Every finding on record at John Fitzgibbon Memorial Hospital Inc

The Emergency Preparedness regulations were reviewed as part of the Medicare certificatin survey completed on 01/27/2021. During the survey it was determined Fitzgibbon Community Home Health is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Agencies.

A partial extended survey for Medicare certification for Fitzgibbon Community Home Health was completed on 01/27/2021. The agency had 19 current patients. A COVID-19 Focused Infection Control survey was completed in conjunction with the survey and one deficiency was identified related to the Focused Infection Control survey.

Written notice of patient's rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient's rights and responsibilities under this rule, and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This ELEMENT is not met as evidenced by: Based on admission packet review, review of the agency's current patient rights information, and interview, the agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include: - Discharge for cause; - Rights and responsibilities that are understandable to persons who have limited English proficiency; and - Rights and responsibilities accessible to individuals with disabilities. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: The administrator provided an admission packet for review on 01/25/2021. The agency notice of patient rights and other information given to a patient during the initial visit contained no written information regarding the patient's right to be informed about: - The agency discharge for cause policies; - The need for patient rights and responsibilities to be given in a language the patient understands; and - The need for the patient rights and responsibilities to be accessible to individuals with disabilities. On 01/25/2021 at 3:12 PM, the findings were reviewed with the agency registered nurse (RN) A. No additional information was provided.

Written notice within 4 business days CFR(s): 484.50(a)(4) Provide written notice of the patient's rights and responsibilities under this rule and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section to a patient-selected representative within 4 business days of the initial evaluation visit. This ELEMENT is not met as evidenced by: Based on review of the agency's current patient rights information, home visit observations, and interview the agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: The agency clinical nurse manager (CNM) provided an admission packet for review on 01/25/2021. The patient rights written information was reviewed. The agency failed to include the patient right, that a written notice of the patient's rights and responsibilities and a copy of the agency's transfer and discharge policies should be provided, if the patient has a patient-selected representative, within four business days of the initial evaluation visit. During the home visit observations of Patients #1, #2 and #3 the written patient rights information was reviewed in the patients' home folder. All home visits showed the same missing information as the above admission packet review. On 01/25/2021 at 3:12 PM, the findings were reviewed with the agency registered nurse (RN) A. No additional information was provided.

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: Based on review of the agency's current patient rights information, home visit observation, and interview, the agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include the patient has the right to be advised of financial liability changes as soon as possible, in advance of the next home health visit. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: The agency clinical nurse manager (CNM) provided an admission packet for review on 01/25/2021. The agency notice of patient rights and other information given to a patient during the initial visit contained no written information regarding the patient's right to be advised of financial liability changes as soon as possible, in advance of the next home health visit. During the home visit observations of Patients #1, #2 and #3 the written patient rights information was reviewed in the patients' home folder. All home visits showed the same missing information as the above admission packet review. On 01/25/2021 at 3:12 PM, the findings were reviewed with the agency registered nurse (RN) A. No additional information was provided.

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on review of the agency's current patient rights information, home visit observation, and interview, the agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include the patient has the right to receive proper written notice, in advance of a specific service being furnished, if the agency believes that the service may be non-covered care; or in advance of the agency reducing or terminating on-going care. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: The agency clinical nurse manager CNM) provided an admission packet for review on 01/25/2021. The agency notice of patient rights and other information given to a patient during the initial visit contained no written information regarding the patient's right to receive proper written notice, in advance of a specific service being furnished, if the agency believes that the service may be non-covered care; or in advance of the agency reducing or terminating on-going care. During the home visit observations of Patients #1, #2 and #3 the written patient rights information was reviewed in the patients' home folder. All home visits showed the same missing information as the above admission packet review. On 01/25/2021 at 3:12 PM, the findings were reviewed with the agency registered nurse (RN) A. No additional information was provided.

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on review of the agency's current patient rights information, home visit observation, and interview, the agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that the patient and representative (if any) should be advised of the name, address, and telephone number of the Quality Improvement Organization. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: The agency clinical nurse manager (CNM) provided an admission packet for review on 01/25/2021. The agency notice of patient rights and other information given to a patient during the initial visit showed the written information for the patient and representative (if any) should be advised of the name, address, and telephone number of the following Federally funded and State funded entities that serve the area where the patient resides to include the Quality Improvement Organization (QIO). The agency had KEPRO listed (current QIO is Livanta). During the home visit observations of Patients #1, #2 and #3 the written patient rights information was reviewed in the patients' home folder. All home visits showed the same information as the above admission packet review. On 01/25/2021 at 3:12 PM, the findings were reviewed with the agency registered nurse (RN) A. No additional information was provided.

Freedom from discrimination or reprisal CFR(s): 484.50(c)(11) Be free from any discrimination or reprisal for exercising his or her rights or for voicing grievances to the HHA or an outside entity. This ELEMENT is not met as evidenced by: Based on review of the agency's current patient rights information, home visit observation, and interview, the agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include the patient has the right to be free from any discrimination or reprisal for exercising his or her rights or for voicing grievances to the home health agency or an outside entity. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: The agency clinical nurse manager (CNM) provided an admission packet for review on 01/25/2021. The agency notice of patient rights and other information given to a patient during the initial visit contained no written information regarding the patient has the right to be free from any discrimination or reprisal for exercising his or her rights or for voicing grievances to the home health agency or an outside entity. During the home visit observations of Patients #1, #2 and #3 the written patient rights information was reviewed in the patients' home folder. All home visits showed the same information as the above admission packet review. On 01/25/2021 at 3:12 PM, the findings were reviewed with the agency registered nurse (RN) A. No additional information was provided.

Patient refuses services CFR(s): 484.50(d)(4) The patient refuses services, or elects to be transferred or discharged; This ELEMENT is not met as evidenced by: Based on review of the agency's current patient rights information, home visit observation, and interview, the agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge when the patient refuses services or elects to be transferred or discharged. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: The agency clinical nurse manager (CNM) provided an admission packet for review on 01/25/2021. The agency notice of patient rights and other information given to a patient during the initial visit contained no written information regarding that the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge when the patient refuses services or elects to be transferred or discharged. During the home visit observations of Patients #1, #2 and #3 the written patient rights information was reviewed in the patients' home folder. All home visits showed the same information as the above admission packet review. On 01/25/2021 at 3:12 PM, the findings were reviewed with the agency registered nurse (RN) A. No additional information was provided.

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: Based on policy review, review of the agency's current patient rights information, home visit observation, and interview, the agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that the agency must advise the patient or representative, physicians, and healthcare professionals who will be responsible for providing care after discharge, when a discharge for cause is being considered. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: Review of the agency's policy titled, "Discharge or Transfer of Patients," dated June, 2018 showed: - Purpose: To provide appropriate ongoing care, treatment and services; transfer or discharge based on the patient's care, treatment and/or service needs and the agency's scope of care; - To ensure a standardized process for discharging patients from the agency; and - Advise the patient, representative (if any), the physician(s) issuing orders for the home health plan of care, and the patient's primary care practitioner of other health care professional who will be responsible for providing care and services to the patient after discharge from the agency (if any), that a discharge for cause is being considered. The agency clinical nurse manager (CNM) provided an admission packet for review on 01/25/2021. The agency notice of patient rights and other information given to a patient during the initial visit contained no written information regarding that the agency must advise the patient or representative, physicians, and healthcare professionals who will be responsible for providing care after discharge, when a discharge for cause is being considered. During the home visit observations of Patients #1, #2 and #3 the written patient rights information was reviewed in the patients' home folder. All home visits showed the same information as the above admission packet review. On 01/25/2021 at 3:12 PM, the findings were reviewed with the agency registered nurse (RN) A. RN A said the agency had a policy and procedure for discharge for cause but he/she was unable to find the verbiage in the written patient rights.

Make efforts to resolve the problem(s) CFR(s): 484.50(d)(5)(ii) (ii) Make efforts to resolve the problem(s) presented by the patient's behavior, the behavior of other persons in the patient's home, or situation; This ELEMENT is not met as evidenced by: Based on policy review, review of the agency's current patient rights information, home visit observation, and interview, the agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that if the patient is being considered for a discharge for cause, the agency must make efforts to resolve the problem. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: Review of the agency's policy titled, "Discharge or Transfer of Patients," dated June, 2018 showed: - Purpose: To provide appropriate ongoing care, treatment and services; transfer or discharge based on the patient's care, treatment and/or service needs and the agency's scope of care; - To ensure a standardized process for discharging patients from the agency; and - Make efforts to resolve the problem(s) presented by the patient's behavior, the behavior of other persons in the patient's home, or situation. The agency clinical nurse manager (CNM) provided an admission packet for review on 01/25/2021. The agency notice of patient rights and other information given to a patient during the initial visit contained no written information regarding that the agency must make efforts to resolve the problem, if the patient is being considered for a discharge for cause. During the home visit observations of Patients #1, #2 and #3 the written patient rights information was reviewed in the patients' home folder. All home visits showed the same information as the above admission packet review. On 01/25/2021 at 3:12 PM, the findings were reviewed with the agency registered nurse (RN) A. RN A said the agency had a policy and procedure for discharge for cause but he/she was unable to find the verbiage in the written patient rights.

Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This ELEMENT is not met as evidenced by: Based on policy review, review of the agency's current patient rights information, home visit observation, and interview, the agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that if the patient is being considered for a discharge for cause, the agency must provide the patient or representative with contact information for other agencies or providers who may be able to provide care after discharge. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: Review of the agency's policy titled, "Discharge or Transfer of Patients," dated June, 2018 showed: - Purpose: To provide appropriate ongoing care, treatment and services; transfer or discharge based on the patient's care, treatment and/or service needs and the agency's scope of care; - To ensure a standardized process for discharging patients from the agency; and - Provide the patient and representative (if any) with contact information for other agencies or providers who may be able to provide care. The agency clinical nurse manager (CNM) provided an admission packet for review on 01/25/2021. The agency notice of patient rights and other information given to a patient during the initial visit contained no written information regarding that if the patient is being considered for a discharge for cause, the agency must provide the patient or representative with contact information for other agencies or providers who may be able to provide care after discharge. During the home visit observations of Patients #1, #2 and #3 the written patient rights information was reviewed in the patients' home folder. All home visits showed the same information as the above admission packet review. On 01/25/2021 at 3:12 PM, the findings were reviewed with the agency registered nurse (RN) A. RN A said the agency had a policy and procedure for discharge for cause but he/she was unable to find the verbiage in the written patient rights.

Document efforts to resolve problems CFR(s): 484.50(d)(5)(iv) (iv) Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records; This ELEMENT is not met as evidenced by: Based on policy review, review of the agency's current patient rights information, home visit observation, and interview, the agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that if the patient is being considered for a discharge for cause, the agency must document the problem and efforts made to resolve the problem into the clinical record. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: Review of the agency's policy titled, "Discharge or Transfer of Patients," dated June, 2018 showed: - Purpose: To provide appropriate ongoing care, treatment and services; transfer or discharge based on the patient's care, treatment and/or service needs and the agency's scope of care; - To ensure a standardized process for discharging patients from the agency; and - Document the problem(s) and efforts made to resolve the problem(s) in the patient clinical record. The agency clinical nurse manager (CNM) provided an admission packet for review on 01/25/2021. The agency notice of patient rights and other information given to a patient during the initial visit contained no written information regarding that if the patient is being considered for a discharge for cause, the agency must document the problem and efforts made to resolve the problem into the clinical record. During the home visit observations of Patients #1, #2 and #3 the written patient rights information was reviewed in the patients' home folder. All home visits showed the same information as the above admission packet review. On 01/25/2021 at 3:12 PM, the findings were reviewed with the agency registered nurse (RN) A. RN A said the agency had a policy and procedure for discharge for cause but he/she was unable to find the verbiage in the written patient rights.

Death of patient CFR(s): 484.50(d)(6) The patient dies; or This ELEMENT is not met as evidenced by: Based on review of the agency's current patient rights information, home visit observation, interview, the agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge if the patient dies. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: The agency nurse manager provided an admission packet for review on 01/25/2021. The agency notice of patient rights and other information given to a patient during the initial visit contained no written information regarding that the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge if the patient dies. During the home visit observations of Patients #1, #2 and #3 the written patient rights information was reviewed in the patients' home folder. All home visits showed the same information as the above admission packet review. On 01/25/2021 at 3:12 PM, the findings were reviewed with the agency registered nurse (RN)A. No additional information was provided.

Accessibility CFR(s): 484.50(f)(1,2) Standard: Accessibility. Information must be provided to patients in plain language and in a manner that is accessible and timely to- (1) Persons with disabilities, including accessible web sites and the provision of auxiliary aids and services at no cost to the individual in accordance with the Americans with Disabilities Act and Section 504 of the Rehabilitation Act. (2) Persons with limited English proficiency through the provision of language services at no cost to the individual, including oral interpretation and written translations.Standard: Accessibility Information must be provided to patients in plain language and in a manner that is accessible and timely to- This STANDARD is not met as evidenced by: Based on review of the agency's current patient rights information, home visit observation, and interview, the agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that information must be provided to patients in a language and in a manner that is accessible and timely to persons with disabilities, including accessible web sites and the provision of auxiliary aids services are at no cost to the individual and must be provided to persons with limited English proficiency, at no cost to the individual including oral interpretation and written translations. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: The agency nurse manager provided an admission packet for review on 01/25/2021. The agency notice of patient rights and other information given to a patient during the initial visit contained no written information regarding the patient's right to be informed about information must be provided to patients in a language and in a manner that is accessible and timely to persons with disabilities, including accessible web sites and the provision of auxiliary aids services are at no cost to the individual and must be provided to persons with limited English proficiency, at no cost to the individual including oral interpretation and written translations. During the home visit observations of Patients #1, #2 and #3 the written patient rights information was reviewed in the patients' home folder. All home visits showed the same information as the above admission packet review. On 01/25/2021 at 3:12 PM, the findings were reviewed with the agency registered nurse (RN) A. No additional information was provided.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on clinical record review and interview, the agency failed to complete the initial assessment of the patient within 48 hours of the referral to home care, or 48 hours after the patient's return home, or on the physician ordered start of care date in one (Record/Patient #1) of five records reviewed. This deficient practice has the potential to affect the immediate needs of all the agency's patients. Findings included: RECORD/PATIENT #1: Review of the hospital referral dated 01/15/2021 showed the scheduled start of care date was 01/15/2021 -- end date 01/20/2021. The scheduled start of care date was 01/16/2021. Review of the plan of care, dated 01/19/2021 showed skilled nursing to assess and evaluate 01/15/2021 through 01/20/2021. Review of the start of care OASIS (assessment tool) form dated 01/19/2021 and signed by the registered nurse (RN) showed the patient's inpatient discharge date was 01/16/2020. The start of care date was 01/19/2021 (three days after the patient was discharged from the hospital.) During a home visit and interview on 01/26/2021 at 8:30 AM, the patient's caregiver said the patient was sent home from the hospital on 01/16/2021. The agency brought the patient oxygen on 0/16/2021 and admitted the patient on 01/19/2021. During an interview on 01/27/2021 at 8:35 AM, the clinical nurse manager said the agency only had two nurses when the patient was discharged from the hospital and was unable to start the patient's care until 01/19/2021. He/she had no documentation to show communication with the physician or a physician's order.

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, record review, home visit observation, and interview, the agency failed to ensure an accurate medication review and/or update of the patient's medications was completed in three (Records/Patients #1, #2 and #3) of three home visit observations performed. This deficient practice has the potential to affect the agency's ability to ensure safe and effective use of medications for all patients served by the agency. Findings included: Review of the agency's policy titled, "Patient Medication Information and Reconciliation," date February, 2017 showed: - Procedure: Orders for medication and treatment shall be documented in the patient's medical record, signed by the patient's licensed independent practitioner as allowed by state law and hospital policy; - Any medication orders that are questionable shall be clarified with the physician, rewritten and submitted to the physician for verification and signature; - Unless otherwise specified, doses will be administered at the following times: three times a day 9:00 AM, 1:00 PM and 5:00 PM and every eight hours at 6:00 AM, 2:00 PM and 10:00 PM; and - All medication orders are verified with the ordering physician and must contain the phrase "orders read back and verified with __________", the date of verification and the signature of the nurse verifying the orders. Review of the agency's policy titled, "Patient Medication Information and Reconciliation," revised 08/2017 showed: - Definition: A medication is any product designated by the Food and Drug Administration as a drug, as well as any prescription medications, sample medications, herbal remedies, vitamins and over-the-counter drugs used on or administered to persons to diagnose, treat or prevent disease or other abnormal conditions and respiratory therapy treatments; - Purpose: To facilitate continuity of care, treatment and/or services for home agency patients by providing accurate and comprehensive information about patients' medications; - To create and maintain an accurate medication history and current medication profile while the patient is receiving care, treatment and/or services from the agency; - To safely order, administer and monitor the agency's patients' medications; - To minimize the opportunity for medication-related sentinel events and medication errors; - Policy: The agency will implement a patient information/reconciliation process to obtain and document a complete list of a patient's current medications upon admission to service and at other transitions of care, including the name, dosage, route, frequency and purpose for every scheduled and as-needed medication a patient reports; - The patient's attending physician will be provided a review of potential medication interactions as well as any documented discrepancies regarding drug therapy; - The attending physician will make any additions, deletions or corrections to the patient's medication orders and communicate those findings to the agency; - The complete list of the patient's medications will be provided to the patient or the patient's family as necessary; - Procedure: During the initial assessment visit, the registered nurse (RN) will generate a list of the patient's medications and document in the patient's electronic health record; - The medication profile is completed in its entirety; - Any questions or concerns about the patient's current medications are directed toward the ordering physician; - The list of current medications is incorporated into the plan of care; and - The patient's medications are reviewed and assessed during each skilled visit. Any changes to the medications are conveyed to the ordering physician and the medication profile is updated as necessary. RECORD/PATIENT #1: Review of the hospital discharge record, dated 01/16/2021 showed oxygen per nasal cannula (device to deliver supplemental oxygen) if needed (no amount or duration provided) to keep oxygen saturation (sats) (extent to which hemoglobin is saturated with oxygen) greater than 90% (normal blood oxygen saturation is around 95-100%) and orders to stop taking temazepam 30 milligrams (mg) at bedtime. Review of the plan of care (POC) dated 01/19/2021 for the certification period of 01/19/2021 through 03/19/2021 showed: - Start of care (SOC) date 01/19/2021; - Diagnoses included but not limited to: Pleural effusion (a buildup of fluid between the tissues that line the lungs and the chest), pneumothorax (the presence of air or gas in the cavity between the lungs and the chest wall, causing collapse of the lung), dependence on supplemental oxygen and hypoxemia (low blood oxygen); and - Oxygen at 3 liters (flow rate of oxygen) per nasal cannula (device to deliver supplemental oxygen), and - The POC failed to include an order to check the patient's oxygen saturation. During a home visit observation on 01/26/2021 at 8:30 AM, review of the patient's bottles of medications and interview with the patient and caregiver showed: - Temazepam (used to treat insomnia) 30 milligrams (mg), take one capsule by mouth every day at bedtime as needed, the prescription fill date was 12/21/2020 (medication was not listed on the agency's medication list); and - The patient's caregiver said it was the patient's choice to take temazepam and the home health agency called and said it was ok; - Oxygen at 2 liters (rate of flow) per nasal cannula; and - The patient's caregiver said he/she didn't know where the 3 liters of oxygen came from, the patient has always been on 2 liters, however, he/she always thought the oxygen should be at 3 liters when the patient walked because his/her O2 sats would drop. During an interview on 01/26/2021 at 11:13 AM, the nurse clinical manager stated: - The patient's medication list should be updated each visit; - Oxygen sats are standard parameters with low being below 90% and should have been on the physician orders; - He/she was not sure if the oxygen was 2 or 3 liters, the oxygen should have been titrated to 3 liters to keep the sats above 90%, this was in the admission orders and not on the plan of care; and - He/she would expect the plan of care to include all care the patient is receiving. During an interview on 01/26/2021 at 12:42 PM, the registered nurse (RN) C stated: - He/She compares discharge medications to what is actually in the patient's home; - If discrepancies are found, notify the physician and follow up in 24 hours if no response; - Clarify all medications in the home with the physician; - The patient's physician was going to follow up during the patient's next visit, regarding the sleeping pill, but RN C forgot to follow up with the physician to see if there were changes; and - The instruction for oxygen use should be on the plan of care. During an interview on 01/26/2021 at 01:04 PM, RN D stated: - Staff should review the discharge medication list when a patient is admitted to home health and clarify any discrepancies with the physician; - The patient's oxygen was 3 liters but could be "weaned" down and he/she thought there was a note to keep the oxygen sats above 90 and this should have been on the plan of care; - The patient wanted to take a sleeping pill but the caregiver said the physician did not want him/her to take it, the medication was not added to the medication list and RN B asked for clarification from the physician; and - There was no follow up documentation. RECORD/PATIENT #2: Review of the plan of care (POC) dated 01/21/2021 through 03/21/2021 showed: - The start of care (SOC) date was 12/21/2021; and - Diagnoses included but not limited to: Osteoarthritis right knee and polyosteoarthritis (pain and inflammation occur in multiple joints at once). Review of the skilled nursing visit note dated 01/21/2021 at 8:30 AM showed: - The patient reports he/she has not had a bowel movement since surgery; - The patient was educated to get over-the-counter laxative such as MiraLax (gentle laxative) or Senna (laxative); and - The patient plans to obtain both and will take MiraLax daily for two days until he/she has a bowel movement and if that is not effective he/she will take the Senna along with the MiraLax. During a home visit observation on 01/26/2021 at 10:00 AM, review of the patient's medications showed: - Miralax (gentle laxative); - Senokot (natural vegetable laxative) regular strength; and - These medication were not on the medication list. During an interview on 01/26/2021 at 12:33 PM, the clinical manager stated he/she would expect to have orders for any over the counter medications and especially if the nurse suggests the medication. RECORD/PATIENT #3: Review of the agency's current Medication Profile sheet dated 01/25/2021 showed: - Torsemide (a diuretic to rid the body of excess fluid) 20 milligrams (mg), one tablet every eight hours. A home visit observation on 01/26/2021 at 1:00 PM showed: - The patient's discharge medication list from the hospital dated 01/07/2021 showed Torsemide 20 mg every eight hours; - Review of the patient's medication bottles showed Torsemide 20 mg, hand written on the label, one TID (three times per day); and - A bottle of Hydrocodone Acetaminophen 5/325 mg, one tablet TID PRN (as needed). During an interview on 01/26/2021 at 1:15 PM, the patient's spouse stated: - The patient had been taking Hydrocodone Acetaminophen since his/her fall in January; - The frequency of Torsemide change to TID started upon admission to home health; and - The patient took the Torsemide in the morning when he/she got up, in the afternoon, and before bedtime. During an interview on 01/26/2021 at 2:30 PM, the clinical nurse manager (CNM) stated: - The Hydrocodone was not on the agency's medication list and not on the hospital discharge list; - The patient and spouse were told not to wake the patient at night to give him/her a dose of Torsemide, but to give one tablet in the morning when they got up around 9:30 AM, one in the afternoon, and one before bedtime; and - Every eight hours is the same as TID.

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to ensure/document the transfer summary was sent and included all necessary medical information pertaining to the patient's current course of illness and treatment, for one (Record/Patient #5) of one record that was transferred to the hospital. This deficient practice has the potential to affect the continuity of care for all patients served by the agency. Findings included: Review of the agency's policy titled, "Discharge Summary," dated February, 2017 showed: - To ensure that appropriate information related to the care, treatment, and/or services provided is exchanged with other service members when patients are transferred or discharged from the agency. RECORD/PATIENT #5: Review of the Agency Transfer Summary for Patient #5 dated 11/16 2020 showed: - The patient transferred to Fitzgibbon Hospital on 11/14/2020; - Physical therapist (PT) C sent a transfer summary to the patient's primary care physician from the Veteran's Administration in Columbia, Mo; - The summary only contained the PT current course of illness and treatment; - No occupational therapy (OT) summary or skilled nursing (SN) summary was sent to the physician at the time of transfer; - There was no record of the agency sending information for the transfer or the comprehensive transfer summary to the admitting hospital in the record; - There was no record of a fax or other communication as to the date the summary was sent to the VA physician; - PT C signed the summary on 11/16/2020 and the VA physician signed the summary on 12/02/2020. During an interview on 01/26/2021, Licensed Practical Nurse (LPN) B stated: - Only the transfer summary is sent to the VA physician; other information will be sent if the physician or VA hospital requests it; - Usually the date the clinician signs the summary is the date it is sent to the physician; - Fitzgibbon hospital has access to all home health records via the computer program Tiger Institute; and - There is no record of the actual date that a transfer summary is sent for patients admitted to Fitzgibbon hospital. During an interview on 01/26/2021 at 10:00 AM, the administrator stated only a transfer summary is sent to the physician whether it is to a Fitzgibbon physician or an outside physician; no summary is sent to an outside receiving hospital or nursing facility; and the Fitzgibbon hospital has access to all home health records when a patient is admitted from home health.

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 review of the agency's policy, observation, and interviews, the facility failed to follow their policy to document and provide the COVID-19 printed information for education purposes upon admission for one (Record/Patient #3) of three home visit observations; and failed to put in place a program for screening visitors/non-employees for COVID-19 (pandemic infection) who entered the home health agency office. This deficient practice has the potential to affect infection control needs for all newly admitted patients served by the agency and all visitors/non-employees, employees and patients served by the agency. Findings included: Review of the agency's undated policy titled, "COVID-19 Response/Guidance," showed: - Screening for all home health employees which included self-check temperature and self-screen for presence of shortness of breath, dry cough, or sore throat of the employee who sees patients prior to reporting to the office; - All employees reporting to the office at the beginning of the shift will be screened for symptoms and temperature check; - Universal masking guidance as followed by the associated hospital; - The policy did not address visitors/non-employees screening for COVID-19; and - All patients will be provided a printed handout that provided instruction related to COVID-19 symptoms, precautions, and personal protective equipment. Observation on 01/25/2021 at 12:40 PM upon surveyor entrance to the agency for the recertification survey showed: - The agency was located in a separate, non-attached building from the main hospital, but was on the hospital campus; - A red stop sign on the outside entrance door indicated enter with appropriate face mask in place; - No signage to indicate the need for handwashing, social distancing or other COVID-19 information; - No signage to instruct visitors/non-employees to proceed to the main hospital for COVID-19 screening before entering the home health agency office; - No signage to indicate visitors/non-employees needed to call the agency phone number listed on the door prior to entering the agency office; - The two surveyors entered the outer door into the vestibule of the building with appropriate face masks in place, the door to the left of entry was open (physical/occupational therapy office) and no staff was in the office; - The door to the right of entry was closed to the home health office; - The surveyors knocked and opened the door to enter the home health office and were greeted by licensed practical nurse (LPN) B, introductions were made, and LPN B escorted the surveyors to a conference room; and - Staff did not screen the surveyors for temperature or COVID-19 screening questions upon entrance. Observation on 01/26/2021 at 8:30 AM showed one surveyor entered the agency with appropriate face mask in place, and no staff screened the surveyor for temperature check or COVID-19 questions. Observation on 01/26/2021 at 11:15 AM showed the second surveyor entered the agency after a home visit and agency staff took the surveyor's temperature but did not screen with COVID-19 questions. During an observation and interview on 01/26/2021 at 11:30 AM, the clinical nurse manager (CNM) did and stated: - The agency had a COVID-19 policy for employees in place and gave a copy of the policy to the surveyor; - Employees that came into the agency filled out a screening form with self-checked temperatures, answered COVID-19 questions listed on the form, and signed their name; - Showed the screening list to the surveyor with employee information recorded; - There was no process in place to screen visitors or non-employees for COVID-19 because visitors were "less than rare" to the agency office; - Only staff and physicians attended meetings held in the agency office and all self-checked their temperatures, answered COVID-19 questions, and did not attend if they had any symptoms of COVID-19; - If staff met with families, they would use a room in the main hospital or in the hospice office; - The surveyors should not have entered the agency office because of the red stop sign on the door and there was a phone number on the door to call before entering; - Informed the surveyors that they should have proceeded to the main hospital to be screened before entering the agency office; - During previous surveys, all surveyors entered through the main hospital; and - The surveyor stated the red stop sign only showed to wear appropriate face mask when entering, there was no instruction to call before entering, there was no instruction to proceed to the main hospital for screening before entering the agency office, and that both surveyors wore appropriate face masks at the time of entry to the agency office. Observation on 01/27/2021, the final day of survey, at 8:30 AM showed that staff checked the temperature of both surveyors and staff wrote the names of the surveyors and temperatures on the screening form but did not ask COVID-19 screening questions. RECORD/PATIENT #3: During an interview on 01/26/2021 at 11:30 AM the CNM stated: - The agency did not have a COVID-19 policy for patients; - It depended on the patient whether screening was performed; - The nurse called the patient the day before or the day of a patient home visit to screen the patient for COVID-19 with questions related to COVID-19; - On admission, a COVID-19 test was performed on patients; - He/she expected staff to use good sense for infection control during the COVID-19 pandemic; - The patient admission packet included COVID-19 printed instructions; and - Because COVID-19 is evolving and changing continually, instruction was only done on admission and staff did not document the instruction was done on the plan of care or the admission OASIS (a mandated assessment tool). Review of the admission packet left in the patient's home during a home visit on 01/26/2021 at 1:00 PM showed no COVID-19 printed handout instructions related to the COVID-19 infection. During an interview on 01/26/2021 at 1:30 PM, the patient's spouse stated he/she did not receive any education or instruction related to the COVID-19 infection and did not know of any printed information related to COVID-19.