Every finding on record at Home Instead Care LLC

Purpose of Visit: To conduct one complaint investigation. On 03/03/22 at 9:51 a.m., the surveyors conducted an unannounced visit, and an entrance conference was conducted with the Alt Adm/ADON. Census: Licensed & Certified Home Health Services - 142 Complaint Intake #336285 was unsubstantiated and not cited and unrelated violations cited. An exit conference was conducted on 03/04/22 at 11:00 a.m., with the Alt Adm/ADON. The preliminary findings were discussed. The agency was given the opportunity to provide additional information. Written instructions were provided for submitting a Plan of Correction within 10 days of receipt of the Statement of Violations. Abbreviations: Alt Adm – Alternate Administrator ADON – Alternate Director of Nurses CDC - Centers for Disease Control & Prevention CFR- Code of Federal Regulations COVID-19 - Novel Coronavirus of 2019 HTN - Hypertension HHSC - Health and Human Services Commission HR - Human Resources ISP- Individual Service Plan LVN- Licensed Vocational Nurse OASIS - Outcome and Assessment Information Set OSHA- Occupational Safety and Health Administration POC - Plan of Care PRN - As needed PT - Physical Therapy RN - Registered Nurse SN - Skilled Nurse

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 and interview, the agency failed to ensure that treatments were performed only as ordered by the physician for one of six active patients (#3) whose records were reviewed. Patient #3’s POC did not include orders for the SN to perform fingerstick blood sugar and wound care. This failure places patients at risk of receiving inadequate care and services and could place the patients at risk of negative outcomes. The findings included: Review of active Patient #3 electronic clinical record revealed a “Home Health Certification and POC” signed by the Alt Adm/ADON for the period of 12/18/21 to 02/15/22 with a principal diagnosis of Hemiplegia Following Cerebral Infarction Affecting Left Non-Dominant Side. The POC included a SN visit frequency of once a week for three weeks, twice a week for five weeks, once a week for one week plus three PRN visits for reported falls/injuries, HTN, respiratory and skin breakdown. The POC listed “Other Diagnosis” as Heart Failure (Unspecified), Hypotension (Unspecified), Acute Kidney Failure with Tubular Necrosis, Unilateral Primary Osteoarthritis (Right Knee), Retention of Urine (Unspecified), Type 2 Diabetes Mellitus without Complications, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Type 2 Diabetes with Diabetic Peripheral Angiopathy without Gangrene, Venous Insufficiency (Chronic)(Peripheral), Emphysema (Unspecified), Hyperlipidemia (Unspecified), Essential (Primary) Hypertension, Primary Generalized (Osteo)arthritis, Vitamin D Deficiency (Unspecified), Benign Prostatic Hyperplasia without Lower Urinary Tract Symptoms, Presence of Cardiac Pacemaker, Major Depressive Disorder (Single Episode, Unspecified) and Dependence on Wheelchair. The POC included orders for the SN to assess vital signs and notify the physician of heart rate greater than 100 or less than 60, temperature greater than 100.5 or less than 96.5, respirations greater than 24 or less than 12, pain level greater than 5, blood oxygen saturation level less than 88%, systolic blood pressure greater than 160 or less than 90, diastolic blood pressure greater than 90 or less than 60, fasting blood sugar greater than 200 or less than 70 and random blood sugar greater than 250 and less than 70. Patient #3’s electronic clinical record included 13 SN visits signed by LVN G. The forms revealed the visit dates as 12/21/21, 12/28/21, 01/04/22, 01/11/22, 01/13/22, 01/18/22, 01/20/22, 01/25/22, 01/27/22, 02/01/22, 02/03/22, 02/08/22 and 02/10/22. Review of the SN visits revealed fingerstick blood sugars were performed by the LVN G. Further review of SN visit dated 01/11/22 revealed LVN F performed wound care to left lower leg. Further review of Patient #3’s electronic clinical record failed to reveal orders for the SN to perform fingerstick blood sugars and wound care to left lower leg. During an interview on 03/04/22 at 9:47 a.m. with the Alt Adm/ADON, Surveyor Z presented the above findings of Patient #3’s POC not having an order for the SN to perform fingerstick blood sugar. The Alt Adm/ADON stated, “No I don’t see it.” Surveyor Z presented the above findings of Patient #3’s POC not having an order for the SN to perform wound care. The Alt Adm/ADON stated, “No there was nothing in the plan of care for that.” The Alt Adm/ADON also stated, “No,” there were no orders for wound care in the electronic clinical record. Review of the agency’s policy manual revealed a policy titled “Plan of Care” numbered PC.8 with a revision date of 01/13/18. The policy read in part: “PROCEDURE… V. Each patient must receive the home health services that are written in an individualized pan of care… VIII. Drugs, services, and treatment are administered only as ordered by a physician.”

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 clinical record review and interview, the agency failed to maintain a coordinated agency-wide program for the prevention of infectious diseases by failing to conduct daily screening of patients and patients' household members based on the CDC Guidelines on COVID-19 and the agency policy for four of six active patients (#1, #2, #3 and #6) whose records were reviewed. This failure could place the agency's staff and patients at risk for exposure to communicable and/or infectious diseases. The findings included: 1. Review of active Patient #1’s electronic clinical record revealed a “Home Health Certification and POC” signed by RN A for the period of 01/08/22 to 03/08/22 with a principal diagnosis of Nontraumatic Subdural Hemorrhage, Unspecified. The POC included a SN visit frequency of once a week for one week, twice a week for one week, once a week for seven weeks plus three PRN visits for new/changed medications, falls, injury and exacerbation of diagnosis. The POC also included a PT visit frequency of once a week for one week to evaluate and treat. Patient #1’s electronic clinical record included two PT Evaluations signed by PT J. The evaluations revealed the visit dates as 01/08/22 and 02/11/22. Review of the Patient #1’s electronic clinical record failed to reveal documentation PT J screened Patient #1 and household members for COVID-19. During an interview on 03/4/22 at 9:36 a.m. with the Alt Adm/ADON, Surveyor Z presented the above findings of Client #1’s electronic clinical record failing to reveal documentation PT J screened Patient #1 and household members for COVID-19. The Adm stated the screening was not documented. 2. Review of active Patient #2’s electronic clinical record revealed a “Home Health Certification and POC” signed by RN C for the period of 11/10/21 to 01/08/22 with a principal diagnosis of Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. The POC included a SN visit frequency of once a week for nine weeks plus three PRN visits for falls, cardiac and respiratory complications effective 11/10/21. Patient #2’s electronic clinical record included an OASIS-D1 Recertification assessment signed by the Alt Adm/ADON and dated 01/10/22. Review of the OASIS-D1 Recertification assessment failed to reveal documentation the Alt Adm/ADON screened Patient #2 and household members for COVID-19. During an interview on 03/04/22 at 9:40 a.m. with the Alt Adm/ADON, Surveyor Z presented the above findings of Patient #2’s electronic clinical record failing to reveal documentation the Alt Adm/ADON screened Patient #2 and household members for COVID-19 on 1/10/22. The Alt Adm/ADON stated there was no documentation for COVID-19 screening, only the documentation for COVID-19 instruction. 3. Review of active Patient #3’s electronic clinical record revealed a “Home Health Certification and POC” signed by the Alt Adm/ADON for the period of 12/18/21 to 02/15/22 with a principal diagnosis of Hemiplegia Following Cerebral Infarction Affecting the Left Non-Dominant Side. The POC included a SN visit frequency of once a week for three weeks, twice a week for five weeks, once a week for one week plus three PRN visits for reported falls/injuries, HTN, respiratory and skin breakdown. The POC also included a PT visit frequency of once a week for one week to evaluate and treat. Patient #3’s electronic clinical record included two PT Evaluations signed by PT J. The evaluations revealed the visit dates as 12/22/21 and 01/19/22. Review of the Patient #3’s electronic clinical record failed to reveal documentation PT J screened Patient #3 and household members for COVID-19. During an interview on 03/04/22 at 9:47 a.m. with the Alt Adm/ADON, Surveyor Z presented the above findings of Patient #3’s electronic clinical record failing to reveal documentation PT J screened Patient #3 and household members for COVID-19. The Alt Adm/ADON stated, “No,” PT J did not screen Patient #3 and household members for COVID-19. 4. Review of active Patient #6’s electronic clinical record revealed a “Home Health Certification and POC” signed by RN A for the period of 12/01/21 to 01/29/22 with a principal diagnosis of Type 2 Diabetes Mellitus with Other Specified Complication. The POC included a SN visit frequency of once a week for nine weeks plus three PRN visits for reported falls/injuries, new/changes in medication regimen. Patient #6’s electronic clinical record included an OASIS-D1 Recertification assessment signed by RN A and dated 01/26/22. Review of the OASIS-D1 Recertification assessment failed to reveal documentation RN A screened Patient #6 and household members for COVID-19. During an interview on 03/04/21 at 10:21 a.m. with the Alt Adm/ADON, Surveyor Z presented the above findings of Patient #6’s electronic clinical record failing to reveal documentation RN A screened Patient #6 and household members for COVID-19. The Alt Adm/ADON stated, “No,” RN A did not screen Patient #6 and household members for COVID-19. Review of the agency’s policy manual revealed a policy titled “Infection Control Program” numbered IC.2 with a revision date of 01/13/18. The policy read in part: “POLICY I. The Agency’s infection control program will be based on the following criteria:… C. Current scientific methods of surveillance and prevention or control of adverse outcomes related to infections, D. CDC guidelines… H. Current federal, state, and local laws and regulations…” Further review of the agency’s policy manual revealed a policy titled “Infection Control Plan Policy (not numbered) with an effective date of 06/22/20. The policy read in part: “PURPOSE: 1. To update the agency’s infection control policies and procedures for the protection of the patients/clients and staff for Coronavirus (COVID 19) Pandemic… 4. To comply with Local, State and Federal laws and regulations… Plan:… 2. All agency home visiting staff will be required to continue calling patients to arrange home visits, and ask patient or caregivers in household if within 2-14 days, they have been in contact with or experiencing any signs or symptoms of COVID-19 such as: fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache and new loss of taste or smell.”

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 clinical record review and interview, the agency skilled nurses failed to provide services ordered in the plan of care for three of six active patients (#1, #5 and #6) whose records were reviewed. 1. The Alt Adm/ADON and LVN G did not follow active Patient #3’s POC as written to provide instruction as ordered. 2. LVNs H and I did not follow active Patient #5’s POC as written to provide instruction as ordered. 3. RN A and LVN H did not follow active Patient #6’s POC as written to provide instruction as ordered. This failure could place the agency's patients at risk of receiving inadequate care and services and could place the patients at risk of negative outcomes. The findings included: 1. Review of active Patient #3’s electronic clinical record revealed a “Home Health Certification and POC” signed by the Alt Adm/ADON for the period of 12/18/21 to 02/15/22 with a principal diagnosis of Hemiplegia Following Cerebral Infarction Affecting Left Non-Dominant Side. The POC included a SN visit frequency of once a week for three weeks, twice a week for five weeks, once a week for one week and three PRN visits for reported falls/injuries, HTN, respiratory and skin breakdown. The POC included orders for the SN to provide instruction on safety/fall precautions, disease process of integumentary system, pressure ulcer prevention and management of hemiplegia. Patient #3’s electronic clinical record revealed 13 SN visits signed by LVN G. The forms revealed the visit dates as 12/21/21, 12/28/21, 01/04/22, 01/11/22, 01/13/22, 01/18/22, 01/20/22, 01/25/22, 01/27/22, 02/01/22, 02/03/22, 02/08/22 and 02/10/22. Patient #3’s electronic clinical record included an OASIS-D1 Recertification assessment signed by the Alt Adm/ADON and dated 02/15/22. Review of the SN visits and OASIS-D1 Recertification assessment failed to reveal documentation the Alt Adm/ADON and LVN G followed the POC as written to provide instruction on safety/fall precautions, disease process of integumentary system, pressure ulcer prevention and management of hemiplegia. During an interview on 03/04/22 at 9:47 a.m. with the Alt Adm/ADON, Surveyor Z presented the above findings of the Alt Adm/ADON and LVN G not following the POC as written to provide instruction. After review of the record, the Alt Adm/ADON stated, “No,” instruction was not provided as ordered. 2. Review of active Patient #5’s electronic clinical record revealed a “Home Health Certification and POC” signed by RN D for the period of 12/21/21 to 02/18/22 with a principal diagnosis of Essential (Primary) Hypertension. The POC included a SN visit frequency of once a week for nine weeks effective 12/21/21 plus three PRN visits for HTN, falls, change in condition or new/changed medications. The POC also included orders for the SN to provide instruction on self-management of hypertensive status, management of Essential (Primary) Hypertension, signs/symptoms of heart attack, pulmonary disfunction and fall prevention. Patient #5’s electronic clinical record included eight SN visits signed by LVNs H and I. The forms revealed the visit dates as 12/22/21, 12/27/21, 01/05/22, 01/10/22, 01/19/22, 01/26/22, 02/02/22 and 02/11/22. Review of the SN visit notes failed to reveal documentation LVNs H and I followed the POC as written to provide instruction on self-management of hypertensive status, management of Essential (Primary) Hypertension, signs/symptoms of heart attack, pulmonary disfunction and fall prevention. During an interview on 03/04/22 at 1:11 a.m. with the Alt Adm/ADON, Surveyor Z presented the above findings of LVNs H and I failing to follow the POC as written to provide instruction. The Alt Adm/ADON stated, “No,” instruction was not provided on self-management of hypertensive status, management of Essential (Primary) Hypertension, signs/symptoms of heart attack, pulmonary disfunction and fall prevention. 3. Review of active Patient #6’s electronic clinical record revealed a “Home Health Certification and POC” signed by RN A for the period of 12/01/21 to 01/29/22 with a principal diagnosis of Type 2 Diabetes Mellitus with Other Specified Complication. The POC included a SN visit frequency of once a week for nine weeks plus three PRN visits for reported falls/injuries and new/changes in medication regimen. The POC included orders for the SN to provide instruction on pain management measures. Patient #6’s electronic clinical record included seven SN visits signed by LVN H. The forms revealed the visit dates as 12/03/21, 12/11/21, 12/17/21, 12/24/21, 01/06/22, 01/13/22 and 01/21/22. Patient #6’s electronic clinical record included an OASIS-D1 Recertification assessment signed by RN A and dated 01/26/22. Review of the SN notes and OASIS-D-1 Recertification assessment failed to reveal documentation RN A and LVN H followed the POC as written to provide instruction on pain management measures. During an interview on 03/04/22 at 10:26 a.m. with the Alt Adm/ADON, Surveyor Z presented the above findings of RN A and LVN H failing to follow the POC as written to provide instruction. After review of Patient #6’s electronic clinical record, the Alt Adm/ADON stated instruction on pain management was not provided. Review of the agency’s policy revealed a policy manual revealed a policy titled “Responsibilities of the Supervising Nurse” numbered LD.6 with a revision date of 01/13/18. The policy read in part: “PROCEDURE I. The responsibilities of the Supervising Nurse include but are not limited to:… H. Ensuring that a patient’s/client’s Plan of Care or care plan is executed as written,…” Further review of the agency’s policy manual revealed a policy titled “Plan of Care” numbered PC.8 with a revision date of 01/13/18. The policy read in part: PROCEDURE… V. Each patient must receive the home health services that are written in an individualized plan of care that identifies patient/client-specific measurable outcomes and goals,…”