Every finding on record at Lakewood Health System

A survey for compliance with CMS Appendix Z Emergency Preparedness Requirements, was conducted 6/22/21 through 6/25/21, during a recertification survey. The facility was in full compliance and no deficiencies were issued.

A partial extended survey was conducted at Lakewood Health System Home Care and Hospice on 6/22/21 through 6/25/21. The agency was found to have not met the requirements at 42 CFR. Part 484 for Home Health Agencies. Unduplicated census: 482 (3 home visits completed). No branch offices. Hours of Operation: 8:00 a.m.- 4:30 p.m. Total number of records reviewed: 7

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on interview and document review, the agency failed to ensure 1 of 7 patients (P2) was informed or consented to services or care being provided including any ongoing changes in services. Findings include: P2's plan of care (POC) indicated start of care (SOC) date of 4/27/21. The POC for certification date 4/27/21 to 6/25/21 included diagnoses of mild cognitive impairment, anxiety, hypertension, and spinal stenosis. The POC further indicated P2 received skilled nursing (SN) one visit per week for nine weeks and five additional visits as needed, speech language pathology (SLP) one visit per week for six weeks. Review of P2's record revealed service plan dated and signed by P2 on 4/27/21, indicated SN one time per week under self pay. The service plan did not indicate SLP. P2's record lacked evidence that P2 was informed of and agreed to any changes in the planned services and care. During interview on 6/23/21, at 3:10 p.m. the clinical manager (CM)-A, confirmed P2's services included on the POC dated 4/27/21 to 6/25/21 were billed to Medicare. She stated P2 was initially admitted to self pay on 4/27/21 for SN services, then her payer was switched to Medicare due to therapy needs. CM-A's stated expectations would have been that a new SOC date and a new POC would have been done with a payer and service change, especially Medicare. She said at least a new service plan should have been signed to notify the client. A policy for Service Plan was requested, but not received.

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 observation, interview, and document review, the agency failed to complete a comprehensive drug regimen review to ensure the accuracy of all medications/dosages for 2 of 7 patients (P4, P3) whose medications were reviewed during home visits and record review. Findings include: P4's start of care (SOC) was 2/13/20. P4's plan of care (POC) for certification period 6/12/21 to 8/10/21, included diagnoses of basal cell carcinoma of skin of scalp, neck and nose, kidney disease, atrial fibrillation, hearing loss, and depressive disorder. The POC indicated SNV one per week for eight weeks, for various assessments, blood draws, treatments, medication setup and education. P4's POC included the following medications: levothyroxine (a thyroid medication) 50 micrograms (mcg) po (by mouth) qd (everyday); nitroglycerin 0.4 milligrams (mg) under the tongue every five minutes prn (as needed) for chest pain; polyethylene glycol powder (for constipation) 17 grams po qd prn; enteric coated aspirin 81 mg po qd; famotidine (an acid reducer) 20 mg po qd; docusate sodium (a stool softener) 100 mg po bid (twice daily); dorzolamide 2% ophthalmic solution one drop in eyes bid; furosemide (a diuretic) 20 mg po qd; Vaseline gel around right eye bid; mirtazapine (an anti-depressant) 15 mg po qd; and warfarin (a blood thinner) 3.75 mg po qd. During a home visit conducted on 6/23/21, at 12:30 p.m. P4's current medication bottles were compared to the medications listed on the POC and the medications setup in P4's medication boxes by the registered nurse (RN)-A. RN-A stated she set up P4's medication every week using the medication setup list in his electronic medical record (EMR), however, several medications in the home were not on the POC and the warfarin RN-A set in P4's medication boxes differed from P4's medication setup list. RN-A was observed to setup P4's medication boxes for nine days of medication setup. An unlabeled ibuprofen and Aleve medication bottles, as well as a labeled hydroxyzine (used to relieve itch) bottle was noted on P4's kitchen table. RN-A stated the medications were for prn use and P4 took the medications on his own. RN-A indicated the hydroxyzine was from an earlier order for an allergic rash, so it was completed and no longer ordered and was not on the POC for that reason, however, P4 refused to dispose of the remainder of the medication. RN-A indicated she had not listed the prn ibuprofen or Aleve on P4's medication list or POC and verified it should have been listed. RN-A was observed to setup P4's medications in an automated medication box using the EMR medication setup list on her computer. Warfarin was observed setup in P4's medication setup as 2.5 mg (1 tablet) in P4's Monday, Wednesday and Friday medication boxes and 3.75 mg (one and one half tablets) in P4's Sunday, Tuesday, Thursday, and Saturday medication boxes. However, 3.75 mg (one and one half tablets) daily was listed on his current POC. RN-A stated P4's warfarin was changed recently due to his lab work and she kept his medication setup list current with his medication changes in his medical record between certification periods. Review of P4's EMR medication setup list for medication setup during skilled nurse visits the weeks of 6/7/21, 6/14/21 and 6/21/21, indicated medications were setup per the medication setup list. The medication lists for the visits indicated warfarin 3.75 mg (one and one half tablets) were being setup. The medication setup list record lacked documentation of the dosage change ordered 6/7/21, to administer warfarin 2.5 mg every Monday, Wednesday, and Friday and warfarin 3.75 mg every Sunday, Tuesday, Thursday and Saturdays. During interview on 6/24/21, at 4:30 p.m. clinical manager (CM)-A stated the nurse was suppose to review client's medications and manually enter any changes in medications into the care plan when they setup medications. CM-A verified skilled nurse visit notes for the weeks of 6/7/21, 6/14/21 and 6/21/21, indicated warfarin 3.75 mg was setup daily in P4's medication boxes. CM-A indicated medication changes required a manual entry to make the change and it did not appear to have been done in P4's record. CM-A verified a nurse that was not aware of the verbal order on 6/7/21 would mistakenly setup 3.75 mg of warfarin in P4's medication boxes. Review of the agency's policy, General Procedures for Medication Administration, Set up and Documentation with review date 4/8/21, directed licensed personnel to open the electronic Medication Administration Record (eMAR) making sure that a current, accurate medication profile was in the clinical record. Verify the medication was the right medication, dose, route, time and patient, was not expired, had no contraindications and was labeled correctly. If setting up the medication, the nurse was to document each medication and the number of days setup, as well as any exceptions. Review of the agency's policy, Medication Reconciliation with review date 4/8/19, indicated the skilled nurse performing the visit would reconcile the medications on the medication list located in the client's home and the permanent record in the office. If the medication had been changed during the episode of care, the nurse would discontinue the previously ordered medication and write the correction on a new line item on the medication form in the office clinical record and the medication record in the client's home. Medications would be addressed at each nursing visit. Findings include P3's POC indicated a SOC date of 2/6/20. The POC for certification date 5/31/21 to 7/29/21 included diagnoses of urinary tract infection, hematuria, multiple sclerosis, hypertension, hypothyroidism, vitamin B12 deficiency, encounter for fitting and adjustment of urinary device (indwelling/Foley catheter). The POC further indicated skilled nursing (SN) one visit every three weeks for nine weeks for assessment, education on urinary catheter and infection prevention, risk of infection and catheter change, management of home medications, along with four additional visits as needed, and home health aide (HHA) visits, one visit every week for one week, three visits every week for eight weeks, and two visits every week for one week to assist with personal cares, nutrition, socialization, elimination, Foley catheter care, repositioning, and various activities. P3's POC included the following medication: multiple vitamin with minerals po (by mouth) qd (daily); cranberry 300 mg (milligrams) tab, take 900 mg po qd; krill oil 300 mg po qd; apple cider vinegar one po qd; cannonball (form of vitamin B12) 2,500 mcg (micrograms) sl (sublingual) qd; folic acid (B vitamin) 800 mcg, take 1,600 mcg po qd; acidophilus probiotic blend, one po qd; acetaminophen 325 mg, take one to two tablets po every four hours as needed for pain-limit to 4,000 mg per day from all sources; magnesium oxide 500 mg po qd, influenza vaccine 0.5 solution, inject into muscle one time; nystatin (antifungal) 100000 unit/gram powder, apply 2 gram topically bid (two times per day); Avonex (treat multiple sclerosis) prefilled syringe 30 mcg/0.5 ml (milliliters), inject into muscle one time per week; aspirin enteric coated 81 mg po qd; gabapentin (pain relief) 100 mg po, take three capsules with breakfast qd, one capsule qhs (every bedtime); levothyroxine (thyroid medication) 125 mcg po qd; Requip (treat restless legs) 0.25 mg po q (every) evening; Macrobid (treat bladder infections) 100 mg capsule, one po bid; Provigil (narcolepsy agent) 200 mg po, take ½ tab q morning and also ½ tab one time per day as needed for pain; tramadol (treat severe pain) 50 mg po tid (three times per day) prn (as needed) for pain; and D-mannose (supplement for bladder health) 500 mg po qd. During a home visit on 6/23/21, at 10:30 a.m. P3 stated her son sets up her medications once per week. P3 stated her nurse helped with her medications sometimes especially since she started on a new blood pressure medication recently. P3 stated the bottle for the new medication was not in the home as her son went to get it refilled. P3's current medication bottles were compared to the POC dated 5/31/21 to 7/29/21. P3 reported the following dose discrepancies: cranberry 15,000 mg po bid; krill oil 500 mg po qd; and folic acid 400 mcg po qd. Medications listed on the POC that P3 was not taking included: acetaminophen 325 mg tablets; Macrobid 100 mg; and cyanocobalamin 2,500 mcg. Medications P3 stated she was taking that were not on the POC included: acetaminophen 500 mg, two tablets po q morning and noon; acetaminophen PM 500 mg two po tablets q bed time; Osteobiflex two tablets po qd, vitamin D3 125 mcg one po qd, and biotin (vitamin B7 supplement) one po qd. During an interview on 6/23/21, at 3:35 p.m. registered nurse (RN)-B stated Macrobid was a standing order for P3 and was not current, although the POC did not indicate that. P3's son sets up her pills. RN-B stated at nurse visits, she asks about anything new. RN-B stated she had been working with P3 on her blood pressure and just got a new medication going. RN-B stated she never talks with P3's son about the medications. She stated she tried to keep up on the supplements. During an interview on 6/25/21, at 10:45 a.m. clinical manager (CM)-A stated she expected nurses to ask patients about medication changes at every nurse visit. CM-A confirmed if a patient caregiver was responsible for setting up a patient's medications, it would be appropriate for the nurse to review medications with the caregiver. Review of the agency's policy, Medication Reconciliation, reviewed on 4/8/19, indicated all field staff will ask about medication changes at every visit. The skilled nurse performing the visit will reconcile the medication list located in the client's home, and the permanent record in the office. Medications will be addressed at each visit.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to ensure visits were conducted in accordance with physician orders for 2 of 7 patients (P1, P4) and failed to notify the physician when the visits were not conducted according to the plan of care (POC). Findings include: P1's start of care (SOC) was 7/11/19. The POC certification period 9/13/20 to 11/14/20, included diagnoses of diabetes with diabetic nephropathy, kidney disease, peripheral vascular disease, cardiac arrhythmia, schizoaffective disorder, long term use of insulin, acquired absence of other specified parts of digestive tract and acquired absence of right lower leg below the knee. The POC indicated skilled nurse visits (SNV) one time weekly for nine weeks for various assessments and education and home health aide (HHA) visits three times per week for eight weeks and two visits per week for one week to assist with personal care. The POC certification period 11/15/20 to 1/13/21, included diagnoses of diabetes with diabetic nephropathy, kidney disease, peripheral vascular disease, cardiac arrhythmia, schizoaffective disorder, long term use of insulin, acquired absence of other specified parts of digestive tract and acquired absence of right lower leg below the knee. The POC indicated SNV one time weekly for nine weeks for various assessments and education and HHA visits three times per week for eight weeks and two visits per week for one week to assist with personal care. Review of P1's medical record indicated P1 had HHA visits only twice during the week of 9/27/20, and only two visits during the week of 10/4/20, and 10/25/20. During the certification period 11/15/20 to 1/13/21, P1 only received HHA visits two times weekly for the entire certification period, instead of the three times per week as ordered by his physician. There was no documentation to indicate the physician was notified or consulted regarding the decreases in the HHA visits. During an interview on 6/23/21, at 3:10 p.m. the clinical manager (CM)-A stated the decreased HHA visits were a part of the agency's contingency plan for low staffing during the COVID-19 pandemic. A letter was mailed to patients and providers to notify them of the agency's contingency plan in September 2020. Review of the undated, non addressed letter indicated the agency would no longer provide homemaking chore services, effective April 13th, however, the letter did not address home health aide services. The CM indicated in November 2020, an agency nurse did phone individual clients to notify them HHA services would be decreased and adjustments made due to staff illness's. No physician orders had been obtained to decrease HHA services as the agency decreased these services as part of their contingency plan. P1's clinical record lacked documentation that he or his physician had been notified of missed HHA visits in September and October of 2020 or the decrease of HHA services for the certification period 11/15/20 through 1/13/21. P4's SOC was 2/13/20. The POC certification period 6/12/20 to 8/10/20, included diagnoses of basal cell carcinoma of skin of scalp, neck and nose, kidney disease, atrial fibrillation, hearing loss, and depressive disorder. The POC indicated SNV one per week for eight weeks, for various assessments, blood draws, treatments, medication setup and education. The POC indicated SNV one time per week for eight weeks. Review of P4's medical record indicated P4 had SNV two times per week for the four week time period between 7/12/20 through 8/8/20. There was no documentation to indicate the physician was notified or consulted regarding the increase in SNV's. During an interview on 6/23/21, at 3:54 p.m. CM-A stated she was unable to find an order to increase SNV during the time period in question. She was able to find an order to increase dressing changes to P4's wound, however, the order did not indicate SNV's were to be increased as well. CM-A verified the dressing changes could be done by the client's spouse or a HHA and was not clear the skilled nurse would be performing the increase dressing changes. CM-A indicated the nurse was new to the agency and did not understand an order to increase services would require frequency and duration of visits on the orders. Review of the agency's policy, Discharge Criteria and Process with revision date of November 2017, indicated when the patient's POC changes and the change results in discharge or reduction of services, the patient, as well as his/her primary physician, would be notified and involved in planning decisions. Review of the agency's policy, Home Care- Hospice Physician Orders policy with review date of 4/8/19, indicated medical orders were to be obtained for all treatments, procedures and equipment. Written orders signed by the attending physician were required for all health services with the exception of homemaker/companion. The physician was to be notified of any missed visits either by obtaining an order to cover the missed visit or notifying the physician and maintaining documentation in the clinical record indicating the physician was aware of the missed visit. The orders on the plan of care must indicate the type of services to be provided to the patient, both with respect to the professional who will provide them and the nature of the services, as well as the frequency of the services. Physician was to be notified of any significant change in client condition and of any changes in the plan of care.

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on observation, interview, and document review, the agency failed to provide patient and staff education regarding care of foley catheter for 1 of 7 patients (P3). Findings include: P3's plan of care (POC) indicated start of care (SOC) date of 2/6/20. The POC for certification date 5/31/21 to 7/29/21 included diagnoses of urinary tract infection, hematuria, multiple sclerosis, hypertension, hypothyroidism, vitamin B12 deficiency, encounter for fitting and adjustment of urinary device (indwelling/foley catheter). The POC further indicated skilled nursing (SN) one visit every three weeks for nine weeks for assessment, education on urinary catheter and infection prevention, risk of infection and catheter change along with four additional visits as needed, and home health aide (HHA) visits, one visit every week for one week, three visits every week for eight weeks, and two visits every week for one week to assist with personal cares, nutrition, socialization, elimination, foley catheter care, repositioning, and various activities. During home visit and observation on 6/23/21, at 10:30 a.m. P3, was sitting in her recliner in her living room upon surveyor arrival. P3's foley catheter drainage bag was laying on the living room floor without a protective covering on it. When surveyor asked P3 what she does with her drainage bag when she is sitting in the chair or when she is in bed at night, she stated, "I just throw it on the floor." P3 stated she never thought about hooking her bag on anything to keep it off the floor. During interview on 6/23/21, at 11:30 a.m. home health aide (HHA)-A stated it was ok for P3 to put the catheter bag on the floor, as it was her own house, and she will do what she wants. HHA-A stated, P3 was an old farm girl. During interview on 6/23/21, at 3:35 p.m. registered nurse (RN)-B confirmed P3 did put her catheter bag on the floor. She stated she had told P3 not to do that as it could introduce bacteria into the bag. RN-B stated P3 could hook the bag on her walker or on the edge of her bed and that she could further educate P3 about this as P3 had a history of urinary tract infections. During interview on 6/25/21, at 10:45 a.m. clinical manager (CM)-A confirmed P3's catheter bag should not be laying on the floor in any situation. CM-A obtained a barrier bag for P3 that she put on RN-B's desk to bring out to P3's house for the next visit to instruct the patient to use to better protect the catheter bag. With P3's history of frequent urinary tract infections, P3 needs further teaching on care of bag. CM-A stated it could be hung from walker or her bed at night. The agency policy "Indwelling urinary catheter (Foley) care and management, home care," revised 5/21/21, was reviewed and lacked how to care for the foley catheter drainage bag in the home.