Every finding on record at Pruitthealth Home Health Inc

An unannounced on-site recertification survey was conducted 04/01/2024-04/03/2024. No deficiencies to the emergency preparedness Medicare Conditions of Participation were identified.

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 direct observation, policy review, clinical record review, and staff interview, the agency failed to maintain accurate medication profiles for 2 of 7 home visits conducted. (Patient #9, Patient #12) Findings included: Patient #12 was admitted to the agency on 02/19/24 with diagnoses including Type 2 diabetes with diabetic chronic kidney disease, pulmonary hypertension (affects blood vessels in the lungs), and atrial fibrillation (irregular heart rhythm). Plan of Care from 02/19/24 to 04/18/24 revealed orders for skilled nursing two times per week for one week, one time per week for nine weeks, and 2 PRN (as needed). On 04/02/23, Employee #5, registered nurse, conducted a home visit, that was observed during survey. Employee #5 was observed performing a medication review during the home visit. Patient #12 stated that he was no longer taking losartan 12.5 milligrams (used for hypertension), meclizine 25 milligrams (used for nausea or motion sickness) was only being taken as needed and not scheduled as listed on the agency’s medication profile, and valacyclovir 500 milligrams (used to treat shingles) was being taken twice daily and not three times daily as listed on the agency’s medication profile. Additionally, Patient #12 stated that he was taking the following medications that were not listed as current medications on the agency’s medication profile: furosemide 40 milligrams daily (used to treat fluid retention), omeprazole 20 milligrams daily (used to treat acid in the stomach), and potassium chloride extended release 10 milliequivalents daily (used to treat and/or prevent low potassium). In an interview on 04/03/24 at 9:12 AM, Employee #1, agency director, stated that employees are told that they should be doing it (medication reconciliation) every visit. In an interview on 04/03/24 at 11:05 AM, Employee #5 stated, “I typically do it [medication reconciliation] every other visit…it should have been done two weeks ago.” A policy, Medication Management for Home Health (revised 07/21/2021) was received on 04/03/2024 at approximately 11:30 A.M. The policy stated, “The home health agency will maintain accurate documentation of all medications that the patient is currently taking.” 1. Patient #9 was admitted on 01/24/2024 with a diagnosis of DISPL (displaced) bimalleol (ankle) FX (fracture) L (left) lower leg. The plan of care (POC) for 03/24/2024-05/22/2024 included orders for occupational therapy (OT) 1 time a week for 6 weeks. A home visit was conducted with OT #2 on 04/02/2024 at approximately 9:30 A.M. OT #2 conducted a comprehensive medication review. The POC included Amlodipine (blood pressure medication) 2.5 mg 1 time daily. Patient #9’s care giver stated, “That was discontinued on 02/20/2024.” The POC included Remeron (appetite stimulant) 15 mg 1 time daily. Patient #9’s care giver stated, “Not [taken] since the end of January [2024].” The POC included ibuprofen (anti-inflammatory) 800mg as needed. Patient #9’s care giver stated, “Not [taken] since the end of January [2024].” An interview was conducted on 04/03/2024 at approximately 9:05 AM with OT #2. OT #2 stated, “I ask every visit if there has been any [medication] changes. [Physical Therapist name] had recently done a recert and found no changes. I do them [medication reviews] on evals [evaluations], reassessment recert [recertifications], and discharges.” An interview was conducted on 04/03/2024 at approximately 9:12 A.M. with the agency administrator. The agency administrator stated, “They [clinicians] are told that they need to reconcile the meds at every visit, that’s our policy.”

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 agency policy, observation, and staff interviews the agency failed to follow accepted standards of practice to prevent the transmission of infections and communicable diseases for 2 of 5 patients with home visits conducted. (Patients #9 & 11) Findings included: A policy, Infection Control Plan-Home Health (effective 04/01/2024) was received on 04/03/2024 from the agency director at 11:30 A.M. The policy stated, “Hand hygiene must be performed at least in the following instances: … Prior to donning sterile or non-sterile gloves… After removing gloves.” Patient #9 was admitted on 01/24/2024 with a diagnosis of DISPL (displaced) bimalleol (ankle) FX (fracture) L (left) lower leg. The plan of care for 03/24/2024-05/22/2024 included orders for occupational therapy (OT) 1 time a week for 6 weeks. A home visit was conducted with OT #2 on 04/02/2024 at approximately 9:30 A.M. OT #2 donned clean gloves, assessed patient #9’s skin, and removed the clean gloves. OT #2 failed to perform hand hygiene before donning the gloves and fail to perform hand hygiene after removing the gloves. An interview was conducted with OT #2 on 04/03/2024 at approximately 9:05 A.M. OT #2 stated, “I should have used hand sanitizer after I took my gloves off. I thought I used hand sanitizer before I put the gloves on, I may not have.” Patient # 11 was admitted on 01/26/2024 with a diagnosis of dehiscence (splitting open) of amputation stump. The plan of care for 03/26/2024-05/24/2024 included orders for skilled nurse visits 1 time a week for 1 week, 2 times a week for 8 weeks, and 2 PRN (as needed) A home visit was conducted on 04/03/2024 at approximately 1:00 PM with registered nurse (RN) #4. RN #4 donned clean gloves, measured patient #11’s wound, removed the gloves and donned a clean pair. RN #4 failed to perform hand hygiene after removing the soiled gloves before donning clean gloves. An interview was conducted on 04/03/2024 at approximately 10:30 A.M. RN #4 stated “You should always wash your hands in-between gloves.” An interview was conducted with the agency administrator on 04/03/2024 at approximately 9:12 A.M. The agency director stated, “They should be washing hands or using hand sanitizer before and after gloves.”

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review, and staff interview the registered nurse failed to document the assessment or response to treatment of penile cellulitis (skin infection of the penis) for 1 of 1 clinical record reviewed with the diagnosis of penile cellulitis (Patient #13). Findings included: A policy titled “Skilled Nursing Services for Home Health”, and reviewed 11/21/22, was received from the agency administrator on 04/03/24 at 11:34 AM. This policy revealed, “Nursing visits are individually based on the need, but not necessarily limited, to…assess and reassess the patient’s condition and response to the treatment plan.” Patient #13 was admitted to the agency 02/27/24 with diagnoses including penile cellulitis (skin infection of the penis), bradycardia (heart rate lower than 60), and pressure ulcer of sacral region, stage 2 (wound with a superficial opening of skin). Plan of Care from 02/27/24 to 04/26/24 included orders for skilled nursing one time per week for nine weeks with two PRN (as needed) and “skilled nurse to assess/evaluate…conditions including penile cellulitis…” A hospital discharge note dated 02/26/24 revealed “…they [hospital staff] found that he [Patient #13] had a lot of cottage cheese type discharge from his penis and his entire penis is erythematous [red]…was noted patient also suffering from penile cellulitis…he will be discharged to complete an additional 4 days of oral Cipro [antibiotic] and oral fluconazole [antifungal]…” Employee #6, registered nurse, conducted skilled nursing visits for Patient #13 on 02/27/24, 03/08/24, 03/13/24, 03/20/24, 03/27/24, and 04/02/24. There was no documented evidence that the status of Patient #13’s penile cellulitis was assessed during those visits. In an interview on 04/03/24 at 10:11 AM, Employee #6 stated, “That [cellulitis of penis] is resolved…it’s been resolved for about 2 weeks. I guess I didn’t [assess the status of Patient #13’s penile cellulitis] because I don’t see it in his notes… I did a full assessment on him, but I really don’t think he had that [penile cellulitis] when he went in [to the hospital] … he had a pretty bad yeasty rash and wound [of the buttocks] … sometime after that, I had to call the doctor because he did have a yeasty area in the penile area, a rash or redness.” In an interview on 04/03/24 at 10:30 AM, Employee #7, clinical manager, stated, “We’re told to do a head-to-toe assessment and document as such.”

An unannounced, on-site recertification survey was conducted 10/25//21 to 10/27/21. No deficiencies to the Emergency Preparedness program were identified.- MHB An unannounced, onsite recertification survey was conducted 10/25//21 to 10/27/21. Standard level deficiencies to the Medicare Conditions of Participation were identified. -MHB

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 clinical record review and staff interview, the agency failed to document an accurate diagnosis on the Plan of Care for 1 of 8 patients receiving physical therapy (Patient #6) and failed to list oxygen with the medications on the Plan of Care for 1 of 1 patients receiving oxygen (Patient #4). Findings included: 1. Patient #6 was admitted to the agency on 09/20/21. Plan of Care dated 09/20/21 to 11/18/21 includes a principle diagnosis, “UNSPECIFIED DISLOCATION OF RIGHT SHOULDER JOINT…” with physical therapy services ordered 2 times per week for 3 weeks and 1 time per week for 4 weeks. Clinical record review revealed a hospital discharge summary dated 09/14/21 with a documented “closed dislocation of her left shoulder.” Further clinical record review revealed a physical therapy admission visit note dated 09/20/21, “…Ortho (orthopedic physician who treats bone and joint conditions) hospitalist has been contacted due to no specific instructions noted in paperwork regarding sling or weight-bearing of left upper extremity and or protocol and follow up appointment.” In an interview on 10/27/21 at 3:25 PM, Employee #1, the agency director, stated “It is the left shoulder that is dislocated.” Employee #1 confirmed that documentation regarding the right shoulder dislocation was an error and stated that this error was made in coding, had been caught by the billing department, and been corrected. 2. Patient #4 was admitted to the agency on 10/03/21 with diagnoses including, “COVID-19, PNEUMONIA DUE TO CORONAVIRUS DISEASE 2019, ACUTE AND CHRONIC RESPIRATORY FAILURE WITH HYPOXIA, DEPENDENCE ON SUPPLEMENTAL OXYGEN…” Clinical record review revealed a Plan of Care from 10/08/21 to 12/06/21 with orders for skilled nursing 2 times per week for 3 weeks, 1 time per week for 6 weeks, 2 PRN (as needed) and physical therapy 1 time per week for 1 week, 2 times per week for 2 weeks and 1 time per week for 4 weeks. Hospital discharge note dated 10/07/21 included a discharge medication list that included, “DME – Oxygen, See instructions…” and a hospital course narrative note which included, “Home oxygen has been arranged today.” In an interview on 10/27/21 at approximately 4:00 PM, Employee #1, the agency director, stated, “Looks like she does have oxygen. Yes, that (including oxygen on the medication list) is a policy.” Employee #1 stated that this error should have been caught by coding.

An onsite complaint investigation was conducted July 12-13, 2021. The complaint was substantiated and deficiencies to the Medicare Conditions of Participation were identified. CI 18950

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to notify the physician of medication discrepancies for 1 of 3 patients (#1). Findings include: 1A. Patient #1 was admitted on 3/30/21 with diagnoses of sepsis due to enterococcus, urinary tract infection and bacteremia (infection in the blood). The Plan of Care (POC) for 3/30/21-5/28/21 included orders for skilled nursing visits 1 time per week for 2 weeks, 2 times per week for 1 week and 1 time per week for 1 week and 1 prn (as needed) visit. The orders also included “skilled nurse for observation/assessment of IV access site, response to medication and skilled teaching regarding infusion procedure, care of infusion line and site care, care and use of infusion equipment and sign/symptoms of complications of IV therapy.” The patient was to take ampicillin 2 grams IV every 4 hours via PICC (peripherally inserted central catheter) line. The Start of Care was completed on 3/30/21. The visit note stated, “PICC has good blood return, flushed easily…RN instructed spouse and adult son on administration of IV ampicillin 2 gm/100 ml NS [normal saline] q4hr [every 4 hours] over 30 minutes using a dial a flow, instructed on flushing PICC line…” A Coordination Note on 4/5/21 revealed the wife called on-call regarding an issue with flushing the PICC line. The RN “attempted to trouble shoot with wife on phone to no avail. Advised that a nurse would make a visit first thing in this am to assess. Wife agreed.” A late entry made on 4/9/21 for 4/5/21 stated the wife had called at 2:17 am to report that she was unable to flush the PICC line. On 4/5/21 a visit was conducted. The visit note stated, “SN was informed that patient did not receive medication at 2 am and 6 am this morning due to inability to flush PICC. SN contacted RN case manager ___ for assistance…RN case manager arrived and was able to successfully flush the PICC line with no resistance.” An interview with the area vice president on 7/13/21 at 10:35 confirmed there was no evidence the physician was notified of the missed doses of ampicillin. The interview also confirmed the physician should have been notified regarding the 2 am and 6 am missed doses of the antibiotic. 1B. On 4/23/21, a Resumption of Care was completed after a hospitalization because of positive blood cultures. The ROC assessment stated, “Patient returned home with continuous IV infusion of penicillin and ceftriaxone q [every] 12 hours, patient with PICC line in place…Taught patient and spouse how to assemble and operate CADD pump…CADD pump running with no issues on departure.” An updated POC for 4/23/21-5/28/21 included an order for SN 1 time per week for 6 weeks and 3 prn (as needed) visits. The orders also included “skilled nurse for observation/assessment of IV access site, response to medication and skilled teaching regarding infusion procedure, care of infusion line and site care, care and use of infusion equipment and sign/symptoms of complications of IV therapy.” The patient was receiving a continuous infusion of penicillin 24 million units per 1200 ml to run at 49.1 milliliters per hour.” A Coordination Note from 4/24/21 at 1:38 p.m. revealed, “Received call from wife stating IV bag is empty and it is 3 hrs [hours] early. Advised to change the bag and continue the infusion. Also encouraged to let IV company know the bag ran out early, when they call for supply request.” There was no evidence the RN notified the physician of the infusion finishing too quickly or notifying the pharmacy. An interview with the area vice president on 7/13/21 at 10:35 a.m. confirmed the physician should have been notified that the medication infusion finished 3 hours earlier than ordered/expected.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the skilled nurse failed to conduct an as needed visit based on the plan of care for 1 of 3 patients (#1). Findings include: Patient #1 was admitted on 3/30/21 with diagnoses of sepsis due to enterococcus, urinary tract infection and bacteremia (infection in the blood). The Resumption of Care Plan of Care (POC) for 4/23/21-5/28/21 included an order for SN 1 time per week for 6 weeks and 1 prn (as needed) visit for “complications with PICC”. The orders also included “skilled nurse for observation/assessment of IV access site, response to medication and skilled teaching regarding infusion procedure, care of infusion line and site care, care and use of infusion equipment and sign/symptoms of complications of IV therapy.” The patient was receiving a continuous infusion of penicillin 24 million units per 1200 ml to run at 49.1 milliliters per hour via a PICC line (peripherally inserted central venous catheter). A Coordination Note from 4/24/21 at 1:38 p.m. revealed, “Received call from wife stating IV bag is empty and it is 3 hrs [hours] early. Advised to change the bag and continue the infusion. Also encouraged to let IV company know the bag ran out early, when they call for supply request.” There was no evidence of a prn visit to assess the reason for the IV medication to be completed 3 hours early. An interview with the area vice president on 7/13/21 at 10:35 a.m. confirmed there was no evidence that a visit was made. The interview also confirmed that an infusion finishing 3 hours earlier than ordered/expected would be an acceptable reason for a prn visit according to the POC order “complication with PICC.”