Every finding on record at Greatland Home Health Services, Inc

An investigation was conducted on 08/21/2024 for Complaint #242861/108043. The Home Health Agency was not in compliance with the related standards surveyed for 42 CFR 484 for Home Health Agencies.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on review of clinical records, staff interview and policy review, it was determined for 1 of 3 (Pt. #1) clinical records reviewed, the Agency failed to ensure the Skilled Nurse documented all necessary information in the clinical notes. Findings include: 1. Patient (Pt.) #1 was admitted to home health services on 11/02/2023 and discharged on 06/25/2024. The clinical record was reviewed on 08/21/2024. The clinical record included plans of care, clinical notes, physician orders and discharge notes. The record lacked clinical notes documenting disposal of medication and physician notification in reference to Employee (E) #3 disposing of unidentifiable medications while filling Pt. #1’s pill box. 2. An interview was conducted with E #3 on 08/21/2024 at 1:30 PM. During the interview E #3 stated she remembered taking care of Pt. #1. She stated the pill box for Pt. #1 was filled by the family or by “me”. E #3 stated she recalled a day when she filled the pill box and had to dispose of unidentifiable medication for patient’s safety. She stated, she didn’t remember if she documented information regarding disposal of medication. 3. The policy for medication disposal was reviewed. The policy included, “…Medication can be disposed of by the staff after notifying the physician or pharmacy and in agreement with the client for safety for the following reasons… 5. Drugs not in original medication container and unidentifiable…” The clinical record lacked documentation that the physician was notified of medication disposal. 4. During interviews with the Administrator and Director of Clinical Services on 08/21/2024, the above findings were confirmed.

An investigation was conducted on 6/17/24 for complaint 106911/242638. The Agency was in substantial compliance with the Medicare requirements at 42 CRF 484 for Home Health Agencies with standard level citations. Abbreviations: Pt./Pts. = Patient/Patients SN = Skilled Nursing WK = Week MD = Medical Doctor E = Employee PM = afternoon

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on clinical record review, policy review and staff interviews, it was determined for 3 of 3 (Pts. # 1, 2 and 3) clinical records reviewed, the Agency failed to ensure care and/or services were provided in conformance with the orders of the physician and as indicated in the Plan of Care. Findings include: 1. Pt. #1 was admitted to home health services on 4/14/24 with a diagnosis of Pressure Ulcer of Sacral Region Stage 3. Pt. #1’s record included a Plan of Care for the certification period of 4/14/24 to 6/12/24 which required: “Skilled Nurse to perform/teach wound care to sacrum; Goals…Wound status will improve as evidenced by a decrease in size, drainage, absence of infection…” The SN note/Wound Record Report dated 4/14/24, 4/25/24 and 4/29/24 lacked documentation of wound measurements. The Plan of care also required: “Frequency/Duration of Visits: SN 2WK8, 1WK1.” The clinical record lacked documentation of a SN visit and/or documentation of a physician notification of a missed visit for the week of 5/5/24 to 5/11/24. 2. Pt. #2 was admitted to home health services on 1/19/24 with the diagnosis of Pressure Ulcer of Other Site Stage 2. Pt. #2’s record included a Plan of Care for the certification period of 3/19/24 to 5/17/24 which required: “Skilled Nurse to perform/teach wound care to left buttocks; Goals…Wound status will improve as evidenced by a decrease in size, drainage, absence of infection…” The SN notes/ Wound Record Report dated 3/26/24, 4/4/24, 4/11/24 and 4/17/24 lacked documentation of wound measurements. 3. Pt. #3 was admitted to home health services on 9/29/23 with the diagnosis of Pressure Ulcer of Sacral Region Stage 3. Pt. #3’s record included a Plan of Care for the period of 3/27/24 to 5/25/24 which required, “Skilled Nurse to perform/teach wound care to left buttock; Goals…Wound status will improve as evidenced by a decrease in size, drainage, absence of infection…” The SN notes/Wound Record Report from 4/19/24 through 6/5/24 lacked documentation of wound measurements. The record also included a physician order dated 4/9/24: “Per MD see patient 2x per week until wound heals… SN effective 4/7/24, 2WK7.” The SN notes/Client Calendar Report lacked documentation of 2 SN visits or physician notification of the missed visits for the week of 5/12/24 to 5/18/24. 4. The Policy titled, “Clinical Documentation” was reviewed and required: “Purpose: To document conformance with the Plan of Care…1. All skilled services provided by Nursing…will be documented in the clinical record. 6. Services not provided and the reason for the missed visits will be documented and reported to the physician.” 5. The Policy titled, “Missed Visit Policy” was reviewed and required: “If the scheduled missed visit cannot be completed within the same week: i) the nurse must notify the doctor of the reason of the missed visit and follow doctor’s order if he recommends the visit be made up. ii) complete the missed visit as scheduled or document the missed visit in the coordination note. 6. A telephone interview was conducted with E#3 (Registered Nurse) on 6/17/24 at 2:59 PM. E#3 stated that wound measurements are to be done weekly and should be documented on the medical record. E#3 also stated that if a visit is missed, it should be rescheduled within the same week and if not, the physician should be notified of the missed visit. 7. A telephone interview was conducted with E#4 (Registered Nurse) on 6/17/24 at 3:10 PM. E#4 stated that the SN visits are conducted based on the visit frequency as ordered by the physician. E#4 stated that the if a visit is missed, it should be rescheduled within the same week, and to call the physician if the visit is missed and document in the record. E#4 stated that wound measurements are to be done weekly and documented on the electronic record to determine if the wound has improved or deteriorated, and also to know there is a need to change the wound treatment. 8. An interview with the Administrator (E#1) on 6/17/24 at 4:00 PM. E#1 stated that nurses are sent to see patients according to the Plan of Care or physician orders. E#1 stated that if a visit is missed, it should be rescheduled during the same week, if not possible, then the doctor should be notified. E#1 also confirmed that the Agency practice is to measure the wound weekly to determine if the wounds have improved or deteriorated, and to document the measurements in the electronic record. During the same interview, the above findings were confirmed.

G000 Tag Substantial Allegation Survey conducted for complaints # 196C0 (212962/31920, 212963/31922, 212964/31923, 212977/31938). Standard level deficiencies cited Abbreviations: x = times WK - week # = number AM = morning E = Employee abt = antibiotic IV = intravenous d/c = discontinue PRN = as needed MG = Magnesium SN = Skilled Nurse POC = Plan of care SOC = Start of care PsOC = Plans of Care RN = Registered Nurse PM = afternoon/evening Pt./ Pts. = Patient/Patients CBC = Complete Blood Count LPN = Licensed Practical Nurse CMP = Comprehensive Metabolic Panel PICC = Peripherally Inserted Central Catheter

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: A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure staff provided services as ordered by the Physician as required in the PsOC. This was found in 2 of 5 (Pt. #2 and #3) clinical records reviewed. Findings include: 1. Pt. #2. SOC 3/25/21. Principal Diagnosis: Sepsis, Unspecified Organism. The clinical record was reviewed on 10/6/21 at 10:00 AM. The record included a physician order dated 3/30/21, requiring “…that the IV abt will be done on Friday (4/2/21) and asking to remove midline on Saturday (4/3/21) and d/c weekly labs as well. Will send orders as well.” The record contained a “Visit Note Report” dated 4/2/21 that included documentation, “Call out to (MD’s) office… and per the order, (Pt. #2) to complete dose on Friday, 4/2/21, so (Pt. #2) to take IV abt until the last dose on 4/2/21 then stop…” The record also contained a “Visit Note Report” included documentation that on that skilled nursing visit dated 4/5/21, Pt. #2 still had an “IV access…PICC line.” The record lacked documentation of the IV access line being discontinued on 4/3/21 as ordered. 2. Pt. #3. SOC 6/8/21. Principal Diagnosis: Anal Abscess. The clinical record was reviewed on 10/5/21 at 2:50 PM. The record included a POC for the certification period of 6/8/21 to 8/6/21 requiring, "Frequency/Duration of Visits: SN 2 Wk 2, 1 Wk 7, 1 SN PRN Visit for Clinical Management." The record lacked documentation of an SN visit for the week of 6/27/21 to 7/3/21. The record contained a “Client Coordination Note Report” that included the documentation “(Pt.#3) phoned for visit; however (Pt.#3) stated (Pt. #3) wouldn’t be home today.” The same clinical record also included a physician order dated 7/1/21 which required, “IV abt completed on 7/2. Pull Midline on either 7/2 or 7/3.” The record lacked documentation that the midline catheter was discontinued on 7/2 or 7/3/21 as ordered. The record lacked documentation the physician was notified of the missed skilled visit and midline was not removed. 3. The Agency Policy, “Physician Orders” was reviewed on 10/6/21 at 1:00PM. The policy requires, “All medications, treatments, and services provided to clients must be ordered by a physician…” 4. The Agency Policy, “PICC line cannula removal” was reviewed on 10/6/21 at 1:15 PM. The policy requires, “Documentation Guidelines: Document in the record: a. The Procedure, b. Condition of Site, c. Client tolerance of the procedure, d. Condition of the catheter and appearance of the tip, e. date and time sutures removed, if applicable, f. type of dressing applied, g. Any complications or problems encountered in removing the catheter, h. Physician notification, j. Client/caregiver instructions." 5. The Agency Policy, “Missed Visit Policy” was reviewed on 10/6/21 at 2:15 PM. The policy requires, “…If the scheduled missed visit cannot be completed within the same week: i) The nurse must notify the doctor of the reason of the missed visit and follow doctor’s order if he recommends the visit be made up; ii) Complete the missed visit as scheduled or document the missed visit in coordination note.” 6. During an interview with E#1 (Executive Director) and E#2 (Clinical Manager), on 10/6/21 at 3:44 PM, the above findings were confirmed. E#1 and E#2 stated the Physician should be notified of missed visits or anytime when orders are delayed, or when the procedures cannot be carried out according to the physician’s orders and the notification should be documented on the clinical record.

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: A. Based on clinical record review and staff interviews, the Agency failed to ensure that the physician was notified regarding services that were not provided as ordered and indicated in the PsOC. This was found in 2 of 5 (Pts. #2 and #3) clinical records reviewed. Findings include: 1. Pt. #2. SOC 3/25/21. Principal Diagnosis: Sepsis, Unspecified Organism. The clinical record was reviewed on 10/6/21 at 10:00 AM. The record included a physician order dated 3/30/21, requiring “…that the IV abt will be done on Friday (4/2/21) and asking to remove midline on Saturday (4/3/21) and discontinue weekly labs as well. Will send orders as well.” The same record contained “Visit Note Report” on 4/2/21 that included documentation, “Call out to (physician’s) office… and per the order, (Pt. #2) to complete dose on Friday, 4/2/21, so (Pt. #2) to take IV abt until the last dose on 4/2/21 then stop…” The “Visit Note Report” on 4/5/21 included documentation that on that skilled visit, Pt. #2 still had an “IV access…PICC line.” The record lacked physician notification that the IV access line was not removed on 4/2/21 as ordered. 2. Pt. #3. SOC 11/6/20. Principal Diagnosis: Anal Abscess. The clinical record was reviewed on 10/5/21 at 2:50 PM. The record included a POC for the certification period of 6/8/21 to 8/6/21 requiring, "Frequency/Duration of Visits: SN 2 Wk 2, 1 Wk 7, 1 SN PRN Visit for Clinical Management." The record lacked documentation of an SN visit for the weeks of 6/27/21 to 7/3/21. The record contained a “Client Coordination Note Report” that included the documentation “(Pt.#3) phoned for visit; however (Pt.#3) stated (Pt. #3) wouldn’t be home today.” The record lacked Physician notification of the missed visit. The clinical record also included a physician order dated 7/1/21 which required, “IV abt completed on 7/2. Pull Midline on either 7/2 or 7/3.” The record also lacked Physician notification that the midline catheter was not discontinued on 7/2 or 7/3/21 as ordered. During an interview with E#1 (Executive Director) and E#2 (Clinical Manager) on 10/6/21 at 3:40 PM, E#1 stated that the nurse missed the visit because Pt. #3 was not at home, was not able to reschedule a visit and was not able to discontinue the midline catheter due to the missed visit. E#1 stated that the midline catheter was removed in the doctor's office the following week, however it was not documented in the patient's record. 3. The Agency Policy “Medical Supervision” was reviewed on 10/6/21 at 2:00 PM. The policy requires, “…Physician will be contacted when any of the following occurs: e. Any change in client condition or agency services…” 4. The Agency Policy “Missed Visit Policy” was reviewed on 10/6/21 at 2:15 PM. The policy requires, “…If the scheduled missed visit cannot be completed within the same week: i) The nurse must notify the doctor of the reason of the missed visit and follow doctor’s order if he recommends the visit be made up; ii) Complete the missed visit as scheduled or document the missed visit in coordination note.” 5. During an interview with E#1 and E#2, on 10/6/21 at 3:44 PM, the above findings were confirmed. E#1 and E#2 stated the Physician should be notified of missed visits or anytime when the orders are delayed, or when the procedures cannot be carried out according to the physician’s orders and the notification should be documented on the clinical record.

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: A. Based on review of a clinical record, complaint log, staff interview, staff in-services and personnel file review, it was determined the Agency failed to ensure staff practice infection control measures and receive infection control education. This was found in 1 of 5 clinical records reviewed. Findings include: 1. The Agency’s complaint log was reviewed on 10/6/21 at 9:45 AM. The log contained a complaint regarding Pt. #1. “Date of Event 08/30/2021…The nurse draw blood with butterfly needle and did not have a sharp container to dispose needle so the nurse wrapped the needle up in a glove…” The complaint had a section titled, “Intervention/Resolution Comments” which included: “Nurse provided with education about properly disposal of sharps.” The complaint log lacked the name of the nurse. 2. During an interview with the Executive Director and the Director of Clinical Services on 10/6/21 at 3:20 PM, both stated that E #2 was the nurse that failed to dispose of the butterfly needle properly which resulted in the complaint the Agency received on 8/27/21. 3. The Agency’s staff in-service log was reviewed on 10/6/21 at 9:40 AM. The in-service log contained documentation that one (1) in-service was provided to staff in August (8/27/21). The log contained multiple topics including: “Infection Control, Orders, PICC line, Midline, Physician Notification, Patient Education and Documentation”. The section titled Infection Control included this entry: “Sharp are to be placed in a sharp container and not in paste bag or left in the patient home”. The in-service log dated 8/27/21 lacked the name of E #2. 4. The personnel file of E #2 was reviewed on 10/6/21 at 11:50 AM and lacked documentation E #2 received any in-service education pertaining to infection control and/or proper disposal of needles on 8/27/21 or after. The file included documentation that E #2 separated from the Agency on 8/29/21. The Agency failed to provide to E #2 education pertaining to infection control issues, as indicated above. 5. The Agency policy titled, “Universal Body Substance Precautions” was reviewed on 10/6/21 at 1:40 PM. The policy required: “…3. Syringe/Sharps Disposal a) In the home setting, a sharps disposal container is to be brought to the point of use by the clinicians who will be administering the injection or drawing the blood sample…” 6. The Agency policy titled, “Competency Evaluation of Home Care Staff” was reviewed on 10/6/21 at 12:30 PM. The policy required: “…4…actions will be taken when opportunities for improvement are identified…” 7. During an interview with the Executive Director and the Director of Clinical Services on 10/6/21 at 3:30 PM, both confirmed the above findings.

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: A. Based on a review of personnel files, Agency policy and staff interview, it was determined the Agency failed to ensure that hiring practices were followed. This was found in 1 of 7 (E #6) employee personnel files reviewed. Findings include: 1. The personnel file of E #6 was reviewed on 10/6/21 at 12:15 PM. The file lacked documentation of competency skill evaluations. 2. The Agency policy titled, “Competency Evaluation of Home Care Staff” was reviewed on 10/6/21 at 12:30 PM. The policy required: “…2. The assessment will verify and focus on the individual staff knowledge and skill appropriate to assigned responsibilities, communication skills, and the ability to respond to client needs within their scope of responsibility…4. All competencies will be documented, and actions will be taken when opportunities for improvement are identified. 3. During an interview with the Executive Director and the Director of Clinical Services on 10/6/21 at 3:30 PM, both confirmed the personnel file of E#6 lacked competency skill evaluations, as required by the Agency.