Every finding on record at Crenshaw County Health Care Authority

Based on review of the agency Emergency Preparedness Plan and interview it was determined The Hospital Home Health was in substantial compliance with 484.102 Conditions of Participation: Emergency Preparedness.

A recertification survey was conducted on 6/23/22 with standard level deficiencies cited.

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 observations, review of medical records (MR), agency policy and procedure, and interviews, it was determined the agency failed to ensure staff reconciled medications in 3 of 3 Home Visits (HV) conducted, including HV # 1 HV # 2, and HV # 3, 1 of 4 MR reviewed, including MR # 2, and had the potential to negatively affect all patients served by the agency. Findings include: Agency Policy: Medication Administration and Documentation Policy Number: HH101100 Revised Date: 12/21/18 Procedure: Obtain a physician's order for the patient's medication. It should include the following information: a. Name of patient b. Name of medication c. Medication dose, route, and frequency of administration. Inscribe the physician's order on the medication record...Update record as needed. …Ask to see all medicines that the patient is taking. Check the labels on all medication containers, compare these with the prescribed medication regimen... Documentation Guideline: Document the following on the visit report: Document the medication's name, dosage, route, frequency of administration, and administration site as appropriate on the medication record. Keep medication record current. Update the plan of care with all new changes of medications. 4. HV # 3 was admitted to the agency on 5/3/22 with diagnoses including Type 2 Diabetes Mellitus with Hyperglycemia and Essential (Primary) Hypertension. Review of the HHC and POC dated 5/3/22 to 7/1/22 revealed a SN frequency of twice a week for 2 weeks then once a week for 3 weeks. A HV was conducted on 6/21/22 at 11:59 AM with EI # 5, Home Health Aide, to observe care provided. During the HV the agency PMS, printed by the agency on 6/21/22 at 11:15 AM, and the medications in home were compared with the following discrepancies found and verified by the patient's caregiver. Metformin 500 mg 2 tablets three times daily was found in the home with the prescription bottle dated 3/28/22. Review of the agency PMS revealed documentation of Metformin 500 mg 1 tablet twice daily. Zyrtec 10 mg OTC (over the counter) 1 tablet daily as needed for allergies was found in home. The caregiver verbalized the patient has been taking Zyrtec for 6 months and took the last dose the "day before yesterday." There was no documentation of the Zyrtec on the agency PMS. Hydralazine 25 mg 1 tablet daily was found in the home with the prescription bottle dated 5/11/22. Review of the agency PMS revealed documentation of Hydralazine 25 mg 1 tablet twice daily. An interview was conducted on 6/23/22 at 10:16 AM with EI # 1, who confirmed the SN failed to reconcile medications in home per the agency policy. 1. HV # 1 was admitted to the agency on 3/15/22 with admitting diagnoses of Abscess of Bursa, Right Knee and Primary Generalized (Osteo) Arthritis. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 5/14/22 revealed a Skilled Nurse (SN) frequency of 1 time a week for 9 weeks. A HV was conducted on 6/21/22 at 11:00 AM with Employee Identifier (EI) # 3, Licensed Practical Nurse to observe care provided to the patient. During the HV the patient's medication bottles were reviewed with the Patient Medication Sheet (PMS) provided to the surveyor on 6/21/22 by the agency. The following discrepancies were found: Doxepin 50 mg (milligrams) 1 capsule by mouth every night. Patient stated the medication was discontinued in March 2022 and remains on the PMS as active. Levothyroxine 50 mg 1 tablet by mouth every day. Patient stated the medication was discontinued in March 2022 and remains on the PMS as active. Nitro Stat 0.4 mg 1 tablet SL (sublingual) PRN (as needed) chest pain times 3 tablet 5 minutes apart. Patient stated the medication was discontinued March 2022 and remains on the PMS as active. Vitamin B 12 5000 mcg (micrograms) SL 1 tablet every day. Patient stated the medication was discontinued in March 2022 and remains on the PMS as active. The following medication was on the PMS with a different frequency: Fluticasone 50 mcg 1 spray each nostril every day was on the PMS and bottle directions was BID (twice daily) and confirmed by the patient. KCL (Potassium) 10 meq (milliequivalent) 2 tablets by mouth every day was on the PMS and the bottle frequency was BID (twice daily). Patient stated he/she takes twice a day. An interview was conducted on 6/23/22 at 12:15 PM with EI # 1, Manager, who confirmed the staff failed to update the patient's medication sheet and the above medication should have bee removed or dosage changed. 2. HV # 2 was admitted to the agency on 4/9/22 with a recertification dates of 6/8/22 to 8/6/22 with diagnoses of Displaced Intertrochanter Fracture Right Femur, Subsequent For Closed Fracture with Reduction and Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris. Review of the HHC and POC dated 6/8/22 revealed a Physical Therapy (PT) frequency of 1 time a week for 1 week then 2 times a week for 2 weeks. Then continue Physical Therapy 1 time a week for 1 week, 2 times a week for 2 weeks, then 1 time a week for 1 week. A HV was conducted on 6/21/22 at 11:50 AM with EI # 4, Licensed Physical Therapy Assistant to observe care provided to the patient. During the HV the patient's medication bottles were reviewed with the PMS provided to the surveyor on 6/21/22 by the agency. The following discrepancies were found: Hydrocodone APAP (acetaminophen) 5-325 mg 1-2 tablets every 4 hours PRN. The medication remained on the PMS and the patient stated it was stopped the second week of May 2022. Colace 100 mg capsule 1 by mouth BID remained on the PMS and patient stated he/she has not taken for over 2 years. Oxygen 2-3 liters per minute via nasal cannula remained on the PMS and patient stated that was stopped in May of 2022. The following medication was found in the home and not on the PMS: Atorvastatin 40 mg 1 tablet by mouth every day. The patient stated she has been on this medication for at least 8 years. An interview was conducted on 6/23/22 at 12:00 PM with EI # 1 and was asked who checks the medications with the patient medication sheet? EI # 1 stated "a nurse is not in the home to check the medications and the only discipline in the home is the therapists who do not check the medications. EI # 1 was then asked how the patients medications on the PMS were updated? EI # 1 replied right now they are not updated but maybe the therapists will have to start checking the medications." 3. MR # 2 was admitted to the agency on 4/1/22 with recertification dates of 5/31/22 to 7/9/22 and admitting diagnoses of Type 2 Diabetes Mellitus With Foot Ulcer and Pressure Ulcer of Other Site Stage 2. Review of the HHC and POC dated 5/31/22 revealed a SN frequency of 1 time a week for 4 weeks then 1 time a month for 1 month and an order for the SN to access med (implanted medication) port and flush with Saline followed by Heparin Flush Q (every) month. Review of the SN note dated 5/31/22 revealed the SN documented patient was on Oxygen (O2) at 2 liters a minute by nasal cannula. Review of the PMS printed on 6/21/22 revealed no Oxygen listed on the medication sheet and no Saline or Heparin Flush was listed on the medication sheet. An interview was conducted on 6/23/22 at 11:35 AM with EI # 1 who confirmed the Oxygen was not on the PMS. The Saline and Heparin Flush should have been added to the medication sheet.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on review of medical records (MR), agency policy and staff interviews, it was determined the staff failed to develop the plan of care and include:1. Goals for Home Health Aide (HHA) services.2. Physical Therapy (PT) specific procedures and modalities for therapy services. 3. Interventions related to management of Diabetic disease process and when to notify the physician. 4. All pertinent diagnoses with dates of onset. 5. Interventions related to management of Alcohol Dependence and Seizure disease processes and when to notify the physician. This affected 4 of 7 records reviewed including Home Visit (HV) # 3, MR # 3, MR # 4 and MR # 1 and had the potential to affect all patients admitted to the agency.Findings include:Agency Policy: Development of Plan of Care Policy Number: HH 101.500 Revised: 12/21/18Policy: ...Planning for care is a dynamic process that addresses the care, treatment and services to be provided. The plan of care will be consistently reviewed to ensure the patient's needs are met...Purpose: To provide guidelines for agency staff to develop a Plan of Care individualized to meet specific identified needs...Special Instructions: 2. The Plan of Care shall be completed in full to include: a. All pertinent diagnoses, principle and secondary, including dates of onset. ...d. Specific procedures and modalities for therapy services. ...l...treatments and procedures....p. Treatment goals. ...u. All of the above items must always be addressed on the Plan of Care......4. Orders for therapy services shall include the specific procedures and modalities to be used and the amount, frequency, and duration... 1. HV # 3 was admitted to the agency on 5/3/22 with diagnoses including Type 2 Diabetes Mellitus with Hyperglycemia and Essential (Primary) Hypertension. Review of the Home Health Certification (HHC) and Plan Of Care (POC) dated 5/3/22 to 7/1/22 revealed the following frequencies and orders: a. Skilled Nurse (SN) twice a week for 2 weeks then once a week for 3 week. b. HHA twice weekly for 9 weeks. c. PT twice weekly for 9 weeks. d. SN to instruct pt/cg (patient/caregiver) in the management of pt's (patient's) disease management and when to notify the physician. Further review of the HHC and POC revealed no documentation of specific procedures and modalities for PT and HHA, a goal for the HHA services, interventions related to management of Diabetic disease process including when to notify the physician. Review of the SN Comprehensive Start of Care Note dated 5/3/22 revealed documentation of "...patient continues to have issues with blood sugar..." An interview was conducted on 6/23/22 at 10:16 AM with Employee Identifier (EI) # 1, Manager, who confirmed the agency staff failed to include specific procedures and modalities for PT and HHA, a goal for the HHA services, and interventions related to management of Diabetic disease process including when to notify the physician. 2. MR # 3 was admitted to the agency on 12/10/21 with diagnoses including Anemia, Unspecified, Primary Generalized (Osteo) Arthritis and Acquired Absence of Both Cervix and Uterus. Review of the Agency Referral Record dated 12/8/21 and information provided to the agency from the patient's primary care physician dated 12/9/21 revealed documentation of a Diabetes Mellitus diagnosis. Review of the HHC and POC dated 12/10/21 to 2/7/21 revealed a SN frequency 1w1, 2w2, 1w6 for "SN to instruct in ADA (American Diabetic Association) Diet and Exercise Program...SN to instruct on s/s of Hypo/Hyperglycemia and maintain glucose between 80-120..." Further review of the HHC and POC dated 12/10/21 to 2/7/21 revealed no documentation of a Diabetes Mellitus diagnosis with onset date. An interview was conducted on 6/23/22 at 11:14 AM with EI # 1 who confirmed there was no documentation of a Diabetes Mellitus diagnosis with onset date on the patient's POC. 3. MR # 4 was admitted to the agency on 5/26/22 with diagnoses including Alcohol Dependence, Uncomplicated, Blood Alcohol level of 120-199 mg (milligram)/ 100 ml (milliter) and Other Seizures. Review of the HHC and POC dated 5/26/22 to 7/24/22 revealed the following frequencies and orders: a. SN once a week for 1 week, twice a week for 1 week then once a week for 1 week. b. HHA twice weekly for 8 weeks. c. PT once a week for 1 week then three times a week for 7 weeks. d. SN to instruct pt/cg in the management of pt's disease management and when to notify the physician. Further review of the HHC and POC revealed no documentation of specific procedures and modalities for PT and HHA, a goal for the HHA services, and interventions related to management of Alcohol Dependence and Seizure disease processes including when to notify the physician. An interview was conducted on 6/23/22 at 11:00 AM with EI # 1 who confirmed the agency staff failed to include specific procedures and modalities for PT and HHA, a goal for the HHA services, and orders for the interventions related to management of Alcohol Dependence and Seizure disease processes including when to notify the physician. . 4. MR # 1 was admitted to the agency on 6/2/22 with diagnoses including Unspecified Cirrhosis of Liver, Type 2 Diabetes Mellitus with Hyperglycemia and Type 2 Diabetes Mellitus with Hypoglycemia Without Coma. Review of the HHC and POC dated 6/2/22 to 7/31/22 revealed the following frequencies and orders: a. SN once a week for 1 week, twice a week for 2 weeks then once a week for 2 week. b. PT once a week for 1 week, twice a week for 2 weeks then once a week for 1 week. d. SN to instruct pt/cg in the management of pt's disease management and when to notify the physician. Further review of the HHC and POC revealed no documentation of specific procedures and modalities for PT and interventions related to management of Cirrhosis of the Liver and Diabetic disease process including when to notify the physician. An interview was conducted on 6/23/22 at 10:00 AM with EI # 1 who confirmed the agency staff failed to include specific procedures and modalities for PT and interventions related to management of Cirrhosis of the Liver and Diabetic disease process including when to notify the physician.

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 review of medical records, agency policies and procedures and interviews with the staff it was determined the agency failed to ensure agency staff entered a complete order for treatments and medications per the facility policy. This affected 1 of 7 MR's reviewed, including MR # 2, and had the potential to negatively affect all patients served by the agency. Findings include: Agency Policy: Physician Orders Policy Number: AHW.500.0050 Revised Date: 2/29/16 Procedure: Written Orders: The Registered Nurse and Licensed Practical Nurse may accept orders that have been entered on the patients record by...healthcare professionals, provided the nurse adheres to the following stipulations: 2. The order must be written on the appropriate form and must include the name of the physician...involved and the name and title of the person recording the order. 3. The order must be legible and easy to read so medication/treatment errors do not occur... 5. The order must be signed by the appropriate physician...as soon as possible. Agency Policy: Development of Plan of Care Policy Number: HH 101.500 Revised Date: 12/21/18 Policy: Home care services are furnished under the supervision and direction of the patient's physician. The plan of care is based on a comprehensive assessment and information provided by the patient/family and health team members. Planning for care is a dynamic process that addresses the care, treatment and services to be provided... Purpose: To provide guidelines for agency staff to develop a plan of care individualized to meet specific identified needs... Special Instructions: 2. The Plan of Care shall be completed in full to include: l. Medications, allergies, treatments and procedures... 6. Signed physicians orders will be obtained as quickly as possible... 1. MR # 2 was admitted to the agency on 4/1/22 with recertification dates of 5/31/22 to 7/9/22 and admitting diagnoses of Type 2 Diabetes Mellitus With Foot Ulcer and Pressure Ulcer of Other Site Stage 2. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 5/31/22 revealed a SN (Skilled Nurse) frequency of 1 time a week for 4 weeks then 1 time a month for 1 month and a order to access med (medication) port and flush with Saline followed by Heparin Flush Q (every) month. The order failed to include the amount of Saline and Heparin flush and failed to include the type and size of needle to access the port. Review of the SN note dated 5/31/22 revealed the SN documented patient was on Oxygen (O2) at 2 liters a minute by nasal cannula. Review of the MR revealed an no physician order for the use of Oxygen at 2 liters a minute by nasal cannula. An interview was conducted on 6/23/22 at 11:35 AM with Employee Identifier (EI) # 1, Manager, who confirmed there was no order for the Huber needle, flush with Saline and Heparin and EI # 1 also confirmed there was not an order written for the Oxygen.

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 Medical Record (MR) review, and staff interview it was determined the agency failed to ensure the staff was in conformance with physician orders for: 1. Teaching signs and symptoms of Hypoglycemia and Hyperglycemia. 2. Skilled Nurse (SN) and Physical Therapy (PT) frequencies. This deficient practice did affect 2 of 7 MRs, including MR # 2 and MR # 1 and had the potential to negatively affect all patient's served by the agency. 2. MR # 1 was admitted to the agency on 6/2/22 with diagnoses including Unspecified Cirrhosis of Liver, Type 2 Diabetes Mellitus with Hyperglycemia and Type 2 Diabetes Mellitus with Hypoglycemia Without Coma. Review of the HHC and POC dated 6/2/22 to 7/31/22 revealed a SN frequency of once a week for 1 week, twice a week for 2 weeks then once a week for 2 week and PT frequency of once a week for 1 week, twice a week for 2 weeks and once a week for 1 week. Review of the SN visit notes for the week of 6/6/22 to 6/12/22 revealed a SN visit was completed on 6/9/22. There was no documentation of an attempt to complete the second SN visit for the week. Review of the PT visit notes for the week of 6/6/22 to 6/12/22 revealed a PT visit was completed on 6/10/22. There was no documentation of an attempt to complete the second PT visit for the week. An interview was conducted on 6/23/22 at 10:00 AM with EI # 1 who confirmed the agency staff failed follow the physician ordered SN and PT frequency for the week of 6/6/22 to 6/12/22. 1. MR # 2 was admitted to the agency on 4/1/22 with recertification dates of 5/31/22 to 7/9/22 and admitting diagnoses of Type 2 Diabetes Mellitus With Foot Ulcer and Pressure Ulcer of Other Site Stage 2. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 5/31/22 revealed a SN (skilled nurse) frequency of 1 time a week for 4 weeks then 1 time a month for 1 month. Further review of the HHC an POC dated 5/31/22 revealed an order for the SN to instruct on signs and symptoms of Hypo/Hyperglycemia. PT (patient) / CG (caregiver) will verbalize understanding of Disease process, management, interventions and when to notify the physician. Review of the SN visit (SNV) note dated 5/27/22 the SN Comprehensive Recertification, and SNV notes dated 6/3/22, 6/10/22 and 6/17/22 revealed no documentation under the Endocrine section of the notes nor under the teaching section of the notes to indicate teaching for Hypo/Hyperglycemia had been completed. An interview was conducted on 6/23/22 at 11:35 AM with Employee Identifier (EI) # 1, Manager, who confirmed the SN failed to teach the PT/CG the signs and symptoms of Hypo/Hyperglycemia.

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 review of medical records (MR), and interviews with the staff it was determined the agency failed to ensure: 1. Staff notified the physician of patient's need for a glucometer. 2. Staff notified the physician of Altered Mental status with the caregiver request for Skilled Nursing visit. 3. The physician was notified of missed Skilled Nurse and Physical Therapy visits. This affected 4 of 7 medical records reviewed and did affect MR # 2, Home Visit (HV) # 1, HV # 3, MR # 1 and had the potential to negatively affect all patients served by the agency. 3. HV # 3 was admitted to the agency on 5/3/22 with diagnoses including Type 2 Diabetes Mellitus with Hyperglycemia and Essential (Primary) Hypertension. Review of the HHC and POC dated 5/3/22 to 7/1/22 revealed a SN frequency of twice a week for 2 weeks then once a week for 3 weeks. Review of the Case Communication note dated 6/7/22 revealed documentation the patient's caregiver called the agency and reported the patient wouldn't answer when called, inability to get the patient up and "...just not acting right..." Further review revealed a SNV was completed with documentation of "...talking about...drives a log truck and they tried to take (his/her) license. Caregiver states...was talking to their dead daughter this morning..." There was no documentation the physician was notified of the caregiver's report and the assessed patient's altered mental status. An interview was conducted on 6/23/22 at 10:16 AM with EI # 1, who confirmed there was no documentation to the SN notified the physician of the caregivers report on 6/7/22 and the assessed patient's altered mental status on 6/7/22. 4. MR # 1 was admitted to the agency on 6/2/22 with diagnoses including Unspecified Cirrhosis of Liver, Type 2 Diabetes Mellitus with Hyperglycemia and Type 2 Diabetes Mellitus with Hypoglycemia Without Coma. Review of the HHC and POC dated 6/2/22 to 7/31/22 revealed a SN frequency of once a week for 1 week, twice a week for 2 weeks then once a week for 2 week and Physical Therapy (PT) frequency of once a week for 1 week, twice a week for 2 weeks and once a week for 1 week. Review of the SNV and PT visit notes for the week of 6/6/22 to 6/12/22 revealed documentation 1 of 2 SN and 1 of 2 PT visits were completed. There was no documentation the physician was notified of the missed second SN and PT visits. An interview was conducted on 6/23/22 at 10:00 AM with EI # 1 who confirmed the agency staff failed to notify the physician of the missed SN and PT visits. 1. MR # 2 was admitted to the agency on 4/1/22 with recertification dates of 5/31/22 to 7/9/22 and admitting diagnoses of Type 2 Diabetes Mellitus With Foot Ulcer and Pressure Ulcer of Other Site Stage 2. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 5/31/22 revealed a skilled nurse (SN) frequency of 1 time a week for 4 weeks then 1 time a month for 1 month. Review of the skilled nurse visit (SNV) notes dated 6/3/22 and 6/17/22 revealed the SN documented under Blood Sugar "Patient has non working glucometer. Further review of the SNV notes dated 6/3/22 and 6/17/22 revealed the physician was not notified of the need for a glucometer. An interview was conducted on 6/23/22 at 11:35 AM with Employee Identifier (EI) # 1, Manager, who confirmed the nurse failed to notify the physician of the need for a glucometer. 2. HV # 1 was admitted to the agency on 3/15/22 with recertification dates of 5/14/22 to 7/12/22 and admitting diagnoses of Abscess of Bursa, Right Knee and Primary Generalized (Osteo) Arthritis. Review of the HHC and POC dated 5/14/22 revealed a SN frequency of 1 time a week for 9 weeks and an order for the SN to measure/record wound dimensions weekly. Review of the SN Comprehensive Recertification note dated 5/13/22 revealed wound # 1 to the right knee measured 0.3 cm (centimeters) in length by 0.3 cm width and 0.8 cm deep. Review of the SNV dated 6/13/22 revealed the SN documented the wound measurements to wound # 1, the right knee as 1.0 cm in length,1.2 cm in width and 3.0cm in depth. Further review of the SNV note dated 6/13/22 revealed no documentation the physician was notified of the increase in wound size. An interview was conducted on 6/23/22 at 12:15 PM with EI # 1 who confirmed the SN failed to notify the physician of the change in the wound size.

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 policies and procedures, observation and interview, it was determined the agency failed to ensure staff followed infection control standards and discarded contaminated gloves, performed hand hygiene and donned clean gloves prior to continuing with clean procedures. This deficient practice affected 1 of 3 home visits (HV) including HV # 3 and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: Hand Washing Policy Number HH101100 Revised: 12/21/18 Purpose: To prevent the transmission of microorganisms from patient to patient and from inanimate surfaces to patients by the hands of all healthcare providers. Policy: Hand hygiene shall be practiced before and after each patient contact... ...When going from a dirty site to a clean site, hands shall be washed or an alcohol hand rub applied... Routine Handwashing Procedure: ...use the paper towel to turn off the faucet. Agency Policy: Bag Technique Policy Number: HH101100 Reviewed: 12/21/18 Purpose: To prevent contamination of the nursing bag. To prevent cross-contamination and spread of infectious organisms. Procedure: 1...The inside of the nursing bag should be regarded and maintained as a clean area... ...10. After providing care, clean all equipment with gloves using Sani-wipes before returning to the bag... 1. HV # 3 was admitted to the agency on 5/3/22 with diagnoses including Type 2 Diabetes Mellitus with Hyperglycemia and Essential (Primary) Hypertension. Review of the Home Health Certification (HHC) and Plan Of Care (POC) dated 5/3/22 to 7/1/22 revealed a SN frequency of twice a week for 2 weeks then once a week for 3 weeks. A HV was conducted on 6/21/22 at 11:59 AM with Employee Identifier (EI) # 5, Home Health Aide, to observe care provided. EI # 5 performed hand hygiene, removed clean gloves and bag from agency bag and placed on barrier. EI # 5 donned gloves and attempted to pick up bag but in the attempt the bag fell to the patient's floor. EI # 5 picks up the bag from the patient's floor with gloved hand and placed the bag on top of the agency bag. EI # 5 removed thermometer and thermometer cover from within small black bag and proceeded to obtain the patient's temperature then radial pulse without removing contaminated gloves and performing hand hygiene. After the patient's temperature was obtained, EI # 5 obtained an alcohol pad and cleaned the thermometer then placed the thermometer immediately into the bag. EI # 5 failed to clean the thermometer with Sani-Cloth per agency policy, did not allow the thermometer to dry prior to placement in the bag and cleaned the thermometer while wearing contaminated gloves. EI # 5 continued to wear contaminated gloves through obtaining clean towels, wash cloths and showering the patient. After the shower was completed, EI # 5 dried the patient's chest, back and legs then obtained a second towel to clean the groin and buttock area with continued use of contaminated gloves throughout the drying of the patient. After drying the groin and buttock area the patient sat on the toilet to aide dressing and EI # 5 dried the patient's right arm with the towel used to dry the groin and buttock. The patient then motioned to EI # 5 for a towel to dry his/her hands and EI # 5 provided the patient the towel used to dry the patient groin and buttock. After the patient dried his/her hands with the towel provided the patient then dried his/her face with the same towel used to dry the groin and buttock. EI # 5 then applied lotion to the patient then obtained clean clothes for the patient with continued use of contaminated gloves. EI # 5 placed the clean clothes obtained on top of the used towels and clothes on the bathroom counter. EI # 5 then proceeded to assist patient with dressing. EI # 5 then assisted the patient to a chair and removed all trash. EI # 5 then removed the contaminated gloves and performed hand hygiene in the patient's bathroom sink. After performing hand hygiene, EI # 5 used bare hand to turn off the bathroom faucet. An interview was conducted on 6/23/22 at 10:16 AM with EI # 1, Manager, who confirmed the HHA failed to follow the agency infection control policies and procedures for hand hygiene, cleaning of reusable equipment, bag technique and prevention of cross contamination.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on review of agency policy, infection control documentation and staff interviews, it was determined the agency failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention and investigation of infectious and communicable diseases which included a method for identifying infectious and communicable disease problems and a plan for the appropriate actions that are expected to result in improvement and disease prevention. This had the potential to affect all patients admitted to the agency. Findings include: Agency Policy: Infection Prevention Program Policy Number: IC. 100.0010 Date: 6/21 I. Goals: The goals of the infection prevention program are to ...B. Monitor for occurrence of infection and implement appropriate control measures... II. Scope of the Infection Prevention Program: The infection prevention program is comprehensive in that it addresses detection, prevention, and control of infections among patients and personnel... The major activites of the program include the following: A. Surveillance of infections with implementation of control measures and prevention of infections. There is ongoing monitoring for infections among patients and personnel and subsequent documentation of infections that occur... ...IV. Reporting mechanisms for infection prevention A. Patient infection cases monitored by the IP (Infection Preventionist). The IP completes the appropriate forms summarizing infections... B. Employee infections are reported by the employee to the employee's supervisor to the IP or Occupational Health Nurse (OHN). The IP/OHN completes the employee infection report form... On 6/23/22 at 8:26 AM a review of the agency infection control program and interview with Employee Identifier (EI) # 1, Manager, and EI # 2, IP was conducted. During the interview, EI # 2 verbalized he/she finds out about home health infection by the hospital (hospital affiliated with the home health agency) laboratory who will contact him/her when a home health patient has a positive culture. EI # 2 verbalized if the patient does not have a culture or it is done at a different facility (other than the agency affiliated hospital), the home health patient infection would not be included in the infection control program due to him/her not being alerted to the infection. The surveyor asked how the agency staff report an infection/new antibiotic usage when an infection was not cultured. EI # 1 stated, the home health agency does not have an infection report and "...only infections captured in the infection control program are the ones with lab work." The surveyor asked for documentation of personnel infections included in the agency infection control program. EI # 1 and EI # 2 verbalized the only employee infections included in the infection control program were COVID-19 infections which are report via phone to EI # 2. Review of the Infection Surveillance Report and Infection Control Tracking Forms for March 2021 through April 2022 revealed 4 Home Health patient infections were documented. There was no documentation the 4 agency infections were reviewed/investigated to identify patterns/trends of infections. Further review of the Infection Surveillance Report and Infection Control Tracking Form for December 2021 revealed no documentation of MR # 3, a patient who was hospitalized on 12/14/21 for vaginal bleeding, had and I&D (Incision and Drainage) of a pelvic abscess, evacuation of Hematoma and Vaginal Cuff Revision then discharged home with the agency resumption of care on 12/19/21 with a new medication order for Doxycycline 100 milligrams 1 tablet twice daily. The surveyor asked for documentation of MR # 3's infection with new antibiotic usage in the agency infection control program. EI # 2 verbalized since the patient was hospitalized at a different hospital than the one affiliated with the agency he/she was not made aware of the infection/new antibiotic and therefore MR # 3 was not included in the agency infection control program data. EI # 1 confirmed there was no documentation of an infection control report for MR # 3 and/or MR # 3's placement on Doxycycline after having an I&D of a pelvic abscess. The surveyor asked EI # 2 for documentation the agency reviewed/investigated the home health infections. EI # 2 verbalized when he/she received a positive laboratory culture on a home health patient he/she would call the home health and speak to a staff member to make sure the patient "...is on the appropriate antibiotic" but the infection is not reviewed/investigated and/or a root cause analysis performed.

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on review of medical records (MR), agency policies and procedures and interviews with the staff it was determined the agency failed to ensure the staff educated: a. The patient/caregiver on the new wound care and the patient/caregiver provided a return demonstration of new wound care. b. The patient/Caregiver on the signs and symptoms of Hypoglycemia and Hyperglycemia per physician orders. c. Patient's disease management per physician orders. d. Patient's medication regimen. This affected 4 of 7 MR's review, including MR # 2, Home Visit (HV) # 3, MR # 3, MR # 1 and had the potential to negatively affect all patents served by the agency. Findings include: Agency Policy: Wound Assessment and Documentation Policy Number: HH101100 Revised Date: 12/21/18 Purpose: To identify parameters of wound assessment Procedure: Explain the procedure to the patient/caregiver Nursing Considerations/Documentation Guidelines: Document the following on the visit report: Any patient/caregiver instructions on wound care and response to teaching, including the ability to change dressings and manage wound at home. Agency Policy: Electronic Medical Record Policy Number: None Effective Date: 5/8/17 Policy: The Hospital Home Health will strive for complete and accurate documentation in electronic medical records and will follow specific guideline to ensure accurate documentation... Procedure: Documentation Content of the Medical Record: 19. Nurses notes, which shall include, but not limited to the following: a. Nursing assessment... b. Concise and accurate record of nursing care administered c. Record of pertinent observations...physical manifestations and relevant nursing interpretations of such observations... 2. HV # 3 was admitted to the agency on 5/3/22 with diagnoses including Type 2 Diabetes Mellitus with Hyperglycemia and Essential (Primary) Hypertension. Review of the HHC and POC dated 5/3/22 to 7/1/22 revealed a SN frequency of twice a week for 2 weeks (2w2) then once a week for 3 week (1w3) with orders for SN to instruct pt/cg (patient/caregiver) on all aspects of medication regimen and SN to instruct pt/cg in the management of patient's disease management. Review of the Patient Medication Sheet revealed documentation of Lantus 20 Units Subcutaneous (SQ) at bedtime and Humalog SQ per sliding scale three times daily. Review of the SN Comprehensive Start of Care Note dated 5/3/22 revealed documentation of "...patient continues to have issues with blood sugar..." Review of 6 of 6 SNV's dated 5/3/22 to 6/7/22 revealed no documentation the SN provided education to the pt/cg on the use of the glucometer, Diabetic management or Humalog insulin. Further review of 6 of 6 SNV's dated 5/3/22 to 6/7/22, revealed no documentation the SN received a return demonstration from the pt/cg in the use of the glucometer and insulin to ensure competency. An interview was conducted on 6/23/22 at 10:16 AM with EI # 1, who confirmed the agency staff failed to provided education to the pt/cg on the use of the glucometer, Diabetic management or Humalog insulin and received a return demonstration from the pt/cg in the use of the glucometer and insulin to ensure competency. 3. MR # 3 was admitted to the agency on 12/10/21 with diagnoses including Anemia, Unspecified, Primary Generalized (Osteo) Arthritis and Acquired Absence of Both Cervix and Uterus. Review of the HHC and POC dated 12/10/21 to 2/7/22 revealed a SN frequency 1w1, 2w2, 1w6 for "SN to instruct in ADA (American Diabetic Association) Diet and Exercise Program...SN to instruct pt/cg on pain managment...SN to instruct pt/cg in the management of pt's disease management...SN to instruct on s/s of Hypo/Hyperglycemia and maintain glucose between 80-120..." Review of 5 of 5 SNV's from 12/10/21 to discharge date of 1/5/22 revealed no documentation the SN provided the patient and/or caregiver with education on ADA diet and exercise program, pain management, Diabetes, s/s of Hypo/Hyperglycemia, maintaining blood glucose between 80-120, use of the glucometer and/or a return demonstration was obtained to ensure competency with the glucometer. . An interview was conducted on 6/23/22 at 11:14 AM with EI # 1 who confirmed there was no documentation the SN provided the patient and/or caregiver with education on ADA diet and exercise program, pain management, Diabetes, s/s of Hypo/Hyperglycemia, maintaining blood glucose between 80-120, use of the glucometer and/or a return demonstration was obtained to ensure competency with the glucometer. 4. MR # 1 was admitted to the agency on 6/2/22 with diagnoses including Unspecified Cirrhosis of Liver, Type 2 Diabetes Mellitus with Hyperglycemia and Type 2 Diabetes Mellitus with Hypoglycemia Without Coma. Review of the HHC and POC dated 6/2/22 to 7/31/22 revealed a SN frequency of once a week for 1 week, twice a week for 2 weeks then once a week for 2 week with orders for SN to instruct pt/cg (patient/caregiver) on all aspects of medication regimen and SN to instruct pt/cg in the management of patient's disease management. Review of the Patient Medication Sheet revealed documentation of Tresiba 50 Units SQ at bedtime. Review of 4 of 4 SNV's dated 6/2/22 to SN discharge date of 6/16/22 revealed no documentation the SN provided education to the pt/cg on the use of the glucometer, Diabetic management or Tresiba insulin. Further review of 4 of 4 SNV's dated 6/2/22 to 6/16/22 revealed no documentation the SN received a return demonstration from the pt/cg in the use of the glucometer and insulin to ensure competency. An interview was conducted on 6/23/22 at 10:00 AM with EI # 1, who confirmed the agency staff failed to provided education to the pt/cg on the use of the glucometer, Diabetic management or Humalog insulin and received a return demonstration from the pt/cg in the use of the glucometer and insulin to ensure competency. 1. MR # 2 was admitted to the agency on 4/1/22 with recertification dates of 5/31/22 to 7/9/22 and admitting diagnoses of Type 2 Diabetes Mellitus With Foot Ulcer and Pressure Ulcer of Other Site Stage 2. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 5/31/22 revealed a SN frequency of 1 time a week for 4 weeks then 1 time a month for 1 month. Further review of the HHC and POC dated 5/31/22 revealed an order for skilled nurse (SN) to instruct on signs and symptoms of Hypo/Hyperglycemia and patient (PT) /caregiver (CG) verbalize understanding of disease processes, management, intervention and when to notify physician. Further review of the HHC and POC dated 5/31/22 revealed an order for the SN to perform wound care to right lateral aspect of Right leg as follows: clean wound with Vashe, and apply Opticell Ag, cover with gauze, secure with tape every SN (Skilled Nurse) visit. Review of the physician order dated 6/10/22 revealed the following order for wound care: Wd (wound) care to Rt (right) lateral foot as follows: Clean with Vashe, apply Silvercell or, 4 by 4, medipore tape to secure. To be done by caregiver o days skilled nurse not in home. Review of the SN Visit (SNV) notes dated 6/3/22, 6/10/22 and 6/1722 revealed no documentation education was performed for the Hypoglycemia nor the Hyperglycemia. Review of the SN visit notes dated 6/10/22 and 6/17/22 revealed under the wound section of the note no documentation wound care was taught to the CG with a return demonstration. Review of the SNV notes dated 6/10/22 and 6/17/22 revealed no documentation the CG was taught the new wound care and no documentation of a return demonstration of the wound care. An interview was conducted on 6/23/22 at 11:35 AM with Employee Identifier (EI) # 1, Manager, who confirmed the SN failed to document any teaching and observation of wound care or a return demonstration.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on medical record (MR) review, agency policy and staff interviews, it was determined the Registered Nurse (RN) failed to prepare a written patient plan of care with specific instructions for the Home Health Aide (HHA). This affected 3 of 3 records with HHA services and included Home Visit (HV) # 3, MR # 4, HV # 1 and had the potential to affect all patients with HHA services. Findings include: Agency Policy: Home Health Aide Plan of Care and Documentation Policy Number: Not documented Review Date: 12/21/18 Purpose: To ensure the safety and care of the Home Health Patients, while the HHA provides adequate care... Policy: The...Registered Nurse (RN) will develop the patients' plan of care and provide instructions...to all HHAs providing care to patients... II....The HHA shall only work under the supervision of the RN. Duties include: a. Perform those personal care activities contained in the RN's plan of care... 3. HV # 1 was admitted to the agency on 3/15/22 with recertification dates of 5/14/22 to 7/12/22 and admitting diagnoses of Abscess of Bursa, Right Knee and Primary Generalized (Osteo) Arthritis. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 5/14/22 revealed a visit frequency for the HHA as 2 times a week for 9 weeks. Review of the HHA Care Plan dated 5/16/22 revealed documentation the HHA was to perform the following tasks PRN: Complete bed bath/pan bath unable to determine which bath was to be given and how often the complete bed bath/pan bath was to be given, comb/brush hair, shampoo hair, lotion skin, apply Lantiseptic/skin barrier, apply deodorant, foot care, nail care, make bed, change linens and tidy patient care area, Dentures had no frequency by the SN. There was no documentation to instruct the HHA on the specific frequencies the tasks were to be performed. An interview was conducted on 6/23/22 at 12:15 PM with EI # 1 who confirmed the SN failed to document a frequency for each assigned task on the HHA Care Plan. 1. HV # 3 was admitted to the agency on 5/3/22 with diagnoses including Type 2 Diabetes Mellitus with Hyperglycemia and Essential (Primary) Hypertension. Review of the HHA Care Plan dated 5/4/22 revealed documentation the HHA was to perform the following tasks PRN (as needed): Shower, Complete bed bath, comb/brush hair, shampoo hair, lotion skin, apply Lantiseptic/skin barrier, apply deodorant, denture care, foot care, nail care, shave, make bed, change linens and tidy patient care area. There was no documentation to instruct the HHA on the specific frequencies the task, were to be performed or how the HHA was to determine if the task was needed. An interview was conducted on 6/23/22 at 10:16 AM with Employee Identifier (EI) # 1, Manager, who confirmed there was no documentation to instruct the HHA on the specific frequencies the task, were to be performed or how the HHA was to determine if the task was needed. 2. MR # 4 was admitted to the agency on 5/26/22 with diagnoses including Alcohol Dependence, Uncomplicated, Blood Alcohol level of 120-199 mg (milligram)/ 100 ml (milliter) and Other Seizures. Review of the HHA Care Plan dated 5/30/22 revealed documentation the HHA was to perform the following tasks PRN (as needed): Shower, Complete bed bath...pan bath, comb/brush hair, shampoo hair, lotion skin, apply Lantiseptic/skin barrier, apply deodorant, Bed side commode, denture care, foot care, nail care, shave, make bed, change linens and tidy patient care area. There was no documentation to instruct the HHA on the specific frequencies the task, were to be performed or how the HHA was to determine if the task was needed. An interview was conducted on 6/23/22 at 11:00 AM with EI # 1 who confirmed there was no documentation to instruct the HHA on the specific frequencies the task, were to be performed or how the HHA was to determine if the task was needed.