Every finding on record at Spartanburg Medical Center

An onsite unannounced Emergency Preparedness Program (EPP) Survey was conducted at Spartanburg Regional Home Health from 08/28/2023 to 08/31/2023. Spartanburg Regional Home Health is in compliance with the Medicare Conditions at 42 CFR PART 484.102 (Establishment of the Emergency Program).

An onsite unannounced Recertification Survey was conducted at Spartanburg Regional Home Health from 08/28/2023 to 08/31/2023. Spartanburg Regional Home Health is in compliance with the Medicare Conditions at 42 CFR PART 484.

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 record reviews and interviews, the home health agency failed to ensure a Registered Nurse timely reconciled medications for 5 of 8 patients. (Patient #8, #9, #14, #16, and #17) Record review on 8/30/23 at 11:45 AM with the Director of Nursing revealed Patient #17 had a start of care date of 2/27/23. The Physical Therapist documented a medication reconciliation on 2/27/23, but there was no documentation in the record of a medication reconciliation by a nurse. Review on 8/30/23 at 1:30 PM revealed Patient #8 with a start of care date of 5/25/23. A medication reconciliation by the nurse had been documented on 7/4/23 for the patient. During an Interview on 8/30/23 at 1:40 PM, the Compliance Officer verified the finding and stated the medication reconciliation should have been done by the nurse within 7 days from the start of care.. Chart review on 08/29/2023 at 1 PM for Patient #9 reveals, Start of Care (SOC) on 07/18/2023 by physical therapy. There is no documentation in the chart for medication reconciliation by a Registered Nurse (RN). Interview on 8/30/2023 at 12:45 PM, RN #1 reports “should be done within 7 days” and RN #3 verifies the findings. Chart review on 08/29/2023 at 11:55 AM for Patient #14 reveals, SOC on 06/17/2023 by physical therapy. There is no documentation in the chart for medication reconciliation by a RN. Interview on 8/30/2023 at 12:25 PM, RN #1 reports “should be done within 7 days” and RN #3 verifies the findings. Chart review on 08/30/2023 at 10:30 AM for Patient #16 reveals, SOC on 03/23/2023 by physical therapy. Chart documents RN medication reconciliation dated 04/14/2023. Interview on 8/30/2023 at 12:10 PM, RN #1 reports “should be done within 7 days” and RN #3 verifies the findings.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on observations and interviews, the home health agency failed to ensure medications were updated for three of five patients. (Patient #3, #6, and #7) Home visit for Patient #6 on 08/28/2023 between 3:54 PM and 4:20 PM reveals agency medication list inaccuracies: Caregiver reports Allopurinol 300 mg one tablet by mouth daily, agency lists Allopurinol 100 mg one tablet by mouth daily. Magnesium oxide 400 mg one tablet by mouth daily, agency lists magnesium oxide 400 mg 2 tablets by mouth daily. Agency lists midodrine 10 mg one tablet by mouth 3 times a day, caregiver reports this medication has been discontinued. On 8/30/2023 at 11:54 AM, Registered Nurse (RN) #3 verifies the findings. Home visit for Patient #7 on 08/28/2023 between 2:04 PM and 2:58 PM reveals agency medication list inaccuracies: Patient reports taking Vitamin D3 125 Mg one tablet by mouth daily, Vitamin B12 5000 mcg. One tablet by mouth daily and Vitamin C 500 mg one tablet by mouth daily. None of these medications are listed on the agency list. On 8/30/2023 at 11:545 AM, RN #3 verifies the findings. Observation on 8/29/23 at 2:15 PM during a home visit with Physical Therapy for Patient #3 revealed medication bottles for the patient that included Aspirin 81 milligrams (mg) and Vitamin D3. The patients home health medication list indicated the patient took Aspirin 325 mg one daily. The list did not include Vitamin D3. When questioned about the discrepancies, the patient's sister who manages the medications stated the patient took 81 mg daily and had been off the 325 mg dose for a long time. The sister verified the patient had been taking the Vitamin D3, one a day. The Physical Therapist verified the patient's medication list had not been updated. An empty bottle of Montelukast (Singulair) was observed with the patient's other medications. The sister stated the patient had been out and s/he was not sure if the patient was to continue the medication. The Physical Therapist called the patient's doctor's office and a nurse there verified the patient should be taking this medication. The home health medication list did not include the Montelukast.

A survey of the Home Health Agency's (HHA) Emergency Preparedness Program (EPP) was conducted from 6/21/2021 to 6/24/2021. Based on observations, record reviews, interviews, review of the HHA's EPP, and review of the HHA's policies and procedures, it was determined the HHA is in compliance with Condition CFR 484.102 (Establishment of the Emergency Program – HHA).

A survey of the Home Health Agency's (HHA) Recertification Survey was conducted in conjunction with the HHA’s COVID-19 focused infection control requirements from 6/21/2021 to 6/24/2021. Based on observations, record reviews, interviews, and review of the HHA's policies and procedures, it was determined the HHA had standard level deficiencies that resulted from the HHA’s Recertification Survey for CMS regulations at 42 CFR PART 484 and the HHA was in substantial compliance with the COVID – 19 focused infection control requirements.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review, interview and the review of the facility’s policy and procedure, the Home Health Agency (HHA) failed to document measurable outcomes for all identified problems listed in the patient’s Plan of Care (POC) for fourteen of seventeen patient records reviewed. (Patient #1, #2, #4, #5, #6, #7, #8, #11, #12, #13, #14, #15, #16, and #17) The findings are: Patient #2 On 6/22/2021 at 1:34 PM, review of Patient #2’s chart revealed the following patient outcomes listed in the patient’s POC were not measurable: “Improved strength, Ambulate, Strategies to reduce fall risk, Verbalize understanding of home exercise, Strategies to reduce risks with home safety, and Progress in transfers”. The finding was verified by the Director of Nursing (DON) at 2:13 PM on 6/23/2021. Patient #1 On 6/22/2021 at 2:06 PM, review of Patient #1’s chart revealed the following patient outcomes listed in the POC were not measurable: “Patient environment, Monitoring blood pressure, Pain, Personal Care, Disposal of Sharps, and Understanding of Cerebral Vascular Accident”. The finding was verified by the DON at 1:55 PM on 6/23/2021. Patient #11 On 6/22/2021 at 3:40 PM, review of Patient #11’s chart revealed the following patient outcomes listed in the patient’s POC were not measurable: “Understanding of Congestive Heart Failure, Understanding of Advanced Lung Disease, Verbalize signs and symptoms of Hypoglycemia, Independent of diabetic management, Pain, and Resuscitation”. The finding was verified by the DON at 2:23 PM on 6/23/2021. Patient #12 On 6/23/2021 at 8:12 AM, review of Patient #12’s chart revealed the following patient outcomes listed in the patient’s POC were not measurable: “Verbalize signs and symptoms of hypoglycemia, Independent with diabetic management, Demonstrate safe insulin administration, Verbalize basic standard precaution, Pain, Practices to prevent urinary tract infection” . The finding was verified by the DON at 2:49 PM on 6/23/2021. Patient #14 On 6/23/2021 at 9:32 PM, review of Patient #14’s chart revealed the following patient outcomes listed in the patient’s POC were not measurable: “Care plan review, Progressive strengthening program, Verbalize proper antibiotic, Implement strategies to reduce fall risk, Understanding of home exercise, Implement strategies to reduce risks in home safety, Verbalize signs of infection, Pain, and Resuscitation”. The finding was verified by the DON at 2:43 PM on 6/23/2021. Patient #13 On 6/23/2021 at 10:17 PM, review of Patient #13’s chart revealed the following patient outcomes listed in the patient’s POC were not measurable: “Care plan review, Verbalize how to practice good hand hygiene, intravenous therapy, Verbalize signs of infection, and Pain”. The finding was verified by the DON at 2:36 PM on 6/23/2021. Patient 4 On 6/22/2021 at 2:40 PM, a review of Patient 4’s chart revealed all of the patient outcomes within the Plan of Care (POC) are not measurable: Physical Therapy - decreased fall risk; reduce risks associated with home safety; transfers utilizing equipment. The findings were verified by The Director of Nursing (DON) at 2:58 PM on 6/23/2021. He/she stated, “These should have a date.” Patient 5 On 6/22/2021 at 1:48 PM, a review of Patient 5’s chart revealed all of the patient outcomes within the POC are not measurable: Recognize signs and symptoms of hyper/hypoglycemia. This finding was verified by the DON at 2:50 PM on 6/23/2021. He/she stated, “This should have a date.” Patient 6 On 6/22/2021 at 3:10 PM, a review of Patient 6’s chart revealed all of the patient outcomes within the POC are not measurable: Occupational therapy – Increased functional mobility. This finding was verified by the DON at 1:00 PM on 6/23/2021. He/she stated, “This should have a date.” Patient 7 On 6/22/2021 at 3:30 PM, a review of Patient 7’s chart revealed all of the patient outcomes within the POC are not measurable: Verbalize and recognize signs/symptoms of hyper/hypoglycemia. This finding was verified by the DON at 1:15 PM on 6/23/2021. Patient 8 On 6/22/2021 at 2:32 PM, a review of Patient #8’s chart revealed all of the patient outcomes within the POC are not measurable: Demonstrate knowledge of Congestive Heart Failure (CHF); proper antibiotic use; proper disposal of antibiotics. This finding was verified by the DON at 1:20 PM on 6/23/2021. He/she stated, “These should have dates.” Patient 15 On 6/22/2021 at 3:00 PM, a review of Patient #15’s chart revealed all of the patient outcomes within the POC are not measurable: Blood clot prevention; demonstrate knowledge of CHF. This finding was verified by the DON at 1:23 PM on 6/23/2021. He/she stated, “These should have dates.” Patient 16 On 6/22/2021 at 3:30 PM, a review of Patient #16’s chart revealed all of the patient outcomes within the POC are not measurable: Reduce risks associated with home safety; patient will ambulate 250 feet. This finding was verified by the DON at 1:25 PM on 6/23/2021. He/she stated, “These should have dates.” Patient 17 On 6/22/2021 at 3:45 PM, a review of Patient #15’s chart revealed all of the patient outcomes within the POC are not measurable: Relief of symptoms with draining; demonstrate knowledge of CHF. This finding was verified by the DON at 9:01 AM on 6/23/2021. He/she stated, “These should have dates.” The facility’s policy and procedure titled “Assessment/Reassessment” reads “….10. The comprehensive assessment must accurately reflect the patient’s status and at a minimum include the following….f. Identification of the patient’s strengths, goals, and care preferences inclusive of information that may be used to demonstrate progress toward patient identified goals and measureable outcomes identified by the homehealth agency….”.