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

Based on a recertification survey conducted from 1/25/22 to 1/27/22, Amedisys Home Health of Selma was found in substantial compliance with the Emergency Preparedness regulations.

A recertification survey was conducted at Amedisys Home Health of Selma from 1/25/22 to 1/27/22 and standard level deficiencies were cited. A plan of correction is required.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on review of medical records (MR), agency policy and procedure, onsite observations and interviews with the staff it was determined the agency failed to ensure the Client Medication Report (CMR) had been updated per agency policy. This affected 4 of 7 home visits (HV) conducted this included HV # 1, HV # 7, HV # 4, HV # 6 and had the potential to negatively affect all patients served by the agency. Findings include: Agency Policy: Drug Regimen Review Policy Number: MA-002 Revised Date: 1/2020 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 Assessment (Outcome and Assessment Information Set) must complete a comprehensive drug regimen review of all medications the patient is currently taking at the time of admission... 3. A copy of the Medication Profile is taken to the patient's home and placed in the patient's home folder and also incorporated in the medical record. 4. When medication additions or changes are not received verbally from the physician but identified in the home by review of prescription bottle or written prescription for the physician: The clinician/therapist will document new or changed medication on the clinicians visit note. The medication is then entered into the computer system.... A new medication list is generated, printed and taken to the patient's home as appropriate. 2. HV # 7 was admitted to the agency on 10/01/2020 and recertified for home care on 12/15/2021 with diagnoses including Infection of Amputation Stump Left Lower Extremity, Type 2 Diabetes Mellitus, and Other Acute Osteomyelitis. A HV was conducted on 1/26/22 at 9:50 AM to observe care provided by EI # 8, Registered Nurse (RN). EI # 7, Clinical Manager was also present during the HV. During the HV a review of the medications was conducted with EI # 7 and the caregiver (cg) and compared to the CMR provided to the surveyor on 1/25/22. The following discrepancies were observed: Metformin 1000 mg take one tablet daily was on the CMR. The medication bottle in the home was Metformin 1000 mg, take twice daily. Date on bottle was 12/15/2021. The cg stated HV # 7 has been taking the Metformin twice daily since 12/15/2021. In an interview on 1/26/22 at 12:00 PM, EI # 7 confirmed the CMR had not been updated per agency policy. 1. HV # 1 was admitted to the agency on 12/2/21 with an admitting diagnosis of Urinary Tract Infection, Site Not Specified. A HV was conducted on 1/25/22 at 1:52 PM with Employee Identifier (EI) # 12, PT to observe care provided to the patient. During the HV the patient's medication bottles were reviewed with the CMR provided by the agency to the surveyor. During the review of the medications the following medication were in the home and not on the CMR: Multivitamin 1 tablet every morning. Caregiver stated patient has been taking for years. Acetaminophen 325 mg (milligrams) 1 tablet at HS (night). Caregiver stated the patient has been taking the Acetaminophen for years. Vitamin D 1 tablet every day. Caregiver stated has been taking prior to admission to Home Health. The following medication was on the CMR listed with a different dosage: Albuterol Sulfate HFA 9 Mcg (micrograms) Aerosol Inhaler. Label on the inhaler has 1 puff ever 4 hours as needed. When speaking to the caregiver the caregiver stated the patient has been administering 2 puffs every 4 hours as needed prior to admission to Home Health because the physician had changed the order. An interview was conducted on 1/25/22 at 2:30 PM with EI # 3, Clinical Manager # 1, who confirmed the medication profile was not updated per the agency policy and the medications should be reviewed with each visit to ensure accuracy. 3. HV # 4 was admitted to the agency on 1/8/22 with diagnoses including Hemiplegia Following Cerebral Infarction Affecting Left Non-Dominant Side, Other Sequelae of Cerebral Infarction and Unqualified Visual Loss Left Eye. A HV was conducted on 1/25/22 at 12:20 PM to observe EI # 11, Licensed Practical Nurse (LPN) provide wound care. EI # 6, (Clinical Manager # 2) was also present during the visit. During the visit the surveyor and EI # 6 reviewed the home folder and there was no Medication Profile. The staff failed to ensure a Medication Profile was provided to the patient per policy. In an interview conducted on 1/27/22 at 10:14 AM, EI # 4, (Director of Operations DOO # 2) confirmed the agency failed to follow policy and provide a Medication Profile and place in patient's home folder. 4. HV # 6 was admitted to the agency on 12/23/21 with diagnoses including Pressure Ulcer (PU) Of Sacral Region Stage 4, PU Hip Unstageable, PU Of Right Heel Unstageable, Unspecified Severe Protein-Calorie Malnutrition, and Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. A HV was conducted on 1/26/22 at 9:05 AM with EI # 10, HHA, (Home Health Aide) to observe care provided and EI # 6, (Clinical Manager # 2) was also present during the visit. During the visit the surveyor and EI # 6 compared the medications listed on the CMR printed 1/26/22 at 6:41 AM. A comparison of the medications in the home and the medications listed on the CMR revealed rhe following medications were in the home and not listed on the CMR: Combigan 0.2/05% 1 drop in each eye every 12 hours. The caregiver confirmed the patient is still receiving the eye drops every 12 hours as ordered for at least a year. Latanoprost 0.005% 1 drop in each eye at bedtime. The caregiver confirmed the patient is still receiving the eye drops as ordered at bedtime for at least a year. EI # 6 confirmed at the time of the visit the agency's CMR was not accurate. Review of the home folder revealed no Medication Profile (CMR) as stated per policy. In an interview conducted on 1/27/22 at 10:39 AM, EI # 4, confirmed the staff failed to ensure the CMR was accurate and the Medication Profile was provided to the patient as stated per agency policy.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on review of agency policies and procedures, medical record (MR) reviews and staff interviews, it was determined the agency failed to include the following in the plan of care (POC): 1. Blood sugar parameters to report to the physician. 2. Pain parameters acceptable to the patient and reportable to the physician. These deficient findings affected 2 of 12 active records reviewed and did include MR # 2, MR # 4 and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Blood Glucose Monitoring - Agency Glucose Monitoring system Policy Number: END-003(b) Policy Revised Date: 12/2/21 Purpose: ...To assess changes in the blood glucose level used to modify treatment.... Note: Parameters for blood glucose monitoring need to be obtained from the patient's treating Physician for the patient's pan of care. Blood Glucose Reporting Parameters: Request attending physician provide patient-specific blood glucose reporting parameters. If the physician does not establish patient-specific parameters, verify with the physician that the following (Adult) blood glucose parameters may be utilized for physician notification: Blood glucose equal or less than 70 - have patient eat or drink something and notify the physician. Blood glucose is equal or greater than 300 - notify the physician. Agency Policy: Pain Assessment and Management Policy Number: MSC-001 Policy Review Date: 11/21 Purpose: To assess patient level of pain.... To promote comfort. Procedure: Pain Assessment should include: a. Assessing for the presence of pain at each visit. m. Teaching and assessing patient's goal for pain control. q. Ongoing goals and outcomes of pain control and management. Pain Management and Quality Indicators: 5. Implement treatment plan 10. The physician should be notified when there are new complaints of pain or when prescribed interventions do not result in adequate pain relief. 1. MR # 2 was admitted to the agency on 12/31/21 with diagnosis including Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Essential (Primary) Hypertension and Type 2 Diabetes Mellitus Without Complications. Review of the Home Health Certification and POC dated 12/31/21 to 2/28/22 revealed orders for Diabetes management (PT) Physicial Therapy. There was no documentation of established blood sugar parameters to report to the physician. Review of the PTA (Physical Therapist Assistant) Visit Note Reports dated 1/5/22, 1/7/22. 1/10/22, 1/12/22, 1/17/22, 1/19/22, and 1/24/22 revealed instructions for the patient/caregiver to, "check and record blood glucose", but no documentation of the results obtained by the patient/caregiver were documented by the PTA and no documentation the physician was contacted for orders on when the blood sugar results should be reported to the physician. An interview conducted on 1/27/22 at 10:10 AM with Employee Identifier (EI) # 1, Director of Operations (DOO) # 1, confirmed there was no physician orders for blood sugar parameters documented in the POC and the PTA did not document the blood sugar results obtained by the patient/caregiver or contact the physician for parameters to manage the diabetes. 2. MR # 4 was admitted to the agency on 1/7/22 with diagnosis including Chronic Pain Syndrome, Pain in Right Hip, and Other Spondylosis with Radiculopathy, Lumbosacral Region. Review of the Home Health Certification and POC dated 1/7/22 to 3/7/22 revealed orders for Physical Therapy to evaluate, assess, monitor and provide skilled therapeutic intervention, pain at LS (Lumbar Spine), R (Right) hip and coccyx. There was no documentation of established pain parameters to report to the physician. Review of the PT Admission Visit Note Report dated 1/7/22 revealed a diagnosis of Chronic Pain Syndrome and, "symptoms poorly controlled, patient needs frequent adjustments in treatment and dose monitoring. Pain level of 6." There was no documentation the physician was notified and no documentation of an acceptable pain level reported by the patient. Review of the PTA Visit Note Report dated 1/13/22 revealed pain level of 7 and pain medication was administered during the visit. There was no documentation the pain was relieved after the pain medication was administered and no documentation the physician was contacted for orders and pain parameters to report. An interview conducted on 1/27/22 at 10:30 AM with EI # 5, DOO # 3, confirmed there was no pain parameters documented to manage the patient's pain level and the physician was not notified.

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 2 of 17 MR reviewed including Home Visit (HV) # 6 and MR # 10 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. 5. Revisions to the Plan of Care due to changes in patient health status is communicated to the patient, ... caregiver and all physicians issuing orders for the home health plan of care- includes as appropriate: a. Patient's current condition b. Changes in condition c. Patient's response to treatment, if negative, will be reported to MD (physician) immediately... 1. HV # 6 was admitted to the agency on 12/23/21 with diagnoses including Pressure Ulcer (PU) Of Sacral Region Stage 4, PU Hip Unstageable, PU Of Right Heel Unstageable, Unspecified Severe Protein-Calorie Malnutrition, and Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. Review of the Home Health Certification (HHC) and Plan of Care (POC) 12/23/21 to 2/20/22 included the following orders: Diabetes management: Skilled Nurse (SN) for instructions for diabetic care ..., proper administration of diabetic medication... SN to assess, evaluate, and develop an individualized plan of care...medication management, and nutrition management... Enteral feeding/care teaching: SN to perform and instruct in management of gastrostomy including: care of site, equipment, and preparation/administration of feedings. Nepro @ 35 ml (milliliter)/hr (hour) gravity continuous, H2O (water) 20 ml/hr gravity, check placement daily, check residual every day. SN to perform/teach patient (pt)/caregiver (cg) pressure ulcer ... apply Santyl with Dakin's moistened gauze into wound bed. Cover with abd (abdominal) pad... Review of the 12/27/21 SN Visit Note (SNVN) revealed documentation patient was receiving Nutrene, 6 cartons a day. There was no documentation of a physician's order to change the enteral feeding from Nepro to Nutrene 6 cartons a day. Review of the 12/31/21 SNVN revealed documentation the patient received 4 cartons of Novasource, which has 48 grams of carbs per carton of feeding... Family is flushing with feeding per bolus feedings with 150 cc (cubic centimeters) H2O flush. There was no documentation the SN contacted the physician or obtained a new order to change the enteral feeding from Nepro to Novasource. Review of the 1/21/22 SNVN revealed documentation the patient's family is still using Novasource feeding. SN suggested Glucerna 2.0. There was no documentation the SN contacted the physician for new orders for enteral feeding. Review of the 7 SNVN dated 12/27/21 to 1/25/22 revealed the same measurements each week for each of the 4 wounds (wd) included: # 7 Right (Rt) Calf 10 X (by) 3 X 0.1 cm (centimeters) # 9 Rt Heel PU Unstageable 6 X 3.5 X 0.1 cm #10 Rt Lower Buttock 3 X 3 X 0.1 cm; and #11 Mid-Sacral PU Stage 4, 7 X 7 X 3 cm. There was no documentation the staff had notified the physician the wounds were not healing and had not decreased in size in 4 weeks. Review of the 1/7/22 SNVN revealed documentation of the caregiver voiced concerns of (1) blood pressure has been going up and down today. (2) questioning need to administer insulin 3 times a day as ordered. (3) reported to SN the physician instructed family to obtain a strong over-the-counter (OTC) medication for yeast. Further review of the 1/7/22 SNVN revealed family was instructed to apply Santyl ointment to yellow slough only. There was no documentation the SN reported the family's concerns to the physician regarding blood pressure, administering insulin 3 times a day as ordered, or confirmed OTC medication for yeast. And there was no order written to change the wound care. In an interview conducted on 1/27/22 at 10:39 AM Employee Identifier (EI) # 2, (Director of Operations # 2) confirmed the SN failed to report to the physician the changes the caregivers were making to the ordered plan of care for enteral feedings, caregiver concerns about blood pressure and insulin and OTC yeast medication. EI # 2 also confirmed, the staff failed to notify physician for the non-healing wounds for possible change in wound care. 2. MR # 10 was admitted to the agency on 8/23/21 with diagnoses including Schizoaffective Disorder, Bipolar Type, Unspecified Intellectual Disabilities and Long Term (current) Drug Therapy. Review of the HHC and POC dated 8/23/21 to 10/21/21 revealed orders for SN 2WK2, 1WK7 (2 times a week for 2 weeks and 1 time a week for 7 weeks.) Medication management: SN to review medications...effectiveness of drug therapy, and s/s (signs/ symptoms) of adverse reactions. May instruct and reinforce teaching related to the use of medications... and to report complications... Psychiatric SN to observe, assess and provide education on management of psychiatric condition. Psychiatric SN to observe, assess, and provide education on management of schizophrenia spectrum disorder. SN to instruct patient/caregiver... teach s/s that put patient at risk, when to notify nurse of complications /decline, or call 911... s/s to be on the alert for early intervention, prior to needing emergency services. Call SN for decline in stats and home health agency to facilitate physician follow up... Review of the Start of Care dated 8/23/21 revealed patient was recently discharged from hospital with increased agitation, frequent hypersexuality, patient aggressive, hitting family and breaking furniture. Patient unable to care for self and relies on mother for care. Patent lacks insight and judgment and during the visit the patient left the room for several minutes and returned to the room and announced to the psychiatric skilled nurse (PSN) he/she had just masturbated and asked if he/she needed to take more medicine. The PSN documented the next physician appointment was scheduled 9/10/21. Review of the next PSN visit 8/30/21 revealed documentation the patient had been in jail over the weekend. And during the visit the patient put on a condom and masturbated in the living room floor. There was no documentation the PSN notified the physician the patient had been in jail or of his/her unacceptable behavior. Review of the 9/1/21 PSN visit note revealed documentation the patient was in the car and refused to leave. Patient had refused morning medications. PSN documented a message was left with physician. The surveyor asked EI # 2 "Is there any documentation of SN follow up with physician?" EI # 2 replied, "No, there is no documentation." Review of the 9/2/21 Social Worker (SW) phone visit note revealed documentation the SW would contact mental health center to inquire of any programs provided in the home to assist and would call the patient's caregiver back. There was no documentation in the MR of who the SW contacted or any follow up with the caregiver. Review of the next visit was 9/9/21 and a PSN Discharge from agency note with instructions to follow up with physician on 9/10/21. There was no documentation the PSN had reported to the physician regarding the patient's behaviors, concerns and refusals to take medications or the agency's plan to discharge the patient from home health services. In an interview conducted on 1/27/22 at 10:23 AM, EI # 2 confirmed the PSN failed to follow POC orders for management of the of the Schizophrenic Affective Disorder and Bipolar Type and notify physician in patient behaviors for possible changes in medications / treatment. EI # 2 also confirmed, the PSN failed to notify the physician of agency's plan to discharge patient or provide any discharge planning.

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), and interviews, it was determined the agency failed to ensure infection control practices were observed. This deficient practice did affect 4 of 7 home visits (HV) patients including HV # 7, HV # 4, HV # 6, HV # 1, and had the potential to affect all patients admitted to this agency. Agency Policy: The Provision of Wound and Skin Care Policy #: WC-001 Date Revised: 1/20/22 ...Hand Hygiene: Wound care provision consists of hand hygiene before and after the actual care and at various time during wound care provision per our hand hygiene policy. ... Wound Field Set Up: A field is set up to work off of when providing wound care. The field consists of a barrier (preferably waterproof) on a clean hard surface when possible on which all supplies necessary for the provision of wound care are laid. ...Procedure: 1. Perform hand hygiene per policy. 2. Position the patient to provide access to the wound... 11. Gently clean wound with prescribed solution and gauze pad. Cleanse exudate away from the wound from inside to out using a new gauze pad with each stroke... Agency Policy: Hand Hygiene Policy #: PCP-001 Revised Date: 6/24/21 ...Guidelines: ...4. Perform hand hygiene as follows: a. Before having direct contact with patients b. Before donning gloves c. Before performing a procedure... d. After contact with a patient's intact skin e. After contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings f. When moving from a contaminated body site to a clean body site during patient care g. After contact with inanimate objects (e.g. medical equipment) in the immediate vicinity of the patient h. After removing gloves ...11. Change gloves during patient care if moving from a contaminated body site to a clean body site... Hand Hygiene Procedure: 1. Use of alcohol-based hand rubs: Apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers. Continue rubbing the product over hand and finger surfaces until the solution dries completely (usually this takes about 20 seconds or more)... 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: Nothing inside the bag should ever be "dirty" or soiled. Staff should not re-enter the bag with used gloves. Always perform hand hygiene before entering bag... Procedure: 2...Alcohol-based hand sanitizer, liquid antibacterial soap and paper towels are placed in an outside compartment for ease of access. 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 (i.e. blood pressure cuffs, pulse oximeters, stethoscopes...) should be cleaned with 70% isopropyl alcohol or agency approved, single-use disinfectant wipe after each use and before placing the equipment back in the supply bag...and dry using a disposable towel. Agency Policy: Central Venous Access Device (CVAD) Dressing Change Policy Number: IV-009 Revised Date: 12/30/2021 ...Procedure: ...4. Position the patient for comfort. A supine position is recommended to decrease the chance of air embolism. 5. Perform hand hygiene... 6. Assemble equipment and prepare flush solutions. 7. Open dressing change kit and put on mask. Assemble supplies on sterile field. ...9. Don non-sterile gloves: gently remove old dressing... ...13. Remove non-sterile gloves and discard. 14. Perform hand hygiene. 15. Apply sterile gloves. 16. Clean catheter-skin junction and surrounding skin with antiseptic solution...With Chlorhexidine solution (preferred), apply using back and forth motion... 4. HV # 1 was admitted to the agency on 12/2/21 with an admitting diagnosis of Urinary Tract Infection, Site Not Specified. A home visit was conducted on 1/25/22 at 1:52 PM to observe care provided to the patient per EI # 12, Physical Therapist (PT). During the HV EI # 12 sanitized hands and donned clean gloves and removed equipment needed for the patient assessment from the bag and placed on barrier. EI # 12 then completed the patient's vital signs and laid the equipment on the barrier. After the vital signs were complete EI # 12 cleaned the thermometer with a Sani Wipe wearing the same gloves used to perform the vital signs. EI # 12 then continued to clean the rest of the equipment using the same Sani wipe and the same gloves. EI # 12 laid all equipment on the barrier and did not remove gloves, sanitize hands or don clean gloves and began to work with the patient completing exercises with the dirty gloves. Once EI # 12 completed all exercises with the patient, EI # 12 failed to remove gloves, sanitize hands or don clean gloves and began checking the patient's medication bottles. EI # 12 documented the medication discrepancies on the tablet and failed to remove gloves and sanitize hands prior to documentation on the tablet. EI # 12 did not remove gloves or sanitize hands and placed a gait belt around the patient and began walking the patient around the home. Once complete EI # 12 removed the gait belt and cleaned it with a Sani wipe using the same gloves used to perform all activities in the home. EI # 12 then removed gloves, reached into uniform pocket and removed a bottle of hand sanitizer. Placed the hand sanitizer bottle back into the uniform pocket and donned clean gloves. EI # 12 then place all the equipment on the barrier back into the nursing bag. EI # 12 removed gloves and did not sanitize hands, picked up trash and the barriers and placed in a bag. EI # 12 reached into uniform pocket, sanitized hands and placed sanitizer back in pocket. EI # 12 then exited the home. An interview was conducted on 1/25/22 at 2:30 PM with EI # 3, Clinical Manager # 1, who stated EI # 12 only changed gloves one time during the visit and even while cleaning equipment re-contaminated the equipment by using the same dirty gloves and also the hand sanitizer should not be kept in the uniform pocket. 2. HV # 4 was admitted to the agency on 1/8/22 with diagnoses including Hemiplegia Following Cerebral Infarction Affecting Left Non-Dominant Side, Other Sequelae of Cerebral Infarction and Unqualified Visual Loss Left Eye. A HV was conducted on 1/25/22 at 12:20 PM to observe EI # 11, Licensed Practical Nurse (LPN) provide wound care. EI # 6, (Clinical Manager # 2) was also present during the visit. After obtaining vital signs EI # 11 opened the package for a single Large Sani-cloth wipe and cleaned blood pressure cuff, stethoscope, thermometer and pulse oximeter. After cleaning each piece of the visibly wet equipment, EI # 11 then replaced the wet equipment to the nursing bag. EI # 11 failed to dry the equipment before replacing to bag per policy. During the visit the surveyor and EI # 6 observed in home folder 2 paper wound measuring tapes dated 1/8/22. The surveyor asked EI # 6 are these re-usable? EI # 6 stated the paper measuring tapes should have been disposed after use and not placed in the patient's home folder. In an interview conducted on 1/27/22 at 10:14 AM, EI # 4, (Director of Operations # 2), confirmed the staff should have allowed the reusable equipment to dry before replacing to the nursing bag and the single use paper measuring tapes should have been disposed of after use and not be placed in the home folder. 3. HV # 6 was admitted to the agency on 12/23/21 with diagnoses including Pressure Ulcer (PU) Of Sacral Region Stage 4, PU Hip Unstageable, PU Of Right Heel Unstageable, Unspecified Severe Protein-Calorie Malnutrition, and Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. A HV was conducted on 1/26/22 at 9:05 AM with EI # 10, Home Health Aide (HHA), to observe care provided and EI # 6 was also present during the visit. As EI # 10 placed barriers to the patient's couch and removed blood pressure cuff, thermometer, pulse oximeter and several gloves from the nursing bag. EI # 10 failed to perform hand hygiene before entering nursing bag. EI # 10 then proceeded to obtain vital signs and realized a thermometer probe cover was needed. EI # 10 while wearing dirty gloves went into the clean bag and removed a thermometer probe cover and a few more gloves and then placed the new gloves on the other gloves already on the barrier. EI # 10 failed to remove dirty gloves and perform hand hygiene before removing clean items from the nursing bag. In an interview conducted on 1/27/22 at 10:39 AM, EI # 4, confirmed the HHA did not follow the hand hygiene and bag technique policy. 1. HV # 7 was admitted to the agency on 10/01/2020 and recertified for home care on 12/15/2021 to 2/12/22with diagnoses including Infection of Amputation Stump Left Lower Extremity, Type 2 Diabetes Mellitus, and Other Acute Osteomyelitis. Review of the Home Health Certification and Plan of Care (HHC and POC) dated 12/15/2021 to 2/12/22 revealed orders for SN (Skilled Nurse) 1 x week x 8 weeks, Cleanse wound to left 3rd toe with Vashe moistened gauze, pat dry with gauze, apply vashe wet to dry to wound twice daily. Wrap toes/foot/leg with rolled gauze to knee. Apply ace wrap from toe to knee and secure with tape. SN to perform PICC (Peripherally inserted central catheter) site care per protocol weekly using a PICC site care kit. A HV was conducted on 1/26/22 at 9:50 AM to observe PICC line site care and wound care provided by Employee Identifier (EI) # 8, RN (Registered Nurse). EI # 7, Clinical Manager, was also present during the HV. EI # 8 set up a clean barrier and opened PICC line care kit, syringes, flushes, and end caps for use with the PICC line care. EI # 8 used the HV # 7 bandage scissors to cut part of the dressing from around the PICC line in the right upper arm. EI # 8 then placed the soiled scissors on the barrier with the clean supplies. EI # 8 failed to keep clean items separated from contaminated items. EI # 8 then removed the cap from port # 1 of 2, wiped with an alcohol swab, adjusted his/her glasses with the gloved hand, then continued to wipe the open port with the same gloved hand. EI # 8 failed to remove gloves and perform hand after touching a contaminated surface before proceeding with site care. After cleaning port # 2, EI # 8 flushed the ports with 10 ml of Normal Saline (NS) then aspirated 10 milliliters (ml) of blood from port # 1. EI # 8 then discarded the aspirated blood in the sharps container and closed the sharps container with gloved hands. EI # 8 failed to remove gloves and perform hand hygiene after touching the unclean surface. While still wearing the same gloves, EI # 8 then used the Chlorhexidine swab stick in back and forth motions from the edges of the dressing area to the center insertion site. While swabbing the outer edges EI # 8 touched an unclean surface, the sofa HV # 7 arm was resting, with the chlorhexidine swab multiple times. EI # 8 failed to discard the contaminated swab stick before proceeding to clean around the PICC line insertion site. After PICC line site care complete, EI # 8 removed gloves, performed hand hygiene with hand sanitizer and set up a clean area with a moisture barrier and assembled items for wound care to left toe. While setting up the clean supply area, EI # 8 dropped the hand sanitizer onto the floor then picked the bottle up and placed it onto the clean barrier area. EI # 8 failed to clean the unclean item before placing it onto the clean dressing supply area. After the dressing from the left toe, foot, and leg was removed, EI # 8 soaked 4 x 4s from a bulk pack with Vashe. EI # 8 wiped around the wound area and between toes then wiped toward the open wound multiple times with the same 4x4. EI # 8 failed to observe agency policy for wound care which stated to clean away from the wound from inside to out. EI # 8 then soaked cotton tipped applicators with Vashe and used them to clean between the toes and the open wound site. The surveyor observed EI # 8 wiping toward the open wound site multiple times. EI # 8 failed to observe agency policy for wound care which stated to clean away from the wound from inside to out using a new gauze pad with each stroke. In an interview with EI # 7 on 1/26/22 at 12:00 PM, EI # 7 confirmed agency infection control policies were not followed during the PICC line and wound care procedures.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on review of agency policies and procedures, medical records (MR) reviews and staff interviews, it was determined the agency failed to follow the plan of care (POC) for the following: 1. Manage Diabetes including monitoring of blood sugars. 2. Manage pain 3. Manage blood pressures. This deficient practice affected 3 of 12 active records reviewed including MR #2, MR # 4, Home Visit (HV) # 6, and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Blood Glucose Monitoring - Agency Glucose Monitoring system Policy Number: END-003(b) Policy Revised Date: 12/2/21 Purpose: ...To assess changes in the blood glucose level used to modify treatment. To teach client/caregiver home diabetic management. Blood Glucose Reporting Parameters: Request attending physician provide patient-specific blood glucose reporting parameters.... Document in Clinical Record: Date and time of test including test results. Assessment findings. Any actions taken to correct symptoms of hyperglycemia or hypoglycemia. The patient's response to interventions and instruction. Care coordination with Physician/healthcare providers as indicated. Agency Policy: Pain Assessment and Management Policy Number: MSC-001 Policy Review Date: 11/21 Purpose: To assess patient level of pain.... To promote comfort. Procedure: 1. Pain Assessment should include: b. Evaluation of effectiveness of each pain management intervention once a sufficient time has elapsed for the treatment to reach peak effect. m. Teaching and assessing patient's goal for pain control. Pain Management and Quality Indicators: 6. Evaluate the effectiveness of the treatment or medication. 8. Specifically assess response to any intervention - pharmacologic or not. 10. The physician should be notified when there are new complaints of pain or when prescribed interventions do not result in adequate pain relief. Document in the clinical Record: ...Treatments/interventions and patient response. Physician notification as appropriate.... 3. HV # 6 was admitted to the agency on 12/23/21 with diagnoses including Pressure Ulcer (PU) Of Sacral Region Stage 4, PU Hip Unstageable, PU Of Right Heel Unstageable, Unspecified Severe Protein-Calorie Malnutrition, and Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. Review of the HHC and POC 12/23/21 to 2/20/22 included the following orders: Medication management: Skilled Nurse (SN) to review medications..., effectiveness of drug therapy, and signs/symptoms (s/s) of adverse reactions...and to report complications. Diabetes management: Skilled Nurse (SN) for instructions for diabetic care to include diet, skin care, signs/symptoms (s/s) of hypo/hyperglycemia, proper administration of diabetic medication... monitor for skin lesions on lower extremities. Blood glucose testing 1-2 X(times) daily and PRN (as needed) ... SN to report to physician blood glucose readings greater than 300 or less than 60... SN to assess, evaluate, and develop an individualized plan of care...medication management, and nutrition management... Review of the medications listed on the HHC and POC revealed Levemir Flextouch U-100 Insulin 30 Units daily for blood sugar and Midodrine 5 milligram (mg) every 8 hours daily for blood pressure support. Review of the 7 SN Visit Notes dated 12/27/21 to 1/25/22 revealed documentation the caregiver reported random blood sugars and had blood pressure concerns. There was no documentation the SN reviewed the blood sugars or blood pressures readings the caregivers reported. A HV was conducted on 1/26/22 at 9:05 AM with EI # 11, Home Health Aide (HHA) to observe care and EI # 6, (Clinical Manager # 2) was also present. During the HV the caregiver referred to a patient notebook. The surveyor glanced at the note book revealed documentation of notes, blood pressures, blood sugars and when medications were administered. The surveyor asked the caregiver, "At what blood pressure reading do you consider low enough for you to administer the Midodrine 5 mg every 8 hours?" The caregiver said, "We were given something at the hospital. But we don't give it to her 3 times a day. If it's low we give it before dialysis." The caregiver did not provide the instructions of when to administer the Midodrine. The surveyor asked, "What about blood sugars?" The caregiver replied, "Sometime we check his/her blood sugar 8 times a day if she doesn't look right. We put them in the book." In an interview conducted on 1/27/22 at 10:39 AM Employee Identifier (EI) # 2, (Director of Operations # 2) confirmed the SN failed to assess and manage the patient's blood pressure and diabetic medications as ordered on the plan of care. 1. MR # 2 was admitted to the agency on 12/31/21 with diagnosis including Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side and Essential (Primary) Hypertension. Review of the Home Health Certification (HHC) and POC dated 12/31/21 to 2/28/22 revealed orders for Physical Therapy (PT) to visit 1WK1, 2WK5 (once per week for one week, two times per week for five weeks). ...PT to evaluate, assess and monitor...Diabetes Management (PT). Review of the Physical Therapist Assistant (PTA) visits dated 1/5/22, 1/7/22, 1/10/22, 1/12/22, 1/17/22, 1/19/22 and 1/24/22 revealed, "Clinician... instructed (patient/caregiver) to check and record Blood Glucose." There was no documentation of blood glucose assessments. An interview conducted on 1/27/22 at 10:10 AM with Employee Identifier (EI) # 1, Director of Operations (DOO) # 1, confirmed there was no documentation of blood sugar assessments and the PTA should have obtained the blood sugar assessments performed by the patient/caregiver and documented the blood sugar assessments in the clinical record. 2. MR # 4 was admitted to the agency on 1/7/22 with diagnosis including Chronic Pain Syndrome, Pain in Right Hip, and Other Spondylosis with Radiculopathy, Lumbosacral Region. Review of the HHC and POC dated 1/7/22 to 3/7/22 revealed PT to visit 1WK1, 2WK4 (once per week for one week, twice per week for four weeks). PT to evaluate, assess and monitor, provide skilled therapeutic intervention, activity, education and training to address:...Pain at LS (Lumbar Spine), Right Hip and Coccyx. Review of the PTA visit dated 1/13/22 beginning at 8:56 AM and ending at 9:41 AM revealed, "Current pain scale rating: 7." Pharmacological Intervention: "Oxycodone given at 9:00 AM, during visit." There was no documentation that the pain level was reassessed following the administration of Oxycodone to determine effectiveness. An interview conducted on 1/27/22 at 10:30 AM with EI # 5, DOO # 3, confirmed there was no documentation EI # 4's pain level was re-assessed for medication effectiveness.