Every finding on record at Annex Healthcare Providers, Inc

The following reflects the findings of the Department of Public Health during a Recertification Survey. Representing the Department of Public Health Surveyor ID #- 35893 RN-HFEN Surveyor ID #- 22303 RN-HFEN Unduplicated Admissions - 42 Active Patients -40 Sample Size - 7 Patients Home Visit - 3

The following reflects the findings of the Department of Public Health during a Recertification Survey. Representing the Department of Public Health Surveyor ID #- 35893 RN-HFEN Surveyor ID #- 22303 RN-HFEN Unduplicated Admissions - 42 Active Patients -40 Sample Size - 7 Patients Home Visit - 3

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 observation, interview, and record review, the home health agency (HHA) nurse failed to review all medications the patient is currently using for one of seven patients (Patient 4). This failure has the potential risk to result in medication errors and or delay of administration of the prescribed medications. A review of Patient 4’s clinical record indicated a start of care date of 10/5/16, with diagnoses of neurogenic bladder (a problem in which a person lacks bladder control due to a brain, spinal cord, or nerve condition) and left buttock Stage I pressure ulcer ( reddened area to the skin because of prolonged pressure to the area ). A review of Patient 4’s plan of care for the period of 11/6/21 to 1/4/22, included a physician's order for the skilled nurse (SN) visit once a week for nine weeks. The SN was to instruct Patient 4 on medication compliance dosage and action of medication. During a home visit at Patient 4’s place of residence on 12/29/21, at 2:30 p.m., with Registered Nurse (RN 2), reviews of the patient's medication was conducted. During the review it was indicated Patient 4 had a physician's order on 11/11/20, of Clonazepam 0.5 milligrams (anti-seizure medication) twice a day. A review of the prescription bottle label indicated Clonazepam 1 mg twice a day as needed. During a concurrent interview with Patient 4, stated he takes the medication as ordered. RN 2 also stated the prescription bottle label should match the physician's order to ensure the medication is taken correctly. During further review of Patient 4's medications the following were missing: Omeprazole (for heartburn) Benadryl (for allergies) Fluticasone nasal spray (symptoms of allergies) Senokot (for constipation) Temazepam (for trouble sleeping). On 12/29/21 at 2:40 p.m., during an interview with Patient 4 stated, the medications were ordered but were not delivered yet. During a concurrent interview with RN 2 stated the nurse should check the patient's medications every visit. The HHA's undated policy and procedure titled "Medications" indicated to ask to see all medications the patient is taking and check labels with prescribed medication regimen every visit.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the skilled nurses failed to administer drugs and treatments as ordered by the physician for one of seven sample patients (Patient 1). SN failed to provide wound care treatment and to irrigate the patient's suprapubic catheter (drains urine from the bladder) as ordered. This deficient practice placed the patient's open wound and bladder at risk to infection that could lead to complications. A review of Patient 1's clinical record indicated a start of care dated 12/29/06, with primary diagnoses of quadriplegia (paralysis of all limbs).A review of Patient 1's plan of care from 12/10/21 to 2/7/22, included an order for skilled nurse (SN) services. The SN was to perform a comprehensive skilled assessment on integumentary status (skin), wound care to Stage II (skin breaks open or forms an ulcer) occipital pressure ulcer. The wound care treatment included: cleanse with normal saline, pat dry, apply no sting skin prep to peri-wound, apply Medi-honey , apply Collagen Powder, apply plain Aquacel, then cover with Silicone Foam Border dressing daily and as needed. SN was to irrigate the suprapubic catheter with 30 ml (milliliter) 0.25 percent Acetic Acid twice daily and as needed. On 12/29/21, at 11 a.m., a joint home visit was made to Patient 1's residence with Registered Nurse (RN) 1. Patient 1 was observed Stage II occipital pressure sore on the back of the head with no drainage. Patient 1 also had a suprapubic catheter size 26 French connected to a Foley catheter bag draining yellow, clear urine. On 12/29/21, at 12 p.m., during an interview with RN 1, she stated that she provides wound care treatment and irrigates the patient's suprapubic catheter daily and document it in the nursing notes. A review of Patient 1's ADLT LVN Shift Care Notes from dates 12/24/21 to 12/28/21, indicated no documented evidence the visiting nurse provided wound care treatment and irrigated the suprapubic catheter as ordered. On 1/3/22, at 1 p.m., during an interview with the DPCS (director of patient care services), she stated the SN should document every treatment they provide to the patient in their nursing notes.

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 observation, interview and record review, the SN (skilled nurse) failed to follow accepted standards of practice during wound care treatment for two of seven patients (Patients 1 and 4). RN 1 and RN 2 failed to perform hand hygiene and change soiled gloves in between patient's wound care treatment. This failure had the potential for an increased risk of infection and cross contamination. A review of Patient 4’s clinical record indicated a start of care date of 10/5/16 with a primary diagnosis of neurogenic bladder (a problem in which a person lacks bladder control due to a brain, spinal cord, or nerve condition) and left buttock stage 1 pressure ulcer ( reddened area to the skin because of prolonged pressure to the area ). A review of Patient 4’s plan of care for the period of 11/6/21 to 1/4/22 , included an order for the skilled nurse (SN) visit once a week for nine weeks. . The SN was to clean left buttock pressure ulcer site with normal saline (NS) and cover with dressing. During a home visit at Patient 4’s residence on 12/29/21 at 2:30 p.m., Registered Nurse (RN 2) was observed performing a dressing change on Patient 4's left buttock Stage 1 pressure ulcer. She proceeded to removed old dressing with gloves and clean area with normal saline. She then proceeded to apply a clean gauze dressing to the buttocks area without changing gloves. During this same tie and date the RN 2 was stopped before she could apply the clean dressing. She confirmed she should have changed gloves before applying the new dressing to the area to prevent cross contamination and risk of infection. The HHA's policy and procedure titled " Infection control /exposure practices" dated 4/1/2002, indicated gloves are to be worn during a procedure such as wound care. The policy also indicated hands are to be washed prior to gloving and upon removal of disposable gloves. a. A review of Patient 1's clinical record indicated a start of care dated 12/29/06, with primary diagnoses of quadriplegia (paralysis of all limbs).A review of Patient 1's plan of care from 12/10/21 to 2/7/22, included an order for nursing care of 24 hours a day for 60 days, to perform a comprehensive skilled assessment on integumentary status (skin), to do wound care to Stage II occipital pressure ulcer as follows: cleanse with Normal Saline, pat dry, apply no sting skin prep to peri-wound, apply Medihoney , apply Collagen Powder, then apply plain Aquacel, then cover with Silicone Foam Border dressing daily and as needed. On 12/29/21, at 11 a.m., a joint home visit was made to Patient 1's residence with Registered Nurse (RN) 1. During a wound care observation on 12/29/21 at approximately 11: 30 a.m., Patient 1 was observed lying on the bed on supine position while RN 1 provided wound care to the Stage II occipital pressure ulcer. RN 1 was observed initially washing her hands, then putting on a new pair of gloves, picked up a clean pair of gauze, wet the gauze with normal saline and wiped the open wound with it. She then threw the soiled gauze in the trash. RN 2 then picked up a new pair of gauze, wet it with normal saline and wiped and cleaned the open wound again. RN 1 then applied the Medi-honey ointment, the Collagen powder and Aquacel to the wound bed using the soiled gloves. RN 1 failed to remove her soiled gloves and wash her hands in between cleaning the wound and applying the medication.On 12/29/21, at 12 p.m., during an interview with RN 1, she stated she forgot to remove her soiled gloves and wash her hands because she was too nervous.On 12/30/21, at 11:30 a.m., during an interview with the Director of Patient Care Services (DPCS), she stated that RN 1 should have changed her gloves and wash her hands as per the agency's policy. A review of the agency's policy and procedure " Infection control /exposure practices" dated 4/1/2002, indicated gloves are to be worn during a procedure such as wound care. The policy also indicated hands are to be washed prior to gloving and upon removal of disposable gloves.

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: Based on interview and record review, the agency failed to ensure the Condition of Participation for Skilled Professional Services was met as follows: The agency failed to ensure that skilled professionals were qualified while doing skilled professional services for two of seven sampled patients as indicated in the agency's policy and procedure (Refer to G 702). Patient 1, who has a tracheostomy tube (curved tube that is inserted into a tracheostomy stoma [the hole made in the neck and windpipe]) connected to a ventilator machine (breathing machine), was provided respiratory services by a registered nurse (RN 1). RN 1 had no ventilator machine training when hired. Patient 2, who has a tracheostomy tube connected to a ventilator machine was provided respiratory services by a licensed vocational nurse services (LVN 1). LVN 1 had no ventilator machine training when hired. The cumulative effect of this systemic practice resulted in the agency's failure to ensure their skilled professionals were qualified to take care of patients who were dependent on ventilators, and placed the patients at risk to respiratory distress or death due to the lack of staffs knowledge and training to respond in emergency situations related to ventilator malfunction, dislodgement, and or blockage of the tracheostomy tube. Refer to G 702

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure health care professionals providing skilled services for two of two patients on ventilators (Patients 1 and 2) in a sample of 7 were qualified as defined in their policy and procedure. Patient 1, with a tracheostomy tube connected to a ventilator machine was provided registered nurse services (RN 1). RN 1 had no ventilator machine training when hired. Patient 2, with a tracheostomy connected to a ventilator machine was provided licensed vocational nurse services (LVN 1). LVN 1 had no ventilator machine training when hired. This deficient practice placed the patients at risk to respiratory distress or death due to the lack of staffs knowledge and training to respond in emergency situations related to ventilator malfunction, dislodgement, and or blockage of the tracheostomy tube. a. A review of Patient 1's clinical record indicated a start of care dated 12/29/06, with primary diagnoses of quadriplegia (paralysis of all limbs).A review of Patient 1's plan of care from 12/10/21 to 2/7/22, included an order for nursing care of 24 hours a day for 60 days, to perform a comprehensive skilled assessment on respiratory status (lungs) , to monitor PLV-100(designed for long term use in the home) ventilator machine (at bedside) and LTV 800 ventilator machine (while up in chair) with vent support 24 hours a day, to monitor ventilator function and setting every shift as follows: control mode= R 10, IE= 1:2, FI02=21 percent, TV= 1500 if trach cuf deflated, 600 if inflated, high pressure alarm at 70, low=10. On 12/29/21, at 11 a.m., a joint home visit was made to Patient 1's place of residence with Registered Nurse (RN) 1. Patient 1 was observed lying in bed in supine position with a tracheostomy connected to a ventilator machine. On 12/29/21, at 11:15 a.m., during an interview with RN 1, was asked if she had a ventilator training or certificate before providing the care to the patient. RN 1 stated "Yes", she did provide a copy to the agency. b. A review of Patient 2's clinical record indicated a start of care dated 10/6/11, with primary diagnosis of muscular dystrophy (disease that cause progressive weakness and breakdown of skeletal muscles).A review of Patient 2's plan of care from 12/12/21 to 2/9/22, included an order for nursing care of LVN for 345 hours per month for 60 days, 40 hours per week a month for respite, to perform a comprehensive skilled assessment on respiratory status (lungs) , to monitor patient on LTV 800 ventilator machine (w/c and bedside) as follows: AC mode= Rate 11, TV 650, PEEP 0-5, FI02 21 percent, alarm high 70 and low 10, flow 58, IE 1:2:9, SENS 1. On 12/29/21, at 1 p.m., a joint home visit was made to Patient 2's place of residence with LVN 1. Patient 2 was observed lying in bed in supine (lying face up) position , height of bed (HOB) in 30 degree angle, with a tracheostomy connected to a ventilator machine. On 12/29/21, at 1:15 p.m., during an interview with LVN 1, was asked if he has a ventilator training or certificate when hired, he stated "Yes", he had one. A review of LVN 1's personnel files indicated that there was no documented evidence of a ventilator machine training nor certificate provided to agency upon hire in order to be qualified to take care of patients in ventilator settings. On 1/3/22, at 11 a.m., during an interview with the DPCS (director of patient care services), she stated that the agency will ask the applicants (RN/LVN) upon hire to fill up/complete the agency's skilled nursing competency form and check the necessary criteria skills box if they have experience on doing that skill. Once hired and starts going out in field to see patients, the agency's RN supervisor will follow them and check off the skilled competency form for skill approval demonstrated. She also stated that the agency does not ask for a ventilator training /certificate when hiring their nurses to take care of ventilator patients. She further stated that the agency have 40 active patients, 9 out of 40 patients are on ventilators and 1 RN and 21 LVN's are taking care of ventilator patients without ventilator training upon hire. A review of the agency policy and procedure "Care Staff Competency", dated 4/1/2002 indicated verification of licensure or certification by the clinical supervisor or their designee will be assessed at the time of employment.

Participate in HHA-sponsored in-service CFR(s): 484.75(b)(9) Participation in HHA-sponsored in-service training. This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to provide documented evidence of in-services training to licensed staff. This failure had the potential to affect the patient's care and treatment. On 1/3/2022 at 2 p.m., during a record review of HHA's previous year in-services indicated no documentation of staff attendance or documented evidence of in-services training. During an interview with the Director of Patient Care Services (DPCS) at the same time and date, she stated they mail the in-service education every month to staff but do not have evidence of signatures of staff completion. The HHA policy and procedure titled "Orientation Program Policy" dated 5/27/20 indicated agency will mail in-service education. The policy failed to identify who is responsible for follow-up on education and how the HHA would document completion.