Every finding on record at Sky Lakes Home Health

An unannounced Federal recertification survey was completed at this agency on 5/24/2022. The agency was surveyed for compliance with 42 CFR Conditions of Participation for Home Health Agencies, Part 484. An entrance conference was held with the Nursing Clinical Manager on 5/16/2022 at 1:52 PM. The purpose of the survey and the survey needs were explained. An opportunity was provided for questions, answers and comments. Definitions and abbreviations: appt - appointment CFR - Code of Federal Regulations Epic - shared health care electronic medical record system gm - gram HCA - home care aide HH - home health MCG/ACT - microgram/actuation, used to describe inhaler dosage MD - doctor of medicine MG or mg - milligram min - minute OT - occupational therapy PT - physical therapy pt - patient rcvd - received schd - schedule SLMC - Sky Lakes Medical Center SLPCC - Sky Lakes Primary Care Clinic SN - skilled nursing SOC - start of care suprapubic catheter - flexible catheter inserted directly into the bladder through a surgical opening in the abdomen tab - tablet TC - telephone call

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct 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. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on clinical record review and interview, it was determined the agency failed to ensure the registered nurse or applicable rehabilitation skilled professional performed an initial assessment to determine the immediate care and support needs of the patient within 48 hours of referral, or within 48 hours of the patient's return home, for 3 of 7 active patient records reviewed (Patients #1, 2 and 5). Findings include: Patient #1: Review of information in the "Notes" tab of the electronic medical record for Patient #1 revealed the statement "3/23/2022 Rcvd Epic referral from SLMC for HH Services: SN, PT, OT, HCA, ordered by [MD name]." The following statement revealed "3/29/22 TC to patient to discuss HH services..." The entries indicated the referral was received 3/23/2022 and contact with the patient was not made until 3/29/2022; 6 days later. During interview with Employee #1 and Employee #2 on 5/18/2022 beginning at 10:00 AM, Employee #2 indicated Patient #1 was discharged from the hospital on 3/26/2022. The additional information indicated Patient #1 returned home 3/26/2022 and contact with the patient was not made until 3/29/2022; 3 days later. Employees #1 and #2 acknowledged the findings that an initial assessment was still not performed within 48 hours of the patient's return home and stated "We agree." Patient #2: Review of information in the "Notes" tab of the electronic medical record for Patient #2 revealed the statement "12/27/2021 Rcvd Epic referral from SLPCC for HH Services: SN..." The following statement revealed "12/30/21 TC to patients [sic] [family member] to discuss HH services, pt agreed and HH will call back with a scheduled date..." The next statement revealed "1/3/2022 TC to pt to schd HH SOC appt." The entries indicated the referral was received 12/27/2021 and contact with the patient was not made until 12/30/2021; 3 days later. Additionally, contact 12/30/2021 indicated the patient would be called back to schedule the date of the initial assessment. The patient was contacted on 1/3/2022 to schedule start of care; 7 days after the referral was received. During interview with Employee #2 on 5/18/2022 beginning at 11:18 AM the above findings were presented. Employee #2 acknowledged the findings and stated "Yes, it was delayed." Patient #5: Review of information in the "Notes" tab of the electronic medical record for Patient #5 revealed the statement "3/22/2022 Rcvd Epic referral from SLPCC for HH Services: PT, OT..." A subsequent entry revealed "4/4/2022 TC to pt to inform HH PT is out 10 weeks. Pt asked HH to call [his/her] [family member]. TC to [family member] and stated [he/she] would like to wait for an open appt with HH." The entries indicated the referral was received on 3/22/2022 and contact with the patient was not made until 4/4/2022; 13 days later. During interview with Employee #2 on 5/18/2022 beginning at 11:18 AM Employee #2 acknowledged the finding and stated "Yeah, that was a delay."

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 interview, it was determined the agency failed to ensure the individualized plan of care included complete medication orders for 4 of 7 active patient clinical records reviewed (Patients #4-7). Findings include: Patient #4: Review of information in the "Medications" tab of the electronic medical record for Patient #4 revealed the order "Pyridium By Mouth Tablet 200 MG, 1 tab as needed, urinary pain relief." The order failed to include the frequency the medication could be taken. Patient #5: Review of information in the "Medications" tab of the electronic medical record for Patient #5 revealed the order "Calcium Carbonate Antacid By Mouth Tablet Chewable 500 MG, 1 tab as needed, heartburn." The order failed to include the frequency the medication could be taken. Further review of medication information for Patient #5 revealed the order "NitroQuick Sublingual Tablet Sublingual 0.4 MG, 1 tab as needed, 1 tab under the tongue every 5 min as needed for chest pain." The order failed to include the number of times the medication could be taken in 5 minute intervals. Patient #6: Review of information in the "Medications" tab of the electronic medical record for Patient #6 revealed the order "Albuterol Inhaler Aerosol Solution 90 MCG/ACT, 2 puffs as needed, rescue inhaler." The order failed to include the frequency the medication could be taken. Further review of medication information for Patient #6 revealed the order "Colace, 100 mg as needed, constipaton [sic]." The order failed to include the frequency the medication could be taken. Patient #7: Review of information in the "Medications" tab of the electronic medical record for Patient #7 revealed the order "Miralax By Mouth Powder, 17 gm as needed, constipation." The order failed to include the frequency the medication could be taken. During an interview via phone with Employee #1 on 5/23/2022 beginning at 2:00 PM the above findings were presented. Employee #1 acknowledged the findings and stated "Yeah, right, that makes sense."

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 observation of home visits, it was determined the agency failed to follow accepted standards of practice to prevent the transmission of infections for 1 of 4 home visits observed. Findings include: Observation of a home visit for Patient #4 revealed Employee #6 provided direct patient care including, but not limited to, checking vital signs and suprapubic catheter change. A paid caregiver of Patient #4 was also present during the visit and provided some assistance with supply retrieval. Throughout the visit, Employee #6 failed to perform hand hygiene between non-sterile glove changes. During the suprapubic catheter change, Employee #6 prepared the catheter insertion kit field, including opening the package of sterile gloves. During preparation, the patient's pet entered the field leading Employee #6 to question the sterility of the new catheter. Rather than asking the caregiver to retrieve a new catheter, Employee #6 left the room to enter a closet to obtain a new catheter, leaving the sterile gloves exposed. Failure to maintain sight of the sterile equipment is not accepted standard of practice and makes Employee #6 unable to verify that sterility was maintained. During interview with Employee #1 on 5/17/2022 at 2:28 PM the above findings were presented. Employee #1 acknowledged the findings and stated the findings provided "good opportunities for us to fine tune for sure."