Every finding on record at Southeast Health Center of Stoddard County, LLC

The Emergency Preparedness regulations were reviewed as part of the Medicare certification survey completed on 07/22/2021. During the survey it was determined Southeast Home Health of Dexter 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 certification for Southeast Home Health of Dexter was completed on 07/22/2021. The agency had 34 current patients. A COVID-19 Focused Infection Control Survey was completed in conjunction with the survey. No deficiencies were identified related to the Focused Infection Control Survey.

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on review of the agency's current patient rights information, home visit observation, and interview, the agency failed to update the written notice of patient rights to meet the requirements of the Federal home health regulations to include the name, address and phone number of the current Quality Improvement Organization (QIO) that serves the area where the patient resides in two (Patient/Record #2 and #3) of three home visit observations. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the current patient rights information failed to include the current QIO organization. The agency listed TMF Health Quality Institute as the current QIO organization for their area. The current QIO is Livanta LLC. RECORD/PATIENT #2: Review of the patient rights information in the agency folder during a home visit observation on 07/21/2021 at 09:30 AM showed TMF Health Quality Institute as the QIO. RECORD/PATIENT #3: Review of the patient rights information in the agency folder during a home visit observation on 07/20/2021 beginning at 1:00 PM showed TMF Health Quality Institute as the QIO. During an interview on 07/19/2021 at 3:45 PM, the administrator stated that he/she was not aware this had changed.

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, record review, home visit observation, and interview the agency failed to ensure an accurate medication reconciliation was performed in, but not limited to, three (Record(s)/Patient(s) #1, #2, and #4) of five records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Home Health: Drug Profile," revised 08/15/2019, showed in part: - Upon admission to home care the registered nurse (RN) will review all medications that the patient is currently taking including over the counter, prescription, and herbal supplements; - This will be compared to the most recent medication list from the referring agency; and - Medication discrepancies found will need to be called to the patient's physician for clarification and a note will need to be placed in the patient's electronic medication record of this call and any new order. RECORD/PATIENT #1: During a home visit observation on 07/20/2021 at 10:00 AM a medication review showed: - The agency medication profile (AMP) showed the patient taking furosemide (a pill used to remove excess fluid from the body) 40 milligram (mg) tablet, take one tablet daily, and the patient's medication in the home showed the patient taking 20 mg daily since 06/22/2021; - The AMP showed the patient taking guaifenesin extended release 600 mg tablets two times daily, and the patient reported that he/she has not taken the medication for several months; and - The AMP showed the patient taking metoprolol succinate extended release 50 mg tablets, two tablets in the morning, and one tablet in the evening, the patient reported that he/she takes one tablet two times per day. RECORD/PATIENT #2: During a home visit observation on 07/21/2021 at 09:30 AM a medication review showed: - The agency medication profile (AMP) showed the patient taking benzonatate (a medication used to suppress cough) 200 mg capsule, one to two capsules every six hours, and the prescription bottle in the home dated 04/14/2021 showed the medication was to be taken every six hours as needed for cough; and - The AMP showed the patient taking Tylenol Extra strength 500 mg tablets, 2 tablets every six hours, the patient reports that he/she is taking the medication as needed for pain. RECORD/PATIENT #4: Review of the hospital discharge medication list dated 06/25/2021 showed the following discrepancies with the agency medication profile: -The hospital list showed calcium-cholecalciferol (supplement) 500 milligrams (mg) -200 units one tablet two times a day. The agency medication profile showed calcium 500 + D -200 units one tablet daily; -The hospital list showed oxycodone (narcotic pain medication) five mg every four hours. The agency medication profile showed oxycodone one tablet daily as needed for pain; -The hospital list showed polyethylene glycol (laxative) 17 grams one packet two times daily. The agency medication profile showed polyethylene glycol 17 grams daily; and -The hospital list showed acetaminophen (Tylenol) 325 mg two tablets every six hours as needed for pain. The agency medication profile showed acetaminophen 325 mg one capsule every six hours as needed for pain. Review of the registered nurse (RN) admission assessment dated 06/27/2021 showed no documentation that the medication discrepancies were clarified with the physician. During an interview on 07/21/2021 at 9:40 AM RN A stated that they compare the medication bottles in the home with the discharge medication list. If anything was not correct, they contact the physician. He/she thought the oxycodone order had been put in incorrectly. During an interview on 07/21/2021 at 1:40 PM, the administrator stated that the nurse compares the discharge medication list with the medication bottles in the home. If there were discrepancies they would call the physician to clarify the order.

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, record review, and interview, the agency failed to ensure the plan of care (POC) included complete wound care orders for one (Record/Patient #4) of five records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Plan of Care/Reassessment," dated 08/15/2019, showed in part: - Each patient will receive an individualized written POC, including revisions or additions; and - The individualized POC must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment. RECORD/PATIENT #4: Review of the comprehensive assessment dated 06/27/2021 showed the patient had two abdominal wounds. The nurse provided wound care which consisted of cleansing with normal saline (a salt solution), apply Santyl (an ointment that helps remove dead tissue from wounds) nickel thick to the edges of the wound bed where slough (dead tissue) is present, apply saline moistened kerlex (gauze) to the wound bed, cover with an ABD (large absorbent pad) and secure with tape. Review of the POC dated 06/27/2021 showed the wound care order failed to include to apply Santyl to the edges of the wound bed where slough is present. During an interview on 07/21/2021 at 9:40 AM, registered nurse (RN) A stated that the Santyl order should have been on the POC. During an interview on 07/21/2021 at 1:45 PM, the administrator stated that the Santyl order should be on the POC.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on policy review, home visit observation, patient home folder review, and interview, the agency failed to provide the patient and/or caregiver a copy of written instructions outlining the visit schedule, including frequency of visits by agency personnel in one (Record/Patient #3) of three home visits conducted. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Home Health Visit Schedules," revised 08/15/2019, showed in part: - Upon admission each ordered discipline will determine the patient's visits schedule based on the needs and input of the patient; - A calendar will be complete in the electronic medical record establishing the days that each discipline will be making visits; and - A paper calendar will also be completed in the patient's home with each disciplines' visit schedule. RECORD/PATIENT #3: Per interview conducted during a home visit observation with the physical therapist (PT) on 07/20/2021 beginning at 1:00 PM showed: - A review of the information in the patient's home folder showed a blank calendar with no written instructions outlining the visit schedule; - The PT stated that they tell the patients when they are coming. They call the patients on Monday and set up the plan for the week; and - The caregiver stated that he/she did not have a calendar of visits. Normally they just called to let him/her know when they are coming. During an interview on 07/21/2021 at 1:35 PM the administrator stated that on the day of the first visit they tell the patient when they will be there. Staff are supposed to put the frequency on the patient's calendar.

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 agency policy, clinical record review, and interview, the agency failed to provide services that were ordered by the physician as indicated in the plan of care in three (Records/Patients #1, #2 and #5) of five full records reviewed. This deficient practice has the potential to affect the provision of care to all patients served by the agency. Findings included: Review of agency policy dated 08/15/2018 and titled, "Home Health Visit Schedules," showed that in the event that a visit cannot be rescheduled, the visit is missed. When the determination is made the visit needs to be missed, the clinician missing the visit will complete a missed visit note in the electronic medical record (EMR). The clinician missing the visit is responsible for ensuring the patient's physician is notified of the missed visit by auto faxing the missed visit note from the EMR. The clinician will make a note on the missed visit note stating it was faxed. Review of agency policy dated 08/15/2018 and titled, "Home Health: Pain Documentation," showed that: - Pain is assessed at start of care and with each visit to ensure that pain is being managed and that patient's reported pain goal is being observed; and - At the start of care nursing will interview the patient in regards to pain that is current or has occurred in the last 24 hours. During this interview the patient will be asked about their pain rating using the numeric 1-10 scale, Wong-Baker facial scale or NIPS scale for pediatric patients. The rating will be for current pain, the least/best amount of pain and the worst pain in the last 24 hours. The interview will also include what makes the pain better and what makes the pain worse, what pharmacological and non-pharmacological methods to relieve pain has been used, how they worked and how often they are being used. Patient's pain goal will be recorded in the medical record to ensure that each staff member sees the goal at the start of each visit. Patient's pain that is not controlled to meet the patient's goal will be reported to the patient's primary nurse and the patient's physician will be notified regarding this information. Every step possible, within the agency's control will be taken to make sure that the patients admitted to home health will have pain control within acceptable levels for the patient. PATIENT/RECORD #1: Review of the clinical record showed the patient was admitted to home health services on 05/25/2021 with a primary diagnosis of congestive heart failure (a syndrome in which the heart is unable to sufficiently pump enough blood to supply the body's metabolic needs), and secondary diagnosis of pleural effusion (a build up of fluid in the sack surrounding the lungs). Review of the nursing visit schedule showed: - The visit frequency for the week of 06/13/2021 was four times per week, only two nursing visits were performed, and the clinical record failed to contain physician notification of the missed visits; - The visit frequency for the week of 06/20/2021 was three times per week, only two nursing visits were performed, and the clinical record failed to contain physician notification of the missed visits; and - The visit frequency for the week of 06/27/2021 was four times per week, only three nursing visits were performed, and the clinical record failed to contain physician notification of the missed visits. During an interview on 07/21/2021 at 2:15 PM the administrator stated that there should have been missed visit notes written for the missed visits the weeks of 06/14/2021, 06/20/2021, and 06/27/2021. PATIENT/RECORD #2: Review of the clinical record showed the patient was admitted to home health services on 05/29/2021 with a primary diagnosis of a cutaneous abscess of left lower limb (a localized collection of pus in the skin) and cellulitis of left lower limb (an infection of the skin). Review of the plan of care dated 05/29/2021 showed that the skilled nurse was to observe and assess pain, effectiveness of pain management, and provide skilled teaching related to pain management. Review of the comprehensive nursing assessment performed 05/29/2021 showed the patient had pain, "daily but not constantly,"there was no additional documentation of a pain assessment. Review of the physical therapy visit schedule showed: - The visit frequency for the week of 06/08/2021 was three times per week, only one physical therapy visit was performed, and the clinical record failed to contain physician notification of the missed visits; - the visit frequency for the week of 06/20/2021 was two times per week, there were no physical therapy visits performed, and the clinical record failed to contain physician notification of the missed visits. During an interview on 07/21/2021 at 1:30 PM the administrator stated that there should have been a missed visit note for the physical therapy missed visits. RECORD/PATIENT #5: Review of clinical record showed that the patient was admitted to home health services on 05/13/2021 with a primary diagnosis of cutaneous abscess of the right foot (a localized collection of pus in the skin, and a secondary diagnoses of type 2 diabetes (a disease in which the way to body regulates and uses sugar for fuel is impaired) with polyneuropathy (a condition in which the peripheral nerves are damaged). Review of the plan of care dated 05/13/2021 showed the nurse was to assess pain, effectiveness of pain management regimen, teaching of pain management. Review of the comprehensive nursing assessment performed 05/13/2021 showed that the, "current pain medication regimen controls pain adequately at this time," and failed to contain further information about the patient's pain and pain regimen.

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 policy review, and interview, the agency failed to designate an alternate administrator in writing to act in the absence of the administrator. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Home Care - Absence of the Administrator/Chain of Command," revised 07/20/2020 and approved by the quality committee 08/19/2020, showed in part: - In the absence of the administrator of home health, the clinical staff will be informed who will be in charge of day to day operations; - 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 approval on this policy and minutes from the governing body serves as this authorization; - The administrator or a pre-designated person is available during all operating hours; - Home health staff should utilize the chain of command to make the appropriate leadership decisions when the administrator is absent; - 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 a clinical registered nurse (RN). In the absence of the home health administrator, the clinical RN shall direct any administrative concerns to the CNO (chief nursing officer). The approval on this policy and minutes from the governing body serves as this authorization. During an interview on 07/19/2021 at 3:10 PM, the administrator stated that he/she was the administrator and clinical manager. There was not someone specifically named as the alternate administrator. They had three RN's who knew how to do the scheduling and assignment of visits. The CNO was available if the RN's needed anything. During an interview on 07/21/2021 at 10:05 AM, RN A stated that the administrator would designate someone to be in charge if he/she were gone. He/she usually covered for the administrator if he/she had to be gone. The nurses would report any concerns to the director of nursing at the hospital. All the nurses were able to put in the referrals and keep the schedule and assignments going.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on policy review, review of Federal and State law, agency admission packet review, home visit observation, and interview, the agency failed to ensure patients and/or representatives were provided written information regarding the Missouri case law "The Cruzan Case" in, but not limited to, two (Record/Patient #2 and #3) of three home visit observations. Based on review of Section 192.2490.12 RSMo, and Section 192.2495.6 and 7, RSMo, personnel file review, and interview, the agency failed to request and obtain results of findings of the the Family Care Safety Registry (FCSR) prior to patient contact for one (Employee #1) of three personnel files. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Home Care - Advance Directives," dated 08/15/2019, showed in part individuals have the right to make decisions concerning their care, including the right to formulate advance directives as permitted under state statutory and case law. Review of the agency policy titled, "Family Care Safety Registry,", dated 04/20/2021, showed in part: - Those required to register include employees of a home health agency licensed by the Department of Health and Senior Services; and - Prior to hire, the new hire will complete the worker registration form. Results must be completed and received prior to the start date. Review of Section 192.2490.12 RSMo: "No person, corporation, organization, or association who received the employee disqualification list under subdivisions (1) to (7) of subsection 11 of this section shall knowingly employ any person who is on the employee disqualification list." Section 192.2495 RSMo, requires employees of licensed home health agencies under contract with the Missouri Department of Health and Senior Services, to register with the Family Care Safety Registry regardless of hire date. This section also requires home health agencies to conduct criminal background screenings by checking the Family Care Safety Registry. Review of Section 192.2495.6, RSMo: "A provider is guilty of a class A misdemeanor if the provider knowingly hires or retains a person to have contact with patients or residents and the person has been found guilty in this state or any other state or has been found guilty of a crime, which if committed in Missouri would be a class A or B felony violation of chapter 565, 566 or 569, or any violation of subsection 3 of section 198.070 or section 568.020." Review of Section 192.2495.7, RSMo (effective August 28, 2018): "Any in-home services provider agency or home health agency shall be guilty of a class A misdemeanor if such agency knowingly employs a person to provide in-home services or home health services to any in-home services client or home health patient and such person either refuses to register with the family care safety registry or if such person: (1) Has any of the disqualifying factors listed in subsection 6 of this section; (2) Has been found guilty of or pleaded guilty or nolo contendere to any felony offense under chapter 195 or 579; (3) Has been found guilty of or pleaded guilty or nolo contendere to any felony offense under section 568.045, 568.050, 568.060, 568.175, 570.023, 570.025, 570.030, 570.040 as it existed prior to January 1, 2017, 570.090, 570.145, 570.223, 575.230, or 576.080; (4) Has been found guilty of or pleaded guilty or nolo contendere to a violation of section 577.010 or 577.012 and who is alleged and found by the court to be an aggravated or chronic offender under section 577.023; (5) Has been found guilty of or pleaded guilty or nolo contendere to any offense requiring registration under section 589.400; (6) Is listed on the department of health and senior services employee disqualification list under section 192.2490; (7) Is listed on the department of mental health employee disqualification registry under section 630.170; or (8) Has a finding on the child abuse and neglect registry under sections 210.109 to 210.183." The agency failed to provide the patient with information regarding applicable Missouri case law as set forth in Cruzan v. Director, Mo. Dept. of Health, 497 U.S. 261, 110 S.Ct. 2841, 111 L.Ed.2d 224 (1990). This case identified that advance directives that do not meet the formal requirements of either a living will or durable power of attorney for health care can be established by "clear and convincing evidence" of the patient's wishes as to the withdrawal of life-sustaining treatment. Review of the agency's admission packet on 07/19/2021 failed to contain information regarding applicable Missouri case law as set forth in Cruzan v. Director, Mo. Dept. of Health. RECORD/PATIENT #2: Observation and interview during the patient's home visit, 07/21/2021 at 09:30 AM, showed the patient's admission packet from the agency failed to include information regarding the Missouri state law "The Cruzan Case." RECORD/PATIENT #3: Observation and interview during the patient's home visit, on 07/20/2021 beginning at 1:00 PM, showed the patient's admission packet from the agency failed to include information regarding the Missouri state law "The Cruzan Case." During an interview on 07/21/2021 at 10:20 AM, the administrator provided information regarding Missouri case law. He/she did not know why the information was not in the admission packets. EMPLOYEE #1 (E1): Review of E1's personnel file showed: - Date of hire 11/12/2018; - Date of first patient contact 11/27/2018; and - No FCSR results. During an interview on 07/21/2021 at 10:25 AM, the administrator stated that the FCSR results had not been obtained but he/she was obtaining it today.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to ensure a completed transfer summary was sent within two business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the agency became aware of the transfer in one (Record/Patient #7) of two discharge/transfer records reviewed. This deficient practice has the potential to affect the continuity of care of all patients served by the agency. Findings included: Review of the agency policy titled, "Home Health Discharge/Transfer," revised 08/15/2019, showed in part: - An episode summary report will be sent to the IP (in patient) facility where the patient has been admitted, and should include advanced directive information, diagnosis, allergies, current medication list, vital sign statistics, client orders in the last 30 days, plan of care, client disposition, plans and a discharge summary when applicable. RECORD/PATIENT #7: Review of a visit note report dated 04/15/2021 showed the patient was transferred to an inpatient facility and was not discharged from the agency. Review of the record showed no evidence of a transfer summary being sent to the inpatient facility. During an interview on 07/21/2021 at 3:55 PM, the administrator stated that the patient lived at an assisted living facility (ALF). The ALF did not notify them the patient was in the hospital. By the time they found out the patient was in the hospital, the nurse at the ALF had already sent information to the hospital. The agency did not send a transfer summary to the hospital. The nurse thought that since the ALF had already sent information they did not send one. The nurse should have sent a transfer summary to the hospital.