Every finding on record at St Louis Home Health LLC

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 11/02/2022. 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 Agencies.

A partial extended survey for Medicare recertification for the home health provider was completed on 11/02/2022. The agency had 388 current patients. The COVID-19 Health Care Staff Vaccination regulation was reviewed as part of the Medicare recertification survey. During the survey it was determined the agency was in compliance with the regulation.

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 agency failed to ensure a complete and accurate list of all the medications that the patient was currently using in one (Record/Patient #3) of three home visit observations. This deficient practice has the potential to affect the agency's ability to ensure safe and effective use of medications for all patients served by the agency. Findings included: Review of the agency's policy titled, "Medication," revised date January 13, 2020 showed: A registered nurse (RN) conducts an assessment of the patient's current medication regimen by inspecting all bottles of on-hand prescription and over-the-counter (OTC) medication and comparing them to the facility discharge list in the home (when available); An RN creates a medication profile by documenting the name and dosing instructions for each drug and, using electronic medical record (EMR) alerts, notes major interactions, duplicated drugs, and allergy alerts and; An order must be written and the reason stated for all OTC medication modifications after the start of care (SOC). RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to the agency on 10/28/2022 after a hospital stay to have surgery for a right hip joint replacement. He/she lived at home. The patient received nursing and physical therapy care. Observation on 11/01/2022 at 10:15 AM, during the patient's home visit, showed the medications were reconciled using a current medication profile supplied by the agency and a written list provided by the patient to the surveyor. The following medications were on the agency's medication profile: Cholecalciferol (vitamin D3) 125 microgram (mcg) (5000 unit) tablet, take one tablet every morning; Cyanocobalamin (vitamin B12) take one tablet every morning; Multi-Day (vitamin tablet) one tablet every morning; PreserVision AREDS (multivitamin and mineral combination) 2,148 mcg-113milligram (mg)-45mg-17.4 take one tablet two times daily; and Biotin (vitamin) 1,000 mcg chewable tablet take one tablet every morning. Per patient interview during medication observation, the patient stated that he/she had stopped taking his/her vitamins two weeks ago. During an interview conducted at the time of the medication observation, the occupational therapist (OT) stated that he/she had no explanation for the medications not reconciling.

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 record review and interview the home health agency failed to ensure the plan of care (POC) included all of the required elements in, but not limited to, one (Records/Patients #4) of five full record reviews. This deficient practice has the potential to affect the care of all patients served by the agency. Findings Included: Review of the agency’s undated policy titled, “Plan of Care,” showed the following: - Home care services are furnished under the supervision and direction of the client’s physician; - The plan of care (POC) is based on current assessment by a registered nurse (RN), therapists, and other health care team members; - The POC services as a measurable guideline to care given by all professional disciplines involved in client care; - Meets state/federal guidelines, and all applicable laws and regulations; - The POC will be completed in full to include: * Specific procedures and modalities for therapy services * Functional limitations and precautions * Activities permitted or restrictions * Medications, treatments, and procedures; * Instructions to client/caregiver, as applicable; and - Orders for therapy services will include specific modalities to be used and the amount, frequency, and duration. RECORD/PATIENT #4 Review of the medical record showed the patient was admitted to the agency on 10/01/2022 with a diagnosis of aftercare following joint replacement and presence of right artificial knee joint. Review of the hospital after visit summary dated 09/29/2022 through 09/30/2022 showed: - Your incision is closed with Prineo (a clear liquid sealant and mesh) that will remain on your incision for 21 days after surgery. During your first home health visit the healthcare provider will remove the Telfa (non-adherent dressing), webril (white dressing rolled around leg) and ace wrap to evaluate your incision to ensure it is sealed and perform return demonstration regarding wound care management and removal of Prineo. Do not scratch, rub, scrub or pick at the Prineo- this could cause it to loosen or come off before incision is healed; - Reapply ace wrap from toes to thigh once incision has been assessed to reduce swelling. May remove for showering and at night if needed; - The patient may remove mesh 21 days after surgery. At the time of the Prineo removal, rub a petroleum based ointment such as Vaseline on the entire width and length of the Prineo tape to loosen glue, then loosen one of the edges and slowly and gently peel it back form the incision; - If you notice the Prineo beginning to loosen or coming off, contact your surgeon’s nurse for further instructions; - Do not submerge your incision (in a tub, etc.) until it is healed. Do not use lotion, oil, alcohol or cream on your incision; - Change clothes and undergarments daily to help keep incision clean; - Don not take non-steroidal anti-inflammatory drugs that your surgeon does not prescribe for four weeks after surgery; - Daily wound checks: Always wash your hands before touching your dressing. Check the wound daily, look for and take actions for the following: * Increased redness, warmth or color, increased drainage or opening of the wound, moderate pain while resting. Ice and elevate, change dressing after washing hands, check wound daily, and call surgeon to report any symptoms * Fever above 101 degrees, swelling of legs and feet, pain that is not relieved by current pain medicines, redness, warmth or opening of the wound, drainage with an odor, and unable to walk or bear weight on leg. Call your surgeon to schedule appointment; - Do not put pillows under your knee- we want the leg to be as straight as possible. Place a rolled towel under your ankle while lying in bed or when leg is elevated on chair/ottoman, this will straighten your leg; - Apply ICE to your knee up to 20 minutes an hour, as needed, while awake- especially after therapy and home exercise; - Elevate your operative leg, keeping your toes higher than your knee and your knee higher than your heart, use pillows (lengthwise) to create a ramp that will support your entire leg and keep your knee as straight as possible. Try to do this position for 40 minutes about three times a day; - Do not rest your operative leg on the floor longer than 30 minutes at a time. Always put your heel up on a chair/ottoman. Take frequent short walks around your home/room daily to help decrease the swelling; and - Use your incentive spirometer ten deep breaths every hour while awake. Review of the OASIS (Outcome and Assessment Information Set) start of care assessment, dated 10/01/2022 at 11:27 AM, showed the following: - Diabetic precautions; - Instructed on care and removal of Prineo on 21st day; and - Patient instructed on use of Ace wrap and when to notify physician; Review of the POC dated 10/01/2022 through 11/29/2022 showed the following: - Diabetic precautions; - Compression wrap toes to thigh/surgical leg for three weeks; - Compression wrap toes toe to thigh/surgical leg for three weeks post-operation; - Therapeutic elevation and cold therapy 20 minutes per hour per site, four to six times daily as needed for pain and swelling; - Prineo: Registered nurse, physical therapy or patient to remove three weeks post-operation; - Teach wound management and signs/symptoms reportable to physician; and - Skilled nurse goals diabetic care as appropriate. The POC failed to include diabetic interventions and education. Specific instructions on when to apply and remove the compression wrap/Ace bandage. Educate patient to assess wound daily and what problems to notify the physician. Specific education and interventions regarding wound care/management/precautions that were included on the hospital after visit summary. Type of cold therapy. There was no incentive spirometer included on the plan of care. Review of physical therapy assistant visit dated 10/03/2021 at 12:30 PM, showed the patient stated he/she was told he/she did not have to have his/her right surgical site covered during the day. He/she keeps the dressing and Ace wrap off during the day, and places a dressing on and wraps with an Ace wrap at night (the POC failed to include a dressing in POC [a Telfa dressing was to be removed on admission] and instruction when to use the Ace wrap). During an interview on 11/02/2022 at 10:14 AM, the director of nursing stated most patients admitted to the agency have joint replacements so they would utilize the same POC.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on policy review, home visit observation, and interview the agency failed to follow accepted standards of practice for infection control, to prevent the transmission of infections and communicable diseases in one (Record/Patient #2) of three home visit observations. This deficient practice has the potential to affect the infection control for all patients served by the agency. Findings included: Review of the agency's undated policy titled "Handwashing," showed the following: Hand washing is indicated after removing gloves; Between tasks on the same client; and After touching objects that are potentially contaminated. Review of national standard McGoldrick, M (2015). Home Care Infection Prevention and Control Program. Saint Simons Island, GA: Home Health Systems, Inc. Isolation Precautions: "Gloves" Gloves will be used on a one-time basis (i,e,, disposable gloves) and not washed or decontaminated for reuse; Changed during patient care if the gloved hands will move from a contaminated body-site to a clean body site; Removed after contact with the patient and/or the surrounding environment (including medical equipment); and Removed using proper technique to prevent hand contamination, with hand hygiene performed after each glove removal. Review of the agency's undated policy, "Standard Precautions for All Health Care Workers" showed the following: Gloves must be worn when having direct contact with blood, body fluids, mucous membranes or non-intact skin. Gloves should be changed after each client contact. When gloves are removed, thorough hand washing is required. Gloves do not take the place of hand washing. RECORD/PATIENT #2: Review of the clinical record showed that the patient was admitted to home health services on 10/23/2022 for aftercare following joint replacement surgery, presence of right artificial hip joint. Observation on 11/01/2022 at 9:00 AM, during the patient's home visit, showed the physical therapist (PT): Applied gloves and provided care to the patient; Assessed the patient's vital signs (blood pressure, pulse etc); Removed the patient's wound dressing; and assisted patient with walking activities; and During all of these patient activities, the PT failed to remove his/her gloves, the PT used alcohol hand sanitizer on his/her gloves. Per interview with the PT immediately following the home visit observation, the PT stated: Have always used hand sanitizer on my gloves; Never have I changed my gloves; and This was the common practice in outpatient clinics. During an interview on 11/01/2022 at 2:15 PM, the director of nursing stated "No" you do not do hand hygiene to gloves. Gloves need to be removed and staff need to perform hand hygiene prior to donning a new pair of gloves.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on record review, and interview, the agency failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control and investigation of infectious and communicable diseases that is an integral part of the quality assessment and performance improvement (QAPI) program. This deficient practice has the potential to affect the health and safety of all the agency's patients. Findings included: Review of the agency’s QAPI information on 11/01/2022 at 09:45 AM, failed to show infection control information related to agency-wide surveillance. During an interview on 11/01/2022 at 2:30 PM, the director of nursing stated that the agency does not track infections. He/she stated that they used to track infections, but the person responsible left and it got dropped.

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 review of Section 192.2490.12 RSMo and Section 192.2495.6 and 192.2495.7 RSMo, and 19 CSR-30-26.101 (l) (B) (3), agency policy review, employee file review, and interview, the agency failed to ensure all staff had the Employee Disqualification List (EDL) checked prior to hire for two (E#3 and E#4) of four employee files reviewed, and had obtained the Family Care Safety Registry (FCSR) prior to patient contact in one (E4) of four employee files reviewed. This deficient practice had the potential to affect all patients served by the agency. Findings included: Review of the agency’s undated policy titled “Personnel Records” showed: - Ensure required documentation is available to demonstrate compliance with established policies and procedures, and Federal and State regulations for all employees including those providing services under arrangement or contract. - For all employees, the agency maintains documentation of original application for employment, interview(s), and references if obtained, Family Care Safety Registry report, and quarterly EDL checks. Review of Section 192.2490.12 RSMo: "No person, corporation, organization, or association who received the employee disqualification list under subdivisions (1) and (7) of subsection 11 of this section shall knowingly employ any person who is on the employee disqualification list." Review of Section 192.2495 RSMo, requires employees of licensed home health agencies under contract with the Missouri Department of Health and Senior Services, to register with the Family Care Registry, regardless of hire date. This section also requires home health agencies to conduct criminal background screenings by checking the Family Care Registry. Review of Section 192.2495.6, RSMo: "A provider is guilty of a Class A misdemeanor if the provider knowingly hires or retains a person to have contact with patients or residents and the person has been found guilty in this state or any other states or has been found guilty of a crime, which if committed in Missouri would be a Class A or B felony violation of Chapter 565,566, or 569, or any violation of Subsection 3 of section 198.070 or section 568.020." Review of Section 192.2495.7, RSMo (effective August 28, 2018): "Any in-home services provider agency or home health agency shall be guilty of a Class A misdemeanor if such agency knowingly employs a person to provide in-home services or home health services to any in-home services client or home health patient and such person either refuses to register with the Family Care Safety Registry or if such person: - (1) Has nay disqualifying factors listed in Subsection 6 of this section; - (2) Has been found guilty of or pleaded guilty or nolo contendere to any felony offense under Chapter 195 or579; - (3) Has been found guilty of or pleaded guilty or nolo contendere to any felony offense under Section 568.045, 568.050, 568.175, 570.023, 570.025, 570.030, 570.040, as it existed prior to January 1,2017, 570.090, 570.145,570.223, 575.230, or 576.080; - (4) Has been found guilty of or pleaded guilty or nolo contendere to a violation of Section 577.010 or 577.012 and who is alleged and found by the court to be and aggravated or chronic offender under Section 577.023; - (5) Has been found guilty of or pleaded guilty or nolo contendere to any offense requiring registration under Section 589.400; - (6) Is listed on the Department of Health and Senior Services Employee Disqualification List under Section 192.2490; - (7) Is listed on the Department of Mental Health Employee Disqualification Registry under Section 192.2490; - (8) Has a finding on the Child Abuse and Neglect Registry under Sections 210.109 to 210.183." Employee #3 (E#3): Review of the employee file showed: - Licensed Physical Therapist Assistant (PTA); - Date of hire: 09/07/22; - Date of first patient contact: 09/19/2022; and - EDL obtained 09/12/2022 (five days after hire). Employee #4 (E#4) Review of the employee file showed: - Licensed Registered Nurse (RN); - Date of hire: 10/24/2022; - No EDL or FCSR contained in the employee file at the time of survey on 11/01/2022. During an interview at time of employee files review, the office manager stated that the agency typically runs the EDL prior to hire but did not run for E#4 and acknowledged that E#3’s EDL’s check was late. The office manager stated that the state system for FCSR has been late in returning information.

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 policy review, record review, and interview, the agency failed to ensure a completed comprehensive discharge summary was sent to the primary care physician or other professional who would be responsible for providing care and services to the patient after discharge from the agency/services within five business days of the patient's discharge in two (Records/Patient #5 and #6) of two discharge records reviewed; and failed to send a comprehensive transfer summary within two business days of the patient's unplanned transfer for two (Records/Patients #5 and #6) of two transfer records reviewed. This deficient practice has the potential to affect the post-discharge care of all patients served by the agency. Findings included: Review of the agency's undated policy titled, "Transfer and / OR Discharge from Services," showed: - In the case of discharge when the patient transfers to another health care facility, the clinical manager completes and sends a transfer form to provider pertinent information regarding the patient’s needs and plan of care; - Notifies the patient’s physician of the transfer and provides information as appropriate; - After discharge, the discharging staff member completes a discharge summary within five days and files the original copy in the clinical record; and - The discharge summary is sent to the physician within five days. RECORD #5: Review of the patient’s plan of care (POC) dated 09/29/2022 through 11/27/2022 and admission diagnoses included aftercare following joint replacement surgery, with presence of right artificial knee joint. Patient had additional cardiac conditions. Review of therapy care coordination note showed: - Patient went to the hospital Friday, 10/07/2022 with cardiac and vision complaints; - Patient discharged from the hospital on 10/12 (five days later), and no transfer summary sent to the hospital. No discharge sent to the physician after patient chose another home health agency for further care. Registered nurse (RN) discharge note showed patient discharged from nursing on 10/05/2022, and discharge note sent to the physician on 10/25/2022 (20 days after discharge from nursing). During an interview on 11/02/2022 at 1:30 PM, the director of nursing concurred that no discharge and/or transfer summaries were sent to the physician in the time frames per agency’s policy. RECORD #6: Review of the patient’s plan of care (POC) dated 09/22/2022 through 11/20/2022 and admission diagnoses included aftercare following joint replacement surgery, with presence of right artificial hip joint. Patient had additional kidney conditions. Review of therapy care coordination note showed: - Patient complained of dizziness, shortness of breath and fluctuating blood pressure on 10/06/2022; - Patient was admitted to the hospital on 10/07/2022; - Patient was discharged from the hospital on 10/09/2022; and - Patient refused further therapy on 10/10/2022. RN discharge notes showed, RN discharged patient on 09/28/2022. Record showed discharge sent to physician on 10/16/2022 (18 days post RN discharge). Clinical manager failed to send transfer summary and/or discharge summary after therapy notification of patient’s hospitalization. During an interview on 11/02/2022 at 1:30 PM, the director of nursing concurred that no discharge and/or transfer summaries were sent to the physician in the time frames per agency’s policy.