Every finding on record at Saint Thomas Home Health

The Emergency Preparedness (EP) review was conducted on 2/16/2023 during the recertification. The Home Health Agency was in compliance with the EP requirements.

A recertification survey was initiated on 2/14/2023. An entrance conference was held with the Clinical Nurse Manager on 2/14/2023 at 9:03 AM. An exit conference was held on 2/16/2023 with the following Home Health Agency (HHA) representatives in attendance: Clinical Nurse Manager, Administrative Assistant, Quality Manager, Hospital Administrator, and Regulatory Specialist (via telephone). The exit meeting included time for the HHA representatives to ask questions about the survey 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 policy review, medical record review, observation and interview, the facility failed to ensure medications were accurately updated to reflect the current changes to the plan of care for 3 of 3 (Patient #1,2 and 3) patients observed during home visits. The findings included: 1.Review of the policy "Reconciled Medications" last revised 08/2016, revealed, "...The admitting RN [Registered Nurse] will complete a medication profile of all medications that the patient is taking in the home...Staff will reconcile medications with every visit. If therapy is making visit, therapist will question patient about any changes in medication and therapist will notify RN of medication changes, so nurse can clarify medications profile with physician..." 2. Medical record review for Patient #1 revealed a 95-year-old patient with a Start of Care (SOC) dated 1/24/2023, and a primary diagnosis of Hypertension. Observations in Patient #1's home on 2/14/2023 at 10:45 AM revealed the following medications that were not documented on the Medication profile: Over the counter (OTC) Calcium 333 milligram (mg)-Magnesium 133 mg and Zinc 8 mg combination. In an interview on 2/14/2023 at 10:50 AM, Patient #1 stated he had been taking the OTC Calcium, Magnesium and Zinc combination tablet once daily for several weeks. 3. Medical record review for Patient #2 revealed an 80-year-old patient with a SOC dated 2/10/2023, and a primary diagnosis of right arm fracture. Observations in Patient #2's home on 2/14/2023 at 2:45 PM revealed the following medications that were not documented on the Medication profile: OTC Calcium 600 mg and Fish Oil minis- Omega 3 tablets. In an interview on 2/14/2023 at 2:54 PM, Patient #2 stated she took 2 of the 600 mg Calcium daily and took one of the Omega 3 daily. 4. Medical record review for Patient #3 revealed a 67-year-old patient with a SOC dated 11/18/2022, and a primary diagnosis of Type 2 Diabetes Mellitus with a skin ulcer. Observations in Patient #3's home on 2/15/2023 at 10:10 AM revealed the following medications that were not documented on the Medication profile: Clonidine 0.3 mg as needed, Simvastatin 10 mg once daily, Cymbalta 60 mg once daily, Glipizide 5 mg once daily. In addition, the Medication profile listed the following medication incorrectly: Methocarbamol 500 mg one at bedtime. The medication bottle observed in the home revealed Methocarbamol 500 mg take as needed. In an interview on 2/15/2023 at 10:15 AM, Patient #3 verified she was taking the above medications.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on policy review, medical record review, observation and interview, the facility failed to ensure nursing staff followed physician orders for wound treatment for 1 of 1 nurse (Licensed Practical Nurse #1) observed performing wound care. The findings included: 1. Review of the facility policy "Procedure References" last reviewed 2/2023 revealed, "...The agency adopts a standard for practice the procedures and techniques found on the EBSCO (EBSCO is the leading provider of evidence-based clinical decision support solutions) Nursing Reference Center...as the standard of all nursing procedures. All of [named agency] established policies, procedures, protocols, pathways and physician orders shall take precedence over any information available through the NRC [nursing reference center] site... 2. Medical record review for Patient #3 revealed a 67-year-old female with a primary diagnosis of Type 2 Diabetes Mellitus with a skin ulcer to her left heel. Patient #3's Start of Care (SOC) date was 11/18/2022 with a most recent recertification period of 1/17/2023 through 3/17/2023 which included skilled nursing visits 2 times a week to perform dressing changes. Review of physician orders dated 1/26/2023 revealed, "...Clean wound with Normal Saline..." 3. Observations on 2/15/2023 at 9:50 AM revealed Licensed Practical Nurse (LPN) #1 cleaned Patient #3's heel wound with Dakins wound cleaner. LPN #1 did not follow the physician order to clean the wound with normal saline. 4. In an interview on 2/15/2023 at 11:45 AM, the Clinical Nurse Manager verified LPN #1 did not follow the most recent order from the wound care center to clean the wound with normal saline.

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, medical record review, observation and interview, the facility failed to ensure staff followed acceptable practices for infection control for 1 of 1 nurse (LPN #1) observed during wound care. The findings included: 1. Review of the facility policy "Procedure References" last reviewed 2/2023 revealed, "...The agency adopts a standard for practice the procedures and techniques found on the EBSCO (EBSCO is the leading provider of evidence-based clinical decision support solutions) Nursing Reference Center...as the standard of all nursing procedures. All of [named agency] established policies, procedures, protocols, pathways and physician orders shall take precedence over any information available through the NRC [nursing reference center] site..." Review of the EBSCO/ NRC protocol for "Performing Negative Pressure Wound Therapy" provided by the Clinical Nurse Manager on 2/15/2023 revealed, "...Procedure Steps...Perform hand hygiene. Put on nonsterile gloves. Clean skin around wound...Remove and dispose of soiled gloves. Perform hand hygiene. Prepare foam dressing..." 2. Medical record review for Patient #3 revealed a 67-year-old female with a primary diagnosis of Type 2 Diabetes Mellitus with a skin ulcer to her left heel. Patient #3's Start of Care (SOC) date was 11/18/2022 with a most recent recertification period of 1/17/2023 through 3/17/2023 which included skilled nursing visits 2 times a week to perform dressing changes. Patient #3 required a wound vac continuously on her left heel wound. 3. Observations on 2/15/2023 at 9:50 AM revealed LPN #1 removed the dirty dressing from Patient #3's left heel, performed hand hygiene and donned clean gloves. LPN #1 then cleaned the heel and placed the clean dressing on the wound. LPN #1 did not remove her gloves or perform hand hygiene before applying the clean dressing to the wound. In an interview on 2/15/2023 at 10:36 AM, the Clinical Nurse Manger verified the LPN should have performed hand hygiene and donned clean gloves after cleaning the wound and before applying the clean dressing.

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on policy review, medical record review, and interview, the facility failed to ensure supervision of Licensed Practical Nurses (LPN) by a Registered Nurse (RN) for 1 of 5 (Patient #3) active patient records reviewed. The findings included: 1. Review of the facility policy "Medical Mangement: LPN Supervision" last revised 08/2016, revealed "...LPNs are allowed to provide care to patient with the supervision of an RN...The RN will make on-site plan of care re-evaluation visits at least once every 30 days on patients. RN will evaluate and/or observe LPN's performance pertaining to the patient's plan of care..." 2. Medical record review for Patient #3 revealed a 67-year-old female with a primary diagnosis of Type 2 Diabetes Mellitus with a skin ulcer. Patient #3's Start of Care (SOC) date was 11/18/2022 with a most recent recertification period of 1/17/2023 through 3/17/2023. Further review revealed an LPN had been providing nursing services for Patient #3, including dressing changes and education. There were no documented RN Supervisory visits for the certification period reviewed. 3. In an interview on 2/15/2023 at 12:19 PM, the HHA Clinical Nurse Manager verified the RN had not documented and supervision of the LPN on her visits dated 2/1/2023, 2/3/2023 and 2/10/2023.