Every finding on record at Peacehealth

An Emergency Preparedness Survey was conducted by the State Survey Agency in accordance with 42 CFR 484.102 44 Active Patients (36 patients in Ketchikan and 8 patients at Prince of Wales Branch) 188 Skilled Unduplicated Census Sample Size: 10 sampled patients, 0 non-sampled patients, with 2 records reviewed from the branch. At this Emergency Preparedness survey, Peacehealth Ketchikan Medical Center Home Health was found to be in compliance with 42 CFR 484.102, Emergency Preparedness Requirements for Medicare Participating Providers and Suppliers. State of Alaska Department of Health and Social Services Health Facilities Licensing and Certification 4601 Business Park Blvd. Bldg. K Anchorage, AK 99503.

The following deficiencies were noted during an unannounced Federal Recertification survey conducted 2/21/22 - 2/25/22 at PeaceHealth Ketchikan Medical Center Home Health. 44 Active Patients (36 patients in Ketchikan and 8 patients at Prince of Wales Branch) 188 Skilled Unduplicated Census Sample Size: 10 sampled patients, 0 non-sampled patients with 2 records at the Prince of Wales Branch. State of Alaska Department of Health and Social Services Health Facilities Licensing and Certification 4601 Business Park Blvd. Building K Anchorage, AK 99503.

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to advise the patients and their representatives of the names, addresses and telephone numbers of the following Federally - funded and state - funded entities that serve the area where the patient resides: 1. Area on Agency, 2. Center for Independent Living, 3. Protection and Advocacy agency, 4. Aging and Disability Resource Center, and 5. Quality Improvement Organization. This agency failure to advise the patients / representatives limited the patients and their representatives' ability to make necessary contact with these offices for assistance information. Review of the undated admission packet on 2/22/22 at 10:00 AM revealed this informational folder, given to the patients and representatives at the start of care, did not advise the patients and their representatives of the names, addresses and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: 1. Area on Agency 2. Center for Independent Living 3. Protection and advocacy agency 4. Aging and Disability Resource Center 5. Quality Improvement Organization During an interview on 2/24/22 at 9:10 AM, the Administrator, when asked if the Federally - funded and state - funded entities that served the area where the patient resides were in the admission folder or anywhere in the information given to the patients / representatives, agreed that these names and contact information for these agencies were not readily available in the patient admission folder or information given to the patient / representative at the start of care.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the skilled nurse had provided care and services in accordance with the plan of care and physician orders for 1 of 10 records reviewed (#5). Specifically, the skilled nurse performed manual extraction of stool and administered an enema without physician orders. This failed practice placed the patient at risk for receiving cares and treatments not ordered by physician and potential adverse events. Based on record review and interview, the agency failed to ensure the skilled nurse had provided care and services in accordance with the plan of care and physician orders in 1 of 10 records reviewed. This failure resulted in the skilled nurse completing a procedure which resulted in a patient's fainting episode which resulted in an emergency room visit. Review of Patient #5's medical record on 2/25/22 revealed a start of care of 12/1/21 and a primary diagnosis of Parkinson's Disease. This record included a plan of care for the certification period of 1/30/22 - 3/30/22. The record review revealed Skilled Nurse #1 had completed two procedures with Patient #5 without physician orders on 2/1/22. After these procedures, the patient fainted and then was sent to the emergency room with EMS (Emergency Medical System) providers. Record review revealed the Plan of care for the certification period of 1/30/22 - 3/30/22 contained orders for the skilled nurse to visit once a week for 9 weeks and 4 visits as needed. The plan of care did not include tasks for the nurse to complete regarding care for constipation or a bowel impaction including giving an enema or manual removal of stool. Record review revealed a skilled nurse visit note dated 2/1/22. This note stated, "Skilled Nurse Routine Visit" completed by Skilled Nurse #1. This visit revealed the nurse visited from 12:45 PM - 1:45 PM. The nurse completed the encounter notes as follows: "Pt. [patient] reportedly as not had a BM [bowel movement] in 4 days. An enema was performed to help [him/ her] move [his / her] bowels as well as manual extraction of stool. After the enema had been performed, Pt. stated that [he / she] would like to use the toilet. Pt. was transferred to [his / her] bathroom which is in [his / her] room with 2 - person assist … had difficulty transferring and could not pick up [his / her] feet all the way and wound up shuffling as [he/she] walked to the bathroom. Pt. was sat on the toilet where [he / she] was able to have some progress in moving [his / her] bowels. Pt. was then stood up by [informal caregiver] so that [he / she] could be cleaned up. While in standing position, [Patient #5] slumped over and was nonresponsive. [He / she ] was then slowly moved to the floor, and a pillow placed under [his / her] head. No injury occurred. [Patient] would not respond when [informal caregiver] would yell [Patient #5's name] repeatedly. [He /she] was unresponsive for about one minute. Once on the floor [his / her] blood pressure was reassessed and had dropped from 175 / 78 at the beginning of the visit to 119 / 59. [His / her] pulse had stayed stable going from 78 at the beginning visit to 83 after the fall. EMS arrived on the scene and took [him / her] to the ER for further treatment and evaluation." Record review revealed a document titled "Emergency Room Encounter" dated 2/1/22 at 3:37 PM and signed by the physician. This note stated, "Today the patient was being managed by home health nurse for constipation with attempted manual dis-impaction, when [the patient] needed to go to the bathroom. [Patient] was able ...to sit on the toilet. Upon standing [the patient] became unconscious … and gently lowered to the floor." Record review revealed a document titled "Discharge Summary" dated 2/18/22 from the patient's hospital stay from 2/1/22 - 2/18/22. This document was completed by the physician and revealed the following: "Reason for hospitalization: This is a [patient #5] with a past medical history of diabetes … and hypertension who presented to the ED [emergency department] from home for a syncopal [fainting] episode while trying to have a BM [bowel movement]." During an interview on 2/25/22 at 9:30 AM, the administrator stated, when asked if there was a need to have physician orders in the record for the digital removal of stool and the enema used, that there should be orders for both of these treatments and that it was unknown what type of enema the patient had received. The nurse who completed this procedure was not available due to planned time off today. Review of the policy titled "Home Care Record / Orders Policy" revised 10/12/20 stated, "Home Health caregivers maintain a clinical record for each patient receiving care. The clinical record will contain sufficient information to identify the patient, describe patient problems and needs, justify care and services, accurately document the care and services provided as well as the outcome and facilitate continuity of care among agency and contract personnel … Legible, complete and individualized diagnostic and therapeutic orders as required by law and regulation." Review of the policy titled "Provider Management of Medical Care in Home Health" revised 9/2/20 stated, "Following the initial visit, a plan of treatment is developed with the provider including any additional requests for services identified during this visit. Any subsequent changes to the plan of treatment are documented via orders requiring the provider's signature." Review of the "Caregiver Job Profile RN - Home Health" dated 2/27/2019 stated, "Essential functions … provide skilled nursing care to patients and skilled education / instruction to patients and caregivers according to the home health / hospice plan of treatment."