Every finding on record at Athens-Limestone Homecare, LLC

Based on the recertification survey conducted on 8/11/22, Athens-Limestone Homecare was found to be in substantial compliance with the Conditions of Participation for Emergency Preparedness and related standards.

A recertification survey was conducted 8/9/22 to 8/11/22 at Athens-Limestone Homecare. Standard level deficiencies were cited and will require an acceptable plan of correction.

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), facility policy and procedure, and interviews, it was determined the agency failed to ensure the Medicine List (ML) was current and accurate for all patients. This affected four of seven Home Visits (HV) conducted, and did affect HV # 5, HV # 6, HV # 2, and HV # 7, and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Monitoring Medications Policy Number: 10.008 Revised Date: 05/01/19 Purpose: To provide a process to ensure continuous monitoring of medications in the patient’s home. Policy: …all clinicians will participate in medication review and reconciliation throughout the episode. Procedure: 1. The discipline responsible for the drug regimen will: a. Compare medication list… to actual medications patient is taking b. Review all medications… to identify issues such as: …ix. Dosage errors; and x. Drug omissions. …e. Notify the physician of the above identified issues/discrepancies… 3. HV # 2 was admitted to the agency on 4/13/22 and recertified for care on 6/12/22 with diagnoses including Parkinson's Disease and Hypertensive Heart Disease Without Heart Failure. Review of the HHC and POC for certification period 6/12/22 revealed a Speech Therapy (ST) visit frequency of two times a week for three weeks. Review of the Physician Order dated 7/26/22 revealed an ST visit frequency of three times a week for one week, two times a week for one week, then one time a week for one week, effective 7/24/22. A HV was conducted on 8/9/22 at 2:15 PM to observe care provided by EI # 8, ST. During the HV a comparison was made between the medications observed in the home and the current ML. The following discrepancy was observed: Pantoprazole 40 mg Delayed Release Tablet, one tablet daily was on the ML. The prescription in the home dated 3/29/22 was Pantoprazole 40 mg, one tablet daily as needed. The patient's caregiver (CG) confirmed HV # 2 did not take the Pantoprazole daily. In an interview conducted 8/11/22 at 1:14 PM, EI # 1 confirmed the the staff failed to update the ML with the patient's current medications. 4. HV # 7 was admitted to the agency on 5/4/22, and recertified for care on 7/3/22 with diagnoses including Pressure Ulcer of Right Hip, Stage four, and Cerebral Palsy, Unspecified. Review of the HHC and POC dated 7/3/22 to 8/31/22 revealed a SN visit frequency of two times a week for eight weeks, one time a week for one week, and two as needed visits for wound or foley catheter complications. A HV was conducted on 8/10/22 at 1:13 PM to observe care provided by EI # 4, Registered Nurse (RN). During the HV a comparison was made between medications observed in the home and the current ML. The following discrepancies were observed: Cholestyramine Light 4 Gram Oral Powder, dissolve one packet in two to six ounces of water, take two times daily was on the ML. The patient's CG stated the Cholestyramine was discontinued around 7/18/22. Diazepam 2 mg tablet, one tablet two times daily was on the ML. The prescription in the home dated 3/2/22 was Diazepam 2 mg, take one half tablet in the morning, one tablet in the evening. The patient's CG confirmed HV # 7 took the Diazepam as prescribed. In an interview conducted 8/11/22 at 1:23 PM, EI # 1 confirmed the staff failed to update the ML with the patient's current medications. 2. HV # 6 was admitted on 6/28/22 with diagnoses including Type 2 Diabetes Mellitus with Diabetic Polyneuropathy and Essential (Primary) Hypertension. Review of the HHC and POC dated 6/28/22 revealed orders for SN one time a week for nine weeks and Physical Therapy (PT) two times a week for one week then one time a week for eight weeks. A HV was conducted on 8/9/22 at 3:30 PM to observe care provided by EI # 5, Physical Therapist. During the HV a review of the medications in the home was compared to the ML provided to the surveyor prior to the visit. Aspirin 325 mg take one tablet daily was listed on the ML but not found in the home. HV # 6 stated he/she had never been on a regular dose of Aspirin. In an interview conducted on 8/11/22 at 12:12 PM, EI # 1 confirmed the staff failed to update the Medication List with the patient's current medications. 1. HV # 5 was admitted to the agency on 6/18/22 with diagnoses including Encounter For Surgical Aftercare Following Surgery on the Digestive System and Colostomy Status. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 6/18/22, revealed orders for the Skilled Nurse (SN) one time a week for one week, two times a week for one week, one time a week for six weeks and then two times a week for one week. A HV was conducted on 8/9/22 at 1:28 PM to observe care provided by Employee Identifier (EI) # 2, Licensed Practical Nurse (LPN). During the HV, the surveyor and EI # 2 compared the current ML with the medications in the home. The following discrepancies were observed: a. Ondansetron Hcl (Hydrochloride) 4 mg (milligrams) 1 tablet two times daily was listed on the ML. The prescription bottle dated 7/20/22 read, 1 tablet two times daily as needed. The patient stated she/he had been taking this medication as needed for a long time and not two times daily as written on the ML. b. Questran 4 gram Oral Powder two times daily, take one packet dissolved in beverage twice daily was listed on the agency ML. Per the patient, the doctor changed this medication on 7/27/22 to 2 packets two times daily and she/he had been taking two packets two times daily since then. c. Vancomycin 250 mg 1 capsule three times daily - take tid (three times a day) for 10 days was listed on the ML. The prescription bottle in the home was dated 6/28/22. The patient stated she/he had not taken this medication since early July and confirmed that Vancomycin was not a current medication. An interview was conducted on 8/11/22 at 12:36 PM with EI # 1, Executive Director who verified the staff failed to update HV # 5's ML 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 observation, Medical Record (MR) review, agency policy and procedure, and interviews, it was determined the agency failed to ensure: 1. Physician orders for wound care were followed. 2. Physician orders for PICC (Peripherally Inserted Central Catheter) line care were followed. 3. Physician orders for foley catheter size were followed. This deficient practice affected three of twelve current records reviewed, including Home Visit (HV) # 3, MR # 3, HV # 7, and had the potential to affect all patients admitted to this hospice. Findings include: Agency Policy: Physician Orders Policy Number: 2.1.008 Revised Date: 11/01/2021 Policy: No medications, treatments, diagnostic studies or therapeutics will be administered without the order of a qualified physician or authorized practitioner... Procedure: ... 10. Services are provided according to the most recent orders updating the patient's Plan of Care... 3. HV # 7 was admitted to the agency on 5/4/22, and recertified for care on 7/3/22 with diagnoses including Pressure Ulcer of Right Hip, Stage four, and Cerebral Palsy, Unspecified. Review of the HHC and POC dated 7/3/22 to 8/31/22 revealed a SN visit frequency of two times a week for eight weeks, one time a week for one week, and two as needed visits for wound or foley catheter complications. Further review of the HHC and POC revealed an order for the SN to insert a 16 FR (french) 10 to 20 cc (cubic centimeter) balloon indwelling (foley) catheter. Instill 10 to 20 cc of sterile water into balloon. Change every month and as needed. Review of the 7/18/22 SN Visit Note Report (VNR) revealed the SN inserted a new 14 FR catheter during the visit. There was no documentation the SN instilled 10 to 20 cc of sterile water into the balloon. The SN failed to follow the physician's order to insert a 16 FR catheter and instill 10 to 20 cc of sterile water into the balloon. Review of the Physician Order dated 7/21/22 revealed new wound care orders for wound # 5, a stage four pressure ulcer (PU) to the right greater trochanter (part of the hip bones) as follows: SN to cleanse wound # 5 with Vashe, pat dry, prepare peri-wound area with window paning. Fill entire cavity with black foam, apply white foam to exposed bone. Apply transparent drape and apply tubing, apply negative pressure device at 125 (millimeters per mercury) continuous (suction). Dressing to be changed three times a week. Review of the SN VNR dated 7/25/22 (Monday) revealed the SN provided wound care as ordered. Review of the next SN VNR dated 7/30/22 (Saturday) revealed the SN documented wound care was not provided during the visit due to it not being ordered. The SN failed to follow the physician's order to provide wound care three times a week. In an interview conducted on 8/11/22 at 1:23 PM, EI # 1 confirmed the SN did not follow the physician's order to place a size 16 FR catheter and instill 10 to 20 cc of sterile water into the catheter balloon. EI # 1 also confirmed that wound care was ordered three times a week, and that wound care should have been provided on the 7/30/22 SN visit per the physician's order and was not. 1. HV # 3 was admitted to the agency on 3/9/22 and recertified for home care on 7/7/22 with diagnoses including Local Infections of the Skin and Subcutaneous Tissue snd Chronic Venous Hypertension With Ulcer of Right Lower Extremity. Review of the Physician Order dated 7/19/22 revealed orders for wound care to wound # 5 of the proximal dorsum, right stasis ulcer...cleanse with soap and water, rinse with vashe, pat dry with gauze, and apply Urgotul AG/Silver and Zetuvit Plus to wound bed. A HV visit was conducted on 8/9/22 at 1:40 PM to observe wound care provided by Employee Identifier (EI) # 3, Registered Nurse (RN). EI # 6, Executive Director, was also present. EI # 3 removed the dressing from right lower leg of HV # 3, cleaned the wound to the medial ankle area with soap and water, patted dry then applied Santyl Cream to the wound bed and covered with Urgotul AG/Silver and Zetuvit Plus. Santyl Cream was not included in the orders for wound care. In an interview conducted on 8/11/22 at 12:45 PM, EI # 1, Executive Director, confirmed the staff failed to follow the physician orders for wound care. 2. MR # 3 was admitted on 7/16/22 with diagnoses including Encounter for Orthopedic Aftercare Following Surgical Amputation and Type 2 Diabetes Mellitus with Other Specified Complication. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 7/18/22 revealed orders for Skilled Nurse (SN) one time a week for ten weeks. SN to perform lab draw from PICC line access device. SN to flush with 10 ml (milliliters) of Normal Saline prior to specimen draw, discard 10 ml of blood, flush with 10 ml of Normal Saline and 5 ml of Heparin after specimen draw. Review of the SN Visit Note Report (VNR) dated 8/1/22 revealed the SN documented labs were obtained from the vascular access device and 20 ml blood was discarded. The site was then flushed with 20 ml of Normal Saline followed by 5 ml of Heparin. The SN nurse failed to follow the physician order to discard 10 ml of blood and flush with 10 ml of Normal Saline. In an interview conducted on 8/11/22 at 12:55 PM, EI # 1 confirmed the staff failed to follow the physician orders for the amount of blood to discard and the amount of Normal Saline flush after blood draw.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on a review of medical records (MR), agency policy and procedures, I Train Skills: Urinary Catheter: Straight and Indwelling (Foley) Catheter Insertion (Female), and staff interviews, it was determined the agency failed to ensure medical record documentation was complete and accurate regarding foley catheters and wound care. This did affect two of two medical records reviewed with a foley catheter, including MR # 1, Home Visit (HV) # 7, and one of one medical records reviewed with a Wound Vac (Vacuum assisted closure), including HV # 7. This had the potential to negatively affect all patients with foley catheters and Wound Vacs at this agency. Findings include: Agency Policy: Home Care Record Policy Number: 7.003 Revised Date: 11/01/21 Policy: A medical record is maintained for all patients... Procedure: 2. The patient home care record shall contain the following clinical information: e. Interventions...treatments, and services, and responses to those interventions. I Train Skills Printed 8/11/22 8:54 AM Urinary Catheter: Straight and Indwelling (Foley) Catheter Insertion (Female) Documentation: ...Character and amount of urine Amount of fluid used to inflate the balloon ...Type and size of catheter inserted... Agency Policy: Negative Pressure Wound Therapy (NPWT) Policy Number: 2.2.007 Revision Date: 1/1/2020 Procedure: ...4. The clinician will document the number of foam/sponge pieces placed in the wound bed and the number of foam/sponge/filler pieces removed from the wound. 2. HV # 7 was admitted to the agency on 5/4/22, and recertified for care on 7/3/22 with diagnoses including Pressure Ulcer of Right Hip, Stage four, and Cerebral Palsy, Unspecified. Review of the HHC and POC dated 7/3/22 to 8/31/22 revealed a SN visit frequency of two times a week for eight weeks, one time a week for one week, and two as needed visits for wound or foley catheter complications. Further review of the HHC and POC revealed an order for the SN to insert a 16 FR 10 to 20 cc balloon indwelling (foley) catheter. Instill 10 to 20 cc of sterile water into the balloon. Change every month and as needed. Review of the 7/18/22 SN Visit Note Report (VNR) revealed the SN documented he/she inserted a new 14 FR catheter during the visit. Review of the SN VNR Genitourinary Assessments dated 7/30/22, 8/1/22, 8/5/22, and 8/10/22 revealed the SN documented a size 16 FR foley catheter was in place. The SN failed to document accurately the size of the foley catheter. Review of the Physician Order dated 7/21/22 revealed new wound care orders for wound # 5, a stage four pressure ulcer (PU) to the right greater trochanter (part of the hip bones) as follows: SN to cleanse wound # 5 with Vashe, pat dry, prepare peri-wound area with window paning. Fill entire cavity with black foam, (manufacturer for the Genadyne Brand Wound Vac utilized by the agency supplies green colored foam for use, and not black), apply white foam to exposed bone. Apply transparent drape and apply tubing, apply negative pressure device (Wound Vac) at 125 (millimeters per mercury) continuous (suction). Dressing to be changed three times a week. Review of the SN VNR Narratives dated 8/1/22, 8/3/22, 8/5/22, and 8/10/22 revealed the SN documented one piece of green foam was removed with wound care. The SN failed to document the white foam pieces were removed. In an interview conducted on 8/11/22 at 1:23 PM, EI # 1 confirmed the SN documentation was not accurate for the size of the foley catheter, and that the SN should have documented removing the white foam with wound care, and did not. 1. MR # 1 was admitted to the agency 3/10/22 and recertified from 7/8/22 to 9/5/22 with diagnoses including Unspecified Systolic (Congestive) Heart Failure and Encounter For Fitting and Adjustment of Urinary Device. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 7/8/22 to 9/5/22 revealed a Skilled Nurse (SN) frequency of one time a week and "SN for insertion of 16 Fr (French) 5-20 cc (cubic centimeters) balloon indwelling catheter using aseptic technique: instill 5-20cc of sterile water into balloon. Change every month and prn (as needed)..." Review of the SN Visit Note Report dated 7/28/22 revealed, "Foley catheter changed and pt (patient) tolerated well". There was no documentation of the type and size of catheter inserted, amount of fluid used to inflate the balloon and character and amount of urine returned per agency policy. An interview was conducted on 8/11/22 at 12:50 PM with Employee Identifier (EI) # 1, Executive Director (ED), who confirmed the staff failed to document the type and size of catheter inserted, amount of fluid used to inflate the balloon and character and amount of urine returned per agency policy on MR # 1 on 7/28/22.