Every finding on record at Esteem Home Health Inc

A recertification and complaint entrance conference was conducted on 05/07/2023 at 09:17 a.m. with the Administrator. Intake #368058 Census: LHH: 3 An exit conference was conducted on 05/05/2023 at 03:03 p.m. with the Administrator. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information.

A recertification and complaint entrance conference was conducted on 05/07/2023 at 09:17 a.m. with the Administrator. Intake #368058 Census: LHH: 3 An exit conference was conducted on 05/05/2023 at 03:03 p.m. with the Administrator. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. Acronyms: POC - Plan of Care RN - Registered Nurse SOC - Start of Care u - units

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 observation, record review, and interviews, the agency failed to ensure the patient's comprehensive assessment included a current medication list in each patient records to identify any potential adverse effects and drug interactions, including ineffective drug therapy, significant side effects, and significant drug interactions for one of three active patients (Patients #3 ), in that: Patient #3's Novulin R and Lantus (Insulin Glarine) (medications to control blood sugar) were not listed on his medication profile. This deficient practices could affect all Patients on insulin and could result in ineffective drug therapy, significant side effects, and drug to drug interactions. The findings included: Record review of the agency's policy and procedure titled "Medication Profile (date unknown)" read in part, "...2.54. Purpose: To ensure all patients/clients have a current list of medications...Agency staff will check all medicines a patient/client may be taking to identify possible ineffective drug therapy of adverse reactions, significant side effects, drug allergies, and contraindicated medication..." Record review of Patient #3's POC revealed a SOC of 11/16/2022, diagnoses included Burn of Unspecified Degree of Left Foot. Record review of Patient #3's medication profile revealed no evidence it included Patient #3's medications Novulin R and Lantus (Insulin Glarine). During a home visit on 05/03/2023 at 11:20 a.m., Patient #3's current medications were compared with the medication profile. Further observation of Patient #3's medications revealed he currently used Novulin R 10 u three times daily and Lantus (Insulin Glarine) 30 u twice daily (morning and at night). During an interview on 05/03/2023 at 11:27 a.m., Patient #3 revealed he had been taking the Novolin R and Lantus insulin even before he was admitted to the agency. Patient #3 further revealed LVN A should be aware because she's helped him administer the insulins when he first started with the agency. During an interview on 05/03/2023 at 05:20 p.m. LVN A revealed she conducted visits on the three active patients from the agency. During an interview on 05/05/2023 at 11:26 a.m., RN C, Case Manager revealed she conducted the admission and recertification visits and updated the medication profile based on what the patient told her. During an interview on 05/05/2023 at 02:52 p.m., LVN A revealed she was not aware Patient #3 was on Insulin; he was probably on insulin before he was admitted to their service. Further interview with LVN A revealed she wasn't sure why the insulins were not in Patient #3's medication profile. During an interview on 05/04/2023 at 11:44 a.m., the Administrator revealed the nurses check physically the medications the patient had with the medication profile so they could update the profile. Further interview with the Administrator revealed whoever visited should tell the agency if there were any medication discrepancies so agency can update the medication profile.

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: This deficiency was previously cited during the last recertification on 09/11/2020. Based on record review and interview, the agency failed to ensure the individualized POC for three of three active clients (Patients #1, #2, and #3) included information related to any advance directives. There was no Advance Directive (document that includes the client's wishes when he/she is not capable at the end of life) information included in the Plan of Care (POC) for Clients #1, #2, and #3. This failure could affect all patients in the agency and could result in the patient not receiving medical care when they are incapable of making their needs known. The findings included: Record Review of the agency's policy titled "2.8 Care Plan" (undated) revealed in part "...Steps to be taken in developing the care plan include: 1. Collection of baseline data including all pertinent diagnoses...Evaluation of the Care Plan...Patient/Client involvement in Care planning and Decision-Making order to optimize patient/family participation in care planning and decisions affecting patient/client care, including …executing advance directives..." Review of Patient #1's clinical record revealed a Start of Care (SOC) date of 01/30/2023 for a Plan of Care (POC) certification period from 01/30/2023 to 03/30/2023 with a diagnosis of non Pressure Chronic Ulcer of Left Foot. Further review revealed no documented evidence that included information related to the Patient #1's advance directive was on his POC. Review of Patient #2's clinical record revealed a Start of Care (SOC) date of 04/10/2023 for a Plan of Care (POC) certification period from 04/10/2023 to 06/08/2023 with a diagnosis of non Malignant Neoplasm of Unspecified Site. Further review revealed no documented evidence that included information related to the Patient #2's advance directive was on his POC. Review of Patient #3's clinical record revealed a Start of Care (SOC) date of 03/19/2023 for a Plan of Care certification period from 03/19/2023 to 05/17/2023 with a diagnosis of Burn of Unspecified Degree of left foot. Further review revealed no documented evidence that included information related to the Patient #3's advance directive was on his POC.. During an interview on 05/04/2023 at 11:34 a.m., the Administrator revealed he didn't know information on advance directive had to be in the POC. Further interview revealed the Case Manager was responsible for ensuring the correct information and contents were in the POC. During an interview on 05/05/2023 at 11:26 a.m., the RN C, Case Manager revealed she had been doing some of the care plans and was not aware the advance directive were not on the POC.

Coordination of Care CFR(s): 484.60(d) Standard: Coordination of care. The HHA must: This STANDARD is not met as evidenced by: Based on observation, interview, and record review the agency failed to ensure coordination of care for one of three patients (#1) whose records were reviewed in that: RN C did not coordinate with Patient #1 for the follow up with his podiatrist for wound care order for his left foot. This failure could affect all patients in the agency and could result in care and treatment not being implemented or treatment provided without an order. The findings were: Record review of the agency's policy and procedure titled "2.36 Coordination of Services (unknown date)" read in part, "...Purpose: to coordinate services in order to provide comprehensive home care, and assure continuity of care...4. The staff professional nurse is responsible for the following: a. the professional coordination of all home care services...c. The on-going evaluation and assessment of the patient/client's home care needs, d. Maintaining channels of communication between/among all active caregivers and documents same on patient/client record. Record review of Patient #1's POC (signed by DPM D 02/07/2023 and electronically signed by RN C, Case Manager on 01/30/2023) for certification period 01/30/2023 to 05/30/023 revealed a SOC of 01/30/2023, diagnosis included Non-pressure Chronic Ulcer Other Part Left Foot, Anxiety Disorder, and Depression. Further review revealed orders for the skilled nursing to provide site care/dressing change to left foot (cream) once a week. Record review of an addendum to POC 02/07/2023 (electronically signed by Case Manager C on 03/30/2023) revealed an order for SN to provide wound care to left foot. The order did not specify how or which treatment to provide. Record review of a documented visit provided by the agency revealed Patient #1 had a follow up visit with DPM D on 02/23/2023. Further record review revealed treatment orders included Iodosorb 0.9% tropical gel, apply 1 gm three times a week by topical route. Record review of another documented visit provided by the agency revealed Patient #1 had another visit on 03/22/2023 for debridement of his left foot ulcer. Further record review of this visit revealed an order to continue the dressing change regimen. During a home visit on 05/03/2023 at 05:30 p.m., LVN A was observed providing care to Patient #1's left foot ulcer. Further observation revealed LVN A soaked a gauze with normal saline and wiped the ulcer and dried the area Kerlix. Observation at this time revealed the left foot ulcer was a pea-sized scab. LVN A then applied Mupirocin Calcium 2% cream (not Iodosorb) over the wound and covered the area with Hyperfix tape. During an interview on 05/05/2023 at 11:26 a.m., RN C, Case Manager revealed she saw Patient #1 on 03/29/2023 and Patient #1 had an open wound. RN C further revealed the Mupirocin cream was ordered previously, but there were no clear order on what to use it for. RN C told Patient #1 to follow up on 03/30/2023 with his podiatrist to get clear orders. Further interview with RN C revealed she did not follow up with Patient #1 for specific orders for Patient #1's left foot ulcer. During an interview on 05/05/2023 at 02:52 p.m., LVN A revealed Patient #1 saw the podiatry (date unknown) and he informed LVN A the podiatrist told him to change the order to back to Mupirocin cream. Further interview revealed LVN A hadn't written the order for the treatment. During an interview on 05/04/2023 at 11:44 a.m., the Administrator revealed the Case Manager was responsible for ensuring the POC was correct. Whoever visits the patient needs to tell the agency if there is any changes in treatment or meds, so the RN could update it.