Every finding on record at Brevard Hma Home Health, LLC

During the Recertification survey from 9/7 to 9/9/21, the Home Health Agency’s Emergency Preparedness Plan was reviewed. The Home Health Agency was in compliance with 42 CFR 484, Requirements for Home Health Agencies.

A Recertification and Focused Infection Control survey were conducted from 9/7/21 to 9/9/21. Wuesthoff Health System Home Health was not in compliance with 42 CFR 484, Requirements for Home Health Agencies.

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 interview and record review, the Home Health Agency failed to enter an inaccurate dose of antibiotic, add a medication to the patient’s plan of care and reconcile the medications during each home visit for 1 of 13 patients (#7). Findings: Patient #7 was admitted to the agency on 7/27/21 with diagnoses that included sepsis due to methicillin resistant Staphylococcus aureus (MRSA), type 2 diabetes, osteomyelitis, and left foot ulcer. MRSA is an infection caused by a type of bacteria resistant to many antibiotics. Retrieved from www.healthline.com on 9/12/21. Review of the “VA (Veterans) Form 10-7080 – Approved Referral for Medical Care” dated 7/26/21 included the following information, “Home IV (intravenous) therapy as follows: Daptomycin 600 milligrams (mg) IV Q (every) daily x 6 weeks.” Review of Rockledge Regional Medical Center “Active Medical Staff” prescription form dated 7/25/21 read, “Daptomycin 600 mg IV daily x 6 weeks…” Review of the “Delivery Ticket” form from BioScript Infusion Services dated 7/27/21 showed the following among the items delivered to patient #7 on 7/27/21: 7 of Daptomycin 600 mg in NS 100 ml and 10 of Heparin 10 units/ml 5 ml. Heparin is a medication “used to keep IV catheters open and flowing freely.” Retrieved from www.webmd.com on 9/12/21. During the admission visit on 7/27/21, Registered Nurse (RN) C entered the Daptomycin Intravenous (IV) solution dose as 500 milligrams (mg) in the Outcome and Assessment Information Set (OASIS). The list of medications in the “Visit Note Report” included a pre-filled 0.9% saline with blunt plastic cannula injection syringe to be used per instructions. The visit note did not include the Heparin. Review of the “Visit Note Report” dated 7/29/21 revealed RN G documented teaching and observed return demonstration from patient #7 about the IV infusion and what to do if the infusion line did not flush properly. RN G listed 10 milliliters (ml) of normal saline (NS) before and after the infusion was used and 5 ml of Heparin to flush the line. RN G did not indicate if the 5 ml of Heparin was to be done before or after the infusion. Review of the “Visit Note Report” dated 8/2/21 indicated a blood specimen was collected from the vascular access device for a lab ordered by the physician. RN G documented the vascular access device was flushed with 10 ml of NS before and after blood was drawn and 5 ml of Heparin post blood draw. Review of the “Home Health Certification and Plan of Care” with certification period 7/27/21 to 9/24/21 read, “Skilled Nurse (SN) may obtain labs from PICC (peripherally inserted central catheter) as follows: flush PICC with 10 ml 0.9% sodium chloride, withdraw and waste 10 ml blood. Withdraw blood for specimen, and flush PICC with 10 ml 0.9% sodium chloride.” The plan of care (POC) did not include Heparin. RN C made an additional (PRN) visit on 8/3/21 after patient #7 called the agency stating he was unable to flush the vascular access device. The “Visit Note Report” indicated RN C flushed the vascular access device with 10 ml of NS with slight resistance and 5 ml of Heparin without difficulty. RN C also documented she coordinated care with her supervisor regarding the patient status and re-educated the patient and caregiver about infusion administration and care of the line. There was no documentation of communication with the physician regarding the incorrect dose of the Daptomycin or the missing Heparin in the POC and the medication list, which was being used by the patient on days there were no nursing visits and documented by nurses on their visit notes. On 9/08/21 at 4:08 PM, the Executive Director (ED), confirmed Daptomycin 500 mg in the POC was inaccurate because the physician order read 600 mg. The ED further indicated the nurses are expected to perform medication reconciliation every visit. The ED also confirmed Heparin was included in the visit notes as used by the nurses but was not included in the POC and was not listed as one of the patient’s active or discontinued medications. The ED could not explain why the nurses did not reconcile the medications during the visits and called the physician. On 9/9/21 at 4:45 PM, the ED confirmed patient #7 had a vascular access device in place at the time of admission. The ED also confirmed patient #7 had been delivered Daptomycin 600 mg, Heparin, and NS flushes when admitted to the agency. The ED did not know why the admitting RN did not include Heparin in the POC or was not added to the medications.

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 observation, interview, and record review, the home health agency failed to alert the physician to changes in the plan of care regarding physical therapy services for 1 of 13 sampled patients (#8). Findings: Patient #8’s start of care (SOC) date was 8/18/21. His diagnoses included right sided hemiplegia following a cerebral vascular accident (CVA), atherosclerotic heart disease, and history of falling. Patient #8’s orders for his initial certification period of 8/18/21 -10/16/21 included skilled nursing (SN), occupational therapy (OT), speech therapy (ST), and physical therapy (PT) services. The SOC orders for PT services read: “Physical Therapy to evaluate /assess and develop physical therapy plan of care that will be approved by the physician prior to implementation.” Continued review of patient #8’s plan of care read the following: “The patient was recently hospitalized 8/14/21-8/17/21 for onset of CVA. The patient was referred to home care…for onset of CVA. The patient’s primary focus of care is education and instruction and therapy services…Patient living situation/caregiver status: This patient lives with family in a single story home that does not have steps for entry…The patient is further considered unstable as evidenced by weakness fatigue, shortness of breath (SOB), unsteady gait, and balance. The plan of care was signed by the physician on 8/26/21. Review of the patient #8’s home visit assessments and visit notes from 8/18/21 through 9/9/21 revealed that a PT evaluation had not been done. There was not any evidence that PT services were provided. Patient #8’s addendum orders did not reveal any evidence that the physician had discontinued the PT orders. There was not any evidence that the home health agency notified the physician that PT services were not being provided. Review of the occupational therapy and speech therapy evaluations and notes beginning 8/18/21 did not mention any reason as to why PT had not assessed and developed a plan of care. Review of the team case conference note dated 8/19/21 did not reveal that PT services were not to be provided. On 9/9/21 at 3:30 PM, interview with the patient #8’s care manager acknowledged that the patient had not received PT services. She state that she would check as to why that had occurred. At 3:45 PM she stated that the patient had declined PT services. She acknowledged that there was not any documentation in the patient’s record that he had declined the PT services. The care manager indicated that it was expected to be documented. She acknowledged that the physician was not notified of the refusal and needed change to the plan of care. At 3:55 PM, the administrator stated the physician should have been notified and the plan of care revised. At 4:15 PM, a phone call was made to patient #8 in an attempt to validate whether or not he had declined PT services. There was no answer and no return call prior to the end of the survey.

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 interview and record review, the Home Health Agency failed to provide services in the plan of care for 1 of 9 patients of a total sample of 13 patients (#4). Findings: Findings: Patient #4’s record revealed he was admitted into home care services on 4/28/21. His diagnoses included coronavirus disease 2019, bacteremia, large b-cell lymphoma, and cirrhosis of the liver. Patient #4 was being seen by nursing 1 time a week for 8 weeks. The most recent certification period began on 8/26/21 to 10/24/21. The ““Home Health Certification and Plan of Care” orders included skilled nurse (SN) to perform site care for infusion access device on the right arm once a week and as needed for loose and soiled dressing. The plan of care (POC) also included a clinical summary indicating the patient’s primary focus of care was to maintain midline patent and perform weekly dressing care and the required procedure could not be performed by the patient or the caregiver due to documented lack of knowledge. Review of the “Visit Note Report” dated 9/07/21 did not contain evidence that the infusion site care was performed by the agency nurse. The question on the visit note, “Does patient have an infusion access?” was answered, “no.” The note did not include a narrative or explanation as of why the site care was not performed as ordered. Review of 2 previous “Visit Note Report”, dated 8/10/21 and 8/17/21 by the same nurse, LPN H, were answered in the exact same manner as the note dated 9/07/21. On 9/9/21 at approximately 3:50 PM, the Executive Director (ED), reviewed the visit notes and confirmed there was no documentation indicating the infusion access dressing change was performed. The ED further confirmed the documentation on the 3 visit notes from LPN H showed the patient did not have an infusion access site. The ED stated if the nurse did not document the infusion access dressing was changed on her visit note, it was not done, and the POC was not followed. The ED indicated LPN H was certified for intravenous (IV) infusions and IV site care and did not know why the infusion access dressing was not changed as ordered on any of those days.