Every finding on record at Prairie Lakes Health Care System Inc.

A standard recertification survey for compliance with 42 CFR Part 483, Subpart G, Subsection 484.113, Emergency Preparedness Requirements for Home Health Agencies, was conducted from 5/17/22 to 5/19/22. Prairie Lakes Home Health was found not in compliance with the following requirements: E0021.

HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This STANDARD is not met as evidenced by: Based on observation, interview, and policy review, the provider failed to develop policies and procedures on what measures the staff were to implement after inclement (severe) weather or other emergency situations to ensure patient safety and if the patient's needs were being met. Findings include: 1. Observation and interview on 5/18/22 at 9:30 a.m. during a hospice patient's home visit (the hospice survey was conducted at the same time as the home health recertification survey) the elderly caregiver revealed: *There had been a violent wind/thunderstorm on 5/12/22. -Tornadoes had been reported in Hamlin County just south of their farm, their home was also located in Hamlin County. *A large grain bin was laying on the ground approximately thirty feet from their north facing dining room picture window. *The grain bin had been torn off the cement foundation and bent nearly in half during the storm. *One of two garage doors on the south side of the house had also sustained a vertical dent from top to bottom and was no longer functional. *The caregiver stated: -"It was pretty scary". -Their son had checked on them following the storm. Interview on 5/18/22 at 11:10 a.m. with RN (registered nurse) C revealed: *EP (emergency preparedness) was discussed monthly at the nurse's meetings. *If there had been a tornado or other natural disaster, they would meet at the office or await home health administrator A's instruction. *She was unsure if there was a secondary meeting place. *Administrator A would call them on the agency provided phones to give direction on what to do next. Interview on 5/19/22 at 10:00 a.m. with RN D regarding the 5/12/22 storm revealed she: *Was assigned to a hospice patient. *Had not recalled receiving a phone call, text, or email from administrator A. *Had been surprised she had not received any direction from the agency office staff or from administrator A. *Had expected to hear from someone within the agency when the storm hit. *Had not known: -How many high risk level patients she had. --Stated office staff could run a report on patient EP levels, but she had not known how to do that. -How to access the EP plan. *Had a routine visit with the hospice patient the day after the storm and observed the damage mentioned above. -Had not called that patient's home the day of the storm to check on their status. *Stated the hospice agency had recently had an EP meeting. -"We talked about EP but no 'black and white' on what to expect from staff during an emergency." *Had not called any of her assigned patients following the storm to check on their status. -"It [EP] could be better." Review of the provider's healthcare system February 2022 Disaster Alert Activation/Emergency Operations Plan revealed no mention of a home health/hospice disaster plan in the following sections: *Incident Command System. *Staff assignments. *Job action sheets. *Staff recall procedures. *Patient unit-specific evacuation plans were only for critical care, maternal/child health, medical/surgical/pediatric, and the emergency department. *Appendix H Disaster Alert Department Emergency Operations Plans. Review of the provider's July 2020 Disaster Plan Home Health/Hospice (HH/hospice) revealed: *The purpose was to provide guidance to home health, hospice, and home connections in the event of an internal or external disaster or weather-related to safely serve patients in our region. *A patient roster would be printed daily to ensure a complete list of all patients served was readily available. *An individual EP plan would be completed on all patients on admission and assigned a priority level. -Level one patients were high priority whereas level 3 would be a low priority. *Paper documentation sheets were available for all discipline visits in the event of an electrical outage. *All staff were provided with a smartphone. *For threatening weather, the administrator would be notified by emergency management, the hospital, weather radio, or public radio that threatening weather was approaching. *All staff would be notified by the administrator or designee by an email that weather was approaching and to be alert of danger in each area. *Field staff should seek shelter. *Office staff or those located in the hospital should close all blinds in the immediate area upon the issue of a weather WATCH. The hospital staff should seek shelter in the hospital basement or an inner area away from windows. Interview on 5/19/22 at 9:00 a.m. with administrator A revealed: *Their service area covered seven counties. *Currently two hospice patients were level one. -Level one would be a patient that was a quadriplegic or required oxygen by a concentrator. *Each nurse was aware of what level their patients were categorized. *The priority list was printed weekly for all home health, hospice, and home connection patients. -Home connection patients received care through a contract with the Department of Human Services (DHS). -The list was maintained in a three-ring binder with level one first, followed by level two then level three categories. -The list was not separated by counties or areas where the patients lived in the seven counties. *On 5/12/22 a DHS patient's home had been damaged from the severe weather in Hamlin County. -The DHS patient did not have electricity and required oxygen. -The patient was transported to the hospital and then to a local motel where she would receive services. -The nurse had independently implemented safety and continuing care needs for the DHS client. *For severe weather, she would send a mass email out to the staff as all staff had a smart phone issued to them. *The expectation was for the nurses to check on their level one patients first to ensure safety, then to check on level two and then level three. *She had not sent out a mass email to the staff regarding the severe weather until the following morning on 5/13/22 as she had no electricity at her home. *The current policy did not address what procedures the staff were to conduct to ensure patient safety following inclement weather. *She agreed the policy was not all-inclusive by providing direction to the staff for patient safety.

A standard recertification survey for compliance with 42 CFR Part 484, Subparts B-C, requirements for home health services, was conducted from 5/17/22 to 5/19/22. Prairie Lakes Home Health was found not in compliance with the following requirements: G536, G572, and G682.

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 and interview, the provider failed to verify with the pharmacist and obtain a physician’s order to crush medications for one of one sampled patient (4) administered through a gastrostomy feeding tube. Findings include: 1. Review of patient 5’ Home Health Certification and Plan of Care for the 3/19/22 to 5/17/22 certification period revealed she received the following medications through her gastrostomy feeding tube: *Vitamin C. *Guaifenesin ER [extended release], for cough. *Tramadol, for pain. *Escitalopram, for depression. *Ondansetron disintegrating tablet, for nausea and vomiting. *Melatonin, for insomnia. *"Cetrizine", for allergic rhinitis. *Loperamide, for diarrhea. *"Atorvastin", for decreasing cholesterol levels. *"Apixaben", blood thinner. *There was no documentation a pharmacist had been consulted if the above medications were safe to crush to be administered through the gastrostomy tube. *There was no physician’s order indicating the medications may be crushed, if appropriate, and administered through the gastrostomy tube. Interview on 5/18/22 at 2:45 p.m. with registered nurse (RN) clinical manager B revealed: *There was no documentation the pharmacist had been consulted if it was acceptable to crush the above medications including the extended-release medication. *There was no current order from the physician to crush the above medications to be administered through the gastrostomy tube. *It was possible the physician’s order had not been brought forward from the prior recertification periods. Review of the information provided by RN clinical manager B from Lippincott Procedures – Enteral drug administration, home care obtained from the following website: https://procedures.lww.com/Inp/view.do?pld=5317744&hits=medications> revealed: *Careful consideration is necessary when administering an oral medication via the enteral route. *Liquid medication formulations are preferred if they are appropriate for enteral administration. *Modified-release medication formulations (such as extended-release, delayed-release, and enteric-coated tablets) generally are not appropriate for enteral administration because these medications shouldn’t be crushed or dissolved for administration.”

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, interview, and policy review, the provider failed to follow physicians' orders for services for four of twelve sampled patients (1, 2, 5, and 8) home health visits. Findings include: 4. Review of patient 2's EMR revealed supervisory home health aide (HHA) visits had been completed on 4/27/22 and again on 4/29/22 by a registered nurse. There had been no HHA supervisory visits completed after 4/29/22 as required. Interview on 5/19/22 at 11:00 a.m. with RN clinical manager B confirmed: *Supervisory HHA visits were to be conducted no less than every fourteen days. *A supervisory HHA visit should have been completed on 5/13/22. *There was no documentation in the EMR to support a supervisory visit had been completed. Interview on 5/19/22 at 3:30 p.m. with administrator A regarding the missed/canceled visits confirmed: *The provider referred to missed visits as canceled visits. *The physicians were not notified of missed/canceled visits at until the patient finished each sixty-day certification/recertification period. *Each primary physician received a copy of the POC at the end of each period. *All the missed/canceled visits were documented in the patients’ POCs. *It could take up to sixty days before the physician was notified. *The POC contained those physicians’ orders for how often the provider is to visit the patient. *The provider should offer a make up visit at the time of the cancelation. *She did not know when the physician was to have been notified of changes in the visit orders. *The provider did not have a policy for missed/canceled visits, notification to physicians of changes in the visit orders, or offering to move the visit to another day. 1. Review of patient 1’s electronic medical record (EMR) including the 3/7/22 through 5/5/22 certification period revealed documentation that her home health aide visits were canceled on 3/31/22, 4/4/22, and 4/25/22. Interview on 5/19/22 at 10:30 a.m. with registered nurse (RN) clinical manager B regarding patient 1’s canceled visits revealed there was no documentation in the medical record to indicate: -She had been offered an alternative date to make up the missed visits. -Her physician had been notified of those canceled visits at the time they were canceled. Further interview at that time with RN clinical manager B revealed: *Patient 1’s physician had been notified of the above missed visits on 5/2/22 after she had been recertified. *All canceled/missed visits were added to the plan of care (POC) narrative and sent to the patients’ physicians at the end of each recertification. *The recertification occurred every sixty days. *The provider's home health consultant had instructed the home health workers that the physicians did not need to be notified at the time of the canceled/missed visits. *If the missed visit occurred at the beginning of the recertification period the physician could have to wait up to sixty days to be notified. 2. Review of patient 8’s EMR including the 4/6/22 through 6/4/22 recertification period revealed a physician’s order for skilled nursing visits twice weekly. The POC revealed a cancellation by the patient on 4/14/22 due to the weather. There was no documentation in the medical record to indicate: *He had been offered an alternative date to make up the missed visit. *His physician had been notified of that canceled visit. 3. Review of patient 5’s EMR including the 11/24/21 through 1/23/22 first certification period revealed: *A physician’s order for two occupational therapy (OT) visits. *A canceled OT visit on 12/3/21. The service order note stated “Due to staffing did not have time to see pt [patient] this date.” Interview on 5/19/22 at 10:35 a.m. with RN clinical manager B regarding patient 5’s canceled visit confirmed: *The OT visit was missed on 12/3/21. *The OT sent a notification to her physician on 12/15/21 to discontinue visits and the order was received by the home health to discontinue the visits on 12/17. *The physician had not been notified of the missed visit until the end of the first certification period on 1/23/22.

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 observation, interview, and policy review, the provider failed to disinfect work equipment by one of one registered nurse (RN) E for one of five patient (4) home visits (HV) . Findings include: 1. Review of patient 5's medical diagnoses revealed she had the following listed in her electronic medical record: *She had a tracheotomy and a gastrostomy. *She was a diabetic. Observation on 5/18/22 at 11:35 a.m. of RN E during the HV revealed while wearing gloves she: *Touched the back of the patient's chair and table with both gloved hands. *Placed a blood pressure (BP) cuff around the patient's left arm. *Discussed with the patient about the HHA visits to assist with bathing, which the patient refused. *Without removing her soiled gloves she reached into her scrub pants pocket and obtained her work cell phone. *Called into the main office to cancel the HHA visits until 5/20/22. *Without removing her gloves or disinfecting the work cell phone she returned the work cell phone to her scrub pants pocket and resumed taking the patients’ BP. Interview with RN E following the above HV confirmed she had properly performed hand hygiene or disinfection of the work cell phone. Interview on 5/18/22 at 2:45 p.m. with RN clinical manager B revealed RN E should have removed her gloves and disinfected the work cell phone. Review of the provider’s revised May 2022 General Hand Hygiene Guidelines revealed staff were to have used an alcohol-based hand sanitizer: *Before and after having direct contact with patients intact skin including taking a BP. *After contact with inanimate objects including medical equipment in the immediate vicinity of the patient. *After glove removal.