Every finding on record at Community Nurses Home Health and Hospice Inc

Based on the findings of an onsite unannounced Medicare recertification and state relicensure survey completed 5/9/2025, Penn Highlands Community Nurses was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies – Emergency Preparedness.

Based on the findings of an onsite unannounced Medicare recertification and state relicensure survey completed 5/9/2025, Penn Highlands Community Nurses was found not to be in compliance with the following requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

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 review of agency policy, medical records (MR) and staff (EMP) interviews, the agency failed to maintain an accurate medication profile and to ensure review of potential adverse effects for one (1) of fourteen (17) medical records reviewed (MR17). Findings included: Review of the agency policy and procedures was conducted on 5/19/2025 at approximately 11:00 AM revealed, Policy “Medication Reconciliation…PURPOSE To define the medication reconciliation process…PROCEDURE 1. At time of admission, the admitting RN, PT, or SLP will create and document a complete list of medications that patient is taking at home, including dose, strength, route, and frequency. *Any discrepancies will be reconciled by a RN with the patient’s physician. *Discrepancies include duplications, omissions, changes, contraindications and/or unclear information. *(Agency) provides the patient and/or caregiver with written patient medication schedule/instructions, including medication name, dose, strength, route and frequency as well as which medications will be administered…” Review of (OBV2 MR17) was conducted on 5/16/2025 at approximately 3:02 PM revealed, "HOME HEALTH CERTIFICATION AND PLAN OF CARE" with a start of care date of 4/14/2025 and a current certification period starting 4/14/2025 to 6/12/2025. The primary diagnosis was critical illness myopathy. The home health certification and plan of care was compared to the facility document “Physician’s Orders.” The home health certification and plan of care listed under section “17. Allergies: diclofenac, lisinopril…” The physician’s orders list under section “Allergies: No Know Drug Allergy…” An exit interview with the area operation manager on 5/9/2025 at approximately 3:45 PM which confirmed the above findings.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on review of agency policy and procedure, observations (OBV) during home visits and staff (EMP) interview, the agency failed to ensure staff followed infection control standards of practice and agency policy and procedure for three (3) of seven (7) observations providing direct care to patients (OBV1, OBV2 and OBV5). Findings Included: Review of the agency policy and procedures was conducted 5/9/2025 at approximately 3:45 PM revealed, “Infection Control: Preparation of Work Area and Bag Technique…PURPOSE: To prevent contamination of bag and equipment, avoid cross infection, and establish a clean work area…PROCEDURE: 1. Adhere to Standard Precautions. 2. Select a flat surface to place bag and set up work area. Use discretion and consideration when placing bag on patient’s furniture. Never place bag on floor. Keep bag closed when not in use. 3. Place a barrier (paper towels, clean newspaper or other appropriate material) on flat surface before setting bag down…” During a home visit observation (MR14 OBV1) , on 5/9/2025 at approximately 0800 AM EMP5 provided direct patient care. EMP5 placed the supply bag on top of a counter with no chuck/barrier between the counter and the nursing/supply bag. During a home visit observation (MR17 OBV2) , on 5/9/2025 at approximately 9:12 AM EMP6 provided direct patient care. EMP6 placed a chuck/barrier on a chair with the nursing/supply bag on top of the chuck/barrier. The supply bag was laying off the side of the chuck/barrier onto the arm of the chair. During a home visit observation (MR11 OBV5) , on 5/9/2025 at approximately 12:26 AM EMP7 provided direct patient care. EMP7 placed four (4) chuck/barrier on a kitchen table with the backpack on top of one (1) chuck/barrier. Part of both straps from the backpack was laying off the side of the chuck/barrier onto the kitchen table. An exit interview with the area operation manager on 5/9/2025 at approximately 3:45 PM which confirmed the above findings.