Every finding on record at Mercy Hospital South

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 01/05/2023. During the survey it was determined the home health provider is in compliance with the requirements of 42 CFR 418.113 Condition of Participation: Emergency Preparedness for Home Health Agencies.

A partial extended survey for Medicare recertification for the home health provider was completed on 01/05/2023. The agency had 87 current patients. The COVID-19 Health Care Staff Vaccination regulation was reviewed as part of the Medicare recertification survey. One standard level deficiency was identified.

Written notice within 4 business days CFR(s): 484.50(a)(4) Provide written notice of the patient's rights and responsibilities under this rule and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section to a patient-selected representative within 4 business days of the initial evaluation visit. This ELEMENT is not met as evidenced by: Based on policy review, review of the agency’s current patient rights information, and interview, the agency failed to provide the written notice of patient rights that included the right to have a copy of the patient’s rights and responsibilities, and the agency’s transfer and discharge policies, provided to a patient-selected representative within four business days of the initial evaluation visit. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency’s policy titled, “Informed Consent Patient Rights and Responsibilities,” dated 08/31/2022, showed: - The agency will be responsible for knowing, observing, and implementing each patient’s rights and responsibilities on an ongoing basis; and - All patients will be informed of their rights and responsibilities both verbally and in writing upon admission to the agency. Review of the agency’s admission folder, provided by the director on 01/03/2023, showed the notice of patient rights, and other information given to a patient during the initial visit, failed to contain information regarding the patient’s right to have a copy of the patient’s rights and responsibilities and the agency’s transfer and discharge policies provided to a patient-selected representative within four business days of the initial evaluation visit. The above findings were reviewed with the administrator on 01/03/2023 at 12:40 PM. Per an interview conducted during the review, the administrator stated that he/she also looked through the agency’s patient rights information and could not find anything regarding this particular right.

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 policy review, clinical record review, and interview, the agency failed to include the elements of an individualized plan of care in, but not limited to, two (Records/Patients #2, and #4) of five full records reviewed. This deficient practice has the potential to affect all of the patients served by the agency. Findings included: Review of the agency’s policy titled, “Plan of Care – Order and Medical Supervision – Home Care Policy,” dated 08/30/2022, showed, in part, the following: - An individualized plan of care will be developed, and medical supervision provided for each patient admitted to the agency and reviewed/revised as needed to meet the patient’s needs and goals; - Patients will be instructed on their disease process and relationship to the plan of care; - The individualized plan of care includes: * The types of services, supplies, and equipment recommended; * Patient, caregiver, patient selected representative education and training to facilitate a timely discharge; and * Patient-specific interventions and education and measurable outcomes and goals identified by the agency and the patient. Review of the agency’s policy titled, “Wound Assessment and Care,” dated 08/29/2022, showed: - The patient/caregiver will be instructed in wound care technique during the first one to two visits; - Teaching is done based on the patient/caregiver level of understanding and includes a demonstration of the wound care procedure using the teach-back method; - The teaching and patient/caregiver response must be documented in the clinical record; and - The documentation must include an evaluation of the patient/caregiver’s ability. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to the agency for aftercare following a left total knee replacement (a surgical procedure to replace parts of an injured or worn out knee joint). The patient lives at home with his/her adult children. Review of the patient referral, dated 11/24/2022, showed: - The patient had a left knee incision with orders for dry dressing changes two times a week; and - The patient was to follow up with the surgeon 14 days post-operatively for staple removal. Review of the start of care assessment, dated 11/25/2022, showed, in part, the following entries; - Wound: dry dressing changes twice weekly, per the physician; and - “Mepore dressing (a type of breathable, self-adhesive dressing) clean and dry. Orders to be changed twice weekly.” Review of the plan of care (POC), dated 11/25/2022 to 01/23/2023, showed, in part: - An order for dry dressing changes twice weekly; - The POC failed to contain information that the patient would be performing his/her own dressing changes; and - The POC failed to contain documentation that the patient was educated on dressing changes or an evaluation of the patient’s ability during the return demonstration of the dressing change. Per an interview conducted during home visit observation on 01/04/2023 at 11:15 AM, the patient stated that he/she performed the dry dressing changes to the left knee incision twice weekly. During an interview on 01/04/2023 at 1:15 PM, the director and the administrator stated that they would expect the POC to contain information that the patient was performing the dressing changes and that he/she had been educated on and returned demonstration on changing his/her dressing. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 12/06/2022 with a primary diagnosis of hemiplegia and hemiparesis (muscle weakness or partial paralysis of one side of the body) following cerebral infarction (a stroke) affecting the right side. The patient also has additional diagnoses of aphasia following cerebral infarction (loss of ability to understand or express speech after a stroke), osteoarthritis of right knee, atrial fibrillation (an irregular often rapid heart rate that commonly causes poor blood flow), primary hypertension (high blood pressure), migraines (a headache of varying intensity, often accompanied by nausea and sensitivity to light and sound), history of malignant neoplasm of the breast (breast cancer), and hyperlipidemia (high cholesterol). Review of the POC, dated 12/06/2022 to 02/03/2023, showed: - A skilled nursing (SN) intervention to instruct the patient to manage diabetes (a condition that affects the way the body processes blood sugar) and keep their blood sugar levels within a target range; and - The patient does not have a diagnosis of diabetes. Review of the skilled nursing (SN) initial discipline visit, dated 12/09/2022, showed: - The SN documented an intervention to teach the patient to manage their diabetes and keep their blood sugar levels within target range; and - The patient does not have a diagnosis of diabetes. During an interview on 01/05/2023 at 10:10 AM, the clinical nurse manager stated that the agency’s software contains different “smart phrases” that link to various disease processes. Once the clinician pulls over the disease diagnosis, they are supposed to delete the portions that are not relevant or do not apply to the particular patient. The administrator and director stated that they would expect the POC to be more individualized and the information on diabetes should have been deleted to make the education and interventions more specific to this patient’s needs.

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 policy review, record review, and interview, the agency failed to promptly alert the physician to changes in the patient’s condition that suggest a need to alter the plan of care in one (Record/Patient #5) of five full records reviewed. This deficient practice has the potential to adversely affect the quality of care provided to all patients served by the agency. Findings included: Review of the agency’s policy titled “South HH Coordination of Services – Home Care Policy," dated 10/03/2022 showed, in part, the following field staff responsibilities: - All staff is encouraged to consult with appropriate disciplines/services as the patient’s condition warrants through telephone contact or written communication and document in the patient’s clinical record; and - Staff members are expected to maintain and document regular communication with patients, primary caregivers, and other staff appropriate to patient’s needs and changes in condition/situation/services; and - Any staff member receiving information regarding a change in the patient’s location or phone number, re-hospitalization, or other occurrence, is expected to notify clinical manager/supervisor and the physician as appropriate. Review of the agency’s policy titled “South HH Reassessment – Home Care Policy,” dated 09/16/2022 showed: - “Named Agency” will utilize and adhere to defined assessment guidelines in order to accurately/consistently assess the patient’s needs as a basis for planning care; - Each assessment will be completed by qualified “named agency” staff that have the necessary skills and training and comply with all federal and state laws and regulations; - The assessment data/information will be gathered and documented on the appropriate discipline’s assessment within the electronic medical record, or on paper form in the event of a computer systems failure; - Pertinent date/information will be communicated within the inter-disciplinary team, as well as to the patient’s physician, verbally, electronically, and/or in writing when appropriate; - Reassessment may also be needed when there is a major change in health status; - A major change can occur when the patient’s condition has improved or deteriorated causing significant change in the plan of care. This change may alter the treatment, the frequency or the discipline(s) involved; and - The patient will be assessed to determine response to care/outcome at each professional’s visit and special attention given to any changes in the environment or support system. RECORD/PATIENT #5: Review of a physical therapy visit note dated 11/04/2022 showed, in part: - Upon arrival patient sitting in recliner, states he/she has had diarrhea all day today; - States his/her son/daughter in law is bringing him/her some Imodium (over the counter medication used to treat diarrhea); - Documentation failed to be present of the clinical manager and/or the physician being notified of the new onset of diarrhea or the medication the family member was bringing. Further review of the clinical record failed to show an order for Imodium. During an interview on 01/04/2023 at 10:00 AM, the director stated that the doctor should have been contacted about the diarrhea and an order obtained for the Imodium. During an interview on 01/04/2023 at 3:15 PM the rehabilitation supervisor stated that: - The reason the therapist never obtained an order for the Imodium was because the patient never took it; the family member never obtained it; and - The patient was no longer having diarrhea by the next visit (which was four days later).

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on policy review, observation and interview, the agency failed to continue implementing their program to protect visitors and staff who entered the home health agency office from those employees that had chosen not to be vaccinated against Covid-19. This deficient practice has the potential to adversely affect infection control needs for all visitors/non-employees, employees and patients served by the agency. Findings included: Review of the agency’s policy titled “MW HR Mandatory COVID-19 Vaccination Policy,” dated 09/30/2022 showed: - Co-workers who do not receive the COVID-19 vaccination- due to an approved medical or religious exemption – and new co-workers and co-workers returning from leave who receive only the first dose of the COVID-19 vaccine must follow all social distancing standards, comply with all applicable policies, and adhere to these requirements; and - Co-workers who do not serve in patient care areas must wear a surgical mask (the mask must cover both nose and mouth) when present in “named facilities”- including facilities where no patient care is delivered. Review of the agency staff vaccinated/unvaccinated information showed one employee (unvaccinated employee) with a noted religious exemption. Observation on 01/03/2023 throughout the day showed the unvaccinated employee unmasked throughout the office. During an interview on 01/04/2023 at 11:15 AM, the administrator stated that he/she: - Was aware of a masking policy for unvaccinated/exempt staff; - Was unaware which employee had an exemption; and - Should know who had exemptions.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on policy review, clinical record review, and interview, the provider failed to ensure that skilled professional services were delivered according to the agency’s policies and procedures in one (Record/Patient #2) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency’s policy titled, “Initial Assessment Admission – Home Care Policy,” dated 09/06/2022, showed, in part, the following: - A qualified staff member will perform an initial comprehensive assessment in the patient’s home, gathering data on skilled health care, psychosocial needs, and environmental situation; and - The initial assessment information will be documented on the appropriate electronic medical record to include a wound addendum, if applicable. Review of the agency’s policy titled, “Wound Assessment and Care,” dated 08/29/2022, showed, in part, the following: - The purpose was to establish minimum practice standards for appropriate assessment, monitoring, and management of wound and skin care and to ensure services provided to patients promote healing; - An agency skilled nurse, registered physical therapist, or registered occupational therapist will assess wound(s) as part of the comprehensive initial assessment and will document all clinical findings as per agency policy; - The admission clinician will document each wound status including: location, description of the wound bed, peri-wound skin condition, drainage, odor, signs and symptoms of infection, measurements of length, width, depth, undermining, and tunneling, if present; - At each visit the patient’s skin will be assessed and documented. At each dressing change the wound will be assessed and documentation will include a description of the wound bed, drainage, signs and symptoms of infection, healing and peri-wound skin condition; and - At least every week, the wound assessment and documentation will include location, description of the wound bed, peri-wound skin condition, drainage, odor, signs and symptoms of infection, measurements of length, width, and depth, undermining and tunneling, if present. RECORD/PATIENT #2: Review of the start of care assessment, dated 11/25/2022, showed: - The question, M1340 – “Does this patient have a surgical wound?” was answered “Yes, patient has at least one (observable) surgical wound;” - The question, M1342- “Status of most problematic surgical wound that is observable”, was answered “Not healing;” -An entry titled, “Wound: Dry dressing changes twice weekly,” and “visit notes- see note in musculoskeletal section of physical assessment;” - The musculoskeletal section of the physical assessment stated that Mepore (a breathable self-adhering bandage) dressing was clean and dry with orders to be changed twice weekly; and - The start of care assessment failed to contain documentation of the location of the surgical wound, a description of the wound, a measurement of the wound, the presence of staples or sutures, a description of the skin surrounding the incision, or the presence of drainage, odor or signs and symptoms of infection. Review of the physical therapy (PT) visit notes, with dates ranging from 11/29/2022 through 12/08/2022, showed: - Documentation that the wound was “intact with staples, dressing”; and - The notes failed to include any assessment of the location, appearance of incision or surrounding skin, any measurements, presence of drainage, odor, or signs of infection. Review of the PT visit notes dated 12/12/2022 and 12/30/2022 showed the clinician(s) failed to document any assessment of the left knee incision. Review of the PT visit notes dated 12/15/2022 to 12/28/2022 showed: - On 12/15/2022 and 12/19/2022, documentation that the wound was “intact with steri- strips” (thin adhesive bandages often used by surgeons after regular stitches or staples are removed); - On 12/28/2022 documentation that the wound was intact, no signs or symptoms of infection; and - The notes failed to include any assessment of the location, appearance of incision or surrounding skin, any measurements, presence of drainage or odor. During an interview on 01/04/2023 at 1:15 PM, the agency’s director stated that he/she would expect a wound assessment to have been conducted during the initial assessment and weekly thereafter and documented in the clinical record. The assessment should have included measurements, the appearance of the incision and the appearance of the surrounding skin, whether there were sutures or staples, the presence of any drainage, odor, and any signs or symptoms of infection.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure clinical record documentation was complete and/or accurate in two (Records/Patients #2 and #5) of five full records reviewed. This deficient practice has the potential to adversely affect the care of all patients served by the agency. RECORD/PATIENT #2: Review of the patient referral, dated 11/24/2022, showed the patient: - Had orders for home health physical therapy; - Had a left knee incision with orders for dry dressing changes two times a week; and - Was to follow up with the surgeon 14 days post-operatively for staple removal (the patient was discharged from the hospital on 11/24/2022). Review of the physical therapy notes dated 11/29/2022 through 12/08/2022 showed the patient had a wound that was intact with staples. Review of the physical therapy notes dated 12/15/2022 through 01/02/2023 showed: - On 12/15/2022 and 12/19/2022, the clinician documented the patient had a wound that was intact with steri-strips (thin adhesive bandages often used by surgeons after regular stitches or staples are removed); and - On 12/15/2022 through 01/02/2023, the clinician continued to document that the patient will need to schedule staple removal with RN (registered nurse) at physician’s office (after the staples had been removed). During an interview on 01/04/2023 at 1:15 PM, the administrator and the director stated that they would expect the documentation to be accurate and they would not expect the clinician to continue to document that the patient needed to see the physician to remove staples after the patient had already had their staples removed. Findings included: RECORD/PATIENT #5: Review of the clinical record showed the following: - A principal diagnosis of spondylosis without myelopathy or radiculopathy, lumbar region (age related wear and tear of the spinal disks in the low back often associated with low back pain, without compression on, or injury of the spinal cord); - A physician order dated 11/30/2022 4:24 PM showed hold physical therapy until after vertebroplasty (a treatment that injects cement into cracked or broken spinal bone to help relieve pain) on 12/15/2022; reassess for physical therapy needs week of 12/19/2022; - A physical therapy note dated 12/20/2022 showed patient awaiting scheduling of kyphoplasty (a treatment that injects cement into the vertebrae with an additional step of creating space for the treatment with a balloon-like device) (although this procedure had already taken place five days prior); and - A physical therapy noted dated 12/20/2022 failed to show a complete pain assessment when it failed to include pain location, severity, character, frequency, duration, exacerbating factors, relieving factors, highest and lowest pain levels in the last 24 (twenty four) hours. During an interview on 01/04/2023 at 11:14 AM in regards to the pain assessment documentation, the clinical nurse manager stated that: - It looks like the grid wasn’t completed; and - It is an incomplete pain assessment. During an interview on 01/.4/2023 at 11:14 AM in regards to the vertebroplasty/kyphoplasty procedure, the clinical manager stated that: - He/she found in the “named hospital” documentation that the patient did go in on 12/15/2022 and had the outpatient procedure done; and - The documentation on the 12/20/2022 physical therapy note that stated that the patient was awaiting scheduling of the procedure was incorrect. During an interview on 01/05/2023 at 10:10 AM, the director stated that he/she would expect the clinician’s documentation to be complete and accurate.