Every finding on record at St. Joseph Medical Center

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 1/30/25. The Agency was in compliance with the Condition, 42 CFR 484.102, Establishment of the Emergency Program for this survey.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 1/30/25. The Agency was not in compliance with 42 CFR 484, Standards for Home Health Agencies, for this 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 observation, document review and interview, it was determined for 1 of 7 (Pt #8) patients, where home visits were conducted, the Home Health Agency (HHA) failed to visualize all medications and compare them to the current medication profile to ensure the patient was taking the correct medication(s). 1. On 1/29/25 at 3:30 PM, a home visit was conducted at Pt #8’s residence. SOC (Start of Care) 12/17/23, diagnosis: left lower leg wound. At no time was the Registered Nurse observed visualizing the patient’s medication bottles to ensure they matched the current medication profile, ensuring proper medication administration and accurate medication profile. The following discrepancies were noted: a. The wrong dose was written for Gabapentin on the HHA’s medication list. The medication list reads Gabapentin 300mg Three times daily. (Pt #8 reports she has been taking Gabapentin 300mg twice daily and this was also confirmed on her medication bottle). b. Losartan 25mg was missing completely from the HHA’s medication list (Pt #8 reports she has been taking this medication for years). 2. On 1/30/25 at approximately 2:30 PM, the policy “Medication Reconciliation and Drug Review” (approved 4/5/2024), was reviewed and stated, “Home Health, Hospice 1. On admission after a hospitalization, minimally every 60 days by home health or minimally every 90 days by Hospice, the registered nurse, physical therapist, occupational therapist, or speech language pathologist will compare the hospital discharge medication list or current medication list. If not hospitalized with the patient's current medication bottles, including over-the-counter medications.” 4. On 1/30/25 at approximately 2:00 PM, an interview was conducted with the Manager of Home Health Care Services (E #1). E #1 reviewed Pt #8’s medication record and verbally agreed with the above findings.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on document review and interview, it was determined in 1 of 17 (Pt #14) patient’s records reviewed, the Agency failed to ensure staff provided care as indicated on the written POC (Plan of Care). 1. The policy “Home Care Aide Services” (Origination 6/1/92) was reviewed on 1/29/25 at approximately 12:00 PM. The policy stated, “…4. Services are administered in accordance with the HCA (Home Care Aide) care plan and with the patient’s overall plan of care (POC).” 2. Pt #14 Start of Care (SOC): 11/24/24 Diagnosis: Pneumonia Unspecified. The clinical record was reviewed 1/29/25 at 11:10 AM. The POC dated 11/24/24 included an order for Home Care Aide 1 visit every week for 8 weeks. The record indicates that Pt #14 did not receive a Home Care Aide visit until 12/13/24 (20 days after SOC). 3. During an interview on 1/29/25 at 12:05 PM, the Manager of Home Health Care Services (E #1) verbally agreed the Home Care Aide hadn’t conducted any visits to Pt #14 until 12/13/24.

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 1/27/22. The Agency was in compliance with the Condition, 42 CFR 484.22, Establishment of the Emergency Program for this survey.

A recertification survey was conducted on 08/04/2021. The Agency was not in compliance with Standards for Home Health Agencies, 42 CFR 484, as evidenced by: Abbreviations #-number E-employee HHA-home health agency P-patient PTA - Physical Therapy Assistant

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, document review and interview, it was determined for 1 of 7 (Pt #5) home visit observed the Physical Therapist Assistance (PTA) failed to follow the policy for Home visit bag care to prevent the transmission of infections. This has the potential to affect all patients serviced by the Agency with 366 current patients. Findings include: 1. The policy titled "Care and Use of Home Visit Bags and Equipment (A5007-0 approved 6/2/2021)" The policy noted "1...Place appropriate barrier on surface...to attain a clean surface..." 2. Pt #5 SOC: 12/31/21 Diagnoses: Hypertensive Heart Disease and Dissection of Aorta. The clinical record was reviewed on 1/26/22 at approximately 11:00 AM. During a home visit conducted on 1/25/21 at approximately 3:00 PM with the Physical Therapy Assistant (PTA). The PTA placed the home visit bag on the floor without a barrier. 3. During an interview with the Coordinator Regulatory Registered Nurse (E#2) on 1/26/21 at approximately 1:00 PM, E#2 verbally confirmed the home bag should not be placed on the floor.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on document review and interview, it was determined in 1 of 17 ( Pt #8) clinical records reviewed, the Agency failed to ensure services were provided per physician's order. This has the potential to affect all patients serviced by the Agency with a current average monthly census of 366. Findings include: 1. The policy titled "Speech Therapy Evaluation (approved 12/15/2020) was reviewed on 1/27/22 at approximately 9:15 AM noted "...1. Once an order has been obtained for a speech therapy evaluation, a standardized Home Health Speech Therapy Evaluation shall be completed on each patient following the admission..." 2. Pt #8 Start of Care (SOC): 11/9/21 Diagnosis: Pressure Ulcer of Sacral Region. The clinical record was reviewed on 1/26/22 at approximately 2:00 PM. The record noted a physicians order dated 1/7/22 for a Speech Therapy Referral. As of survey date 1/27/22 the record lacked a visit by the Speech Therapist. The Plan of Care (POC) dated 1/8/22 noted for the Aide to conduct visits 1 time every week for 9 weeks. The record lacked Aide visits for the week of 1/9/22. 3. During an interview on 1/27/22 at approximately 9:15 AM with the Coordinator Regulatory Registered Nurse (E#2), E#2 verbally confirmed the Speech Pathologist hasn't conducted any visits yet, the referral was sent changed to out patient Speech Pathologist and the Agency should have checked to be sure it was completed. E#2 also confirmed the Aide missed the visit for the week of 1/9/22.