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 of Monroeville was in substantial compliance with 484.102 Conditions of Participation: Emergency Preparedness.

A recertification survey was conducted 4/19/21 to 4/21/22 at Amedisys Home Health of Monroeville with standard level deficiencies cited.

Make complaints to the HHA CFR(s): 484.50(c)(3) Make complaints to the HHA regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the HHA; This ELEMENT is not met as evidenced by: Based on review of medical records (MR), agency Afterhours Telephone Log, policy and procedure, and interviews, it was determined the agency failed to ensure the agency policy and procedure was followed for complaint investigation in 1 of 1 on call complaint(s) reviewed, including Unsampled Identifier (UI) # 1, and the potential to negatively affect all patients served by this agency. Findings include: Agency Policy: RI-009 Subject: Patient/Caregiver Grievance/Complaint Date(s) Revised: 6/24/21 Purpose: Appropriate action will be taken to address all complaints... Procedure: ...2. The agency is to initiate a complaint investigation within 10 business days of the agency's receipt of the complaint and document all components of the investigation. 3. Documentation of the complaint is completed by the employee to whom the complaint is received and forwarded to the agency that includes the following: a. Date of complaint. b. Person filing report. c. Person involved in complaint. d. Person lodging complaint. e. Nature of complaint(s). f. Actions taken by agency's Director of Operations (DOO)/designee. g. Response of person involved in complaint. 4. The DOO(Director of Operations)/designee must (have) documentation of all components of the investigation including actions taken to prevent further potential violations - including retaliation, while that complaint is being investigated. The investigation must be completed within 30 calendar days after the agency receives the complaint, unless the agency has and documents reasonable cause for delay. Actions taken to prevent further potential violations and retaliation include: a. Log complaint on complaint log. b. Investigate complaint as soon as possible. ...f. Take immediate corrective actions as indicated. g. Follow-up communication with complainant with complaint resolution. h. Document existence of complaint; resolution and communications. 5. The DOO, or designees, is responsible for reviewing every complaint; determining the necessity of corrective action; and communication regarding the resolution with the client/patient/caregiver/family member/consumer no later than 30 calendar days following the receipt of complaint; as well as documenting all activities involved with the complaint, investigation, analysis, resolution and communication. 6. Complaints are documented and a Complaint Log is maintained... 1. Review of the agency Afterhours Telephone Log on 4/20/22 revealed documentation of a call from UP # 1 on 3/16/22 as follows: "... pt (patient) then quickly becomes upset and says (he/she) needs...nurse to come today and to bring...dressings...states (he/she) is 'tired of us telling (him/her) the dressings have been ordered', pt states we have 'failed (him/her) as a home health agency' and...wants someone to call...and to bring...dressings...SN (Skilled Nurse) will inform...local office/DOO of (his/her) complaints, and that someone will give (him/her) a call back today, emailed DOO, office notified." Review of the Client Coordination Note dated 3/16/22 revealed documentation by Employee Identifier (EI) # 1, Clinical Manager, of two attempts to contact the patient via phone in regards to the on call service call with no answer. EI # 1 documented inability to leave a message on the patient's phone. Review of the Client Coordination Note dated 3/21/22 revealed documentation the SN called the patient to schedule a discharge visit with documented patient reply of "...I don't want another visit from y'all. I'm through with home health." Review of the SN Visit Note Report dated 3/21/22 revealed documentation UP # 1 was discharged on 3/21/22 in the agency computer system only with no visit made to the patient's home. Review of the agency Complaint Log on 4/20/22 revealed no documentation of UP # 1's complaint on 3/16/22 nor 3/21/22. An interview was conducted on 4/20/22 at 3:15 PM with EI # 2, Area DOO, who confirmed there was no documentation of UP # 1's complaint(s) in the agency complaint log nor a complaint investigation had been initiated.

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, review of medical records (MR), policy and procedure, and interviews, it was determined the agency failed to ensure staff reconciled medications in 3 of 4 home visits (HV) including, HV # 3, HV # 1, HV # 4 and had the potential to negatively affect all patients served by this agency. Findings include: Agency Policy: MA-002 Subject: Drug Regimen Review (Home Health Only) Date(s) Revised: 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. (Medications will be visualized minimally at SOC (Start of Care,… and upon any medication change). 2. HV # 1 was admitted to the agency on 4/5/22 with diagnoses including Unspecified Open Wound, Left Lower Leg, Subsequent Encounter and Personal History of Other Venous Thrombosis and Embolism. A HV was conducted on 4/19/22 at 1:45 PM to observe EI # 4, Licensed Physical Therapy Assistant (LPTA), to observe care provided. During the HV, EI # 4 and the Surveyor reviewed the patient's medications and compared the medications in the home to the CMR printed on 4/19/22 at 10:41 AM and provided to the surveyor for the home visit. The following discrepancies were observed: Alendronate Sodium 70 mg 1 tablet weekly with date on the bottle of 4/4/22 was found in home and verified as current by the patient. There was no documentation of the Alendronate Sodium on the CMR. Macuhealth multivitamin 1 tablet daily was found in home. The patient stated she/he has been taking Macuhealth for "over 2 years." There was no documentation of the Macuhealth on the CMR. An interview was conducted on 04/19/2022 at 9:08 AM with EI # 1, who confirmed the staff failed to reconcile HV # 1's medications per agency policy. 3. HV # 4 was admitted to the agency on 2/17/22, recertified for continued care from 4/18/22 to 6/16/22, with diagnoses including Unspecified Open Wound, Left Lower Leg, Subsequent Encounter and Hypertensive Heart Disease with Heart Failure. Review of the MR revealed an OASIS recertification visit was completed by the RN on 4/13/22. A HV was conducted on 4/20/22 at 9:02 AM to observe EI # 5, Registered Nurse (RN), to observe care provided. During the HV, EI # 5 and the Surveyor reviewed the patient's medications and compared the medications in the home to the CMR printed on 4/19/22 at 2:21 PM and provided to the surveyor for the home visit. The following discrepancies were observed: Enalapril 20 mg 1 tablet twice daily with date on the bottle of 1/24/22 was found in home and verified as current by the patient. There was no documentation of the Enalapril on the CMR. Potassium Chloride 10 mEq (Milliequivalents) 1 tablet daily with date on the bottle of 3/31/22 was found in home and verified as current by the patient. There was no documentation of the Potassium Chloride on the CMR. Hydrochlorothiazide 12.5 mg 1 tablet daily with date on the bottle of 2/22/22 was found in home and verified as current by the patient. There was no documentation of the Potassium Chloride on the CMR. An interview was conducted on 04/19/2022 at 9:36 AM with EI # 1, who confirmed the staff failed to reconcile HV # 4's medications per agency policy. 1. HV # 3 was admitted to the agency on 2/17/22 with diagnoses including Encounter for Surgical Aftercare Following Surgery On The Circulatory System and Type 2 Diabetes Mellitus With Diabetic Chronic Kidney Disease. A HV was conducted on 4/19/22 at 2:02 PM to observe Employee Identifier (EI) # 3, Licensed Practical Nurse (LPN), perform a skilled nursing visit including wound care with HV # 3. During the HV, EI # 3 and the Surveyor reviewed the patient's medications and compared the medications in the home to the Client Medication Report (CMR) printed on 4/19/22 at 11:44 AM and provided to the surveyor for the home visit. The following discrepancies were observed: 1) Aleve 220 mg (milligrams) 2 tablets every 6 hours for pain greater 4 on scale from 0 - 10. There was none found in the home. Per HV # 3, "Haven't taken those for a month". 2) Oxycodone-Acetaminophen 7.5 mg-325 mg 1 tablet every 6 hours pain greater than 4 on scale from 0 - 10. There was none found in the home. Per HV # 3, "Stopped taking that in March". 3) Vitamin D 3 25 mcg (micrograms) 1 tablet 1 time a day was found in the home and not listed on the CMR. Per HV # 3, "Been on this for about 2 years". An interview was conducted on 4/21/22 at 9:29 AM with EI # 1, Clinical Manager (CM), who confirmed the staff failed to reconcile HV # 3's medications per agency 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 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 documented physician's orders for the wound care provided. 3. The staff obtained and/or recorded patient weight, instructed patient to weigh daily and ensured the patient had a way to obtain daily weight as ordered by the physician. 4. The staff documented wound care per the physician orders. 5. The staff documented Blood Glucose (BG) readings as ordered by the physician. This deficient practice affected 1 of 4 discharge records reviewed including MR # 1, and 3 of 9 active records reviewed including Home Visit (HV) # 3, HV # 4, MR # 5, and had the potential to negatively affect all patients serviced by the agency. Findings include: Agency Policy: TX-001 Subject: Physician Orders and Medical Supervision of the Plan of Care 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 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... 3. HV # 4 was admitted to the agency on 2/17/22, recertified for continued care from 4/18/22 to 6/16/22, with diagnoses including Unspecified Open Wound, Left Lower Leg, Subsequent Encounter and Hypertensive Heart Disease with Heart Failure. Review of the HHC and POC dated 2/17/22 to 4/17/22 revealed a physician order for "SN to..assess patient ability to monitor and record daily weights....record patient reported weight, or weigh patient as needed. May measure abdominal girth if unable to weigh. Scales...to be provided if needed." Review of the SN VNRs dated 2/21/22, 2/24/22, 3/2/22, 3/8/22, 3/21/22, 3/28/22, 4/1/22, 4/5/22, 4/8/22, 4/11/22 and 4/13/22 revealed no documentation HV # 4 weight or abdominal girth. A HV was conducted on 4/20/22 at 9:02 AM with EI # 5, Registered Nurse, to observe care provided. During the HV, EI # 5 asked the patient if she/he weighed daily. The patient verbalized she/he did not. EI # 5 asked if the patient had a scale. The patient verbalized she/he had a scale in the bathroom and went to obtain the scale. The patient moved the scale to the kitchen area and attempted to weigh on the scale. When the patient attempted to weigh the scale would not work to which the patient verbalized it was an old scale that she/he has not used in a long time that she/he had when living in another home. Review of the MR revealed no documentation the SN instructed the patient to weigh daily and ensure the patient had a working scale in the home to assess weight daily. An interview was conducted on 4/21/22 at 9:36 AM with EI # 1, who confirmed there was no documentation the patient's weight and/or abdominal girth on the above dates. EI # 1 also confirmed there was no documentation the SN instructed the patient to weigh daily and ensure the patient had a working scale in the home to assess weight daily. 4. MR # 5 was admitted to the agency on 4/1/22 with diagnoses of Unspecified Open Wound, Left Thigh, Initial Encounter, Methicillin Resistant Staphylococcus Aureus Infection, Unspecified Site and Type 2 Diabetes with Diabetic Peripheral Angiopathy Without Gangrene. Review of the HHC and POC dated 4/1/22 to 5/30/22 revealed physician orders for: a. "...BG testing daily...SN to assess patient/caregiver ability to perform and record BG 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 100 or less than 60..." b. "...SN to perform/teach patient/caregiver wound care to Left Inner Thigh as follows: Cleanse with wound cleanser...pack lightly with Iodoform gauze. Cover with ABD (abdominal) pad and secure with tape...daily..." Review of the SN VNR dated 4/1/22 revealed documentation the SN provided wound care to the Left Inner Thigh wound and "...packed with provided gauze from patient's discharge..." There was no documentation the wound was packed with ordered Iodoform gauze. Further review of the SN VNR dated 4/1/22 revealed no documentation of a BG reading. Review of the SN VNR dated 4/6/22 revealed no documentation of a BG reading. An interview was conducted on 4/21/22 at 9:32 AM with EI # 2, Area Director of Operations, who confirmed the wound care to the Left Inner Thigh was not performed per the physician orders on 4/1/22 and there was no documentation of BG readings on 4/1/22 and 4/6/22. 1. MR # 1 was admitted to the agency on 10/23/21 with a primary diagnosis of Encounter For Other Orthopedic Aftercare. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 10/23/21 to 12/21/21 revealed Physical Therapy (PT) effective 10/24/21 2wk2,1wk6 (2 times week for 2 weeks, then 1 time week for 6 weeks). Review of the MR revealed no documentation that a second PT visit was made the week of 10/31/21 to 11/6/21 to meet the ordered visit frequency of 2wk2. An interview was conducted on 4/21/22 at 9:18 AM with Employee Identifier (EI) # 1, Clinical Manager (CM), who verified the PT staff failed to follow the physician's ordered visit frequency. 2. HV # 3 was admitted to the agency on 2/17/22 with diagnoses including Encounter for Surgical Aftercare Following Surgery On The Circulatory System and Type 2 Diabetes Mellitus With Diabetic Chronic Kidney Disease. Review of the Skilled Nurse Visit Note Report (SNVNR) dated 4/13/22 revealed, "Skilled Nurse (SN) assessed wound area and followed previous MD (Medical Doctor) instructions to apply Bacitracin to area and cover with bordered gauze". There was no physician's order for the wound care provided. An interview was conducted on 4/21/22 at 9:29 AM with EI # 1, who confirmed the staff failed to document a physician's order for the wound care provided.

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 and/or Plan of Care. This deficient practice affected 2 of 9 current MRs reviewed, including MR # 7 and MR # 5, 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… 1. MR # 7 was admitted to the agency on 2/23/22 with diagnoses including Type 2 Diabetes Mellitus with Foot Ulcer and Non-Pressure Chronic Ulcer of Other Part of Left Foot Limited to Breakdown Skin. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 2/23/22 to 4/23/22 revealed physician orders for Skilled Nurse (SN) twice a week for 1 week then once a week for 8 weeks and "assess Diabetic Foot Ulcers...report significant changes in status to physician for early intervention... SN to perform/teach Diabetic Ulcer...care to bilat (bilateral) great toes: Cleanse separately with wound cleanser, pat dry with gauze, apply xeroform gauze to wound bed, cover with gauze, secure with rolled gauze and tape...twice daily..." Review of the SN Visit Note Report (VNR) dated 3/23/22 revealed wound # 1, Diabetic Ulcer to the Right Great Toe, measured 2.8 centimeters (cm) in length (L) by (x) 2.8 cm in width (W) x 0.1 cm in depth (D). Review of the SN VNR dated 4/1/22 revealed no documentation of a wound measurement to wound # 1. Review of the SN VNR dated 4/8/22 revealed wound measurement to wound # 1 of 4.5 cm L x 3.5 cm W x 0.1 cm D, which was an increase of 1.7 cm in length and 0.7 cm in width. There was no documentation the physician was notified of the increased wound length and width. An interview was conducted on 4/21/22 at 9:25 AM with Employee Identifier (EI) # 2, Area Director of Operations (DOO), who confirmed there was no documentation the SN notified the physician of the increase in wound measurements on the 4/8/22 SN visit. 2. MR # 5 was admitted to the agency on 4/1/22 with diagnoses of Unspecified Open Wound, Left Thigh, Initial Encounter, Methicillin Resistant Staphylococcus Aureus Infection, Unspecified Site and Type 2 Diabetes with Diabetic Peripheral Angiopathy Without Gangrene. Review of the HHC and POC dated 4/1/22 to 5/30/22 revealed physician orders for "...Blood Glucose (BG) testing daily...SN to assess patient/caregiver ability to perform and record BG 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 100 or less than 60..." Review of the SN VNR dated 4/1/22 revealed documentation the patient does not perform and record BG monitoring in the home and only has A1C (laboratory test for Diabetes) at the physician office. There was no documentation the SN notified the physician of the patient not performing and recording BG daily as ordered. Review of the SN VNR dated 4/15/22 revealed documentation the patient "...rarely..." monitors BG in the home. There was no documentation the SN notified the physician of the patient not performing and recording BG daily as ordered. An interview was conducted on 4/21/22 at 9:32 AM with EI # 2, who confirmed there was no documentation the physician was notified of the patient not performing and recording BG daily as ordered.

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 observations, Agency Policies and Procedures (P/P), Sani-Cloth Germicidal Disposable Wipe manufactures instructions, and interviews, it was determined the agency failed to ensure infection control practices were observed. This deficient practice did affect 1 of 4 Home Visits (HV) observation including, HV # 4, and had the potential to affect all patients admitted to this agency. Agency Policy: Hand Hygiene Policy #: PCP-001 Revised Date: 6/24/21 Purpose: To prevent the spread of infection by contaminated hands. ...Guidelines: ...4. Perform hand hygiene as follows: ...b. Before donning gloves ...d. After contact with a patient's intact skin ...g. After contact with inanimate objects (e.g. medical equipment) in the immediate vicinity of the patient h. After removing gloves Agency Policy: Bag Technique Policy Number: PCP-002 Revised Date: 9/8/21 Purpose: To provide guidelines for the adherence of the principles of infection prevention in relationship to practitioner equipment and supply bag usage. ...Guidelines: ...Staff should not re-enter the bag with used gloves. Always perform hand hygiene before entering bag... Procedure: ...3. Field staff members cleanse hands prior to accessing materials from the supply bag... ...5. Wash hands again if you need to re-enter the bag for additional supplies during patient care. Do not go back into bag without removing gloves and performing hand hygiene... ...8. Hands are cleansed prior to returning clean equipment and supplies to the bag... Agency Policy: Decontamination of Re-usable Equipment Policy Number: PCP-003 Revised Date: 6/24/21 Purpose: To prevent and control the spread of infection by the provision of sound decontamination guidelines... 3. Non-critical items...should be cleaned with...agency approved, single-use disinfectant wipe after each use and before placing the equipment back in the supply bag... Sani-Cloth Germicidal Disposable Wipe manufactures instructions Date: Not documented ...To disinfect and deodorize: To disinfect...unfold a clean wipe and thoroughly wet surface. Allow treated surface to remain wet for a full two (2) minutes. Let air dry... 1. HV # 4 was admitted to the agency on 2/17/22, recertified for continued care from 4/18/22 to 6/16/22, with diagnoses including Unspecified Open Wound, Left Lower Leg, Subsequent Encounter and Hypertensive Heart Disease with Heart Failure. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 4/18/22 to 6/16/22 revealed a physician order for "SN (Skilled Nurse) to cleanse Left Lower Extremity wound with wound cleanser, pat dry with gauze, apply Unna boot...apply kerlix over Unna boot and apply coban over kerlix twice weekly..." A HV was conducted on 4/20/22 at 9:02 AM to observe Employee Identifier (EI) # 5, Registered Nurse (RN), perform wound care. At the start of the HV, EI # 5 obtained the patient's vital signs and performed the physical assessment. EI # 5 then removed writing pen from uniform pocket, documented on the patient's home folder and electronic medical record (EMR) tablet and returned the writing pen to his/her uniform pocket without cleaning the pen prior to use or after use and placement in the uniform pocket. While performing wound care, EI # 5 applied the Unna boot to the patient's left leg then removed glove on the right hand, obtained a new glove and donned new glove on the right hand, without hand hygiene after removal of used glove or donning new glove, EI # 5 then continued with the patient's wound care by the application of kerlix over the Unna boot. At the end of the HV: EI # 5 removed Sani-Cloth from nursing bag, opens the Sani-Cloth and individually wipes the equipment used during the visit on the patient including, thermometer, blood pressure cuff, wound care scissors, pulse oximetry (ox) and soap bottle. After each piece of equipment was individually cleansed with the Sani-Cloth, EI # 5 placed the equipment piece in nursing bag not allowing disinfectant to air dry on the surface of the equipment. EI # 5 then donned gloves, without hand hygiene, obtained patient medication bottles and medication planner, documented on EMR tablet, removed pulse ox from nursing bag, without removing contaminated gloves, obtained the patient's oxygen saturation using pulse ox, cleaned pulse ox with previously used Sani-Cloth and returns the pulse ox to nursing bag, without removing contaminated gloves. EI # 5 then verified the patient's medication bottle against the EMR tablet, obtained new Sani-Cloth with contaminated gloves out of nursing bag, cleaned stethoscope using contaminated gloves and immediately places stethoscope into nursing bag, without allowing the disinfectant to air dry on the surface of the stethoscope or removing contaminated gloves. EI # 5 then removed gloves, gathered trash with placement in trash can and performed hand hygiene. An interview was conducted on 4/21/22 at 9:36 AM with EI, # 1, Clinical Manager, who confirmed EI # 5 failed to perform hand hygiene, glove use and cleaning of equipment per the agency policy.

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 observations, Agency Policies and Procedures and interviews, it was determined the agency failed to ensure the agency policy and procedure was followed for wound measurements. This deficient practice did affect 2 of 8 Medical Records (MR) reviewed with wounds including, MR # 4, Home Visit (HV) # 4 and had the potential to affect all patients admitted to this agency with wounds. Findings Include: Agency Policy: WC -001 Subject: The Provision of Wound and Skin Care Date(s) Revised: 1/20/22 Purpose: ...To provide standardization around the practice of wound and skin care. ...General Guidance: ...Measuring: In accordance with best practice and standard of care, wounds will be measured a minimum of one time a week... 1. MR # 4 was admitted to the agency on 2/14/22 with diagnoses including Other Fracture of Right Femur, subsequent encounter for closed fracture with routine healing and Acute Posthemorrhagic Anemia. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 2/14/22 to 4/14/22 revealed a Skilled Nurse (SN) frequency of once a week for 5 weeks then once every 2 weeks for 4 weeks. Review of SN Visit Note Report (VNR) dated 2/14/22, for the week of 2/14/22 to 2/19/22, revealed documentation of a surgical incision to the right thigh. There was no documentation of wound measurements for the surgical incision. An interview was conducted on 4/21/22 at 9:15 AM with Employee Identifier (EI) # 2, Area Director of Operations (DOO), who confirmed there was no documentation of wound measurements for the week of 2/14/22 to 2/19/22 of the right thigh surgical incision. 2. HV # 4 was admitted to the agency on 2/17/22, recertified for continued care from 4/18/22 to 6/16/22, with diagnoses including Unspecified Open Wound, Left Lower Leg, Subsequent Encounter and Hypertensive Heart Disease with Heart Failure. Review of the HHC and POC dated 2/17/22 to 4/17/22 revealed a physician order for "SN to perform/teach patient/caregiver wound care to Left Lower Leg Ulcer wound # 1 twice weekly...cleanse wound normal saline..., pat dry with clean gauze, apply Xeroform, wrap with kerlix cover with coban..." Review of the SN VNRs dated 2/17/22 (week of 2/17/22 to 2/19/22), 2/21/22 and 2/24/22 (week of 2/20/22 to 2/26/22), 3/2/22 (week of 2/27/22 to 3/5/22), 3/8/22 (week of 3/6/22 to 3/12/22) revealed no documentation of a left lower leg wound measurement. An interview was conducted on 4/21/22 at 9:36 AM with EI # 1, Clinical Manager, who confirmed there was no documentation of wound measurements for the weeks of 2/17/22 to 2/19/22, 2/20/22 to 2/26/22, 2/27/22 to 3/5/22 and 3/6/22 to 3/12/22 of the left lower leg wound.

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 interviews with agency staff, it was determined the agency failed to ensure: 1. The patient and/or caregiver was provided foley catheter care education as directed per the physician’s order. 2. The patient and/or caregiver was provided education on Diabetic injectable medications and glucometer use with a return demonstration provided to determine competency. 3. The patient and/or caregiver was provided education on disease processes as ordered by the physician. 4. The patient and/or caregiver was provided education on Lovenox injection with a return demonstration provided to ensure competency. 5. The patient and/or caregiver were provided education on physician ordered wound care and provided a return demonstration of wound care to ensure competency. 6. The patient and/or caregiver was provided education on daily weights as ordered by the physician. This affected 5 of 13 MR's reviewed, including MR # 8, MR # 4, MR # 7, Home Visit (HV) # 4, MR # 5 and had the potential to negatively affect all patients served by the agency. Findings include: Agency Policy: TX-003 Subject: Patient/Caregiver Education Date Revised: 02/25/21 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... 2. MR # 4 was admitted to the agency on 2/14/22 with diagnoses including Other Fracture of Right Femur, subsequent encounter for closed fracture with routine healing and Acute Posthemorrhagic Anemia. Review of the HHC and POC dated 2/14/22 to 4/14/22 revealed a SN frequency of once a week for 5 weeks then once every 2 weeks for 4 weeks. Review of the Client Medication Report (CMR) revealed documentation MR # 4 was prescribed Lovenox 40 mg (milligrams)/ 0.4 ml (milliliter) Subcutaneous (SQ) injection daily on 2/13/22. Review of the MR revealed no documentation MR # 4 was provided education on Lovenox administration and/or provided a return demonstration on the administration of Lovenox. An interview was conducted on 4/21/22 at 9:15 AM with EI # 2, Area Director Of Operations (DOO), who confirmed there was no documentation the patient was provided education on Lovenox administration and/or provided a return demonstration of Lovenox administration. EI # 2 was asked if the agency would expect the patient and/or caregiver to be provided education on Lovenox administration and provide a return demonstration of the administration. EI # 2 stated, "Yes, on the very first visit and re-education if needed." 3. MR # 7 was admitted to the agency on 2/23/22 with diagnoses including Type 2 Diabetes Mellitus with Foot Ulcer and Non-Pressure Chronic Ulcer of Other Part of Left Foot Limited to Breakdown Skin. Review of the HHC and POC dated 2/23/22 to 4/23/22 revealed physician order for SN frequency of twice a week for 1 week then once a week for 8 weeks. Further review revealed the following physician orders: a. "SN to assess and teach related to altered respiratory status to minimize complications and reduce hospitalization..." b. "SN for instructions of Diabetic care to include: diet 1800 ADA...proper administration of Diabetic Medication...Blood Glucose testing 2xdaily (twice daily). SN to assess patient/caregiver ability to perform and record blood glucose testing as ordered and to report abnormal findings to physician..." c. "SN to perform/teach Diabetic Ulcer...care to bilat (bilateral) great toes: Cleanse separately with wound cleanser, pat dry with gauze, apply xeroform gauze to wound bed, cover with gauze, secure with rolled gauze and tape...twice daily..." Review of the CMR revealed documentation MR # 7 was prescribed Lantus Solostar Insulin 22 Units SQ daily. Review of the SN VNRs dated 2/23/22 to 4/19/22 revealed no documentation the patient and/or caregiver was provided education and/or provided a return demonstration, to ensure competency, on the wound care to the bilateral great toes, altered respiratory status, ADA diet, Lantus Solostar insulin administration, or the use of the glucometer to monitor blood glucose. An interview was conducted on 4/21/22 at 9:25 AM with EI # 2, who confirmed there was no documentation the patient and/or caregiver was provided education and/or provided a return demonstration, to ensure competency, on the wound care to the bilateral great toes, altered respiratory status, ADA diet, Lantus Solostar insulin administration, or the use of the glucometer to monitor blood glucose. 4. HV # 4 was admitted to the agency on 2/17/22, recertified for continued care from 4/18/22 to 6/16/22, with diagnoses including Unspecified Open Wound, Left Lower Leg, Subsequent Encounter and Hypertensive Heart Disease with Heart Failure. Review of the HHC and POC dated 2/17/22 to 4/17/22 revealed a physician orders for: a. SN to perform/teach patient/caregiver wound care to Left Lower Leg Ulcer wound # 1 twice weekly... patient/caregiver to provide wound care all other days: cleanse wound normal saline (may use wound cleanser if normal saline not available), pat dry with clean gauze, apply Xeroform, wrap with kerlix cover with coban..." b. "SN to..assess patient ability to monitor and record daily weights....record patient reported weight, or weigh patient as needed. May measure abdominal girth if unable to weigh. Scales...to be provided if needed." Review of the SN VNRs dated 2/17/22 to 3/27/22 revealed no documentation the patient and/or caregiver was provided education and/or provided a return demonstration, to ensure competency, on the wound care to the Left Lower Leg. Review of the SN VNRs dated 2/17/22 to 4/19/22 revealed no documentation the patient was provided education to weight daily. An interview was conducted on 4/21/22 at 9:36 AM with EI # 1, who confirmed there was no documentation the patient was provided education to weigh daily, the patient was provided wound care education to the Left Lower Leg and/or provided a return demonstration of the wound care to the Left Lower Leg. 5. MR # 5 was admitted to the agency on 4/1/22 with diagnoses of Unspecified Open Wound, Left Thigh, Initial Encounter, Methicillin Resistant Staphylococcus Aureus Infection, Unspecified Site and Type 2 Diabetes with Diabetic Peripheral Angiopathy Without Gangrene. Review of the HHC and POC dated 4/1/22 to 5/30/22 revealed physician orders for "...Blood Glucose (BG) testing daily...SN to assess patient/caregiver ability to perform and record BG testing as ordered and to report abnormal findings to physician. Review of the SN VNR dated 4/1/22 revealed documentation the patient does not perform and record BG monitoring in the home and only has A1C (laboratory test for Diabetes) at the physician office. There was no documentation the patient was provided education on BG testing daily as ordered by the physician. Review of the SN VNR dated 4/15/22 revealed documentation the patient "...rarely..." monitors BG in the home. There was no documentation the patient was provided education on BG testing daily as ordered by the physician. An interview was conducted on 4/21/22 at 9:32 AM with EI # 2, who confirmed there was no documentation the patient was provided education on BG testing daily as ordered by the physician. 1. MR # 8 was admitted to the agency on 4/2/22 with diagnoses including Pneumonia, Unspecified Organism, Encounter for Adjustment and Management of Venous Access Device (VAD) and Encounter for Fitting and Adjustment of Urinary Device. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 4/2/22 to 5/31/22 revealed, "SN (Skilled Nursing): 1wk1,2wk1,1wk7 (1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 7 weeks)... SN to instruct patient/caregiver on indwelling urinary catheter management including care of catheter... Catheter will be discontinued at MD (Medical Doctor) appt (appointment) on 4/7/22... Review of the SN Visit Note Reports (VNR) dated 4/2/22, 4/4/22, and 4/6/22 revealed there was no documentation the SN instructed the patient/caregiver on foley catheter care as directed per the physician's order. An interview was conducted on 4/21/22 at 9:19 AM with Employee Identifier (EI) # 1, Clinical Manager (CM), who verified the agency failed to ensure the patient/caregiver were provided education on care on the foley catheter as ordered.

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, and interview, it was determined the agency failed to ensure medical record documentation was complete and accurate with all events, medications, and treatments administered which included: 1. Accurately documented assessments of patients with foley catheters. 2. Care and maintenance of a Venous Access Device (VAD) as ordered. This affected 1 of 9 active MR's reviewed including MR # 8, and had the potential to negatively affect all patients served by this agency. Findings include: Agency Policy: IM-008 A Subject: Clinical Record, Contents Date Revised: 6/24/21 Purpose: A clinical record is initiated and maintained in a standardized ...format for every patient...All documentation is timely, detailed, accurate, and reflects the care, treatment, and services provided by an employee... Procedure The record must include:... 2. All entries must be legible, clear, complete… 4. The contents of the medical record include, but not limited to: …All interventions, including medication administration, treatments, and services, and responses to those interventions... 1. MR # 8 was admitted to the agency on 4/2/22 with diagnoses including Pneumonia, Unspecified Organism, Encounter for Adjustment and Management of VAD and Encounter for Fitting and Adjustment of Urinary Device. Review of the Home Health Certification and Plan of Care dated 4/2/22 to 5/31/22 revealed, "SN (Skilled Nursing): 1wk1,2wk1,1wk7 (1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 7 weeks)... SN to instruct patient on administration of Ceftriaxone 1 gram IV (Intravenous) daily x (times) 7 days via Heplock (Heparin lock), flush with 10 cc (cubic centimeters) Normal Saline before and after IV ABX (antibiotic treatment), Heparin 5 cc after final Normal Saline flush daily. SN to resite IV Heplock site every 72 hours... SN to instruct patient/caregiver on indwelling urinary catheter management including care of catheter... Urinary catheter will be discontinued at MD (Medical Doctor) on 4/7/22. There was no documentation of the size of the indwelling urinary catheter. Review of the SN Visit Note Report (SNVNR) dated 4/4/22 revealed the SN documented "No" to the question "Does the patient have a catheter?" There was no other documentation regarding the foley catheter in the SNVNR dated 4/4/22. Further review of the SNVNR dated 4/4/22 revealed, "SN resited patients IV... IV site flushed easily". There was no documentation of what the SN used to resite the IV. There was no documentation of what solution or amount was used to flush the Heplock as directed per the agency policy. Review of the SNVNR dated 4/6/22 revealed, "SN resited patients IV... IV site flushed easily". There was no documentation of what the SN used to resite the IV. There was no documentation of what solution or amount was used to flush the Heplock as directed per the agency policy. An interview was conducted on 4/21/22 at 9:19 AM with Employee Identifier # 1, Clinical Manager (CM), who verified the staff failed to accurately document the urinary assessment on MR # 8 with a foley catheter. EI # 1 also verified the staff failed to document the solution or amount used to flush the Heplock on MR # 8.