Every finding on record at St. Luke's Episcopal-Presbyterian Hospitals

The Emergency Preparedness regulations were reviewed as part of the Medicare certification survey completed on 4/07/2021. During the survey it was determined St. Luke's Home Health Services 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 St. Luke's Home Health Services was completed on 04/07/2021. The agency had 248 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.

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to ensure the patient's financial liability information was updated when a new service was ordered in one (Record/Patient #3) of five records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Informed Consent," revised July. 2017 showed: - In the event that the financial information is not yet available at the time of admission and the consent form cannot be completed, the agency's bill rates should be noted in the estimated cost per visits section of the consent; - When the completed financial information is obtained, the follow up should occur at the next scheduled visit; and - A new consent form with updated financial responsibility information is to be signed and dated by the patient or their authorized representative and also witnessed and dated. Review of the Patient's Handbook given to patients at admission which included patient rights showed: - Most services that our agency provides are at no cost to you; - We accept payment for services from Medicare, private insurance and private pay; - If there are any charges for services not covered under your private insurance, Medicare or Medicaid, these charges will be discussed with you before these services are provided; and - The patient has the right to be advised, before care is initiated, of the extent to which payment for the home health agency services may be expected from Medicare, Medicaid, or any other federally funded or aided program known to the agency, uncovered charges, the extent to which payment may be required from the patient, and if changes to the patient's financial responsibility occur, the home health agency must advise the patient and representative (if any) of these changes as soon as possible, in advance of the next home visit. RECORD/PATIENT #3: Review of the admission note report dated 03/09/2021 showed the patient would be discharged from the hospital on 03/09/2021. Discharge orders included for physical therapy and occupational therapy to evaluate and treat. Review of the physician orders dated 03/15/2021 showed an order for the skilled nurse (SN) three times a week for one week and two times a week for one week for assessment of the left inner buttock pressure sore. Review of the consent form signed on 03/10/2021 showed the financial liability portion for the SN was not updated. Review of the patient's home folder showed the financial liability portion for the SN was not updated on the consent form. During an interview on 04/06/2021 at 2:45 PM, the administrator stated that: - Staff should have updated the financial liability information; and - Staff are supposed to fill out the cost for all disciplines at admission so if a discipline is added, the patients have the information.

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, home visit observation, record review, and interview, the agency failed to maintain a complete/accurate medication profile in two (Record/Patient #1 and #3) of five records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Medication Reconciliation," revised 03/2020, showed: - Medication reconciliation is intended to identify and resolve discrepancies. It is a process of comparing the medications a patient is taking (and should be taking) with newly ordered medications; -The comparison addresses duplications, omissions, contraindications and interactions and the need to continue current medications; -The types of information that clinicians use to reconcile medications include medication name, dose, route, frequency and purpose; -The RN will be responsible for monitoring the patient's medication regiment through a collaborative effort with the multi-disciplinary team and physician involved in the patient's care; -All required comprehensive assessments will include 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; -At the time of admission, resumption of care, recertification and discharge and on an ongoing basis, a complete list of all prescription and over the counter medications taken by the patient will be maintained in the electronic medical record; -After an inpatient stay, the clinician will compare the discharge medication list to what the patient has in the home and is currently taking. Later, the most recent medication list will be compared to what the patient has in the home and is taking. Any discrepancies will be reconciled and will be documented in the medication profile in the clinical record; -The clinician will ask the patient to describe or confirm any prescription medications, over the counter medications, vaccines, respiratory therapy treatments, vitamins, herbal remedies, neutraceuticals (foods with health benefits) or other supplements. This will be accomplished by requesting to see the bottles of medications or supplements that the patient has in the home. The current medication profile should include medications taken on a regular basis, as well as those taken on an as needed basis; -If the admission is performed by a qualified therapist, the therapist will be expected to do a complete medication reconciliation. An RN in the office will perform a medication regiment review via telephone; and -The case manager will reconcile medications on an ongoing basis to assure that the patient's medication profile is accurate. RECORD/PATIENT #1: Review of the skilled nurse (SN) admission visit dated 03/02/2021 showed: -Issues were found during the drug regimen review; -The nurse notified the physician; -Reviewed medications with the physician; -Medication discrepancies discussed and clarifications made: None; -Patient no longer taking the following medications from the discharge/physician list: None; -Patient wishes to continue taking these home medications which are not on the discharge list; and -The physician approved L-lysine (immune supplement), meclizine (for dizziness), bisacodyl (stool softener) and centrum silver (vitamin). During a home visit observation on 04/06/2021 beginning at 9:00 AM, the nurse reviewed the patient's medications. The following discrepancies were found: -The medication profile showed an order for L-lysine (immune supplement) 500 milligrams (mg) one capsule daily. The home medication list showed two tablets daily. The caregiver said he/she took two tablets daily; -The discharge medication list showed an order for metoprolol tartrate (blood pressure medication) 25 mg two times a day. The medication profile showed an order for metoprolol tartrate 25 mg two times a day. The home medication list showed to take two times a day. The prescription bottle dated 03/03/2021 showed to take once a day; -The discharge medication list showed an order for tamsulosin (Flomax, used for urinary retention) one capsule two times a day. The medication profile showed an order for tamsulosin 0.4 mg two capsules daily. The home medication list showed to take one capsule two times a day. The prescription bottle dated 03/01/2021 showed to take one capsule two times a day; -The discharge medication list showed an order for acetaminophen (Tylenol) 325 mg two tablets every six hours as needed for pain. The medication profile showed an order for acetaminophen 500 mg one to two tablets every six to eight hours as needed for pain; and -The nurse said he/she would clarify the medications with the physician. During an interview on 04/06/2021 at 12:05 PM, with the administrator and clinical manager, the administrator stated that staff look at the medications listed on the referral/discharge medication list and look at all medications in the home. If there are any discrepancies, they call the physician to clarify what the patient should be taking. In therapy only cases, the clinical support nurse will call the patient to review medications, and if there are any discrepancies the clinical support nurse will call the physician to get orders then update the medication profile. The findings were reviewed with the administrator and clinical manager on 04/06/2021 at 12:25 PM. They will look for further information. During an interview on 04/07/2021 at 10:45 AM, the clinical manager stated that: -He/she did not find documentation in the clinical record that the nurse clarified the Tylenol, Flomax, and L- lysine doses at the start of care; and -The nurse called the physician regarding the metoprolol and is getting clarification regarding the dose. RECORD/PATIENT #3: Review of the physical therapy admission comprehensive assessment dated 03/10/2021 showed there were no issues with the drug regimen review. Review of a communication note from the physical therapist dated 03/10/2021 showed the patient was not taking metoprolol which was on the discharge medication list. Review of the RN communication/medication notes dated 03/15/2021 (five days later) showed: -The RN reviewed the medications; -He/she spoke with the patient's caregiver; -Discussed metoprolol being discontinued at physician office visit; and -Spoke with physician office staff who confirmed the directions given at the physician's appointment. During a home visit observation on 04/06/2021 beginning at 1:00 PM the medications were reviewed with the patient's caregiver. Review of the medication profile showed the following discrepancies with the discharge and home medication list: -The discharge medication list showed an order for Lisinopril 40 mg daily. The home medication list showed an order for Lisinopril 40 mg daily. The caregiver stated that the patient had been taking this "forever". This was not included on the medication profile; - The discharge medication list showed an order for famotidine (Pepcid, antacid) 20 mg one tablet every 12 hours. The home medication list showed famotidine 10 mg daily. The caregiver said the patient had been taking one at night for a long time. This was not included on the medication profile; -The discharge medication list showed an order for cyanocobalamin (B12) 1000 micrograms (mcg) one tablet every week. The home medication list showed B12 1000 mg one tablet daily. The caregiver said the patient took 1000 mcg one time a week. This was not included on the medication profile; -The discharge medication list showed an order for calcium-vitamin D 250 mg-125 units one tablet two times a day and an order for cholecalciferol (vitamin D3) 1000 international units one tablet daily. The home medication list showed an order for calcium plus vitamin D (500 mg calcium /20 mcg vitamin D) one daily. The caregiver said the patient took one calcium plus vitamin D in the morning and one at night. This was not included on the medication profile. During an interview on 04/06/2021 at 4:15 PM, the clinical manager stated that staff failed to update the patient's medication profile. During an interview on 04/07/2021 at 10:15 AM, the clinical manager stated that in therapy only cases, the clinical support nurse reviews the medications within five days unless there is an issue. The metoprolol should have been clarified with the physician at the start of care.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to ensure the physical therapy (PT) and occupational therapy (OT) plan of care (POC) was reviewed with the physician after the initial evaluation visit in two (Record/Patient #3 and #4) of five records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Plan of Care/Physician Orders," revised 01/2018 showed: - Upon completion of the initial assessment and determination that the patient meets the admission criteria, the patient is officially accepted for care and the POC is developed; - Services are provided under an individualized POC that is established by the attending physician and the homecare staff. The POC is written by the appropriate staff member in collaboration with the multi-disciplinary team, the physician and based on the initial homecare assessment of the patient's problems and needs at the start of care; - The POC will serve as physician's orders for patient care and all staff providing services will be in compliance with the orders; and - Staff members may administer medications or treatments only as ordered by the physician. RECORD/PATIENT #3: Review of the referral orders dated 03/09/2021 showed an order for PT and OT to evaluate and treat. Review of the PT admission visit dated 03/10/2021 failed to show that the plan of care was discussed with the physician regarding the evaluation. Review of the OT evaluation dated 03/12/2021 failed to show the OT plan of care was discussed with the physician regarding the evaluation. During an interview on 04/07/2021 at 10:10 AM the clinical manager stated that the PT and OT clarify orders with the physician at the time of their evaluations. He/she did not find documentation that the PT and OT communicated their plan with the physician at the time of the evaluations. RECORD/PATIENT #4: Review of the referral orders dated 01/21/2021 showed an order for PT to evaluate and treat. Review of the PT admission visit dated 01/25/2021 failed to show that the plan of care was discussed with the physician regarding the evaluation. During an interview on 04/07/2021 at 9:38 AM the clinical manager stated he/she did not find documentation that the PT communicated with the physician and he/she expected orders to be verified with the physician by the next business day.

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, home visit observation, and interview, the agency failed to ensure the patient's caregiver received written instructions regarding wound care in one (Record/Patient #1) of three home visit observations. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Education - Patient/Family Agency Philosophy," revised 01/2018, showed in part: - Staff will educate the patient/family in skills and behavior that promote recover, maintain or improve function, manage progression, and promote independence whenever possible; - Based on the patient's condition and assessed needs, the education and training provided to the patient includes an explanation of the plan for care, treatment or services; and - Staff will utilize available resources, including written instructions, as appropriate to meet the patient/family educational needs. RECORD/PATIENT #1: Review of the plan of care dated 03/02/2021 showed an order for wound care daily to the patient's abdominal surgical wound which consisted of cleansing with normal saline (salt water solution), apply saline moistened 2 x 2 gauze, cover with a 4 x 4 gauze and secure with tape. Per interview conducted during observation on 04/06/2021 at approximately 9:30 AM, the patient's home folder was reviewed. No written wound care instructions were included in the patient's home folder. Registered Nurse (RN) A stated that he/she did not leave written wound care instructions because the caregiver did return demonstrations of the wound care. During an interview on 04/07/2021 at 9:50 AM, the administrator stated that it would depend on the situation whether he/she expected staff to leave written wound care instructions in the home. If the caregiver needed the instructions for support, then he/she would expect the nurse to provide written instructions for the caregiver.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to ensure the skilled nurse documented ongoing assessments in one (Record/Patient #3) of five records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Skin Integrity," (undated) showed in part: - Document color and general condition of the wounds every visit; - Measure and document on all wounds weekly; and - If there is any change in a wound, document at each visit During an interview on 04/07/2021 at 11:20 AM, the administrator stated that: - He/she could not find their current wound assessment policy; - He/she provided the policy regarding skin integrity, but it was not their most up to date policy; and - He/she wound expect the nurse to document assessments of wounds each visit and measure the wounds weekly. RECORD/PATIENT #3 Review of the plan of care showed an order dated 03/15/2021 for the following: - SN visits three times a week for one week the two times a week for one week for assessment of the left inner buttocks pressure sore; - Wound care consisted of cleansing with soap and water or wound cleanser, apply Aquacel AG bordered dressing (a foam, antimicrobial dressing); - Assess wound for healing; and - Measure wound weekly. Review of the SN visits showed: - On 03/15/2021 the patient had a Stage 2 (partial thickness skin loss) pressure sore to the left inner buttock that measured 0.5 x 0.4 x 0.1 centimeters (cm) with pink/red tissue and scant serous (thin, clear) drainage; - On 03/18/2021 the patient had a healing Stage 2 pressure ulcer to the left inner buttock with pink/red tissue and no drainage; and -From 03/23/2021 through 04/05/2021 the nurse failed to document any information regarding the status of the Stage 2 pressure sore. Per interview conducted during the patient's home visit, on 04/06/2021 beginning at 1:00 PM, patient's caregiver stated that the sore had healed. The findings were reviewed with the administrator, assistant administrator, clinical manager and clinical supervisor on 04/06/2021 at 2:45 PM. They will look for further information. During an interview on 04/07/2021 at 9:50 AM, the administrator stated that: - He/she did not find documentation of the pressure sore being healed in the clinical record; - He/she found documentation in a non-clinical note that the sore had healed, but that was not part of the clinical record; and - He/she would expect the nurse to document in the clinical record that the pressure sore had resolved/healed.

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 policy review, record review, and interview, the agency failed to provide services as directed by the physician ordered plan of care (POC) in one (Record/Patient #3) of five records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Plan of Care/Physician Orders," revised 01/2018, showed: - Services are provided under an individualized POC that is established by the attending physician and homecare staff; and - The POC will serve as physician's orders for patient care and all staff providing services will be in compliance with the orders. RECORD/PATIENT #3: Review of the POC showed an order dated 03/15/2021 for skilled nursing (SN) three times a week for one week and two times a week for one week for assessment of the left inner buttock pressure sore. Review of a physician order dated 03/15/2021 showed an order for SN three times a week for one week and two times a week for one week for assessment of the left inner buttock pressure sore. Review of the nursing visits showed the SN visited the patient twice the week of 03/15/2021. During an interview on 04/06/2021 at 4:15 PM, the clinical manager stated that he/she could not find a missed visit report for the week of 03/15/2021.

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 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 one (Record/Patient #4) of two discharge 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 policy titled "Discharge/Transfer, Patient", revised 04/26/2021 showed, in part, a discharge/transfer summary will be completed by the discharging discipline and forwarded to the attending physician within five days. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to the agency on 01/23/2021 with diagnoses left total hip replacement and physical therapy (PT). Review of the clinical record showed PT discharged the patient from service on 03/04/2021 at 4:45 PM. The record showed the discharge summary was not sent to the patient's physician until 04/02/2021 (29 days after the agency discharged the patient). During an interview on 04/06/2021 at 12:13 PM, the Administrator said the discharge summary is sent to the patient's physician or other service providing care within five business days of discharge.