Every finding on record at Open Waters Home Health Care, Inc

Recertification survey completed. Standard Level deficiencies cited. Abbreviation: # = number

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: Based on clinical record review, Agency policy and staff interview, it was determined the Agency failed to ensure Patients were assessed for the status of the pneumococcal vaccine at the Start of Care per Agency policy. This was found in 4 of 7 (Patients #2, #3, #5 and #6) clinical records reviewed. 3. Patient #5 was admitted to Home Health Services on 09/20/23 with the primary diagnosis of Essential (Primary) Hypertension. The clinical record was reviewed on 11/13/23 and contained the “Flu/Pneumonia Vaccine Questionnaire” dated 09/20/23, lacked any information related to patient's pneumonia vaccination status. 4. Patient #6 was admitted to Home Health Services on 07/08/23 with the primary diagnosis of Hemiplegia Unspecified Affecting Left Nondominant Side. The clinical record was reviewed on 11/14/23 and contained the “Flu/Pneumonia Vaccine Questionnaire” dated 07/08/23, lacked any information related to patient's pneumonia vaccination status. 5. The Agency's policy titled, "Pneumonia Vaccination Policy" was reviewed on 11/15/23. The policy included: "...5. The following shall serve as guideline to the staff initiating the services...shall document in the patient's medical record that a vaccination against pneumococcal pneumonia was offered and administered, arranged, refused or medically contraindicated or that the patient not a member of the vaccination priority population. 6. Standardized check for recording patient specific information, date of offer or referral, patient response, administration, contraindication, or refusal and any follow up activities shall be used for documentation." 6. During an interview with the Administrator and the Director of Nursing on 11/15/23 at 10:45 AM and 11:45 AM, the Director of Nursing confirmed the staff failed to inquire regarding patients pneumococcal pneumonia vaccine status. Findings include: 1. Patient #2 was admitted to Home Health Services on 09/06/23 with primary diagnosis of Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 11/14/23 and contained the “Flu/Pneumonia Vaccine Questionnaire” dated 09/06/23, lacked any information related to pneumonia vaccination status. 2. Patient #3 was admitted to Home Health Services on 07/12/23 with primary diagnosis of Pressure Ulcer, right and left buttock, stage 2. The clinical record was reviewed on 11/14/23 and contained the “Flu/Pneumonia Vaccine Questionnaire” dated 07/12/23, lacked any information related to pneumonia vaccination status.