Every finding on record at Robeson County Health Department

An onsite, unannounced recertification survey was conducted 08/08/22-08/09/22. No deficiencies to the Emergency Preparedness Program were identified. -MHB

An onsite, unannounced recertification survey was conducted 08/08/22-08/09/22. 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 policy review, clinical record review, and staff interview, the agency failed to include oxygen on the Plan of Care for 1 of 2 records reviewed of patients receiving oxygen. (Patient #12) Findings include: Policy titled Medication Administration, approved December 2021, was received from Employee #6, the agency’s Processing Assistant, on 08/09/22 at 12:30 PM. This policy revealed, “The nurse enters the medication list into the [name of software] electronic record…” Patient #12 was admitted to the agency on 10/06/21 with diagnoses including hypertensive heart and chronic kidney disease (heart and kidney disease related to high blood pressure) with heart failure (heart’s inability to pump effectively), chronic respiratory failure, chronic obstructive pulmonary (lung) disease, and tracheostomy (an opening in the trachea that allows access to a breathing tube) status. Plan of Care from 10/06/21 to 12/04/21 revealed skilled nursing orders 2 times per week for 2 weeks and 1 time per week for 7 weeks and included orders for “…teaching on 02 (oxygen) safety…”. The plan of care also included orders for safety measures that included oxygen precautions and durable medical equipment supplies included oxygen. Medications included on this Plan of Care did not include oxygen. In an interview on 08/09/22 at 11:50 AM, Employee #4, the agency’s Nurse Supervisor, stated, “…I don’t know that we have a policy for that [including oxygen on the medication list]…It’s [oxygen] a medication so it should be listed…”

Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This STANDARD is not met as evidenced by: Based on client record review, and staff interview the agency failed to obtain PICC (peripherally inserted central catheter) line measurements for 1 of 1 record reviewed with a PICC line (#1). Findings include: Patient #1 was admitted on 07/15/22 with a diagnosis of Secondary unspecified malignant neoplasm of lymph node, hypertensive heart disease with heart failure, acute respiratory failure, and chronic obstructive pulmonary disease. The Plan of Care (POC) for 07/15/22 – 09/12/22 included orders for skilled nurse visits 1 time a week for 1 week, 2 times a week for 2 weeks and 1 time a week for 6 weeks with an order to perform PICC line dressing changes every 7 days and as needed. Review of the clinical record found no evidence of PICC line exposed catheter length measurements between 07/15/22 – 08/08/22. In an interview on 08/08/22 at approximately 4:20 p.m. the Nurse Team Leader stated that it is expected for the nurse to measure the PICC line from “hub to entry site” during all dressing changes.

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 policy review, clinical record review, and staff interview, the agency failed to obtain a lab in July 2022 as ordered for 1 of 1 record reviewed with lab work ordered to be drawn or monitored by the agency (Patient #2). Findings include: Policy titled Nursing Services, approved June 2022, was received from Employee #4, the agency’s Nurse Supervisor, on 08/09/22 at 12:18 PM. This policy revealed, “…The nurse will follow the physician’s orders on the Plan of Treatment at each visit…” Patient #2 was admitted to the agency on 02/07/18 with diagnoses including Vitamin B12 deficient anemia, chronic obstructive pulmonary disease, hypertension, and schizoaffective disorder, bipolar type. Plans of Care from 05/16/22 to 07/15/22 and 07/16/22 to 09/13/22 revealed orders for skilled nursing 1 time per month for 2 months and “Labs: HgbA1C (hemoglobin A1c: a blood test that helps determine blood sugar levels over time) to be drawn q (every) 3 months due in April, July, October, January. Labs may be drawn by an outside lab group…” There was no evidence in the clinical record of an HgbA1C having been drawn by the agency or an outside lab group during the period reviewed between 05/15/22 and 08/09/22. In an interview on 08/09/22 at 12:11 PM, Employee #4, the agency’s Nurse Supervisor, stated, “…Per [Employee #1, Patient #2’s Registered Nurse Case Manager], they [the assisted living facility where the patient resides] have not had anyone coming in to do labs because of COVID. I’m guessing we should have done the A1C in July and did not…”