Every finding on record at Innovative Senior Care Home Health of Durham LLC

An onsite recertification survey was conducted 02/19/2024-02/21/2024. No deficiencies to the Emergency Preparedness Program were identified.

Immediate reporting of abuse by all staff CFR(s): 484.50(e)(2) Any HHA staff (whether employed directly or under arrangements) in the normal course of providing services to patients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of patient property, must report these findings immediately to the HHA and other appropriate authorities in accordance with state law. This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews the agency failed to immediately report unsafe living conditions/neglect to the appropriate state agency for 1 of 1 patient with unsafe living conditions. (patient #4) Findings included: A policy, Patient Abuse, Exploitation, and Neglect: Assessment, Identification, and Reporting (revised 11/01/22) was received on 02/20/2024 at approximately 3:26 P.M. from the Surveyor PI. The policy stated, “The agency with cause to believe a patient/client has been abuse, exploited, or neglected will immediately report the following information to the appropriate state agency…” Patient #4 was admitted on 04/07/2023 with a diagnoses of congestive heart failure, acute respiratory failure, and pressure ulcer of the right heel. The plan of care for 04/07/2023 to 06/05/2023 included orders for skilled nurse (SN) visits 1 time a week for 1 week, 2 times a week for 4 weeks, 1 time a week for 1 week, and 1 every 4 weeks for 4 weeks, physical therapy (PT) 1 time a week for 5 weeks and 1 every other week for 2 weeks, and occupational therapy (OT) 1 time a week for 1 week. For the SN visit of 04/14/2023 LPN #10 stated, “Patient is unsafe and/nor [sic] neglecting needs…” There was no evidence of LPN #10 reporting the patient to Adult Protective Services (APS). For the PT visit of 04/24/2023 PT #11 stated, “Unsafe living situation.” There was no evidence of PT #11 reporting the patient to APS. For the OT visit of 04/25/2023 OT #12 included evidence of a report being made to APS. An interview was conducted on 02/21/2024 with LPN #10 at approximately 2:45 P.M. LPN #10 stated, “We are all mandated reporters [to APS].” LPN #10 was unable to remember why she did not report patient #4 to APS. PT #11 was unavailable for an interview. An interview was conducted on 02/21/2024 with the agency director at 3:00 P.M. The agency director stated, “That would be an immediate need for social work to do a same day visit, if not refer to APS.”

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and staff interview, the agency failed to provide medical social worker services as ordered for 1 of 2 clinical records reviewed with an order for medical social work services. (Patient #5). Findings included: Policy 2.1.002, titled “Patient Assessment, Initial and Reassessment,” last revised 12/01/21, was received from the agency director on 02/21/24 at 9:10 AM. This policy revealed, “…Medical Social Worker…may make initial evaluations of the patient status to determine he need for specific therapies. This initial discipline specific evaluation(s) occur within 5 days from the Start of care [SOC] date or order date or sooner if medically necessary…Additional assessments needs are determined by patient acuity, as well as any of the following…those patients found to have pyscho-social barriers to obtaining the maximum benefit of the plan of care; including financial hindrances may receive a medical social services evaluation…” Patient #5 was admitted to the agency 03/14/23 with diagnoses including hemiplegia following cerebral infarction affecting left side, hypertension, history of falling, and problems related to living alone. Plan of Care from 03/14/23 to 05/12/23 revealed orders for skilled nursing one time per week for one week, physical therapy two times per week for three weeks and one time per week for four weeks, occupational therapy one time per week for four weeks, and medical social worker one time per week for one week. Employee #11, physical therapist, conducted a start of care visit for Patient #5 on 03/14/23. Documentation from this visit revealed, “This patient is currently living alone in a first floor hotel room without steps…pt [patient]/dtr [daughter] are planning for the pt and son to move in together in an apartment closer to pt’s dtr. Pt’s dtr is unable to provide daily assistance…pt’s on provides intermittent and undependable assistance per pt’s dtr. Pt does express concerns of food insecurity or ability to afford meds [medications]/treatment…medical social services are needed to obtain assistance for [home meal delivery program], transportation to medical appointments, possible [veteran] benefits to include private aid…spoke with [representative from physician’s office] to discuss pt status and obtain approval for SOC [start of care] and MSW [medical social worker] …” In an interview on 02/21/24 at approximately 3:00 PM, Employe #1, agency director, stated that she was not able to locate evidence that a medical social work visit was conducted for Patient #5 and that one should have been conducted as ordered.

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 direct observation, policy review, clinical record review, and staff interview, the agency failed to maintain an accurate medication profile for 1 of 6 home visits conducted. (Patient #17) Findings included: Policy 10.008, titled “Monitoring Medications”, effective 05/04/99 and last revised 12/01/23, was received from the agency’s surveyor performance improvement on 02/21/24 at 3:57 PM. This policy revealed, “…all clinicians will participate in medication review and reconciliation throughout the episode…the physician is contacted immediately if any discrepancies between agency information and patient medications are found…” and “The discipline responsible for the drug regimen review will…compare medication list obtained from the facility from which the patient was transferred and/or physician orders to actual medications patient is taking…” Patient #17 was admitted to the agency on 01/23/24 with diagnoses including COVID-19, pneumonia, Type 2 diabetes, chronic atrial fibrillation (irregular heart rhythm), acute kidney failure, and hypertension. Plan of Care from 01/23/24 to 03/22/24 revealed orders for skilled nursing, one time per week for five weeks, and one time every two weeks for two weeks; physical therapy one time per week for one week effective 01/28/24, two times per week for two weeks, and one time per week for five weeks; occupational therapy one time per week for two weeks effective 01/28/24; and home health aide two times per week for three weeks, and one time per week for two weeks effective 02/04/24. In a home visit on 02/20/24, Employee #8, Registered Nurse, was observed reviewing a list of medications that was reportedly received following a recent doctor’s visit. Employee #8 discussed noted discrepancies between the medication list received following the doctor’s visit and the agency’s medication profile with Patient #17’s responsible party. Employee #8 stated that she would contact the physician to “get her [Patient #17] medications straight.” Employee #8 was observed reviewing one medication bottle during the visit, which was acetaminophen (Tylenol). There was no evidence in the clinical record that the physician was contacted, or that any medication discrepancies were resolved by the end of survey. In an interview on 02/21/24 at 4:00 PM, Employee #1, Administrator, stated that the expectation would be that the clinician visualize patient’s pill bottles and compare the bottles to the medication list(s) reviewed. When discrepancies were noted, the clinician would contact the physician, and if unable to reach the doctor, “there should be a documented narrative related to…plans to follow up with the doctor regarding the reconciliation.” Employee #8 was unavailable for interview.

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 agency policy, clinical record review, and staff interviews the agency failed to obtain a physician's order prior to removing a peripherally inserted central catheter (PICC, intravenous medication access for long term use) for 1 of 3 patients with PICC lines. (#10) Finding included: A policy, Removal of Midline and Peripherally Inserted Central Catheters (revised 02/01/2014) was received on 02/21/2024 at approximately 3:57 P.M. from the surveyor PI. The policy stated, “Procedure: 1. Obtain physician’s order…” Patient # 10 was admitted on 12/19/2023 with a diagnosis of infection of amputation stump, right lower extremity. The plan of care for 12/19/2023 – 02/16/2024 included orders for skilled nurse visits with peripherally inserted central line (PICC) care. For the registered nurse (RN) visit of 01/12/2024 RN #2 stated, “SN [skilled nurse] called I&D [sic] to report incision and PICC exposure. PICC pulled without difficulty.” There was no evidence in the clinical record of a physician’s order to remove the PICC line. RN #2 was not available for an interview. An interview was conducted with the agency director on 02/21/2024 at 9:15 A.M. The agency director stated, “There should be an order for it [PICC removal].”

Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This STANDARD is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews the agency failed to obtain measurements of the arm circumference for 1 of 3 patients with a peripherally inserted central line (PICC, intravenous medication line for long term use.) (patient #9) Findings included: A policy Dressing Change Procedure for Central Venous, Midline, and Peripherally Inserted Central Catheters (revised 10/01/2016) was received on 02/21/2024 at 9:10 A.M. from the agency director. The policy stated, “Obtain upper arm circumference [approximately 5cm above the exit site] and compare to baseline measurement.” Patient #9 was admitted on 01/04/2024 with a diagnosis of infection/inflammation reaction due to right hip prosthetic (artificial joint.) The plan of care for 01/24/2024-03/03/2024 included orders for skilled nurse visits 1 time a week for 9 weeks and 2 PRN (as needed) visits and skilled nurse to perform site care for infusion access device PICC (peripherally inserted central line). For the skilled nurse (SN) visit of 01/22/2024 stated the arm circumference in centimeters was “0.0”. There was no evidence in the clinical record of an arm measurement. For the SN visit of 01/29/2024 LPN #13 stated the arm circumference in centimeters was “0.0”. There was no evidence in the clinical record of an arm measurement. For the SN visit of 02/05/2024 LPN #13 stated the arm circumference in centimeters was “0.0”. There was no evidence in the clinical record of an arm measurement. RN #2 was unavailable for an interview. An interview was conducted with LPN #13 on 01/21/2024 at approximately 1:30 P.M. LPN # 13 stated, “I do not know why I would not have measured, that must have been a typo on my part, it must be a typo, because I measure every visit.” An interview was conducted with the surveyor PI on 01/21/2024 at approximately 1:42 PM. The agency surveyor PI stated, “they [arm circumference] should be measured weekly.”

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and staff interviews the agency failed to prepare accurate clinical notes for 2 of 3 patients with peripherally inserted central line (PICC, intravenous medication line for long term use.) (# 9 and 10) and failed to document collaboration with the physician’s office in the clinical record for 1 of 18 records reviewed. (#7) Findings included: Policy 2.1.017, titled “Coordination of Care, From Admit through Discharge,” and last revised 09/01/23, was received from the agency director on 02/21/24 at 9:10 AM. 3. Patient #7 was admitted to the agency12/05/23 with diagnoses including hemiplegia affecting left side, osteoarthritis, shoulder pain, and history of falling. Plan of Care from 02/03/24 to 04/02/24 revealed orders effective 02/04/24 for physical therapy two times per week for two weeks and one time per week for one week, occupational therapy one time per week for four weeks, and speech therapy one time per week for four weeks. Employee #9, occupational therapist (OT), conducted an evaluation visit on 02/09/24 and documented, “Patient reported feelings of isolation, stress and paranoia. Patient believes that her neighbor can see her in the bathroom, therefore she is not showering. In addition, the patient mentioned thoughts of suicide and then followed that statement with ‘I know that’s not in the plan for my life so it won’t happen’. OT encouraged patient to call her psychologist and speak with her family about her concerns/state of mind. OT contacted [names of responsible party, facility executive director, and facility resident director] regarding mental health concerns. In addition, OT attempted to contact PCP [primary care physician] however the office was closed. OT will follow up on Monday, 02/12/24.” There was no documented evidence of follow-up with the PCP in the clinical record at the close of survey. In an interview on 02/21/24 at 1:50 PM, Employee #9 stated, “Yes, I did make contact. It should be in one of my visit notes…I did speak with the physician… I thought I had put it in [the clinical record] …” In an interview on 02/21/24 at 1:54 PM, Employee #4, surveyor, performance improvement, stated “I would expect to see follow up…”. In an interview on 02/21/24 at approximately 2:15 PM, Employee #1, agency director, stated that Employee #9 had taken notes on a note pad (outside of the clinical record) related to a conversation with the physician’s office on 02/12/24 at 9:37 AM and would enter that information in the clinical record as a late-entry. A policy, Home Care Record (revised 10/01/2023) was received on 02/21/2024 at 3:57 P.M. from the surveyor PI. The policy stated, “All entries in the home care record must be legible and accurate.” 1. Patient #9 was admitted on 01/04/2024 with a diagnosis of infection/inflammation reaction due to right hip prosthetic (artificial joint.) The plan of care for 01/24/2024-03/03/2024 included orders for skilled nurse (SN) visits and SN to perform site care for infusion access device PICC (peripherally inserted central line). For the registered nurse (RN) admission visit on 01/04/2024 RN #2 stated arm circumference in centimeters “27.0”. For the SN visit of 01/08/2024 LPN #13 stated arm circumference in centimeters “44.0”. For the RN visit of 01/15/2024 RN #2 stated arm circumference in centimeters “17.0”. For the SN visit of 02/12/2024 LPN #13 stated arm circumference in centimeters “30.0”. 2. Patient # 10 was admitted on 12/19/2023 with a diagnosis of infection of amputation stump, right lower extremity. The plan of care for 12/19/2023 – 02/16/2024 included orders for skilled nurse (SN) visits with peripherally inserted central line (PICC) care. For the Register nurse (RN) admission visit of 12/19/2023 RN #14 stated arm circumference in centimeters “20.0”. For the SN visit of 12/20/2023 LPN #13 stated arm circumference in centimeters “34.5”. For the SN visit of 12/29/2023 LPN #6 stated arm circumference in centimeters “43.0”. RN #2 was not available for an interview. RN #14 was not available for an interview. An interview with LPN #13 on 02/21/2024 at approximately 1:30 P.M. revealed that LPN #13 believed that the arm circumference measurements for patient #9 obtained by RN #2 were not accurate. LPN #13 stated, “He [patient #10] was started by a travel nurse, when I measured, he said that nobody else has done that.” An interview was conducted on 02/21/2024 with LPN #6 at approximately 1:35 P.M. LPN #6 stated, “I know the other measurements were wrong. I measure 10cm insertion site, that’s how I was taught.” An interview with the agency director and surveyor PI on 02/21/2024 at approximately 1:45 P.M. revealed that the expectation is for the nurses to measure the arm circumference and enter the correct measurement into the clinical record