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

Based on the recertification survey conducted on 4/13/21 to 4/15/21, Amedisys Home Health of Fort Payne was found to be in substantial compliance with the Conditions for Participation for Emergency Preparedness.

A recertification survey was conducted from 4/13/21 to 4/15/21 at Amedisys Home Health of Fort Payne and standard level deficiencies were cited.

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 observations, reviews of Medical Record (MR), policy and procedures, and interviews, it was determined the agency failed to ensure staff reconciled medications for 3 of 7 home visits (HV) including, HV # 4, # 7, # 5 and had the potential to negatively affect all patients served by this agency. Findings include: Policy: MA-002 Subject: Drug Regimen Review (Home Health Only) Date(s) Revised: 03/2018; 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 ... 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... The clinician will also ask the patient to periodically allow them to visualize all the medications the patient is currently taking... 1. HV # 4 was admitted to the agency on 3/23/21 with diagnosis including Skin Graft Failure, Malignant Neoplasm of Vulva, Unspecified and Encounter for Change or Removal of Drains. A HV was conducted on 4/13/21 at 1:58 PM to observe EI # 5, Registered Nurse (RN), perform a skilled nursing visit including wound care with HV # 4. During the HV, EI # 5 and the Surveyor reviewed the patient's medications and compared the medications in the home to the Medicine List printed on 4/13/21 and provided to the surveyor for the home visit. The following discrepancies were observed: 1. Bystolic 20 mg tablet one tablet two times daily on the Medicine List. Per HV # 4, takes 10 mg one time per day for 1 1/2 years. 2. Calcium 600 + D(3) 600 mg Calcium (1,500 mg) 200 unit tablet oral listed on the Medicine List and was discontinued 2 weeks ago. 3. Calcium Carbonate 600 mg Calcium (1,500 mg) Vit D3 1,000 Unit Capsule oral listed on the Medicine List. Per HV # 4, takes 1,200 mg Plus 25 mcg (1000 IU) Vit D and has been taking for two weeks. 4. Fish Oil 1,200 mg (144 mg-216 mg) Capsule listed on the Medicine List. Per HV # 4, takes Flaxseed Oil 1400 mg one tablet daily started 3 years ago. 5. Thiamine Hcl (Vitamin B1) 100 mg tablet listed on the Medicine List. Per HV # 4 was discontinued over 1 year ago. 6. Furosemide 20 mg, one tablet daily started over 1 year ago and not listed on the Medicine List. 7. Symbicort 160/4.5 two puffs twice per day as needed started one year ago and not listed on the Medicine List. 8. Ventolin (Albuterol Sulfate) 90 mcg (microgram) two puffs twice per day as needed started one year ago and not listed on the Medicine List. An interview conducted on 4/15/21 at 2:34 PM with EI # 12, RN CM (Clinical Manager)confirmed the Medicine List was not updated per policy. 2. HV # 7 was admitted to the agency on 3/30/21 with diagnosis including Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris and Essential (Primary) Hypertension. A HV was conducted on 4/13/21 at 10:20 AM to observe Employee Identifier (EI) # 9, Home Health Aide (HHA), perform the scheduled visit for HV # 7. EI # 10 was present during the Home Visit. During the HV, the Surveyor reviewed the patient's medications and compared the medications in the home to the Medicine List printed on 4/13/21 and provided to the surveyor for the home visit. The following discrepancies were observed: 1. Hydroxyzine Hcl 25 mg tablet, one three times daily listed on the Medicine List and per caregiver, takes twice per day since 12/23/20. 2. Potassium Chloride ER 20 Meq tablet, extended release, two tablets daily on Medicine List but per caregiver, takes one tablet daily since 1/20/21. 3. Prednisone 10 mg two tablets by mouth twice per day times 5 days, then 1 tablet twice per day times 5 days, then one tablet daily times 5 days ordered on 3/29/21 but not on the Medicine List. 4. Tizanidine 4 mg tablet, take one tablet by mouth three times daily per instructions on medicine bottle dated 12/3/2020, but per caregiver, takes one tablet per night since 12/3/2020. Medication is not listed on the Medicine List. An interview conducted on 4/15/21 with EI # 11, RN, CM confirmed the Medicine List was not updated per policy. 3. HV # 5 was admitted to the agency on 6/20/2020 with diagnosis including Type 2 Diabetes Mellitus with Foot Ulcer, Non-Pressure Chronic Ulcer of Right Heel and Midfoot with Necrosis Bone and Type 2 Diabetes With Diabetic Peripheral Angiopathy Without Gangrene. A HV was conducted on 4/13/21 at 3:25 PM to observe Employee Identifier (EI) # 6, RN, perform a skilled nursing visit including wound care with HV # 5. During the HV, EI # 6 and the Surveyor reviewed the patient's medications and compared the medications in the home to the Medicine List printed on 4/13/21 and provided to the surveyor for the home visit. The following discrepancies were observed: 1. Hydrocodone APAP 10-325 mg one every 6 hours as needed for pain found in the home and per HV # 5, has been taking for 10 to 11 years but was not on the Medicine List. 2. Snapdragon Hemp Lotion 680 mg CBD (Cannabidiol), 680 mg Delta. Apply as needed daily found in the home and per HV # 5, has been applying daily for two months but was not on the Medicine List. An interview conducted on 4/15/21 at 3:17 PM with EI # 1 DO confirmed the Medicine List was not updated per policy.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on review of medical records (MR), agency policy and procedure, and staff interview, it was determined the agency failed to ensure staff completed a comprehensive discharge assessment on patients discharged from the agency, not to an inpatient facility within 48 hours following (or knowledge of) the occurrence, as directed per the agency policy. This affected 1 of 5 MR's reviewed for discharge, including MR # 3 and had the potential to negatively affect all patients discharged from the agency, not to an inpatient facility. Findings include: Policy: AA-006 Subject: Oasis Outcome and Information Set Revised: 12/19; 3/25/21 Last Reviewed: 3/25/21 Purpose: ...The agency will collect, encode and electronically transmit OASIS (Outcome and Assessment Information Set) data as stated in the Federal Conditions of Participation. ...To comply with federal mandates regarding data collection. Procedure: Outcome Assessment and Information Set (OASIS) Table Data Collection Points: Update to Comprehensive Assessment Reason for Update: Discharge from Agency (NOT to an inpatient facility) Time Frame: Within 48 hours following (or knowledge of) the occurrence 1. MR # 3 was admitted to the agency on 3/7/2020 with a primary diagnosis of Hypertensive Heart and Chronic Kidney Disease Without Heart Failure, With Stage 5 Chronic Kidney/End Stage Renal Disease. Review of the SN (Skilled Nurse) Patient Information Report dated 4/24/2020 at 9:54 AM revealed, "...Hospice admitted patient on 4/23/2020. Staff notified and nonbillable visit will be scheduled. Review of the SN No Bill Discharge From Agency visit note was dated 4/30/2020, which was 6 days after the agency had knowledge of MR # 3 being admitted to hospice. The agency failed to complete a comprehensive discharge assessment on MR # 3 discharged from the agency, not to an inpatient facility within 48 hours following (or knowledge of) the occurrence, as directed per the agency policy. An interview was conducted on 4/15/21 at 3:06 PM with Employee Identifier (EI) # 12, Registered Nurse (RN) Clinical Manager (CM), who verified the agency failed to complete the discharge OASIS per agency policy and procedure.

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: 2. HV # 4 was admitted to the agency on 3/23/21 with diagnosis including Skin Graft Failure, Malignant Neoplasm of Vulva, Unspecified and Encounter for Change or Removal of Drains. Review of the HHC and POC dated 3/23/21 to 5/21/21 revealed Home Health Aide (HHA) effective week of 3/28/21 1WK4 (one time per week times 4 weeks). Review of the Client Coordination Note Reports for missed visits by the HHA revealed a missed visit on 4/2/21 and 4/10/21. Further review of the medical record revealed no other scheduled visits by the HHA from 3/23/21 to 5/21/21. An interview conducted on 4/15/21 with EI # 12 confirmed the aide did not meet the ordered visit frequency. 3. MR # 9 was admitted to the agency on 4/1/21 with diagnosis including Encounter for Surgical Aftercare Following Surgery on the Circulatory System, Acute and Subacute Infective Endocarditis and Non-ST Elevation (NSTEMI) Myocardial Infarction. Review of the HHC and POC dated 4/1/21 to 5/30/21 revealed SN to perform/teach incision care to wound # 1 sternal incision as follows: Irrigate/cleanse with normal saline, apply Santyl to wound bed. May apply skin barrier to periwound as needed. Cover with foam dressing. Change dressing every day and as needed. Patient/caregiver to perform on days no SNV (Skilled Nurse Visit). Further review of the HHC and POC dated 4/1/21 to 5/30/21 revealed orders for SN to record patient reported daily weights, or weigh patient as needed. Review of the Visit Note Reports by the SN dated 4/3/21 and 4/5/21 revealed no documentation of patient's daily weights. Further review of the Visit Note Report by the SN dated 4/5/21 revealed the sternal incision dressing was changed but failed to document Santyl was applied as ordered. Review of the Visit Note Report by the SN dated 4/12/21 revealed the sternal incision dressing was changed but failed to document Santyl was applied as ordered. An interview was conducted on 4/15/21 at 1:40 PM with EI # 10 RN CM who confirmed there was no documentation of daily weights as ordered on 4/3/21 and 4/5/21. and there was no documentation that Santyl was applied to the wound as ordered on 4/5/21 and 4/12/21. Based on review of medical records (MR), agency policy and procedure and staff interviews, it was determined the agency failed to ensure: 1. The staff followed the visit frequencies as ordered by the physician. 2. The staff followed wound care as ordered by the physician. This deficient practice affected 3 of 17 records reviewed, and did affect MR # 3, Home Visit (HV) # 4, and MR # 9 and had the potential to negatively affect all patients serviced by the agency. Findings include: Findings: Policy: Physician Orders and Medical Supervision of the Plan of Care Policy Number: TX-001 Policy Date: Revised 12/19; 10/29/2020 Purpose: ...The agency provides care and services according to the most recent physician order... 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 by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration... Medical Supervision: ...2. Drugs, services and treatments are administered only as ordered by a physician that establishes and periodically reviews the plan of care... 1. MR # 3 was admitted to the agency on 3/7/2020 with a primary diagnosis of Hypertensive Heart and Chronic Kidney Disease Without Heart Failure, With Stage 5 Chronic Kidney/End Stage Renal Disease. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 3/7/2020 to 5/5/2020 revealed, "SN (Skilled Nurse) effective 3/7/2020 1wk1 (one time per week times one week), 2wk1, 1wk7". Review of the MR revealed there was no 1 time per wk SN visit documented for the week of 4/5/2020 to 4/11/2020 as directed per the physician's orders. An interview was conducted on 4/15/21 at 3:06 PM with Employee Identifier (EI) # 12, Registered Nurse (RN) Clinical Manager (CM), who confirmed the SN did not meet the ordered visit frequency.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to 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. This ELEMENT is not met as evidenced by: 2. HV # 6 was admitted to home health (HH) on 2/19/21 with the diagnoses of Hemiplegia Following Cerebral Infarction Affecting Left Non Dominant Side, Aphasia Following Cerebral Infarction and Type II Diabetes Mellitus Without Complications. A review of the Client Coordination Note dated 2/24/21 revealed the visiting LPN documentation when the patient was asked if in pain, patient stated 5/10 and placed hand across the abdomen. There was no documentation of intervention or if reported to the patient's registered nurse (RN) or attending physician. A review of the Occupational Therapy Note dated 3/03/21 revealed documentation of bruising in the patient's abdominal area. There was no documentation the physician or the RN Clinical Manager was notified. Review of the Skilled Nurse Visit (SNV) Note dated 3/31/21 revealed documentation the patient right ear drum ruptured and was painful, patient took Tylenol, there was no documentation of relief from discomfort to attending physician. An interview with EI # 1, Director Of Operations (DO) conducted on 4/15/21 at 3:30 PM confirmed the staff failed to report abnormal findings to the physician. Based on review of medical records (MR), agency policy and procedure and interviews with agency staff, it was determined the agency failed to ensure: 1. The physician was notified of a patient's refusal for labs as ordered via venipuncture. 2. Notified the physician of abnormal physical findings. This deficient practice affected 4 of 17 records reviewed and did affect MR # 3, Home Visit (HV) # 6, HV # 4 and MR # 2 and had the potential to negatively affect all patients served by the agency. Findings Include: Policy: TX-002 Subject: Coordination of Care Revised: 4/2019 Purpose: ...To utilize/recommend appropriate internal and external resources as needed throughout the length of service. To ensure consistent documentation, communication, coordination, and retrieval of significant administrative and patient/family information. Procedure: ...4. Relevant physicians are notified promptly of any changes in the patient's condition or needs that suggest than (the) outcomes are not being achieved and/or that the plan of care should be altered... 1. MR # 3 was admitted to the agency on 3/7/2020 with a primary diagnosis of Hypertensive Heart and Chronic Kidney Disease Without Heart Failure, With Stage 5 Chronic Kidney/End Stage Renal Disease. Review of a Physicians order dated 4/15/2020 revealed, "SN (Skilled Nurse) to collect the following labs, CBC (Complete Blood Count) with diff (differential), CMP (Complete Chemistry Profile), Vitamin B12, Vitamin D and TSH (Thyroid-Stimulating Hormone), T4 (Thyroxine), via venipuncture". Review of the SN visit note dated 4/22/2020 revealed, "SN to pt (patient) home for routine visit and lab work... LPN (Licensed Practical Nurse) unable to draw lab work, pt refused any venipuncture sticks due to lymphedema in RUA (right upper extremity)... There was no documentation the physician was notified of MR # 3's refusal for lab's to be drawn via venipuncture as ordered. An interview was conducted on 4/15/21 at 3:06 PM with Employee Identifier (EI) # 12, Registered Nurse (RN) Clinical Manager (CM), who verified the SN failed to notify the physician of MR # 3's refusal for labs to be drawn via venipuncture as ordered. 3. HV # 4 was admitted to the agency on 3/23/21 with diagnosis including Skin Graft Failure, Malignant Neoplasm of Vulva, Unspecified and Encounter for Change or Removal of Drains. Review of the Home Health Certification and Plan of Care dated 3/23/21 to 5/21/21 revealed Physical Therapy (PT) effective week of 3/23/21, 1WK1 (one time per week times one week), 1Every4WK4 (one time every four weeks times four weeks). Review of the Visit Note Report by the PT dated 3/24/21 revealed a pain level of 8 in the left lower extremity and right lower extremity and no documentation the pain level was reported to the nurse. Review of all documentation by the nurse dated 3/24/21 revealed no communication with the PT regarding a pain level of 8. Further review of all documentation dated 3/24/21 revealed no notification of the pain level to the physician. An interview conducted on 4/15/21 at 2:34 PM with EI # 12 confirmed the nurse and physician were not notified of HV # 4's pain level of 8. 4. MR # 2 was admitted to the agency on 8/28/2020 with diagnosis including Hemiplegia Following Cerebral Infarction affecting left non-dominant side, Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris, and Hypertensive Heart Disease with Heart Failure. Review of the Client Coordination Note Report by the nurse dated 8/31/2020 revealed the "Clinical Manager received a call from MR # 2's daughter stating MR # 2 has a sore/rash on the leg and it appears to be spreading. Clinical Manager will arrange nurse visit for assessment." Review of the PT Add-On Evaluation Visit Note Report dated 8/31/2020 revealed caregiver stated MR # 2 "had lesions to right upper thigh which he/she thinks is causing an infection which could be causing the confusion." Review of the Occupational Therapy (OT) Add-On Evaluation Visit Note Report dated 9/2/2020 revealed, "recent decline due to UTI (Urinary Tract Infection) and Shingles." Caregiver "tearful during visit and reports he/she's overwhelmed." Review of the Visit Note Report by the Nurse dated 9/4/2020 revealed care coordination note of "no changes since last visit" and no documentation of sore/rash assessment on leg. Review of the Visit Note Report by the Nurse dated 9/11/2020 revealed, "shingles to groin healed". An interview conducted on 4/15/21 at 3:01 PM with EI # 12 confirmed the nurse did not document a skin assessment for skin lesions/shingles and did not communicate with the physician or update the plan of care.

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: 3. HV # 7 was admitted to the agency on 3/30/21 with diagnosis including Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris and Essential (Primary) Hypertension. Review of the HHC and POC dated 3/30/21 to 5/28/21 revealed HHA effective week of 4/4/21 2WK3 (two times per week times three weeks) , 1WK5. Review of 3 of 3 HHA visits dated 4/7/21, 4/9/21 and 4/14/21 revealed no documentation of the HHA performing a COVID-19 screen prior to visits. An interview conducted on 4/15/21 at 2:16 PM with EI # 11 RN, CM confirmed the aide did not document a COVID-19 screen prior to the home visits as per policy. Based on review of medical records (MR), agency policy, agency document "Screening Questions Prior to Patient Visits", and interviews with staff, the agency failed to ensure home health aides (HHA) screened patients for COVID-19 (Coronavirus Disease 2019) prior to each visit. This affected 3 of 5 records reviewed receiving HHA services, and did affect MR # 4, MR # 6, Home Visit (HV) # 7 and had the potential to negatively affect all patients. Findings include: Policy: ICS-005 Subject: Exposure to Coronavirus (COVID-19): Disease Response and Management Purpose: The purpose of this policy is to follow the recommendation of the CDC (Centers for Disease Control and Prevention) to Covid-19 exposure and disease. Operating Guidelines C. Management of Patient Exposure a. Prior To Each clinician visit (nurse, therapist, social worker, etc.{that is}) a call is made to the home whereby the clinician should perform a brief screening of the patient (and any caregivers that will be present) in the residence, and document in the patient's medical record in HCHB (Home Care Home Base): i. Does the patient have a confirmed or suspected COVID-19 diagnosis? ii. Has the patient or anyone ... fever or chills, cough... vii. Does the patient have a mask to wear or face covering to cover their face during the visit? Does the patient agree to wear to wear the mask or face covering the visit? Screening Questions Prior to Patient Visits Prior to each skilled (nurse, therapist, social worker, etc.) a call is made to the home whereby the clinician should perform a brief screening of the patient... For Aide Visits Has there been any changes in the patient's condition since the last home health visit or is anyone in the home ill? If yes, the HHA places a call to the Clinical Manager ... 1. MR # 4 was admitted to the agency on 1/23/2020 with diagnoses including Alzheimer's Disease with Late Onset, Dementia in Other Diseases Classified Elsewhere with Behavioral Disturbances, and Hypertensive Heart Disease with Heart Failure. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 1/23/2020 to 3/22/2020 revealed HHA effective week of 2/2/2020 2WK7 (two times per week times seven weeks). Review of 7 of 7 HHA visit notes dated 2/4/2020, 2/12/2020, 2/20/2020, 2/27/2020, 3/5/2020, 3/10/2020 and 3/13/2020 revealed no documentation of the HHA performing a COVID-19 screen prior to visits. An interview was conducted on 4/15/21 at 1:54 PM with Employee Identifier (EI) # 10, Register Nurse (RN) Clinical Manager (CM), who verified the HHA failed to document a COVID-19 screening prior to the home visits as directed per the agency policy. 2. MR # 6 was admitted to the agency on 3/12/21 with diagnoses including Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Essential (Primary) Hypertension and Long Term Use of Insulin. Review of the HHC and POC dated 3/12/21 to 5/10/21 revealed HHA effective week of 3/14/21 1WK8. Review of 3 of 3 HHA visit notes dated 3/18/21, 3/25/21 and 4/7/21 revealed no documentation of the HHA performing a COVID-19 screen prior to visits. An interview was conducted on 4/15/21 at 1:30 PM with EI # 10 who verified the HHA failed to document a COVID-19 screening prior to the home visits as directed per the agency policy.

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 policies and interviews with agency staff, it was determined the agency failed to ensure the following: 1. The patient and/or caregiver was provided wound care education including a return demonstration of dressing change competency. 2. The patient and/or caregiver was provided education including a return demonstration of the pump operation and bag change of a Peripherally inserted Central Catheter (PICC). 3. The patient and/or caregiver was provided education on monitoring and recording daily weights, vital signs including pulse, blood pressure and oxygen saturation using a pulse oximeter (Pulse Ox) with return demonstration. 4. The patient and/or caregiver was provided education on early intervention instructions on breathing technique, airway clearance and proper use of COPD (Chronic Obstructive Pulmonary Disease) medications. This affected 1 of 1 patient records reviewed receiving a PICC and did affect MR (medical record) # 9 and had the potential to negatively affect all patients served by the agency. Findings include: Policy: Patient/Caregiver Education Policy Number: TX-003 Revised Date 2/25/21 Purpose: ...To promote patient/caregiver self-management skills to enhance patient health outcomes. Procedure: 1. The agency will utilize educational resources in a form that the patient/caregiver can understand.... 4. The teaching method is individualized and may include... return demonstration. 5. Patient and caregiver education and response to teaching is documented in the patient's clinical record... 8. Patients and caregivers will receive education related to the following as appropriate to care and services rendered:... c. Safe and effective use of medications. d. Management and safety of any equipment utilized by patient, ordered on plan of care. e. Disease management and treatment education... i. Patient/caregiver/family responsibilities during care... Policy: Plan of Care (POC)/Care Planning Process Policy Number: AA-014 Revised Date: 12/4/20 Purpose: ...To provide physician ordered care, treatment, and services through an organized process and plan. Regulatory Guidance: The individualized POC must also specify the patient and caregiver education and training. Procedure: ...6.... n. Patient and caregiver education and training... o. Patient-specific interventions and education... Policy: Documentation of Infusion Therapy Policy Number: IV-003 Revised Date: 3/2019 General Guidelines: ...A record of client/caregiver education and training with return demonstrations as appropriate. Documentation of the assessed level of comprehension of the therapy and the skills needed to provide the care. Specific Documentation Guidelines: ... Instructions given to patient and written materials left with patient; if using teaching checklist, signed by both patient and nurse... MR # 9 was admitted to the agency on 4/1/21 with diagnosis including Encounter for Surgical Aftercare Following Surgery on the Circulatory System, Acute and Subacute Infective Endocarditis and Non-ST Elevation (NSTEMI) Myocardial Infarction. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 4/1/21 to 5/30/21 revealed Skilled Nurse (SN) effective 4/1/21, 1WK8 (one time per week times eight weeks), 2WK1. Further review of the HHC and POC dated 4/1/21 to 5/30/21 revealed orders for SN (Skilled Nurse) to assess patient ability to monitor and record daily weights and vital signs, including pulse and blood pressure; record patient reported weight, or weigh patient as needed. SN to provide early interventions...and instruct on breathing techniques, airway clearance, and proper use of COPD medications. Assess patient/caregiver ability to monitor and record vitals signs including pulse oximetry and blood pressure (BP). Pulse Oximeter (Pulse Ox) and BP monitor to be provided if needed. SN to perform/teach incision care to wound # 1 Sternal incision as follows: Irrigate/cleanse with normal saline, apply Santyl to wound bed. May apply skin barrier to periwound as needed. Cover with foam dressing. Change dressing every day and as needed. Patient/caregiver to perform on days no SNV (Skilled Nurse Visit). IV (Intravenous) Therapy administration: SN to obtain IV access via PICC line to right upper extremity. SN to infuse and/or teach patient/caregiver infusion of Cefazolin 2 G (gram) IV every 8 hours, mix 6 Grams in normal saline 280 ml (milliliters) (24 hour dose load/3 doses per bag) at 85.3 ml to infuse over 60 minutes with 1 ml KVO (keep vein open) rate between each dose. Doses at 10 PM / 6 AM / 2 PM. Change bag daily at 4 PM via Curlin Pump. SN to perform/instruct patient/caregiver to flush IV with 10 ml IVP (IV Push) daily with each Curlin set change, unused lumen daily and as needed HEP (Heparin) lock solution IVP 100 units/ml, 5 ml flush unused lumens every day and as needed. Review of the RN Infusion OASIS (Outcome and Assessment Information Set) Admission Visit Note Report dated 4/1/21 revealed documentation of SN cleaning wound and providing wound care. Further review of the RN Infusion OASIS Admission Visit Note Report dated 4/1/21 revealed patient and caregiver deemed competent to change dressings and education provided on antibiotic administration and how to use the pump with verbalized understanding but no documentation of a return demonstration of wound care, IV pump operation or administration of the IV antibiotic by the patient/caregiver. Review of 4 of 4 Visit Note Reports by the nurse dated 4/1/21, 4/3/21, 4/5/21 and 4/12/21 revealed no documentation of a SN assessment of the patient/caregivers ability to monitor and record daily weights, vital signs including pulse, blood pressure and pulse ox. Further review of 4 of 4 Visit Note Reports by the nurse dated 4/1/21, 4/3/21, 4/5/21 and 4/12/21 revealed no documentation of the SN providing early intervention instructions on breathing technique, airway clearance and proper use of COPD medications. An interview conducted on 4/15/21 at 1:40 PM with EI # 10, RN CM (Registered Nurse Clinical Manager) confirmed there was no documentation of patient/caregiver education and competency with return demonstration for wound care including dressing change, administration of IV antibiotic using PICC line pump, assessment of daily weights, pulse, blood pressure, pulse Ox and no teaching documented of early intervention instructions on breathing technique, airway clearance and proper use of COPD medications.

Contents of clinical record CFR(s): 484.110(a) Standard: Contents of clinical record. The record must include: This STANDARD is not met as evidenced by: 2. HV # 5 was admitted to the agency on 6/20/20 with diagnosis including Type 2 Diabetes Mellitus with Foot Ulcer, Non-Pressure Chronic Ulcer of Right Heel and Midfoot with Necrosis Bone and Type 2 Diabetes With Diabetic Peripheral Angiopathy Without Gangrene. Review of the HHC and POC dated 2/15/21 to 4/15/21 revealed skilled nurse to assess, evaluate and develop an individualized plan of care. SN to instruct patient/caregiver on disease process, self management, signs and symptoms to report to SN/Physician. Review of all Visit Note Reports by the SN dated from 2/15/21 to 4/15/21 revealed no documentation of what blood sugar goals were acceptable for the patient to reach and no documentation of the blood sugar parameters to report to the physician. An interview conducted on 4/15/21 at 3:17 PM with EI # 1, Director of Operations, confirmed there was no documentation of blood sugar management for what was an acceptable daily blood sugar range and no documented blood sugar parameters to report to the physician. Based on medical record (MR) review and staff interview, it was determined the agency failed to ensure the clinical record documentation was complete, accurate and current. This affected 2 of 17 MR's reviewed, including MR # 8 and Home Visit (HV) # 5 and had the potential to affect all patients admitted to the agency. Findings include: 1. MR # 8 was admitted to the agency on 3/30/21 with diagnoses including, Type 2 Diabetes Mellitus with Hyperglycemia and Hemiplegia, Unspecified Affecting Left Dominant Side. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 3/30/21 to 5/28/21 revealed, "Diagnoses: ...7: Long Term (Current) Use of Insulin". Review of the SN (Skilled Nurse) Admission visit note dated 3/30/21 revealed, "Diagnoses/Procedure: ...7: Long Term (Current) Use of Insulin". Further review of the SN Admission visit note dated 3/30/21 revealed, "(M2032) Management of Injectable Medications: NA (Not applicable) - No injectable medications prescribed. Review of the 3/30/21 Client Medication Report (CMR) documented by the SN revealed MR # 8 was prescribed 2 oral Diabetic medications (Glimepiride and Pioglitazone). There was no Insulin documented on the CMR. An interview was conducted on 4/15/21 at 2:09 PM with Employee Identifier (EI) #11, Registered Nurse (RN) Clinical Manager (CM), who stated that MR # 8 was on oral diabetic medications and that the diagnosis, "Long Term (Current) Use of Insulin", was coded inaccurately.