Every finding on record at Salem Memorial District Hospital Home Health Agency

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 01/05/2023. During the survey it was determined the home health provider is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency preparedness for Home Health Agencies.

A partial extended survey for Medicare recertification for the home health provider was completed on 01/05/2023. The agency had 18 current patients. The COVID-19 Health Care Staff Vaccination regulation was reviewed as part of the Medicare recertification survey. During the survey it was determined the agency was in compliance with the regulation.

Investigation of complaints CFR(s): 484.50(e)(1) Standard: Investigation of complaints. The HHA must-- This STANDARD is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to document a complaint, conduct a complaint investigation, and document a resolution in one (Patient/Record #4) of six records reviewed. This deficient practice has the potential to affect the quality of care to all patients served by the agency. Findings included: Review of the agency's undated policy titled, "Home Health Bill of Rights/Grievance Procedure" showed if a complaint regarding services provided is received by an agency staff professional providing care, the complaint will be documented and communicated to the director of home health. The director of home health or his/her designee will contact the patient, caregiver, and/or interested parties, and attempt to reconcile the situation. The complaint shall be documented on the Patient Grievance/Complaint Form. . RECORD/PATIENT #4: Review of the patient's medical record showed: The patient's start of care was 09/23/2022; The patient's primary diagnosis was mild intermittent asthma (difficulty breathing) and muscle weakness; Plan of Care (POC) showed occupational therapy (OT) visits two times a week for four weeks; OT visit dated 10/04/2022, the occupational therapist documented that the spouse had "bad news"; Spouse stated that the physical therapist assistant (PTA) interaction with the patient for the last two visits, that the patient felt the PTA, was "bossy", and that they did not want the PTA back in the home; OT note stated that after "long" discussion, the patient was agreeable for OT to continue and for another physical therapist (PT) to make visits; OT stated that he/she would speak with PT and explain their concerns and that PT would probably be contacting them. Review of the record documentation failed to show further follow-up to the patient complaint. Review of the agency's complaint log showed no grievance for the past three years and did not include a complaint from patient #4. During an interview on 01/04/2023 at 3:30 PM, the home health director stated that the OT should have reported the complaint voiced by the patient and spouse, and that the OT should have documented the complaint and the resolution on the patient grievance/complaint form.

Skilled professional performs assessment CFR(s): 484.55(a)(2) When rehabilitation therapy service (speech language pathology, physical therapy, or occupational therapy) is the only service ordered by the physician or allowed practitioner, who is responsible for the home health plan of care, and if the need for that service establishes program eligibility, the initial assessment visit may be made by the appropriate rehabilitation skilled professional. This ELEMENT is not met as evidenced by: Based on record review, and interview, the agency failed to ensure a rehabilitation skilled professional conducted an initial assessment visit to determine the immediate care and support needs of the patient; and for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status within 48 hours of referral in one of one applicable records (Record/Patient #5) of six records reviewed. The deficient practice has the potential to affect all patients on service with the agency. Findings included: RECORD/PATIENT #5: Review of the clinical record showed a referral to the home health agency for physical and occupational therapy (PT/OT), written on 12/02/2022. Review of the initial assessment, completed by the PT showed the admission was completed on 12/05/2022 (one day late). During an interview on 01/04/2023 at 4:00 PM, the home health director stated that PT was not aware of the 48 hour time frame.

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 agency policy, clinical record review, home visit observation, and interview the agency failed to ensure that staff perform 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 in two (Records/Patient #1 and #3) of three home visit observations performed. This deficient practice has the potential to affect the medication reconciliation process for all the agency's patients. Findings included: Review of the agency’s policy titled, “Drug Regimen Review/Medication Reconciliation,” dated 06/09/2014, showed that: - A drug regimen review is conducted at start of care, resumption of care, recertification, and when any new medications are added to the drug regimen. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 11/30/2022 with a primary diagnosis of acute osteomyelitis (an infection of the bone), and type two diabetes mellitus (a chronic, metabolic disease characterized by elevated levels of blood sugar, which leads over time to serious damage to the heart, blood vessels, eyes, kidneys and nerves).The patient resided in their own home with the spouse administering intravenous antibiotics independently. Observation on 01/03/2023 at 11:50 AM, during the patient’s home visit, a review of the patient’s medication showed that the patient reported that they have not taken apple cider vinegar, ascorbic acid, vitamin b complex, cinnamon, milk thistle, omega three, glucofort, alive diabetic multivitamin, glucocil, and sugar blocker pharma pure (all over the counter medications) since they have been on home health services. The patient and the nurse confirmed that the patient has not taken Ozempic (a once-weekly medicine for adults with type 2 diabetes used to improve blood sugar) for about a month. All of the medications were active medications on the patient’s medication profile printed on 01/03/2023. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 12/05/2022 with a primary diagnosis of type two diabetes mellitus, and other pertinent diagnosis of pain in the right elbow. Observation on 01/04/2023 at 10:10 AM, during the patient’s home visit, the patient reported that they were using acetaminophen (a non-narcotic pain reliever) and biofreeze roll on salve as needed for pain management. Neither medication was listed on the patient’s medication profile printed on 01/03/2023. During an interview on 01/05/2023 at 11:13 AM, the home health director stated that they expect the clinicians to ask the patients every visit about new or changed medications.

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 agency policy, record review, and interview, the agency failed to ensure that the individualized plan of care include, but not limited to, the following: The types of services, supplies, and equipment required; all medications and treatments; patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient in, but not limited to, three (Records/Patients #1, #2, and #3) of six records reviewed. This deficient practice has the potential to affect the care planning for all of the agency's patients. Findings included: Review of the agency’s policy titled, “Plan of Care,” dated 12/19/2020, showed that the plan of care shall be completed in full to include: - Type, frequency, and duration of all visits/services; - Specific procedures and modalities for therapy services; - Medications, treatments, and procedures; and - Medical supplies and equipment required. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 11/30/2022 with a primary diagnosis of acute osteomyelitis (an infection of the bone), and type two diabetes mellitus (a chronic, metabolic disease characterized by elevated levels of blood sugar, which leads over time to serious damage to the heart, blood vessels, eyes, kidneys and nerves).The patient resided in their own home with the spouse administering intravenous antibiotics independently. Review of the initial comprehensive nursing assessment performed 11/30/2022 showed that the patient was using a Dexcom glucose monitoring device (a wearable device for diabetes that provides real-time glucose readings) to manage their blood sugars. Review of the plan of care dated 11/30/2022 showed the document failed to contain orders/information on the Dexcom glucose monitoring device. During an interview on 01/05/2023 at 11:13 AM, the home health director (HHD) stated that they expect the clinicians to list blood glucose monitors on the plan of care. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted on 12/02/2022 with a primary diagnosis of dehydration, and relevant past medical history of urosepsis (an infection which begins in the urinary tract and spreads to the bloodstream), and Parkinson’s Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). The patient resided in their own home with the assistance of their spouse. Observation on 01/03/2023 at 02:20 PM, during the patient’s home visit, the patient and their spouse stated that they had an appointment with the urologist on 01/147/2023 for follow up care related to the indwelling foley catheter (a sterile tube placed in the bladder to drain urine). During an interview on 01/05/2023 at 11:13 AM, the HHD stated that they would expect interventions for the urinary catheter and the name of the urologist to be included on the plan of care RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 12/05/2022 with a primary diagnosis of type two diabetes mellitus, and other pertinent diagnosis of pain in the right elbow. Review of the occupational therapy initial evaluation visit performed 12/06/2022 showed that: - The patient had the goal of decreased edema in right arm; and - The integumentary assessment showed the patient had lymphedema (a condition in which extra lymph fluid builds up in tissues and causes swelling) in the right arm. Review of the occupational therapy routine visits dated 12/13/2022, 12/20/2022, 12/29/2022and 01/04/2023 showed that the therapist performed lymphedema drainage technique on the right arm. Review of the plan of care dated 12/05/2022 showed the plan failed to contain therapy specific interventions for the performance of lymphedema drainage techniques to the right arm. During an interview on 01/05/2023 at 11:14 AM, the HHD stated that they would expect specific interventions to manage pain and the performance of lymphedema drainage techniques to be on the plan of care.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and interview the agency failed to ensure communication with all physicians involved in the plan of care (POC) in two (Records/Patients #4 and #5) of six records reviewed This deficient practice has the potential to affect the quality of care provided to all patients served by the agency. Findings included: Review of the agency's undated policy titled, "Coordination of Patient Services," showed: All personnel shall maintain a liaison to assure that their efforts are coordinated effectively and support the objectives outlined the POC. This may be done through formal care conferences; maintaining complete, current care plan; and written and verbal interaction; To evaluate the adequacy of treatment and the effect of services provided; and To provide the attending physician with an ongoing assessment of the patient and identify the patient's response to services provided. Review of the agency's undated policy titled, "Pain Assessment/Management," showed: Pain is assessed on every home visit and documented on a pain or symptoms flow sheet; The nurse/therapist will use a standardized agency accepted pain assessment tool that evaluates the location, duration, severity (rating scale), alleviating factors, exacerbating factors, current treatment (medication and non-medication) and response to treatment; and The follow-up assessments will address effectiveness of the pain management program and identify if there is a need for referral or additional or alternative therapy. PATIENT/RECORD #4: Review of the POC dated 09/23/2022 through 11/21/2022showed: Primary diagnosis of mild intermittent asthma (difficulty breathing), and additional diagnosis of muscle weakness; Occupation therapy (OT) two visits per week for four weeks; Physical therapy (PT) two visits per week for five weeks; and Physician will be notified of pain intensity greater than six/10 (numerical scale). Review of PT/physical therapy assistant (PTA) visit notes showed: PTA visit on 09/27/2022, patient reported pain level of nine, no documentation of notification to the physician; and PTA visit on 10/04/2022, patient reported pain level of nine, and stated pain "excruciating", no documentation of notification to the physician. During an interview on 01/05/2023 at 9:00 AM, the home health director (HHD) stated that the pain should have been communicated to the physician, the PT, and the skilled nurse. PATIENT/RECORD #5 Review of the POC dated 12/05/2022 through 02/02/2023 showed: Primary diagnosis of intervertebral (spine) disc degeneration lumbar region and repeated falls; PT visits two per week for five weeks; OT visits two per week for four weeks; Physician notification of blood pressure reading (measure of the pressure exerted on the wall of any blood vessel) Physician notification of pain intensity >six/10. Review of the PT visits showed on 12/12/2022, patient stated that he/she fell two days ago. PT documented patient had a bruise on his/her right tricep (arm) down to his/her elbow. Record failed to show notification to the patient's physician. Review of the OT visits showed: 12/10/2022 patient's skin assessment had three + pitting edema (swelling) on right side, and four + pitting edema on left side; Patient complained of pain at seven and severe; Patient's blood pressure was 81/48; and No physician notification on record regarding abnormal findings. During an interview on 01/04/2023 at 3:20 PM, the HHD stated that the physician should have been notified of the abnormal findings.

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 nationally recognized standards, agency policy, record review, and interview, the agency failed to ensure that staff follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases in one (Record/Patient #2) of three home visit observations. This deficient practice has the potential to affect the infection control measures for all of the agency's patients. Findings included: Review of guidelines from the Centers for Disease Control on alcohol as a chemical disinfectant retrieved 01/06/2023 from https://www.cdc.gov/infectioncontrol/guidelines/disinfection/disinfection-methods/chemical.html showed that alcohols were not recommended for sterilizing medical and surgical materials principally because they lack sporicidal action (the ability to kill bacterial spores) and they cannot penetrate protein-rich materials. Review of the agency policy titled, “Healthcare Bag Technique,” dated 10/25/2016 showed that: - Follow proper hand hygiene techniques before removing any items form the healthcare bag and providing patient care; - Remove any items from the healthcare bag, including supplies and equipment, need for patient care. Place these clean supplies and equipment on the barrier; - Wash your hands or use hand sanitizer again if at any time you need to re-enter your healthcare bag for additional supplies or equipment during patient care; and - After finishing with patient care perform hand hygiene, and then use sani-wipes/disinfectant wipes to cleanse your equipment that was used before placing them back into your healthcare bag. Review of the agency policy titled, “Hand Hygiene,” dated 11/9/2020 showed that hand hygiene will be performed after contact with inanimate objects in the immediate vicinity of the patient such as medical equipment, furniture, linens, etc. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted on 12/02/2022 with a primary diagnosis of dehydration, and relevant past medical history of urosepsis (an infection which begins in the urinary tract and spreads to the bloodstream), and Parkinson’s Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). The patient resided in their own home with the assistance of their spouse. Observation on 01/03/2023 at 02:20 PM, during the patient’s home visit, the physical therapy assistant (PTA1) failed to perform hand hygiene prior to cleaning the thermometer after use. The PTA1 used hand sanitizing alcohol wipes containing 75% alcohol to cleanse their medical equipment prior to immediately returning the items to the healthcare bag. During an interview on 01/03/2023 at 2:45 PM, PTA1 stated that they did fail to wash their hands prior to cleansing the thermometer with the alcohol wipes and returning the equipment to the healthcare bag. During an interview on 01/05/2023 at 11:13 AM, the home health director stated that their agency used Cleantize Cleaning and Disinfecting wipes to cleanse equipment and not alcohol wipes.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on interview, record review, and review of Centers for Medicare and Medicaid Services (CMS) COVID-19 guidance, the agency failed to put in place a program/procedure for screening patients prior to home visits for COVID-19 (pandemic infection) who received home health services for two (Record/Patient #4 and #5) of six records reviewed. This deficient practice has the potential to affect infection control needs for all employees and patients served by the agency. Findings included: Review of CMS Quality, Safety & Oversight Group (QSO) Memo, QSO-20-18-HHA dated 03/10/2020 showed in part: When making a home visit, home health agencies (HHAs) should identify patients at risk for having COVID-19 infection before or immediately upon arrival to the home. They should ask patients about the following: International travel within the last 14 days to countries with sustained community transmission. For updated information on affected countries visit: Https://www.cdc.gov/coronavirus/2019-ncov/travelers/index,html; Signs or symptoms of a respiratory infection, such as a fewer, cough, and sore throat. In the last 14 days, has had contact with someone with or under investigation for COVID-19, or are ill with respiratory illness; and Residing in a community where community-based spread of COVID-19 is occurring. Review of agency policies, failed to show a policy for screening of patients prior to HHA visits. Review of patient #4 and #5's patient records failed to show a COVID-19 screening. During an interview with the home health director (HHD) on 01/04/2023 at 4:55 PM, the HHD stated that he/she would expect a COVID-19 screening for every patient visit by all HHA personnel.

Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This ELEMENT is not met as evidenced by: Based on agency policy, record review, and interview the agency failed to ensure that when the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. This deficient practice has the potential to affect the management of the agency's administrative processes. Findings included: Review of the letter addressed to the Department of Health and Human Services showed that the most recent pre-designated alternate administrator approved by the governing body was in 02/18/2020, and that both persons on the letter were no longer employees of the agency. Review of the agency’s undated policy titled, “Administrator and Pre-designated Alternate Administrator,” showed that the administrator authorizes the pre-designated administrator to act in his/her absence with the authority of the administrator and approval of the governing body. During an interview on 01/04/2023 at 4:05 PM, the home health director stated that the previously designated administration left the home health agency and they (the agency) failed to appoint a current pre-designated alternate administrator.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure clinical record documentation was complete and/or accurate in one (Record/Patient #6) of six records reviewed. This deficient practice has the potential to affect the care of all patients served by the agency. Findings included: RECORD/PATIENT #6: Review showed the patient was admitted to home health on 11/17/2022 with a diagnosis of chronic obstructive pulmonary disease (COPD - chronic inflammatory lung disease that causes obstructed airflow from the lungs) with exacerbation. The plan of care (POC) showed oxygen two (2) liters (L) (measurement) per minute intranasally (nose) continuous at the start of care. Health professional charting documented oxygen 2 L per minutes throughout the patients care. Discharge Outcome Assessment Information Set (OASIS) - D1 showed oxygen four (4) L continuous. During an interview on 01/04/2023 at 3.50 PM, the home health director (HHD) stated that this was a documentation error. He/she stated that 2 L should have been documented.