Every finding on record at Perry County Health System

The Emergency Preparedness regulations were reviewed as part of the Medicare certification survey completed on 05/19/2021. During the survey it was determined Perry County Memorial Hospital Home Health Care is in compliance with the requirements of 42 CFR 418.102 Condition of Participation: Emergency Preparedness for Home Health Agencies.

A partial extended survey for Medicare certification for Perry County Memorial Hospital Home Health Care was completed on 05/19/2021. The agency had 24 current patients. A COVID-19 Focused Infection Control Survey was completed in conjunction with the survey and no deficiencies were identified related to the Focused Infection Control Survey.

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 review of the agency's current patient rights information and interview, the agency failed to update the written notice of patient rights to meet the requirements of the updated Federal home health regulations effective 11/29/2019 to include that the patient has the right to be advised of the addresses, of the Federally-funded and state-funded entities that serve the area where the patient resides and failed to provide the Quality Improvement Organization (QIO) that serves the area where the patient resides. This affected all the patient's admitted to the agency since 11/29/2019. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all patients served by the agency. Findings included: The agency administrator provided an admission packet for review on 05/17/2021. The agency notice of patient rights and other information given to a patient during the initial visit failed to show the written information for the patient and representative (if any) the address of the Federally-funded and State-funded entities that serve the area where the patient resides. The notice failed to include the current QIO. The agency had Kepro Medicare Complaints & Quality of Care Reviews listed for the QIO organization. The current QIO is Livanta LLC. On 05/18/2021 at 10:45 AM, the findings were reviewed with the agency administrator. The administrator concurred with the findings.

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: Based on review of the agency's current patient rights information and interview, the agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that the agency must advise the patient or representative, physicians, and healthcare professionals who will be responsible for providing care after discharge, when a discharge for cause is being considered. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: Review of the agency's admission booklet, which included the "Explanation of Patient Discharge Criteria and Transfer of Care", and is given to patients at the start of care, failed to provide information that the agency must advise the patient or representative, physicians, and healthcare professionals who will be responsible for providing care after discharge, when a discharge for cause is being considered During an interview on 05/18/2021 at 10:45 AM the administrator agreed that the information in the admission booklet failed to completely provide the full verbiage of this patient right.

Death of patient CFR(s): 484.50(d)(6) The patient dies; or This ELEMENT is not met as evidenced by: Based on the agency's current patient rights information, and interview, the agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge if the patient dies. The deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all patients served by the agency. Findings included: The administrator provided an admission packet for review on 05/17/2021. The agency notice of privacy rights and other information given to the patient during the initial visit failed to include written information regarding that the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge if the patient dies. During an interview on 05/18/2021 at 10:45 AM, the administrator concurred with the findings.

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 record review, policy review, home visit observation, and interviews, the agency failed to ensure an accurate medication reconciliation was completed in, but not limited to, three (Records/Patients #2, #3, and #5) of five records reviewed. This deficient practice has the potential to affect the accurate use of medications only as ordered by the physician for all the agency's patients. Findings included: Review of the agency's policy titled, "Medication Review & Administration," dated 11/2019 showed, the following: - A routine medication review will also be performed at each regular visits from all entities except Speech therapy. The medication review may be done verbally using current medication administration record (MAR) with patient/care giver (CG)., without reviewing medication containers if there has not been a change in the prescribed medications from the start of care (SOC), most recent resumption of care (ROC), most recent Refortification and/or Discharge; and - If the clinician notes a change in medications or an addition of new medications, they are to amend MAR. If a "Therapy Only" patient, the therapist will contact the nurse per phone or secure email to report the medication changes/additions. The nurse will then verify and obtain interim orders for medication changes, if necessary, from the physician. The nurse will then educate the patient/CG on any new medications ordered per phone. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 05/06/2021 with a primary diagnosis of after care following surgery for replacement of the left hip. Patient also had secondary diagnoses of ulcerative colitis (an inflammation of the colon with ulceration of the tissue), psoriasis (an autoimmune disease characterized by raised areas of abnormal skin), and irregular heart beat with a cardiac pacemaker (a device used to regulate the heart beat). The patient lived at home with the spouse who provided supportive care. Review of the discharge summary provided to the agency from the hospital with a faxed date of 05/05/2021 showed, but not limited to, the following: - Triple antibiotic topical ointment, one application, topical daily at 0600; - Hydromorphone (Dilaudid 2 mg oral tablet) one tablet by mouth every 8 hours as needed pain, moderate, decrease to one pain pill a day; and - Multivitamin one tablet by mouth two times a day. Review of the plan of care dated 05/06/2021 showed the following: - Change left hip dressing at least every three to four days, apply fresh triple antibiotic ointment with dressing change; - Hydromorphone (Dilaudid 2 mg oral tablet) one to two tablets every eight hours as needed for moderate pain. Decrease to one pain pill a day as soon as possible; and - The plan of care failed to contain an order for multivitamin. The initial comprehensive assessment, performed on 05/06/2021, failed to contain documentation that the physician was notified of the discrepancies between the discharge summary dated 05/05/2021 and the home health plan of care dated 05/06/2021. During an interview on 05/18/21 at 11:05 AM the administrator stated that they expect collaboration to occur between the clinician performing the initial comprehensive assessment and the primary physician when discrepancies are noted between the hospital discharge summary and the agency plan of care, and that they were unable to find documentation that the collaboration occurred in this instance. RECORD/PATIENT #3: Review of the patient's clinical record showed the patient admitted on 04/22/2021 with age-related osteoporosis (bone weakness due to loss of calcium salts and bone fabric) with fracture (break) of distal femur (thigh bone extends from the hip to the knee). During a home visit observation on 05/18/2021 beginning at 1:30 PM with the physical therapist (PT), the PT reviewed the patient's medication. Patient medications showed Ropinirole (treat nervous system and/or restless leg during sleep) one milligram at bedtime. Agency medication list failed to show this medication. Patient stated that his/her physician ordered this medication on 05/10/2021. Record review showed that PT visited the patient on 05/11/2021, 05/12/2021 and 05/14/2021. PT failed to observe addition of this medication and failed to update the patient's medication profile and failed to coordinate this medication with agency staff. During an interview with the administrator on 05/18/2021 at approximately 4:30 PM, the administrator stated that staff are to review each medication with the patient during home visits. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to home health services on 04/28/2021 with a primary diagnosis of right hip replacement, and secondary diagnoses of morbid obesity, atrial fibrillation (fluttering of the upper chambers of the heart), long-term use of anticoagulants, and obstructive sleep apnea (failing to breath during sleep because of an airway obstruction). Review of the clinical record showed: - The identification of a major drug interaction noted between the medication used to prevent blood clots (rivaroxaban) and the anti-inflammatory medication (naproxen) during the initial comprehensive assessment performed on 04/28/2021; - The primary physician was notified of the drug interaction on 04/28/2021, and the primary physician's nurse called the agency's nurse back to report that the primary physician had not ordered the rivaroxaban or naproxen, and that the agency's nurse should contact the surgeon's office; - The agency's nurse contacted the surgeon's office and was directed to fax the drug interactions report to their (the surgeon's) office. The major drug interaction report was faxed to the surgeon's office on 04/29/2021; - The clinical record contains a return fax from the surgeon's office dated 04/30/2021 that stated, "Patient is not taking naproxen"; - The clinical record failed to contain documentation of actions taken to resolve the major drug interactions between the naproxen and rivaroxaban, or clarification of whether the patient should be taking naproxen; and - Review of the agency medication showed naproxen as an active medication through the survey date of 05/17/2021. During an interview on 05/18/21 at 10:50 the administrator stated that he/she would expect the staff to follow up on the faxed response from the surgeon's office stating the patient was not taking naproxen.

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 interviews, the agency failed to ensure that each patients' written individualized care plan included all the required elements in, but not limited to, two (Records/Patients #5 and #6) of five full records reviewed. This deficient practice has the potential to impact the care provided to all agency patients. Finding included: Review of the agency policy dated 10/2001 and titled, "Plan of Care," showed that the plan of care must include medications and treatments, and any other pertinent information necessary to complete the plan of care. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to home health services on 04/28/2021 with a primary diagnosis of right hip replacement, and secondary diagnoses of morbid obesity, atrial fibrillation (fluttering of the upper chambers of the heart), long-term use of anticoagulants, and obstructive sleep apnea (failing to breath during sleep because of an airway obstruction). Review of the inpatient discharge instructions showed the patient was to have a complete blood count, comprehensive metabolic profile, and magnesium levels drawn prior to a follow up appointment on 05/03/2021. Review of the initial comprehensive assessment performed on 04/28/2021 showed the nurse obtained a blood sample from the left antecubital site for a complete blood count with differential, comprehensive metabolic profile, and magnesium levels. The plan of care dated 04/28/2021 failed to contain treatment orders for obtaining the blood sample. During an interview on 05/18/21 at 11:05 AM the administrator stated that the orders for blood work were on the discharge paperwork from the hospital and that he/she was unable to locate the orders on the patients plan of care. PATIENT/RECORD #6: Review of the clinical record showed that the patient was admitted to home health services on 02/18/2021 for management of an abdominal wound following surgery. The patient had secondary diagnoses of sleep apnea (failing to breath while sleeping), high blood pressure, narrowing of both carotid arteries, low back pain, and oxygen dependence. The patient entered the second home health certification period on 04/19/2021. Review of the plan of care dated 04/19/2021 showed: - Tylenol 650 mg take as directed per package instructions, as needed for pain or discomfort; and - Biofreeze use as directed to affected areas as needed for pain or discomfort. During an interview on 05/18/21 at 11:05 AM the administrator stated that they would expect the medication orders to contain the frequency of administration.

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, record review, observation, and interview, the agency failed to ensure staff followed infection control standards of practice in two (Records/Patients #1 and #3) of three home visit observations. This deficient practice has the potential to affect the health and safety of all patients served by the agency. Findings included: Review of the agency's policy titled, "Hand Hygiene" dated 09/20, showed: Hands should be washed: - Before applying and after removing gloves; and - After contact with inanimate objects in the immediate vicinity of the patient. Review of the agency's policy titled, "Nursing Bag and Bag Technique," revised date 10/17 showed: - Equipment removed from the bag will also be placed on an appropriate barrier; - Wash hands or use alcohol rub before re-entering the bag and following all care procedures; and - Clean the reusable items with appropriate antiseptic wipes (vital sign equipment, etc.) for low level disinfection of each item observing the kill time for the product utilized. RECORD/PATIENT #1: Review of the patient's plan of care (POC) dated 05/12/2021 showed an order for skilled nursing (SN) to perform wound care to left medial lower leg distal wound twice a week and as needed (prn). During a home visit observation on 05/18/2021, beginning at 9:50 AM, the SN performed wound care. During wound care procedure SN removed wound care supplies from his/her nursing bag. SN after placing supplies on barrier with wound supplies, removed his/her gloves numerous times without performing hand hygiene between glove removal and reapplication of gloves. SN was also observed applying alcohol hand cleaner on the exterior of his/her gloves without changing gloves when indicated in wound care procedure. During an interview following wound care, the SN stated that during the pandemic, gloves were cleaned with alcohol instead of removing gloves, to conserve glove supplies. The SN agreed that this process failed to follow agency policy. RECORD/PATIENT #3: Review of the patient's POC dated 04/22/2021 showed an order for Physical Therapy (PT) to visit two times a week for one week and three times a week for two weeks. During a home visit observation with PT on 05/18/2021 beginning at 1:30 PM, the PT failed to follow infection control policies. The PT dropped his/her clipboard on the patient's floor. The PT picked up the clipboard and laid the clipboard on the patient's table. The PT failed to clean the clipboard/and failed to place it on a barrier. After completion of PT exercises, the PT had the patient sign his/her tablet. The PT cleaned the tablet, but then placed the tablet next to the unclean clipboard in his/her supply bag. During an interview following the home visit, the PT concurred that the clipboard should have been cleaned prior to placing in his/her bag. During an interview with the administrator on 05/18/2021 at 4:00 PM, the administrator stated that the clipboard should have been cleaned after it was dropped.