Every finding on record at Jefferson Co Pub Hlth Svs Chha

This Statement of Deficiencies report is the result of a recertification survey conducted 09/19/23 - 09/26/23. On 09/18/23, during the pre-survey preparation, the surveyor reviewed accuracy of contact information in the Health Commerce System. The following information was reviewed during the survey: the agency's emergency preparedness policies and procedures, the emergency patient roster, and staff call down list. Interviews were conducted with the Administrator, Director of Patient Services and Supervising Nurse. No federal deficiencies were cited.

The following statement of deficiencies represents the results of a partial extended recertification survey of Jefferson County Public Health Services Certified Home Health Agency conducted on 09/19/23 - 09/26/23. A standard recertification survey was initiated on 09/19/23. Deficient practices were identified within Level 1 standards in Condition 484.60 (Care planning, coordination of services, and quality of care), resulting in a partial extended survey. The survey consisted of a review of 17 clinical records, including 5 discharge records, 9 personnel records, and 7 observational home visits. The survey also included a review of pertinent policies and procedures, Quality Improvement Meeting minutes for the past 12 months, agency’s Admission Packet, the Emergency Preparedness Plan, Complaint Log and 2 contracts. Pre-survey activities consisted of a review on 09/18/23 of the agency’s Health Commerce System account, Internet Quality Improvement and Evaluation System (iQIES) reports for the period 06/01/22 through 05/01/23, and the agency’s compliance with report submission for the 2022 statistical report. The Administrator and Director of Patient Services were interviewed. Findings were reviewed at the exit conference on 09/26/23. The following deficiencies were identified as a result of the survey: Federal: G 528 Health, psychosocial, functional; G 574 Plan of care must include the following; G 606 Integration of all services; and G 0798 Home health aide assignments and duties. State: J 1156 Governing authority and J 1424.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on review of clinical records, observational home visits, policies and procedures, and interviews with the Administrator, Director of Patient Services (DPS) and clinical staff, it was determined for 5 of 17 patients (patients #3, 5, 8, 9, and 17 ) the agency failed to ensure comprehensive assessments were of sufficient scope to identify all patient needs. Evidence as follows: Home Visit Patient #3 was admitted to the agency on 08/04/23 with diagnoses of right foot ulcer, type 2 diabetes, cardiomyopathy, and congestive heart failure. The SN failed to consistently assess the frequency of blood glucose (BG) testing and results. The 08/03/23 Hospital Discharge Summary included Novolin 70-30 (combination of long and short acting insulin) insulin 75 units subcutaneous injection each morning and 65 units each evening. There were no instructions regarding BG testing frequency. On 08/04/23 the SN visited the patient for the start of care assessment and documented the patient tested BG daily, before each meal. The SN documented a BG at the visit of 66 and no additional information regarding other readings. The 08/04/23-10/02/23 Home Health Certification and Plan of Care (POC) included fingerstick BG testing twice a day and parameters to report readings of less than 60 or greater than 200. On 08/05, 08/07, 08/09, 08/14, and 08/16/23 the SN documented the patient was testing blood glucoses daily before breakfast and failed to recognize the POC included twice daily testing in order to assess results for both times. On 08/11/23 the SN documented the patient was testing BG before bed, before each meal and documented a reading for the visit of 95 with no additional information regarding the other times. On 08/18, 08/21, 08/23, 08/25, 08/28, 08/30, 09/06, 09/08, 09/11, 09/13, and 09/18/23 the SN documented the patient was testing blood glucoses daily before each meal and failed to assess any readings other than the reading from the morning and if needed, update the POC to include the additional readings. On 09/01 and 09/03/23 the SN visited and did not address BG readings or frequency of testing. On 09/20/23 the surveyor conducted an observational home visit with the SN for wound care to the right foot. During the visit the patient stated BG testing was done twice daily and the patient was adjusting the ordered Novolin 70/30 insulin based on readings. The morning blood glucose was 180 and the patient took 20 units. The patient stated usually the readings were 80-90 in the morning. On 09/25/23 at 1 p.m. the surveyor reviewed the record with the Administrator, DPS and supervisor who acknowledged the findings. Patient #8 was admitted to the agency on 08/19/23 with diagnoses of recent cardiac arrest, heart failure, type 2 diabetes, dysphagia, and end stage kidney disease on dialysis. On 08/19/23 the skilled nurse (SN) visited the patient for the start of care assessment and failed to assess the following: Nitroglycerin The 08/18/23 hospital discharge instructions included Nitroglycerin 0.4 mg tab sublingual as needed for chest pain. The SN failed to assess if there was a history of chest pain and if the patient had the Nitroglycerin available and understood how to use the medication and what to do if it was not effective. Thickened liquids The hospital discharge instructions included nectar thick liquids. The SN documented the patient had a mechanical altered diet, however failed to assess the use and understanding of nectar thick liquids. On 09/25/23 at 1 p.m. the surveyor reviewed the record with the Administrator, DPS and supervisor. They acknowledged the findings, and no additional information was provided. Home Visit Patient #5 was admitted to the agency on 08/30/23 with diagnoses of acute respiratory failure, chronic respiratory disease and type 2 diabetes. The SN failed to perform a comprehensive assessment of the patient's needs. Sleep Apnea The 08/30/23 plan of care included a diagnosis of obstructive sleep apnea with a continuous positive airway pressure (CPAP) machine listed with durable medical equipment (DME) and supplies. On 08/30/23 the SN completed the initial assessessment. There was no evidence the SN assessed and documented the presence of the CPAP machine including the frequency of use, settings and patient compliance with using and maintaining machine as directed. On 09/07/23 the SN visited the patient and documented the patient was on continuous oxygen at 5 liters/minute via nasal cannula and was independent with BIPAP (bilevel positive airway pressure) system. The SN failed to clarify whether the patient was to use CPAP, which provides continuous airway pressure as specified in the plan of care, or BIPAP which delivers 2 levels of pressure during inhalation/exhalation as documented in the assessment. The SN failed to assess frequency of use, machine settings, and instructions for maintaining continuous oxygen during use. Leg/Foot Brace On 08/30/23 the SN documented in the initial assessment the patient required no orthotic or prosthetic devices. On 09/21/23 at 1:00 p.m. the surveyor completed a home visit with the SN. During the visit, the surveyor observed the patient was wearing a brace to the lower left leg and foot. The SN stated the brace was needed due to an injury sustained in car accident. The SN failed to assess and document the patient’s use of the left lower leg/foot brace. On 09/25/23 at 1:00 p.m. the findings were reviewed with the Administrator, DPS and supervising nurse. They acknowledged the findings and provided no additional information.

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 a review of clinical records, observational home visits, and interviews with the Administrator and Director of Patient Services (DPS), it was determined in 3 of 17 records (patients #4, 5, and 10) the agency failed to develop complete and accurate plans of care that were individualized to address the total needs of the patients. Evidence as follows: Patient #10 was admitted to the agency on 07/12/23 with diagnoses of multiple sclerosis, chronic indwelling (Foley) urinary catheter with recurrent urinary tract infections, hydronephrosis, type 2 diabetes, and hypertension. The 07/06/23 hospital discharge summary included prednisone (steroid) 20 mg daily to continue for 4 weeks and Foley catheter changes every 4 weeks. Prednisone The 07/12/23-09/09/23 Home Health Certification and Plan of Care (POC) included prednisone 20 mg every day and had no end date, however, the Documentation of Difficult and Taxing Effort to Leave Home note on the orders stated prednisone would continue for four weeks. Prednisone remained on the 09/10/23-11/08/23 POC. On 08/08/23 the SN documented the patient reported they were out of prednisone and had called the neurologist. The SN failed to recognize the medication should have ended. Catheter On 07/12/23 the SN visited the patient and documented the patient had a 16 Fr. Foley catheter with no specification of the size of the balloon. The POC did not include a balloon size for the Foley catheter. On 09/26/23 at 11 a.m. the surveyor reviewed the record with the Administrator, DPS and supervisors who acknowledged the findings. The DPS later stated the primary nurse confirmed the prednisone had been stopped and the record would be corrected, and the Foley catheter order would be updated. Home Visit Patient #5 was admitted to the agency on 08/30/23 with diagnoses of acute respiratory failure, chronic respiratory disease and type 2 diabetes. The plan of care was incomplete/inaccurate as follows: Sleep Apnea The 08/30/23 plan of care included the patient used a continuous positive airway pressure (CPAP) machine and was on continuous oxygen at 5 liters per minute via nasal cannula. The plan of care failed to include CPAP settings with instructions for frequency of use such as at bedtime and/or when napping, specific number of hours and how/if continuous oxygen was maintained or modified while using CPAP. Medication The 08/30/23 plan of care included the patient was to take oxycodone (narcotic) 10 mg 3 times per day as needed for pain with a maximum daily dose of 3 tablets. On 09/07/23 the SN documented in the visit note the patient currently had no pain but uses non-prescription medication intermittently for low back pain. On 09/21/23 at 1:00 p.m. the surveyor completed a home visit with the SN. During the visit, the surveyor observed the SN conduct a medication review with the patient. The patient stated he occasionally takes Tylenol (non-prescription pain medication). The 08/30/23 plan of care failed to include instruction for the patient to use Tylenol or other non-prescription medication for pain management. Leg/Foot Brace During the 09/21/23 home visit, the surveyor observed the patient was wearing a brace to his left lower leg and foot. The 08/30/23 plan of care failed to include a plan for the patient to use a leg brace including type, location and frequency of application/removal. On 09/25/23 at 1:00 p.m. the findings were reviewed with the Administrator, DPS and supervising nurse. They acknowledged the findings and provided no additional information.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on review of patient records, observational home visits, and interviews with the Administrator and Director of Patient Services (DPS), it was determined in 3 out of 17 patients (patients #5, 10 and 17) the agency staff failed to provide coordinated care to meet the needs of the patients. Evidence as follows: Patient #10 was admitted to the agency on 07/12/23 with diagnoses of multiple sclerosis, chronic indwelling (Foley) urinary catheter with recurrent urinary tract infections, hydronephrosis, type 2 diabetes, and hypertension. On 09/19/23 the licensed practical nurse (LPN) visited the patient and documented the patient had not had a bowel movement since 09/16/23. There were no bowel medications on the plan of care. The LPN contacted the case manager, who called the doctor and obtained verbal orders for MiraLAX 17 Gm daily and Colace 100 mg daily as needed for constipation and called the patient. As of 09/26/23 there was no evidence the agency had contacted the patient to determine if the medications had been effective in relieving constipation. On 09/26/23 at 11 a.m. the surveyor reviewed the record with the Administrator, DPS and supervisors who acknowledged the findings. The DPS later stated a follow-up visit was being scheduled to assess if there had been adequate results from the new bowel medications. Home Visit Patient #5 was admitted to the agency on 08/30/23 with diagnoses of acute respiratory failure, chronic respiratory disease and type 2 diabetes. The SN failed to coordinate care to ensure all patient needs were met. Diabetes The 08/30/23 plan of care included the patient / caregiver (CG) was to check finger stick blood sugar (FSBS) every morning and report result greater than 200 or less than 60 to the physician. Additionally, the SN was to assess fasting blood sugar level at every visit and instruct the patient / CG on the need for at least an annual blood A1C test last done on 08/17/23 with a result of 5.4. On 08/30/23 the SN completed the initial assessment and documented the patient had a diagnosis of diabetes. The note included the patient was on oral diabetes medications and was educated on signs and symptoms of high/low blood sugar. The SN failed to assess/document: - a current fasting blood sugar - blood sugar range to ensure results were within ordered parameters - compliance/ability to correctly perform FSBS testing - instructions regarding A1C testing On 09/07/23 the SN visited and failed to assess fasting blood sugar or whether the patient or CG was performing/monitoring FSBS and for episodes of high or low blood sugar. On 09/21/23 at 1:00 p.m. the surveyor completed a home visit with the SN. The surveyor observed the SN assess the patient’s compliance with diabetic diet and symptoms of high/low blood sugar. The patient stated he was not adhering to ordered consistent carbohydrate diet and recently had cake and cookies. The SN asked the patient if he checked blood sugar after eating all of that. The patient stated, “I don’t check my blood sugar” On 09/25/23 at 1:00 p.m. the above findings were reviewed with the DPS, Administrator and supervising nurse. The DPS stated the physician wants the patient to test his blood sugar, however he refuses. On 09/26/23 at 11:30 a.m. the DPS provided the surveyor with a document titled “Team Care Plan” that included goals/expected health status evaluations and potential for diabetes. The document included an undated SN intervention stating “client does not test blood sugars in home. Blood sugar monitored by MD at office visits”. There was no evidence the SN consulted with the physician regarding the patient’s refusal to test blood sugar and coordinate a plan to ensure physician monitoring of diabetes and update the plan of care. 1. Patient #17 was admitted to the agency on 06/02/21 with diagnoses of left heel stage 4 pressure ulcer, right heel stage 3 pressure ulcer, spina bifida, paraplegia and neuromuscular bladder. The 05/28/22 Plan of Care (POC) ordered wound care to left and right heels, clean wounds with normal saline or wound cleanser, apply drawtex, xtrasorb, and alginate then wrap with kerlix, 3 times a week - SN visits 2 times a week with patient being seen once a week in the wound clinic. On 06/01/22 the patient was evaluated at the wound clinic and ordered left and right heels, clean wounds with normal saline or wound cleanser, apply drawtex,xtrasorb,and alginate then wrap with kerlix, 3 times a week. -Patient to follow up in12 days at the wound clinic. On 06/13/22 the patient was seen for an evaluation of wounds with changes to wound care, new orders to right and left heel clean wounds with normal saline or wound cleanser, apply hydofera blue and drawtex rope xtrasorb, 4 abd (absorbent covering) pads and wrap with kerlix, 3 times a week. - Patient to follow up in one week at the wound clinic. On 06/29/22 the patient was evaluated at the wound clinic with no changes in wound care to left and right heel wounds. - Patient to follow up in one week at the wound clinic On 07/05/22 patient was seen in the wound clinic had ordered right and left heel clean wounds with normal saline or wound cleanser, apply hydofera blue and drawtex rope xtrasorb, 4 abd (absorbent covering) pads and wrap with kerlix, 3 times a week. -Patient to follow up with wound clinic in 2 weeks. The 07/27/22 POC ordered skilled nursing or significant other to preform wound care 2 times a week and to be seen in the wound clinic once a week. On 08/05/22 the wound clinic ordered to continue with the same wound care orders from previous visit on 07/5/22. -Follow up with wound clinic in 3 weeks. The SN failed to coordinate care with wound clinic and how often patient would be evaluated.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on review of clinical records for patients receiving home health aide (HHA) service (patients #8, 9,10 and 11) and interviews with the Administrator and Director of Patient Services (DPS), it was determined in 1 out of 4 records the skilled nurse failed to develop complete and accurate aide written instructions. This was evidenced by: Patient #11 was admitted to the agency on 08/17/23 with diagnoses including pathological fracture with routine healing, connective tissue and disc stenosis of intervertebral foramina of thoracic region, spondylosis, and chronic pain syndrome. The Home Health Aide care plan printed 09/22/23 was incomplete for the following: Bleeding Precautions The 08/17/23 Plan of Care included: - aspirin (blood thinner) 81mg by mouth daily - to assess for signs and symptoms of bleeding at every visit The Home Health Aide care plan failed to include bleeding precautions or to report any signs or symptoms of bleeding. Edema The “active orders” printed on 09/21/23 included an intervention dated 09/16/23 for Ace wraps to bilateral lower extremities. The Home Health Aide care plan failed to include any instructions regarding what to do with the Ace wraps during care. On 09/26/23 at 11 a.m. the surveyor reviewed the record with the Administrator, DPS and Supervising Nurse who acknowledged the findings and provided no additional information. Failure to ensure that home health aide care plans are complete has the potential for unmet patient needs.