Every finding on record at Interim Healthcare of the Triad, Inc

An onsite recertification and follow up survey was conducted. No deficiencies to the Emergency Preparedness Program were identified.

An onsite recertification and follow up survey was conducted 10/2/23-10/3/23. Deficiencies to the Medicare Conditions of Participation were identified. The following tags were put back into compliance: G544 and G578.

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, home visit observation, clinical record review, and staff interview, the agency failed to conduct a comprehensive medication assessment for 1 of 4 patients with joint home visit observations (Patient #9). Findings included: A policy, “Medications” dated 12/21/21, was provided by the agency director on 10/3/23 at 12:40 p.m. The policy stated, “The designated qualified nurse provided the patient/caregiver with medication instructions that include…Dosage, route of administration, and duration of drug therapy…” Patient #9 was admitted on 8/31/23 with diagnoses of chronic diastolic (congestive) heart failure and chronic kidney disease. The Plan of Care (POC) for 8/31/23-10/29/23 included orders for skilled nursing visits weekly for six weeks; and physical therapy visits one time for one week, then two times per week for two weeks. The POC also included orders for skilled nursing “to instruct and assess on medication management…” A joint home visit was conducted with RN #2 on 10/3/23 at 10:00 a.m. A medication review was conducted and revealed the following discrepancies: Dorzolamide-Timolol 2.23%-0.68% eye drops one drop into both eyes daily (used to treat high pressure inside the eye) was on the POC. The patient stated that the drops were to be used twice daily. Metoprolol Succinate 25 mg daily for blood pressure was on the POC. The patient stated that she took two tablets (50 mg) daily. Sodium Bicarb 650 mg take one tablet four times daily as a supplement was on the POC. The patient stated she only took the medication on days that she had dialysis. An interview with RN #2 during the home visit revealed the nurse planned to call the physician to seek clarification.

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: Based on the Exposure Control Plan review, home visit observation, clinical record review, and staff interview, the agency staff did not follow infection prevention standards for 1 of 4 patients with joint home visit observations (Patient #7). Findings included: The “Exposure Control Plan” dated 12/19/22 was provided by the agency director on 10/3/23 at 12:40 p.m. The Plan stated, “…place your bag…in a clean area…on a clean, dry surface, or a barrier should be placed under the bag to avoid contaminating the outside of the bag…” Patient #7 was admitted on 9/11/23 with a diagnosis of chronic pain. The Plan of Care for 9/11/23-11/9/23 included orders for physical therapy three times per week for three weeks, then two times per week for three weeks. A joint home visit was conducted with physical therapist (PT) #1 on 10/2/23 at 2:00 p.m. The PT was observed placing the clinical bag on the floor of the patient’s bedroom. The bag remained open and on the floor throughout the visit. Upon the completion of the visit, the PT placed the barrier (used for equipment), that had laid on the patient’s bedding, into a plastic bag. The plastic bag was then placed in the clinical bag. An interview with the branch manager on 10/3/23 at 12:45 p.m. confirmed the clinical bag should not have been placed on the floor and the used barrier should have been discarded into the trash, not placed into the clinical bag.

An unannounced onsite recertification survey was conducted 7/6/21-7/8/21. No deficiencies to the Emergency Preparedness Plan was identified.

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on clinical record review and staff interviews the agency failed to update the comprehensive assessment the last 5 days of every 60 days for 1 of 18 charts reviewed [#10]. The findings included: Patient # 10 had a Start of Care [SOC] date of 3/8/21 and diagnoses of non-pressure chronic ulcer of right heel and midfoot with fat layer exposed and type 2 diabetes mellitus with diabetic polyneuropathy. A review of the clinical record revealed the initial certification period was 3/8/21 to 5/6/21. Further review of the clinical record revealed the first date of the new certification period was 5/7/21. RN # 3 did not update the comprehensive assessment until 5/7/21. An interview was conducted with RN # 3 on 7/8/21. RN # 3 stated, “He wasn’t my patient. Someone called me on that day and said he had to have a recert [update to the comprehensive assessment done that day. So that’s when I done the recert.” An interview was conducted with RN # 5 on 7/8/21. RN # 5 confirmed the recert should have been done within the last 5 days of the initial comprehensive [5/2/21-5/6/21].

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: Based on clinical record review and staff interviews the agency failed to follow the Plan of Care/Physician's Orders for 4 of 18 charts [# 4, 10, 16, and 18]. The findings included: 1. Patient # 4 had a Start of Care [SOC] date of 7/21/20 and an admitting diagnosis of Hypertensive Chronic Kidney Disease. A review of the Plan of Care [POC]/Physician's orders for the certification period 7/21/20 to 9/18/21 contained an order for PT [physical therapy] 2 times a week for 6 weeks. Further review of the clinical record revealed supplemental orders dated 8/17/20 for SN [skilled nursing] 3 times a week for 5 weeks. A review of the clinical record revealed on 8/17/20 RN # 4 conducted a SN eval for treatment. RN # 4 identified 5 wounds and obtained orders for the wounds as follows: Wound 1 [right lower leg]- “Clean with normal saline…place xeroform dressing over the wound…” Wound 2 [right lower leg]-“Clean with normal saline…place xeroform dressing over the wound…” Wound 3 [right lower leg]- “Clean with normal saline…place xeroform dressing over the wound…” Wound 4 [right thigh]- “Clean with normal saline…apply aquacel ag over the wound…” Wound 5 [left upper thigh]- “Clean with normal saline…apply aquacel ag over the wound…”Further review of the clinical record revealed RN # 4 made a visit on 8/19/20 and documented the following information, “…Wound 4-cleaned with normal saline and applied xeroform to wound…” On 8/21/20 RN # 4 documented the following wound care, “…Wound 4-cleaned with normal saline and applied xeroform to wound bed. Wound 5-cleaned with normal saline and applied xeroform to wound…” RN # 4 was not available for interview. On 7/8/21 RN # 5 was interviewed. During the interview RN # 5 confirmed the POC/Physician's order was not followed for wound care. 2. Patient # 10 had a Start of Care [SOC] date of 3/8/21 and diagnoses of non-pressure chronic ulcer of right heel and midfoot with fat layer exposed and type 2 diabetes mellitus with diabetic polyneuropathy. A review of the Plan of Care/Physician's orders for the certification period 5/7/21-7/5/21 revealed orders for SN [skilled nursing] 3 times a week for nine weeks and all skills to assess vital signs every visit. A review of the clinical record revealed LPN # 2 made 11 visits from 5/7/21 to 6/1/21. No temperature was obtained for any of those visits. LPN # 2 documented, “unable to obtain temperature”. LPN # 2 was not available for interview. An interview was conducted with the agency CEO [RN # 5] on 7/8/21. During the interview RN # 5 confirmed the POC/Physician's order was not followed related to obtaining vital signs each visit. 3. Patient # 16 had a Start of Care [SOC] date of 4/9/21 and a primary diagnosis of bilateral primary osteoarthritis of the knee. A review of the Plan of Care [POC] for the certification period 6/8/21 to 8/6/21 revealed orders for PT [physical therapy] 2 times a week for 5 weeks. A review of the clinical record revealed PT # 1 made only 1 routine visit the week of 6/8/21. An interview was conducted with PT # 1 on 7/8/21. During the interview PT # 1 confirmed the POC was not followed. “I guess I just looked at the calendar wrong. She did get 2 visits that week, but the other visit was done in the old cert period.” 4. Patient # 18 had a Start of Care [SOC] date of 6/5/21 with an admitting diagnosis of type 1 diabetes mellitus with foot ulcer. A review of the Plan of Care [POC] for the certification period revealed orders for SN [skilled nursing] 3 times a week for 9 weeks. On 6/7/21 Patient # 18 was seen at _____ [name of the wound center]. A review of the wound center’s orders dated 6/7/21 included, “…clean all wounds with Anticept…” RN # 3 made routine visits for wound care on 6/9/21, 6/11/21, 6/14/21, 6/16/21 and documented the following information, “…cleaned all wounds with wound cleanser…” Patient # 18 was seen on 6/17/21 at _____[name of wound center] and the following orders were written, “…clean all wounds with Anticept, apply Gentamycin ointment to wound bed and cover with calcium alginate with silver…” A review of the visit notes revealed RN # 3 saw the patient on 6/18/21, 6/21/21, 6/23/21 and 6/25/21 for wound care. RN # 3 documented the following intervention for each visit, “…cleaned with wound cleanser, applied aquacel ag to wound bed and covered with gauze…” On 7/8/21 a phone interview was conducted with RN # 3. RN # 3 confirmed she had cleaned the wound with wound cleanser and stated, “We normally just use wound cleanser or saline to clean the wounds. I don’t know what happened with the gentamycin ointment.”