Every finding on record at Livingston Healthcare

Based on the regulatory requirements and standards of Code 42 CFR 418.113 Emergency Preparedness (EP) Final Rule Requirement for Conditions of Participation for Home Health Agencies, effective 11/15/17, a recertification survey was completed on 8/14/24. No deficiencies were cited.

A Recertification Survey was completed on 8/14/24. A Standard level deficiency was cited. Glossary: LPN Licensed Practical Nurse

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to follow their established policies and procedures and ensure all verbal orders were authenticated and dated by the physician or allowed practitioner for 7 (#s 1, 2, 3, 4, 7, 8 and 9) of 9 sampled patients. Findings include: Review of patient #1's plan of care, with a start of care date of 10/29/23, showed the order was signed by the provider on 11/7/23. The verbal order failed to be authenticated within the agency's established timeframe. Review of patient #2's plan of care, with a start of care date of 12/12/23, showed the order was signed by the provider on 1/5/24. The verbal order failed to be authenticated within the agency's established timeframe. Review of patient #3's plan of care, with a start of care date of 7/25/24, showed the order was signed by the provider on 8/5/24. The verbal order failed to be authenticated within the agency's established timeframe. Review of patient #9's plan of care, with a start of care date of 7/25/24, showed order failed to was not signed by the provider. The verbal order failed to be authenticated within the agency's established timeframe. During an interview on 8/14/24 at 1:07 p.m., staff member H stated the plan of care was considered a verbal order. Staff member H stated after the plan of care is developed, it was then sent out to the provider for signature. Review of the agency’s procedure titled, Home Health Program Guidelines, effective date 9/1/23, showed: - …”Written Orders: - … Verbal orders may be taken by Registered Nurses, LPN’s and Therapists according to their scope of practice. All verbal orders must be followed by written orders within 5 days. …” Review of patient #4’s plan of care, with a start of care date of 1/21/24, showed the order was signed by the physician on 2/5/24. The verbal order failed to be authenticated within the agency’s established timeframe. Review of patient #7’s plan of care, with a start of care date of 7/26/24, showed the attending physician signed the verbal order on 8/14/24. The verbal order failed to be authenticated within the agency’s established timeframe. Review of patient #7’s verbal physician order, dated 7/31/24, showed the order was signed by the physician on 8/8/24. The verbal order failed to be authenticated within the agency’s established timeframe. Review of patient #8’s plan of care, with a start of care date of 9/25/23, showed the order was signed by the physician on 10/24/23. The verbal order failed to be authenticated within the agency’s established timeframe. During an interview on 8/14/24 at 8:23 a.m., staff member H stated verbal orders need to be signed within 5 days, per the agency's policies and procedures. During an interview on 8/14/24 at 1:12 p.m., staff member H stated a patient’s initial plan of care was considered verbal orders for care, including medications and treatment.

An Emergency Preparedness Recertification Survey was completed on 10/28/21. The agency was found to be in substantial compliance with the regulatory requirements and standards of 42 Code of Federal Regulations (CFR) 484.22 Emergency Preparedness (EP) Final Rule Requirement for Condition of Participation for Home Health Agencies.

A Recertification Survey was completed on 10/28/21. Standard level deficiencies were cited. Abbreviations: 02 - Oxygen BID - Twice Daily BS - Blood Sugar LPM - Liters Per Minute MG - Milligram ML - Milliliter OASIS - Outcome and Assessment Information Set PA - Physician Assistant PO - By Mouth POC - Plan of Care PRN - As Needed PT - Patient SOC - Start of Care

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 interview and record review, the agency failed to ensure staff completed a current list of medications and failed to ensure there was an updated list of medications on the plan of care for 1 (#6) of 7 sampled patients. Findings include: During an interview on 10/28/21 at 11:00 a.m., staff member C stated the medication list was discussed with the family and the patient on admit and was compared to the discharge summary. Staff member C stated patient #6 was not taking the Haldol everyday anymore. Review of patient #6's Discharge Summary from an acute stay facility on 10/15/21, showed 0.5 mg of Haldol was to be given at bedtime as needed and 0.25 mg was to be given as needed during the day. Review of patient #6's admission medication list showed the patient was taking Haldol 0.5 mg at bedtime as needed and 0.25 mg scheduled one time daily. Review of patient #6's updated Care Plan, dated 10/28/2021, showed both doses of Haldol were to be administered as needed. A review of the agency's policy and procedure titled, Home Health Program Guidelines, with a revision date of 6/5/20, showed, "...Written orders must be explicit and complete, i.e. medications: name, dosage, frequency and administration.... The plan of care is developed in consultation with the agency staff and covers all pertinent diagnoses, including mental status, types of services and equipment required, frequency of visits, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, medications and treatments, any safety measures to protect against injury, instructions for timely discharge or referral, and any other appropriate items..."

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure all medications and treatments were included and revised on the POC for 2 (#s 2 and 4) of 7 sampled patients. Findings include: 1. Patient #2 had a SOC date of 3/6/21, with a principal diagnosis of diabetes mellitus type II with diabetic foot ulcer. a. Review of patient #2's SOC OASIS, with Date Assessment Complete (M0090) of 3/10/21, showed, Respiratory Status: uses Oxygen via nasal cannula at 3 LPM, intermittent. Review of patient #2's POC and Clinical Medication List, did not show the patient's oxygen treatment listed. b. Review of patient #2’s Discharge Instructions, dated 3/5/21, showed, “HumaLOG 100 units/mL injectable solution (insulin lispro) Take as instructed Instructions: BEFORE MEALS THREE TIMES A DAY. 150-170 5 units 171-270 8 units 271-370 12 units 371-470 15 units greater than 470 call doctor.” Review of patient #2’s POC (485), with a Certification Period from 3/6/21 to 5/4/21, showed, Humalog, effective 3/5/21, three times daily subcutaneously. Further review of the POC, did not show the dosing for the Humalog. Review of patient #2’s Clinical Medication List, did not show the sliding scale dosing for Humalog. c. Review of patient #2’s Care Plan Visit Summary Review, dated 3/20/22, showed, “…Pt is now taking Jardiance…Since beginning Jardiance, BS has ranged between 53-242…” Review of patient #2’s Care Plan Visit Summary Review, dated, 3/26/21, showed, “…New order for Methocarbamol 500 mg one tab PO BID prn pain/cramps…” Review of patient #2’s Revised POC, effective 3/25/21, did not show the patient’s medication list was updated to reflect Jardiance or the Methocarbamol. 2. Patient #4 had a SOC date of 9/10/21, with a principal diagnosis of chronic obstructive pulmonary disease (COPD). Review of patient #4’s SOC OASIS, with Date Assessment Complete (M0090) of 9/10/21, showed, Respiratory Status: uses Oxygen via nasal cannula at 2 LPM, intermittent. Review of patient #4's POC and Clinical Medication List, did not show the patient's oxygen treatment listed. During an interview on 10/28/21 at 8:51 a.m., staff member A stated it was the expectation the patient's medication list and POC reflected all medications the patient was taking at the SOC, and the POC should be revised, and updated to reflect any change in medication, dosing, or treatments. Staff member A stated this was part of the SOC checklist, which clinicians utilize to ensure they capture the required elements for the POC. A review of the agency’s Protocol titled, Home Health Admission Checklist, showed, “…Reconcile medications/make sure 02 is on med list…” A review of the agency’s Policy and Procedure titled, Home Health Program Guidelines, with a revision date of 6/5/20, showed, “…The plan of care is developed in consultation with the agency staff and covers all… medications and treatments…”

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on interview and record review the agency failed to ensure all physician orders were included on the plan of care for 1 (#3) of 7 sampled patients. Findings include: Patient #3 had a SOC of 9/13/21, with a primary diagnosis of stage IV sacral pressure ulcer. Review of patient #3’s Care Plan Visit Summary Review, dated 9/17/21, showed, … "Foley catheter placed today per PA order to help with wound healing. 16 french catheter placed with immediate return of slightly cloudy urine…” [sic] Review of patient #3’s POC (485), with a certification period of 9/17/21 to 11/11/21, with a revision date of 9/17/21, did not show the newly ordered Foley catheter was updated on the patient’s POC. During an interview on 10/28/21 at 8:51 a.m., staff member A stated it was the expectation all treatments ordered during a patient’s certification period were to be updated on the patient’s POC (485). During an interview on 10/28/21 at 10:41 a.m., staff member B stated in proxy for staff member A, patient #3’s POC (485) was not updated when the Foley catheter was started. She stated the documented goals did not transfer to the POC (485).