Every finding on record at Delaware County Memorial Hospital

A Recertification Survey was conducted by the Department of Inspections, Appeals and Licensing from 1/14/24 through 1/16/24 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 1/14/16 through 1/16/24. The recertification survey found the agency operating out of compliance with the following standard level regulatory requirements: The agency reported a census of 51 patients at the time of the survey.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: (1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on patient interview and agency staff interview, clinical record review, and agency policy review, the agency failed to ensure accurate and thorough completion of all pertinent components of each comprehensive assessment for 2 of 7 sampled patients. (Patient #4 and #6) Failure to accurately and thoroughly complete comprehensive assessments to address individualized pertinent areas of health to obtain baseline findings placed patients at an increased risk of unidentified condition changes. Findings include: The agency policy titled Comprehensive Assessment, dated 11/2024, the content of the comprehensive assessment will include: the patient’s current health, psychosocial, functional and cognitive status, the patient’s medical, nursing, rehabilitative, social and discharge planning needs, and the most current version of the Outcome and Assessment Information Set (OASIS) items, will be incorporated into the comprehensive assessment, if applicable. The agency policy titled Wound Assessment, dated 10/2024, directs the agency to complete a thorough assessment and include effective documentation as an essential component in the management of wounds and skin impairments. The agency will assess a client’s wounds/skin impairments and document status on scheduled visit days. The status of open wounds will be documented in the electronic health record. Additionally, any skin areas (even if there is no impairment) that are being monitored and treated will be documented including measurements in the patient's electronic health record. During a interview on 1/15/25, at 1:33 PM, the Clinical Manager stated, the wound policy allowed for generalization and approximation of areas of bruising or rashes, but that any closed wound or incision did not require measurements. The Clinical Manager also stated that pressure ulcers definitely needed assessment and measurements at least weekly. 1.Patient #6 had a start of care date of 5/9/24. Clinical record review revealed the following: a. The Plan of Care (POC), dated 5/9/24 to 7/7/24, included diagnosis of diabetes, kidney disease , and stage 2 pressure ulcer (shallow open wound) to the right buttock. The POC included orders for skilled nurse weekly for medication management, diabetic education and instruction, and for wound assessment, treatment and education. b. The comprehensive initial assessment completed on 5/9/24, by Staff B, Registered Nurse (RN), included documentation of an unhealed pressure ulcer stage 2 on the right buttock, but lacked measurements of the stage 2 pressure ulcer to the right buttock. The agency failed to obtain measurements for the pressure ulcer. 2. Patient #4 had a start of care date of 7/26/24. Clinical record review revealed the following: a. The POC, dated 11/23/24 to 1/21/25, included diagnosis of heart failure with fluid overload, Parkinson's, and anemia. The POC included orders for skilled nursing services to evaluate and assess a right ankle wound and provide wound care 2 times per week. b. Physician orders received from the wound care clinic effective 12/3/24, ordered agency not to remove the dressing that was placed weekly at the wound care clinic. To only reinforce the outer dressing, if necessary when soiled, or drainage had come through the initial dressing, until new physician orders were given. The non removable dressing did not allow the agency to assess or measure the wound per agency policy. c. Physician orders effective 12/30/24, included the following: Clean wound with Normal Saline and Pat dry. Apply Multidex (a wound gel used to maintain a moist environment to promote healing) to wound bed, cover with Hydrofera blue (type of foam dressing) and secure with mepilex (an absorbent outer dressing). Change dressing 2-3 times per week with 1 of those days being in the wound clinic. The other day to be completed by home health or by the caregiver. Skilled nurse to assess wound and complete dressing change on 1/2/24. d. Skilled nurses note dated 1/2/24, completed by Staff C, Licensed Practical Nurse, included a description of the wound, but lacked measurements for the wound. The agency failed to document measurements to the wound on the right ankle. The above findings were reviewed with the Administrator and the Clinical Manager.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on staff interview, policy review and clinical record review, the agency failed to ensure home health aides provided care to agency patients only as ordered by the physician in the Plan of Care and/or as directed by the skilled professional assigning the home health aide to the patient for 2 of 3 sampled patients receiving home health aide services (Patients #2 and #5). The agency reported 39 patients who received care provided by a home health aide. Failure to ensure that home health aide services are provided only as ordered by the physician and according to the home health aide care plan increased the risk that patients' personal care needs were not adequately met. 2.Patient #5 had a start of care date of 1/5/25. Clinical record review revealed the following: a. The Plan of Care, dated 1/5/25 to 3/5/25, included primary diagnosis of subdural hematoma (accumulation of blood in the brain) and transient ischemic attack (temporary blockage of the flow of blood to the brain), with physician orders for physical therapy, skilled nursing and home health aide services. b. The home health aide assignment, with an effective date of 1/5/25, directed the aides to apply cologne, deodorant and lotion per patient request, to clean glasses, to apply Nystatin powder (antifungal powder) if skin folds are red or patient request, to assist the client to clean hard to reach areas, assist the client to dress and undress, to pat dry ensuring all skin folds are completely dried, to gather items for the shower, assist the client to transfer in and out of shower and directions to provide spongebath rather than a shower per patient request. c. The electronically completed home health aide visit note, dated 1/6/25, included documentation all tasks were performed and included, apply cologne, deodorant and lotion per patient request, to clean glasses, to apply Nystatin powder (antifungal powder) if skin folds are red or patient request, to assist the client to clean hard to reach areas, assist the client to dress and undress, to pat dry ensuring all skin folds are completely dried, to gather items for the shower, assist the client to transfer in and out of shower and directions to provide spongebath rather than a shower per patient request. d. The agency failed to document the specific tasks the home health aide completed, and documented both shower activities completed and spongebath per patient request completed. The above findings were reviewed with the Administrator and the Clinical Manager. Findings include: According to the agency policy titled, Clinical Record, dated 11/2024, identified the clinical record will contain at a minimum, all the assessments from the most recent home health admission, clinical notes, all interventions, including treatments and services, and responses to those interventions provided by the agency. Staff will review documentation for accuracy prior to electronically signing them. During an interview on 1/15/25 at 1:33 PM, the Clinical Manager reported aides are to document refusal of tasks not completed on the visit notes. 1.Patient #2 had a start of care date of 12/9/22. Clinical record review revealed: a. The Plan of Care, dated 11/28/24 to 1/26/25, included primary diagnosis of multiple sclerosis and physician orders for skilled nursing and home health aide services. b. The home health aide assignment, with an effective date of 2/28/23, directed the aides to apply a thin layer of Desenex to abdomen, groin, breast, and knee folds if not red or open; apply lotion to arms and legs; assist with sponge bath; assist with undressing and dressing; be sure to wash skin folds well and pat dry; change bedding if sheets get very wet from shampoo boat and spouse is not around to change; change incontinence pads/brief with each visit; client is cognitively able to participate in care decisions; and wash hair with each visit using shampoo boat. Task apply Baza anti-fungal (cream) to any red/moist skin fold areas/under breasts or groin with an effective date 12/30/24, task apply resinol (medicated cream) to top of crack between the buttocks after bathing and dry with an effective date of 1/6/25, and task remove abdominal binder and nubby pad (pressure relieving pad) from left and right upper thigh areas and wash and dry, spouse to reapply with an effective date 1/2/25. c. The electronically completed home health aide visit note, dated 1/8/25, included the task apply resinol (medicated cream) to top of crack between the buttocks after bathing and dry. The note lacked documentation of the additional tasks of apply a thin layer of Desenex to abdomen, groin, breast, and knee folds if not red or open; apply lotion to arms and legs; assist with sponge bath; assist with undressing and dressing; be sure to wash skin folds well and pat dry; change bedding if sheets get very wet from shampoo boat and spouse is not around to change; change incontinence pads/brief with each visit; client is cognitively able to participate in care decisions; and wash hair with each visit using shampoo boat, Baza anti-fungal (cream) to any red/moist skin fold areas/under breasts or groin, and remove abdominal binder and nubby pad (pressure relieving pad) from left and right upper thigh areas and wash and dry, spouse to reapply.

The recertification survey, conducted from 3/7/2022 through 3/9/2022, found the agency operating in substantial compliance with the requirements of the Appendix Z Establishment of Emergency Preparedness.

The recertification survey for 42CFR 484 Home Health Conditions of Participation, conducted 3/7/2022 through 3/9/2022, found the agency operating out of compliance with the following standard level deficient practice:

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on agency policy review, review of the agency's vaccination tracking forms, personnel file review and agency staff interview, the agency failed to maintain consistent policies/procedures addressing contingency plans for unvaccinated employees, including those exempted from COVID-19 vaccination, to mitigate the spread of the virus to other employees and agency patients; and failed to require exempted home health employees follow the contingency plan set forth in the Regional Health Center-wide policies as identified as followed by home health employees for 3 of 3 sampled agency exempted employees (Staff B, C and D). The agency reported a current census of 86 patients; employed 19 staff directly and employed 10 staff by arrangement at the time of the survey. The agency reported 26 fully vaccinated staff; 3 with granted non-medical exemptions and 0 granted exemptions for medical reasons or temporary delay of the vaccination. Failure to maintain consistent policies addressing contingency plans for unvaccinated employees and/or provide each nonvaccinated employee with accurate, consistent contingency plans placed agency patients and other agency employees at an increased risk of exposure/transmission of the COVID-19 virus. Findings include: According to the agency policy/procedure, titled COVID-19 Response Plan and dated 2/14/2022, the requirements of the policy "to reduce the risk of further spreading COVID-19 virus and best protect both healthcare workers and patients will be followed in conjunction with Regional Medical Center-wide policies and procedures implemented during the COVID-19 pandemic." Vaccination for COVID-19 will be provided to all employees by the Regional Medical Center employee health department. Vaccinated employees must wear a procedure mask (paper mask) and eye protection with all in-home visits for patients screening negative and are asymptomatic for COVID-19. Vaccinated employees must wear a procedure mask when in public areas of the home health building or within 6 feet of another person. All staff will wear an N95 or MaxAir and eye protection anytime completing an aerosol generating procedure or if they have completed an aerosol generating procedure within 3 hours of the visit. If a patient has a confirmed positive COVID-19 laboratory test or is in isolation pending results of tesing or is suspected positive but not tested or is in quarantine due to known exposure, all staff must wear an N95/MaxAir, gloves, gown, bouffant cap, shoe coverings and goggles/faceshield when in a patient's home. The patient must wear a mask or face covering. Each employee not fully vaccinated requires additional measures (contingency plan) taken to mitigate the risk of spreading COVID-19 to co-workers or patients. Each unvaccinated employee will check their temperature twice per shift and "ensure they are always masked when around co-workers and patients." (The policy documented all vaccination protocol will also follow the Regional Medical Center-wide policies and procedures.) Employees found not following these additional mitigation measures will be subject to disciplinary action up to and including termination and will be expected to comply with these requirements immediately upon the disciplinary action being taken. The policy lacked a specific description of the type of mask required for non-vaccinated employees. According to the Regional Medical Center-wide policy/procedure, titled Pandemic Respiratory Disease Plan and dated as revised February 2022, "as required by CMS, all Regional Medical Center employees, Contracted staff, students and volunteers will be vaccinated for COVID-19 unless a medical/religious exemption is approved." Any staff who are not yet fully vaccinated or who have been granted exemption or accommodation as authorized by law, or have a temporary delay, adhere to additional precautions (contingency plan) that are intended to mitigate the spread of COVID-19. "Actions or job modifications Regional Medical Center will implement to meet this interim requirement include: i. Requiring staff who have not completed their primary vaccination series to follow additional, CDC-recommended precautions, such as adhering to universal source control and physical distancing measures in areas that are restricted from patient access (ie. meeting rooms, kitchen) even if the facility or service site is located in a county with low to moderate community transmission. ii. Requiring staff who have not completed their primary vaccination series to use a NIOSH-approved N95 or equivalent or higher-level respirator for source control during all patient encounters. iii. Requiring staff who have not completed their primary vaccination series to use a KN95 mask for source control during all non-patient encounters. iv. Each department manager will be responsible for monitoring staff compliance with above mitigation efforts. Non-compliance with the above policy will result in voluntary resignation of employment. Contracted staff, volunteers, and students will be unable to provide care, treatment or other services for the facility and/or its patients, if not compliant with the policy requirements. Review of the agency's COVID-19 tracking forms revealed two directly hired employees and one employee hired by agreement with Regional Medical Center (employee of the hospital and used in the provision of home health services) requested and were granted a non-medical exemption from vaccination for COVID-19; no requested or approved medical exemptions; and no requested or approved temporary delay in vaccination. The tracking forms revealed all other directly hired staff and those hired by agreement with Regional Medical Center were fully vaccinated. Personnel file review revealed: 1. Staff B, Home Health Aide, was directly hired by the agency and granted a non-medical exemption from vaccination on 11/29/2021. 2. Staff C, Home Health Aide, was directly hired by the agency and granted a non-medical exemption from vaccination on 11/22/2021. 3. Staff D, Occupational Therapist, was employed by agreement with Regional Medical Center and had been granted a non-medical exemption from vaccination on 2/14/2022. During agency staff interview on 3/8/2022 at 4:00 PM, the Administrator reported that the agency had a total of 3 employees with approved non-medical exemptions. Regional Medical Center employee health and human resources grant the exemption. Once the exemption has been granted, the Administrator verbally explains to each exempted employee they will be required to wear a mask at all times around other staff and with patients and must check their temperature twice per shift and call in the temperature readings to the home health office for tracking. The Administrator reported she did not present anything in writing to the exempted employees describing the contingency plan. During agency staff interview on 3/9/2022 at 9:05 AM, Staff D, Occupational Therapist, reported she was granted a non-medical exemption in February 2022. In February 2022, she received an email about the vaccine mandate. Staff D, Occupational Therapist, reported she was unsure if she received any written documentation regarding a contingency plan for exemption status but was told verbally "to take temperatures two times daily- call in to home health office; when in the home health building must wear a mask and if I didn't follow I was at risk for discipline leading up to termination." Staff D, Occupational Therapist, could not remember who told her about the contingency plan as she held multiple jobs and had done the same exemption with other employers, making it hard to remember the specifics. During agency staff interview on 3/9/2022 at 10:20 AM, the Administrator reported the home health employees who have been vaccinated wear eye protection and procedure (paper) mask for all patient encounters unless the patient or someone in the household is COVID-19 positive, in isolation, suspected positive or in quarantine due to known exposure and check their temperature once daily and report to the home health office staff for tracking. Employees who are NOT fully vaccinated follow the same procedures and requirements for Personal Protective Equipment (PPE) use as vaccinated staff; however, exempted employees need to wear the procedure (paper) mask at all times when in the office, at all times with patient care and need to monitor their temperature twice daily instead of daily. The Administrator confirmed she had verbally told Staff B, C and D the requirement for the contingency plan for exempted staff was use of a procedure (paper) mask at all times in office and patient homes. On 3/9/2022 at 10:30 AM, the surveyor reviewed the discrepancies between the contingency plan when comparing the home health policy, the Regional Medical Center Policy and the Administrator's and agency staff interview findings with the Administrator. The Administrator stated "I don't know if they (Regional Medical Center) ever implemented that (policy)- I would think they would have notified me of it." During agency staff interview on 3/9/2022 at 12:00 PM, Staff B, Home Health Aide, reported she was granted a non-medical exemption in November 2021. In January 2022, she received an email about the vaccine mandate and the mandate was discussed in a home health aide meeting held something thereafter. Staff B, Home Health Aide, reported the Administrator verbally told her about the contingency plan in February 2022. "I was told temperatures needed taken two times daily- call in or put in chat to the front desk people- wear paper (procedure) mask at all times in the office and with all patient care for anyone not testing positive for COVID-19. The agency maintained conflicting policies/procedures for contingency plan requirements for exempted employees to follow. The exempted employees were not given specific contingency plan requirements in writing from the home health Administrator and were given verbal direction which directly conflicted with the Regional Medical Center- wide policies. The surveyor reviewed the above stated findings with the Administrator. The Administrator reported a governing group met in the morning of 3/9/2022 at Regional Medical Center and altered the policy to reflect future direction to non-vaccinated employees, removing the requirement for the use of an N95 mask or equivalent and decreasing the temperature times to daily as required by vaccinated staff. No other information was provided prior to the survey exit.