Every finding on record at Avera at Home Dba Avera@Home

Avera At Home DBA Avera@Home is in compliance with the requirements of 42 CFR 484.102 Condition of Participation for Home Health Agencies.

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 record review, policy and procedure review, and staff interview, the agency failed to document specific changes needed to reconcile differences identified between the admission medication list and the medications found in the patient's home for 3 of 7 patient records reviewed (Patient 1, 2, and 5). The census was 44. Findings are: A. Review of the agency policy and procedure titled Medication Profile, last revised 7/1/13, revealed: 1. Upon admission, the admitting nurse was to initiate a medication profile to document the current medication regimen of the patient. 2. A drug review will be performed to identify any potential adverse effects, drug interactions, ineffective therapy, significant side effects, drug interactions, duplicate therapy, noncompliance with drugs, and drugs that need lab monitoring. 3. The drug regimen review was to include all of the patient's prescription and over-the-counter drugs, herbal remedies, and alternative treatments that could affect drug therapy. 4. Deviations from taking medications as ordered will be documented in the clinical notes. 5. The policy does not address a process for comparison of the patient's admission medication list with the medications in the patient's home. It also does not provide a process the staff is to follow when differences between the admission medication list and in-home medications are identified, including where and how the staff are to document the differences identified. B. Review of Patient 1's clinical record revealed: 1. A Discharge Medication List (a medication list provided to the agency by the discharging facility when a patient is admitted to the home health agency) dated as received by the home health agency on 9/25/23. 2. A Home Health Certification and Plan of Care (the document completed by the agency and sent to the patient's physician with information found during the comprehensive assessment) for the certification period of 9/27/23 through 11/25/23. 3. The following differences were identified during the survey process when comparing the Discharge Medication List with the medications listed on the Home Health Certification and Plan of Care: Bio- freeze (ointment for pain relief), cefdinir (an antibiotic), levothyroxine (a thyroid hormone), milk of magnesia (bowel care medication), rectal suppository (bowel care medication), Preparation H (for hemorrhoids), simvastatin (a cholesterol medication), triamcinolone (used to treat swelling and itching caused by certain skin conditions), and Prolia injections (used to increase bone mass in those with osteoporosis). These medications were either absent or listed at different dosages on the two medication lists used for medication reconciliation. 4. There was no documentation in the clinical record by the Skilled Nurse conducting the medication reconciliation to verify if these changes were noted, what differences/changes were reported to the physician, and what changes the physician instructed the nurse to make. C. Review of Patient 2's clinical record revealed: 1. A Continuity of Care Document (a medication list provided to the agency by the discharging facility when a patient is admitted to the home health agency), received by the home health agency on 10/2/23. 2. A Home Health Certification and Plan of Care (the document completed by the agency and sent to the patient's physician with information found during the comprehensive assessment) for the certification period of 10/3/23 through 12/1/23. 3. The following differences were identified during the survey process when comparing the medications on the Continuity of Care Document with the medications listed on the Home Health Certification and Plan of Care: levothyroxine (a thyroid hormone), metoprolol (a blood pressure medication), lisinopril (a blood pressure medication), Metamucil (a bowel management medication), fish oil, omega 3 fatty-acids (used to treat high cholesterol), Culturelle (a probiotic used for digestive health), and Citrucel (bowel management medication). These medications were either absent or listed at different dosages on the two medication lists used for medication reconciliation. 4. There was no documentation in the clinical record by the Skilled Nurse conducting the medication reconciliation to verify if these changes were noted, what differences/changes were reported to the physician, and what changes the physician instructed the nurse to make. D. Review of Patient 5's clinical record revealed: 1. A hospital's Discharge Documents (which included a medication list provided to the agency by the discharging facility when the patient was admitted to the home health agency) with a Printed Date of 9/7/2023. 2. A Home Health Certification and Plan of Care (the document completed by the agency and sent to the patient's physician with information found during the comprehensive assessment) for the certification period of 9/12/23 through 11/10/23. 3. The following differences were identified during the survey process when comparing the hospital's Discharge Documents (which included the patient's medication list) with the medications listed on the Home Health Certification and Plan of Care: famotidine (used to prevent/treat heartburn), Lovenox (an injectable anticoagulation medication to prevent clotting), fluocinolone (used to treat swelling and itching caused by certain skin conditions), and triamcinolone (used to treat swelling and itching caused by certain skin conditions). These medications were either absent or listed at different dosages on the two medication lists used for medication reconciliation. 4. There was no documentation in the clinical record by the Skilled Nurse conducting the medication reconciliation to verify if these changes were noted, what differences/changes were reported to the physician, and what changes the physician instructed the nurse to make. E. During an interview on 10/19/23 at 1:00 PM, the Back-up Administrators (Staff L and M) confirmed there was no documentation, in the clinical record of Patients 1, 2, and 5, by the Skilled Nurse conducting the medication reconciliation to verify if the changes were noted, what differences/changes were reported to the physician, and what changes the physician instructed the nurse to make in the patients medication and treatment regimen.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on record review, policy and procedure review, and staff interview, the agency failed to update the plan of care to include all treatments the patients received for 3 of 7 patient records reviewed (Patient 3, 4, and 7). The census was 44. Findings are: A. Review of the agency policy and procedure titled Home Health Plan of Care, revised 12/20/22, revealed: 1. The plan of care was to include all medications and treatments. 2. The plan of care was to be revised as frequently as deemed necessary based on ongoing assessments. B. Review of the the agency policy and procedures also revealed the agency has policies titled Medication Profile and Physician Orders, but neither policy addresses updating the plan of care when a patient reports changes in medications or treatments to the visiting staff member during a home visit. C. Review of Patient 3's clinical record revealed: 1. A Home Health SN Direct Care note (a nurse visit note) dated 9/8/23. The Skilled Nurse (SN) documented in the note the patient reported using Salonpas (an over-the-counter pain relief patch) for back pain. 2. A Home Health SN Direct Care noted dated 9/15/23. The SN documented the patient reported using a lidocaine patch (no type specified) for back pain. 3. There was no documentation the SN updated the patient's plan of care to include the Salonpas or lidocaine patches. D. Review of Patient 4's clinical record revealed: 1. A Home Health SN Direct Care note dated 9/14/23. The SN documented the physician was contacted to change the dressing to the right lower leg to a wet-to-dry dressing (a wound dressing that utilizes applying a moistened dressing directly to the wound bed followed by a dry dressing for cover) and would see the patient in clinic on Monday. 2. There was no documentation the SN updated the patient's plan of care to include the wet-to-dry dressing. E. Review of Patient 7's clinical record revealed: 1. A Home Health SN Direct Care note dated 4/21/23. The SN documented in the note the patient reported a new order was received from [gender] physician on 4/21/23 for Montelukast (used to treat and prevent symptoms of asthma). 2. There was no documentation the SN updated the patient's plan of care to include Montelukast. F. During an interview on 10/19/23 at 1:00 PM, the Back-up Administrators (Staff L and M) confirmed the plan of care for Patient 3, 4, and 7 were not updated to include the new treatment changes as voiced by the patients during the home visits.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on record review, policy and procedure review, and staff interview, the agency failed to include on the revised/updated plan of care the progress towards the agency and patient identified outcomes and goals for 4 of 4 patients (Patient 3, 4, 6, and 7) who had a revised/updated plan of care. The total sample size was 7. The census was 44. Findings are: A. Review of the agency policy and procedure titled Home Health Plan of Care, revised 12/20/22, revealed: 1. The patient's plan of care was to be revised as often as necessary, but at least every 60 days. 2. The revised/updated plan of care will include updated goals which demonstrate the patient's progress towards the outcomes and goals identified by the patient and the agency. B. Review of Patient 3's clinical record revealed: 1. The start of care was 6/15/23. 2. A revised/updated Home Health Certification and Plan of Care for the period of 8/14/23 through 10/12/23 and 10/13/23 through 12/11/23 did not include the patient's progress towards the agency and patient identified outcomes and goals. C. Review of Patient 4's clinical record revealed: 1. The start of care was 8/7/23. 2. A revised/updated Home Health Certification and Plan of Care for the period of 10/6/23 through 12/4/23 did not include the patient's progress towards the agency and patient identified outcomes and goals. D. Review of Patient 6's clinical record revealed: 1. The start of care was 9/19/22. 2. A revised/updated Home Health Certification and Plan of Care for the period of 7/16/23 through 9/13/23 and 9/14/23 through 11/12/23 did not include the patient's progress towards the agency and patient identified outcomes and goals. E. Review of Patient 7's clinical record revealed: 1. The start of care was 3/13/23. 2. A revised/updated Home Health Certification and Plan of Care for the period of 5/12/23 through 7/12/23 did not include the patient's progress towards the agency and patient identified outcomes and goals. F. During an interview on 10/19/23 at 1:00 PM, the Back-up Administrators (Staff L and M) confirmed the revised/updated plan of care for Patients 3, 4, 6, and 7 did not include the patient's progress towards the agency and patient identified outcomes and goals.

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 record review, policy and procedure review, the observation of the provision of cares, and staff interview, 3 of 3 staff (Staff C, D, and E) observed during the provision of cares to Patients 1, 2, and 3, respectively, failed to follow the agency policies and procedures for proper hand hygiene, nurse bag technique, glove use, and/or equipment care. The total sample size was 7. The census was 44. Findings are: A. Review of the policy and procedure titled Bag Technique, revised 9/18/19, revealed: 1. A barrier is to be placed between the bag and the surface in the patient's home. 2. Hand hygiene is to be completed prior to opening the bag and removing equipment. 3. Reusable equipment is to be cleaned using alcohol, soap and water, or other approved solutions prior to returning items to the bag. 4. Hand hygiene is to be completed at any time prior to entering the bag. B. Review of the agency policy and procedure titled Hand Hygiene, last revised 11/8/19, revealed: 1. Hands were to be washed with soap and water when visibly dirty, when contaminated with proteinaceous material, soiled with blood or body fluids, before eating, and after using the restroom with suspected or proven clostridium difficile (C-diff). 2. Hands must be cleansed with alcohol based hand rub, if hands are not visibly soiled, before each patient contact, before donning sterile gloves, before inserting catheter, peripheral vascular devices, prior to wound care, after routine patient care (such as taking vital signs, lifting/positioning/ambulating a patient), after contact with inanimate object (such as patient belongings, equipment), after glove removal, before touching clean supplies, and before touching hand held devices (such as computers, phones or tablets). 3. Wearing gloves does not replace the need for hand washing. 4. Gloves are to be changed with contact of blood or other potentially infectious materials, mucous membranes, non-intact skin, prior to preparing/dispensing medications, and when moving from contaminated site to clean site. 5. Barriers should be placed between items used during the home visit and surfaces in the patient's home. C. The observation of the provision of cares to Patient 1 by Staff C on 10/16/23 at 3:45 PM revealed Staff C failed to clean a gait belt used during ambulation of Patient 1 prior to leaving the patient's home with the gait belt. D. The observation of the provision of cares to Patient 2 by Staff D on 10/17/23 at 10:00 AM revealed Staff D: 1. Failed to place gloves, removed from the supply bag, onto a barrier; instead, placing the gloves on the staff member's coat. 2. Failed to close supply bag after removing items used during the visit from the supply bag; instead, left supply bag open with items sticking out through the opening. 3. Touched the tip of an ointment tube to wound gauze that had previously been placed on the patient's open wound. 4. Failed to dispose of unused gloves that had been placed on the staff member's coat; instead, the unused gloves were placed back in the supply bag. 5. Failed to clean the laptop that had been sitting on the patient's floor prior to returning the laptop to the supply bag. E. The observation of the provision of cares to Patient 3 by Staff E on 10/18/23 at 10:00 AM revealed Staff E: 1. Failed to sanitize hands after removing supplies from a box of supplies in the patient's home and prior to applying gloves to begin wound care. 2. Failed to sanitize scissors used to cut through a wound dressing on the patient's leg and prior to placing the scissors on the barrier with clean wound supplies. 3. Failed to remove gloves and sanitize hands after applying a clean dressing to a wound and prior to entering the supply bag. 4. Failed to clean a contaminated normal saline bottle prior to placing the bottle back in the wound supply box. F. During an interview on 10/18/23 at 1:15 PM, the Back-up Administrators (Staff L and M) confirmed Staff C, D, and E did not follow the agency's policies and procedures for hand hygiene, glove use, barrier use, equipment care, and/or bag technique as described in the observations documented in paragraphs C, D, and E above.