Every finding on record at Carroll County Memorial Hospital

The Emergency Preparedness regulations were reviewed as part of the Medicare certification survey completed on 11/03/2021. During the survey it was determined Carroll County Memorial Hospital Home Health Care Agency is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Agencies.

A partial extended survey for Medicare certification for Carroll County Memorial Home Health Care Agency was completed on 11/03/2021. The agency had 13 current patients.

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: Based on review of the agency's current patient rights information, and interview, the agency failed to update the written notice of patient rights to be advised, orally and in writing, of the extent to which payment for services may be expected from Medicare, Medicaid, or any other Federally-funded or Federal aid program known to the HHA (home health agency). This deficient practice has the potential to adversely affect the patient's knowledge and comprehension of the rights and responsibilities of all the agency's patients. Findings included: The office coordinator provided the current, pre-printed, admit booklet for review on 11/01/2021. The agency notice of patient rights and other information given to a patient during the initial visit failed to contain written information regarding the patient's right to be advised, orally and in writing, of the extent to which payment for services may be expected from Medicare, Medicaid, or any other Federally-funded or Federal aid program known to the HHA (home health agency). The findings were reviewed with the director on 11/02/2021 at 9:15 AM. The director stated that he/she thought that the patient rights were current because the company that prints the admission booklets were to keep them up to date with the current regulations.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on review of the agency's current patient rights information, and interview, the agency failed to ensure staff provided the written notice of the updated state toll free home health telephone hotline hours of operation (7:00 AM to 8:00 PM, seven days a week) in the admission booklet. This deficient practice has the potential to adversely affect the patient's knowledge and comprehension of the rights and responsibilities of all the agency's patients. Findings included: The office coordinator provided the current, pre-printed, admit booklet for review on 11/01/2021. The agency notice of patient rights and other information given to a patient during the initial visit showed inaccurate information regarding the toll free hotline number hours of operation. The admission booklet showed the hotline hours listed as 7:00 AM to 12:00 AM, seven days a week. The findings were reviewed with the director on 11/02/2021 at 9:15 AM. The director stated that he/she thought that the patient rights were current because the company that prints the admission booklets were to keep them up to date with the current regulations.

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 agency policy review, clinical record review, home visit observation, and interview, the agency failed to complete medication reconciliations and ensure staff reviewed all of the medications the patients were currently using in order to identify any potential adverse effects, drug interactions and noncompliance with drug therapy in one (Record/Patient #4) of three home visit observations. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Medication Orders," reviewed 09/20 showed: - Policy: the agency is to educate patients on all aspects of medication management including indication, doses, route, frequency, and possible side effects to protect the home health patients from potential adverse effects of medications; -Procedure: for all patients all medications, including over the counter medications, will be reviewed by the nurse at start of care, resumption of care, and recertification to identify potential interactions, side effects, duplication, non-compliance or contraindications; and -Nurses will inquire about new or changed medications on each skilled visit. During interview on 11/03/21 at 1:50 PM, the director of the agency said they did not have a medication profile or review policy. RECORD/PATIENT #4: Review of the patients medical record showed the patient received Narcan (a prescription used for the treatment of known or suspected opioid overdose emergency with signs of breathing problems and severe sleepiness or not being able to respond) prior to being released from the hospital into care of the home health agency. Review of the plan of care (POC) dated 10/21/2021 through 12/19/2021 showed: -Diagnoses included but not limited to broken femur (long bone in leg), chronic pain, and long-term opioid use; -Medications included but not limited to: *Glipizide (helps to lower blood sugar) oral 5 milligram (mg) one tablet by mouth daily; *Benadryl (antihistamine for allergies) 25 mg one to two tablets by mouth at bedtime as needed; *NyQuil severe cold/flu 30 to 60 milliliters by mouth nightly as needed for congestion; *Norco (opiate pain medication for moderate to severe pain) 5/325 mg one tablet by mouth every six hours as needed for pain; *Morphine sulfate (opiate pain medication for moderate to severe pain) extended release 15 mg one tablet by mouth twice a day; *Baclofen (muscle relaxer) 20mg ½ tablet by mouth every eight hours; *Carbidopa-levodopa (used to treat Parkinson) 10-100 mg one tab by mouth two times a day; and *Atorvastatin calcium (lowers cholesterol) 40 mg two tablets by mouth at bedtime. Review of the agency's medication profile/active medication list left in the patient's home, dated 10/21/2021 to 12/19/2021 showed: *NyQuil severe cold/flu 30 to 60 milliliters by mouth nightly as needed for congestion; *Norco 5/325 mg one tablet by mouth every six hours as needed for pain; *Morphine sulfate extended release 15 mg one tablet by mouth twice a day; *Baclofen 20mg ½ tablet by mouth every eight hours; *Carbidopa-levodopa 10-100 mg one tab by mouth two times a day; and *Atorvastatin calcium 40 mg two tablets by mouth at bedtime. It failed show the following two medications: Glipizide oral 5 milligram (mg) one tablet by mouth daily and Benadryl 25 mg one to two tablets by mouth at bedtime as needed. Observation on 11/03/2021 at 11:30 AM showed registered nurse (RN) A handed the patient a updated medication profile that included the Glipizide oral 5 milligram (mg) one tablet by mouth daily and Benadryl 25 mg one to two tablets by mouth at bedtime as needed. During an interview on 11/03/2021 at 11:30 AM RN A said the nurse that saw the patient last saw the patient was taking Glipizide oral 5 milligram (mg) one tablet by mouth daily and Benadryl 25 mg one to two tablets by mouth at bedtime as needed and contacted the physician and this was the updated medication profile that matched the medication profile this RN had. During an interview with the patient on 11/03/2021 at 11:31 AM, the patient said he/she had taken Benadryl 25 mg one or two tablets by mouth at bedtime for over a year and he/she was not sure when he/she started taking Glipizide. Review of the bottles of medications for the patient during a home visit observation on 11/03/2021 at 11:32 AM showed: -Carbidopa-levodopa 10-100 mg one tab by mouth three times a day filled on 08/052021; and -Atorvastatin calcium 80 mg one tablet by mouth at bedtime filled on 08/05/2021. During the interview on 11/03/2021 at 11:32 AM the patients spouse said he/she wondered why the medication list read two tablets but he/she had always filled the patients planner with one tablet of Atorvastatin 80 mg not two tablets of Atorvastatin 40 mg. During an interview while reviewing the medication bottles and medications with the patient, the patient said he/she takes one Norco 5/325mg, one Morphine Sulfate extended release 15mg, and one Baclofen 20 mg ½ tablet, every morning all at the same time. He/she had taken the pain medication like this for over two years and has never had any issues. Observation on 11/03/2021 at 11:32 showed RN A told the patient about the risk of taking that much opiate medication at one time instead of alternating it and that he/she would be contacting the physician and there were risks of taking all that pain medication together in the morning. During an interview on 11/03/2021 at 11:35 AM, RN A stated: -He/she reviewed the patient’s medication on every visit but did not look at the bottles; -He/she did not know the patient was on Benadryl for over a year, or when the patient started taking Glipizide, or that the patient had been taking his/her pain medication at one time in the morning. During an interview on 11/03/2021 at 1:50 PM the director of the agency said: -He/she would expect staff to reconcile and look at medication bottles with reconciliation of all medications; -He/she expected the patient’s medications to be accurate.

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 policy review, record review, and interview, the agency failed to ensure that the patients received the home health services that were written on the individualized POC (plan of care) when the patients did not receive visits according to the visit frequency ordered on the POC in, but not limited to, one (Record/Patient #2) of five full record reviews completed. This deficient practice has the potential to adversely affect the ordered care provided to all the agency’s patients. Findings included: Review of the agency’s policy titled “Plan of Care,” revision dates 08/17, 01/21 showed, in part: - Services are provided to patients only under a physician’s plan of treatment; - The individualized POC must include, in part, the frequency and duration of visits to be made; and - All patient care orders, including verbal orders, must be recorded in the POC. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to the agency on 08/27/2021 with hemiplegia (paralysis of one side of the body) following cerebral infarct (also known as a stroke) affecting left non dominant side. Review of the plan of care dated 08/27/2021 through 10/25/2021 showed: - SN (skilled nursing) visits ordered 1 time a week for 1 week, then 2 times a week for 4 weeks; - PT (physical therapy) visits ordered 2 times a week for 4 weeks beginning week of 08/30/2021; and - OT (occupational therapy) visits ordered: 1 time a week for 1 week beginning week of 08/30/2021, then 2 times a week for 3 weeks. Further review of the clinical record showed: - SN only made 1 visit week 2 and week 5; - PT only made 1 visit week 2 and week 4; - OT only made 1 visit week 3 and week 4; and - No physician communication or physician order regarding any of the missed visits. During interviews with the Director on 11/03/2021 at 09:10 AM and 1:50 PM he/she stated that: - The agency does not usually notify the doctor of missed visits unless they are frequently missed; and - He/she would expect staff to follow physician orders.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on home visit observation, and interview, the agency failed to ensure staff provided a written visit schedule to patients that included what discipline was visiting, when the discipline would visit, and the frequency of visits in two (Record/Patient #4, and #5) of three home visits. This deficient practice has the potential to affect all patients served by the agency. RECORD/PATIENT #4: During a home visit observation on 11/03/2021 at 11:00 AM, the surveyor requested to review the patient’s home folder. The patient’s home folder showed: - The home folder failed to contain any written schedule or frequency for any of the disciplines ordered to see the patient; and - A blank dry erase calendar in the home folder (never used) to be used to record discipline visits for the patients. During an interview on the 11/03/2021 at 11:30 AM the patient said the agency normally just called to tell him/her when they would be at the home to make the visit. He/she did not have a calendar that showed which entity would be making visits or what day/date they would be making their visit. RECORD/PATIENT #5: During a home visit observation on 11/02/2021 at 10:50 AM, the surveyor requested to review the patient’s home folder. The patient’s home folder showed: - The home folder failed to contain any written schedule or frequency for any of the disciplines ordered to see the patient; and - A blank dry erase calendar in the home folder (never used) to be used to record discipline visits for the patients. During an interview on 11/02/2021 at 11:15 AM, LPN A said he/she would call the patient to schedule appointments to see the patients. They did not leave a calendar with all entities schedule for the patient. During an interview on 09/22/2021 at 12:15 PM, the director said they had white wipe board calendars he/she expected staff to utilize for the patients home calendars.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to provide evidence that a completed comprehensive discharge summary was sent to the primary care physician after discharge from the agency's services within five business days of the patient's discharge in one (RECORD/PATIENT#3) of two discharge records reviewed. This deficient practice has the potential to adversely affect the post discharge care of all patients served by the agency. Review of the policy, "Patient Transfer/Discharge," revision dates of 05/17, 09/20 showed, in part: When a patient is scheduled for discharge a completed discharge summary will be sent to the primary care practitioner or other healthcare professional who will be responsible for providing care and services to the patient after discharge from the home health agency (if any) within 5 business days of the patient's discharge. RECORD/PATIENT #3 Review of the clinical record showed that the patient was admitted to the home health agency on 06/19/2021 with a diagnosis of aftercare following total joint (right knee) replacement (a surgery to replace a knee joint with a man-made artificial joint) with orders for skilled nursing, physical therapy and occupational therapy. The patient was discharged from occupational therapy on 07/09/2021 and was discharged from skilled nursing and physical therapy on 07/15/2021. Further review of the clinical record showed, in part: - A fax cover sheet to the primary physician dated 07/16/2021 with 11 pages including the cover page followed by; - A six page completed discharge summary from skilled nursing dated by the nurse 07/15/2021 and; - A four page completed discharge summary from physical therapy dated by the physical therapist 07/15/2021; - A medication list failed to be included in the eleven pages; and - The completed occupational therapy discharge summary dated 07/09/2021 failed to be sent to the primary care physician. During interviews with the administrator on 11/02/2021 at 9:15 AM and 11/03/2021 at 10:05 AM he/she stated that medication lists are included and sent with the discharge summary and that the OT (occupational therapist) discharge summary was never sent to the primary care physician due to the task that was selected in the EMR (electronic medical record) by the OT completing the discharge summary. He/she stated that this issue had previously been noted and the OT was educated, on Friday 10/29/2021, about which task to select.