Every finding on record at Cass County Home Health Agency

The Emergency Preparedness requirements were evaluated in conjunction with the recertification survey on 12/3/2021. The Home Health Agency was in compliance with the Standards for Establishment of the Emergency Program, 42 CFR 484.22, for this survey.

A recertification survey was conducted in conjunction with an Emergency Preparedness survey on 11/30/21 through 12/3/21. The Agency was in compliance with the requirements Emergency Preparedness, for this survey. The Agency was not in compliance with the Standards, 42 CFR 484, for Home Health Agencies, as evidenced by: Abbreviations: E- Employee mg- milligram NS- Normal Saline PICC- Peripherally Inserted Central Catheter POC- Plan of Care Pt- Patient SN- Skilled Nurse SOC- Start of Care

Written notice within 4 business days CFR(s): 484.50(a)(4) Provide written notice of the patient's rights and responsibilities under this rule and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section to a patient-selected representative within 4 business days of the initial evaluation visit. This ELEMENT is not met as evidenced by: Based on document review and interview, it was determined in 10 of 10 (Pt #1, Pt #2, Pt #3, Pt #4, Pt #5, Pt #6, Pt #7, Pt #8, Pt #9, Pt #10) patients records reviewed, the Agency failed to ensure the transfer and discharge policies were provided to the patient and/or patient's caregiver. This has the potential to affect all patients who receive Home Health services, with a current census of 39 patients. Findings include: 1. The admission folder was reviewed on 11/30/21 at approximately 9:45 AM. The admission folder lacked documentation of a transfer or discharge policy. 2. Pt #1 Start of Care (SOC): 10/27/21 Diagnosis: Aftercare Surgery of Digestive System. During a home visit on 12/1/21 at approximately 10:30 AM, Pt #1's admission folder was observed to lack documentation of a transfer or discharge policy. During the home visit, an interview was conducted. Pt #1 stated "If I got one (transfer and/or discharge policy), it would be in the folder." 3. Pt #2 SOC: 4/10/17 Diagnosis: Fitting and Adjustment of Urinary Device. During a home visit on 12/1/21 at approximately 9:00 AM, Pt #2's admission folder was observed to lack documentation of a transfer or discharge policy. Pt #2 stated "I don't know if there was one (transfer and/or discharge policy). I don't remember anything like that but it was along time ago." 4. The following records were reviewed throughout the survey on 11/30/21 to 12/3/21 and lacked documentation a transfer or discharge policy was provided to the patient and/or patients caregiver: a) Pt #1, SOC: 10/27/21; b) Pt #2, SOC: 4/10/17; c) Pt #3, SOC: 11/16/21 d) Pt #4, SOC: 8/22/21 e) Pt #5, SOC: 10/28/21 f) Pt #6, SOC: 6/3/21 g) Pt #7, SOC: 12/21/17; h) Pt #8, SOC: 12/3/20; i) Pt #9, SOC: 7/28/21 j) Pt #10, SOC: 8/16/21. 5. During an interview on 12/2/21 at approximately 2:00 PM, the Assistant Home Health Director (E#1) verbally agreed the transfer and discharge policies were not included in the admission folder nor provided to the patient and/or patient caregiver and should have been.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on document review and interview, it was determined for 1 of 1 (Pt #1) home visits conducted for wound care, the Agency failed to obtain consent for photography. This has the potential to affect all patients who receive care by the Agency with a current census of 39 patients. Findings include: 1. Pt #1 Start of Care (SOC): 10/27/21 Diagnosis: Aftercare Surgery Digestive System. The record was reviewed on 11/30/21 at approximately 2:30 PM. The record lacked documentation that a consent for photography was obtained. 2. During a home visit on 12/1/21 at approximately 10:30 AM an interview was conducted with the Registered Nurse (E#2). E#2 stated to the patient during the dressing change that the wound "looks so much better... showed me pictures of what it (wound) looked like when you started." E#2 stated the photos are taken on the Agency's phone which is secured although the photos cannot be transferred and stored into the electronic medical record. E#2 stated "We just use them (photos) to show each other (nurses) the progress or orientation or help explain the dressing change if someone else (nurse) is going to go see the patient." 3. During an interview on 12/1/21 at approximately 1:00 PM, the Assistant Home Service Director (E#1) stated the consent for photography was included in the Admission Consent. E#1 reviewed the Admission Consent and verbally agreed the consent for photography was not included and should have been.

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 document review and interview, it was determined for 4 of 4 (Pt #1, Pt #2) patients records reviewed, the Agency failed to ensure the patient and/or patients caregiver was advised in writing the extent of payment from Medicare or covered charges for services. This has the potential to affect all patients who receive services by the Agency with a current census of 39 patients. Findings include: 1. During a home visit on 12/1/21 at approximately 10:30 AM, Pt #1's admission folder lacked documentation of the extent of payment from Medicare and/or the covered charges for services. 2. During an interview after the Home Visit on 12/1/21 at approximately 11:10 AM, E#2 (Pt #1's Registered Nurse) stated "We only fill out a form if services are not covered." 3. During an interview on 12/2/21 at approximately 2:00 PM, the Assistant Home Services Director (E#1) stated "We accept Medicare assignment, therefore the patients don't have to pay for services.

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on document review and interview, it was determined for 2 of 10 (Pt #2, Pt #8) patients records reviewed, the Agency failed to ensure the patient and/or patients caregiver received written notice of services provided. This has the potential to affect all patients who receive services by the Agency with a current census of 39 patients. Findings include: 1. Pt #2 Start of Care (SOC): 4/10/17 Diagnosis: Fitting and Adjustment of Urinary Device. During a home visit on 12/1/21 at approximately 9:00 AM, the Certified Nurses Aide (E#3) was observed to provide care to Pt #2. The admission folder was reviewed during the home visit and lacked documentation of a consent for treatment, services received and/or expected payment for services. E#3 stated Pt #2's insurance didn't cover Home Health Aide service and aide services were self-pay. 2. Pt #2 SOC: 4/10/17 Diagnosis: Fitting and Adjustment of Urinary Device. The record was reviewed on 11/30/21 at approximately 11:30 AM. The Admission Consent dated 4/10/17 noted "Proposed Services" with the Nursing and Home Care Aide checked as services to be received. The "Community Healthcare Program (Private Pay Clients)" dated 7/5/17 noted a sliding fee scale. 3. Pt #8 SOC: 12/3/20 Diagnosis: Chronic Obstructive Disease. The record was reviewed on 12/1/21 at approximately 2:30 PM. The Admission Consent dated 12/3/21 noted "Proposed Services" with the Nursing and Home Care Aide checked as services to be received. The record lacked documentation Home Care Aide services were received from admission to discharge on 9/13/21. 4. During an interview on 12/1/21 at approximately 11:05 AM, the Registered Nurse (E#3) stated admission consent forms were not left in the home. E#3 stated the patient's were only provided written documentation if services were discontinued. 5. During an interview on 12/3/21 at approximately 9:45 AM, the Assistant Home Services Director (E#1) verbally agreed a copy of the Admission Consent form was not left in the home, therefore the patient's did not receive a written notice of services provided and should have been.

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 document review and interview, it was determined in 2 of 10 (Pt#5 and Pt #9) patients records reviewed, the Agency failed to ensure staff provided care as indicated on the physician orders. This has the potential to affect all patients serviced by the Agency with a current census of 39 patients. Findings include: 1. The "Lippincott Nursing Procedures (seventh edition)" was reviewed 12/3/21 at approximately 10:55 AM. The Procedure titled "Peripherally Inserted Central Catheter (PICC) Use" noted "...performing a PICC dressing change...Use a sterile tape to measure the external length of the catheter from hub to skin entry..." 2. Pt #5 SOC (Start of Care): 10/28/21 Diagnoses: Acute Osteomyelitis and Type II Diabetes. The record was reviewed on 12/2/21 at approximately 11:45 AM. The Plan of Care (POC) dated 10/28/21 noted SN: perform wound care/ dressing change: cleanse wound to left foot with normal saline (NS). Apply Xeroform to area, cover with 4X 4 gauze and wrap with kerlex and ace wrap. Dressing to be changed daily. The Skilled Nurse (SN) visit note dated 11/2/21 lacked wound care. 3. Pt. #9 SOC: 7/28/21 Diagnosis: Infection Reaction Due to Internal Right Knee Prosthesis. The record was reviewed on 12/2/21 at approximately 10:30 AM. The POC dated 7/28/21 noted SN: change central venous dressing weekly. 4 of the 7 weekly SN visit notes lacked PICC line measurements were conducted with the dressing change. The SN visit note dated 8/30/21 lacked PICC line dressing change and measurements. 4. During an interview on 12/2/21 at approximately 1:15 PM with the Assistant Home Service Director (E#1) and the Administrator (E#4). E#1 and E#4 verbally confirmed the lack of wound care for Pt. #5. 5. During an interview on 12/2/21 at approximately 1:15 PM with the Assistant Home Service Director (E#1) and the Administrator (E#4). E#1 and E#4 verbally confirmed the lack of PICC line measurements and dressing change Pt. #9. An interview with E#1 on 12/3/21 at approximately 10:40 AM, E#1 stated "the Agency follows Lippincott procedures for PICC line care"

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 document review and interview, it was determined for 3 of 3 (Pt #1, Pt #2, Pt #4) home visits conducted, the Agency failed to provide a written copy of the visit schedule and frequency of visits. This has the potential to affect all patients who receive care by the Agency with a current census of 39 patients. Findings include: 1. Pt #1 Start of Care (SOC): 10/27/21 Diagnosis: Aftercare Surgery Digestive System. During a home visit on 12/1/21 at approximately 10:30 AM, Pt #1's Admission Folder was reviewed. The admission folder lacked a written copy of the visit schedule and frequency of visits. 2. Pt #2 SOC: 4/10/17 Diagnosis: Fitting and Adjustment of Urinary Device. During a home visit on 12/1/21 at approximately 9:00 AM, Pt #2's Admission Folder was reviewed. The admission folder lacked a written copy of the visit schedule and frequency of visits. 3. Pt #4 SOC: 8/11/20 Diagnosis: Vitamin B Deficiency. During a home visit on 12/2/21 at approximately 8:30 AM, Pt #4's Admission Folder was reviewed. The admission folder lacked a written copy of the visit schedule and frequency of visits. 4. During an interview on 12/3/21 at approximately 9:45 AM, the Assistant Home Services Director (E#1) and the Administrator (E#4) verbally agreed the admission folders lacked a written copy of the visit schedule and frequency of visits and a copy should have been provided.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on document review and interview, it was determined for 3 of 4 (Pt #1, Pt #2, Pt #4) home visits conducted, the Agency failed to complete and update the Medication Logs in the home. This has the potential to affect all patients who receive care by the Agency with a current census of 39 patients. Findings include: 1. The policy titled "22.4. Medication Profile... Patients receiving medications during the duration of their home care services... will have a current, accurate medication profile... in the patients home... When a change in medication is made the Home Health Nurse will be responsible for updating the patient's home "Medication Profile" to reflect the change." 2. The Admission Folder was reviewed on 11/30/21 at approximately 10:00 AM. The folder contained a Medication Log to document Date, Medication Name, Dose, How Many or How Much or How Often, Route, Purpose of the Medication and key for route abbreviations. 3. Pt #1 Start of Care (SOC): 10/27/21 Diagnosis: Aftercare Surgery Digestive System. During a home visit on 12/1/21 at approximately 10:30 AM, Pt #1's Admission Folder's Medication Log dated 10/26/21 was reviewed. The home Medication Log lacked documentation of the route and purpose of all medications listed. The Medication Profile (from the electronic medical record) dated 11/30/21 was compared with the home Medication Log. The home Medication Log noted Acetaminophen 1000 mg (milligrams) and the Medication Profile noted Acetaminophen 500 mg and lacked documentation of Protonix. 4. Pt #2 SOC: 4/10/17 Diagnosis: Fitting and Adjustment of Urinary Device. During a home visit on 12/1/21 at approximately 9:00 AM, Pt #2's Admission Folder's Medication Log dated 4/10/17 was reviewed. The home Medication Log lacked documentation of the route and purpose of all medications listed. The Medication Profile (from the electronic medical record) dated 11/30/21 was compared with the home Medication Log. The following medications were not listed on the home Medication Log: a) Celebrex b) Celexa (wrong dose) c) Gentamycin Sulfate d) Lasix e) Nystatin f) Oxybutynin g) Silvadene h) Normal Saline Flush 5. Pt #4 SOC: 811/20 Diagnosis: Vitamin B Deficiency. During a home visit on 12/2/21 at approximately 8:30 AM, Pt #4's Admission Folder lacked a Medication Log dated. The Medication Profile dated 12/1/21 noted Biotin and Vraylar as active medications. During the home visit, Pt #4's caregiver stated "He/she hasn't been on those medications for years." 6. During an interview on 12/3/21 at approximately 9:45 AM, the Assistant Home Services Director (E#1) and the Administrator (E#4) verbally agreed the home Medication Logs lacked documentation of the route and purpose of the medications and had not been updated with current medications and should have been.

Treatments and therapy services CFR(s): 484.60(e)(3) Any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services. This ELEMENT is not met as evidenced by: Based on document review and interview, it was determined for 3 of 4 (Pt #1, Pt #2, Pt #4) home visits conducted, the Agency failed to provide the patient and/or patient's caregiver a written copy of the treatments to be administered by the Agency personnel. This has the potential to affect all patients who receive care by the Agency with a current census of 39 patients. Findings include: 1. Pt #1 Start of Care (SOC): 10/27/21 Diagnosis: Aftercare Surgery Digestive System. During a home visit on 12/1/21 at approximately 10:30 AM, Pt #1's Admission Folder was reviewed. The admission folder lacked a written copy of the treatments to be administered by the Agency personnel. 2. Pt #2 SOC: 4/10/17 Diagnosis: Fitting and Adjustment of Urinary Device. During a home visit on 12/1/21 at approximately 9:00 AM, Pt #2's Admission Folder was reviewed. The admission folder lacked a written copy of the treatments to be administered by the Agency personnel. 3. Pt #4 SOC: 8/11/20 Diagnosis: Vitamin B Deficiency. During a home visit on 12/2/21 at approximately 8:30 AM, Pt #4's Admission Folder was reviewed. The admission folder lacked a written copy of the treatments to be administered by the Agency personnel. 4. During an interview on 12/3/21 at approximately 9:45 AM, the Assistant Home Services Director (E#1) and the Administrator (E#4) verbally agreed the admission folder lacked a written copy of the treatments to be administered by the Agency personnel and a copy should have been provided.

Other pertinent instructions CFR(s): 484.60(e)(4) Any other pertinent instruction related to the patient's care and treatments that the HHA will provide, specific to the patient's care needs. This ELEMENT is not met as evidenced by: Based on document review and interview, it was determined for 3 of 4 (Pt #1, Pt #2, Pt #4) home visits conducted, the Agency failed to provide the patient and/or patient's caregiver a written copy of pertinent instructions related to the patient's care needs. This has the potential to affect all patients who receive care by the Agency with a current census of 39 patients. Findings include: 1. Pt #1 Start of Care (SOC): 10/27/21 Diagnosis: Aftercare Surgery Digestive System. During a home visit on 12/1/21 at approximately 10:30 AM, Pt #1's Admission Folder was reviewed. The admission folder lacked a written copy of pertinent instructions related to the patient's care needs. 2. Pt #2 SOC: 4/10/17 Diagnosis: Fitting and Adjustment of Urinary Device. During a home visit on 12/1/21 at approximately 9:00 AM, Pt #2's Admission Folder was reviewed. The admission folder lacked a written copy of pertinent instructions related to the patient's care needs. 3. Pt #4 SOC: 8/11/20 Diagnosis: Vitamin B Deficiency. During a home visit on 12/2/21 at approximately 8:30 AM, Pt #4's Admission Folder was reviewed. The admission folder lacked a written copy of pertinent instructions related to the patient's care needs. 4. During an interview on 12/3/21 at approximately 9:45 AM, the Assistant Home Services Director (E#1) and the Administrator (E#4) verbally agreed the admission folder lacked a written copy of pertinent instructions related to the patient's care needs and a copy should have been provided.