Every finding on record at St Joseph's Health at Home

This Statement of Deficiencies report is the result of a recertification survey conducted 03/08/22 – 03/16/22. The following information was reviewed on 03/07/22 during the pre-survey preparation: participation in the required emergency drills, and accuracy of contact information in the Health Commerce System. The following information was reviewed during the survey: the agency's emergency preparedness policies and procedures, the emergency patient roster, current listing of agency staff, staff call down list, and staff orientation and annual training. Interviews were conducted with the Director of Patient Services, Clinical Manager and Team Manager. No federal deficiencies were cited. One state deficiency was cited: J1156 Governing Authority.

The following statement of deficiencies represents the results of a partial extended recertification survey of St. Joseph's Health at Home Certified Home Health Agency conducted on 03/08/2022 through 03/16/2022. A standard re-certification survey was initiated on 03/08/2022. Deficient practices were identified within Level 1 standards in 484.55 Comprehensive Assessment of Patients and 484.60 Care Planning, Coordination, Quality of Care, resulting in a partial extended survey. The survey consisted of a review of 17 clinical records including 5 discharge records, 7 observational home visits and 11 personnel records for professional and paraprofessional personnel. The survey included a review of pertinent policies and procedures, Quality Improvement Meeting minutes for the past 8 months, agency's Admission Packet, the Emergency Preparedness Plan, and Complaint Log. Pre-survey activities consisted of review on 03/07/22 of the agency's Health Commerce System account, Home Care Worker Registry, Criminal History Record Check, Internet Quality Improvement and Evaluation System (iQIES) reports for the period 12/2020 to 11/2021, and the agency's compliance with report submissions for the 2019 statistical report and the Emergency Drill conducted 06/11/2019 through 06/13/2019. The Director of Patient Services, Clinical Manager, Quality Manager, Team Managers and staff were interviewed through out the survey. Findings were reviewed at the exit conference on 03/16/2022. The following deficiencies are identified as a result of the survey: Federal: G 476 Investigation of complaints; G 526 Content of the Comprehensive Assessment; G 574 Plan of care Must Include the Following; G 606 Integrate All Services and G 798 Home Health Aide Assignment and Duties State: J 1156 and J 1276 Governing Authority; J 1412, J 1420, J 1428, J 1440 and J 1460 Personnel; R 0610 Requirements before submitting a request.

Investigation of complaints CFR(s): 484.50(e)(1) Standard: Investigation of complaints. The HHA must-- This STANDARD is not met as evidenced by: Based on a review of 17 patient records, the agency's complaint log, and interviews with the Director of Patient Services (DPS), Clinical Manager, Quality Manager and Team Managers, it was determined the agency failed to adequately document, investigate, and resolve potential complaints for 1 of 17 patients (patient # 8). Evidence was as follows: Patient #8 was admitted to the agency on 01/19/22 with diagnoses of corticobasal (neurological) degeneration, dementia, diabetes, sacral pressure ulcer, and difficulty swallowing. The agency failed to ensure a potential complaint was logged, investigated and resolved as follows: On 01/19/22 the SN documented the patient was utilizing a hospital bed with trapeze and one side rail, was completely bed bound, and the caregiver had difficulty positioning the patient in the bed. The patient was incontinent of bladder and bowel. The 01/19/22 Plan of Care included home health aide services (HHA) three times weekly Patient Information Report review revealed the following: On 03/07/22 the home health aide (HHA) documented a missed visit with the reason of “caregiver told me to leave”. On 03/07/22 the HHA scheduler documented further the HHA reported the caregiver may be just having a bad day…but was questioning everything done. The HHA had been caring for the patient for 3 months, and the caregiver wanted to know what the HHA was doing sitting in his vehicle for a few minutes when arriving, an explanation was made of going over plan, making phone calls and the aide always stayed for the full hour ordered and nothing had changed with the routine. The caregiver was “all over” the HHA and questioning every move. The caregiver asked the HHA to leave. There was no evidence the scheduler spoke with the caregiver to identify concerns. The scheduler documented the HHA would be unscheduled from all patient visits. There was no evidence the case manager was notified of the issue. On 03/07/22 the SN visited the patient and there was no documentation of the request to remove the HHA or any problems with the HHA. On 03/08/22 another SN visited the patient and there was no evidence the issue with the HHA was discussed with the caregiver or the patient currently not receiving HHA service. The SN documented in the HHA supervision check list that the HHA was following the aide care plan, meeting the needs of the patient and the client/caregiver was satisfied with care provide by the HHA even though the HHA had been pulled from caring for the patient. On 03/11/22 the HHA scheduler documented a message was left to let the caregiver know an aide was available with no call back. On 03/14/22 the surveyor requested an updated log of any complaints received since a log was provided following the entrance date of 03/08/22. This incident was not included in the complaint log. On 03/15/22 at 11 a.m. the surveyor reviewed the record with the DPS, Clinical Manager, Quality Managers and Team Managers. They acknowledged the findings and provided no additional information. Failure to document, investigate, and resolve potential complaints may lead to unmet patient needs and possible agency wide negative patient outcomes.

Content of the comprehensive assessment CFR(s): 484.55(c) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: This STANDARD is not met as evidenced by: Based on observation, clinical record review, and interviews with the Director of Patient Services (DPS), Clinical Manager, Quality Manager and Team Managers, it was determined for 8 of 17 records (patients # 4, 8, 9, 10, 12, 13, 14, and 15) the agency failed to ensure comprehensive nursing assessments were of sufficient scope to ensure all patient needs were identified. Evidence was as follows: Patient #14 was admitted to the agency on 10/16/21 with diagnoses of infected foot ulcer and type 2 diabetes. The patient was selected from the Centers for Medicare and Medicaid Services (CMS) potentially avoidable event listing for emergent care for hypo/hyperglycemia with a discharge/transfer date of 10/29/21. The patient was discharge from the hospital after a stay for a wound infection and amputation and was discharged on intravenous antibiotics. The 10/14/21 hospital discharge instructions included blood glucose (BG) test strips “as instructed”, Lantus (long-acting) insulin 60 units nightly, and Lispro insulin (short-acting) 30 units under the skin 3 times per day per sliding scale before meals “per home schedule”. The 10/16/21 Certification and Plan of Care included Lispro insulin 30 units with meals per sliding scale in home, however, no specifics regarding how the patient was to use the sliding scale. On 11/04/21 the SN visited the patient for a Resumption of Care (ROC) and documented Insulin- yes, TID, usual BGs TID with no specific range, able to self-inject. The SN documented the patient had a new Freestyle Libre monitor and was independent with use, however, there was no documentation the SN assessed the home sliding scale and patient understanding of it. The 11/04/21 ROC orders continued to include the previous lispro insulin orders with lack of specific sliding scale instructions. On 11/10/21 the SN visited the patient and documented a blood glucose of 187 which was checked during the visit with no further information regarding ranges and sliding scale insulin use. On 11/15/21 the SN visited the patient and documented the patient was monitoring BGs 3 times per day with ranges in the 200s and the patient was instructed to notify the physician of BGs less than 70 or greater than 300 with no assessment of the sliding scale. On 11/17/21 the SN visited the patient and documented since Monday a.m. fasting BG of 300-400 reported to MD. There was no documented assessment of use of the sliding scale. On 11/19/21 the SN visited, and this was the first time the sliding scale was mentioned. The LPN documented the patient took 100 units of Lantus the previous night and took lispro insulin 6 times with a dosage of 10 or 30 units. The fasting BG was 280. The patient stated he checked his meter and if the reading is above 300 took insulin. The patient was aware of physician orders but stated ordered insulin was not enough to keep BG down. The SN documented the physician office was notified and the SN instructed on the correct dosage, however, it was unclear what the correct dose was due to the nonspecific sliding scale orders. On 11/22/21 the SN visited the patient and documented the patient reported takin 40 units of Lispro with meals and Lantus 100 units at bedtime. On 03/11/22 at 2 p.m. the surveyor reviewed the record with the DPS, Clinical Manager, Team Managers and Quality Manager. They acknowledged the findings and provided no additional information. Patient #8 was admitted to the agency on 01/19/22 with diagnoses of corticobasal (neurological) degeneration, dementia, diabetes, sacral pressure ulcer, and difficulty swallowing. The 01/11/22 referral information included diabetes medications as follows: -Lantus (long-acting insulin) 40 units at breakfast, decrease by 2 units if a.m. readings frequently below 100 -Metformin 1000 mg twice daily with meals. -Humalog sliding scale insulin incrementally based on blood glucose (BG) levels of 201-450, with instructions to call the physician with BG greater than 450. On 01/19/22 the skilled nurse (SN) visited the patient for the start of care assessment and documented a BG of 79, and the caregiver was testing BGs three times daily with a range of 60-90. The SN documented the caregiver was able and willing to perform injections, however failed to assess a demonstration of the caregiver’s ability to test BGs and administer insulin. The SN documented due to BGs being low the patient was now taking Lantus 20 units and was not taking Humalog. On 03/15/22 at 11 a.m. the surveyor reviewed the record with the DPS, Clinical Manager, Team Managers and Quality Manager. They acknowledged the findings and provided no additional information. Patient #9 was admitted to the agency on 01/27/22 with diagnoses of squamous cell carcinoma of the tongue, type 2 diabetes, bipolar, schizophrenia, and history of urinary tract infection. On 01/27/22 the skilled nurse (SN) visited the patient for the initial assessment and documented under mouth throat “aftercare oral cancer surgery…plan for RT”. The SN failed to assess the mouth for swelling, drainage, tenderness, or presence of lesions. The pain assessment was incomplete. The SN documented the patient had mouth soreness and generalized aches and pains with a severity of 4 out of 10 treated with medications however failed to assessment what medications the patient was taking, the frequency and effectiveness. The 01/27/22 medication list included the following pain medications: -Acetaminophen 325 mg every 6 hours as needed for pain -Gabapentin 300 mg three times daily -Voltaren arthritis pain 1% topical gel twice daily to knees. (This was different from the 01/11/22 Medication Review Report from the skilled nursing facility listed this medication as applied to right shoulder). On 03/15/22 at 11 a.m. the surveyor reviewed the record with the DPS, Clinical Manager, Team Managers and Quality Manager. They acknowledged the findings and provided no additional information. Patient # 15 was admitted to the agency on 09/28/21 with diagnoses of left femur fracture, fracture around prosthetic left knee joint, type 2 diabetes, rheumatoid and osteoarthritis. The 09/23/21 orthopedic referral included instructions for the patient to increase weight-bearing from 100 to 150 pounds. On 09/28/21 the physical therapist (PT) visited the patient for the initial assessment and documented the patient was taking Trulicity 150 mg weekly, Glucophage 500 in the a.m. and 1000 in the p.m., the patient was testing blood glucose (BG) levels twice daily with a range of 115-125 and taking an anticoagulant, low dose aspirin. There was no evidence the PT observed the patient’s ability to perform blood glucose testing or administer the injection. The medication list included an antifungal medication, Nystatin three times daily, and an antiparasitic medication, Permethrin one inch leave on 12 hours then wash off and repeat in one week. There was no assessment of the presence of rashes, location for use of medications. The pain assessment was incomplete. The PT documented the patient had pain to the left leg with activity with a level of 5 on a scale of 1 to 10 relieved with medications and rest, however failed to include the type of medication taken and frequency of use. On 03/15/22 at 11 a.m. the surveyor reviewed the record with the DPS, Clinical Manager, Team Managers and Quality Manager. They acknowledged the findings and provided no additional information. Failure to ensure comprehensive assessments are complete and accurately reflect the patient's status has the potential for negative outcomes for the agency patient population. Patient # 10 was admitted to the agency on 12/13/21 with diagnoses of parkinson’s disease, small bowel obstruction and bladder cancer with urostomy (surgical opening to drain urine). The SN failed to perform a comprehensive assessment of the patient’s needs. Urostomy On 12/13/21 the SN documented in the initial comprehensive assessment the patient had urostomy that was cared for by his wife. The SN failed to assess the stoma location, site, type of appliance/system used, the frequency of appliance changes and stoma site care, the amount and characteristics of urine draining, the presence of leaks and integrity of surrounding skin. There was no evidence the SN observed the caregiver’s ability to correctly perform urostomy care. On 02/10/22 the SN visited the patient for a recertification assessment. The note included the caregiver reported the patient had skin irritation beneath the urostomy appliance. The caregiver stated she was cleansing the area with barrier wipes. The SN documented the caregiver was advised to monitor and continue to use the barrier wipes. The SN would offer suggestions at the next visit if no improvement. The SN failed to assess the site. The SN visited the patient for reassessment on 02/17/22, 02/24/22, 03/03/22 and 03/10/22. There was no evidence the SN reassessed the urostomy appliance and skin for breakdown. Skin On 01/06/22 the SN visited the patient for reassessment. The SN documented the caregiver reported the patient had redness to the perineal area and was using a barrier cream. The SN failed to assess the perineal area fro redness/breakdown. On 03/15/22 at 11:00 am the record was reviewed with the DPS, Clinical Manager, Quality Manageer and Team Managers. They acknowledged the findings, and no additional information was provided. Patient # 13 was admitted to the agency on 07/07/21 with diagnoses of atherosclerotic heart disease with coronary artery bypass graph x 4 vessels, heart failure and high blood pressure. The SN failed to perform a comprehensive assessment of the patient’s needs. Skin The 07/07/21 plan of care included instructions for the patient to use Nystatin 100,000 units/gram cream to fungal rash 2 times per day and Triamcinolone acetonide 0/1% cream 2 times per day to eczema. On 07/07/21 the SN completed the initial comprehensive assessment. The SN failed to assess the patient’s skin for rash or active eczema and determine if the patient or caregiver were using topical medications 2 times per day as directed in the plan of care. On 03/11/22 at 2:00 pm the record was reviewed with the DPS, Clinical Manage, Quality Manager and Team Managers. They acknowledged the findings, and no additional information was provided. Patient # 4 was admitted to the agency on 02/01/22 with diagnoses of osteoarthritis, asthma, and a history of falls. The SN failed to perform a comprehensive assessment of the patient’s needs. Pain On 02/01/22 the SN documented the patient reported a current pain level of 4/10 on a 0-10 pain rating scale. The SN failed to assess if the patient uses medication or other interventions for pain management including medication/intervention used, the frequency needed and if medication used, the amount and time taken. Respiratory The SN documented the patient had wheezing in the right and left upper lobes. The 02/01/22 plan of care included the following order: Ventolin HFA 90 mcg/actuation aerosol inhaler every 4 hours as needed for wheezing and SN to obtain baseline oxygen saturation via pulse oximeter to ensure adequate oxygen saturation. The SN failed to assess the patient’s oxygen saturation level or use of inhaler for wheezing including assessment of patient/caregiver knowledge regarding inhaler and observation and demonstration of how to correctly administer. On 03/11/22 at 2:00 pm the record was reviewed with the DPS, Clinical Manager, Quality Manager and Team Managers. They acknowledged the findings, and no additional information was provided. Patient # 12 was admitted to the agency on 01/26/22 with diagnoses of type 2 diabetes, blister to right lower leg and chronic kidney disease. The SN failed to perform a comprehensive assessment of the patient’s needs. On 01/26/22 the SN documented the patient had back pain at a level of 4/10 (0-10 pain scale) with 6/10 as most severe. The note included the patient managed pain with medication. The 01/26/22 plan of care contained orders for the patient to take Tramadol (narcotic medication) 50 mg 3 times/day as needed (PRN) for moderate to severe pain and Tylenol (non-narcotic medication) 500 mg 2 tablets every 6 hours PRN for mild to moderate pain. The SN failed to assess which medication the patient was taking, the amount and frequency of each pain medication including the patient’s knowledge of how and when to take each medication correctly based on pain level. Skin On 01/26/22 the SN documented the patient was obese with chronic skin issues. The plan of care included orders for Ketoconazole (antifungal) 2% topical daily PRN and Nystatin powder (anti-fungal) 100,000 units/gm 2 times/day PRN. The aide care plan dated 01/26/22 included instructions for the home health aide to apply Nystatin powder to groin every visit. The SN failed to assess the skin to identify the presence and location of active rashes. On 03/16/22 at 10:45 am the record was reviewed with the DPS, Clinical Manager, Quality Manager and Team Managers. They acknowledged the findings, and no additional information was provided.

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 a review of clinical records, and interviews with the Director of Patient Services (DPS), Clinical Manager, Quality Manager, and Team Managers it was determined in 5 of 17 records (patients # 4, 9, 10, 14. and 15), the agency failed to develop individualized plans of care that were complete and accurate, and addressed the total needs of the patients. This was evidenced by: Patient #14 was admitted to the agency on 10/16/21 with diagnoses of infected foot ulcer and type 2 diabetes. The patient was selected from the Centers for Medicare and Medicaid Services (CMS) potentially avoidable event listing for emergent care for hypo/hyperglycemia with a discharge/transfer date of 10/29/21. The 10/14/21 hospital discharge instructions included blood glucose (BG) test strips “as instructed”, Lantus (long-acting) insulin 60 units nightly, and Lispro insulin (short-acting) 30 units under the skin 3 times per day per sliding scale before meals “per home schedule”. The 10/16/21 Home Health Certification and Plan of Care included Lispro insulin 30 units with meals per sliding scale in home, however, no specifics regarding how the patient was to use the sliding scale. On 11/04/21 the SN visited the patient for a Resumption of Care (ROC) and documented Insulin- yes, TID, usual BGs TID with no specific range. The 11/04/21 ROC orders continued to include the previous lispro insulin orders with lack of specific sliding scale instructions. On 03/11/22 at 2 p.m. the surveyor reviewed the record with the DPS, Clinical Manager, Team Managers and Quality Manager. They acknowledged the findings and provided no additional information. Patient # 15 was admitted to the agency on 09/28/21 with diagnoses of left femur fracture, fracture around prosthetic left knee joint, type 2 diabetes, rheumatoid and osteoarthritis. The 09/23/21 orthopedic referral included instructions for the patient to increase weight-bearing from 100 to 150 pounds. The 09/28/21 Home Health Certification and Plan of Care was incomplete as follows: -The medication list included an antifungal medication, Nystatin three times daily, and an anti-parasitic medication, Permethrin one inch leave on 12 hours then wash off and repeat in one week and failed to include location for use of medications. -The Plan of Care failed to include weight-bearing status, frequency for BG testing and parameters for reporting abnormal BGs. On 03/15/22 at 11 a.m. the surveyor reviewed the record with the DPS, Clinical Manager, Team Managers and Quality Manager. They acknowledged the findings and provided no additional information. Patient #9 was admitted to the agency on 01/27/22 with diagnoses of squamous cell carcinoma of the tongue, type 2 diabetes, bipolar, schizophrenia, and history of urinary tract infection. On 01/27/22 the skilled nurse (SN) visited the patient for the initial assessment and documented the patient was at a high nutritional risk and had a baseline weight of 163 pounds and planned to monitor weight due to planned radiation treatment. The 01/27/22 Plan of Care failed to include an order for measuring weights or parameters for reporting changes to the physician although SNs documented multiple times the patient goal of not losing weight. On 03/15/22 at 11 a.m. the surveyor reviewed the record with the DPS, Clinical Manager, Team Managers and Quality Manager. They acknowledged the findings and provided no additional information. Failure to ensure that a comprehensive individualized plan of care is developed has the potential for unmet patient needs. Failure to ensure that a comprehensive individualized plan of care is developed has the potential for unmet patient needs. Patient # 10 was admitted to the agency on 12/13/21 with diagnoses of parkinson’s disease, small bowel obstruction and bladder cancer with urostomy (surgical opening to drain urine). The 12/13/21 plan of care failed to include the following: Urostomy The 12/13/21 plan of care included the patient had a urostomy and the caregiver provides the urostomy care. The plan failed to include the type of appliance, the frequency for changing/emptying the appliance and instructions for ostomy site care including cleansing agents, application of barrier/skin protectant or adhesive agents. On 02/10/22 the SN documented in the recertification assessment the caregiver reported the patient had skin irritation beneath the urostomy appliance. The note included the caregiver was cleansing the area with barrier wipes. The SN failed to notify the physician for a plan to use barrier wipes or other interventions for skin breakdown. CPAP (continuous positive airway pressure) The 12/13/21 plan of care included the patient wears CPAP at bedtime. The plan failed to include the CPAP machine pressure settings. Pressure Relieving Devices On 01/06/22 the SN visited the patient. The SN documented the caregiver reported the patient’s heels were reddened and blanchable in the morning. The caregiver ordered heel protectors for pressure relief to use while in bed. The SN failed to notify the physician and develop a plan for using heel protectors or other pressure relieving devices. On 03/15/22 at 11:00 am the record was reviewed with the DPS, Clinical Manager, Quality Manager and Team Managers. They acknowledged the findings, and no additional information was provided. HV Patient # 4 was admitted to the agency on 02/01/22 with diagnoses of osteoarthritis, asthma, and a history of falls. The 02/01/22 plan of care failed to include the following: Pain Management On 02/08/22 the SN visited the patient and documented the patient used a heating pad to manage back pain. On 03/09/22 the surveyor completed an observational home visit with the SN. During the visit, the surveyor observed the patient had a heating pad placed in a recliner chair, The SN performed a pain assessment and reported pain level 4/10 on 0-10 rating scale and continued to use a heating pad for pain management. The 02/01/22 plan of care failed to include a plan with instructions for the patient to use heating pad for pain. Nutrition and Weight On 02/16/22 the SN documented the patient’s caregiver stated the patient was taking Boost or Ensure daily due to concerns regarding nutrition and potential weight loss. During the observational home visit, the caregiver discussed nutrition and weight loss concerns with the SN. The SN advised the caregiver to continue with the Ensure supplements and assisted the caregiver with obtaining the patient’s weight. The SN told the caregiver the SN would weigh the patient weekly to monitor weight. The 02/01/22 plan of care failed to include instructions to provide dietary supplements or a plan with parameters for monitoring weight. On 03/15/22 at 11:00 am the record was reviewed with the DPS, Clinical Manager, Quality Manager and Team Managers . They acknowledged the findings, and no additional information was provided.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, 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 disciplines. This ELEMENT is not met as evidenced by: Based on a review of clinical records, and interviews with the Director of Patient Services (DPS), Clinical Manager, Quality Manager and Team Managers it was determined in 3 of 17 records (patients # 4, 12, and 13) the agency failed to ensure the patient's plan of care was effectively coordinated: This was evidenced by: 1. Patient # 13 was admitted to the agency on 07/07/21 with diagnoses of atherosclerotic heart disease with coronary artery bypass graph x 4 vessels, heart failure and high blood pressure. The agency clinicians failed to coordinate care to ensure all patient needs were met. This record was selected for review from the Centers for Medicare and Medicaid Services (CMS) potentially avoidable event listing for the period of 12/2020 to 11/2021 for emergent care for improper medication administration, medication side effects with a discharge/transfer date of 08/09/21. On 07/15/21 at 9:00 a.m. the physical therapist (PT) visited the patient. The PT documented upon standing and walking, the patient became lightheaded and dizzy. The PT assisted the patient to a chair and found the patient’s blood pressure was 96/52. Following a rest period, the PT had the patient stand for blood pressure recheck and it was 90/56. The patient refused emergent care. The PT called the physician’s office and left a message. The note included the PT later spoke with a representative from the physician office and was told the physician’s office would contact the patient. The PT documented the PT coordinator was notified and the coordinator alerted the team. The PT documented the licensed practical nurse (LPN) was scheduled to visit later that day. On 07/15/21 at 12:30 p.m. the LPN visited the patient. The LPN documented the patient’s blood pressure was 100/54 and was not symptomatic for low blood pressure. The caregiver stated they were waiting for a call back from the physician regarding low blood pressure. The agency clinicians failed to recognize sending the LPN to visit the patient following a change in condition was inappropriate as the responsibility of patient assessment is outside of the scope of practice for LPNs. Per Section 6902 of Article 139 of the NY State Education Law. This is clarified by the New York State Education Department information regarding Practice Information "The Differentiated Scope of Practice of Licensed Practical Nurses (LPNs) and Registered Professional Nurses (RNs)" which clarifies that assessment is not within the privilege of an LPN, and that the roles of RN and LPN are not interchangeable; the LPN may not interpret patient clinical data or act independently on such data; they may not triage. On 07/17/21 The caregiver called the agency to report the patient was feeling very cold and lethargic. The caregiver reported the patient’s blood pressure was in the 80’s The SN instructed the caregiver to call 911 to have the patient evaluated in the emergency department (ED). The patient remained in the ED under observational status for hypotension from 07/17/21-07/19/21. The agency clinicians failed to ensure the patient was appropriately assessed and care was coordinated with the physician following a change in the patient’s condition. On 03/11/22 at 2:00 p.m. the record was reviewed with the DPS, Clinical manager and Team Managers.. The surveyor asked if the patient record was audited as a potentially avoidable adverse event. The DPS stated it was and provided the surveyor with the report. Although the agency identified the lack of communication with the physician and case manager was a contributing factor and in need of improvement to prevent similar occurrences; the audit failed to identify the need for the clinicians to coordinate a plan to ensure the appropriate clinician visited, assessed, and followed up with the physician on the date of the episode may have prevented the ED/observational stay. 2. Patient # 12 was admitted to the agency on 01/26/22 with diagnoses of type 2 diabetes, blister to right lower leg and chronic kidney disease. The agency clinicians failed to coordinate care to ensure all patient needs were met. On 02/07/22 the SN visited the patient and documented the patient had a new open and draining wound to the left groin. The SN notified the physician and obtained an order for the SN to assess the left groin wound every visit and for the patient to shower, and cleanse wound with soap and water and cover with DSD daily and PRN. There was no evidence the SN instructed the patient or coordinated a plan to ensure daily wound care was performed as ordered, as SN visit frequency was 2 times per week. On 02/08/22 the SN documented in the patient information report a PRN visit to reassess left groin wound was scheduled. On 02/08/22 the licensed practical nurse (LPN) visited the patient. The LPN documented PRN visit completed for wound care to the left groin area. The SN failed to coordinate a plan for wound reassessment as the responsibility of patient assessment is outside of the scope of practice for LPNs per Section 6902 of Article 139 of the NY State Education Law. (see full definition this tag patient # 13) On 03/16/22 at 10:45 a.m. the record was reviewed with the DPS, Clinical Manager, Quality Manager and Team Managers. They acknowledged the findings, and no additional information was provided. 3. Patient # 4 was admitted to the agency on 02/01/22 with diagnoses of osteoarthritis, asthma, and a history of falls. The agency clinicians failed to coordinate care to ensure all patient needs were met. On 02/09/22 the occupational therapist (OT) visited the patient. The OT documented the patient was referred to the agency due to frequent falls. The note included the caregiver stated concern with increased incontinence at night. The OT recommended a bedside commode to decrease the risk of falling in the bathroom and caregiver agreed, however; There was no evidence the OT coordinated a plan to ensure the patient obtained a bedside commode to decrease the risk of falling. On 03/15/22 at 11:00 am the record was reviewed with the DPS, Clinical Manager, Quality Manager and Team Managers. They acknowledged the findings, and no additional information was provided.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on reviews of clinical records for patients receiving home health aide (HHA) service and interviews with the Director of Patient Services (DPS), Clinical Manager, Quality Manager and Team Managers, evidence was lacking in 3 of 9 records (patients # 11, 12 and 15) that the clinicians develop complete and accurate aide written instructions. This was evidenced by: Patient #11 was admitted to the agency on 11/15/21 with diagnoses of paraplegia (paralysis of lower body), constipation, hypertension, and neurogenic bladder. On 01/27/22 the patient transferred to the hospital and was hospitalized until 02/03/22. On 02/01/22 the patient had a laparoscopic cholecystectomy (removal of gall bladder) and placement of a Jackson-Pratt (JP) drain (drain fluid from surgical area). On 02/04/22 the skilled nurse (SN) visited the patient for the resumption of care assessment and documented the patient had 4 incisions to the abdomen, the JP drain and had a stage II pressure ulcer to the sacrum. The 02/04/22 resumption of care orders included daily home health aide (HHA) services. There was no evidence the Home Health Aide plan was updated to include the presence of the new incisions, drain, or pressure ulcer and instructions of signs and symptoms to report to the SN. On 03/15/22 at 11 a.m. the surveyor reviewed the record with the DPS, Clinical Manager, Team Managers and Quality Manager. They acknowledged the findings and provided no additional information. Patient # 15 was admitted to the agency on 09/28/21 with diagnoses of left femur fracture, fracture around prosthetic left knee joint, type 2 diabetes, rheumatoid and osteoarthritis. The 09/23/21 orthopedic referral included instructions for the patient to increase weight-bearing from 100 to 150 pounds (partial weight bearing) to the left leg. On 09/28/21 the physical therapist (PT) visited the patient for the initial assessment and documented the patient was taking Trulicity (injected diabetic medication) 150 mg weekly, Glucophage (oral antidiabetic medication) 500 mg in the morning and 1000 mg in the evening and was taking an anticoagulant, low dose aspirin. The 09/28/21 Home Health Certification and Plan of Care included home health aide (HHA) services twice weekly for 4 weeks. The 10/14/21 home health aide care plan failed to include diabetic or bleeding precautions. The aide plan included the aide was to assist the patient to transfer to the chair or the bedside commode and did not include the weight-bearing status or any assistive devices. On 03/15/22 at 11 a.m. the surveyor reviewed the record with the DPS, Clinical Manager, Team Managers and Quality Manager. They acknowledged the findings and provided no additional information. Failure to ensure that home health aide care plans are complete has the potential for unmet patient needs. Patient # 12 was admitted to the agency on 01/26/22 with diagnoses of type 2 diabetes, blister to right lower leg and chronic kidney disease. The 01/26/22 plan of care included a home health aide (HHA) 3 times/week for 8 weeks to meet personal care needs. The SN failed to ensure the aide care plan included complete and updated instructions as follows: Bathing The 01/26/22 home health aide care plan included instructions for the aide to shower the patient at each visit. The SN failed to include the level of assistance the patient required The 01/26/22 plan of care included the patient had a wound with a Mepilex dressing to the right shin. The SN failed to include the patient had a wound and what precautions needed to be taken to protect the wound dressing while showering the patient. The aide care plan instructed the aide to apply Nystatin powder to the groin at every visit. On 02/07/22 the SN received a physician’s order for the patient to shower and cleanse open draining boil to the left groin with soap and water, pat dry and cover with 4 x 4 gauze dressing daily and PRN. The SN failed to update the aide care plan with the new wound care and whether the aide should continue to apply Nystatin powder to the groin with an open wound present. Diabetes The 01/26/22 plan of care included the patient was a type 2 insulin dependent diabetic with sliding scale insulin coverage before meals and that the patient was on a cardiac diabetic diet. The home health aide care plan included the aide was to prepare a meal at every visit. The SN failed to include the patient was to test blood sugar and administer sliding scale insulin before meals. The aide care plan failed to include diabetic/cardiac diet and precautions with signs and symptoms the aide was to observe for and report regarding high and low blood sugar. On 03/16/22 at 10:45 am the record was reviewed with the DPS, Clinical Manager, Quality Manager and Team Managers. They acknowledged the findings, and no additional information was provided.