Every finding on record at St. Mary Medical Center

A recertification survey was conducted in conjunction with an Emergency Preparedness survey on 08/19/22. The Agency was in compliance with the requirements Emergency Preparedness, for this survey. The Agency was not in compliance with the Standards, 42 CFR 484, for Home Health Agencies, as evidenced by: Abbreviations: E- Employee G- Gram med- medication mg- milligram ml- milliliters OT- Occupational Therapist POC- Plan of Care PT- Physical Therapist Pt- Patient RN- Registered Nurse SLT- Speech and Language Pathologist SN- Skilled Nurse SOC- Start of Care

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 2 of 7 patients (Pt #1 and Pt #5) patients, where home visits were conducted, the Home Health Agency (HHA) failed to ensure a review of the patient's medications 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 was conducted. This has the potential to affect all patients receiving care from the Agency with a current patient census of 350. 1. On 8/16/22 at approximately 1:00 PM, a home visit was conducted at Pt #1's home. A review of Pt #1's medications revealed Pt #1 was taking Trazodone 50mg at bedtime (antidepressant with tiredness as a side effect). Pt #1 noted they were still taking this medication to help sleep at night. 2. On 8/17/22 at approximately 10:00 AM, the medical record of Pt #1 was reviewed. Pt #1 was admitted on 8/3/22 with the primary diagnoses of fracture of superior rim of left pubis. The discharge instructions from the Hospital noted the Trazodone was discontinued 8/1/22. Pt #1's Plan of Care (POC), certification period 8/3/22-10/1/22 lacked documentation of the Trazodone or the discontinuation of the Trazodone. 3. On 8/17/22 at approximately 11:00 AM the policy "Medication Reconciliation and Drug Review" (approved 5/6/22) was reviewed. The policy noted "On admission, after a hospitalization...the RN, PT, OT, or ST will compare the hospital discharge medication list or current medication list...with the patient's current medication bottles..." 4. On 8/18/22 at approximately 2:00 PM an interview was conducted with the Regulatory Coordinator Quality and Safety (E #2). E #2 stated, "Sometimes the patients will have some of their medication bottles in different places around the house, but regardless we should have caught the Trazodone bottle when we were did her admission visit to the Agency." 1.Pt #5 SOC: 5/28/22 Diagnosis: Age related osteoporosis with pathological fracture right femur. The record was reviewed on 8/17/22 at approximately 1:40 PM. The Plan of Care (POC) for the certification period 7/27/22 to 9/24/22 noted Lovenox 40 mg/0.4 ml every 24 hours. A Physician's discontinuation order dated 8/16/22 noted the Lovenox was started on 5/7/22 and "Stop Date 6/6/22". The POC noted Miralax 17 g (gram) daily and Senna 8.6 mg 2 times daily. A Physician's discontinuation order noted Miralax was discontinued on 5/7/22 and Senna was reported as "Patient not taking... Reason for Discontinuation: Med (Medication) List Clean Up". 2.During an interview on 8/19/22 at approximately 10:15 AM, the Regulatory Coordinator Quality and Safety (E#2) reviewed Pt #5's record and verbally agreed the Lovenox, Miralax and Senna order had not been discontinued and/or removed from the medication list and should have been.

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 document review, observation and interview, it was determined for 1 of 2 (Pt #4) home visits in which wound care was observed and 1 of 17 (Pt #14) patient records reviewed, it was determined the Agency failed to ensure care was provided in accordance with the Plan of Care (POC). This has the potential to affect all patients who receive care by the Agency with a current census of 350 patients. Findings include: 1. Pt #4 Start of Care (SOC): 8/12/22 Diagnosis: Squamous Cell Carcinoma, Right and Left side of face. The Plan of Care (POC) dated 8/12/22 was reviewed on 8/16/22 at approximately 1:00 PM. The POC noted "Wound Care Order To be performed Daily, and as needed. To be performed by Caregiver. Cleanse wound with wound cleanser and pat dry. Use skin prep/moisture (preparation) barrier to protect surrounding skin PRN (as needed)….Instruct/Evaluate signs and symptoms of infection. Instruct/Perform wound care as ordered. Instruct on signs and symptoms to report." a) During a home visit on 8/16/22 at approximately 2:30 PM, the Registered Nurse (E#3) requested and observed the patient's caregiver conduct wound care. The caregiver picked up a 4 by 4 gauze pad, sprayed the gauze with the wound cleanser, wiped the wounds and discarded the gauze. The caregiver was not instructed to wash hands prior to or after the wound care was conducted nor instructed to donn gloves, the patient/patient's caregiver was not instructed on signs and symptoms of infections and when to report the findings, and E#3 did not ensure the skin/prep/moisture barrier was available in the home or instruct the patient/patient's caregiver when or how to apply the skin prep/moisture barrier. 2. Pt #14 SOC: 8/5/22 Diagnosis: Covid-19. The record was reviewed on 8/17/22 at approximately 3:30 PM. The Plan of Care (POC) noted "Heart Failure Order... for weight gain of 3 pounds overnight or 5 pounds in 1 week. Weigh and record... Skilled assessment with focus on: weight..." The record lacked documentation weights were assessed after the Start of Care (SOC) visit. 3. During an interview on 8/16/22 at approximately 3:30 PM, the Regulatory Registered Nurse Coordinator (E#1) verbally agreed E#3 should have ensured the skin/prep/moisture barrier was available for use, instructed the patient/patient's caregiver on when and how to apply the skin prep/moisture barrier, and hand hygiene should have been conducted before and after the wound care and gloves should have been donned per infection control practices. 4. During an interview on 8/19/22 at approximately 11:30 PM, the Regulatory Coordinator Quality and Safety (E#2) reviewed Pt #14's record and stated Pt #14's weights had not been assessed and should have been.