Every finding on record at Sjc Home Health Services , Inc

A recertification survey was conducted at St. Joseph’s/Candler Home Healthcare on March 11, 2024, and concluded on March 13, 2024. At the time of the survey, the agency was in compliance with 42 CFR Part 418.113, Emergency Preparedness and Covid-19 infection control.

A recertification survey was conducted at St Joseph’s/ Candler Home Healthcare on March 11, 2024, and concluded on March 13, 2024. At the time of the survey, the agency was not in compliance with Chapter 42 CFR Part 418, Rules and Requirements for Home Health and Hospice Agencies. The census was 181. The following deficiencies were cited.

Treatment or care CFR(s): 484.50(e)(1)(i)(A) (i)(A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; and This ELEMENT is not met as evidenced by: Based on clinical record review, staff interviews, and review of agency policy, it was determined that the home health agency nurse failed to use the appropriate treatment for pressure ulcer stage II open wound for one patient (P) (P#2) of 18 sampled patients. Findings include: Review of the undated document titled “Dressing Change (Sterile, Non-sterile),” Policy No.: TX-172 reveals the following: Policy Statement It will be the policy of (facility) Home Health Services Inc. to evaluate the condition of a patient’s wound (s) and perform/tech wound care in accordance with the physician’s orders. NOTE: 3. Unless otherwise ordered by the physician, measurement of all wounds is to be performed and documented weekly. A. RN, LPN, PT will: 1. Obtain physician’s order for specific dressing change and order to teach patient/caregiver as appropriate. Document needed supplies on Plan of Care (485) or Physician’s Order. Patient #2 was admitted to home health agency on 3/5/2023, by Registered Nurse (RN) BB with diagnosis of type 2 diabetes (when pancreas does not produce enough insulin, it may cause poor wound healing). Review of the Physician’s order in Plan of Care revealed: Skilled Nurse (SN) to assess and perform/teach pressure ulcer to sacral pressure wound as follows: Cleanse with soap and water or wound cleanser, apply barrier cream and cover with padded foam dressing. Using clean aseptic technique. Change dressing every other day and prn (as needed). May be performed by PT/CG when taught or SN PRN (as needed). May discontinue wound care when healed. Review of document “Visit Note”, admission assessment dated 3/5/23 revealed 3x1x0.1 sacral pressure ulcer stage II, exudate (fluid released)-serosang (a type of wound drainage, or exudate, secreted by an open wound in response to tissue damage) with wound care documented by RN CC as follows: “cleansed with wound cleanser, applied barrier cream and covered with padded foam dressing…”. Review of the “Visit Note Report, Resumption of Care” dated 4/14/2023 revealed RN AA assessed and performed/taught wound as follows: “cleansed with wound cleanser, applied barrier cream and covered with padded foam dressing using clean/aseptic technique.” On 3/12/2024 at 11:45 a.m., an interview was conducted with RN AA, who said she knows better that barrier cream is inappropriate order treatment for sacral open wound pressure ulcer stage II with serosanguineous drainage. On 3/12/2024 at 12:00 p.m., an interview was conducted with RN BB who stated that she could not recollect the P#2, and she did not know the reason why she used barrier cream for sacral open wound pressure ulcer stage 2 with serosanguineous drainage. On 3/12/2024 at 12:00 p.m., an interview was conducted with the Administrator, who said that two of the skilled nurses that visits P#2 and continued to use inappropriate treatment to sacral open wound pressure ulcer stage II with serosanguineous drainage had resigned and were no longer working with the company. The Administrator also confirmed that the home health agency staff including the OASIS nurse, failed to follow the company policies and regulations for wound care treatment.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on staff interview, and review of agency policy, it was determined the agency failed to follow the plan of care and document the teaching related to long term use of aspirin as ordered for one patient (P) (P#9) and to use the appropriate treatment for pressure ulcer stage II open wound for one patient (P#2) of 18 sampled patients. Findings include: Review of document titled “Therapeutic Anticoagulation,” Policy No: TX-177, revised 10/20, 2/22, reveals the following: Policy Statement It will be the policy of (facility), Home Health Services Inc. to manage patients on therapeutic anticoagulation including prescribing, dispensing, administering, monitoring, and educating. Definition of Terms. Therapeutic anticoagulation- An anticoagulation is a substance that prevents coagulation; that is, stops blood from clotting. Procedure: C. Educating 1. Patient/family education will be provided for the specific anticoagulant prescribed and will include: b. Medication action and possible side effects. c. Potential drug-drug and drug-food interactions. d. Importance of compliance. Review of the undated document titled “Dressing Change (Sterile, Non-sterile),” Policy No.: TX-172 reveals the following: Policy Statement It will be the policy of (facility) Home Health Services Inc. to evaluate the condition of a patient’s wound (s) and perform/tech wound care in accordance with the physician’s orders. NOTE: 3. Unless otherwise ordered by the physician, measurement of all wounds is to be performed and documented weekly. A. RN, LPN, PT will: 1. Obtain physician’s order for specific dressing change and order to teach patient/caregiver as appropriate. Document needed supplies on Plan of Care (485) or Physician’s Order. 1. Review of the plan of care (POC) for P#9 (certification period of 2/15/24 to 4/14/24) revealed P#9 was admitted on 2/15/2024 with a diagnosis of coronary artery disease (buildup of plaque that causes arteries to narrow limiting blood flow in the heart), and longtime use of aspirin, (antiplatelet blood thinner). Skilled Nurse (SN) to assess and instruct patient/caregiver on precautions to monitor and document long term use of aspirin complication. Plan of care for P#9 failed to reveal documentation by Registered Nurse (RN) CC of teaching or monitoring of long-term use of aspirin complications such as bruising or bleeding. 2. Patient #2 was admitted to home health agency on 3/5/2023, by RN BB with a diagnosis of type 2 diabetes (when pancreas does not produce enough insulin, it may cause poor wound healing). Review of the Physician’s order in Plan of Care revealed: Skilled Nurse (SN) to assess and perform/teach pressure ulcer to sacral pressure wound as follows: Cleanse with soap and water or wound cleanser, apply barrier cream and cover with padded foam dressing. Using clean aseptic technique. Change dressing every other day and prn (as needed). May be performed by PT/CG when taught or SN PRN (as needed). May discontinue wound care when healed. Review of document “Visit Note”, admission assessment dated 3/5/23 revealed 3x1x0.1 sacral pressure ulcer stage II, exudate (fluid released)-serosang (a type of wound drainage, or exudate, secreted by an open wound in response to tissue damage) with wound care documented by RN CC as follows: “cleansed with wound cleanser, applied barrier cream and covered with padded foam dressing…”. Review of the “Visit Note Report, Resumption of Care” dated 4/14/2023 revealed RN AA assessed and performed/taught wound as follows: “cleansed with wound cleanser, applied barrier cream and covered with padded foam dressing using clean/aseptic technique.”

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on clinical record reviews, staff interviews, and review of agency policy, it was determined the agency failed to follow the plan of care and document the teaching related to long term use of aspirin as ordered for one Patient (P) (P#9) of 18 sampled patients. The findings include: Review of document titled “Therapeutic Anticoagulation,” Policy No: TX-177, revised 10/20, 2/22, reveals the following: Policy Statement It will be the policy of (facility), Home Health Services Inc. to manage patients on therapeutic anticoagulation including prescribing, dispensing, administering, monitoring, and educating. Definition of Terms. Therapeutic anticoagulation- An anticoagulation is a substance that prevents coagulation; that is, stops blood from clotting. Procedure: C. Educating 1. Patient/family education will be provided for the specific anticoagulant prescribed and will include: b. Medication action and possible side effects. c. Potential drug-drug and drug-food interactions. d. Importance of compliance. Review of the plan of care (POC) for P#9 (certification period of 2/15/24 to 4/14/24) revealed P#9 was admitted on 2/15/2024 with a diagnosis of coronary artery disease (buildup of plaque that causes arteries to narrow limiting blood flow in the heart), and longtime use of aspirin, (antiplatelet blood thinner). Skilled Nurse (SN) to assess and instruct patient/caregiver on precautions to monitor and document long term use of aspirin complication. Plan of care for P#9 failed to reveal documentation of the teaching or monitoring of long-term use of aspirin complications such as bruises or bleeding by Registered Nurse (RN) CC. On 3/12/2024 at 4:02 p.m., an interview conducted with RN CC, revealed that she was not aware that she must document the teaching of aspirin complication bleeding or bruises in the nurses’ notes. On 3/12/2024 at 4:20 p.m., an interview was conducted with the Administrator who said revealed that the nurses were in-serviced on the side effects and complication of long term use of antiplatelet medications such as monitoring for bruises or bleeding.

At the time of the survey, St. Joseph's/Candler Home Healthcare in Savannah Ga. was in compliance with 42 CFR Part 484.22 Emergency Preparedness for Home Health Agencies as a result of a standard recertification survey conducted on March 31, 2021. A Focus Infection Control Survey was completed at the time of the survey. No deficiencies were cited.

At the time of the Recertification survey, St Joseph's/Candler Home Healthcare in Savannah, Georgia was in substantial compliance with 42 CFR Part 484, Requirements for Home Health Agencies as a result of the survey conducted on March 31, 2021. A Focus Infection Control Survey was completed at the time of the survey. Current census 144. The follow deficiencies were cited.

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 reviews and staff interviews, it was determined the agency failed to ensure the patients' individualized plan of care/treatments included all of the required elements to address the identified needs for 4 of 17 (#11, #14, #15 and #16). Findings were: 1. Review of the plan of care/treatment for P #14 with a certification period of 8/9/20 to 10/7/20 (discharge record) revealed the patient has a pertinent diagnosis of diabetes mellitus type 2. The skilled nurse (SN) was required to provide instruction of diabetic home management to include: diet, skin care, administration of insulin and blood glucose testing, and diabetic foot care however, the plan of care/treatment lacked orders for the frequency of blood glucose monitoring to instruct the patient/caregiver on how often to monitor blood glucose levels to identify early complications. The agency failed to ensure that the plan of care/treatment covered all pertinent interventions for the comprehensive care of the patient's diabetic status. During an interview on 3/31/21 at 1:00 p.m., the Clinical manager (CM) confirmed the plan of care/treatment lacked a blood glucose monitoring frequency and stated the clinicians are providing education during each visit to instruct the patient on how often to monitor blood glucose levels. The Quality Assurance Nurse also stated the frequencies were left off the plan of care/treatment due to a new charting system and reports the clinicians will be educated on the need to manually insert frequencies to ensure the plan of care/treatment is complete. 2. Review of the plan of care/treatment for P#15 with a certification period of 5/13/20 to 7/11/20 (discharge record) revealed the patient has a pertinent diagnosis of diabetes mellitus type 2 and currently uses insulin therapy to control diabetes. The skilled nurse (SN) was required to provide instruction of diabetic home management to include: diet, skin care, administration of insulin and blood glucose testing, and diabetic foot care however, the plan of care/treatment lacked orders for the frequency of blood glucose monitoring to instruct the patient/caregiver on how often to monitor blood glucose levels to identify early complications. The agency failed to ensure that the plan of care/treatment covered all pertinent interventions for the comprehensive care of the patient's diabetic status. During an interview on 3/31/21 at 1:00 p.m., the CM confirmed the plan of care/treatment lacked a blood glucose monitoring frequency and stated the clinicians are providing education during each visit to instruct the patient on how often to monitor blood glucose levels. The Quality Assurance Nurse also stated the frequencies were left off the plan of care/treatment due to a new charting system and reports the clinicians will be educated on the need to manually insert frequencies to ensure the plan of care/treatment is complete. 3. Review of the plan of care/treatment for P#11 with a certification period of 2/21/21 to 4/21/21 revealed the patient has a pertinent diagnosis of diabetes mellitus type 2 and currently uses insulin therapy to control diabetes. The skilled nurse (SN) was required to provide instruction of diabetic home management to include: diet, skin care, administration of insulin and blood glucose testing, and diabetic foot care however, the plan of care/treatment lacked orders for the frequency of blood glucose monitoring to instruct the patient/caregiver on how often to monitor blood glucose levels to identify early complications. The agency failed to ensure that the plan of care/treatment covered all pertinent interventions for the comprehensive care of the patient's diabetic status. During an interview on 3/31/21 at 1:00 p.m., the Clinical manager confirmed the plan of care/treatment lacked a blood glucose monitoring frequency and stated the clinicians are providing education during each visit to instruct the patient on how often to monitor blood glucose levels. The Quality Assurance Nurse also stated the frequencies were left off the plan of care/treatment due to a new charting system and reports the clinicians will be educated on the need to manually insert frequencies to ensure the plan of care/treatment is complete. 4. Review of the plan of care/treatment for P#16 with a certification period of 8/19/20 to 10/17/20 (discharge record) revealed the patient has a pertinent diagnosis of diabetes mellitus type 2 and currently uses insulin therapy to control diabetes. The skilled nurse (SN) was required to provide instruction of diabetic home management to include: diet, skin care, administration of insulin and blood glucose testing, and diabetic foot care however, the plan of care/treatment lacked orders for the frequency of blood glucose monitoring to instruct the patient/caregiver on how often to monitor blood glucose levels to identify early complications. The agency failed to ensure that the plan of care/treatment covered all pertinent interventions for the comprehensive care of the patient's diabetic status. During an interview on 3/31/21 at 1:00 p.m., the Clinical manager confirmed the plan of care/treatment lacked a blood glucose monitoring frequency and stated the clinicians are providing education during each visit to instruct the patient on how often to monitor blood glucose levels. The Quality Assurance Nurse also stated the frequencies were left off the plan of care/treatment due to a new charting system and reports the clinicians will be educated on the need to manually insert frequencies to ensure the plan of care/treatment is complete.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on clinical record reviews and staff interviews, it was determined the agency failed to ensure the plans of care which contains verbal orders were reviewed and signed by the physician within the required 30 day time frame for 3 of 17 (#2, #5 and #17) sampled patients. Findings were: 1. Review of the plan of care/treatment for P #2 with a recertification period of 2/28/21 to 4/18/21 revealed the physician has not reviewed, signed, and approved the plan of care as of the record review date, 3/31/21. The agency failed to obtain the physician's signature on verbal orders within the 30 day timeframe as required. During an interview on 3/31/21 at 1:30 p.m., the Administrator acknowledged the plan of care/treatment was not counter-signed by the physician within 30 days of receipt of orders. The Adminstrator states the agency has a process in place in an attempt to get orders signed timely which includes resending orders to the physician every 10 days for signature. If unsuccessful, the agency liaison will go to the physcian's office to obtain the signatures. 2. Review of the plan of care/treatment for P#5 with a recertification period of 2/18/21 to 4/18/21 revealed the physician has not reviewed, signed, and approved the plan of care as of the record review date, 3/31/21. The agency failed to obtain the physician's signature on verbal orders within the 30 day timeframe as required. During an interview on 3/31/21 at 1:30 p.m. p.m., the Administrator acknowledged the plan of care/treatment was not counter-signed by the physician within 30 days of receipt of orders. The Adminstrator states the agency has a process in place in an attempt to get orders signed timely which includes resending orders to the physician every 10 days for signature. If unsuccessful, the agency liaison will go to the physcian's office to obtain the signatures. 3. Review of the plan of care/treatment for P #17 with a certification period of 8/12/20 to 10/10/20 ( discharge record) revealed the physician has not reviewed, signed, and approved the plan of care as of the record review date, 3/31/21. The agency failed to obtain the physician's signature on verbal orders within the 30 day timeframe as required. During an interview on 3/31/21 at 1:30 p.m. p.m., the Administrator acknowledged the plan of care/treatment was not counter-signed by the physician within 30 days of receipt of orders. The Adminstrator states the agency has a process in place in an attempt to get orders signed timely which includes resending orders to the physician every 10 days for signature. If unsuccessful, the agency liaison will go to the physcian's office to obtain the signatures.