Every finding on record at Hancock County Health Department

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 1/16/25. The Agency was in compliance with the Condition, 42 CFR 484.102, Establishment of the Emergency Program for this survey.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 1/16/25. The Agency was not in compliance with Standards for Home Health Agencies, 42 CFR 484 as evidenced by:

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, document review, and interview, it was determined that 3 of 3 patients (Pt #3, Pt #4, and Pt #5), where home visits were conducted, the Home Health Agency (HHA) failed to ensure all medications were reviewed for accuracy. Findings include: 1. Pt #3 Start of Care (SOC): 12/26/2024. Diagnosis: Muscle wasting and atrophy multiple sites. A home visit was conducted on 1/13/25 at approximately 1:30 PM with the home health aide (HHA). Pt #3’s medications were in individually sealed packages that a pharmacy prepared. On the back of the sealed medications was a list of Pt #3’s medications dated 12/16/24. The Agency’s Plan of Care and Pt #3’s pharmacy medication list noted the following home medication discrepancies: a) Cetirizine (Depression medication) 5mg 1 tab daily by mouth was noted incorrectly on the Agency’s medication list. Pt #3 is taking Cetirizine 5mg 1 tab 2 times daily by mouth. This is the correct dose and noted correctly on Pt #3’s individually sealed prepackaged medications from the pharmacy. b) Metoprolol Tartrate (Blood pressure medication) 75mg 1 tab twice daily by mouth was noted incorrectly on the Agency’s medication list. Pt #3 is taking Metoprolol Tartrate 25mg 1 tab twice daily by mouth. This is the correct dose and is noted correctly on Pt #3’s individually sealed prepackaged medications from the pharmacy. 2. Pt #4 Start of care: 12/19/24. Diagnosis: Other specified diseases of upper respiratory tract. A home visit was conducted on 1/14/25 at approximately 9:30 AM with a Registered Nurse (E #5). The Plan of Care dated 12/19/24 noted the following medication discrepancy. a) Doxycycline Hyclate (antibiotic) tablet 100 milligrams one tab daily by mouth UTI, for 7 days. Per son of Pt #4, who manages Pt #4’s medication, Pt #4 finished medication on 12/26/24 but the medication remained on the Agency’s medication list. 3. Pt #5 Start of care: 1/8/25. Diagnosis: Aftercare following joint replacement surgery. A home visit was conducted on 1/15/2025 at approximately 3:30 pm with the Physical Therapy Assistant (PTA, E #4) for Patient (Pt) #5. During review of the patient’s medication list, the following discrepancies were noted: a) True Vitamin D3 (vitamin D3 deficiency) by mouth tablet 10 mcg (400 unit) 1 tab one time week PO (by mouth) was discontinued on the patient’s home medication list from the hospital discharge but remained on the agency’s medication list as a current medication. 4. On 1/15/2025 at approximately 3:30 PM, the Agency’s policy, titled, “Medication Reconciliation” (reviewed 4/2024) was reviewed and indicated, “2. Medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication. The patient’s medication list in the home will also be updated.” 5. During an interview on 1/15/25 at approximately 2:30 PM, the Director of Nursing (E# 2) reviewed Pt #3, Pt #4, and Pt #5’s Agency’s medication list and verbally agreed the medication discrepancies were not acknowledged and should have been.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on document review and staff interview, it was determined the Hancock County Health Department and Home Health failed to maintain an emergency preparedness plan that must be [reviewed] and updated at least every 2 years. This failure has the potential to affect all patients, staff, visitors, and community persons. 1. The Health Department EP binder was reviewed on 1/5/22 at 9:30 AM. The binder lacked documentation to indicate EP plan would be updated at least every 2 years. Last update was 1/25/2018. 2. An interview was conducted with the Home Health Director (E#2) on 1/25/22 at 10:15 AM. Staff reviewed the information in the binder and agreed there have been no updates since 1/25/2018.

A recertification survey was conducted in conjunction with an Emergency Preparedness survey on 1/4/22 through 1/6/22. The Agency was not in compliance with the Standards for Home Health Agencies, 42 CFR 484, as evidenced by: Abbreviations: E- Employee EP- Emergency Preparedness POC- Plan of Care Pt- Patient SOC- Start of Care

Standard: Initial assessment visit. CFR(s): 484.55(a) Standard: Initial assessment visit. This STANDARD is not met as evidenced by: Based on document review and staff interview, it was determined in 1 of 3 (Pt #5) records reviewed, the Agency failed to ensure the initial assessment visit for Occupational Therapy was conducted within 5 days of the referral date. This has the potential to affect all patients receiving occupational therapy at the facility with a current census of 19. 1. Pt. #5. SOC 11-17-2021. Diagnoses: Encounter for surgical aftercare following surgery on the genitourinary system. The clinical record was reviewed on 1-5-2022 at approximately 11:00 AM. The physician order indicated a SOC (Start of Care) date of 11-17-2021, with a physician order for occupational therapy to evaluate and treat. On 12-1-2021 a second order for occupational therapy to evaluate and treat was noted in the record. The record indicated the occupational evaluation/ treatment order was completed on 12-13-2021, 27 days after the start of care. A physician ordered dated 12-13-2021 at 4:00 PM indicated “OT did not complete OT eval initially ordered”. 2. On 1-5-2022 at approximately 2:30 PM the policy titled “Initial Assessments/Comprehensive Assessments (Revised October 2017) was reviewed. The policy required on page 2 “6. Completion of the Comprehensive Assessment: Must be completed in a timely manner consistent with the patient’s needs, but no later than five (5) calendar days after the start of care. 3. During an interview with the Home Health Director (E #2) on 1-6-2022 at 3:30 PM, E #2 confirmed the Agency failed to initiate services in a timely fashion. E #2 stated that our practice is to have the to have all initial assessments completed within 5 days.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on document review and interview, it was determined 1 of 7 (Pt #1) patients records reviewed, the hospital failed to ensure the wound was measured and evaluated as ordered by the physician. This has the potential to affect all patients who receive services by the Agency with a current census of 19 patients. 1. The policy titled "Plan of Care-CMS#485 and Physician Orders" (last approved 06/2021) was reviewed on 01/6/2021. The policy noted "20. Care and services provided will be provided according to physician orders. Orders are current and updated." 2. Pt #1 SOC: 11/3/2021 Diagnosis: Change or removal of nonsurgical wound dressing. The record was reviewed on 01/04/2021 at approximately 11:20 AM. The Physician's order dated 11/3/2021 noted, "Measure Wound weekly and PRN." The record noted patient's wound measurement was not provided weekly during the Skilled Nurse visits for 11/24/21, 11/30/21, 12/14/21, and 12/21/21. The record lacked documentation the Skilled Nurse notified the physician that daily wound care was unable to be conducted as ordered. 3. During an interview on 1/4/2021 at approximately 12:30 PM, E#2 reviewed Pt #1's record and stated, "E#3 Should have changed the dressing again and measured the wound as ordered." E#2 verbally agreed the wound measurements were not conducted as ordered.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on document review and staff interview, it was determined the occupational therapist failed to communicate with the physician regarding the missed visit which delayed patient services. This failure has the potential to affect all patients receiving care currently with a census of 19 patients. 1. Pt. #5. SOC 11-17-2021. Diagnoses: Encounter for surgical aftercare following surgery on the genitourinary system. The clinical record was reviewed on 1-5-2022 at approximately 11:00 AM. The “Therapy Visit Report” dated 12/8/2021 indicated that occupational therapy was reporting a missed visit. The “Communication” area was blank and which resulted in the failure to notify the physician or nurse of the missed visit on 12/8/2021. 2. On 1/6/2022 at approximately 1:30 PM the policy titled “Plan of Care – CMS #485 and Physician Orders” (revised October 2017) was reviewed. The policy indicated, “28. A missed visit will be documented in the clinical record with notification to the physician…” 3. During an interview with the Home Health Director (E #2) on 1-6-2022 at 3:45 PM, E #2 confirmed the Agency failed to notify the physician of the missed visit.