Every finding on record at Ssm Health Businesses

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 12/13/2023. During the survey it was determined the home health provider is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Providers.

A partial extended survey for Medicare recertification for the home health provider was completed on 12/13/2023. The provider had 289 current patients.

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 policy review, record review, and interview, the home health provider failed to ensure that the initial assessment visit was held within 48 hours of referral or within 48 hours of the patient's return home in three of five full records reviewed (Records/Patients #1, #2, and #3). This deficient practice has the potential to affect all patients served by the provider. RECORD/PATIENT #1: Review of the initial assessment, dated 12/07/2023, showed in part: - The Outcome and Assessment Information Set (OASIS) item M1000 showed the patient was discharged from a skilled nursing facility (SNF) on 11/29/2023; and - OASIS item M0102 showed the physician ordered start of care (SOC) date was 12/07/2023. Review of the home health referral, creation date 11/30/2023, showed a requested SOC date of 12/03/2023. Review of the physician’s orders failed to show an order for a 12/07/2023 SOC. RECORD/PATIENT #3: Review of the home health referral, creation date 11/10/2023, showed the “Requested SOC Date” was left blank. Review of the initial assessment, dated 11/26/2023, showed in part: OASIS item M1000 showed the patient was discharged from an inpatient rehabilitation facility on 11/20/2023; OASIS item M0102 showed no specific SOC date ordered by the physician; and OASIS item M0090 showed the date the assessment was completed was 11/26/2023 (six days after the patient’s discharge). During an interview on 12/13/2023, at 9:30 AM, the administrator stated that he/she expected the initial assessment to be completed within the 48-hour window per the regulatory requirements. He/she stated that the referral process started when the intake department received the referral, verified the insurance, contacted the physician to ensure they would follow the patient and then contacted home health to review and verify that they would accept the patient. They would tell the intake department what date they could accept the patient but, the intake department entered the date the physician agreed to follow the patient, which was still outside the 48-hour window. The administrator did not know why patient #3’s assessment was completed six days after the patient discharged and they would have to work out a better system between the home health and the intake department. Findings included: Review of the provider's policy titled, "Timeliness of Documentation," dated 06/16/2021, showed OASIS (Outcome and Assessment Information Set) start of care assessments were to be completed within 48 hours of the tine of the referral, the patient's return home, or on the physician-ordered start of care date. RECORD/PATIENT #2: Review of the clinical record showed patient was referred to home health services on 05/12/2023 for wound vac (vacuum-assisted closure of a wound) care. Review of the start of care OASIS assessment shows the initial visit was completed on 05/15/2023, three days after the referral was obtained. During an interview on 12/13/2023 at 10:30 AM, the home health administrator stated that he/she would expect the start of care visit to be completed within 48 hours of the patient’s referral for home health.

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 home health provider failed to review all of the medications the patient was currently using in, but not limited to, one of three home visit observations conducted (Record/Patient #3). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Medication Reconciliation,” dated 05/03/2023, showed in part: - Medication reconciliation is the process of comparing a patient’s medication list to all the medications the patient is taking in order to avoid medication errors such as omissions, duplications, dosing errors or drug interactions; - Reconciliation is performed by nursing staff with every home visit; - Medications are reconciled, by therapy, at every visit by comparing the medication list in the home to the medication profile in the electronic health record and asking the patient/caregiver if there have been any changed or new medications since the last visit; - Therapists will use case communication to send a follow-up note to the administrator, clinical manager, or designee stating medications have been entered on the profile and indicate whether any major drug-drug interactions are noted. The therapist will also advise the administrator, clinical manager, or designee of any discrepancies found; - The administrator, clinical manager, or designee will contact the patient via telephone to confirm medications, answer and questions and document in the record that the medication review was completed, the patient was contacted, and the patient gave a response/validation of understanding; - At start of care (SOC) and resumption of care (ROC) the nurse will reconcile all medications in the home with the most recent after visit summary or discharge summary, including all over the counter (OTC) medications; - If there are discrepancies in the medication list from the referral source and what the patient is taking in the home, the physician is contacted, and the discrepancy should be resolved by midnight of the next calendar day; and - Document on “interventions” in the record. State how medications were reconciled such as with discharge orders or physician office and pill bottles. RECORD/PATIENT #3: Review of the initial assessment, dated 11/26/2023, showed in part: - No clinically significant medication issues were identified during the drug regimen review; - The patient was assessed as unable to take medication unless administered by another person; - The “home care aide” was identified as the person who manages the patient’s medications; and - The patient had a current updated medication list. Observation and interview on 12/12/2023, beginning at 12:00 PM, during the patient’s home visit, showed the patient had a plastic box full of medication bottles. The patient stated that he/she took all of the medications in the box and that he/she sets up his/her own medication planner. The following discrepancies were found with the medications in the patient’s home and the provider’s medication profile: - The provider’s medication list showed finasteride (a prostate medication) 5 milligrams (mg) take one tablet once daily. The medication was not in the home and the patient stated that he/she was not taking it; - The medication list showed loratadine (an allergy medication) 10 mg (no further instructions were on the medication list). The medication was not in the home and the patient stated that he/she was not taking it; - The following medications were found in the home and were not on the provider’s medication profile: * Aleve (an over the counter (OTC) anti-inflammatory medication used for pain) 220 mg, take one every eight to 12 hours as needed (PRN); * Advil (an OTC anti-inflammatory medication used for pain) 200 mg take one every four to six hours PRN; * Escitalopram (an antidepressant) 10 mg take one daily; * Tramadol (a prescription pain medication) 50 mg take one every eight hours as needed; * Gabapentin (a medication for nerve pain)100 mg take one capsule three times a day and the patient stated he/she only takes it when needed; * Atorvastatin (a cholesterol medication) 40 mg take one every evening; * Furosemide (a diuretic) 40 mg one tablet every other day and alternate with furosemide 20 mg one tablet every other day; * Melatonin 3 mg take one tablet daily at bedtime; * Protonix (a medication used to treat acid reflux) 20 mg take one daily; * Flonase (a steroid nasal spray used to treat allergies) 50 micrograms (mcg) use one spray in each nostril daily; * Midodrine (a medication used to treat low blood pressure) 2.5 mg tablets take one daily; * Spironolactone (a diuretic) 25 mg take one tablet daily; and - The clinical manager was present during the home visit and instructed the physical therapist to contact the physician and obtain an order for a nursing visit to do a complete medication reconciliation with patient education on what he/she should be taking. During an interview, immediately following the home visit, the patient stated that he/she had been taking all of the medications in the box and one of the therapists visited the previous week and told him/her that they were not sure if he/she should be taking all of the medications. The patient stated that he/she would like someone to come in and look at his/her medications because he/she did not want to take medications that counteracted each other. Review of the clinical record failed to show documentation that the medication discrepancies were reported to or clarified with the physician. During an interview on 12/13/2023 at 9:30 AM, the administrator stated that medication reconciliation seemed to be a consistent problem, but he/she would expect the medication profile to match what the patient is taking in the home and any discrepancies to be clarified with the physician.

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, observation, and interview, the home health provider failed to ensure the plan of care (POC) was individualized and included the services, supplies, and equipment required for the patient in, but not limited to, two of five full records reviewed (Records/Patients #1 and #2). This deficient practice has the potential to affect all patients served by the provider. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 12/07/2023 with a diagnosis of a colocutaneous fistula (an abnormal connection between the digestive tract, colon and skin) and an abscess (a collection of pus or infected fluid surrounded by inflamed tissue inside the abdomen) with a colostomy (a procedure where part of the colon is surgically diverted to an artificial opening in the abdominal wall). The patient had an additional diagnosis of a cervical spinal fracture related to a motor vehicle accident. The patient was dependent for his/her activities of daily living and lived in an independent living apartment with his/her spouse. Review of the initial assessment, dated 12/07/2023, showed the patient requires a motorized tilt wheelchair and a Hoyer lift (a mechanical lift used for transferring patients). Observation on 12/11/2023 at 12:55 PM, during the patient’s home visit, showed the patient was in a motorized tilt wheelchair, The patient also had a Hoyer lift, a hospital bed with rails and a shower chair. Review of the plan of care (POC), dated 12/07/2023, failed to show any of the patient’s durable medical equipment (DME). During an interview on 12/13/2023 at 9:30 AM, the administrator stated that the DME is on the initial assessment, but it is not carrying over to the POC. It may be a software issue that they will have to fix. Findings included: Review of the provider’s policy titled, “Plan of Care,” dated 04/07/2023, showed, in part, the following: -Standardized plans of care are not acceptable unless each plan is individualized to meet specific needs of the patient and caregiver, -The plan of care includes: *Equipment and supply needs, and *Patient specific interventions and education, measurable outcomes and goals identified by the home health provider and the patient. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 05/15/2023 with a primary diagnosis of ulcer to right lower extremity with fat layer exposed and a secondary diagnosis of type 2 diabetes mellitus. -The plan of care dated 11/11/2023 failed to show the patient was taking insulin to control his/her blood glucose levels; and -The plan of care failed to show interventions and goals regarding the diabetes diagnosis. During an interview on 12/13/2023 at 10:30 AM, the home health administrator stated that he/she would expect any pertinent diagnosis that could affect the patient’s treatment to be included on the plan of care.

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, observation, and interview, the home health provider failed to ensure that a copy of written instructions outlining the visit schedule, including frequency of visits, was provided to the patient in two of three home visits conducted (Records/Patients #1 and #2). This deficient practice has the potential to affect all patients served by the provider. RECORD/PATIENT #1: Review of the initial assessment, dated 12/07/2023, showed the registered nurse (RN) documented the next visit plan as “RN explained plan of care (POC) and frequency of visits. Pt. (patient) agreed and verbalized understanding.” Review of the POC, dated 12/07/2023, showed in part: - The frequency of skilled nursing visits after the initial start of care was two visits a week for one week, then one visit a week for five weeks, and three as needed (PRN) visits; - A home health aide visit frequency of two visits a week for six weeks, effective 12/10/2023; - Physical therapy assistant visit frequency of two visits a week for one week, then three visits a week for one week, then two visits a week for one week; and - Physical therapy visit frequency of one visit for the week of 12/27/2023 to 12/30/2023. Observation on 12/11/2023 at 12:55 PM, during the patient’s home visit showed the patient’s home health folder and information given to the patient by the provider failed to contain a completed visit schedule including the frequency of visits by the nurse and the physical therapist. During an interview immediately following the home visit, the patient and spouse stated that the staff called them to set up a day and time for the week. They stated that they were not aware that a home health aide was going to be provided and they were not given a written schedule to help them keep up with the visits. During an interview on 12/13/2023 at 9:30 AM, the administrator stated that the admitting nurse may document that the patient prefers visits on certain days of the week when the patient signs the consent. The administrator was unable to find documentation that patient #1 had stated their preference. Findings included: Review of the provider’s policy titled, “Coordination of Care and Conference,” dated 06/15/2021, showed the home health provider coordinates care by integrating services to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all discipline. RECORD/PATIENT #2: Observation on 12/12/2023 at 9:45 AM, during the patient’s home visit, showed that the patient home folder provided by the home health provider failed to contain a visit schedule that included a frequency of visits from all disciplines. During an interview on 12/13/2023 at 10:30 AM, the home health administrator stated that he/she would expect this list to be contained in the home folder.

Treatments and therapy services CFR(s): 484.60(e)(3) Any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services. This ELEMENT is not met as evidenced by: Based on policy review, record review, home visit observation and interview, the home health provider failed to provide the patient with a copy of written instructions outlining the patient’s dressing changes, ostomy appliance changes, urinary catheter changes, and therapy home exercise program in two of three home visit observations conducted (Records/Patients #1 and #2). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Patient Rights and Responsibilities,” dated 05/12/2023, showed in part: - Patients have the right to participate in the development and implementation of their inpatient and outpatient plan of care; and - Patients have the right to make informed decisions about their care, treatment and services. This includes being informed of health status, being involved prior to and during the course of treatment, being informed of all proposed procedures and treatment. Review of the provider’s policy titled, “Coordination of Care and Conference,” revised 01/25/2019, showed in part, the home health coordinates care delivery to meet the patient’s needs and involve the patient, representative (if any), and caregivers, as appropriate, in the coordination of care activities. RECORD/PATIENT #2: Observation on 12/12/2023 at 9:45 AM, during the patient’s home visit, showed that the patient home folder provided by the home health provider failed to contain a list of treatments to be administered by the home health provider. During an interview on 12/13/2023 at 10:30 AM, the home health administrator stated that he/she would expect this list to be contained in the home folder. RECORD/PATIENT #1: Review of the plan of care (POC), dated 12/07/2023, showed in part: - Physical therapy established a home exercise program, that included a progressive increase in repetitions, resistance, sitting balance, and trunk activities; - Skilled nurse (SN) to perform ostomy care every five days using a one or two piece appliance. Wash hands, remove old appliance, inspect skin and stoma, cleanse area with prescribed cleaning agent, apply skin barrier, and apply a new appliance; - Wound care- remove old wound dressing and discard per policy, cleanse wound and periwound with soap and water or wound cleanser; moisten rolled gauze with normal saline, wring out excess, gently fill wound cavity with moistened gauze, cover with abdominal pad or bordered dressing, secure with Medipore tape, change dressing daily and PRN (as needed) if saturated or soiled; and - Perform urethral catheter change every 30 days using a 16 French catheter with a 10-milliliter balloon. May change PRN for dysfunction/dislodgement. Observation on 12/11/2023 at 12:55 PM, during the patient’s home visit showed the patient’s home health folder and information given to the patient by the provider failed to contain a written copy of the treatments to be administered by the nurse and the physical therapist. During an interview on 12/13/2023 at 9:30 AM, the administrator stated that he/she wasn’t aware of the requirement that the home health must provide a written copy of the treatments to be administered by the home health personnel, but they will write out a list of treatments from the POC and put it in the homes.

A complaint investigation (#63032) was completed on 05/24/2022 at SSM Health at Home Home Health - St. Louis. The agency had 632 current patients.The complaint is substantiated. One or more of the allegations reported are verified and a deficiency was cited that is related to the allegations being investigated.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to promptly alert the physician to changes in the patient's needs that may suggest the plan of care (POC) should be altered in one (Record/Patient #1) of four 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, “Physician Orders,” revised 01/25/2019, showed the ordering physician will be contacted when there is a change in patient condition or response to care requiring new or modified orders for care or services. RECORD/PATIENT #1: Review of the POC dated 10/06/2021 through 12/04/2021 showed the following: - The patient was admitted to the agency on 02/08/2021; - Diagnosis included malignant neoplasm (a tumor is cancerous) of colon, adjustment and management of vascular access device (provides access to your veins); - Skilled nurse to access port-a-cath (implanted device which allows easy access to a patient’s veins) monthly with 22 French size (Fr.) Huber needle (a specifically designed hollow needle inserted through the skin into the port to give fluids or other treatments) via sterile technique; and - Total parenteral nutrition (TPN: a medication and treatment of malnourishment and supplies all daily nutritional requirements) four days a week to run 12 hours at a time intravenously (the plan of care did not include specific days and times). Review of the skilled nurse’s note dated 11/22/2021 (Monday) at 2:09 PM showed, in part: - Port accessed with no blood return, “access remove attempted times two”; - Patient was going to infusion center today to have them look at port to see if they could successfully access port and get a blood return (the cancer center did not see the patient until 11/23/2021); and - There was no documentation to show the physician was notified the nurse was unable to access the port and if the patient was to receive TPN. Review of an outpatient visit note dated 11/23/2021 at 3:20 PM (24 hours after the agency's skilled nurse could not access the port), showed, in part: - Patient with history of port placement 09/29/2020 for chronic TPN use in setting up with appendiceal carcinoma (type of cancer that grows from cells that make up the appendix) presents for port evaluation; - “Home health nurse attempted to access report was then instilled to flush or draw blood”; - Port was accessed and able to flush and draw blood times two; and - Port appeared to be functioning and felt likely not accessed appropriately. During interview on 05/23/2022 at 12:10 PM, the supervisor stated that he/she would expect the nurses to let the pharmacy or infectious disease doctor know if they were unable to access a patient’s port. During interview on 05/24/2022 at 4:19 PM, the West branch manager stated that he/she would have expected the nurse to notify the physician if he/she was unable to access the port. The plan of care did not specify which four days a week the patient was receiving TPN. During an interview on 05/25/2022 at 12:41 PM, the patient stated that: - He/she would then have to go to the cancer center to address the blocked port; - Sometimes, he/she could get into the cancer center the same day and other times he/she would have to wait until the next day, which meant he/she would not receive TPN that day which was important; - He/she received TPN on Monday, Tuesday, Thursday, and Friday; - Some of the nurses would not show up until later in the afternoon and the cancer center would close at 4:30 PM, if they would have showed up in the morning he/she would have had a better chance of getting into the cancer center the same day; - The agency could have kept “dissolve medication” in stock to use if he/she was not able to go to the cancer center the same day; and - He/she had plenty of the insurance days left for home health and decided to stop home health services because he/she had to go to the cancer center anyway; and if the home health nurses could not access the port there was no point in keeping the home health agency services.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on policy review and interview, the agency failed to ensure that staff are fully vaccinated for Coronavirus Disease 2019 (COVID-19) (infectious disease) in one employee (E1) of three employee files reviewed. This deficient practice has the potential to affect the quality of care to all patients served by the agency. Findings included: Review of the agency's policy titled, "Influenza and COVID-19 Vaccination Program," revised 02/23/2022 showed, in part, the following: ` - All staff must receive the SSM COVID-19 required vaccine or have an approved medical exemption, religious exemption, or temporary delay of COVID-19 vaccine prior to performing work; - Recordkeeping: Records will be maintained documenting vaccinations, boosters, exemptions, and COVID-19 temporary delays; - Compliance: Staff who are not compliant with this policy will not be permitted to work; - The staff member's leader, institution or employer is responsible for ensuring compliance with this policy; - Employees who are not compliant with this policy will be placed on unpaid administrative leave until compliance is achieved. The employee will receive the next level of corrective action, at a minimum a written warning; - Employees who are not compliant with this policy by one month after the start of administrative leave will be dismissed and/or their medical staff membership or clinical privileges will be revoked; and - Employees on approved leave of absence must be in compliance with this policy prior to returning to work. Review of the agency's list of employees vaccination status, received on 05/23/2022, showed the following: EMPLOYEE (E1): E1's vaccination documentation showed: - Position: Registered Nurse- home health and hospice; - Date of hire: 06/07/2013; - Compliance with COVID vaccine program: Not yet compliant; - Vaccination status: Unvaccinated- expired deferral; - Deferral reason: Current illness; - Deferral approved date: 09/15/2021; - Deferral approved until date: 10/01/2021; - Deferral approved by: Med panel; and - There was no further documentation regarding vaccination status or exemption since 10/01/2021. During an interview on 05/24/2022 at 4:05 PM, the West branch manager stated that: - The employee is still working and doing home visits: - All employees had reviewed the COVID 2019 policy and procedures; - Employee health handles exemptions from vaccination; - E1's physician did not want him/her to get the vaccine due to long term post COVID 2019 symptoms; - E1 was not approved for medical exemption and appealed this decision; and - He/she was not sure of E1's current status and had no further information.

A complaint investigation (MO00189051) was completed on 09/14/2021 at SSM at Home Home Health. Four clinical records, grievance log, and policies for admission and discharge were reviewed. The agency's total patient census was 627. The complaint is substantiated. One or more of the allegations reported are verified and a deficiency was cited that is related to the allegations being investigated.

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 policy review, clinical record review, and interview, the agency failed to conduct the initial assessment of the patient within 48 hours of the referral to home care, or 48 hours after the patient's return home, or on the physician ordered start of care date in one (Record/Patient #2) of four 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 "Referrals/Admission Procedure" dated 06/23/2021 showed, in part, telephone or direct contact will be made with each client within 24 hours of receipt of the referral, as appropriate, for the purposes of verifying patient information, notifying the patient/family that a referral for service has been received and establishing a time frame for the initial visit. An initial assessment is made by the skilled nurse, physical therapist or speech therapist to ensure that admission is appropriate and to coordinate care and services. RECORD/PATIENT #2: Review of the referral information dated 07/29/2021 showed: - The date of the physician referral was 07/29/2021; - Admission date 07/30/2021; and - Skilled nurse for start of care assessment post discharge for status post coronary artery bypass graft surgery (CAD S/P CABG) ( a procedure used to treat coronary artery disease). Review of the admission note report dated 07/30/2021 showed: - Disciplines ordered: Skilled nursing for start of care assessment post discharge for CAD S/P CABG; - Skilled nurse to assess vital signs, pulmonary oxygen status, and neurological status; - Skilled nurse to instruct patient/caregiver in home safety, disease and healing process complications and when to call the physician; - Skilled nurse to complete medication medication reconciliation and education for high risk, new and changed medications; - Physical therapy for initial evaluation for therapist to provide/instruct gait and transfer training, safe use of adaptive equipment,, and strengthening exercises; and - Occupational therapy for initial evaluation and instruction on improving independence in activities of daily living by teaching alternative ways to accomplish activities. Review of a case communication note dated 08/02/2021 (3 days after admission to home care), the nursing supervisor documented attempted to call patient several times regarding start of care. Voicemail left with no return calls. The physician's office called to notify of referral not opened. (There was no further documentation provided to show attempts were made to contact the patient prior to 08/02/2021.) During an interview on 09/14/2021 at 2:00 PM, the nursing supervisor stated the following: - He/she tried to call the patient prior to 08/02/2021 but the patient did not answer and there was no documentation to show this; - When the patient is admitted to homecare the staff call or visit by the following day; and - No further information was provided.

The Emergency Preparedness regulation were reviewed as part of the Medicare certification survey completed on 04/21/2021. During the survey it was determined SSM Health at Home 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 SSM Health at Home Home Health was completed on 04/21/2021. the agency had 665 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.

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, clinical record review, home visit observation, and interview, the agency failed to ensure staff, reviewed all medications the patient is currently using in order to identify any potential adverse effects and drug reactions in two (Record/Patient #1 and #2) of three home visit records reviewed. This deficient practice has the potential to affect the care of all patients served by the agency. Findings included: Review of the agency's policy titled "Medication Reconciliation" revised 09/29/2020 showed: - Skilled nurse (SN): Medication reconciliation is the process of comparing a patient's medication list to all the medications the patient is taking in order to avoid medication errors such as omissions, duplications, dosing errors or drug interactions; - Medications are reconciled by nursing staff with every home visit; - Reconcile by comparing list in the home, assessing all medications in the home, and compare medication profile (these must match at all times); - Any changes to medications or new medications initiated must be added to the medication profile and the list in the home and confirmed by the physician; - Document how medications were reconciled and findings in interventions; - Medications are reconciled by therapy every visit by comparing the medication list in the home to the medication profile in the computer and asking patient/caregiver if there have been any changed or new medications since the last visit; - Any changes to medications or new medications initiated must be added to the medication profile and list in the home. If any level 1 interaction is noted, the therapist will call the administrator, clinical manager, or designee; - Therapy: Therapist will use case communication to send follow up note to the administrator, clinical manager, or designee stating medications have been entered on profile and indicate whether or not any level 1 medication interaction noted and will also advise the administrator, clinical manager, or designee of any discrepancies found; - The administrator, clinical manager, or designee will follow up with the physician for any discrepancies or level 1 interactions identified via telephone and document the conversation in a "Case communication note-med review" or use SBAR (a technique that can be used to facilitate prompt and appropriate communication) and fax to the physician; and - The administrator, clinical manager, or designee will contact the patient via telephone to confirm the medication, answer any questions and document in a case communication note. RECORD/PATIENT #1: Review of the POC dated 04/12/2021 through 06/10/2021 showed: - Diagnoses included but not limited to: Generalized arthritis, surgical procedure to left shoulder, and pain; and - Omeprazole (used to treat gastric reflux) 20 mg was not listed on the POC. Review of the agency's current medication profile printed 04/20/2021 showed: - Omeprazole 20 mg was not listed on the current medication profile. A home visit observation and patient interview on 04/20/2021 at 1:00 PM showed: - No hand written or computer copy of a current medication list in the home; - The patient said his/her daughter took care of all his/her medications and set up the medications for him/her; - Omeprazole was kept in a kitchen drawer and he/she took the medication before meals when needed; and - She took the Omeprazole for a while but only if he/she needed it. Review of the clinical record showed no order for Omeprazole 20 mg before meals. During an interview on 04/20/2021 at 2:00 PM, the physical therapist stated - He/she asked about any new or changed medications with each visit and would contact the administrator or clinical manager if medication changes found; - He/she did not always check the medication bottles; - The patient's daughter set up the medications for the patient and could have the list of medications; - He/she did not know the patient took Omeprazole and would notify the administrator or clinical manager that the patient said he/she took the medication as needed. RECORD/PATIENT #2: Review of the plan of care (POC) dated 04/07/2021 through 06/05/2021 showed: - Diagnoses included but not limited to: Orthopedic surgical aftercare (trigger finger release), congestive heart failure, and chronic kidney disease; - Skilled nurse to reconcile medications with patient/caregiver at each visit, visualizing in home pill bottles and comparing to list in home and computer profile; document any discrepancies with physician notification and resolution; and - Occupational therapy (OT) or physical therapy as needed. Review of the OT initial therapy assessment dated 04/08/2021 showed: - OT two visits per week for four weeks (2w4); - No recent medication changes per the patient and reviewed the medication list in folder; and - Did not have prescribed pain medication in the home. Review of the agency's Medication Profile printed 04/19/2021 showed: - Acetaminophen 500 milligram (mg) tablets, take two tablets every eight hours as needed, start date 01/01/2029, start date 01/01/2019, no end date (discontinue date) documented; - Oxycodone (a narcotic pain reliever) 5 mg, one tablet every four to six hours as needed, start date 04/08/2021, no end date documented; - Potassium Chloride (KCL, a supplement) 20 millequivalents (meq) two times per day (BID), start date 01/01/2019, end date 12/17/2020; - Spironolactone (rids the body of excess fluid) 50 mg BID, start date 11/20/2020, hold as of 12/17/2020; - Albuterol inhaler 90 microgram (mcg), inhale 2 puffs every six hours as needed, start date 01/01/2019, no end date documented; and - Isosorbide mononitrate extended release (used to treat angina, heart pain) 120 mg daily, start date 01/01/2019, and no end date documented. Review of the home medication bottles of medications and medication list during a home visit on 04/20/2021 at 11:30 AM showed: - Oxycodone 5 mg, one every four to six hours as needed not listed; - Acetaminophen 500 mg, one every four hours as needed; - KCL ER (extended release) 20 meq BID; - Spironolactone 25 mg, one tablet BID; and - Albuterol inhaler 90 mcg two puffs every six hours as needed not listed. During an interview on 04 2/2021 at 11:30 AM, the patient stated: - He/she took: Acetaminophen 500 mg one every four hours, not two tablets every eight hours; - KCL ER 20 mg BID and Spironolactone 25 mg BID; - Oxycodone 5 mg every six hours and alternates with Motrin (an anti-inflammatory/pain medication); - Isosorbide 120 mg daily but he/she did not know where the bottle of medication was and would need to find the bottle; - Spironolactone 25 mg one tablet BID; and - Does not use the Albuterol inhaler every day. During an interview on 04/20/2021 at 9:30 AM, the certified occupational therapy assistant (COTA) stated: - He/she asked about new or changed medications each visit and reported any changes to the administrator or clinical manager; - Could not find Isosorbide in the home; and - The home medication list was not up to date. During an interview on 04/21/2021 at 8:45 AM, the administrator stated there was no current order for Spironolactone or KCL for Patient #2; - The medication profile contains all medications the patient has been on and should show an end date or discontinue date; and - A current hand written medication list should be left in each home.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on clinical record review, home visit observation, and interview, the agency failed to ensure staff promptly notified the physician for a change of condition of one (Record/Patient #3) of three applicable home visits. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled "Coordination of Care and Conference" revised 01/25/2019 showed: - Outcome Statement: To coordinate care related to patient progress toward established goals of service and/or problems impeding progress toward established goals; - To comply with all applicable regulations and standards of care; - Care is coordinated among members of the care team as needed and may be accomplished by conducting care conferences as needed: - The home health agency coordinates care by ensuring communication with all physicians involved in the plan of care (POC); and - Coordinating care delivery to meet the patient's needs and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. Review of the agency's policy titled "Recertification, Continuation of Care, and Significant Change in Condition (SCIC)" revised 01/24/2019 showed: - Outcome Statement: To assure that appropriate care and services are provided in accordance with established policy, organization philosophy, and regulatory requirements; - To ensure that OASIS (a mandated assessment tool) assessments are performed according to regulatory requirements; - Patient's physical and functional status will be assessed by a qualified professional providing care on an on-going basis; - Decisions related to the continuation of care and services will be based on current problems and needs and response to treatment; and - With any significant change in condition, a visit should be made as soon as possible following recognition of the change and a physician's order for increased or decreased frequency of visits may be indicated; and - The clinical manager/supervisor may direct the staff to perform a follow-up OASIS for other unexpected conditions or changes which appear significant based on professional judgement. RECORD/PATIENT #3: Review of the POC dated 04/08/2021 through 06/06/2022 showed: - Start of care date 04/08/2021; - Diagnoses included, but not limited to: Surgical procedure, diverticulitis of small intestine without perforation or abscess with bleeding, diabetes mellitus (elevated blood sugar levels), and hypertension (high blood pressure, BP); - Admit to home health due to laparoscopic partial colectomy with colorectal anastomosis (a bowel resection is a surgery to remove any part of the bowel, this includes the small intestine, large intestine, or rectum, and is used to treat diseases and blockages of the colon or large intestine) and reversal of an ostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon); - Skilled nurse (SN) to change wound VAC (Vacuum-Assisted Closure of a wound is a type of therapy to help wounds heal. During the treatment, a device decreases air pressure on the wound. This can help the wound heal more quickly) three times per week; - SN to notify physician if systolic blood pressure (the top number, measures the force your heart exerts on the walls of your arteries each time it beats) is higher than 160 or lower than 80; and diastolic blood pressure (the bottom number, measures the force your heart exerts on the walls of your arteries in between beats) higher than 90 or less than 60; - Problem: Alteration in cardiac function manifested by hypertension; - Goals: Blood pressure will remain within normal limits as evidenced by readings within parameters; to be achieved by discharge; - Problem: Open abdominal wound related to surgery; - Assess wound every SN visit, measure and photograph weekly with decline, and with each OASIS visit including discharge visit, update physician as needed; and - Wound will heal without complications. Review of the start of care comprehensive assessment dated 04/08/2021 showed: - Wound length: 6.20 centimeters (cm, a metric unit of length), x width 6.0 cm, x and depth 3.50 cm; - Minimal wound drainage, serosanguineous (wound discharge that contains both blood and blood serum); drainage color pink; - Wound care and wound VAC change provided; - No documentation of wound tunneling (channels that extend from a wound into and through subcutaneous tissue or muscle; they often are difficult to manage/heal); and - BP reading: Systolic 128, diastolic 70 or 128/70, BP to remain within parameters. Review of a SN visit note dated 04/10/2021 showed: - BP reading 135/98; - Wound measurement: L 5.50 x W5.50 x D 1.20, tunneling at 3 o'clock inner measured 1.50 cm; minimal serosanguineous drainage, tan in color; and - No SN documentation of notification of the physician of the change in BP and tunneling of the abdominal wound or change in color of the drainage. Review of a SN visit note dated 04/12/2021 showed: - BP reading 150/98; - Wound measurement: L 5.5 x W5.5 x D 1.3, tunneling 2.50 cm, minimal tan colored serosanguineous drainage; and - No SN documentation of notification of the physician of the increased BP and tunneling of the abdominal wound or color of the drainage. Review of a SN visit note dated 04/14/2021 showed: - BP reading 134/98; - BP will remain within normal limits; patient reported he/she used to take Amlodipine (used to control BP), but currently cannot get a refill due to having to establish care with a new primary care physician (PCP); appointment with a new PCP on 04/28/2021 and he/she will discuss BP at that time; - Wound measurements not documented, tunneling at 3 o'clock with no measurement, and minimal serosanguineous tan colored drainage; and - No SN documentation of notification of physician of the increased BP and wound assessment. Review of a SN visit note dated 04/16/2021 showed: - Moderate serosanguineous tan colored drainage; - No wound measurements, tunneling at 3 o'clock, and BP within parameters; and - No SN documentation of notification of physician of the wound assessment. During an interview on 04/20/2021 at 9:41 AM, the SN A stated: - One physician signed the POC orders but he/she was not sure who managed wound issues; - The patient sees primary care physician in one week; - He/she did not notify the physician of the increase in BP or wound tunneling and increased measurements, many times the physicians will not address these issues; - The computer alerted the amount of drainage increase and the ostomy/wound care nurse was notified; - He/she was not sure if the patient made a follow-up visit with the physician; - The wound was improving; - The start of care assessment did not show documentation of tunneling, but there was a tunnel. During an interview on 04/20/2021 at 3:27 PM, the administrator stated: - The ostomy/wound nurse was notified and would see the patient for recommendations of wound care; and - She was not sure if the ostomy/wound nurse made a visit to assess the wound.

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 review pf the current patient rights information, home visit observation, and interview, the agency failed to ensure staff provided a written visit schedule to patients that included what discipline(s) were visiting, and the frequency of visits in two (Record/Patient #1 and #2) of three home visits. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the patient rights information included in the admission packet left in the patient's home showed the agency must advise the patient in advance of the disciplines that will furnish care, and the frequency of the proposed visits. RECORD/PATIENT #1: Review of the admission packet during a home visit observation with physical therapist (PT) on 04/20/2021 at 1:00 PM, showed: - The patient rights and other information given to the patient during the initial visit contained the right to be advised in advance of the disciplines that will furnish care, and the frequency of proposed visits; and - A blank copy of a calendar to be used to record discipline visits for the patient/caregiver. During an interview on 04/20/2021 at 2:00 PM, the PT stated: - He/she did not always write his/her visits on the schedule in the folder; and - He/she always called the patient the day before to let them know when he/she was going to visit. During an interview on 04/21/2021 at 8:45 AM, the administrator stated that schedules of discipline visits should be left in the patient's home. RECORD/PATIENT #2: Review of the admission packet during a home visit observation with the certified occupational therapist assistant (COTA) on 04/20/2021 at 11:30 AM, showed: - The patient rights and other information given to the patient during the initial visit contained the right to be advised in advance of the disciplines that will furnish care, and the frequency of proposed visits; and - A blank copy of a calendar to be used to record discipline visits for the patient/caregiver. During an interview on 04/20/2021 at 12:15 PM, the patient said staff always call the night before they come to visit; he/she did not know about a calendar in the folder. During an interview on 04/20/2021 at 12:30 PM, the COTA stated: - He/she did not always write his/her visits on the schedule in the folder; and - He/she always called the patient the day before to let them know when he/she was going to visit.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on agency policy, home visit observation, and interview, the agency failed to provide the patient/caregiver with a copy of written and/or updated instructions outlining the patient's medication schedule/instructions, including name of the medication, dosage, and frequency in two (Record/Patients #1 and #2) of three home visit observations. This deficient practice has the potential to affect the patient's knowledge of self-care and expectations in all patients served by the agency. Findings included: Review of the agency's policy titled "Medication Reconciliation" revised 09/29 2020 showed: - Medication reconciliation is the process of comparing a patient's medication list to all the medications the patient is taking in order to avoid medication errors such as omissions, duplications, dosing errors or drug interactions; - The skilled nurse will reconcile all medications in the home with discharge orders or with the physician, to include all over the counter medication at the start of care/ resumption of care; - Leave a completed medication profile in the home; a discharge list from the hospital will work if it is legible and accurate and those medications will be included on the plan of care (POC); - If there are any discrepancies in the medications list from the referral source and what the patient is taking in the home, the physician must be contacted, and the discrepancy should be resolved by midnight of the next calendar day; - With follow-up visits, reconcile medications by comparing list in the home with the medication bottles and medication profile in the computer; and - Ask the patient/caregiver about any medication changes and assess the medication bottles. RECORD/PATIENT #1: During a home visit observation on 04/20/2021 at 1:00 PM with the physical therapist (PT), the surveyor observed the patient's home folder. The agency failed to provide written and/or updated instructions outlining the patient's medication schedule/instruction, including the medications name, dosage, and frequency. RECORD/PATIENT #2: During a home visit observation on 04/20/2021 at 11:30 AM with the certified occupational therapist assistant (COTA), the surveyor observed the patient's home folder. The agency failed to provide written and or updated instructions outlining the patient's medication schedule/instruction, including the medications name, dosage and frequency. During an interview on 04/21/2021 at 8:40 AM, the administrator stated: - Medication profiles contain all medications the patient has been on; there are end dates that show when medications were discontinued; and - Medication sheets left in the home are hand written and should be updated with any changes in medications.

Treatments and therapy services CFR(s): 484.60(e)(3) Any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services. This ELEMENT is not met as evidenced by: Based on agency policy review, home visit observation, and interview, the agency failed to provide the patient/caregiver with a copy of written instructions of any treatments being administered by the agency in one (Record/Patient #3) of three home visit observations. This deficient practice has the potential to affect the patient's knowledge of self-care and agency expectations in all patients served by the agency. Findings included: Review of the agency's policy titled "Education of the Patient and Family" and revised 05/27/2020 showed: - Assessment of the patient/caregiver's knowledge deficits and learning abilities are evaluated during the initiation of care/services; - Instruction will be presented in ways understandable to the patient/family, verbally or in written format, by qualified staff; formal teaching plans and/or informal teaching opportunities with return demonstrations will be implemented as appropriate; - Patient/family education is focused on goal and achievement of outcomes as identified in the plan of care (POC), and may include, but not limited to treatment and disease management; and - Written instructions are provided to the patient. RECORD/PATIENT #3: During a home observation visit on 04/20/2021 at 9:41 AM with the registered nurse (RN), the surveyor observed the patient's home folder. The agency failed to provide written instructions of wound care/wound VAC care and any other treatments administered by the agency. On 04/20/2021 at 3:27 PM, the above findings were reviewed with the administrator and no additional information could be provided.

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 record review and review of Chapter 26 Home Health Agencies, 19 CSR 30-26.010 (1)(B)(2)(A and B)(3) Home Health Licensure Rules, the agency failed to provide Alzheimer's disease training prior to the State COVID-19 waiver dated April 22, 2020, to one employee (Employee/E2) of four employee files reviewed. This deficient practice has the potential to affect the safety of all patients served by the agency. Findings included: Review of Chapter 26 Home Health Agencies, 19 CSR 30.26.010 (1) (B) (2) (A and B) (3) showed: (B) Licensed home health agencies shall provide dementia-specific training about Alzheimer's disease and related dementias to their employees and those persons working as independent contractors who provide direct care to or may have daily contact with residents, patients, clients, or consumers with Alzheimer's disease or related dementias; (2) Employees or independent contractors who do not provide direct care for, but may have daily contact with persons with Alzheimer's disease or related dementias shall receive dementia-specific training that includes at a minimum: (A) An overview of Alzheimer's disease and related dementias; and (B) Communicating with persons with dementia; and (3) Dementia-specific training about Alzheimer's disease and related dementias shall be incorporated into orientation for new employees with direct patient contact and independent contractors with direct patient contact. The training shall be presented by an instructor who is qualified by education, experience, and knowledge in the current standards of practice regarding individuals with Alzheimer's disease and other related dementias. The training shall be provided annually and updated as needed. Review of the agency's policy titled "Education Tracking and Reporting" revised 01/25/2019 showed: - To ensure documentation of competency through education tracking and reporting; - To comply with all applicable regulations and standards of care; - All staff are assigned an educational program each year, some of which is mandatory and some elective; - Non-clinical staff will complete a minimum of eight hours of education per calendar year; - On-going education annually addresses, but is not limited to Alzheimer's and dementia training. Review of the agency's policy titled "Orientation-Employees" revised 02/18/2020 showed: - New hire orientation included Alzheimer's disease and dementia training EMPLOYEE/E2: Review of the employee file on 04/20/2021 showed: - Hire date: 10/26/2015; - No yearly Alzheimer's/dementia training since 09/13/2016. During an interview on 04/21/2021 at 2:44 PM, the administrator stated: - E2 was the scheduling coordinator (staffing coordinator); - E2 did not have Alzheimer's/dementia training because he/she worked in the office; - E2 called patients and had interaction with patients over the telephone.

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 the agency's policy review, record review, and interview, the agency failed to ensure: - A completed transfer summary was sent within five business days of a discharge in one (Record/Patient #4) of two closed records reviewed; and - A completed comprehensive discharge summary to include all necessary components was sent to the primary care practitioner or other health care professional who will be responsible for providing care to the patient after discharge within five business days of the patient's discharge in one (Record/Patient #5) of two closed records reviewed. This deficient practice has the potential to affect the post-discharge care of all patients served by the agency. Review of the agency's policy titled, "Discharge Criteria, Process," and revised 06/30/2020, showed in part: - A discharge summary will be sent to the physician within 5 business days of discharge; - The summary will include medications the patient is on at the time of discharge. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to the agency on 03/08/2021 with diagnosis of alcoholic polyneuropathy (neurological disorder in which peripheral nerves throughout the body malfunction simultaneously), skilled nursing (SN), physical therapy (PT), occupational therapy (OT) and social worker MSW. Review of the clinical record showed SN discharged the patient from service on 03/16/2021. The record showed the discharge summary was not completed until 03/30/2021 at 5:05 PM (14 days after the agency discharged the patient from service). There was no evidence to show when the discharge summary was sent to the patient's physician. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to the agency on 01/21/2021 with diagnosis of acute myeloid leukemia (type of blood cancer that starts in the bone marrow), and physical therapy (PT). Review of the clinical record showed PT discharged the patient from service on 02/24/2021. The discharge summary failed to include a list of the medications the patient was taking at the time of discharge. During an interview on 04/21/2021 at 10:00 AM the administrator stated the medication list was not included in the discharge summary.

An on-site complaint investigation (MO00181423) was completed on 03/01/2021 at SSM Health at Home Home Health. The agency had 624 current patients The complaint was not substantiated. None of the allegations reported were verified, but deficiencies were observed and cited in other areas that are not related to the original allegations being investigated.

Discharge Planning CFR(s): 484.58(a) Standard: Discharge planning. An HHA must develop and implement an effective discharge planning process. For patients who are transferred to another HHA or who are discharged to a SNF, IRF or LTCH, the HHA must assist patients and their caregivers in selecting a post-acute care provider by using and sharing data that includes, but is not limited to HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures. The HHA must ensure that the post-acute care data on quality measures and data on resource use measures is relevant and applicable to the patient's goals of care and treatment preferences. This STANDARD is not met as evidenced by: Based on policy review, record review, and interview the agency failed to document adequate discharge planning and education for one (Record/Patient #2) of one discharge record reviewed. This deficient practice has the potential to affect the discharge needs of all patients served by the agency. Findings included: Review of the agency policy titled, "Policy Discharge Criteria, Process, Advance Beneficiary Notice (ABN), given to patients if the agency has reason to believe a service will not be covered by Medicare) HHCCN (Home Health Change of Care Notice, given to patients if their care is going to be reduced or terminated) and Notice to Patients," revised 06/30/2020, showed (in part): - A home health patient will be discharged when one or more of the following conditions exists: - The agency and physician agree objective goals of treatment have been achieved and home health agency services no longer are medically necessary; - Home health discharge process included: * Whenever possible, the patient will be notified at least three working days in advance (preferably two weeks in advance) of the reason for and date of discharge; * When discharging all services to a patient receiving traditional Medicare or Medicare advantage covered services, at least a two day notice is required; * Communication of pending discharge plans will be documented in the clinical record; - The physician will be notified of discharge when the patient's needs have been met; - The patient record must reflect discharge planning activities, coordination with other care providers, the patient's response and understanding of these activities and patient care instructions; - Comply with Medicare requirements for Advance Beneficiary Notice, Home Health Change of Care Notice for traditional Medicare and Medicare Advantage patients, and documentation; - When discharging all covered services to a traditional Medicare or Medicare Advantage patient, an Expedited Determination Notice is required, notifying the patient in advance in writing of the effective date coverage of home care services will end, documented on the form titled, "Notice of Medicare Non-Coverage" (a notice that tells the patient when their service is ending). Review of the agency policy titled, "Education of Patient and Family," reviewed 01/24/2019, showed: - The patient/family's knowledge, skills and behaviors will be assessed on an ongoing basis and, when indicated, lead to additional education; - Education of patient/family, patient/family response, level of understanding, the patient's level of progress towards meeting goals, and/or return demonstration will be documented in the medical record; - Discharge planning involves: *Discharge planning begins when the patient is admitted to service, the patient should be informed of the reason for discharge within a reasonable time frame (preferably two weeks prior to discharge); and education of the patient on continued self-care; - The patient record includes documentation of all teaching, patient's response to teaching, and the patient's level of progress/achievement of goals/outcomes; - Written instructions are provided to the patient; and - Receipt of all written and verbal instructions must be documented in the patient record. RECORD/PATIENT #2: Review of a skilled nurse (SN) visit note dated 01/21/2021 showed the patient had an upcoming physician appointment on 01/25/2021. Review of a fax from the physician dated 01/25/2021 showed the patient would continue to need home health nursing to help with dressing changes. The wound is not healed enough to discharge from care. Review of a new wound protocol order dated 01/25/2021 showed: - Every other day dressing changes, cleanse the left plantar (bottom) foot diabetic ulcer with normal saline, pat dry. Apply liberal amounts of Silvadene 1% cream (antimicrobial) to the left leg, paint periwound (surrounding wound) with betadine (topical antiseptic), fill wound bed with collagen (a protein that helps stimulate new tissue growth), cover with 4 x 4 gauze and ABD pad (large, absorbent pad), secure with kerlex (gauze roll), and apply tubigrip (elastic bandage) from the foot to knee; and - SN to train caregiver to perform on days with no SN visit. Review of the SN visits dated 01/29/2021 and 02/02/2021 showed: - Interventions to document instruction with patient/caregiver on personal risk factors for hospitalization, document discharge planning and instruction, and to educate the patient/caregiver on wound care and prevention of complications including infection; - The nurse failed to document that discharge planning education was provided and/or that wound care instructions were provided to the caregiver with return demonstration to ensure competency of the caregiver to perform wound care; and - The section for discharge planning showed no documentation of discharge planning or instruction, or that the patient received a copy of a Medicare Notice of Non-Coverage, Home Health Change of Care Notice or Advanced Beneficiary Notice. Review of the nursing discharge visit dated 02/04/2021 showed: - The patient's payment source was Medicare HMO/managed care/Advantage plan; - Non-agency caregiver (s) currently provide assistance with medical procedures/treatments (for example, changing wound dressing); -The patient had an upcoming physician appointment on 02/15/2021; - The patient had an alteration in skin integrity related to a diabetic ulcer. The goal that the wound would show signs of improvement as evidenced in improvement in wound characteristics was met on 02/04/2021; - The nurse performed wound care with the patient instructing how to do the wound care; - Caregivers are available and willing to continue every other day wound care; - No documentation that the caregivers were instructed on the wound care with return demonstration to ensure competency to perform wound care; - No documentation of discussion with the physician regarding discharge; and - The patient was discharged from home care services. During an interview on 02/24/2021 at 9:45 AM, nursing supervisor B said the nurses should document that they discussed discharge plans with the patient, discussed any medical follow up that was needed, any ongoing education that was needed and that the physician was notified. During an interview on 02/24/2021 at 10:25 AM, nursing supervisor B said he/she did not find documentation in the patient's record that the nurse instructed the family on wound care. He/she would expect the nurse to at least document that the caregiver was competent to do wound care. He/she said the discharge note sounded like the patient was doing a "teach back" of the wound care. If a caregiver/family member was doing the wound care, he/she would expect the nurse to document he/she instructed the patient and caregiver on wound care, return demonstration, that they verbalized understanding and that they felt competent to do the wound care. He/she did not see documentation where their policy was followed regarding the discharge process. During interviews on 02/25/2021 with nursing supervisor B showed: - At 9:35 AM he/she stated that he/she did not find a discharge notice for the patient. He/she spoke to the nurse regarding whether a notice for discharge was provided to the patient. The nurse thought that since the patient had managed care he/she did not have to provide a notice; - At 1:30 PM he/she did not see documentation that the patient's discharge had been discussed with the physician, but would discuss this with the nurse; - At 1:50 PM he/she spoke with the patient's nurse. The nurse stated that he/she had a long conversation with the physician and informed the physician that the family was doing well with providing wound care. The physician was comfortable with the family doing the wound care. When asked if he/she documented this information, the nurse thought he/she did, but the nursing supervisor said no documentation was found; and - The nurse was going to speak with the physician to send something regarding their discussion. Review of a fax sent from the physician on 02/25/2021 showed he/she had a conversation with the home health nurse. He/she was informed of the patient's discharge since he/she had a family member who was capable to complete dressing changes. The nurse indicated he/she was able to provide education to the family member and is confident that home health was no longer required. The physician expressed concern since the primary caregiver who was the patient's spouse recently passed away and the patient only had a brother. The nurse said he/she was pretty confident the patient did not need home health and would be discharging the patient as he/she had provided education to the brother. The nurse failed to document this information in the patient's medical record.