Every finding on record at Nhc Home Care South Carolina, LLC

An onsite unannounced Recertification Survey and a COVID - 19 Staff Vaccination Survey were conducted at NHC Midlands HHA from 1/09/2023 to 1/12/2023. NHC Midlands HHA is in compliance with the Medicare COVID-19 Staff Vaccine requirements with 17 staff members fully vaccinated and 2 religious exemptions approved. The facility is in compliance with 42 CFR 484.102 (Establishment of the Emergency Program).

An onsite unannounced Recertification Survey was conducted at NHC Midlands HHA from 1/09/2023 to 1/12/2023. NHC Midlands is in substantial compliance with the Medicare Conditions at 42 CFR PART 484. NHC Midlands HHA had standard level deficiencies.

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 observations and medical record reviews, the home health agency's staff failed to provide clear instructions for medication dosage for Doxepin for 1 of 1 patient receiving Doxepin (Patient #2) and failed to ensure the patient's medication profile was accurate for 2 of 7 patients. (Patient #1 and Patient #2) The findings include: Patient #2 Observation visit on 1/10/2023 between 10:12 AM and 11:50 AM reveals on medication sheet Doxepin 10 mg capsule, Take 1-5 capsules (10-50 mg total) by mouth nightly. There is no instruction for how to determine dosage with this range. Caregiver reports Patient #2’s son is in charge of medications and patient only taking 1 capsule at night. On 1/11/2023 at 10:44 AM, chart review reveals patient admitted on 11/03/2022 with Doxepin same dosage and same range without clear instructions. On 1/11/2023 at 1:15 PM, at chart review Clinical manager report “we needed to clarify this order at admit”. On January 10, 2023 at 12:00 p.m., a home visit was conducted to Patient 1 with the physical therapy assistant (PTA). The PTA was observed reviewing (e.g. reconciling) Patient 1's medications with the medication list and asking the patient questions. The PTA stated the medications metoprolol (used for high blood pressure) 50 mg tablets and trilogy (an inhaled medication to improve breathing) were not on the medication list. The PTA asked Patient 1 if he was taking these medications and he replied, "Yes." Patient 1 stated he had been taking them for a long time. The PTA asked Patient 1 if he was taking amlodipine 10 mg tablets. Patient 1 stated, "No." Patient 1 stated one of his doctors told him not to take it and he had not taken it for a long time. During a concurrent interview with the PTA, the PTA stated the medication amlodipine 10 mg tablets was on the patients active medication list. The PTA confirmed the medication list was not accurate and stated the medications (metoprolol, trilogy and amlodipine) needed to be clarified with the physician. On January 11, 2023 at 2:24 p.m. an interview and a concurrent review of Patient 1's record were conducted with the Clinical Manager (CM). The document titled, "Client Medication Report," indicated, "AMLODIPINE 10 MG TABLET...Date...09/21/2022 (September 21, 2022)..." The CM confirmed Patient 1's medication list was not accurate. The CM stated the medications amlodipine 10 mg tablet, trilogy and metoprolol 50 mg tablet should have been clarified with the physician. The CM stated, "All disciplines are supposed to look at the (medication) bottles and reconcile the medications every visit." The CM confirmed there was no documented evidence Patient 1's medication list had been reconciled by the Home Health Agency (HHA) staff. On January 11, Patient 1's record was reviewed. The document titled, "HOME HEALTH CERTIFICATION AND PLAN OF CARE," dated November 6, 2022 to January 4, 2023 indicated, "...SKILLED NURSE TO REVIEW MEDICATION PROFILE AND RECONCILE MEDICATIONS EVERY 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 record reviews and interview, the home health agency's staff failed to provide care as ordered by the physician regarding the management of the patient's blood glucose result reporting for 2 of 7 patients. (Patient #1 and Patient #7) The findings include: Patient #7 Chart review on 1/11/2023 at 11:32 AM reveals physician orders “Licensed professional to report vital signs falling outside the following established parameters:…FBS >60 >300”. Registered Nurse (RN) visit schedule one visit each week. There is no documented Fasting Blood Sugar (FBS) results for 11/16/2022, 11/21/2022, 125/2022, 12/15/2022 and 12/29/2022. Interview on 1/11/2023 at 1:26 PM Clinical manager reports “should have been done each visit” and verifies the findings. On January 11, 2023 at 9:00 a.m., Patient 1's record was reviewed. The record indicated Patient 1 was admitted to the Home Health Agency (HHA) on September 7, 2022 with diagnoses including, "PRESSURE ULCER OF LEFT HEEL (a type of wound)...TYPE 2 DIABETES W (with) DIABETIC (diabetes mellitus, e.g. DM - a disease which decreases the amount of insulin the body absorbs) PERIPHERAL (distant body site) ANGIOPATH (angiopathy; e.g. disease of the blood vessels) W/O (without) GANGRENE (tissue death)...ACQUIRED ABSENCE OF RIGHT LEG ABOVE KNEE (e.g. amputation)..." The document titled, HOME HEALTH CERTIFICATION AND PLAN OF CARE," dated November 6, 2022 to January 4, 2023 indicated, "...SKILLED NURSE TO ASSESS/EVALUATE...CONDITIONS INCLUDING DM...FOR INSTRUCTIONS/REINFORCEMENT OF DIABETIC CARE TO INCLUDE...BLOOD GLUCOSE TESTING...LICENSED PROFESSIONAL TO REPORT VITAL SIGNS FALLING OUTSIDE THE FOLLOWING ESTABLISHED PARAMETERS...FBS (fasting blood sugar) (greater than) 250..." On January 11, 2023 at 4:05 p.m. an interview and concurrent review of Patient 1's record were conducted with the Clinical Manager (CM). The document titled, "Visit Note Report," dated November 17, 2022 was reviewed. The CM stated there was no documentation of Patient 1's blood sugar. The CM stated there was no documented evidence the nurse assessed Patient 1's blood sugar and stated, "She should have."