Every finding on record at Lakeland Community Hospital, Inc.

Based on a recertification survey completed on 6/16/21, Northwest Home Health of Haleyville was in substantial compliance with the Emergency Preparedness regulations.

A recertification survey was completed on 6/16/21 at Northwest Home Health of Haleyville, standard level deficiencies were cited.

Content of the comprehensive assessment CFR(s): 484.55(c) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: This STANDARD is not met as evidenced by: Based on review of agency policy, medical records (MR), observations, and interviews with the staff it was determined the agency failed to ensure the staff updated each patient's Medication Profile and followed agency policy with changes in the patients medications for 1 of 3 home visits (HV) records reviewed. This affected HV # 2 and had the potential to negatively affect all patients served by the agency. Findings include: Title: MM- Medication Management Policy No.: 901 Revision Date: 9/2020 Purpose: To facilitate continuity of care, treatment, and services. To create an accurate medication history and a current list of medications (a drug profile). To safely order, administer and monitor medications, as appropriate. To prevent/ minimize the occurrence of medication errors, adverse drug reactions, and or other negative outcomes related to medication administration management. Procedure: A. Patient- Specific Information 1. Upon admission, the Registered Nurse (RN) or Physical Therapist (PT) will complete an assessment of all medications the patient is taking, both prescription and over-the-counter (OTC) drugs and begin a medication profile…. 3. All medications will be documented on the medication sheet as to the dose, frequency, route… 4. Medications ordered for the patient while under the care of the organization are compared to those on the list created at the time of admission. Any discrepancies (omissions, duplication's, contraindications, unclear information, and changes) are reconciled and documented. F. Monitoring Medication Usage and Effects 4. Ongoing medication monitoring is collaborative and essential to ensure appropriateness and continuity of care or services and to identify the potential complications from the therapy being provided. 1. HV # 2 was admitted to the agency on 3/11/21 and recertified 5/10/21 to 7/8/21 with diagnoses including Encounter for Change or Removal of Surgical Wound Dressing, Type 2 Diabetes Mellitus with Hyperglycemia, Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Petoris. A home visit was conducted on 6/15/21 at 11:50 AM to observe wound care provided by the RN. The surveyor was accompanied by Employee Identifier (EI) # 2, Clinical Manager/ Intake Coordinator. A comparison was made between medications observed in the home and the medication profile (MP) provided by the agency to the surveyor prior to the visit. The following discrepancies were found: 1) Norco 325 milligrams (mg)- 5 mg tablet (tab), 1 tab orally every 6 hours as needed for pain was listed on the MP. Norco 7.5/325 mg tab orally every 6 hours as need for pain and was filled on 5/16/21 was in the home. 2) Amaryl 2 mg tab, 1 tab orally 2 times a day with meals was listed on the MP. Glimepiride (Amaryl) 4 mg 1 tab 2 times a day was ordered on the bottle which was refilled on 2/2/21. The patient’s caregiver confirmed that was the correct doseage. 3) Dulcolax Stool Softeners 100 mg 1 daily was in the home and not listed on the MP. The patient confirmed he/she had been taking these for several weeks because the pain medication caused constipation. EI # 2, was present during the HV and confirmed the agency's Medication Profile was not accurate.

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on review of agency policy and procedures, medical records (MR) and interview with staff it was determined the agency failed to ensure teaching, education was provided and documented, to the patient and/or caregiver in 2 of 5 active records reviewed. This affected home visit (HV) # 2, MR # 1 and had the potential to affect all patients served by the agency. Findings include: Title: PC- Patient and Family Education Policy No.: 1124 Reviewed Date: 5/19 Policy: Northwest Home Health supports and plans the provision and coordination of patient/ caregiver education. Procedure: 1. The agency meets the goals of education by: a. Assisting the patient/ family/ caregiver in understanding the patient's health status, care or service options, and consequences of option selected;... c. Teaching or maximizing patient/ family/ caregiver care skills; d. Increasing patient/ family/ caregiver ability to cope with the patient's health status, prognosis and outcome... 2. The patient/ family/ caregiver education and training are essential to patient care and services... 6. The patient/ family/ caregiver will receive initial and ongoing education and training specific to the patient's assessed needs, abilities... 19. The patient's/family's/caregiver's knowledge, skills, and behaviors will be assessed on an ongoing basis, during each home visit, and provision of re-education will be implemented as appropriate. 20. Documentation in the medical record of patient/ family/ caregiver education shall include; a. All education activities provided; b. Specific instructions; d. Patient's/ family's/ caregiver's ability to repeat or demonstrate the instructions; e. The patient's response to the instructions... Instructions for Use HUMULIN® (HU-mu-lin) 70/30 insert: How should I store HUMULIN 70/30? All unopened HUMULIN 70/30 vials: • Store all unopened vials in the refrigerator... • Keep away from heat and out of direct light. • Unopened vials can be used until the expiration date on the carton and label, if they have been stored in the refrigerator. • Unopened vials should be thrown away after 31 days, if they are stored at room temperature. After HUMULIN 70/30 vials have been opened: • Store opened vials in the refrigerator or at room temperature below 86°F (30°C) for up to 31 days. • Keep away from heat and out of direct light. • Throw away all opened vials after 31 days of use, even if there is still insulin left in the vial... * HV # 2 was admitted to the agency on 3/11/21 and recertified 5/10/21 to 7/8/21 with diagnoses including Encounter for Change or Removal of Surgical Wound Dressing, Type 2 Diabetes Mellitus with Hyperglycemia, Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Petoris. Review of the Home Health Care Certification (HHCC) and Plan of Care (POC) 5/10/21 to 7/8/21 revealed orders for the Skilled Nurse (SN) to: Assess: blood sugar monitoring and results; diabetic complications; medication compliance. Reinforce signs/symptoms (s/s) and management of Diabetes to prevent complications as needed. Teach: regarding Diabetes management and disease process. A home visit was conducted on 6/15/21 at 11:50 AM to observe wound care provided by the RN. The surveyor was accompanied by Employee Identifier (EI) # 2, Clinical Manager/ Intake Coordinator. During the home visit the surveyor observed unopened vials of 70/30 insulin on the kitchen table and a cup with 24 insulin syringes filled with clear liquid on the kitchen counter. EI # 2 confirmed with the patient’s spouse these were filled 70/30 insulin. Review of the 10 SN visit notes dated 5/10/21 to 6/7/21 revealed no documented education for insulin storage or disposal. Further review of the 6/7/21 SN visit revealed the 70/30 insulin was stopped and Toujeo Max SoloStar 300 units/mL (milliliter) insulin was started. There was no documentation the patient or caregiver demonstrated to the SN how to properly inject the medication with the new insulin pen. In an interview conducted on 6/16/21 at 1:42 PM, EI # 2 confirmed there was no documented education to patient/caregiver for insulin storage/disposal and no return demonstration how to use the new insulin pen. * MR # 1 was admitted to the agency on 5/18/21 with diagnoses including Pneumonia, Unspecified Organism, and COPD (Chronic Obstructive Pulmonary Disease) with Acute Lower Respiratory Infection. Review of the Home Health Care Certification and Plan of Care, dated 5/18/21 to 7/16/21, revealed the following orders: Skilled Nursing: 1 wk (week) 1; 2 wk 1; 1 wk 7. Skilled nurse (SN) to perform wd (wound) care unstageable pressure ulcer rt (right) toe per aseptic tech (technique)... wound care to be performed daily until healed with pt (patient) cg (caregiver) perfoming on days SN not in home... SN to perform wd care to stage 4 gluteal fold per aseptic tech... Wd care to be performed daily until healed with pt cg performing on days SN not in home... SN: Teach care... dressings, supplies... Teach infection control measures... Teach patient/ caregiver measures to reduce risk and avoid wound infection... Review of the SN OASIS Visit note dated 5/18/21 revealed no documentation the wound care education was provided, or a return demonstration observed by the pt cg for either wound. An interview was conducted on 6/15/21 at 1:54 PM with Employee Identifier # 2, Clinic Manager, who confirmed there was no education documented for daily wound care that was to be provided by the caregiver.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on review of agency policies, medical records (MR), and interviews with agency staff, it was determined the agency failed to ensure: 1. All discipline visit notes were electronically signed and dated by each discipline according to agency policy and procedures. 2. The staff followed policy on Non- Outcome and Assessment Information Set (OASIS) documentation should be completed within 3 business days. This deficient practice affected 7 of 7 records reviewed, and did affect MR # 1, HV (Home Visit) # 1, MR # 4, HV # 2, MR # 3, HV # 3, MR # 2 and had the potential to negatively affect all patients served by the agency. Findings include: Title: RC- Documentation Policy Policy No.: 1303 Revision Date: 8/16 Policy: Agency staff are encouraged to document all care provided to each patient during each home visit... Purpose: To ensure timeliness and accuracy of the information provided. To ensure documentation of services that are provided. To provide information relative to patient status and progress. To describe the care provided and need for care at next visit. To communicate with other care providers in an efficient manner. To ensure the process of patient care is economical and efficient. Procedure: ... 2. The documentation will also include, as appropriate: a description of medication, the patient's response to any treatments, the ongoing status of identified problems, any patient instructions, relevant test results, procedure findings, any unusual problems, situations that arise during the visit, and comments regarding plan/s needs to be addressed at the next visit...... 4. Care provided during the visit may be documented throughout the note or in the "Interventions Addressed This Visit" section of the electronic record. 5. Non- OASIS visit note documentation should be completed within 3 business days. 6. Any additions to closed visit notes will be done in the form of an addendum. Title: PC - Admission Procedure Policy: #1103 Revision date: 5/19 Procedure: 5. An initial assessment utilizing Start of Care/Resumption of Care OASIS form will be completed by the registered nurse within 48 hours of the referral, within 48 hours of the patient's return from an inpatient stay... * HV # 2 was admitted to the agency on 3/11/21 and recertified for the dates of 5/10/21 to 7/8/21 with diagnoses including Encounter for Change or Removal of Surgical Wound Dressing, Type 2 Diabetes Mellitus with Hyperglycemia, Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Petoris. Review of the 5/12/21 Skilled Nurse (SN) visit note revealed the note was signed 5/17/21, which was 5 days later. Review of the 5/14/21 SN visit note revealed the note was signed on 5/20/21, which was 6 days later. In an interview conducted on 6/16/21 at 1:42 PM, Employee Identifier (EI) # 2, Clinical Manager/Intake Coordinator, confirmed the staff failed to follow their documentation policy. * MR # 3 was admitted to the agency on 12/8/2020 with diagnoses including Thrombosis due to Vascular Prosthetic Devices, Implants and Grafts Subsequent Encounter; Acquired Absence of Right Leg Above Knee; Other Injury of Popliteal Artery Right Leg Subsequent Encounter. Review of the Home Health Care Certification and Plan of Care 12/8/2020 revealed orders Skilled Nurse (SN) to assess pain including pain level, frequency, location, quality… Notify MD (Medical Doctor) if rates pain level > 5. Review of the 12/29/21 SN visit revealed documentation of pain level was rated at 6/10 in the narrative and the pain description was: Intense- 6 frequency: constant; and the patient had taken pain medication 3 times in the last 24 hours. Review of 1/8/21 Visit Note Addendum dated for visit 12/29/2020 revealed documentation pain documented 6 in error. Patient rates pain 4. The addendum note was signed 1/8/21, which was 13 days later. In an interview conducted on 6/16/21 at 1:02 PM, EI # 2, confirmed the staff failed to follow documentation policy. *HV # 3 was admitted to the agency on 5/12/21 with diagnoses including Spondylosis Without Myelopathy or Radiculopathy Lumbar Region, and Spinal Stenosis Lumbar Region Without Neurogenic Claudication. Review of the SOC (Start of Care) OASIS (Outcome and Assessment Information Set) dated 5/12/21 revealed the SN (Skilled Nurse) signed the note on 5/21/21, which was 9 days later. Review of the SN Visit Note dated 5/21/21 revealed the SN signed the note on 5/25/21, which was 4 days later. Review of the PT (Physical Therapy) Visit Note dated 5/12/21 revealed the PT signed the note on 5/17/21, which was 5 days later. Review of the PT Visit Note dated 5/20/21 revealed the PT signed the note on 5/25/21, which was 5 days later. Review of the OT (Occupational Therapy) Visit Note dated 5/18/21 revealed the OT signed the note on 5/24/21, which was 6 days later. Review of the Aide Visit Note dated 5/14/21 revealed the Aide signed the note on 5/20/21, which was 6 days later. Review of the Aide Visit Note dated 5/28/21 revealed the Aide signed the note on 6/1/21, which was 4 days later. An interview was conducted on 6/16/21 at 1:53 PM with Employee Identifier (EI) # 2, Clinical Manager/Intake Coordinator who confirmed the dates were not within policy. * MR # 2 was admitted to the agency on 11/11/2020 with diagnoses including Pressure Ulcer of Sacral Region, Stage 4, Encounter For Fitting and Adjustment of Urinary Device, and Paraplegia Unspecified. Review of the SN Visit Note dated 5/12/21 revealed the SN signed the note on 5/21/21, which was 9 days later. Review of the SN Visit Note dated 5/17/21 revealed the SN signed the note on 5/21/21, which was 4 days later. Review of the OT Visit Note dated 5/20/21 revealed the OT signed the note on 5/24/21, which was 4 days later. An interview was conducted on 6/11/21 at 12:06 PM with EI # 2 who confirmed the dates were not within policy. * MR # 1 was admitted to the agency on 5/18/21 with diagnoses including Pneumonia, Unspecified Organism, and Pressure Ulcer of Sacral Region, Stage 4. Review of the SOC (Start of Care) OASIS Note dated 5/18/21 revealed the SN (Skilled Nurse) signed the note on 5/25/21, which was 7 days later. Review of the SN Visit Note dated 5/20/21 revealed the SN signed the note on 5/26/21, which was 6 days later. Review of the SN Visit Note dated 6/7/21 revealed the SN signed the note on 6/11/21, which was 4 days later. An interview was conducted on 6/17/21 at 1:54 PM with Employee Identifier (EI) # 2, Clinical Manager/ Intake Coordinator, who confirmed the dates were not within policy. * HV # 1 was admitted to the agency on 6/9/21 with diagnoses including Hypertensive Heart Disease with Heart Failure, and Chronic Combined Systolic and Diastolic Heart Failure. Review of the SOC (Start of Care) OASIS, dated 6/9/21, revealed the nurse signed and dated the form on 6/15/21, which was 6 days after admission. An interview was conducted on 6/17/21 at 12:56 AM with EI # 2, who confirmed the OASIS was not signed and dated per policy. * MR # 4 was admitted to the agency on 3/3/21 with a diagnosis of Cellulitis of Back, Toxic Effect of Venom of Black Widow Spider. Review of the SOC OASIS, dated 3/3/21, revealed the nurse signed and dated the form on 3/18/21, which was 15 days later. An interview was conducted on 6/17/21 at 1:45 PM with EI # 2, who confirmed the date signed was not within policy.

Laboratory services/CLIA waivers CFR(s): 484.100(c)(1) Laboratory services. If the HHA engages in laboratory testing outside of the context of assisting an individual in self-administering a test with an appliance that has been cleared for that purpose by the Food and Drug Administration, the testing must be in compliance with all applicable requirements of part 493 of this chapter. The HHA may not substitute its equipment for a patient's equipment when assisting with self-administered tests. This STANDARD is not met as evidenced by: Based on observation and review of Center of Disease Control and Prevention (CDC) guidance, ContourNext One User Guide, and interview with agency staff, it was determined the agency failed to ensure single patient use glucometers were not used on multiple patients. This affected home visit (HV) # 2 and had the potential to negatively affect all patients with diabetes. Findings include: CDC clinical reminder: use of finger stick devices on more than one person poses risk for transmitting bloodborne pathogens. The meter and lancing device are for single-patient use. Do not share them with anyone including other family members! Do not use on multiple patients. The Contour®Next ONE User Guide: Intended Use blood glucose monitoring system is intended to be used for the quantitative measurement of glucose in fresh capillary whole blood drawn from the fingertips or palm. The Contour Next ONE blood glucose monitoring system is intended to be used by a single person and should not be shared * HV # 2 was admitted to the agency on 3/11/21 and recertified 5/10/21 to 7/8/21 with diagnoses including Encounter for Change or Removal of Surgical Wound Dressing, Type 2 Diabetes Mellitus with Hyperglycemia, Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Petoris. A home visit was conducted on 6/15/21 at 11:50 AM to observe care provided by Employee Identifier (EI) # 3, Registered Nurse (RN). The surveyor was accompanied by EI # 2, Clinical Manager/ Intake Coordinator. During the home visit EI # 3 was observed removing a small bag bag from her nursing bag. The bag contained a Contour NextOne glucometer, lancets and strips and performed a fingerstick blood sugar. The Contour NextOne glucometer is manufactured for single patient use. In an interview conducted on 6/16/21 at 2:00 PM, EI # 2 confirmed the single patient use glucometer has been used on more than one patient.