Every finding on record at Johnson County Community Health Services

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 01/24/2024. During the survey it was determined the home health provider is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Providers.

A partial extended survey for Medicare recertification for the home health provider was completed on 01/24/2024. The provider had 49 current patients.

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, clinical record review, home visit observation and interview, the provider failed to ensure a complete and accurate review of all the medications was completed in one of three home visit observations (Record/Patient #4). This deficient practice has the potential to affect the provider’s ability to ensure safe and effective use of medications for all patient’s served by the provider. Findings included: Review of the provider’s policy, dated most recently revised “2/2023”, titled, “Medication, Regimen Review Comprehensive,” showed in part: - The RN (registered nurse) will be responsible for monitoring the patient’s medication regimen through a collaborative effort with the multi-disciplinary team and physician involved in the patient’s care; - All required comprehensive assessments will include 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; - At the time of admission an accurate, current and complete list of all prescription and over the counter (OTC) medications, as well as herbal medications taken by the patient will be maintained on the medication profile; - The clinician will compare the medication list to those on the referral or other documents and provided to the agency. Any discrepancies will be reconciled with the physician and documented in the clinical record; - Every effort will be made to reconcile any discrepancies with the physician or designee the next calendar day of the assessment; - The clinician will document this contact and any difficulties experienced in obtaining physician response; - The medication profile will be placed in the patient’s home and include essential information about dosages, drug schedules, immunizations, and drug allergies. This medication profile will also include initial order and discontinuation dates, where applicable; - Nursing staff will assess on an ongoing basis the patient’s response to the medication and the patient/caregiver’s compliance with the medication regimen; - Adverse patient response, lack of patient response, and/or compliance concerns will be communicated to the physician as well as documented in the clinical record; - Changes in the medication regimen will be documented in the clinical record as well as communicated to the patient and/or caregiver; and - Review of medications will be on-going but done a minimum of every sixty days. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 01/02/2024 with a principal diagnosis of other specified chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe). Review of the medication list from the long term care facility upon discharge provided to the provider, dated 12/27/2023 showed, in part: - Simvastatin 20mg, give one tablet one time daily for hyperlipidemia (order status marked active); - Tamsulosin 0.4mg, give one capsule by mouth one time a day for retention (given for enlarged prostrate to help the flow of urine) (order status marked active); and - Miralax oral powder 17gms by mouth as need for constipation once daily as needed administer in 4-8 ounces of liquid of choice (order status marked active). Observation on 01/23/2024 starting at 1:00PM, during the patient’s medication reconciliation, the following discrepancies were noted when comparing what the patient was taking with the current medication profile supplied by the provider: - Simvastatin failed to be listed on the current medication profile; - Tamulosin failed to be listed on the current medication profile; - Metamucil gummies failed to be listed on the current medication profile; - Nasal spray failed to be listed on the current medication profile; and - Fiberall powder was listed on the profile. but the patient denied taking any powdered medication for his/her bowels. Per interview conducted during the observation the patient stated that he/she: - Was taking fiber gummies, three daily, instead of the powder medication for his/her bowels; - Just started using a nasal spray as needed; - Had been on simvastatin for twenty years; and - Had been on the tamsulosin for two years. Per interview conducted during the observation, RN A stated that: - He/she thought maybe the simvastatin was on the medication profile; - They had discussed starting a nasal spray but was unaware the patient started until just then; and - He/she would get all the discrepancies clarified. During an interview on 01/24/2024 starting at 1:00 PM the home health director stated that: - RN A has it all clarified/fixed now; and - The medication profile should match what the patient is taking unless it happened since that last visit.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and interview, the provider failed to notify/communicate with the physician when medication needed to be clarified and when the nurse was unable to assess blood glucose as ordered on the plan of care (POC) in two of five full records reviewed (Records/Patients #4 and #5). This deficient practice has the potential to adversely affect the care of all patients served by the provider. Findings included: Review of the provider’s policy dated most recently revised 10/2018, titled, “Physician Plan of Care/Physician Orders,” showed in part: - The relevant physician(s) must be notified of any changes in the patient condition or needs that suggest that outcomes are not being met and/or the POC should be revised; - Any revision to the POC due to a change in patient status must be communicated to the following: * The patient; and * The physician responsible for the POC. Review of the provider’s policy dated © November 2019, titled, “Plan of Care,” showed in part: - The plan of care will serve as physician’s orders for patient care and all staff providing services will be in compliance with the orders; - The patient’s physician orders for treatments and services are the foundation of the plan of care. If the agency misses a visit or a treatment or service as required by the plan of care, which results in any potential for clinical impact upon the patient, then the agency will notify the responsible physician of such missed treatments or service. The physician will decide whether the treatment or service may be skipped or whether additional intervention is required by the HHA (home health agency) due to clinical impact on the patient; - If the patient or the patient’s representative refuses care that could impact the patient’s clinical well being (such as dressing changes or essential medication) on more than one occasion, then the HHA will attempt to identify the reason for the refusal. If the HHA is unable to identify and address the reason for refusal, then the HHA will communicate with the patient’s responsible physician to discuss how to proceed with patient care; and - “Named provider” must promptly alert the relevant physician(s) to any changes in the patient’s condition or needs that suggest outcomes are not being achieved and/or that the plan of care should be altered. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 01/02/2024 with a principal diagnosis of other specified chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe). Review of a SN (skilled nurse) visit noted date 01/04/2024 showed, in part, documentation stating “Has a nebulizer and 2 different medications, they are not sure which one to use, suggested he/she talk with the PCP (primary care physician) at visit to clarify.” During an interview on 01/24/2024 starting at 1:00 PM the home health director stated that: - We seen that (the documentation instructing the patient to clarify the medication orders with the physician); and - The doctor should have been notified by the nurse to clarify. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to home health services on 12/19/2023 with a principal diagnosis of Type 2 (two) diabetes mellitus with foot ulcer. Review of the initial POC dated 12/19/2023 to 02/16/2024 showed, in part; -SN frequency 1w9 (one time a week for nine weeks) starting week of 12/19/2023; and - SN to perform finger stick blood sugar every visit. Review of the SOC (start of care) OASIS (Outcome and Assessment Information Set; a standardized data collection tool) dated 12/19/2023 showed in part: - Patient reported that his/her glucometer (machine utilized to assess blood sugar per fingerstick) needed batteries; - Patient reported that he/she had been diabetic for a long time and knew if his/her blood sugars were high or low depending on how he/she felt; - He/She was educated on the importance of having a working glucometer especially with use of insulin; - Patient stated he/she would get batteries and get it working; and - He/she was educated on importance of keeping BS (blood sugar) well managed for optimal wound healing. Review of a SN visit note date 12/26/2023 showed, in part, patient still had not gotten new battery for glucometer and told him/her to obtain ASAP (as soon as possible). Review of a SN visit note date 01/02/2024 showed, in part, comment documented under endocrine (system of the body that releases hormones that directly or indirectly affect blood sugar) section: never got glucometer battery. Review of a SN visit note date 01/08/2024 showed, in part, under endocrine section documented did not buy batteries for glucometer. Review of a SN visit note dated 01/15/2024 showed, in part, under endocrine section documented not working. Further review of the clinical record failed to show: - Any blood sugars documented; and - Any communication with the physician that the provider was unable to assess the blood sugar due to the patient not purchasing battery/having a working glucometer. During an interview on 01/24/2024 starting at 1:00 PM the home health director stated that he/she: - Was unable to find documentation that the physician was notified of the inability to follow POC and assess blood sugar every visit; and - He/she would expect the physician to be notified.

Revisions communicated to patient and MDs CFR(s): 484.60(c)(3)(i) (i) Any revision to the plan of care due to a change in patient health status must be communicated to the patient, representative (if any), caregiver, and all physicians or allowed practitioner's issuing orders for the HHA plan of care. This ELEMENT is not met as evidenced by: Based on clinical record review, and interview, the provider failed to ensure revision in the plan of care, due to wound healing, was communicated to all physicians issuing orders for the plan of care in one of five full records reviewed (Record/Patient #4). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy dated © November 2019, titled, “Plan of Care,” showed in part, “Named provider” must promptly alert the relevant physician(s) to any changes in the patient’s condition or needs that suggest outcomes are not being achieved and/or that the plan of care should be altered. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 01/02/2024 with a principal diagnosis of other specified chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe). The patient was admitted with a wound to the right dorsal second toe that the patient/caregiver were providing care to. Review of the initial POC (plan of care) dated 01/02/2024 to 03/01/2024 showed, in part, clinician to assess wound to right dorsal second toe. Patient/caregiver to continue cleansing with soap/water daily and placing cotton ball between toes as instructed by podiatrist (there failed to be a stop date documented for these interventions). Review of a SN (skilled nurse) visit note dated 01/17/2024 showed documentation that the wound had re-epithelized (healed). Review of the care plan showed no longer needed/goals met was marked for interventions of clinician to assess wound to right dorsal second toe and patient/caregiver to continue cleansing with soap/water daily and placing cotton ball between toes as instructed by podiatrist and was dated 01/17/2024. Further review of the clinical record failed to show documentation that the PCP (primary care physician) was notified that the wound had re-epithelized. During an interview on 01/24/2024 starting at 1:00 PM, the home health director stated that: - The care plan was updated to indicate that the goal was met, and interventions were no longer needed; - The PCP does not see or sign the care plan; and - The PCP was not notified that the wound had healed, and the assessment and treatment were no longer needed.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on policy review, record review, observation, and interview, the home health provider failed to ensure staff measured/documented abdominal girth measurement as ordered in one of five full records reviewed (Record/Patient #4). This deficient practice has the potential to adversely affect all patients served by the provider. Findings included: Review of the provider’s policy dated © November 2019, titled “Plan of Care,” showed, in part: - The plan of care will serve as physician’s orders for patient care and all staff providing services will be in compliance with the orders; and - The patient’s physician orders for treatments and services are the foundation of the plan of care. If the agency misses a visit or a treatment or service as required by the plan of care, which results in any potential for clinical impact upon the patient, then the agency will notify the responsible physician of such missed treatments or service. The physician will decide whether the treatment or service may be skipped or whether additional intervention is required by the HHA (home health agency) due to clinical impact on the patient. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 01/02/2024 with a principal diagnosis of other specified chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe). Review of a physician order (order No: C-5813), dated 01/11/2024, showed, in part, clinician to obtain abdominal girth to assess for fluid retention (a frequency failed to be documented). Review of a SN (skilled nurse) visit note dated 01/17/2024 failed to show documentation of an abdominal girth. Further review of the clinical record failed to show an order to discontinue measuring abdominal girth. Observation on 01/23/2024 at 1:00 PM, during the patient’s home visit, showed the SN failed to measure an abdominal girth. During an interview on 01/24/2024 at 1:00 PM the home health director stated that: - We know what the problem was, it was a canned (non-individualized) care plan, and the nurse didn’t delete that part out; - Abdominal girths were never actually ordered by the physician; and - Nurses are expected to follow the POC.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the 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) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on policy review, record review and interview, the provider failed to send a completed discharge summary timely in one of two discharge records reviewed (Record/Patient #6). This deficient practice has the potential to adversely affect the post discharge care of all patients served by the provider. Findings included: Review of the provider’s policy dated most recently revised 11/2019, titled, “Discharge/Transfer, Patient”, showed in part: - “Named Provider” will discharge and/or transfer patients in a timely, coordinated manner when the patient meets the agency discharge/transfer criteria; and - A completed discharge summary will be sent to the 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 (Home health agency) (if any) within five (5) business days of the date of the patient’s discharge. RECORD/PATIENT #6: Review of the clinical record showed the patient was admitted to home health services on 09/22/2023 with a principal diagnosis of Type 2 diabetes mellitus (adult onset of a group of diseases that results in too much sugar in the blood) with other skin ulcer, and secondary diagnoses of non-pressure chronic ulcer of other part of right lower leg and non-pressure chronic ulcer of other part of left lower leg. Further review of the clinical record showed, in part: - A discharge OASIS (Outcome and Assessment Information Set; a standardized data collection tool) with a visit date of 12/12/2023 and electronically signed by the RN (registered nurse) 12/12/2023: - A discharge summary completed and electronically signed 12/12/2023; and - A fax cover sheet to the primary care provider, dated 12/26/2023 (nine business days later). During an interview on 01/24/2024 starting at 1:00 PM, the home health director stated that he/she would expect it to be sent within five business days.

EP Program Patient Population CFR(s): 484.102(a)(3) §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: ["Persons at risk" does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This STANDARD is not met as evidenced by: Based on review of the agency's emergency preparedness plan, and interview, the agency failed to ensure their emergency preparedness plan included the types of service the agency has the ability to provide in an emergency. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's emergency preparedness plan failed to include the types of services the agency has the ability to provide in an emergency. During an interview on 06/03/2021 at 11:15 AM, the clinical manager stated that he/she could not find where the emergency preparedness plan identified the types of service the agency has the ability to provide in an emergency.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on review of the agency's emergency preparedness plan and interview, the agency failed to develop and implement an emergency preparedness communication plan that included the names and contact information for the patient's physicians. This deficient practice has the potential to affect all patient's receiving home health services in the event of an emergency. Findings included: Review of the agency's emergency preparedness plan showed the agency failed to develop and implement an emergency preparedness communication plan that included a list of names and contact information for patient's physicians. During an interview on 06/03/2021 at 11:00 AM, the clinical manager stated that the agency's emergency preparedness plan did not contain any information regarding patient's physicians.

Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This STANDARD is not met as evidenced by: Based on review of the agency's Emergency Preparedness plan and interview, the agency failed to develop an emergency preparedness plan that included a communication plan with contact information for federal, state, and local emergency (FEMA) preparedness staff. This deficient practice has the potential to affect the safety of all patients served by the agency. Findings included: Review of the agency's emergency preparedness plan failed to show contact information for federal, state, and local authorities. During an interview on 06/03/2021 at 11:00 AM, the clinical manager verified that there was no contact information included in the agency's emergency preparedness plan for federal, state, and local authorities/emergency preparedness staff.

Methods for Sharing Information CFR(s): 484.102(c)(4)-(5) §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (4) A method for sharing information and medical documentation for patients under the [facility's] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility's] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI's care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4). This STANDARD is not met as evidenced by: Based on review of the agency's emergency preparedness plan, and interview, the agency failed to ensure their emergency preparedness communication plan included a clear method for sharing medical information about patients with other healthcare providers. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's emergency preparedness communication plan failed to include a method for sharing medical information about patients with other healthcare providers. During an interview on 06/03/2021 at 11:00 AM, the clinical manager could not find where the emergency preparedness plan identified the method to share medical information about patients with other healthcare providers.

A partial extended survey for Medicare certification for Johnson County Community Health Services was completed on 06/03/2021. The agency had 69 current patients. A COVID-19 Focused Infection Control Survey was completed in conjunction with the survey and no deficiencies were identified related to the Focused Infection Control Survey. The Emergency Preparedness regulations were reviewed as part of the Medicare certification survey completed on 06/03/2021. Four (4) standard level deficiencies were identified.

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 and interview, the agency failed to update the written notice of patient rights to meet the requirements of the updated Federal home health regulations effective 11/29/2019 to include that the patient has the right to be advised of the names, addresses, and telephone numbers of the Federally-funded and state-funded entities that serve the area where the patient resides. This affected all the patient's admitted to the agency since 11/29/2019. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all patients served by the agency. Findings included: The agency administrator provided an admission packet for review on 06/01/2021. The agency notice of patient rights and other information given to a patient during the initial visit failed to show accurate information for the Federally-funded and State-funded entities that serve the area where the patient resides. The booklet provided a number for Aging and Disability Resource Center in Jefferson City, Mo. The surveyor called the number provided on 06/01/2021 at 3:00 PM and was placed on hold for 30 minutes. The surveyor was told after the 30 minute hold, that Warrensburg was not covered by this phone number. The surveyor was provided with a local number to call. On 06/01/2021 at 3:35 PM, the findings were reviewed with the agency administrator. The administrator agreed with the need to provide a local number for the agency patients.

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 reconcile and maintain a complete/accurate medication profile in three (Records/Patients #1, #3 and #5) of five records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Medication Regimen Review Comprehensive," dated November 2019, showed the Registered nurse (RN) will be responsible for monitoring the patient's medication regimen through a collaborative effort with the multi-disciplinary team and physician involved in the patient's care. Changes in the medication regimen will be documented in the clinical record as well as communicated to the patient and/or caregiver. Review of medications will be on-going but done a minimum of every 60 days. Review of the agency's policy, "Assessment, Comprehensive," dated November 2019, showed that a registered nurse (RN), or qualifying clinician, must conduct an initial assessment within 48 hours of referral or patient's return to home, or on the physician ordered start of care date. The comprehensive assessment must include: - Review of all current medications to identify potential adverse medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy; and - In rehabilitation therapy only cases, the patient's therapist must/will submit a list of patient medications, which the therapist must collect during the comprehensive assessment, to an agency nurse for review. Johnson County Community Health Services will contact the physician if indicated. RECORD/PATIENT #1: Review of the patient record showed: - Patient recently discharged from a hospital due to a joint replacement surgery - left knee; and - Plan of Care (POC)/start of care (SOC) dated 04/09/2021. During a home visit observation on 06/02/2021 beginning at 9:30 AM, the nurse reviewed the patient's medications. The following discrepancies were found: - Agency medication list showed Prenatal multivitamin/Iron every day, patient stated that he/she stopped taking this medication on 03/2021; - Agency medication list showed Tylenol 650 milligrams (mg) every four hours as needed for pain, patient stated that he/she took 500 mg as needed (prn); - Agency medication list showed Miralax 17 gram (gm) (laxative), patient stated that he/she never took this medication; - Agency medication list showed ProAir HFA (inhaler for treatment of breathing difficulties) two puffs - four times a day as needed for shortness of air, patient stated that he/she never took; - Agency medication list showed aspirin 81 mg (pain or treat stroke symptoms) daily, patient stated that he/she took prior to surgery, and is no longer taking; - Agency medication list showed dicyclomine HCL (irritable bowel/antispasmodic) four times a day, patient stated don't take, took a a couple of times when in the hospital; - Agency list showed hydrochlorothiazide (treat fluid retention) 25 mg daily, patient stated stopped taking two weeks ago; and - Agency list showed hydroxyzine HCL (anxiety treatment) 37.5 mg four times a day prn, patient stated not taking; During an interview with the clinical manager on 06/02/2021 at 2:30 PM, he/she stated that the RN goes by the medications in the home, and that medications are not checked at every nurse visit. RECORD/PATIENT #3: Review of the patient record showed: - Patient admitted to agency due to fracture (break) of right femur (leg bone); - Patient SOC dated 05/16/2021; During a home visit observation on 06/02/2021 beginning at 11:40 AM, the nurse reviewed the patient's medications. The following discrepancies were found: - Agency medication list showed atorvastatin calcium 40 mg daily for blood pressure (B/P - measure of the pressure exerted on the wall of any blood vessel), patient medication bottle showed that this medication should be taken with food, agency medication list failed to contain this direction; - Agency medication list showed Colace (stool softener) 100 mg twice a day, patient stated that he/she takes this medication daily; - Agency medication list showed omeprazole (antacid) one capsule daily, patient medication bottle showed one capsule before breakfast; - Agency medication list showed tramadol HCL 50 mg every four hours as needed for pain, patient medication bottle showed tramadol twice a day prn; and - Agency medication list showed trazodone HCL 150 mg at bedtime, patient medication bottle showed two tablets at bedtime; Agency medication list failed to show the following medications found in the home: - Thick layer of zinc based product to pressure ulcer (skin sore) twice a day; - Preser vision (eye vitamin and mineral supplement) one daily; -Tylenol eight hour arthritis (pain) 650 mg prn; and - Fluticasone propionate (runny nose) one spray nasal spray 50 microgram prn. During an interview with clinical manager on 06/02/2021 at 3:45 PM, the clinical manager stated that the medications in the home should match the agency medication list. RECORD/PATIENT #5: Review of the clinical record showed: - The agency's client referral information showed a referral dated 05/06/2021; - Physical therapy performed initial patient assessment on 05/08/2021; - The patient was admitted post incision and drainage of right hematoma (blood clot) of right knee that occurred on 04/22/2021; - The physician referral information showed a list of seven home medications for the patient; - The physician referral information showed "can remain on his/her usual home medications, with the exception of any other blood thinners. They can be restarted a day or two after surgery."; - No RN medication review was included in the patient's comprehensive assessment; - Patient plan of care showed only three medications with doses different than referral medication information; and - Communication note dated 05/21/2021, from the RN, stated "Spoke with son, and he reports no problem with medications and denies questions." During an interview on 06/03/2021 at approximately 9:30 AM, the clinical manager stated that he/she could not find a physician order for the medication discrepancies and could not find an RN medication review.

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 policy review, record review, observation, and interview, the agency failed to ensure staff followed infection control standards of practice in two (Records/Patients #1 and #2) of three home visit observations. This deficient practice has the potential to affect the health and safety of all patients served by the agency. Findings included: Review of the agency's policy titled, "Hand Hygiene," dated November 2019, showed: Hand hygiene is to occur: - Before downing gloves to administer care to the patient; - After removing and disposing of gloves and other protective equipment; - Before performing an aseptic task (e.g., performing wound care); - After contact with blood, body fluids, mucous membranes, non-intact skin, and wound dressings even if hands are not visibly soiled; - After contact with the patient or objects in the immediate vicinity of the patient; and - After each episode of removing gloves, including in between all glove changes. Review of the agency's policy titled, "Handling of Equipment taken into home," dated 5/12/21 showed: - Prepare clean area along side of bag using wax paper as a barrier if indicated; and - Wax paper barrier use is mandatory for nursing bag and equipment laid down outside of bag. RECORD/PATIENT #1: The patient was admitted to home health services on 04/09/2021 with a primary diagnosis of fracture (break) of right femur (leg bone). The plan of care (POC) showed on 05/19/202, the primary diagnosis changed to chronic myelomonocystic leukemia (type of cancer, with overgrowth of white blood cells) anemia (low red blood cell count). Review of the POC showed an order for CBC (complete blood count) via venipuncture (blood draw) on 05/19/2021 and then weekly. During a home visit observation on 06/02/2021, beginning at 9:30 AM, the skilled nurse (SN) performed the blood draw. The SN placed a clean barrier on the table for clean items, supplies to draw the patient's blood. During the blood draw procedure, the SN placed his/her soiled gloves on the clean barrier, with the rest of his/her clean supplies for the blood draw procedure. During an interview on 06/02/2021 at 2:30 PM, the clinical manager stated that he/she would expect the SN to use two barriers, one for clean supplies and one for soiled supplies. RECORD/PATIENT #2: Review of the plan of care (POC) dated 05/03/2021 showed: - Start of care (SOC) date: 11/04/2020; - Diagnoses included but not limited to chronic venous hypertensive ulcer (open sore) and inflammation (redness) of both lower legs; and - POC directed skilled nurse (SN) to perform wound care two times a week. During a home visit observation with SN on 06/02/2021 beginning at 11:00 AM, the SN failed to follow infection control policies during performance of wound care. The SN failed to change gloves and perform hand hygiene after removing the soiled dressing on the patient's left leg. The SN proceeded to apply ointment to the left leg and apply dressing wrap to the leg. During an interview following the home visit, the SN concurred that he/she had been distracted by a "fly" that kept trying to land on the patient's left leg. During an interview with the administrator on 06/02/2021 at 4:00 PM, the administrator concurred that hand hygiene after glove removal and after soiled dressing removal is the agency policy.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on clinical record review, home visit observation, and interview, the agency failed to provide services as ordered by the physician on the plan of care (POC) in three (Records/Patients #1, #2 and #3) of five records reviewed. This deficient practice has the potential to affect the safety and outcomes of the care provided to all of the agency patients. Findings included: Review of the agency's policy titled, "Plan of Care," dated November 2019, showed that the patient's physician orders for treatments and services are the foundation of the plan of care. If the agency misses a visit or a treatment or service as required by the POC, which results in any potential for clinical impact upon the patient, then the agency will notify the responsible physician of such missed treatment or service. Review of the agency's policy titled, "Wet to Dry Dressing ," dated 04/28/2021 showed wound measurements at least weekly with first visit of the week, including length, depth, and width of wound in centimeters (cm). Review of agency policy titled, "Collection of Blood," dated 04/26/2021, showed: - Staff obtain a venipuncture kit, venojet, butterfly, or appropriate needle, vacutainer, sterile 10 milliliter (ml) syringe (optional) and a biohazard specimen bag. - Procedure - withdraw blood by slow traction on the plunger of the syringe, if using syringe; - If flow of blood ceases before obtaining adequate samples remove tube and repeat using new tube. If adequate samples remove tube and repeat using new tube. Review of agency policy titled, "Description of Services Policy, Skilled Nursing," dated November 2019, showed that the qualified Registered Nurse (RN) will provide services requiring professional nursing skills, including administration of medications, treatments and procedures in acceptance with standard nursing practice. Nurses should not perform any treatments or procedures with which they are unfamiliar. RECORD/PATIENT #1: The patient was admitted to home health services on 04/09/2021 with a primary diagnosis of fracture (break) of right femur (leg bone). POC showed on 05/19/2021 primary diagnosis changed to Chronic myelomonocystic leukemia (type of cancer, with overgrowth of white blood cells) anemia (low red blood cell count). Review of the POC showed an order for CBC (complete blood count) via venipuncture (blood draw) on 05/19/2021 and then weekly. During an observation of CBC blood collection on 06/02/2021 beginning at 9:30 AM, the RN attempted to draw blood sample. RN was unsuccessful obtaining sample. RN went to his/her blood sample supplies and failed to have another syringe to use for the blood draw. RN had a 12 ml normal saline (NACL) syringe in his/her supplies. RN discarded the NACL solution from the syringe and used the syringe to obtain blood sample for CBC testing. During an interview with a lab specialist from the department of health and senior services on 06/03/2021 at 10:45 AM, the specialist stated that this was inappropriate, that the residual NACL in the syringe could alter the lab findings. During an interview with the RN on 06/03/2021 at 11:30 AM, the RN stated that he/she should have obtained another sterile syringe. He/she stated that he/she should not have used the NACL syringe. During an interview with the administrator on 06/03/2021 he/she stated that this would not happen again, and that there would be a lot of education provided to staff related to lab procedures. RECORD/PATIENT #2: Review of the plan of care (POC) dated 05/03/2021 showed: - Start of care (SOC) date: 11/04/2020; - Diagnoses included but not limited to chronic venous hypertensive ulcer (open sore) and inflammation (redness) of both lower legs; and - POC directed skilled nurse (SN) to perform wound care two times a week, and SN to measure wounds weekly. Review of SN weekly visit notes showed SN measured wounds three times out of six weeks. Review of resumption of care SN notes dated 05/06/2021, showed an order for physical therapy (PT) and occupational therapy (OT). Further review of patient record failed to show notes from either PT and/or OT. During an interview on 06/03/2021 at 9:30 AM with the clinical manager, he/she stated that he/she believed that the patient declined PT and OT. Clinical manager stated that he/she was unable to find communication to the physician in regard to patient refusal of these services. RECORD/PATIENT #3: Review of the POC dated 05/16/2021 showed: - Stage one (red skin) pressure ulcer located coccyx (tail bone), SN to cleanse with mild soap and water, rinse, pat dry, apply thick layer of zinc based product. No wound measurement on the SOC on 05/16/2021, and only one wound measurement found on record on 05/26/2021. During an interview on 06/02/2021 at 4:05 PM, the clinical manager stated that she would expect wounds to be measured at SOC and then measured weekly.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to request and obtain results of findings of the Employee Disqualification List (EDL) prior to hire in two (E #2 and E #3) of four employee files reviewed. This deficient practice has the potential to affect all of the patients served by the agency. Findings included: Review of Section 192.2490.12 RSMo: "No person, corporation, organization, or association who received the employee disqualification list under subdivisions (1) to (7) of subsection 11 of this section shall knowingly employ any person who is on the employee disqualification list." Review of the agency policy dated November 2019 titled, "Employment Process," showed that Johnson County Community Health Services Human Resource Department will check the EDL maintained by the Missouri Department of Health and Senior Services EDL before hiring an individual and will not continue to employ a person whose name appears on the EDL. E #2: Review of E #2's employee file showed: - Date of hire 07/26/19; and - EDL was checked 07/29/19 (three days after hire). E #3: Review of E #3's employee filed showed: - Date of hire 11/04/19; and - EDL was checked on 11/5/19 (one day after hire). During an interview with the administrator on 06/02/2021 at 4:30 PM, the administrator stated that the EDL will be checked prior to offer of employment from now on.