Every finding on record at Mercy Health Services, LLC

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 08/31/2022. 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 Agencies.

A partial extended survey for Medicare recertification for the home health provider was completed on 08/31/2022. The agency had 564 current patients. The COVID-19 Health Care Staff Vaccination regulation was reviewed as part of the Medicare recertification survey. During the survey it was determined the agency was in compliance with the regulation.

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, observation and interview, the agency failed to ensure an accurate and complete review of all medications was completed upon admission/ SOC (start of care) in 1 (Record/Patient #2) of five full record reviews. This deficient practice has the potential to adversely affect the agency’s ability to ensure safe and effective use of medications for all patients served by the agency. Findings included: Review of the agency’s policy titled, ““Named Agency”/Medication Management/Drug Regimen Review,” dated 07/01/2021 showed, in part: - The “Named Agency” is responsible for completing a drug regimen review at the time of the comprehensive assessment, and as needed throughout the patient’s episode of care, 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; - “Named Agency” will enter a current, accurate list of all prescription, over the counter (OTC) medications, and home remedies taken by the patient, on the medication profile in the electronic record and create a patient medication list to be kept by the patient in the home; and - A complete drug regimen review will be competed at all comprehensive assessments and as needed with new medications added to the patient’s medication regimen. Review of the agency’s policy titled, ““Named Agency” Medication Monitoring Policy,” dated 08/20/2021 showed, in part: - The “Named Agency” RN (registered nurse) will be responsible for monitoring the patient’s medication regimen data through a collaborative effort with “Named Agency” staff involved in the patient’s care; - “Named Agency” will maintain a current, accurate list of all prescription, over the counter (OTC) medications, and home remedies taken by the patient, on the medication profile; - “Named Agency” qualified staff will assess on an ongoing basis the patient’s response to the medication and the patient/caregiver’s compliance with the medication regimen; and - 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. RECORD/PATIENT #2: Review of the clinical record showed the following medication discrepancies: - The current medication profile showed acetaminophen mg (milligram) tablet, take 1,000mg by mouth every 6 hours as needed for pain, mild. Indications: pain; This medication failed to be on the referral After Visit Summary Medication list dated printed 8/10/2022 4:30 PM and the clinical record failed to show documentation of communication with the physician regarding this discrepancy at SOC; - The current medication profile showed aspirin-acetaminophen-caffeine (Excedrin Migraine) 250-250-65mg tablet, take 2 tablets by mouth 1 time daily as needed for headaches. Indications: headaches; This medication failed to be on the referral After Visit Summary Medication list dated printed 8/10/2022 4:30 PM and the clinical record failed to show documentation of communication with the physician regarding this discrepancy at SOC; - The current medication profile showed diphenhydramine-acetaminophen (acetaminophen PM) 25/500mg tablet, take 1-2 tablets by mouth nightly as needed for insomnia. Indications: insomnia; This medication failed to be on the referral After Visit Summary Medication list dated printed 8/10/2022 4:30 PM and the clinical record failed to show documentation of communication with the physician regarding this discrepancy at SOC; - The current medication profile showed ondansetron (Zofran) 4 mg tablet, take 4mg by mouth every 6 hours as needed for nausea/emesis. Indications: nausea/emesis; This medication failed to be on the referral After Visit Summary Medication list dated printed 8/10/2022 4:30 PM and the clinical record failed to show documentation of communication with the physician regarding this discrepancy at SOC; - The current medication profile showed pantoprazole (Protonix) 20mg tablet, take 20mg by mouth daily. Indications: prevention of indigestion and ulcer; This medication failed to be on the referral After Visit Summary Medication list dated printed 8/10/2022 4:30 PM and the clinical record failed to show documentation of communication with the physician regarding this discrepancy at SOC; - The current medication profile failed to show cetirizine 10mg tablet, take 10mg by mouth 1 time daily as needed (for seasonal allergies) as was listed on the referral After Visit Summary Medication list dated printed 8/10/2022 4:30 PM and the clinical record failed to show documentation of communication with the physician regarding this discrepancy at SOC or any interim orders to discontinue the medication; - The current medication profile failed to show cholecalciferol (vitamin D3) 1,000 units take by mouth every morning (supplement) as was listed on the referral After Visit Summary Medication list dated printed 8/10/2022 4:30 PM and the clinical record failed to show documentation of communication with the physician regarding this discrepancy at SOC or any interim orders to discontinue the medication; - The current medication profile failed to show dicyclomine 10mg capsule, take 1 capsule by mouth 4 times daily as needed (abdominal cramping and bowel urgency) as was listed on the referral After Visit Summary Medication list dated printed 8/10/2022 4:30 PM and the clinical record failed to show documentation of communication with the physician regarding this discrepancy at SOC or any interim orders to discontinue the medication; - The current medication profile failed to show fluticasone propionate (used to decrease inflammation caused by allergies) 50mcg (microgram)/spray suspension nasal inhaler, administer 2 sprays in each nostril daily as was listed on the referral After Visit Summary Medication list dated printed 8/10/2022 4:30 PM and the clinical record failed to show documentation of communication with the physician regarding this discrepancy at SOC or any interim orders to discontinue the medication; - The current medication profile failed to show levocetirizine 2.5mg/5ml (milliliter), take 2.5mg by mouth 1 time daily as needed (used to treat allergies) as was listed on the referral After Visit Summary Medication list dated printed 8/10/2022 4:30 PM and the clinical record failed to show documentation of communication with the physician regarding this discrepancy at SOC or any interim orders to discontinue the medication; - The current medication profile failed to show nystatin 100,000 unit/gram powder, apply to affected area 2 times daily as was listed on the referral After Visit Summary Medication list dated printed 8/10/2022 4:30 PM and the clinical record failed to show documentation of communication with the physician regarding this discrepancy at SOC or any interim orders to discontinue the medication; and - The current medication profile failed to show omeprazole 20mg capsule, delayed release, take 20mg by mouth 1 time daily as needed (used to treat heartburn) as was listed on the referral After Visit Summary Medication list dated printed 8/10/2022 4:30 PM and the clinical record failed to show documentation of communication with the physician regarding this discrepancy at SOC or any interim orders to discontinue the medication. Review of the SOC RN visit dated 08/13/2022: - Showed medications reviewed and reconciled; and - Failed to show any communication with the physician regarding medication discrepancies. Observation on 08/30/2022 at 1:02 PM, during the patient’s home visit, showed the home medication list matched the current medication profile in the medical record. The patient stated during this visit that he/she is following the home medication list but is now taking Zyrtec 10mg 1 tablet daily as needed (for seasonal allergies). This medication was listed on the referral After Visit Summary Medication list dated printed 8/10/2022 4:30 PM. Per interview conducted during observation, RN stated that he/she would usually write out the medication discrepancies on admission if they were prescription medications but not necessarily for over the counter medications if what the patient was taking on SOC didn’t match the discharge medication list. During an interview on 08/30/2022 at 3:45 PM, the administrator stated that he/she would expect documentation of medication discrepancies from the hospital discharge medication list versus what the patient is taking at the SOC visit. During an interview on 08/31/2022 at 9:25 AM, the administrator stated that: - They looked for documentation of physician notification of medication discrepancies at SOC and were unable to find any; and - They were surprised.

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 review of the agency’s policy, record review, and interview, the agency failed to promptly alert the physician to changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care (POC) should be altered, in two (Records/Patients #4 and #5) of five full records reviewed. This deficient practice has the potential to adversely affect all patients served by the agency. Findings included: Review of the agency’s policy titled ““Named Agency” Coordination of Services Vital Sign Parameters Agency Guidelines Policy,” dated 07/01/2021, showed, in part: - Purpose: Clinicians will have guidance on when to report vital sign readings; - “Named Agency” will follow the following agency guidelines for normal vital signs parameters: Heart rate: 50-110, Pulse oximeter: greater than or equal to 89%; and - All disciplines performing patient care will follow the normal vital signs parameters per our agency’s guidelines listed above. The exception is if patient specific vital sign parameters have been ordered by the physician. Review of the agency’s policy titled ““Named Agency” initial patient admission assessment policy,” dated 08/23/2021 showed ongoing assessment will occur with each visit and necessary revisions will be made to the plan of care. Review of the agency’s policy titled ““Named Agency” patient reassessment policy,” dated 06/16/2021 showed: - “Named Agency” will reassess each patient on an ongoing basis to evaluate current problems and needs as well as to adjust the care provided as needed; and - The patient will be assessed to determine response to care/outcome at each clinicians visit. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 08/02/2022 with a diagnosis of A-Fib RVR (Atrial fibrillation with rapid ventricular response- irregular heart beat causing the two lower chambers in the heart to beat too quickly). The patient was receiving SN (skilled nursing), PT (physical therapy) and OT (occupational therapy) services. Review of a PT note dated 08/12/2022 showed, in part: - SpO2 (pulse oximeter- measurement of oxygen saturation level of the blood): 56 (lower than the normal vital signs parameter of 89%; - Pulse: 18 (out of the normal vital signs parameter of 50-110); and - No documentation of physician notification of vital signs out of parameters or clarification of vital signs documentation (i.e. typographical error). Further review of the clinical record failed to show a case communication note for the 08/12/2022 PT visit regarding the out of parameters vital signs. During an interview on 08/31/2022 at 9:07 AM the administrator stated that: - He/she thought the therapist put the respirations where the pulse was to be documented; - If it (the pulse) was 18 everybody should be notified; - He/she wondered if the 56% documented as the SpO2 was actually the pulse; and - He/she would expect the physician to be notified if vital signs were out of parameters by telephone and telephone encounter. RECORD/PATIENT #5: Review of the clinical record showed: - Patient admitted to home health services after hospitalization for right foot incision (cut) and drainage (to release pus or pressure built up under the skin) with removal of all nonviable (not able to survive) soft tissue (Muscles, fat, blood vessels, nerves, tendons, and tissues that surround the bones and joints) and bone; - SN (skilled nurse) visits three (3) times weekly for wound VAC (vacuum-assisted closure of wound, which is a type of therapy to help wounds heal) dressing changes; - SOC (start of care) visit on 05/12/2022 at 9:30 AM, showed, patient with 1+ (grading scale used to determine the severity of edema on a scale from 1+, being the least severe, to 4+, being worst severity) edema (swelling that is caused by excess fluid being trapped in the body’s tissues) to BLE (bilateral lower extremities) and fatigues easily; - Wound measurements obtained on SOC visit for wound to right foot, showed, length of 3 cm (centimeters), width of 6 cm, and depth of 1.7 cm; - SN visit on 05/16/2022 at 1:00 PM, showed, wound measuring 4 cm in length, 6.9 cm in width, and 1.9 cm in depth (Wound increased in size from the previous visit); - SN visit on 05/18/2022 at 8:30 AM, showed, patient with 1+ edema to left ankle and foot and 2+ edema to right foot and ankle; - SN visit on 05/20/2022 at 10:45 AM, showed, patient with 2+ edema to left foot and 1+ edema to left ankle and right foot and ankle (Edema increased in severity since previous visit); - SN visit on 05/23/2022 at 2:30 PM, showed, no documentation of cardiovascular assessment; - SN visit on 06/01/2022 at 12:45 PM, showed, 3+ edema to right foot and ankle, and 2+ edema to left foot and ankle (Edema increased in severity since previous visit); - SN visit on 06/03/2022 at 12:30 PM, showed, 1+ edema to left LE (lower extremity), and 2+ edema to right foot and ankle; and - SN visit on 06/08/2022 at 12:00 PM, showed, 1+ edema to left foot and ankle, and 2+ edema to right foot and ankle. Review of the clinical record, failed to show: - Diagnosis or documentation of patient having a history of edema; - Documentation of physician communication regarding edema; - Interventions and/or patient education for edema on plan of care; and - Physician communication regarding increase in wound size. During an interview on 08/31/2022 at 9:30 AM, the administrator stated that: - He/she would expect the physician to be contacted for the wound increasing in size; - Review of the hospital records showed no edema; - No records of history of edema; and - He/she would expect the physician to be contacted regarding edema.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on review of the agency’s policy, record review, home visit observation, and interview, the agency failed to ensure ongoing interdisciplinary assessment of patient, in one (Record/Patient #3) of six full records reviewed. This deficient practice has the potential to affect the coordination of care and services for all patients on service with the agency. Findings included: Review of the agency’s policy titled, “Initial Patient Assessment,” dated 08/23/2021, showed, ongoing assessments will occur with each visit and necessary revisions will be made to the plan of care. RECORD/PATIENT #3: Review of the clinical record showed: - Patient admitted to home health services for surgical aftercare following lumbar laminectomy (surgery that creates space by removing part or all of the vertebral bone, called lamina, from the lower spine); - SN (skilled nurse) SOC (start of care) visit on 08/16/2022 showed patients last BM (bowel movement) was on 08/14/2022; - PT (physical therapy) evaluation visit on 08/17/2022 showed patients last BM was on 08/13/2022 (This date differs from the SOC documentation one day prior); - On 08/17/2022 at 6:35 PM, a communication note was entered from the PT to the SN regarding patient not having a BM since 08/13/2022 and patient was going to start taking Miralax (used to treat constipation) 17 gram/dose powder daily PRN (as needed) for constipation, as ordered in the hospital discharge records (No documentation of follow up by skilled nurse); - PT visit on 08/19/2022 at 9:00 AM, showed, no gastrointestinal (tract or passageway that food and liquids travel through when they are swallowed, digested, absorbed, and leave the body as feces) assessment documented; - SN visit on 08/19/2022 at 1:45 PM, showed patient with constipation, last BM on 08/15/2022 (No documentation on ongoing assessment to clarify conflicting dates), and laxatives and stool softeners used to help treat constipation; - SN visit on 08/23/2022 at 12:30 PM, showed, patient with normal BM pattern, usual frequency for BM daily, and no assessment documentation of last BM; and - PT visit on 08/29/2022 at 9:15 AM, showed, bowel pattern of normal, last BM on 08/29/2022, and usual frequency was less than daily. Observation on 08/30/2022 at 1:15 PM, showed, during the patient’s home visit, showed: - Patient reported last BM was on 08/27/2022 (PT documented last BM was on 08/29/2022); - Patient reported he/she started taking milk of magnesia (laxative used to treat constipation) due to no bowel movements since returning home from the hospital after surgery; - No milk of magnesia taken since bowel movement three days prior; - No other laxatives or stool softeners taken since last BM; - Patient unsure of what medications to take and how often to take them if he/she starts having bowel movements daily; and - SN educated patient on taking a daily stool softener, even if having BM daily, due to narcotic pain medication use increasing risk for constipation. During an interview on 08/30/2022 at 3:55 PM, the administrator stated that: - The therapist did not do a gastrointestinal assessment during visit on 08/19/2022; and - There should be detailed assessments with the patient during each visit because of the patient’s history with constipation and conflicting dates charted for last bowel movements.