Every finding on record at Capital Home Health Agency Inc

The following reflects the findings of the Department of Public Health during a Recertification Survey. Representing the Department of Public Health: Surveyor ID #- 44916 RN-HFEN Surveyor ID #- RN-HFEN Unduplicated Admissions - 79 Active Patients -29 Sample Size - 7 Patients Home Visit - 3

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to ensure the emergency preparedness plan/drill for field staffs were completed in an annual basis. This failure had the potential for the staff to lack the knowledge to respond effectively during a emergency/disaster situation. Findings: During a review of the emergency preparedness plan of the HHA on 7/03/22, at 12:30 p.m., the HHA did not have documented evidence of Emergency Preparedness training/disaster drill for all field staffs. During a concurrent interview with the Executive Director and Director of Nursing on 7/3/22, at 12:30 p.m., stated they could not provide evidence of the field staffs receiving Emergency Preparedness training/disaster drill training. The HHA's policy statement titled "Emergency Preparedness Policy" dated and approved by DON on 2/22/21 indicated in the event of an office fire, life threatening emergency, or other serious situation, the offices/building may need to be evacuated. An orderly evacuation is essential. Office staff are trained in evacuation procedures. All staff are also trained in emergency preparedness.

The following reflects the findings of the Department of Public Health during a Recertification Survey. Representing the Department of Public Health: Surveyor ID #- 44916 RN-HFEN Surveyor ID #- RN-HFEN Unduplicated Admissions - 79 Active Patients -29 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) failed to maintain an accurate, and current medication profiles for two of seven patients (Patient 5 and Patient 6). This failure has the potential to result in placing the patient at risk for medication errors and adverse drug reactions. Findings: a. A review of Patient 5's Patient Profile indicated, a start of care (SOC) date of 6/10/22, with a diagnoses that included wedge compression fracture ( This fracture usually occurs in the front of the vertebra, collapsing the bone in the front of the spine and leaving the back of the same bone unchanged, which results in the vertebra taking on a wedge shape), and wound care post operative surgery. During a review of Patient 5's Plan of Care (POC), for the certification period from 6/10/22 to 8/8/22, included an order for skilled nurse (SN) to visit once a week for one week, three times a week for three weeks and and weekly at the end of the certification period. On 7/2/22, at 11:15 a.m., a home visit was conducted at Patient 5's residence with Director of Nursing (DON). Patient 5 was observed sitting on a recliner chair in the living room. Patient 5 was alert, verbally responsive, oriented to name, place, time, and person. Patient 5 used walker to ambulate. It was further observed Patient 5's medication bottles were scattered in the living room and in the kitchen. DON proceeded to perform wound care and check vital signs to Patient 5. A review of Patient 5's medication profile dated 6/10/22 indicated the following medications listed and not updated in the medication profile as follows: 1. Ativan 0.5 mg one tablet twice daily. Patient 5 stated "I refused to take that it makes me feel worse. i have not taken that since it was sent to me. " 2. Benadryl 25 mg liquigel capsule as needed was not found at Patient 5's home. 3. Calquence 100 mg capsule twice daily. Patient 5 stated " It was changed to a new medication by my oncologist last week." 4. Colace 100 mg capsule daily as needed was not found at Patient 5's home. 5. Epi-pen Auto injector 0.3 mg per 3 milliliter (ml- unit of measure for liquids) intramuscularly as needed. Patient 5 stated " I never had an Epi-pen, I don't have that." 6. Lomotil 2.5 mg tablet four times daily. Patient 5 stated "I don't take that anymore." 7. Robaxin 500 mg tablet as needed. Patient 5 stated " It was removed by my oncologist when I started my baclofen after the surgery." 8. SSD cream on wound. Patient 5 stated it was a new order. On concurrent interview with the DON, stated she reviewed Patient 5's medication every visit. DON also confirmed that she visited Patient 5 three times a week and as needed when patient notifies the agency. DON further stated that Patient 5's medication changed frequently whenever Patient 5 had blood work done. b. A review of Patient 6's "Patient Profile" indicated, a start of care (SOC) date of 6/9/20, with a diagnosis that included osteopetrosis (a rare disorder that causes bones to grow abnormally and become overly dense. When bones become overly dense, they are brittle and can fracture [break] easily), and iron deficiency anemia ( is a common type of anemia - a condition in which blood lacks adequate healthy red blood cells). During a review of Patient 6's Plan of Care (POC), for the certification period from 5/30/22 to 7/28/22, included an order for SN visit once a month for two months and as needed for change in condition and recertification visits. On 7/2/22, at 3:15 p.m., a home visit was conducted at Patient 6's residence with the DON. Patient 6 was observed lying in bed comfortably, alert and oriented to name, place, time and person. DON started to administer Patient 6's care. A review of Patient 6's medication profile dated 5/31/22 indicated the following medications listed and not updated in the medication profile as follows: 1. Ascorbic Acid 500 mg one tablet twice daily. Patient 6 stated " I don't take that anymore. It was discontinued by my infectious disease doctor" 2. Calcitonin nasal spray 1 spray daily. Patient 6 stated "It was discontinued , I don't remember when" 3. Calcium carbonate 500 mg tablet every four hours as needed. Patient 6 stated, "it is also discontinued by my primary doctor, it makes my condition worse." 4. Colace 100 mg capsule twice daily. Patient 6 stated " It is changed to as needed. " 8. Gabapentin 300 mg capsule twice daily. Patient 6 stated "I take it for my right hand at bedtime." 9. Methocarbamol 750 mg 1 tablet three times daily. Patient 6 stated " I only took that a few months and was discontinued , I wasn't feeling better, I was in bed all the time." 10. Multi-Vitamin one tablet daily with breakfast. Patient 6 stated " It was discontinued" 11. Zyrtec 10 mg daily as needed was not on medication profile. Patient 6 stated " I take that for severe allergies" 12. Epi-pen for severe food allergies not on medication profile. Patient 6 stated " I always have it in my bag when I go to my medical appointments just in case." 13. Patient 6 also stated that she goes to a naturalistic/ wholistic doctor who prescribed 12 more medications but not found on medication profile. During a concurrent interview with DON, stated she reviews medications every visit, patient calls and updates the DON on any new medication. However, during the home visit and review of Patient 6's medication revealed no documented evidence Patient 6's current medications taken were updated in the medication profile. A review of the HHA's policy and procedure titled " medication Monitoring" dated 2/22/19 approved and signed by the DON indicated the HHA professional will monitor the medications of each client for medication effectiveness and actual or potential medication-related problems. The HHA's professional will check all medications to identify possible ineffective drug therapy, adverse reactions, significant side effects, drug allergies and contraindicated medications. The HHA's professional will notify the physician promptly of any problems noted. The HHA's professional will collaborate with the physician and the pharmacist as appropriate for medication monitoring. The HHA's professional will maintain a current medication profile of the client's current medication therapy. All medications are listed on the drug profile and is maintained in the client's travel chart. A copy of the client's drug profile is placed in the medical record.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the visiting nurse failed to ensure care followed the written plan of care for one of seven sampled patients (Patient 2). The visiting nurse failed to assess Patient 2's porta-catheter central line (an implanted device which allows easy access to a patient's veins used to draw blood and give treatment, including intravenous fluids, blood transfusion, or drugs, antibiotics) on the right upper chest area as indicated in the plan of care (POC). This deficient practice has the potential risk to develop infection around the surrounding skin area of the catheter and the non-patency (obstruction) of the central line catheter will not be be mitigated promptly. Findings: A review of Patient 2's clinical record indicated the start of care date of 3/17/22, with a diagnosis of unspecified bacterial infection. A review of Patient 2's plan of care (POC) from 5/6/22 to 7/4/22, included an order for the skilled nurse (SN) to visit twice a week for 9 weeks, to perform a comprehensive skilled assessment on integumentary status (skin). Skilled nurse to assess porta catheter for patency, and sign and symptoms of infection. On 7/2/22, at 2 p.m., a home visit was conducted at Patient 2's residence with the DPCS (director of patient care services). Patient 2 was observed sitting in his chair at the family room with a porta-catheter attached on his right upper chest. No bleeding or redness noted around the skin area. A review of Patient 2's SN (skilled nurse) Visit Notes from dates 5/6/22 to 7/2/2dated 6/28/22, indicated no documented evidence the SN assessed the patient's porta catheter and skin condition around the area for sign and symptoms of infection during the visits. During an interview with the Director of Patient Care Services) on 7/3/22, at 12 p.m., stated she forgot to document her assessment on the patient's porta-catheter patency and skin condition around the area for infection. According to the agency's policy and procedure "Wound Assessment (undated)," indicated during initial and follow-up nursing visits, any non-intact skin areas shall be assessed and document, to complete measurement of the wound (length, width, depth) shall be documented at least weekly.

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 home health agency (HHA) failed to obtain orders to perform porta catheter dressing change and IV (intravenous) port flushing before and after IV administration for one out of 7 patients (Patient 2). This failure has the potential risk for infection and non-patency of the central line catheter. Findings: A review of Patient 2's clinical record indicated the start of care date of 3/17/22, with a diagnosis of unspecified bacterial infection. A review of Patient 2's plan of care (POC) from 5/6/22 to 7/4/22, included an order for the skilled nurse (SN) to visit twice a week for 9 weeks, to perform a comprehensive skilled assessment on integumentary status (skin). SN was to administer Ceftriaxone (antibiotic) 2 gm ( grams) /50 ml (milliliters) solution for IV injection daily. On 7/2/22, at 2 p.m., a home visit was conducted at Patient 2's residence with the DPCS (director of patient care services). Patient 2 was observed sitting in his chair at the family room with a porta-catheter attached to the patient's right upper chest. No bleeding or redness noted around the skin area. A review of Patient 2's SN Visit Notes from dates 5/6/22 to 7/2/2dated 6/28/22, indicated the visiting nurse cleansed the porta-catheter site with alcohol and chloro-prep, flushed the port with Normal Saline 10 cc, and Heparin 5 cc after administration of IV medication. A further review of Patient 2's clinical records indicated no documented evidence of a physician's order for porta-catheter dressing change and IV port flushing before and after administering IV medication. During an interview with the Director of Patient Care Services) on 7/3/22, at 12 p.m., stated the visiting nurse should have obtained a physician's order for porta-catheter dressing changes and port flushing of the central line.

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on observation, interview and record review , the HHA staff failed to ensure the the physician's plan of care was reviewed and or revised for 2 out of 7 sampled patients (Patient 6 Patient 7). This failure has the potential for the patients significant changes of condition and or decline of their health status will not be identified promptly that could result in the delay of further treatment to achieve the patient care goals. Findings: a. A review of Patient 6's "Patient Profile" indicated, a start of care (SOC) date of 6/9/20, with a diagnoses that included osteopetrosis (a rare disorder that causes bones to grow abnormally and become overly dense. When bones become overly dense, they are brittle and can fracture [break] easily), and iron deficiency anemia ( is a common type of anemia- a condition in which blood lacks adequate healthy red blood cells). During a review of Patient 6's Plan of Care (POC), for the certification period from 5/30/22 to 7/28/22, included an order for SN visit once a month for two months and as needed for change in condition and recertification visits. On 7/3/22 during a review of the Patient 6's case conference dated 1/30/22, 3/31/22 and 5/30/22, indicated no signatures of meeting facilitator and no check on the box provided for "physician notified of significant findings and /or POC changes. b. A review of Patient 7's "Patient Profile" indicated, a start of care (SOC) date of 6/6/2011, with a diagnoses that included intestinal malabsorption ( is a digestive disorder that prevents your body from effectively absorbing nutrients from your food), and gastrostomy tube placement (A tube inserted through the wall of the abdomen directly into the stomach. It allows air and fluid to leave the stomach and can be used to give drugs and liquids, including liquid food, to the patient). During a review of Patient 7's Plan of Care (POC), for the certification period from 6/8/22 to 8/6/22, included an order for SN visit once once a week for nine weeks and as needed for changes in condition. On 7/3/22, during a review of the Patient 7's case conference dated 2/8/22, 4/9/22, and 6/8/22, indicated no signatures of meeting facilitator and no check on the box provided for "physician notified of significant findings and /or POC changes. On 7/3/22 at 10:30 a.m., during an interview with the HHA's Director of Nursing stated "I am not fond of doing the computer part, the office staff does it for me every time we conduct our case conference." DON further stated that " if it is not checked, It is not done. " On 7/3/22 at 11:30 a.m., during an interview with the HHA's Executive Director (ED) stated " Since Covid-19 started, we have not done the 30 or 60 day summary in office." ED further stated that the case conference includes the physician, DON, skilled staff can be Licensed vocational nurse (LVN) or the home health aid (HHA) and the rehab if they have physical therapy, attends the case conference and sign the document. A review of the HHA's policy statement titled "Case Conferences" dated 1/04/04 approved by the DON, indicated case conferences will be conducted every 30 days within the patient's certification period. All disciplines are to use written documentation every 60 days and it is to be signed and dated by all disciplines involved in the case conference. the written documentation will be kept in the patient's chart.

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA) failed to provide infection control education and training for office and field staffs. This failure has the potential for the staffs' lack of knowledge to implement infection prevention and identify routes of infection transmission that could affect the patient's health status and well being. Findings: During a concurrent interview and record review on 7/3/22, at 12:30 p.m., with the Executive Director (ED) and the Director of Nursing (DON) regarding the agency's infection control education and training program for field and office staffs, both ED and DON could not provide written documentation for any education or In-service training program. ED further stated that she only calls staff and do reminders for infection control. A review of the HHA's document titled " Infection Control Program" dated 2/22/2019 indicated that surveillance activities definition of types of infection to be identified and tracked. Identification activities identification of anything in the organization that could have led to the infection's transmission. Prevention activities: establishment of policies and the monitoring of personal hygiene practices, policies and precautions to protect clients , caregivers and staff, and monitoring of appropriate cleaning and disinfecting.