had no refills. A bottle of Vitamin D3 1000 IU (International Units) observed with HV # 7’s medications and not the ML. Patient stated he/she was prescribed the new medication by primary doctor on 5/17/22. An interview was conducted on 6/2/22 at 2:03 PM with EI # 7 who confirmed the medication list had not been reconciled per agency's policy. 2. HV # 3 was admitted to the agency on 4/26/22 with diagnoses including Encounter for Change or Removal of Non-Surgical Dressing, Fistula of Intestine, and Pressure Ulcer of Left Buttock. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 4/26/22 revealed orders for Skilled Nurse (SN) 2 x a week x 1 week, Physical Therapy (PT) 2 x a week x 1 week, and Occupational Therapy (OT) 1 x a week x 1 week. Review of the MR revealed HV # 3 was transferred to an inpatient facility on 4/28/22 and returned to home care on 5/15/22. Review of physician order dated 5/15/22 revealed orders for SN 2 x a week x 3 weeks then 1 x a week x 3 weeks. On 5/31/22 at 12:15 PM a HV was conducted to observe care provided by EI # 10, Licensed Physical Therapy Assistant (LPTA). During the HV the current medications in the home were compared to the Client Medication Report (CMR) provided to the surveyor on 5/31/22. Levothyroxine 150 mg take one daily was listed on the CMR. Levothyroxine 200 mg take one daily was in the home, prescription dated 4/7/22. HV # 3 stated he/she had been taking the Levothyroxine 200 mg daily since his/her doctor visit on 4/7/22. In an interview conducted on 6/2/22 at 1:55 PM, EI # 1 confirmed the medications had not been reconciled per agency policy. 1. HV # 5 was admitted to the agency on 5/20/21 and recertified for services on 5/15/22 with diagnoses including Venous Insufficiency (Chronic) (Peripheral) and Non-Pressure Chronic Ulcer of Other Part of Left Lower Leg with Fat Layer Exposed. A HV was conducted 5/31/22 at 2:07 PM with Employee Identifier (EI) # 6, LPN (Licensed Practical Nurse) to observe wound care and medication reconciliation. The medications in the home were compared to the current Medication List (ML) provided by the agency and the following discrepancies were found and verified by the patient and EI # 6: Clonidine HCL 0.2 mg (Milligram) tablet, one tablet two times daily on the ML and per the patient, "the medication was discontinued a little over three months ago." Losartan 100 Mg tablet, one tablet daily on the ML and per the patient, "was changed to 1/2 tablet daily a little over three months ago." Meclizine 25 mg Chewable tablet, one tablet daily on the ML and per the patient, "I take one tablet twice daily and have for years." Oxybutynin Chloride 5 mg tablet, one tablet four times daily on the ML and per the patient, "I take two tablets twice daily and have for years." Vitamin C 500 mg tablets found in the home and not on the ML and per the patient, "I have taken one tablet daily for a little over one year." Vitamin D3 1000 IU (International Unit) tablets found in the home and not on the ML and per the patient, "I have taken one tablet daily for a little over one year." Vitamin E 400 IU tablets found in the home and not on the ML and per the patient, "I have taken one tablet daily for a little over one year." Tylenol 650 mg tablets found in the home and not on the ML and per the patient, "I take two tablets daily for a little over 3 months." Fish Oil 1000 mg (Omega 3 300 mg) tablets found in the home and not on the ML and per the patient, "I have taken one tablet daily since February 2022." Omega XL 300 mg tablets found in the home and not on the ML and per the patient, "I have taken two tablets daily since January 2022." Women's Centrum Silver Vitamins found in the home and not on the ML and per the patient, "I have taken one daily for years." During the medication review, the surveyor asked the patient to confirm the information on the ML revealing, "NKA" (No Known Allergies) and per the patient, "I am allergic to Claritin and Generic Provera and have had that allergy for years" and if taken, "feels like something is attacking my body." An interview conducted on 6/2/22 at 1:25 PM with EI # 1, Director of Operations (DOO) confirmed the medications were not updated each visit per policy.

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 review of agency policies and procedures, medical record (MR) reviews and staff interviews, it was determined the agency failed to ensure physicans orders were followed for the following: 1. Monitoring blood glucose on diabetic patients. 2. Monitoring Oxygen (O2) saturation levels. 3. Monitoring vital signs. 4. Monitoring weights. 5. Managing pain. This deficient practice affected 2 of 7 home visit (HV) record reviews, 1 of 5 active MR, 1 of 5 discharge record reviews and did affect HV # 5, MR # 9, HV # 1, MR # 1, and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Physician Orders and Medical Supervision of the Plan of Care Policy Number: TX-001 Date Revised: 9/17/21 Procedure: 2. Each patient receives the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed... Agency Policy: Coordination of Care Policy Number: TX-002 Policy Revised Date: 5/9/22 Procedure: 5. Relevant physicians are notified promptly of 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. The Plan of Care is appropriately revised/updated to reflect current information concerning the patient's measurable outcomes and goals. 4. MR # 1 was admitted to the agency on 5/6/22 with diagnoses including Aftercare Following Surgery for Neoplasm, Malignant Neoplasm of Rectosigmoid Junction, and Type 2 Diabetes Mellitus. Review of the HHC and POC dated 5/6/22 revealed orders including: SN 1 x a week x 1 week, 3 x a week x 1 week, 2 x a week x 1 week, 1 x a week x 2 weeks, then 1 visit every 2 weeks x 4 weeks; Blood Glucose testing every AM. SN to assess patient/caregiver ability to perform and record blood glucose testing as ordered and to report abnormal findings to physician. Review of the SN VNR dated 5/6/22 revealed the SN documented "...patient doesn't check blood sugar..." Further review of the SN VNR dated 5/6/22, 5/10/22, 5/11/22, 5/13/22, 5/18/22, and 5/24/22 revealed no documentation of a blood glucose reading and no documentation the physician was notified the blood glucose was not being monitored. In an interview conducted on 6/2/22 at 1:15 PM, EI # 1 confirmed the blood glucose had not been monitored and the physician had not been notified. 3. HV #1 was admitted to the agency on 5/16/22 with diagnoses including Encounter For Orthopedic Aftercare Following Surgical Amputation and Acquired Absence of Right Leg Below Knee Amputation. Review of the HHC and the POC dated 5/16/22 revealed orders for SN frequency 1wk1, 2wk2, 2wk4 to assess patient/caregiver ability to perform and record blood glucose testing as ordered and to report abnormal findings to physician, SN may perform blood glucose as needed, blood glucose testing twice daily, to report to physician blood glucose reading greater than 245 or less than 65. Further review of the HHC and the PoC dated 5/16/22 revealed Physical Therapist (PT) to ... monitor diabetic management. Review of the SN visit note dated 5/16/22 revealed a documented blood glucose of 144 Review of the SN visit note dated 5/25/22, 5/26/22 and 5/31/22 revealed no documentation the blood glucose was assessed . Review of the PT visit note 5/17/22 and 5/25/22 revealed no documentation the blood glucose was assessed. An interview conducted on 6/2/22 at 1:05 PM with EI #1 DOO confirmed the blood glucose was not monitored per physician orders. 1. HV # 5 was admitted to the agency on 5/20/21 and recertified for services on 5/15/22 with diagnoses including Venous Insufficiency (Chronic) (Peripheral) and Non-Pressure Chronic Ulcer of Other Part of Left Lower Leg with Fat Layer Exposed. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 5/15/22 to 7/13/22 revealed orders for, "Skilled Nurse (SN) frequency 1WK9 (once per week for 9 weeks) to assess patient's ability to monitor and record daily weights and vital signs, including pulse and blood pressure. Record patient reported weight, or weigh patient as needed. Report increased edema or weight gain of greater than 3 pounds in one day or greater than 5 pounds in one week or 5 pounds or more over target weight. May measure abdominal girth if unable to weigh. Scales and blood pressure (BP) monitor to be provided if needed." There was no documentation of what the target weight should be. Review of the SN Visit Note Reports (VNR) dated 5/17/22, 5/24/22 and 5/31/22 revealed no documentation the SN assessed the patient's ability to monitor and record daily weights and vital signs including pulse and blood pressure and no documentation of the patient's recordings of daily weights and vital signs including pulse and blood pressure. An interview conducted on 6/2/22 at 1:25 PM with Employee Identifier (EI) # 1, Director of Operations (DOO) confirmed the physician's orders for the patient were not followed including no assessment of the patient's ability to monitor and record daily weights and vital signs and no documentation of the patient's reported weight. EI # 1 also confirmed there was no documentation of a target weight for the patient. 2. MR # 9 was admitted to the agency on 4/4/22 with diagnoses including Other Complications of Amputation Stump and Infection of Amputation Stump, Right Lower Extremity. Review of the HHC and POC dated 4/4/22 to 6/2/22 revealed orders for the SN to visit 3WK8, 1WK1 and "SN may perform O2 (Oxygen Saturation) level on admission and every visit to assess patient, with notification to the physician if saturation is less than 90%...SN to observe, assess, and provide education on pain management techniques...SN to assess patient/caregiver ability to perform and record blood glucose testing as ordered and to report abnormal findings to the Physician. SN may perform blood glucose test as needed. SN to report to physician blood glucose readings greater than 270 or less than 70. SN to instruct patient on importance of HGBA1C (Average Blood Sugar level over the last 2 to 3 months) monitoring." Further review of the HHC and POC dated 4/4/22 to 6/2/22 revealed orders for "SN to monitor patient/caregiver adherence to monitor and record vitals signs including temperature, heart rate, respirations, and symptoms... Licensed Professional to report vital signs falling outside the following established parameters...temperature less than 96 greater than 100, pulse less than 60 greater than 100, respirations less than 12 greater than 20." Review of the OT /OTA (Occupational Therapy/Occupational Therapy Assistant) VNR dated 4/11/22 at 12:11 PM revealed a pain level of 5. Review of the SN VNR dated 4/11/22 at 1:25 PM revealed a pain level of 6, Diabetes managed by insulin and patient waiting on a glucometer (to assess the blood sugar). There was no documentation of what pain level was acceptable to the patient, no documentation the physician was notified and no documentation the blood sugar was monitored by the SN. Further review of the medical record revealed no documentation the patient/caregiver was monitoring the vital signs including temperature, heart rate and respirations and no documentation the SN monitored the O2 saturation as ordered. Review of the SN VNR dated 4/15/22 at 6:28 PM revealed a pain level of 7 and the patient last had pain medication, "in the AM, duration of relief, 2-3 hours." There was no documentation the SN evaluated the pharmacological and non-pharmacological pain regimen including patient's response to the pain scale and no documentation of what pain level was acceptable to the patient. Further review revealed, "not applicable to current visit." Further review of the SN VNR dated 4/15/22 at 6:28 PM revealed instructions to the patient/caregiver to report signs and symptoms of infection and sepsis...increased pain, elevated glucose levels...heart rate greater than 90 beats per minute (may indicate sepsis), respirations greater than 20 per minute (may indicate sepsis), temperature greater than 101 degrees or less than 96.8 (may indicate sepsis). There was no documentation the patient/caregiver was monitoring the vital signs including the temperature, heart rate and respirations and no documentation the patient/caregiver was monitoring the blood glucose as ordered. Review of the SN VNR dated 4/18/22 and 4/20/22 revealed "diabetes managed by insulin and waiting for glucometer" (to monitor blood glucose). There was no documentation the patient/caregiver was monitoring the vital signs including the temperature, heart rate and respirations and no documentation the SN monitored the blood glucose while the patient/caregiver was waiting for a glucometer. Review of the SN VNR dated 4/22/22 revealed, "diabetes managed with insulin pen...blood sugars not routinely checked. To get monitor next week." There was no documentation the SN assessed the blood sugar during the visit. Further review of the medical record revealed there was no documentation the patient/caregiver was monitoring the vital signs including the temperature, heart rate and respirations as ordered. Review of the VNR TIF (Transfer to Inpatient Facility) by the RN (Registered Nurse) dated 4/25/22 revealed, "Transferred to an inpatient facility, emergent care for wound infection or deterioration and fluid overload." An interview conducted on 6/2/22 at 1:25 PM with EI # 1 confirmed, the patient was not assessed per physician orders, there was no documentation of an acceptable pain level and the patient's blood sugar was not monitored as ordered. EI # 1 also confirmed the agency had access to a glucometer to assess the patient's blood sugar and should have.

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 review of agency policies and procedures, observations and interviews, it was determined the agency failed to ensure the staff followed their own policies and procedures for hand hygiene and bag technique. This deficient practice affected 2 of 7 home visits (HV) including HV # 7 and HV # 1, and had the potential to negatively affect all patients admitted to this agency. Findings include: Agency Policy: Hand Hygiene Policy Number: PCP-001 Revised: 6/24/21 Purpose: To prevent the spread of infection by contaminated hands. Guidelines: 4. Perform hand hygiene as follows: a. Before having direct contact with patients b. Before donning gloves d. After contact with a patient's intact skin e. After contact with body fluids or excretions, mucous membranes… and wound dressings f. When moving from a contaminated body site to a clean body site during patient care g. After contact with inanimate objects … h. After removing gloves 11. Change gloves during patient care if moving from a contaminated body site to a clean body site. Agency Policy: Bag Technique Policy Number: PCP-002 Revised: 9/8/21 Purpose: To provide guidelines for the adherence of the principles of infection in relationship to practitioner equipment and supply bag usage. Applicable Disciplines: All Staff Guidelines: Agency staff performing home visits should utilize the supply bag from the Amedisys formulary… Procedure: 2. Alcohol-based hand sanitizer, liquid antibacterial soap and paper towels are placed in an outside compartment for ease of access. Agency Policy: The Provision of Wound and Skin Care Policy Number: WC-001 Revised: 1/20/22 Purpose: To provide general guidance on wound and skin care... To provide standardization around the practice of wound and skin care General Guidance: Wound Field Set Up: A field is set up to work off of when providing wound care. The field consists of a barrier … on which all supplies necessary for the provision of wound care are laid. This includes the placement of hand sanitizer, all wound care supplies including gloves, … Agency Policy: Bath: Bed Bath and Partial/Bed Bath Policy Number: PC-004 Policy Review Date: 11/21 Purpose: To provide guidelines for the provision of the patient's bed bath and partial/bed bath. Procedure: 5. a. ...if perineal care is performed prior to bath, then remove gloves afterwards, wash hands, obtain clean washcloth and clean warm water and fresh gloves. 2. HV #1 was admitted on 5/16/22 with diagnoses including Encounter for Orthopedic Aftercare Following Surgical Amputation and Acquired Absence of Right Leg Below Knee. Review of the HHC and POC dated 5/16/22 revealed order for Home Health Aide (HHA) to visit 2wk2 then 1wk7 for assistance with personal care, hygiene and activities of daily living. A HV was conducted on 5/16/22 at 1:00 PM to observe a bed bath and care provided by EI #4, HHA. During the visit, EI #4 sanitized hands, donned gloves, provided perineal care, washed buttocks, emptied the dirty water from the basin and without performing hand hygiene obtained clean water and a clean washcloth. EI #4 then performed hand hygiene, donned clean gloves and rewashed the buttocks. Then without performing hand hygiene and using the same dirty gloves EI #4, applied lotion to the patient's back. An interview conducted on 6/2/22 at 1:05 PM with EI #1 confirmed hand hygiene was not performed per policy. 1. HV # 7 was admitted to the agency on 5/16/22 with diagnoses including disruption of Traumatic Injury Wound Repair, and Laceration Without Foreign Body, Right Thigh. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 5/16/22 revealed orders for Skilled Nurse (SN) to visit 3wk9 (3 times per week for 9 weeks) to assess for signs and symptoms of sepsis… and intervene to minimize complications. SN to apply Smith Cline Renasis Wound Vac Negative Pressure Device (NPD) to left thigh three times a week and PRN (as needed). A HV was conducted on 6/1/22 at 11:55 AM to observe wound care provided by Employee Identifier (EI) # 5, Registered Nurse (RN), Case Manager. During the visit, EI # 5 assessed the vital signs and the pulse in the feet of HV # 7 and with unclean hands retrieved the hand sanitizer from his/her uniform pocket. EI # 5 then performed hand hygiene, retrieved gloves from the same uniform pocket, donned the gloves and removed the soiled dressing from HV # 7's wound. EI # 5 then doffed gloves, and without performing hand hygiene reached into the same uniform pocket, retrieved the hand sanitizer and sanitized his/her hands. EI # 5 removed the dirty wound vac canister from the NPD, placed the dirty canister in the trash and without doffing the gloves and performing hand hygiene, applied a new wound vac canister to the NPD. An interview was conducted on 6/2/22 at 1:35 PM with EI # 7, Director of Operations (DOO) of North Alabama Region, who confirmed the staff failed to follow agency policies and procedures of hand hygiene and bag technique.

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on review of Medical Records (MR), agency policy and procedure, and interview, it was determined the agency failed to ensure patient/caregivier (pt/cg) instruction including return demonstration was performed with a patient requiring wound care. This deficient practice affected 1 of 1 MR review of patients with wounds and did include MR # 1 and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: Patient/Caregiver Education Policy #: TX-003 Date last reviewed: 2/25/2021 ...Procedure: ...4. The teaching method is individualized and may include written teaching materials, verbal instructions, and return demonstration. 5. Patient and caregiver education and response to teaching is documented in the patient's clinical record... 1. MR # 1 was admitted to the agency on 5/6/22 with diagnoses including Aftercare Following Surgery for Neoplasm, Malignant Neoplasm of Rectosigmoid Junction, and Type 2 Diabetes Mellitus. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 5/6/22 revealed orders including: Skilled Nurse (SN) 1 x a week x 1 week, 3 x a week x 1 week, 2 x a week x 1 week, 1 x a week x 2 weeks, then 1 visit every 2 weeks x 4 weeks; SN to perform/teach incision care to wound # 1 midline lower abdomen area, cleanse with soap and water, leave open to air, change dressing daily. Review of the SN Visit Note Reports (VNR) dated 5/6/22 revealed no documentation of wound care instructions or return demonstration. Review of the SN VNR dated 5/10/22 revealed the nurse documented "...patient/caregiver verbalized/gave return demonstration of incision care..." which was 4 days after the start of care. In an interview conducted on 6/2/22 at 1:15 PM, Employee Identifier (EI) # 1, Director of Operations, confirmed pt/cg instruction and return demonstration was not performed on the initial SN visit.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on review of medical records (MR), agency policy and procedure, Alabama Board of Nursing (ABON) Administrative Code 610-X-.06 Documentation Standards, observations and interviews with staff, it was determined the agency failed to follow their policy for Coordination of Care and the ABON Administrative Code for Documentation Standards to ensure consistent documentation . This deficient practice affected 2 of 7 Home Visits (HV) and did affect HV # 1, HV # 5 and had the potential to negatively affect all patients served by the agency. Agency Policy: Coordination of Care Policy Number: TX-002 Purpose: ...To ensure consistent documentation, communication, coordination... Procedure: 13. ....case conferences and verbal coordination between or among disciplines are documented in the clinical record to establish effective interchange, reporting, and coordination of patient care.... Alabama Board of Nursing Administrative Code Code Number: 610-X-6-.06 Documentation Standards (1) The Standards for Documentation of nursing care provided to patients by licensed nurses are based on principles of documentation, regardless of the documentation format. (2) Documentation of nursing care shall be: (a) legible, (b) accurate, (c) complete.... 2. HV # 5 was admitted to the agency on 5/20/21 and recertified for services on 5/15/22 with diagnoses including Venous Insufficiency (Chronic) (Peripheral) and Non-Pressure Chronic Ulcer of Other Part of Left Lower Leg with Fat Layer Exposed. Review of the HHC and POC dated 5/15/22 to 7/13/22 revealed orders for, "SN frequency 1WK9 (once per week for 9 weeks). SN to perform/teach venous stasis ulcer care to left lower extremity irrigate/cleanse with wound cleanser, or NS (Normal Saline)....Change dressing weekly and PRN (As Needed)... Review of the SN VNR dated 5/24/22 revealed wound care provided, cleaned with dry gauze, then Unna Boot... There was no documentation of what solution was used to clean the wound. An interview conducted on 6/2/22 at 2:25 PM with EI # 1 confirmed the documentation was incomplete and should have included what the wound was cleaned with per the physician orders. 1. HV #1 was admitted 5/16/22 and certified for care 5/16/22 to 7/14/22 with diagnoses including Encounter for Orthopedic Aftercare Following Surgical Amputation, Acquired Absence of Right Below the Knee Amputation and Acquired Absence Left Above the Knee Amputation. Review of the Home Health Certification (HHC) and Plan Of Care (POC) orders dated 5/16/22 revealed Skilled Nurse (SN) for instruction of diabetic care to include: Diabetic diet, skincare, signs and symptoms of hypo/hyperglycemia, proper administration of diabetic medication. SN to instruct for diabetic foot care and monitor for skin lesions on lower extremities. Review of the SN Visit Note Report (VNR) dated 5/25/16 revealed the following instructions to patient/caregiver: " Avoid lotion between toes, inspect feet every day for sores and cuts. Use a mirror to help see the bottom of your feet. Routine nail and footcare by a professional. Proper footwear and socks. Dry between the toes well and inspect feet and lower extremities daily and report any new open or red discolored areas. Pressure relief for heels and ankles and any bony prominences of the lower extremities. Avoid going barefoot." Further review of the SN VNR dated 5/25/22 revealed Functional Assessment: "Amputation, lower bilateral." Review of the SN VNR dated 5/26/22 revealed patients diabetes managed by "oral antidiabetic". Review of the Client Medication Report (CMR) printed for surveyor 5/31/22 revealed Levemir Flextouch U-100 Insulin 100 unit/ml (Milliter) (3ml) subqutaneous pen (SQ) at bedtime. Further review of the SN VNR ,dated 5/31/22 revealed instruction to, "Inspect feet daily and report any new wounds or changes on the skin to nurse or doctor. Wash feet daily with warm soap and water and pat dry, especially between toes. Gently file toenails with an emery board." A HV was conducted on 5/31/22 at 1:00 PM to observe the Aide perform a bed bath. During the visit, surveyor observed that HV #1 was a bilateral amputee. An interview conducted on 6/2/22 at 1:00 PM with Employee Identifier (EI) #1 Director of Operations confirmed this was not accurate and consistent documentation.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on review of Agency Policy and Procedure, Medical Records (MR) and staff interviews, it was determined the agency failed to ensure the Home Health Aide (HHA) Plan of Care (POC) was followed. This deficient practice affected 1 of 7 home visits (HV) which was HV # 1 and had the potential to affect all patients served by the agency. Agency Policy: Services Provided/Supervision of Disciplines- Home Health Aide (HHA). Policy Number: AA-007 (b) Date Revised: 5/9/22 Purpose:...The Agency will provide supervised, coordinated, and individualized services for each patient in accordance with the written POC... To outline the services provided by each discipline... i. Following the patient POC for completion of tasks assigned to the HHA... v. Reporting changes in the patient's condition... Procedure: 1.The HHA may provide services in the POC from the Registered Nurse Supervisor. These services include but are not limited to the following...weight... Notifying appropriate discipline of results outside of parameters defined on HHA care plan... Documentation of observations and services in the individual client record... 1. HV #1 was admitted to the agency on 5/16/22 with the diagnoses including Encounter for Orthopedic Aftercare Following Surgical Amputation and Acquired Absence of Right Leg Below the Knee Amputation. Review of the Aide Care Plan Report dated 5/16/22 revealed an Aide frequency of 2wk2 (2 times a week for 2 weeks) then 1wk7 (1 time a week for 7 weeks). Task assigned included " Weight to be recorded weekly." Review of HHA Visit Note Report (VNR) dated 5/17/22, and 5/20/22 revealed no documentation the weight was obtained per orders. Review of the HHA VNR dated 5/24/22, 5/27/22 and 5/31/22 revealed, " Weight not completed, patient/caregiver declined." An interview conducted 6/2/22 at 1:05 PM with Employee Identifier (EI) #1 Director of Operations confirmed weekly weights were not being performed by the HHA and there was no documentation that the HHA reported to the Skilled Nurse the inability to complete the task as assigned.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on review of medical records (MR), agency policy and procedure and staff interviews, it was determined the agency failed to complete a discharge summary for 2 of 5 discharge records reviewed and did affect MR # 6 and MR # 10 and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Discharge of Patients Procedure: 10. The clinician assigned to supervise and coordinate care for a particular patient must complete a discharge summary when services are terminated. A completed discharge summary is sent to the primary care practitioner, receiving facility or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (Home Health Agency) (if any) within 5 business days of the patient's discharge. The Discharge Summary includes: a. Date of discharge b. Patient identifying information c. Patient's Physician and phone Number d. Diagnosis e. Reason for Discharge f. Brief summary of care provided/progress towards goals g. Patient's medical and health status at the time of discharge h. Symptoms needing continued management i. Instructions given to patient or responsible party 1. MR # 6 was admitted to the agency on 11/4/14 with diagnoses including Encounter For Fitting and Adjustment of Urinary Device and Retention of Urine, Unspecified. Review of the Physician Order Dated 12/30/21 revealed, "Discharge due to insurance change first of year." Review of the Visit Note Report by the Registered Nurse dated 12/31/21 revealed, "Patient being discharged today due to insurance change."... Further review of the MR revealed there was no documentation a discharge summary was completed per policy. An interview conducted on 6/2/22 at 1:25 PM with Employee Identifier (EI) # 1 Director of Operations (DOO) confirmed there was no discharge summary completed per policy. 2. MR # 10 was admitted to the agency on 12/10/21 with diagnoses including Encounter for Other Orthopedic Aftercare and Spinal Stenosis, Lumbar Region Without Neurogenic Claudication. Review of the Physician Order dated 1/13/22 revealed, "Patient to be discharged due to insurance change." Review of the VNR by the Physical Therapist (PT) dated 1/13/22 revealed, "Discharge from Agency." Further review of the MR revealed there was no documentation a discharge summary was completed per policy. An interview conducted on 6/2/22 at 1:25 PM with EI # 1, DOO confirmed a discharge summary was not completed per policy.