Every finding on record at Good Shepherd Health Care Systems

An unannounced Federal recertification survey was completed at this agency on 7/28/2022. The agency was surveyed for compliance with 42 CFR Conditions of Participation for Home Health Agencies, Part 484. An entrance conference was held with the Home Health & Hospice Manager, and the Home Health Coordinator on 7/25/2022 at 10:45 AM; 2 Quality Review Nurses joined at 11:07 AM. The purpose of the survey and the survey needs were explained. An opportunity was provided for questions, answers and comments. Definitions and abbreviations: BID - twice a day CEO- Chief Executive Officer CFR - Code of Federal Regulations mg - milligram po - by mouth

Have a confidential clinical record CFR(s): 484.50(c)(6) Have a confidential clinical record. Access to or release of patient information and clinical records is permitted in accordance with 45 CFR parts 160 and 164. This ELEMENT is not met as evidenced by: Based on observation, document review and interview, it was determined the agency failed to protect the right of a patient to have a confidential clinical record. Findings: During the entrance conference, the agency was asked to provide a blank admission packet prepared to present to a new patient on admission. Review of information in the packet provided revealed it contained carbon copies of an "Admission Agreement" and a "Medicare/Medicaid/VA - Patient Payment Liability" form that had been presented to a potential patient. The forms contained the patient name, representative's name, representative's contact number and representative's signature. During an interview with Employee #1 on 7/26/2022 beginning at 1:20 PM the above finding was presented. Employee #1 acknowledged the seriousness of a potential HIPAA violation if the packet had been presented to another patient and stated "Wow, I don't even know what to say. That should not have happened."

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on agency document review and interview, it was determined the agency failed to advise patients of the names, addresses, and telephone numbers of the Federally-funded and state-funded entities that serve the area where the patient resides required by this regulation. Findings: Review of the packet presented to patients on admission to the agency revealed the information failed to include the names, addresses and telephone numbers for the local Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. During an interview with Employee #1 on 7/26/2022 beginning at 1:20 PM the above finding was presented. Employee #1 was asked if the agency presented the information to the patient in another way. Employee #1 asked for the assistance of Employee #2. Employee #2 stated he/she thought the information was in the admission packet but looked through the packet and stated "It's not there." Both employees acknowledged the information was not being presented to patients as required.

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 clinical record review and interview, it was determined the agency failed to ensure the individualized plan of care included complete medication orders for 3 of 7 active patient clinical records reviewed (Patients #1, 2 and 5). Findings: Patient #1: Review of information on the "Medication Profile," printed on 7/26/2022, revealed the order "glucosamine-chondroitin 500-400mg [sic]; oral tablet; 2 tablets daily; Instructions: actual dose 1500-1200mg [sic]." During an interview with Employee #2 on 7/27/2022 beginning at 9:15 AM, it was discussed that the tablet dosage and instruction to take 2 tablets daily did not add up to the "actual dose 1500-1200mg [sic]" instructions. It was discussed that taking 2 tablets daily would result in a dose of 1000-800 mg; while 3 tablets daily would be required to achieve a dose of 1500-1200 mg. Employee #2 acknowledged the "dose versus instructions are confusing" and needed to be clarified. Patient #2: Review of information on the "Medication Profile," printed on 7/26/2022, revealed the order "docusate sodium 250 mg; oral capsule." The order failed to include further instructions. During an interview with Employee #2 on 7/27/2022 beginning at 9:15 AM, a request was made for documentation that would clarify the instructions. Employee #2 searched the electronic health record of Patient #2 for additional information and stated "It should be 100 mg po BID." It was then discussed that the medication dosage listed was a 250 mg oral capsule; Employee #2 acknowledged that the information needed to be clarified. Patient #5: Review of information on the "Medication Profile," printed on 7/26/2022, revealed the order "acetaminophen 326 mg; oral tablet, 1-2 Tablets as needed." The order failed to include how often the medication could be taken. During an interview with Employee #2 on 7/27/2022 beginning at 9:15 AM, Employee #2 stated that the order "Needs a dosing update."

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on interview, it was determined the agency failed to document interdisciplinary team meetings in a way that demonstrated that the meetings held were "interdisciplinary." Findings: During the entrance conference, the agency was asked to provide documentation showing that the interdisciplinary team held periodic discussions regarding the patients' health status and recommendations for the plan of care. During an interview with Employee #1 on 7/26/2022 beginning at 1:20 PM, Employee #1 was reminded of the request for documentation. Employee #1 stated "We can show that meetings were done but not who attended." Employee #1 acknowledged that being able to show interdisciplinary attendance at the meetings was an integral part of the regulation.