Every finding on record at Cedar County

A Recertification Survey was conducted by the Department of Inspections, Appeals and Licensing completed on 11/2/23 through 11/8/23 and the home health agency was found to be operating in compliance with the requirements of the Establishment of Emergency Preparedness.

A recertification survey was conducted by the Department of Inspections, Appeals and Licensing from 11/2/23 through 11/8/23. The recertification survey found the agency operating out of compliance with the following standard level regulatory requirements: The home health agency reported a census of 48 patients at the time of the survey.

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 clinical record review, agency policy review and agency staff interview, the agency failed to complete a drug regimen review with each comprehensive assessment and identify patient specific medication issues for 5 of 7 sampled patients (Patients #1, #2, #3, #5 and #6). Failure to complete a drug regimen review with each comprehensive assessment placed the patient at risk for increased potential unidentified medication interactions, side effects and duplication of medications. Findings include: According to the agency policy, titled Drug Regimen Review and Medication Reconciliation, dated July 2023, all patients will have a drug regimen review completed whenever comprehensive assessments are completed. Drug regimen review will be completed and documented on patients receiving skilled care at the following times: Start of Care comprehensive assessment, subsequent comprehensive assessments at 60-day recertification, following a major decline or improvement in the patient’s health status, resumption of care, and at time of discharge. During an interview on 11/2/23 at 1:42 PM, the Clinical Manager reported drug regimen reviews are completed with comprehensive assessments at Start of Care, Resumption of Care, Recertification and Discharge assessments. The completed drug regimen review will be documented on the skilled nursing comprehensive assessment visit note. 1. Patient #3 had a start of care date of 12/16/22. Clinical record review revealed the following: a. Plan of Care, dated 12/16/22 to 2/13/23, included orders for lactulose, Clear Lax and Senexon-S (bowel meds); and ferrous gluconate, folic acid, Therems-H (multivitamin), Vitamin B1 and Vitamin D3 (vitamins). b. Start of Care comprehensive assessment visit note, dated 12/16/22, included documentation a drug regimen review had been completed and identified duplicate medications: yes. The note lacked documentation of the duplicate bowel meds and vitamins. c. Plans of Care, dated 8/13/23 to 10/11/23 and 10/12/23 to 12/10/23, included orders for bisacodyl, lactulose, Clear Lax and Senexon-S (bowel meds); acetaminophen and ibuprofen (pain meds); and ferrous gluconate, folic acid, Therems-H (multivitamin), Vitamin B1 and Vitamin D3 (vitamins). d. Recertification comprehensive assessment visit note, dated 8/8/23, included documentation a drug regimen review had been completed, identified patient demonstrated non-compliance with medications: yes and duplicate medications: yes. The note lacked documentation of the duplicate bowel meds, pain meds and vitamins, and the non-compliance patient demonstrated. e. Recertification comprehensive assessment visit note, dated 10/10/23, lacked documentation a drug regimen review had been completed. The agency failed to complete drug regimen reviews with all comprehensive assessments and completed drug regimen reviews failed to identify the duplicate medications the patient was taking and the patient’s non-compliance. 2. Patient #5 had a start of care date of 11/18/22. Clinical record review revealed the following: a. Plan of Care, dated 11/18/22 to 1/16/23, included orders for warfarin and aspirin (blood thinners) (potential interactions); ferrous sulfate, oyster shell calcium, Vitamin D3, and magnesium (vitamins), and omeprazole (potential interaction with warfarin). b. Start of Care comprehensive assessment visit note, dated 11/18/22, included documentation a drug regimen review had been completed, identified potential drug interactions: yes and duplicate medications: yes. The note lacked documentation of the duplicate vitamins and blood thinners and the potential interaction between warfarin and aspirin and omeprazole. c. Plan of Care, dated 9/14/23 to 11/12/23, included orders for warfarin and aspirin (blood thinners) (potential interactions); ferrous sulfate, oyster shell calcium, Vitamin D3, and magnesium (vitamins), and omeprazole (proton pump inhibitor for stomach acid), naproxen (nonsteroidal anti-inflammatory med) and Diflucan (antifungal med) (potential interaction with warfarin). d. Recertification comprehensive assessment visit note, dated 9/11/23, included documentation a drug regimen review had been completed and identified duplicate medications: yes and potential drug interactions: no. The note lacked documentation of the duplicate blood thinners and vitamins, and the potential drug interactions between warfarin and aspirin, omeprazole, naproxen and diflucan. The completed drug regimen reviews failed to identify the duplicate medications the patient was taking and the potential drug interactions. 3. Patient #6 had a start of care date of 4/28/23 and a discharge date of 5/25/23. Clinical record review revealed the following: a. Plan of Care, dated 4/28/23 to 6/28/23, included orders for Tylenol and ibuprofen (pain meds) and magnesium, Vitamin B12 and Vitamin D3 (vitamins). b. Start of Care comprehensive assessment visit note, dated 4/28/23, included documentation a drug regimen review had been completed and identified duplicate medications: no. The note failed to identify the duplicate vitamins and pain medications the patient was taking. c. Discharge comprehensive assessment visit note, dated 5/25/23, failed to include documentation a drug regimen review had been completed. The agency failed to complete a drug regimen review with the discharge comprehensive assessment and completed drug regimen review failed to identify the duplicate medications the patient was taking. 4. Patient #1 had a start of care date of 3/21/16. Clinical record review revealed the following: a. Plans of Care, dated 6/13/23 to 8/11/23 and 8/12/23 to 10/10/23, included orders for Colace and Imodium (bowel meds); potassium chloride and Vitamin B12 (vitamins); and Icy Hot, Salonpas lidocaine pain relieving liquid, and Tylenol (pain medications). b. Plan of Care, dated 10/11/23 to 12/9/23, included orders for Colace and Imodium (bowel meds); potassium chloride and Vitamin B12 (vitamins); and Icy Hot, Salonpas lidocaine pain relieving liquid, Tylenol, Aspercreme with lidocaine topical patch, and equate pain relief patch (pain medications). c. Recertification comprehensive assessment visit notes, dated 6/12/23, 8/7/23 and 10/9/23 included documentation a drug regimen review had been completed and identified duplicate medications: yes, telephone call to primary care physician review with review of patient condition and medications/possible duplicates for review. The note lacked documentation of the duplicate bowel meds, vitamins and pain meds. Completed drug regimen reviews failed to identify the duplicate medications the patient was taking. 5. Patient #2 had a start of care date of 5/25/22. Clinical record review revealed the following: a. Plans of Care, dated 5/20/23 to 7/18/23, 7/19/23 to 9/16/23 and 9/17/23 to 11/15/23, included orders for multivitamin, Vitamin C and Vitamin D3 (vitamins). b. Recertification comprehensive assessment visit notes, dated 5/18/23, 7/18/23 and 9/14/23, included documentation a drug regimen review had been completed and identified duplicate medications: yes. The note lacked documentation of the duplicate vitamins. Completed drug regimen reviews failed to identify the duplicate medications the patient was taking. The above stated findings were reviewed with the Administrator, Clinical Manager and Business and Quality Manager and the agency provided no additional information prior to the end of the survey.

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 clinical record review, agency policy review and agency staff interview, the agency failed to update the Plan of Care with all new physician orders for 4 of 5 sampled patients with interim physician orders. (Patients #3, #4, #5 and #7). Failure to update the Plan of Care increased the potential for medication errors in administration or inaccurate provision of care. Findings include: According to the agency policy, titled Plans of Care, dated November 2020, the plan will be revised to reflect any verbal order received during the 60-day certification period so that all agency staff are working form a current plan. the plan of care is updated to reflect all current ongoing orders including any verbal orders received during the 60-day period. During an interview on 11/2/23 at 1:42 PM, Clinical Manager, reported the updated Plan of Care is in the electronic medical record system under episode tab and then the Plan of Care section will have the plans of care listed by date. 1. Patient #1 had a start of care date of 12/16/22. Clinical record review revealed the following: a. Plans of Care, dated 6/14/23 to 8/12/23 and 8/13/23 to 10/11/23, included orders for skilled nursing services. b. Interim physician order, dated 6/27/23, for new medications: lamotrigine and risperidone and discontinue Quetiapine. c. Interim physician order, dated 7/10/23, for medication changes: bisacodyl, melatonin and finasteride. d. Interim physician order, dated 7/19/23, for medication update: increased risperidone. e. Interim physician order, dated 9/12/23, for new medication: skin, hair, nails gummy and patient has stopped taking lactulose. The clinical record lacked documentation of Plan of Care updates for the interim physician orders. 2. Patient #4 had a start of care date of 10/24/23. Clinical record review revealed the following: a. Plan of Care, dated 10/24/23 to 12/22/23, included orders for skilled nursing services. b. Interim physician order, dated 10/24/23, for laboratory bloodwork to be drawn. c. Interim physician order, dated 10/27/23, for laboratory bloodwork to be drawn. d. Interim physician order, dated 11/3/23, for patient to hold Bactrim. The clinical record lacked documentation of Plan of Care updates for the interim physician orders. 3. Patient #5 had a start of care date of 11/18/22. Clinical record review revealed the following: a. Plans of Care, dated 7/16/23 to 9/13/23 and 9/14/23 to 11/12/23, included orders for skilled nursing and home health aide services. b. Interim physician order, dated 8/23/23, for the addition of paste, powder and ointment for skin healing. c. Interim physician order, dated 10/23/23, for change in wound care. The clinical record lacked documentation of Plan of Care updates for the interim physician orders. 4. Patient #7 had a start of care date of 6/27/23 and a discharge date of 7/27/23. Clinical record review revealed the following: a. Plan of Care, dated 6/27/23 to 8/12/23 and 8/25/23, included orders for skilled nursing, home health aide services and physical therapy evaluation. b. Interim physician order, dated 6/29/23, for physical therapy services 2 times a week for 4 weeks. The clinical record lacked documentation of a Plan of Care update for the interim physician order. The above stated findings were reviewed with the Administrator, Clinical Manager and Business and Quality Manager and the agency provided no additional information prior to the end of the survey.

HH aide supervision elements CFR(s): 484.80(h)(4)(i-vi) Home health aide supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to, the following elements: (i) Following the patient's plan of care for completion of tasks assigned to a home health aide by the registered nurse or other appropriate skilled professional; (ii) Maintaining an open communication process with the patient, representative (if any), caregivers, and family; (iii) Demonstrating competency with assigned tasks; (iv) Complying with infection prevention and control policies and procedures; (v) Reporting changes in the patient's condition; and (vi) Honoring patient rights. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to ensure registered nurses supervising home health aides maintained documentation of a review of all required supervisory elements including following the patient plan of care, maintaining open communication with patient/caregiver, demonstrating competency of all assigned tasks, complying with infection prevention and control policies, reporting changes in the patient condition and honoring patient rights for 3 of 3 sampled patients receiving home health aide services (Patients #1, #5 and #7). Failure to ensure the supervision of home health aides by registered nurses maintained documentation of a review of all required supervisory elements increased the risk of agency staff not meeting the patients' personal care needs. Findings include: During an interview on 11/2/23 at 1:42 PM, the Clinical Manager reported the aide supervision is documented in the skilled nursing visit note or on a separate supervision form under the episode tab in the electronic medical record. 1. Patient #1 had a start of care date of 3/21/16. Clinical record review revealed: a. The Plans of Care, dated 8/12/23 to 10/10/23 and 10/11/23 to 12/9/23, included orders for skilled nursing and home health aide services. b. Supervision report notes, dated 8/14/23 and 9/28/23, included documentation the home health aide was supervised by the skilled nurse for the required supervisory elements. c. Skilled nursing visit notes, dated 8/28/23, 9/11/23, 9/25/23, 10/10/23 and 10/23/23, included documentation the aide followed the plan of care but lacked documentation of the elements: maintaining open communication with patient/caregiver, demonstrating competency of all assigned tasks, complying with infection prevention and control policies, reporting changes in the patient condition and honoring patient rights. The agency failed to complete home health aide supervision that included the required regulatory elements. 2. Patient #5 had a start of care date of 3/21/16. Clinical record review revealed: a. The Plan of Care, dated 9/14/23 to 11/12/23, included orders for skilled nursing and home health aide services. b. Skilled nursing visit notes, dated 9/22/23, 9/25/23, 9/28/23, 9/29/23, 10/2/23, 10/3/23, 10/6/23, 10/9/23, 10/12/23, 10/13/23, 10/16/23, 10/19/23, 10/20/23, 10/23/23, 10/27/23, 10/31/23 and 11/3/23, included documentation the aide followed the plan of care but lacked documentation of the elements: maintaining open communication with patient/caregiver, demonstrating competency of all assigned tasks, complying with infection prevention and control policies, reporting changes in the patient condition and honoring patient rights. The agency failed to complete home health aide supervision that included the required regulatory elements. 3. Patient #7 had a start of care date of 6/27/23 and a discharge date of 7/27/23. Clinical record review revealed: a. The Plan of Care, dated 6/27/23 to 8/25/23, included orders for skilled nursing, home health aide and physical therapy services. b. Supervision report notes, dated 6/30/23, included documentation the home health aide was supervised by the skilled nurse for the required supervisory elements. c. Skilled nursing visit notes, dated 7/10/23 and 7/24/23, included documentation the aide followed the plan of care but lacked documentation of the elements: maintaining open communication with patient/caregiver, demonstrating competency of all assigned tasks, complying with infection prevention and control policies, reporting changes in the patient condition and honoring patient rights. The agency failed to complete home health aide supervision that included the required regulatory elements. The above stated findings were reviewed with the Administrator, Clinical Manager and Business and Quality Manager and the agency provided no additional information prior to the end of the survey.