Every finding on record at Mederi Caretenders

During the Recertification survey conducted on 09/19/2023 through 09/21/2023 at Mederi Caretenders, a Home Health Agency, Emergency Preparedness was reviewed. Mederi Caretenders is in compliance with Emergency Preparedness per Code of Federal Regulations (CFR) 42, Part 484.102, Condition of Participation for Home Health Agencies.

An unannounced Recertification survey was conducted on 09/19/2023 through 09/21/2023 at Mederi Caretenders, located at 603 17th Street, Vero Beach, FL 32960. The Home Health Agency was not in compliance with 42 Code of Federal Regulations (CFR) Part 484, Subpart A-C, Conditions of Participation for Home Health Agencies.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to ensure coordination of care for 2 of 14 sampled patients. During a home visit observation, Staff A, Registered Nurse (RN), failed to coordinate care with the physician after an unexpected Emergency Room visit, to ensure laboratory services for Patient #1 were not completed unnecessarily. Home Health Agency staff failed to follow up with the family of Patient #7 regarding an inquiry of additional laboratory services (Patient #1 and Patient #7). The findings included: 1) A home visit observation was made for Patient #1 on 09/20/23 beginning at 10:25 AM with Staff A, Registered Nurse (RN), to provide skilled services that included an ordered laboratory blood draw. Upon entering the home, Patient #1 informed Staff A that he had gone to the Emergency Room (ER) the previous day because his left arm hurt; Patient #1 told the RN they had "checked him out" at the ER and that they had drawn some blood. The Administrator/Director of Nursing (DON) was present at the home visit and stated maybe they wouldn't need to do the laboratory blood draw, but apparently the RN did not hear the DON, as she did not respond or inquire more about the ER visit. Staff A assessed the patient's left arm, and then asked Patient #1 if she could go ahead and do the laboratory blood draw before the full assessment. Patient #1 agreed, and the RN set up a clean field, gathered her supplies, and was ready to draw the laboratory bloodwork. Before drawing the blood, the surveyor asked if it were possible the blood work had been done at the ER the previous day and was not needed. At that point, the RN asked the caregiver of Patient #1 if there was any paperwork from the ER. Upon review of the ER discharge paperwork, the RN noted the same laboratory blood work that she was preparing to draw, had been drawn at the ER the previous day. Staff A then called the Nurse Practitioner, who agreed to obtain the laboratory results from the ER so that Patient #1 would not have to have the same laboratory blood work drawn again during that home visit. During an interview on 09/20/23 at 1:53 PM, when asked her reasoning for drawing the laboratory blood work without calling to ensure it was needed, Staff A, RN, stated she knew that they had been unable to draw blood on previous visits, so she was just focused on getting the blood drawn, and didn't think about checking the ER paperwork, until suggested. 2) Review of the record revealed Patient #7 had been admitted to the HHA on 07/30/23 for skilled services to include the provision of IV (Intravenous) fluids and to obtain blood for laboratory analysis. Skilled Nursing notes documented IV fluids were provided to Patient #7 on 08/05/23 and blood was drawn on 08/06/23 by an outside company. On 08/12/23 as per a Skilled Nursing note, additional IV fluids were provided to Patient #7. A "Coordination Note," dated 08/17/23 documented an inquiry by the family of Patient #7 as to when the next laboratory blood draw would be completed. This note documented the Skilled Nurse was going to contact the HHA's office to follow up on the mobile laboratory services. Further review of the record lacked any evidence the HHA followed up on the laboratory services inquiry by the family. During an interview on 09/21/23 at 12:15 PM, the Director of Nursing (DON) was told of the note regarding the inquiry of a second set of laboratory blood work to be drawn; the DON confirmed she was the current office care coordinator and was unaware of the inquiry by the family; the DON was asked to provide evidence of the second laboratory blood draw if it was completed, and none was provided.

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 record review and interview, the Home Health Agency (HHA) failed to ensure skilled services were provided as per the physician's signed Plan of Care for 2 of 14 sampled patients (Patient #8 and Patient #10). The findings included: 1) Review of the record revealed Patient #8 was admitted to the Home Health Agency (HHA) on 07/29/23 for skilled services to include Nursing and Physical Therapy. Review of the physician's signed Plan of Care for the certification period of 07/29/23 through 09/26/23 revealed Skilled Nursing services were ordered once weekly for ten weeks. Review of the Skilled Nursing notes for the second week of service revealed two Skilled Nursing visits were made on 08/05/23 by two different nurses. During an interview on 09/21/23 at 1:50 PM, the Intake Coordinator/Scheduler was asked about the two Skilled Nursing visits on 08/05/23. The Scheduler was unaware of the two visits and stated she would look into it. During a subsequent interview on 09/21/23 at 2:29 PM, the Scheduler was unable to determine the reason for the extra visit, stating it was a Saturday and there may have been some confusion between the On-Call Nurse and the Direct Care Nurse. Continued review of the Plan of Care revealed the Physical Therapist was to complete three home visits as of 07/30/23, which was the second week of service. Review of the Physical Therapy notes revealed home visits were done on 08/01/23 and 08/04/23 but lacked a third visit during that week. The record also lacked any documented "Missed Visit" for Physical Therapy that week. During the interview on 09/21/23 at 1:50 PM, the Scheduler agreed there were only two Physical Therapy home visits completed during the second week of service for Patient #8. 2) Review of the record revealed Patient #10 was admitted to the HHA on 04/06/23 for the provision of Skilled Nursing services. Review of the physician's signed Plan of Care for the certification period of 04/06/23 through 06/04/23 revealed the Skilled Nurse was to complete three home visits during the first week of service. Review of the Skilled Nursing visit notes revealed a visit on 04/06/23, but lacked visits on 04/07/23 or 04/08/23, the last two days of that week. During an interview on 09/21/23 at 2:50 PN, the Scheduler stated their computer system picks up the PRN (as needed) visits and adds them to the first week automatically, and staff need to manually correct it before it is sent out to the physician for signature. The scheduler agreed the visits did not follow the Plan of Care.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on record review and interview, the Home Health Agency (HHA) failed to ensure complete and accurate clinical records for 3 of 14 sampled patients; the Plan of Care and or orders for Patient #3 and Patient #8 were inaccurate and a Skilled Nursing note for Patient #7 was inaccurate (Patient #3, Patient #8 and Patient #7). The findings included: 1) Review of the record revealed Patient #3 was admitted to the Home Health Agency (HHA) on 09/08/23 for the provision of Skilled Nursing and Physical Therapy services, after having had a Total Knee Replacement. During a home visit on 09/20/23 at 9:30 AM, when asked if a CPM (Continuous Passive Motion) machine was being utilized in the home, both Staff B, Physical Therapist and Patient #3 stated it was in the home. Review of the clinical record lacked any documented CPM use in the Plan of Care. Review of the surgeon's "Standing Orders" (standard orders used by a physician for all patients who had the same surgical procedure) documented, "CPM as per MD (Physician) order." Further review of the record lacked any orders for the CPM use. During an interview on 09/21/23 at 10:15 AM, when asked about the CPM for Patient #3, Staff B, Physical Therapist, stated the CPM machine was not in the home upon her evaluation and development of the Plan of Care on 09/09/23; the Physical Therapist further explained when the first CPM arrived in the home, it was not functioning properly, so she had to have another delivered the following day; the Physical Therapist stated she could not put the CPM on the Plan of Care as it had not arrived. Upon review of the "Standing Orders," the Physical Therapist agreed the record lacked an order for the CPM use, but again agreed it was part of the patient's therapy. 2) Review of the record revealed Patient #7 was admitted to the HHA on 07/30/23 for the provision of IV (Intravenous) fluids. Review of the physician's orders dated 08/03/23 and 08/11/23 both documented the nurse was to administer two liters of Normal Saline. A liter is the same as 1000 ml. (milliliters). Review of the "Skilled Progress Notes," dated 08/05/23 and 08/12/23 both documented Staff C, Registered Nurse (RN) provided two 500 ml. bags of Normal Saline. During an interview on 09/21/23 at 12:15 PM, when asked about the amount of IV fluids administered for Patient #7, the Director of Nursing (DON) stated she called Staff C and confirmed the nurse provided the large bag of IV fluids, which would be 1000 ml., and agreed the clinical record was inaccurate. 3) Review of the record revealed Patient #8 was admitted to the HHA on 07/29/23 for the provision of Skilled Nursing and Physical Therapy services. Review of the physician's signed Plan of Care documented care to be provided by the Hospice Skilled Nurse. During an interview on 09/21/23 at 12:20 PM, when shown the Plan of Care with Hospice participation, the DON stated it was an entry error, as the staff "clicks" on certain disciplines, and must have "clicked" on Hospice in error.