Every finding on record at Southeast Missouri Hospital Association

The Emergency Preparedness regulations were reviewed as part of the Medicare certification survey completed on 12/16/2021. During the survey it was determined Southeast Home Health 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 was completed on 12/16/2021. The agency had 50 current patients. A COVID-19 Focused Infection Control Survey was completed in conjunction with the survey and 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 policy, current patient rights information, and interview, the agency failed to update the written notice of patient rights to ensure that the patient and representative (if any) were advised of the name, address, and telephone number of the Center for Independent Living that served the area where the patient resides. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: Review of the agency policy titled, “Home Care-Confidentiality and Patient’s Rights/Responsibilities,” last reviewed/revised 12/02/2021, showed the agency provides “care to persons in Cape Girardeau, Perry, Bollinger, Scott, portions of Stoddard, portions of Mississippi, and portions of New Madrid counties.” The administrator provided an admission packet titled, “Patient Education”, for review on 12/13/2021. The agency notice titled, “The Home Health Patient’s Bill of Rights and Responsibilities,” dated 09/2021, given to a patient during the initial visit showed the Delta Center for Independent Living listed was an entity in St. Peters, MO. During a telephone interview on 12/13/2021 at 2:05 PM, employee (ILC1) at the Delta Center for Independent Living in St. Peters, MO stated that their agency does not service the Cape Girardeau county area. ILC1 stated that the SEMO Alliance for Independent Living Inc. (SADI) and Bootheel Area Independent Living Services (BAILS) are the entities that serve the counties named in the agency’s policy. During an interview on 12/13/2021 at 2:40 PM, the administrator stated that he/she did not know why the Independent Living Center listed in their packet was in St. Peters, MO. He/she stated that the agency should list community services where the patients reside and the patient’s rights information should include local entities.

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, record review, home visit observation, and interview, the agency failed to assure that staff performed 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 (Record/Patient #2 and #3) of three home visit observations. This deficient practice has the potential to affect the medication reconciliation for all of the agency patients. Findings included: Review of the agency policy titled, “Home Care-Medication Documentation,” revised 09/27/21, showed that each patient will have all current medications listed under, "Medications," and updated when applicable. This will be completed/reviewed/updated by a home health registered nurse (HHRN) on admission, with any medication change, discontinuation or addition, on new plan of care with each certification, resumption of care, and upon the patient’s discharge. RECORD/PATIENT #2: An interview conducted during the patient’s home visit on 12/14/2021 beginning at 9:05 AM showed: - The nurse stated that he/she had updated the patient’s medication list yesterday; - The medication profile showed an order for amitriptyline 25 milligrams (mg) two tablets at bedtime for anxiety/sleep. The patient stated that he/she no longer took this. He/she only took it for one or two weeks after coming home from the hospital; - The patient used a Trelegy ellipta inhaler 100-62.5-25 AE (a steroid based medication used to reduce airway inflammation). Inhale one puff daily. The patient stated that he/she used this for COPD (chronic obstructive pulmonary disease) and had used it for about two years. This was not included on the medication profile; - The patient used albuterol sulfate (inhaler used to treat breathing problems) 90 micrograms (mcg) two puffs every six hours as needed. This was not included on the medication profile. The patient stated that he/she had used this as needed for about two years; - The patient took calcium 600 mg with vitamin D3 one tablet once a day for about five to eight years. This was not included on the medication profile; - The patient took vitamin D3 50 mcg one table once a day. This was not included on the medication profile. The patient stated that he/she had been taking this for about four years; - The patient took aspirin 81 mg one tablet once a day. This was not included on the medication profile. The patient stated that he/she has been taking this since coming home from the hospital; and - The patient took super B complex vitamin, one tablet once a day for about two weeks. This was not included on the medication profile. During an interview with the administrator and clinical manager on 12/14/2021 at 11:30 AM, the clinical manager stated that when they admit a patient the nurse compares the medication discharge list or most recent medication list from the physician with what the patient is taking in the home. If there are discrepancies, the nurse sends that information to the physician and obtains an order for what the patient should be taking. The nurses and therapists review the medications once a week. They have asked the staff to look at the bottles to compare with the medication list. RECORD/PATIENT #3: Observation during the patient’s home visit on 12/14/2021, beginning at 1:05 PM showed: - The medication profile showed an order for Ambien (used for sleep), one tablet at bedtime as needed. The patient stated that he/she quit taking this after coming home from the hospital. He/she stated that he/she told the nurse; - The medication profile showed an order for torsemide (used to decrease fluid retention), 20 mg one tablet daily. The patient stated that he/she currently took ten mg daily; and - The medication profile showed an order for Lantus insulin (a medication used to control blood sugar), 18 units at bedtime. The patient stated that the doctor changed this to take in the mornings a long time ago. The findings were reviewed with the administrator and clinical manager on 12/14/2021 at 4:25 PM. The clinical manager stated that the nurse was updating the medications at this time.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to ensure that all patient care orders, including verbal orders, were recorded in the plan of care in, but not limited to, one (Record/Patient #4) of six full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency’s policy titled, “Home Care-Plan of Care/Reassessment,” last revised 12/08/2021, showed that each patient or caregiver will receive an individualized plan of care including revisions or additions. RECORD/PATIENT #4: Review of the clinical record showed that the patient was admitted to the agency for wound care on 11/02/2021. The patient resided in his/her own home with his/her spouse. Review of orders from the referring entity, dated 11/01/2021, showed that: - The next dressing change was due on 11/04/2021; - Dressing/wound care orders for wounds on the right anterior (front) tibia, left lateral (side) heel, right forearm, right dorsal (back) medial (middle) hand, and right dorsal lateral hand were as follows: * Nurse/caregiver to apply Triad moisture barrier to protect intact skin around wound, apply Aquacel AG (a dressing used for wound healing) cut to fit to wound bed, cover with 4x4 gauze, wrap with Kerlix (a gauze bandage roll), and secure with paper tape. Nursing visit note dated 11/04/2021 showed, “Pt. (patient) noted to have small scratches present to right forearm that are scabbed over. Scratches left OTA (open to air).” The agency plan of care failed to contain orders to discontinue current treatments to the right forearm and right hand, and leave the wounds open to air. Review of a coordination note, dated 11/13/2021, showed a late entry dated 11/12/2021, stating that the patient's spouse had contacted HHRN (home health registered nurse), and informed nurse of a new skin eruption on the patients left leg. HHRN instructed spouse to follow current wound care orders for other wounds. The plan of care failed to contain orders for care of the new left leg wound. During an interview on 12/16/2021 at 9:25 AM, the clinical manager stated that they were unable to locate an order to leave the patients forearm/hand wounds open to air. The clinical manager showed confirmation that the physician was faxed notification of new wounds to left leg but was unable to produce an order for treatment of the left leg wound.

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, home visit observation, and interview, the agency failed to assure staff follow agency policy 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 for all of the agency patients. Findings included: Review of agency policy last reviewed 09/23/2021 and titled, "Home Care: Coronavirus Disease Response Management," showed that staff should place their nursing bag on a barrier such as a trash bag or newspaper in the home. Review of agency policy, last reviewed 12/02/2021 and titled, "Home Care - Infection Control Responsibilities," showed that vehicles have designated soiled areas (trunk or rear end of vehicle) and designated clean areas (front or back seat of the car). RECORD/PATIENT #2: Observation during the patient’s home visit on 12/14/2021 beginning at 9:05 AM showed: - The nurse lay his/her clipboard on the patient’s dresser without a barrier underneath. The nurse took the patient’s blood pressure and checked his/her oxygen saturation (oxygen level in the blood) then lay the blood pressure cuff and pulse oximeter (machine used to measure oxygen saturation) on the patient’s dresser without a barrier. The nurse failed to clean the clipboard then lay the clipboard in the floor board of his/her car. The nurse stated that he/she cleaned the clipboard at the end of the day. During an interview on 12/14/2021 at 4:20 PM with the administrator and clinical manager, the clinical manager stated that they had talked with the staff about placing barriers under everything.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to perform an ongoing interdisciplinary assessment of the patients in, but not limited to, two (Records/Patients #4 and #5) of six full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency’s policy titled, “Wound Care and Assessment,” last reviewed/revised 12/10/2021, showed: - Wounds should be measured one time per week or more often if the wound changes drastically; and - For all wound assessments, the nurses/therapist will document in the EMR (electronic medical record). Review of the agency’s policy titled, “Home Care-IV Infusion Documentation,” last reviewed/revised 09/27/2021, showed upper arm circumferences should be routinely measured and documented in the EMR at least one time per week on patients with PICC (peripherally inserted central catheter) lines. RECORD/PATIENT #4: Review of the clinical record showed that the patient was admitted to the agency for wound care on 11/02/2021. The patient resided in his/her own home with his/her spouse. Review of the Outcome and Assessment Information Set (OASIS) admission, dated 11/02/2021, showed that the wounds on the right tibia and left heel were covered by non-removable dressings that were due to be changed Thursday (11/04/2021). Review of nursing visit notes dated, 11/04/2021, 11/13/2021, 11/16/2021, 11/18/2021, and 11/23/2021 failed to contain wound measurements of the right tibia. On 11/30/2021 the wound on the right tibia was healed. Review of nursing visit notes dated, 11/04/2021, and 11/13/2021 failed to contain wound measurements for the left heel. On 11/16/2021, the left heel was healed. During an interview on 12/14/2021 at 4:25 PM, the administrator and clinical manager stated that they would expect weekly wound measurements to be taken per the agency’s policy. RECORD/PATIENT #5: Review of clinical record showed the patient was admitted on 11/09/2021 for intravenous (IV) antibiotics due to an infected heart valve prosthesis (an artificial heart valve that is surgically implanted into a person’s heart to replace a valve that is not functioning properly) and sepsis (an infection of the bloodstream). The initial nursing visit, dated 11/09/2021, the OASIS admission, dated 11/10/2021, and routine nursing visit, dated 11/16/2021, failed to contain arm circumference measurements above the PICC line in the right upper arm. During an interview on 12/14/2021 at 4:25 PM, the administrator and the clinical manager stated that they would expect staff to measure the patients arm circumference weekly.