Every finding on record at Chelsea Health Care LLC

SUBSTANTIAL ALLEGATION SURVEY SUBSTANTIAL ALLEGATION OH00121084 The following deficiency is based upon substantial allegation OH00121084 completed on 04/07/21. Chelsea Health Care LLC, 369090, is not in compliance with the requirements found at 42 CFR Part 484, Subpart B, C for Home Health Agencies.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on medical record review, review of facility incident report, and staff interview, the agency failed to ensure the skilled nurse communicated the patient's medication needs to the physician in a timely manner in order to prevent missed doses. This affected one (#1) of three medical records reviewed. The facility census was 55. Findings include: A review of Patient #1's medical record for the certification period of 01/26/21 to 03/26/21 revealed a start of care date as 11/27/20. The primary diagnosis was type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene. Other diagnoses listed included cerebral infarction, chronic obstructive pulmonary disease, repeated falls, bipolar disorder, and major depressive disorder. The skilled nurse was to provide two visits daily, morning and afternoon. A review of the Patient #1's Service Plan #759788 under the Ohio Home Care Program revealed a goal for medication which described in the narrative that the nurse will secure medication and set up daily doses for the patient to help her take medication as prescribed by the physician. The nurse will help reorder prescriptions, arrange to get prescriptions from pharmacy, secure medication and administer medications daily. The nurse is also to keep a count of all the medications. Review of a visit note dated 03/26/21 at 7:03 AM documented a 60 day summary which notes the following in part: Patient had been compliant with medication but ran out of her medications last Sunday when the daughter canceled scheduled appointment the second time last Thursday. Doctor was contacted on Monday morning and they said they need to see her to order any refills. The pharmacy was contacted on the same Monday and they refilled medications that lasted her for three days. She saw the doctor on Thursday and all medications were refilled. Case manager aware of the incident on Monday. Patient and caregiver educated to be compliant with medication to prevent re-occurrence of such an incident to run out. A review of an agency incident report dated 03/22/21, documented by Staff C and reviewed by staff B, the Director of Nursing (DON), revealed Patient #1 ran out of some medications due to her daughter rescheduling Patient #1's doctor's appointment. The report indicated this occurred twice and Staff C had called previously to request Patient #1 be provided a few medications in order keep her supply going until her scheduled appointment. On the back of the incident report form in the administrative comments box, the DON noted the doctor ordered new medications and Patient #1 received them the evening of 03/22/21. A new appointment date was set for Patient #1 to visit the doctor. Interview on 04/06/21 at 9:08 AM, Staff A stated on 3/22/2021 in the evening, the pharmacy refilled all missing medication including psychotropic medication. The patient went to the doctor on 03/25/21 and her medication was refilled. The physician insisted the patient must come for an appointment before he could fill any more medications. An addendum to the agency's incident report dated 03/22/21 was received on 04/06/21 at 9:32 AM. There was additional clarification to the dates of when Patient #1 ran out of medications and when the doctor's appointments were scheduled and changed. The addendum, documented by Staff C, noted Patient #1's daughter changed the doctor's appointment date from 03/18/21 to 03/23/21, then again to 03/25/21. This caused Patient #1 to run out of medications on 03/22/21. Staff C called the doctor and a script was sent to the pharmacy that same day, which supplied Patient #1 with enough medications to last until the appointment on 03/25/21. Patient #1 was able to obtain her medications for the evening dose but did miss the 03/22/21 afternoon dose. According to the agency's incident report Staff C was aware that Patient #1's daughter changed Patient #1's doctor's appointment from 03/18/21 to 03/23/21 and Patient #1 ran out of medications on 03/22/21. According to Patient #1's Service Plan #759788 under the Ohio Home Care Program Staff C, among other responsibilities, was to keep count of the medications and when Staff C was aware that Patient #1's appointment had been changed to a later date, a call should have been placed to the doctor at that time to have the medications supplied so that Patient #1 would not have missed the afternoon dose on 03/22/21. Additional interview with Staff A at 9:07 AM on 04/05/21 revealed Patient#1's daughter was supposed to take Patient #1 to the physician who oversees her psychotropic medications, but she canceled the appointment because she had to work. The appointment was rescheduled and canceled the second time by the daughter. Staff A stated Patient #1 cannot get any refills on her psychotropic medications without seeing the doctor and the nurse could not ensure those medications without cooperation from the daughter to take Patient #1 to her appointment. Staff A stated Staff C did forget to contact the doctor to have the regular medications ordered but also called the doctor on 03/22/21 to ensue Patient #1 had her medications that evening. This finding substantiates Substantial Allegation OH00121084.

EMERGENCY PREPAREDNESS SURVEY The following deficiency is based on the emergency preparedness survey completed 03/18/21.

Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This STANDARD is not met as evidenced by: Based on interview and document review, the facility failed to ensure emergency preparedness policies addressed patient mobility. This had the potential to affect all patients receiving services from the agency. The agency's census was 83 patients. Findings include: A review of the agency's emergency preparedness plan was completed on 03/18/21. The review revealed the patients were triaged into four categories: category one was the highest indicating a high probability of hospital admission if home care was not provided, and category four being the lowest. The review did not reveal how patient mobility affected the patients' placement into the triage categories. On 03/18/21 at 11:34 AM in an interview, Staff A confirmed patient mobility was not taken into account when assigning the patients into a triage category.

Partial Extended Recertification Survey COVID 19 Focused Infection Control Survey The following deficiency is based on the partial extended recertification survey completed 03/18/21. Chelsea Health Care, LLC 369090, is not in compliance with the requirements found at 42 CFR Part 484, Subpart B, C for Home Health Agencies. At the time of the partial extended recertification survey, a COVID 19 Focused Infection Control Survey was also completed with no deficiencies.

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 interview and medical record review, the facility failed to ensure treatments were administered only as ordered by the physician or allowed practitioner for two of seven patients reviewed (Patient #3 and #2). The agency's census was 83 patients. Findings include: 1. The medical record review for Patient #3 was completed on 03/18/21. The patient's care began with the agency on 08/03/16. Review of the physician ordered plan of care for the certification period beginning 01/09/21 revaled the patient was diagnosed with neuromuscular dysfunction of the bladder, neurogenic bowel, quadriplegia, and injury at unspecified level of cervical spinal cord. The patient was to receive daily skilled nursing visits where the nurse would irrigate the suprapubic catheter with 30 cubic centimeters (cc) of normal saline on Sunday, Monday, Wednesday, Friday and Saturday, and to irrigate it with acetic acid on Tuesday and Thursday. The medical record review revealed from 02/01/21 to 03/13/21 (with the exception of 02/04/21 and 02/24/21) the skilled nurse visit notes stated the supra pubic catheter was "patent and flushes without difficulty." The notes did not state what was used to irrigate it and with how much. The medical record review revealed a skilled nurse visit note for 03/08/21 that stated, "Started on Macrobd (sic) (an antibiotic) one capsule by mouth every 12 hours for 10 days for urinary tract infection." On 03/18/21 at 11:25 AM in an interview, Staff N was unable to show what was used to irrigate the catheter and with how much. She said there was a quality assurance nurse who should be validating the charting to ensure what was ordered was done. 2. The medical record review for Patient #2 was completed on 03/18/21. The physician ordered plan of care for the certification period beginning 01/24/21 revealed the patient was diagnosed with a stage 3 pressure ulcer to the left heel, osteomyelitis, hypertension, type two diabetes mellitus, and end stage renal disease. The patient was to receive two skilled nursing visits a week where the nurse would irrigate the left heel with normal saline, apply silver alginate (absorbent dressing used to provide a moist environment for healing), and then apply kerlix roll. The medical record review revealed the patient went to a wound clinic on 02/08/21. A review of the wound clinic note of that day revealed orders to cleanse the heel with soap and water, apply saline-moist prisma (dressing used to maintain a moist environment for wound healing), and then an allevyn border dressing (used for sensitive skin) and "note-there is a change here." The medical record review revealed skilled nursing visit notes for 02/14/21 and 02/17/21 that stated the wound was cleansed with dakin's solution (diluted bleach solutions used to kill bacteria), patted dry, and silver alginate dressing with kerlix applied. The medical record review revealed the patient returned to the wound clinic on 02/22/21. The review revealed the wound was continued to be cleansed with soap and water, apply saline moist prisma, and then an allevyn border dressing. The medical record review revealed a skilled nurse visit note dated 02/28/21 that stated the wound was cleansed with dakin's solution, patted dry, and silver alginate dressing with kerlix applied. On 03/17/21 at 2:27 PM in an interview, Staff N confirmed the staff was not cleaning the wound with soap and water. She said she spoke with the nurse who said he was using normal saline and that he did not know he was charting "dakin's". On 03/18/21 at 11:23 AM in an interview, Staff A stated some fields in the skilled nurse visit notes were prepopulated and needed changed at each visit and was concerned that was causing the continued charting of dakin's solution.

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 interview and medical record review, the facility failed to ensure the relevant physician or allowed practitioner was notified of changes in the patient's condition that suggested that outcomes were not being achieved and/or that the plan of care should be altered for one of seven patients reviewed (Patient #1). The agency's census was 83 patients. Findings include: The medical record review for Patient #1 was completed on 03/18/21. The medical record review revealed the patient's care began with the agency on 08/30/19. The physician ordered plan of care for the certification period beginning 02/26/2020 revealed the patient was diagnosed with type two diabetes mellitus, congestive heart failure, obesity, chronic obstructive pulmonary disease and polyarthritis. The patient was to receive skilled nursing visits once a week. The patient was on three blood pressure medications: amlodipine (used to treat high blood pressure and chest pain), lisinopril (used to treat high blood pressure and heart failure), and coreg (used to treat high blood pressure and heart failure). Review of the skilled nursing visit note for 03/24/2020 revealed the patient's blood pressure was 99/54 (low blood pressure would be lower than 90 millimeters of mercury (mm Hg) for the top number (systolic) or 60 mm Hg for the bottom number (diastolic)) with a pulse of 67 beats per minute. The note said the physician was called. The medical record review revealed a verbal order dated 03/24/2020 at 2:30 PM that stated to hold the coreg and amlodipine until the systolic blood pressure returns to 140s, to increase skilled nursing visits to twice a week to monitor blood pressure and patient response to changes in blood pressure medications, and to report to the physician. There was no change to the lisinopril order. The medical record review revealed a skilled nursing visit note for 04/03/2020 that stated the blood pressure medications continued to be held for a blood pressure of 99/53. The medical record review revealed a skilled nursing visit note for 04/11/2020 that stated the patient's blood pressure was 91/56 with a pulse of 67 beats per minute. The note stated, "Discussed sending patient to the emergency room. Patient and daughter refused." The review did not reveal where the physician was notified of the low blood pressure or patient presentation. The medical record review revealed a skilled nursing visit note for 04/15/2020 that stated the patient's blood pressure was 79/45 with a pulse of 86 beats per minute. The note stated the patient's blood pressure remained low and recorded at 79/45 after "multiple attempts" and the nurse called 911. The note said the nurse left the residence while the patient was still in the care of the emergency medical services. The note did not reveal that the physician was notified. On 04/10/21 at 2:00 PM in an interview, Staff N confirmed there was no evidence the physician was notified of the patient's continued low blood pressure or patient's presentation on 04/11/2020 or 04/15/2020.