Every finding on record at HHC, Inc

A Recertification Survey and Health Emergency Preparedness Survey was conducted on 11/1/2021 through 11/3/2021. An entrance conference was held with the Director of Operations. An exit conference was held with the Director of Operations, the Area Vice President-Clinical and via phone, the Area Vice President -Operations. They were afforded the opportunity to ask questions of the survey team. The facility was found to be out of compliance with 484.5-Condition of Participation Comprehensive Assessment of Patients: due to the failure to provide accurate medication documentation.

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: Based on policy review, medical record review, observation and interview, the facility failed to ensure all patients' received patient-specific and ongoing assessments of their medications in order to ensure each patient received the necessary care and services associated with the medications for 7 of 7 (Patient's #1,#2, #3, #4, #5, #6 and #7) patients selected for home visits. . The findings included: 1. Review of the agency’s policy titled “Medication Administration” revealed “…Any type of medication order, must contain the following…Route of administration…Medication management is assessed at the start at start of care and ongoing…” 2. Medical record review for Patient #1 revealed 10 medications were to be administered to the patient by mouth. Per the patient’s daughter (caregiver), the patient receives the medications via gastrostomy tube. There was no documentation the ten medications were reviewed and documented accurately to ensure the patient received the medications as prescribed. 3. Observations and interviews at Patient #2’s home revealed 1 medication the patient was taking that was not documented in the medical record. 4. Observations and interviews at the Assisted Care Living Facility (ACLF) where Patient #3 resided revealed a total of 3 medications the patient was taking that were not documented in the home health agency's (HHA) medical record. Additionally, the patient’s HHA medical record indicated the patient was taking Lispro Insulin, but the ACLF record indicated he was taking Lantus Insulin. 5. Observations and interviews at the ACLF where Patient #4’s resided revealed a total of 7 medications the patient was taking that were not documented in the HHA medical record. 6. Observations and interviews at Patient #5’s home revealed a total of 3 medications the patient was taking that were not documented in the medical record. 7. Observations and interviews at Patient #6’s home revealed a total of 4 medications the patient was taking that were not documented in the medical record. Additionally, there were 2 medications the patient was taking that had different dosages documented. 8. Observations and interviews at Patient #7’s home revealed incorrect dosage for 1 medication and 1 medication had been discontinued in September but was still listed as a current medication in the medical record. 9. In an interview on 11/3/2021 at 12:40 PM, the Area Vice President-Clinical stated, "All disciplines are supposed to do a medication reconciliation every visit..." Refer to G536.

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 policy review, medical record review, observation and interview, the agency failed to ensure all medications were reviewed and documented in order to identify any potential adverse effects and/or drug reactions for 7 of 7 (Patients #1, #2, #3, #4, #5, #6, and #7) patients selected for home visits. The finding included: 1. Review of the agency’s policy titled, “Medication Administration” revealed “…Any type of medication order, must contain the following…Route of administration…Medication Management…Medication management is assessed at start of care and ongoing. This assessment includes a drug regimen review with follow-up as indicated, management of oral and injectable medications, prior medication management, types and sources of medication assistance and patient/caregiver medication education requirements…Staff remind and instruct patients on the importance of maintaining a current list of their medications and to ask questions about their medications, especially if newly prescribed…” 2. Medical record review for Patient #1 revealed a Start of Care (SOC) date of 9/27/2021 with diagnoses of Dysphagia following Cerebral Infarction. Review of the Client Medication Report dated 11/01/2021 revealed the following medications were to be administered orally: Alprazolam 0.5 milligrams (mg), Bisacodyl 5 mg, delayed release, Labetalol 100 mg, Lactulose 10 grams, Memantine 10 mg, Methimazole 5 mg, Pantoprazole 40 mg delayed release, Quetiapine 25 mg, Rosuvastatin 20 mg, and Tylenol 8 hour 650 mg extend release. During an interview in the patient’s bedroom on 11/1/2021 at 1:38 PM, the patient’s daughter stated she administers all medications via tube (gastrostomy- a tube inserted through the skin of the abdomen to the stomach) except the baby Aspirin (Aspirin 80 mg delayed release), which she gives by mouth. She further stated the patient does not take Quetiapine, it was replaced by Xanax (Alprazolam). She stated she gives her mother Loratadine 10 mg by tube daily. The Client Medication Record was reviewed with Physical Therapy Assistant (PTA) #1, who verified Loratadine and Aspirin were not on the profile. PTA #1 also verified that above medications were listed to be administered orally and should be by tube and should not be administered by tube. There was no documentation the HHA had reviewed and accurately documented the patient's medications in order to ensure the patient was receiving the medications as prescribed. 3. Medical record review for Patient #2 revealed a SOC of date of 10/27/2021 with diagnoses of Acute Respiratory Failure, Type 2 Diabetes Mellitus, and Hypertension. Observations in Patient #2’s home on 11/1/2021 beginning at 12:30 PM, revealed 1 bottle of Glipizide 2.5 mg tablets with instructions of 1 tablet by mouth daily dated 10/22/2021. This medication was not listed on Patient #2's medication profile in the medical record. During an interview on 11/1/2021 at 12:45 PM, Patient #2 verified he had been taking the Glipizide since 10/23/2021. The HHA failed to review the patient's medications in order to ensure the patients needs were being met. 4. Medical record review for Patient #3 revealed a SOC date of 9/24/2021 with diagnoses of Stage 2 Pressure Ulcers of the Right and Left Buttock, Type 2 Diabetes Mellitus, Hypertension, Hypothyroidism, Gastro-Esophageal Reflux Disease, and Long Term (Current) use of Insulin. Observations at the medication cart at Patient #3’s home completed with Assisted Care Living Facility (ACLF) staff on 11/2/2021 beginning at 11:55 AM revealed Patient #3 was taking Vitamin D 3, 50 micrograms (mcg) once a day, Meclizine 25 mg 1 tablet as needed for dizziness, and Lantus Insulin 62 units (U) subcutaneously every day. The Vitamin D 3, Meclizine, and Lantus Insulin were not listed on Patient #3’s medication profile. Patient #3’s medication profile included Lispro Insulin 20 units three times a day. During an interview on 11/2/2021 at 12:45 PM, ACLF Staff Member #1 verified Patient #3 was not taking Lispro Insulin. The HHA failed to review the patient's medications to determine if the patient's needs were being met. 5. Medical record review for Patient #4 revealed a SOC date of 2/2/2021 and a post hospitalization resumption of care date of 10/25/2021 with diagnoses of Type 2 Diabetes Mellitus with non-gangrene ulcer, Long Term Use of Oral Hypoglycemic Drugs Atherosclerotic Heart Disease, and Hypertensive Chronic Kidney Disease. Review of the Resumption of Care Visit Note dated 10/27/2021 and updated 10/29/2021 revealed, “…Medications…Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant medications issues...No issues found during review…” Observations with Nurse #2 at Patient #4’s home at the ACLF on 11/3/2021 beginning at 9:07 AM revealed Patient #4 was taking the following medications that were not listed on the medication profile: Amiodarone 200 mg twice a day with a start date of 10/25/2021 Cephalexin 500 mg three times a day with a start date of 10/25/2021 Eliquis 5 mg twice a day with a start date of 10/25/2021 Fluticasone 50 mcg 1 spray in each nostril every day with a start date of 10/25/2021 Acetaminophen 500 mg, 2 tablets four times a day as needed with a start date of 9/20/2021 Bisacodyl 5 mg every day as needed with a start date of 9/20/2021 Docusate Sodium 100 mg twice a day as needed with a start date of 10/25/2021. During an interview on 11/3/2021 at 9:10 AM, Nurse #2 verified the medications were not listed on Patient #4’s medication profile in the HHA medical record. The HHA failed to review the patient's medications in order to determine, prepare and provide any written instructions regarding the patient's medication regimen. 6. Medical record review for Patient #5 revealed a SOC date of 10/29/2021 with diagnoses of Sepsis, Type 2 Diabetes Mellitus, Supraventricular Tachycardia, and Acute Kidney Failure. Observations in Patient #5’s home on 11/2/2021 beginning at 10:15 AM revealed 1 bottle of Omeprazole 20 mg capsules once daily, 1 bottle of Adult 50 plus multivitamins, and 2 bottles of polyethylene glycol laxative. The Omeprazole, multivitamins, and polyethylene glycol laxatives were not listed on Patient #5’s medication profile. During an interview on 11/2/2021 at 11:35 AM, Patient #5 verified the medications observed by this surveyor were the medications he was currently taking. Patient #5 further stated he had been taking the polyethylene glycol laxative for several months. The HHA failed to review and document patient #5's currently medications in order to determine and provide and educational needs. 7. Medical record review for Patient #6 revealed a SOC date of 5/29/2020 with recertification date of 9/26/2021 with diagnoses of Fracture Left Femur and Right Ankle, Chronic Obstructive Pulmonary Disease, and Chronic Respiratory Failure with Hypoxia. Review of the Client Medication Record dated 11/01/2021 revealed the following medications: Odansetron 4 mg, one tablet every 6 hours as needed dated 5/26/21, and Potassium Chloride 10 meq (milliequivalents) daily. Observations of the medication bottles in the patient’s home revealed the patient was prescribed Ondansetron 8 mg twice a day as needed on 5/26/2021. The following medications were not listed on the Client Medication Record and the patient verified she was taking them: Cyclobenzaprine 10 mg at bedtime, Metronidazole gel 1% twice a day, Symbicort 160/4.5 handheld inhaler and ZTLido patch 1.8% every day. During an interview on 11/2/2021 at 10:30 AM in the Patient’s kitchen, the patient stated her doctor changed her Potassium to 2 pills a day. During an interview on 11/2/2021 at 10:50 AM, Physical Therapist #1 stated, “I’m the one that usually comes. I ask her if she has any new meds, and she shows me.” The Physical Therapist verified the above findings. The HHA failed to review the medications for Patient #6 in order to determine any educational needs. 8. Medical record review for Patient #7 revealed a SOC date of 10/6/2021 with diagnoses of Encounter for Other Orthopedic Aftercare, Spinal Stenosis, Lumbar Region and Fibromyalgia. Review of the Client Medication Record dated 11/1/2021 revealed Duloxetine 60 mg daily and Aspirin 81 mg daily. During an interview in the patient’s kitchen on 11/2/2021 at 9:00 AM, the patient stated, “I take Duloxetine 60 mg in the morning and 30 mg at night. I stopped the Aspirin prior to surgery [9/29/2021]”. She also verified she had a prescription for Sumatriptan 50 mg (ordered 4/20/2021) for headaches. These two medications (Duloxepine and Sumatriptan) were not listed on the current Client Medication Record. The HHA failed to review the medications for Patient #6 in order to determine any educational needs. 10. During an interview on 11/3/2021 at 12:40 PM, the Area Vice President-Clinical stated, “All disciplines are supposed to do a medication reconciliation every visit…”

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on policy review, medical record review, and interview, the agency failed to follow the post-hospitalization Resumption of Care orders for Physical Therapy (PT) and Occupational Therapy (OT) evaluations for 1 of 12 (Patient #8) sampled patients. The findings included: 1. Review of the agency’s policy titled, “Coordination of Care” revealed, “…The Direrctor of Operations is responsible for the overall coordination of patient care and services…A missed visit communication note is completed when a home care visit is unable to be completed as scheduled and can not be rescheduled…In the event an ordered service cannot be performed, the physician shall be notified and new orders obtained as indicated…” 2. Medical record review for Patient #8 revealed a Start of Care date of 4/7/2021 with diagnoses of Stage 4 Pressure Ulcers of Bilateral Buttocks and Paraplegia. Review of the Resumption of Care order dated 10/21/2021 revealed, “…Physical Therapist to Evaluate. Occupational Therapist to Evaluate…” There was no documentation Patient #8 was evaluated by a Physical Therapist or Occupational Therapist and no documentation the physician was notified or new orders were obtained. During an interview on 11/2/2021 at 2:55 PM, the Area Vice President-Clinical verified the evaluations were not completed and there was no documentation as to why the evaluations were not completed.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on policy review, medical record review, observation and interview, the agency failed to ensure hand hygiene was performed by 1 of 2 (Nurse #1) nurses observed providing wound care during home visits. The findings included: 1.Review of the agency’s policy titled, "Hand Hygiene" revealed, "...To prevent the spread of Infection by contaminated hands…Perform hand hygiene as follows:...b. Before donning gloves ...After removing gloves…” 2. Review of the agency’s policy titled, “The Provision of Wound and Skin Care” revealed, “…Wound care will be provided using clean techniques and standard precautions unless specified otherwise by the ordering physician…Wound care provision consists of hand hygiene before and after the actual care and at various times during wound care provision per our hand hygiene policy…” 3. Medical record review for Patient #3 revealed a Start of Care date of 9/24/2021 with diagnoses of Stage 2 Pressure Ulcers of bilateral buttocks and Type 2 Diabetes Mellitus. Observations in Patient #3’s home on 11/2/2021 beginning at 11:55 AM, revealed Nurse #1 performed hand hygiene, donned gloves and cleaned the patient’s buttock wounds with wound cleanser and patted dry while the patient was in the bathroom. The nurse then assisted the patient back into her wheelchair and over to her recliner where she assisted the patient back into her chair. Nurse #1 removed her gloves and donned new gloves without performing hand hygiene, then opened the wound care supplies, and assisted the patient back into a standing position. The nurse then measured the wounds on the patient’s buttocks, and applied the new dressing. Nurse #1 did not perform hand hygiene prior to applying the new gloves. During an interview on 11/3/2021 at 12:40 PM, the Area Vice President-Clinical verified hand hygiene should be performed every time gloves were changed.