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

Based on review of the agency Emergency Preparedness Plan and interview it was determined Amedisys Home Health was in substantial compliance with 484.102 Conditions of Participation: Emergency Preparedness.

A recertification survey was conducted on 1/20/22 with standard deficiencies cited.

Before discharge for cause HHA must: CFR(s): 484.50(d)(5) The HHA determines, under a policy set by the HHA for the purpose of addressing discharge for cause that meets the requirements of paragraphs (d)(5)(i) through (d)(5)(iii) of this section, that the patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. The HHA must do the following before it discharges a patient for cause: This ELEMENT is not met as evidenced by: Based on review of agency policies and procedures, Medical Record (MR), and interviews with staff, it was determined the agency staff failed to follow agency policy and procedure when discharging for cause. This affected 1 of 1 discharged for cause MR reviewed. This affected MR # 5 and had the potential to affect all patients who are admitted to this home health agency.Findings include:Agency Policy: Discharge of PatientsPolicy Number: AA-016Reviewed date: 8/26/21 Purpose: To ensure a standardized process for discharging patients from the home health agency (HHA)...To have a discharge process to ensure the patient is being discharged appropriately and arrangements have been made to address any ongoing health care needs the patient may have at the time of discharge. Procedure: ...2. The HHA may only transfer or discharge the patient from the HHA for: ...E. Discharge for cause: (1) The patient's...behavior...uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired... Agency Policy: Patient Assessment/ReassessmentPolicy Number: AA-003Reviewed date: 9/13/21 ...Procedure: ...9. Recertification: A recertification assessment occurs during the last 5 days of the 60-day episode of care... 1. MR # 5 was admitted to the agency on 9/19/21 with a diagnosis of Other Psychoactive Substance Use, Unspecified with Mood Disorder. Review of the Home Health Certification and Plan of Care dated 9/19/21 to 11/17/21 revealed a Skilled Nurse (SN) frequency of once a week for 5 weeks then once every 2 weeks for 4 weeks. Review of the Client Coordination Note dated 10/24/21 revealed documentation of a missed SN visit due to "no answer phone" and "attempted to reach on 10/18/21 and 10/21/21 and no answer. Psych clinician out of town until next week. Will reattempt next week." There was no documentation the SN attempted to reach the patient other than by phone and no documentation the SN attempted another visit following 10/21/21, which was a Thursday, until 11/11/21. Review of the Physician order dated 11/8/21 revealed an order to "omit Psych (Psychiatric) RN (Registered Nurse) visit week of 10/31/21 due to no available staff to perform visit due to SN illness. Psych RN to perform visit on week of 11/7/21 1 wk 1 (once a week for 1 week)." Review of the Client Coordination Note dated 11/08/21 revealed documentation of "...recertification visit scheduled for continued Psych RN Education and Monitoring." Review of the Client Coordination Note dated 11/11/21 revealed documentation of a missed SN visit due to patient refusal. Review of the Client Coordination Note dated 11/18/21 revealed documentation of "last day of cert (certification) period 11/17/21. Did drive by and no answer to door and still no answer or call back to phone..." Review of the RN discharge visit note dated 11/17/21 revealed no discharge visit was completed. Review of the Discharge-Transfer Summary Report revealed the patient was discharged due to "non compliant with plan of treatment...reason for discharge: unable to reach patient x (times) multiple attempts for recert, and noncompliant with treatment plan..." There was no documentation another attempted SN visit was made during the 5 day recertification window, other than the 11/17/21 missed visit, and how the patient was noncompliant with treatment plan. Review of the MR revealed no documentation the patient was notified of the agency discharge or the patient's behavior was uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. An interview was conducted on 1/21/22 at 11:20 AM with Employee Identifier (EI) # 1, Director of Operations, who confirmed the agency treatment week is Sunday - Saturday, the weekly SN visit for the week of 10/17/21 to 10/24/21 was not reattempted after the unsuccessful attempt on Thursday 10/21/21 until 11/11/21, when the patient refused the SN visit. EI # 1 confirmed there was a missed visit on the last day of the recertification period and no documentation of prior attempts within the 5 day recertification window, the patient was not notified of the discharge for cause, and patient's behavior was not uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired.

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient's 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) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: Based on review of agency policy and procedure, Medical Record (MR), and interviews with staff, it was determined the agency staff failed to notify the patient of discharge for cause. This affected 1 of 1 discharged for cause MR reviewed. This affected MR # 5 and had the potential to affect all patients who are admitted to this home health agency.Findings include:Agency Policy: Discharge of PatientsPolicy Number: AA-016Reviewed date: 8/26/21 Purpose: To ensure a standardized process for discharging patients from the home health agency (HHA)...To have a discharge process to ensure the patient is being discharged appropriately and arrangements have been made to address any ongoing health care needs the patient may have at the time of discharge. Procedure: ...2. The HHA may only transfer or discharge the patient from the HHA for: ...E. Discharge for cause: (1) The patient's...behavior...uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired... ...(3) The HHA must do the following before it discharges a patient for cause: a. Advise the following that a discharge for cause is being considered: i. The patient... 1. MR # 5 was admitted to the agency on 9/19/21 with a diagnosis of Other Psychoactive Substance Use, Unspecified with Mood Disorder. Review of the Home Health Certification and Plan of Care dated 9/19/21 to 11/17/21 revealed a Skilled Nurse (SN) frequency of once a week for 5 weeks then once every 2 weeks for 4 weeks. Review of the Client Coordination Note dated 10/24/21 revealed documentation of a missed SN visit due to "no answer phone" and "attempted to reach on 10/18/21 and 10/21/21 and no answer. Psych clinician out of town until next week. Will reattempt next week." There was no documentation the SN attempted to reach the patient other than by phone and no documentation the SN attempted another visit following 10/21/21, which was a Thursday, until 11/11/21. Review of the Physician order dated 11/8/21 revealed an order to "omit Psych (Psychiatric) RN (Registered Nurse) visit week of 10/31/21 due to no available staff to perform visit due to SN illness. Psych RN to perform visit on week of 11/7/21 1 wk 1 (once a week for 1 week)." Review of the Client Coordination Note dated 11/08/21 revealed documentation of "...recertification visit scheduled for continued Psych RN Education and Monitoring." Review of the Client Coordination Note dated 11/11/21 revealed documentation of a missed SN visit due to patient refusal. Review of the Client Coordination Note dated 11/18/21 revealed documentation of "last day of cert (certification) period 11/17/21. Did drive by and no answer to door and still no answer or call back to phone..." Review of the RN discharge visit note dated 11/17/21 revealed no discharge visit was completed. Review of the Discharge-Transfer Summary Report revealed the patient was discharged due to "non compliant with plan of treatment...reason for discharge: unable to reach patient x (times) multiple attempts for recert, and noncompliant with treatment plan..." There was no documentation another attempted SN visit was made during the 5 day recertification window, other than the 11/17/21 missed visit, and how the patient was noncompliant with treatment plan. Review of the MR revealed no documentation the patient was notified of the agency discharge before or after discharge of the patient. An interview was conducted on 1/21/22 at 11:20 AM with Employee Identifier (EI) # 1, Director of Operations, who confirmed there was no documentation the patient was notified of the agency discharge before of after the discharge.

Make efforts to resolve the problem(s) CFR(s): 484.50(d)(5)(ii) (ii) Make efforts to resolve the problem(s) presented by the patient's behavior, the behavior of other persons in the patient's home, or situation; This ELEMENT is not met as evidenced by: Based on review of agency policy and procedure, Medical Record (MR), and interviews with staff, it was determined the agency staff failed to notify the patient of discharge for cause. This affected 1 of 1 discharged for cause MR reviewed. This affected MR # 5 and had the potential to affect all patients who are admitted to this home health agency.Findings include:Agency Policy: Discharge of PatientsPolicy Number: AA-016Reviewed date: 8/26/21 Purpose: To ensure a standardized process for discharging patients from the home health agency (HHA)...To have a discharge process to ensure the patient is being discharged appropriately and arrangements have been made to address any ongoing health care needs the patient may have at the time of discharge. Procedure: ...2. The HHA may only transfer or discharge the patient from the HHA for: ...E. Discharge for cause: (1) The patient's...behavior...uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired... ...(3) The HHA must do the following before it discharges a patient for cause: ...b. Make efforts to resolve the problem(s) presented by the patient's behavior...or situation... ...d. Document the problem(s) and efforts made to resolve the problem(s) and enter this documentation into its clinical records... 1. MR # 5 was admitted to the agency on 9/19/21 with a diagnosis of Other Psychoactive Substance Use, Unspecified with Mood Disorder. Review of the Home Health Certification and Plan of Care dated 9/19/21 to 11/17/21 revealed a Skilled Nurse (SN) frequency of once a week for 5 weeks then once every 2 weeks for 4 weeks. Review of the Client Coordination Note dated 10/24/21 revealed documentation of a missed SN visit due to "no answer phone" and "attempted to reach on 10/18/21 and 10/21/21 and no answer. Psych clinician out of town until next week. Will reattempt next week." There was no documentation the SN attempted to reach the patient other than by phone and no documentation the SN attempted another visit following 10/21/21, which was a Thursday, until 11/11/21. Review of the Physician order dated 11/8/21 revealed an order to "omit Psych (Psychiatric) RN (Registered Nurse) visit week of 10/31/21 due to no available staff to perform visit due to SN illness. Psych RN to perform visit on week of 11/7/21 1 wk 1 (once a week for 1 week)." Review of the Client Coordination Note dated 11/08/21 revealed documentation of "...recertification visit scheduled for continued Psych RN Education and Monitoring." Review of the Client Coordination Note dated 11/11/21 revealed documentation of a missed SN visit due to patient refusal. There was no documentation the SN provided education and the agency need to perform a visit for the assessment of the patient. Review of the Client Coordination Note dated 11/18/21 revealed documentation of "last day of cert (certification) period 11/17/21. Did drive by and no answer to door and still no answer or call back to phone..." Review of the RN discharge visit note dated 11/17/21 revealed no discharge visit was completed. Review of the Discharge-Transfer Summary Report revealed the patient was discharged due to "non compliant with plan of treatment...reason for discharge: unable to reach patient x (times) multiple attempts for recert, and noncompliant with treatment plan..." There was no documentation another attempted SN visit was made during the 5 day recertification window, other than the 11/17/21 missed visit, how the patient was noncompliant with treatment plan, and the agency efforts to resolve the patient behavior or situation. An interview was conducted on 1/21/22 at 11:20 AM with Employee Identifier (EI) # 1, Director of Operations, who confirmed there was no documentation of the agency efforts to resolve the patient behavior or situation and the patient's behavior was not uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired.

Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This ELEMENT is not met as evidenced by: Based on review of agency policy and procedure, Medical Record (MR), and interviews with staff, it was determined the agency staff failed to notify the patient of discharge for cause. This affected 1 of 1 discharged for cause MR reviewed. This affected MR # 5 and had the potential to affect all patients who are admitted to this home health agency.Findings include:Agency Policy: Discharge of PatientsPolicy Number: AA-016Reviewed date: 8/26/21 Purpose: To ensure a standardized process for discharging patients from the home health agency (HHA)...To have a discharge process to ensure the patient is being discharged appropriately and arrangements have been made to address any ongoing health care needs the patient may have at the time of discharge. Procedure: ...2. The HHA may only transfer or discharge the patient from the HHA for: ...E. Discharge for cause: (1) The patient's...behavior...uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired... ...(3) The HHA must do the following before it discharges a patient for cause: ...c. Provide the patient...with contact information for other agencies or providers who may be able to provide care... 1. MR # 5 was admitted to the agency on 9/19/21 with a diagnosis of Other Psychoactive Substance Use, Unspecified with Mood Disorder. Review of the Home Health Certification and Plan of Care dated 9/19/21 to 11/17/21 revealed a Skilled Nurse (SN) frequency of once a week for 5 weeks then once every 2 weeks for 4 weeks. Review of the Client Coordination Note dated 10/24/21 revealed documentation of a missed SN visit due to "no answer phone" and "attempted to reach on 10/18/21 and 10/21/21 and no answer. Psych clinician out of town until next week. Will reattempt next week." There was no documentation the SN attempted to reach the patient other than by phone and no documentation the SN attempted another visit following 10/21/21, which was a Thursday, until 11/11/21. Review of the Physician order dated 11/8/21 revealed an order to "omit Psych (Psychiatric) RN (Registered Nurse) visit week of 10/31/21 due to no available staff to perform visit due to SN illness. Psych RN to perform visit on week of 11/7/21 1 wk 1 (once a week for 1 week)." Review of the Client Coordination Note dated 11/08/21 revealed documentation of "...recertification visit scheduled for continued Psych RN Education and Monitoring." Review of the Client Coordination Note dated 11/11/21 revealed documentation of a missed SN visit due to patient refusal. Review of the Client Coordination Note dated 11/18/21 revealed documentation of "last day of cert (certification) period 11/17/21. Did drive by and no answer to door and still no answer or call back to phone..." Review of the RN discharge visit note dated 11/17/21 revealed no discharge visit was completed. Review of the Discharge-Transfer Summary Report revealed the patient was discharged due to "non compliant with plan of treatment...reason for discharge: unable to reach patient x (times) multiple attempts for recert, and noncompliant with treatment plan..." There was no documentation another attempted SN visit was made during the 5 day recertification window, other than the 11/17/21 missed visit, and how the patient was noncompliant with treatment plan. Review of the MR revealed no documentation the patient was provided contact information for other agencies or providers who may be able to provide care. An interview was conducted on 1/21/22 at 11:20 AM with Employee Identifier (EI) # 1, Director of Operations, who confirmed there was no documentation the patient was provided contact information for other agencies or providers who may be able to provide care.

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 policies and procedures, Home Visit (HV) observations and staff interviews the agency staff failed to ensure: 1. A comprehensive list of medications were maintained for each patient. 2. Only physician ordered medications were recommended to the patient for administration. This deficient practice affected 5 of 7 HV observations including, HV # 4, HV # 3, HV # 5, HV # 7, and HV # 2 had the potential to affect all patient's served by the agency. Findings Include Agency Policy: Drug Regimen Review Policy Number: MA - 002 Revised 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 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 (OTC) medications; ...Vitamins and Supplements... ...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 OTC medications...supplements...). The clinician will also ask the patient to periodically allow them to visualize all the medications the patient is currently taking... Agency Policy: Physician Orders and Medical Supervision of the Plan of Care Policy Number: TX - 001 Revised Date: 4/29/21 ...Procedure: ...Medical Supervision: ...2. Drugs...are administered only as ordered by a physician... 3. HV # 5 was admitted to the agency on 10/23/2021 and recertified for home care on 12/22/2021 with diagnoses including Hemiplegia Following Cerebral Infarction Affecting Left Non-Dominate Side, Dysphasia, and Epilepsy. A HV was conducted on 1/18/22 at 2:05 PM to observe care provided by EI # 6, MSW (Master of Social Work). During the HV a review of the medications was conducted with HV # 5 and compared to the CMR provided to the surveyor on 1/18/22. The following discrepancies were observed: Lantus Insulin inject 10 units in the morning and 40 units in the evening was on the CMR. HV # 6 states he/she injects 20 units in the morning and 40 units in the evening. HV # 5 stated he/she had been on that dosage since discharge from the hospital on 10/22/2021 Vimpat 100 mg tablet take 2 x daily ordered 11/02/2021 was on the medication list but not in the home. HV # 5 stated he/she was on it when he/she was in the hospital on but could not afford to get it so he/she has not been taking it since discharge from hospital on 10/22/2021. Baclofen 5 mg take 3 x daily prescription dated 1/4/22 was in the home but not on the CMR. Review of the Visit Note Reports revealed the patient had 2 SN visits, 2 PT (Physical Therapy) visits, and 2 ST (Speech Therapy) visits since prescription was filled. Ferrous Sulfate 325 mg take 1 daily ordered 4/20/2021 was on the CMR but not in the home. HV # 5 stated he/she has not taken it for 6 months because it constipates him/her. Potassium Chloride 10 meq take 2 x daily ordered 11/2/2021 was on the CMR but not in the home. HV # 5 stated he/she has not taken it since he/she left the hospital on 10/22/2021 and just ate banana a day for the potassium. Meclizine 12.5 mg take 2 x daily was listed on the CMR but not in the home. HV # 5 stated he/she did not have any because the VA (Veteran’s Administration) would not send any. HV # 5 stated he/she had not had any since discharge from the hospital on 10/22/2021. In an interview conducted on 1/20/22 at 10:50 AM, EI # 1 confirmed the CMR had not been updated to include all of the patients medication and correct dosages. 4. HV # 7 was admitted to the agency on 12/28/2021 with diagnoses including Encounter for Change and Removal of Surgical Wound Dressing, Type 2 Diabetes, and Osteomyelitis. A HV was conducted on 1/19/22 at 9:32 AM to observe care provided by EI # 8, LPN (Licensed Practical Nurse). During the HV a review of the medication was conducted with HV # 7 and EI # 8 and compared to the CMR provided to the surveyor on 1/18/22. The following discrepancy was observed. Ferrous Sulfate 325 mg take 1 x daily, ordered 1/7/22 was listed on the CMR. Ferrous Gluconate 325 mg prescription bottle dated 1/17/2020 was in the home. The caregiver stated he/she had just been giving the Ferrous Gluconate because it was what they already had. In an interview conducted on 1/20/22 at 10:50 AM, EI # 1 confirmed the CMR did not list the current medications the patient was taking. 5. HV # 2 was admitted to the agency on 1/6/22 with diagnoses including Acute and Subacute Infective Endocarditis, Bacteremia, and Methicillin Resistant Staphylococcus Infection. A HV was conducted on 1/18/22 at 12:15 PM to observe care provided by EI # 3, Registered Nurse (RN). During the HV a review of the medications was conducted with EI # 3 and HV # 2 and compared to the CMR provided to the surveyor on 1/18/22. The following discrepancy was observed: Rizatriptin Benzoate 10 mg prescription on bottle dated 11/24/2021 was in the home but not listed on the CMR. HV # 2 states he/she takes it as needed for his/her cluster headaches. In an interview on 1/18/22 at 1:13 PM, EI # 3 confirmed the CMR had not been updated to include all of the current medications. 1. HV # 4 was admitted to the agency on 12/30/21 with diagnoses including Diverticulitis of Both Small and Large Intestine with Perforation and Abscess Without Bleeding and Syndrome of Inappropriate Secretion of Antidiuretic Hormone. A HV was conducted on 1/18/22 at 4:25 PM with Employee Identifier (EI) # 5, Certified Occupational Therapy Assistant, to observe care provided. During the HV the following medication discrepancies were found in the home and were started prior to the admission OASIS assessment and verified by the patient and/or caregiver as a current medication: Vitamin D 3 50,000 Units 1 tablet every week with the date on the prescription bottle of 12/23/21. Review of the agency Client Medication Report (CMR) revealed no documentation of the Vitamin D 3. Nexium 40 mg (milligrams) 1 tablet daily with the date on the prescription bottle of 12/2/21. Review of the agency CMR revealed no documentation of the Nexium. Tamsulosin 0.4 mg 1 tablet daily with the date on the prescription bottle of 10/5/21. Review of the agency CMR revealed no documentation of the Tamsulosin. Melatonin OTC 5 mg. The caregiver verbalized the patient takes 1 tablet at bedtime and the patient verbalized he/she has been taking the Melatonin 5 mg for "maybe 3 or 4 months." Review of the agency CMR revealed documentation of Melatonin 3 mg 1 tablet at bedtime. Quetiapine 25 mg 1 tablet at bedtime with the date on the prescription bottle of 10/29/21. Review of the agency CMR revealed documentation of Quetiapine 25 mg 0.5 tablet at bedtime. The patient verbalized during the HV he/she received a Privigen infusion in the home, administered by another agency, three days a week once a month and has received this infusion for a "long time, for months" with the last infusion administered the week prior to visit. The patient and caregiver were not aware of the dose and due to the medication being administered by another agency it was not in the home to determine dose administered. EI # 5 verbalized during the visit he/she was aware of the infusion. Review of the agency CMR revealed no documentation of the Privigen infusion. EI # 5 confirmed the above medications were in the home and not documented on the agency CMR prior to the end of the visit. An interview was conducted with EI # 1, Director of Operations, on 1/20/22 at 10:51 AM who confirmed the above medication should have been on the patient's CMR per the agency policy. 2. HV # 3 was admitted to the agency on 9/16/21, recertified for continued care from 11/15/21 to 1/13/22, with diagnoses including, Urinary Tract Infection, Site Not Specified, Type 2 Diabetes with Diabetic Peripheral Angiopathy without Gangrene and Heart Failure, Unspecified. Review of the SN VNR dated 12/27/21 revealed documentation of "pt (patient) verbalized still having c/o (complaint of) diarrhea. SN adked (asked) if able to get Imodium tablets to help decrease episodes of diarrhea. Pt has liquid Imodium and SN instructed pt on use..." There was no documentation the physician was notified of the patient report of diarrhea, provided a physician order for the use of Imodium tablets, and/or was notified of the patient's intended use of the Imodium. An interview was conducted on 1/20/22 with EI # 1, who confirmed there was no documentation the physician provided an order and/or approval for the OTC Imodium tablet use.

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 Medical Records (MR), agency policies and procedures and staff interviews it was determined the agency failed to ensure physician orders were followed for: 1. Daily patient weights. 2. Weight(s) outside of physician ordered parameters were reported to the physician. 3. Blood Glucose readings outside of physician ordered parameters were reported to the physician. 4. Wound care including wound care with a Vacuum Assisted Closure (VAC) device. 5. Orders for wound care included use of Coban dressing. This deficient practice did affect 5 of 17 MRs reviewed including, MR # 2, Home Visit (HV) # 3, MR # 3, MR # 6 and HV # 7 and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Physician Orders and Medial Supervision of the Plan of Care Policy Number: TX-001 Date Revised: 9/17/21 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... Agency Policy: V.A.C Wound Therapy (Vacuum Assisted Closure) aka Negative Pressure Wound Therapy Date Revised: 2/25/21 Care Considerations: Change dressing as ordered by the physician/ Recommended to change every 48-72 hours, no less than 3 times/ week. Infected wounds: evaluate need for more frequent dressing change. Measure the amount of drainage as indicated. Procedure: 1. Obtain and/or review with a Physician's order for V.A.C, Therapy. Note: use KCI Physician's Verbal Orders form. Agency Policy: The Provision of Wound and Skin Care Policy #: WC-001 Date Revised: 2/25/21 ...an order must be written and signed by the physician for any care and products utilized for the patient... 5. HV # 7 was admitted to the agency on 12/28/2021 with diagnoses including Encounter for Change and Removal of Surgical Wound Dressing, Type 2 Diabetes, and Osteomyelitis. Review of the HHC and POC dated 12/28/2021 revealed orders for 3 x week for 1 week then 1 x week of 8 weeks, SN to perform/teach incision care to left lateral foot, 5th digit amputation site…cleanse with Normal Saline (NS) pat dry, apply Maxorb AG to wound bed…cover with bordered foam dressing, wrap wit roll gauze, secure with paper or medipore tape. Change dressing 2 to 3 times weekly and as needed. A HV was conducted on 1/19/22 at 9:32 AM to observe wound care provided by EI # 8, LPN (Licensed Practical Nurse). EI # 8 removed the old dressing, cleaned the site with NS, patted dry, applied Maxorb AG, to wound, covered with bordered foam dressing, wrapped with rolled gauze, then wrapped the toes, foot, ankle, and lower leg with Coban dressing. There was no order documented to wrap the wound with Coban dressing. In an interview conducted on 1/20/22 at 10:50 AM, EI # 1 confirmed Coban dressing wrap was not included in the physician orders for wound care. 3. MR # 3 was admitted to the agency 7/24/21 with diagnosed including Hypertensive Heart Disease, Heart Failure and Encounter for Orthopedic Aftercare Following Surgical Amputation. MR # 3 had a Resumption of Care (ROC) on 8/3/21 with diagnoses including Dehiscence of Amputation Stump and Infection of Amputation Stump Left Lower Extremity. Review of the ROC order dated 8/3/21 revealed the following wound care orders: SN (skilled nurse) to apply wound vac device (a negative pressure wound treatment) to left pre-tibial wound at 125 MM Hg (milliliters of mercury) continuous, change 1-2 times per week and prn (as needed) according to manufacturer's guidelines; cleanse with Vashe (wound cleanser), pat dry, apply transparent dressing to periwound to protect skin and help maintain seal; apply Adaptic (a non-adhering silicone contact layer) or Adaptic like dressing to wound bed; apply/fill wound with black foam, cover with transparent dressing, apply trac-pad with suction tubing over foam...SN to visit 3 times per week. Review of the SNV (skilled nurse visit) note dated 8/3/21 revealed wound # 10, left amputation site, measured 9 cm (centimeters) length (L), by 5 cm width (W) by 0.5 cm depth (D) with a small amount of purulent drainage. Review of the SNV note dated 8/5/21 revealed the Adaptic layer was not applied to the wound bed as ordered. Review of the SNV notes dated 8/7/21, 8/9/21, 8/11/21, 8/18/21, 8/20/21, 8/27/21, 9/3/21, 9/6/21, and 9/10/21 revealed no documentation the wound care was provided as ordered and the SN documented the patient did not have a NPWT (Negative Pressure Wound Treatment) device. Review of the SNV notes dated 8/13/21, 8/16/21, 8/30/21 revealed documentation the Adaptic layer was not applied to the wound bed as ordered. Review of the physician's order dated 9/13/21 revealed SN to provide wound care to left amputation 3 times per week as follows: cleanse with soap and water, pat dry, apply Xeroform gauze to wound bed then cover with dry gauze. May use ABD (abdominal) pad for increased drainage, wrap with rolled gauze, secure with tape. Review of the SNV dated 9/13/21 revealed the patient's physician had removed the wound vac unit 'last Tuesday" and "SN provided wound care as ordered." The wound assessment section of the SNV note included documentation of the wound vac and no documentation the nurse followed the new wound care order of applying Xeroform gauze. It was not clear what wound care order was followed nor what wound care was provided. Review of the SNV notes dated 9/16/21 and 9/17/21 revealed no documentation wound care was provided as ordered on 9/13/21. Further review of the 9/16/21 visit note revealed the patient was to have a skin graft procedure the following Tuesday. An interview conducted 1/20/22 at 10:30 AM with EI # 1 confirmed the wound care orders were not followed. 4. MR # 6 was admitted to the agency 10/28/21 and recertified for care 12/27/21 with diagnoses including Pressure Ulcer Right Heel Stage 2 and Type 2 Diabetes Mellitus. Review of the HHC and POC dated 12/27/21 to 2/24/22 revealed orders for SN to perform/teach patient/caregiver pressure ulcer care to wound # 1 right heel as follows: cleanse with dial soap and water, pat dry, apply Mupirocin to wound bed, cover with saline wet to dry gauze, secure with tape, change dressing daily and prn. SN frequency 1 time per week. Review of the weekly SNV note dated 12/31/21 revealed no documentation of the size of the wound, no description of the wound bed and no documentation of the specific wound care provided. The "wound care provided" section of the note included multiple non-wound entries and interventions from the POC. The surveyor was unable to determine what care was provided. Review of the weekly SNV note dated 1/5/22 revealed no documentation of the size of the wound, no description of the wound bed and no documentation of the specific wound care provided. The "wound care provided" section of the note included multiple non-wound entries and interventions from the POC. The surveyor was unable to determine what care was provided. Review of the MR revealed the wound was identified as a Stage 2 Pressure Ulcer in the POC order dated 12/27/21 and in the Location identifier (# 1 Heel, Right, Pressure Ulcer, Stage II) in the SNV notes dated 12/31/21 and 1/5/22 under "wound assessment." Further review of the wound assessment section of the SNV notes dated 12/32/21 and 1/5/22 revealed documentation indicating the wound was a SDTI (Suspected Deep Tissue Injury) which would be unstageable. The surveyor was unable to determine the status of this wound. An interview conducted 1/20/22 at 11:49 AM with EI # 1 confirmed the wound was not measured weekly, the wound documentation was unclear and there was no documentation the wound care order was followed. 1. MR # 2 was admitted to the agency on 8/20/21 to 10/18/21 with diagnoses including, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease and End Stage Renal Disease. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 8/20/21 to 10/18/21 revealed a physician order for "...record patient reported weight, or weigh patient as needed. Report increased edema or weight gain of > (more than) 2 lbs (pounds) in 1 day or > 5 lbs in 1 week..." with a Skilled Nurse (SN) frequency of once a week for one week then once every two weeks for two weeks. Review of the SN Visit Note Report (VNR) dated 9/3/21 revealed a documented patient weight of 205 lbs. Review of the SN VNR dated 9/9/21 revealed no documentation of a patient reported weight or a visit obtained weight. Review of the SN VNR dated 9/17/21 revealed a documented patient weight of 220 lbs, which was a 15 lb weight gain since the last weight on 9/3/21. There was no documentation the physician was notified of the 15 lbs weight gain. Review of the SN VNRs dated 9/9/21, 9/23/21, and 9/28/21 revealed no documentation of a patient reported weight or a visit obtained weight. An interview was conducted on 1/20/22 at 11:34 AM with Employee Identifier (EI) # 1, Director of Operations, who confirmed there was no documentation of a patient weight on the above dates and the physician was notified of the 15 lbs weight gain on 9/17/21. 2. HV # 3 was admitted to the agency on 9/16/21, recertified for continued care from 11/15/21 to 1/13/22, with diagnoses including, Urinary Tract Infection, Site Not Specified, Type 2 Diabetes with Diabetic Peripheral Angiopathy without Gangrene and Heart Failure, Unspecified. Review of the HHC and POC dated 11/15/21 to 1/13/22 revealed a SN frequency of once a week for 9 weeks and a physician order for "SN to assess patient/caregiver ability to...record BG (Blood Glucose) testing as ordered and to report abnormal findings to Physician. SN may perform BG test as needed. SN to report to physician BG readings greater than 200 or less than 70..." Further review of the HHC and POC dated 11/15/21 to 1/13/22 revealed a physician order for "SN to...record patient reported weight, or weigh patient as needed..." Review of the SN VNR dated 11/19/21 revealed documentation of the patient's usual BG readings as "100 - 300." There was no documentation the SN notified the physician of the BG readings above 200. Review of the SN VNR dated 11/30/21 revealed no documentation of a patient weight. Review of the SN VNR dated 12/7/21 revealed no documentation of a BG reading and/or the patient's usual BG readings and a patient weight. Review of the SN VNR dated 12/17/21 revealed no documentation of a patient weight. Review of the SN VNR dated 12/20/21 revealed documentation the patient's BG reading at the visit was 214 and usual BG readings as "150 - 300." There was no documentation the SN notified the physician of the BG 214 reading and the BG reading above 200 for the usual BG readings documented. Review of the SN VNR dated 12/27/21 revealed documentation the patient's BG reading at the visit was 239. There was no documentation of a patient weight and the SN notified the physician of the 239 BG reading. Review of the SN VNR dated 1/12/22 revealed documentation the patient's BG reading at the visit was 231 and usual BG readings as "150 - 250." There was no documentation the SN notified the physician of the BG 214 reading and the BG reading above 200 for the usual BG readings documented. An interview was conducted on 1/20/22 with EI # 1, who confirmed there was no documentation the SN notified the physician of the above 200 BG readings and obtained the patient's weight on the above dates per the physician order.

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: Based on review of Medical Records (MR), Agency Policy and Procedure and interviews, it was determined the agency failed to ensure the physician was notified of changes in the patient condition. This deficient practice affected 3 of 17 MR reviewed including Home Visit (HV) # 5, MR # 1, HV # 3 and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: Coordination of Care Policy Number: TX-002 Date revised: 04/2019 …Procedure: …4. 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… 3. HV # 3 was admitted to the agency on 9/16/21, recertified for continued care from 11/15/21 to 1/13/22, with diagnoses including, Urinary Tract Infection, Site Not Specified, Type 2 Diabetes with Diabetic Peripheral Angiopathy without Gangrene and Heart Failure, Unspecified. Review of the SN VNR dated 12/27/21 revealed documentation of "pt (patient) verbalized still having c/o (complaint of) diarrhea. SN adked (asked) if able to get Imodium tablets to help decrease episodes of diarrhea. Pt has liquid Imodium and SN instructed pt on use..." There was no documentation the physician was notified of the patient report of diarrhea, provided a physician order for the use of Imodium tablets, and/or was notified of the patient's intended use of the Imodium. An interview was conducted on 1/20/22 with EI # 1, who confirmed there was no documentation the SN notified the physician of the patient's report of diarrhea, provided a physician order for the use of Imodium tablets, and/or was notified of the patient's intended use of the Imodium. 1. HV # 5 was admitted to the agency on 10/23/2021 and recertified for home care on 12/22/2021 with diagnoses including Hemiplegia Following Cerebral Infarction Affecting Left Non-Dominate Side, Dysphasia, and Epilepsy. Review of the Physical Therapy Assistant (PTA) VNR (Visit Note Report) dated 12/29/2021 revealed the PTA documented in the Genitourinary section, “abnormal findings” … ”burning with urination”. There was no documentation the PTA notified the home health nurse or physician of the abnormal findings. In an interview conducted on 1/20/22 at 11:20 AM, Employee (EI) # 1, Director of Operations, confirmed the nurse nor physician had been notified of the changes in the patient condition. 2. MR # 1 was admitted to the agency on 11/23/2021 with diagnoses including Type 1 Diabetes Mellitus and Enterocolitis. Review of the Plan of Care dated 11/23/2021 revealed orders including SN (Skilled Nurse) 2 x week x 1 week, then 1 x week x 8 weeks, and SN to report to physician blood glucose readings greater than 350 or less than 70… Review of the Coordination Notes dated 11/26/2021 revealed MR # 1's caregiver (cg) called the on-call nurse at 12:43 AM to report “machine does not give a number but shows High BS (Blood Sugar) error. The cg reported to the nurse the 9:00 PM dose of insulin had not been given. The on-call nurse instructed the cg to give the 9:00 PM dose of Lantus. There was no documentation the physician was notified of the high blood sugar and no documentation of a physician order to give the 9:00 PM dose of insulin at 12:43 AM. Review of the Visit Note Report (VNR) dated 11/27/2021 revealed the nurse documented MR # 1's BS was 366. There was no documentation the physician was notified of the high blood sugar. In an interview conducted on 1/20/22 at 10:18 AM, EI # 1 stated the patient’s BS machine will give BS readings of at greater than 350 and confirmed the agency nurse did not notify the physician of the high BS.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; 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 ensure a fall occurrence report was completed for all patient falls as directed in agency policy. This deficient practice affected 1 of 17 MRs reviewed including MR # 3 and had the potential to affect all patient's served by the agency. Agency Policy: Incident /Occurrence Reporting System Policy Number: PI-001 Revised Date: 3/25/21 Purpose: To identify activities to reduce the risk of patient and staff incidents. Procedure: 1. An Occurrence Report is completed by the staff member who is involved in the incident/occurrence, or who initially receives information from the patient or family regarding an occurrence... 6. Examples of events or occurrences requiring completion...client/patient/family injury, including falls (witnessed and non-witnessed) 1. MR # 3 was admitted to the agency 7/24/21 with diagnosed including Hypertensive Heart Disease, Heart Failure and Encounter for Orthopedic Aftercare Following Surgical Amputation. MR # 3 had a Resumption of Care (ROC) on 8/3/21 with diagnoses including Dehiscence of Amputation Stump and Infection of Amputation Stump Left Lower Extremity. Review of the SNV (skilled nurse visit) note dated 9/3/21 revealed the patient had a fall "yesterday" with a skin tear to the right knee. There was no documentation of the details or cause of the fall and no documentation of fall prevention measures/instructions. Review of the SNV note dated 9/21/21 revealed the patient "reported fall to occupational and physical therapist which occurred yesterday." There was no documentation of the details or cause of the fall and no documentation of fall prevention measures/interventions. Review of the occupational therapy visit dated 9/20/21 revealed no documentation of a reported fall. The surveyor requested the fall occurrence report for the 2 falls reported above. An interview was conducted 1/20/22 at 10 30 AM with EI # 1 who confirmed there was no documentation a fall occurrence report was completed for these 2 falls.

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on Medical Record (MR), Agency Policy, and interviews, it was determined the agency failed to ensure the patients and/or caregivers (pt/cg) received education and training appropriate for care. This deficient practice affected 1of 6 records reviewed with Diabetes including MR # 1, and had the potential to affect all patients admitted to this agency. Agency Policy: Coordination of Care Policy #: TX-002 Date Revised: 04/2019 … Standard: Coordination of Care. The HHA (Home Health Agency) must: … 5. Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA (Home Health Agency), as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge… 1. MR # 1 was admitted to the agency on 11/23/2021 with diagnoses including Type 1 Diabetes Mellitus and Enterocolitis. Review of the Plan of Care dated 11/23/2021 revealed the following orders: 1. Skilled Nurse (SN) frequency of 2 x week x 1 week then 1 x week x 8 weeks. 2. Orders of Discipline and Treatments included diabetes management: skilled nurse for instructions of diabetic care to include…proper administration of diabetic medication… 3. Humalog U-100 Insulin subcutaneous injection as needed for elevated Blood Sugar (BS) as follows: For BS readings 70-140 give 0 units. For BS readings 141-220 give 2 units. For BS readings 221-280 give 4 units For BS readings 281-320 give 6 units For BS readings 321-400 give 8 units Review of the Visit Note Reports (VNR) from 11/23/2021 to 12/22/2021 revealed no documentation of patient/caregiver (pt/cg) education for the use of the sliding scale insulin. Review of the physician order dated 12/8/2021 revealed orders to place patient on hospital hold, admitted to (hospital) room 493 on 12/6/2021 with DX (Diagnosis) DKA (Diabetic Ketoacidosis). Review of the physician order dated 12/22/2021 revealed orders to transfer patient to (hospital) on 12/22/2021 for Hyperglycemia. Review of the Visit Note Report (VNR), Transfer to Inpatient Facility, note dated 12/22/2021 revealed the MR # 1 was admitted to the hospital due to Hypo/Hyperglycemia, diabetes out of control. In an interview conducted on 1/20/22 at 10:18 AM, Employee Identifier (EI) # 1, Director of Operations, stated MR # 1 had been admitted to the hospital due to hyperglycemia and confirmed there was no documentation of diabetic teaching to include the use of sliding scale insulin use.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on review of agency policy and procedure, V.A.C. (Vacuum Assisted Closure) Therapy Clinical Guidelines, Medical Record (MR) review and interviews it was determined the agency failed to ensure nursing staff: A. Completed and documented VAC wound care accurately. B. Documented the number of foam pieces utilized with each VAC dressing change. C. Assessed and documented the amount of drainage in the VAC cannister and changed the cannister weekly. D. Measured wounds weekly. This deficient practice affected 1 of 1 records with a wound VAC including MR # 3, and had the potential to affect all patients with wound VAC Therapy. Findings include: Agency Policy: V.A.C. Wound Therapy (Vacuum Assisted Closure) aka Negative Pressure Wound Therapy Policy Number: WC-017(a) Date Revised: 2/25/21 Purpose: To enhance delayed or impaired wound healing... Procedure: 1. Obtain and/or review with a Physician's order for VAC Therapy... Care Considerations: Change dressing as ordered by the physician/Recommended to change every 48-72 hours, no less than 3 times/week. Infected wounds: evaluate need for more frequent dressing change. Measure the amount of drainage as indicated. Document in the Clinical Record: Appearance and odor of wound. Measure wound once each calendar week. Dressing procedure and time of dressing change. Type pf foam used and number of pieces used. 3M V.A.C. Therapy Clinical Guidelines A reference source for clinicians 3M V.A.C. Dressing General Guidelines, page 23 Dressing Changes Wounds being treated...should be monitored on a regular basis. In a monitored, non-infected wound...dressings should be changed every 48-72 hours but not less than three times per week...Infected wounds must be monitored often and very closely. For these wounds, dressings may need to be changed more often than 48-72 hours...The dressing change intervals should be based on a continuing evaluation of wound condition and the patient's clinical presentation, rather than a fixed schedule. Changing the 3M V.A.C Cannister, page 25 The 3M V.A.C. Cannister should be changed when full (the alarm will sound) or at least once a week to control odor... 1. MR # 3 was admitted to the agency 7/24/21 with diagnosed including Hypertensive Heart Disease, Heart Failure and Encounter for Orthopedic Aftercare Following Surgical Amputation. MR # 3 had a Resumption of Care (ROC) on 8/3/21 with diagnoses including Dehiscence of Amputation Stump and Infection of Amputation Stump Left Lower Extremity. Review of the ROC verbal order dated 8/3/21 revealed the following wound care orders: SN (skilled nurse) to apply wound vac device (a negative pressure wound treatment) to left pre-tibial wound at 125 MM Hg (milliliters of mercury) continuous, change 1-2 times per week and prn (as needed) according to manufacturer's guidelines; cleanse with Vashe (wound cleanser), pat dry, apply transparent dressing to periwound to protect skin and help maintain seal; apply Adaptic (a non-adhering silicone contact layer) or Adaptic like dressing to wound bed; apply/fill wound with black foam, cover with transparent dressing, apply trac-pad with suction tubing over foam...SN to visit 3 times per week. Review of the agency policy and the wound vac manufacturer's clinical guidelines revealed the dressing change was to be no less than 3 times per week. The verbal order above dated 8/3/21 was not in compliance with the recommended guidelines for frequency of dressing changes for vac wound therapy. Review of the SNV (skilled nurse visit) note dated 8/3/21 revealed wound # 10, left amputation site, measured 9 cm (centimeters) length (L), by 5 cm width (W) by 0.5 cm depth (D) with a small amount of purulent drainage. Review of the SN wound documentation from 8/3/21 through 9/21/21 revealed no wound measurement the weeks of 8/22/21 to 8/28/21 and 8/29/21 to 9/4/21. Further review of the SN wound documentation from 8/3/21 to 9/21/21 revealed no documentation regarding the drainage cannister, amount and description of the drainage nor that the cannister was changed weekly. Review of the SNV notes dated 8/7/21, 8/9/21, 8/11/21, 8/18/21, 8/20/21, 8/27/21, 9/3/21, 9/6/21, and 9/10/21 revealed no documentation of the specific dressing procedure/steps and the SN documented in the wound flowsheet "No" patient did not have a NPWT (Negative Pressure Wound Treatment) device. Review of the SNV notes dated 8/11/21, 8/18/21, 8/20/21, 8/27/21, 9/3/21, 9/6/21 and 9/10/21 revealed no documentation of the number of foam pieces removed/applied during the wound care. An interview conducted 1/20/22 at 10:30 AM with Employee Identifier # 1, Director of Operations, confirmed the dressing change frequency was not 3 times per week as per policy and clinical guidelines, the wound was not measured weekly as directed per policy, the dressing change procedure was not documented, the nurses documented incorrect information in the wound flowsheet, the number of foam pieces used was not documented and there was no documentation regarding the drainage cannister. .