Every finding on record at Synergy Home Care-Southeastern Region,Inc.

The entity is in compliance with the federal emergency preparedness requirements.

Recertification Survey

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the skilled nurse assessed the patient’s weight for changes per the plan of care for 1 (Patient #3) of 8 (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, and Patient #8) sampled patients reviewed for services per the plan of care. Findings: Review of Patient #3’s Home Health Certification and Plan of Care for certification period of 12/01/2023 to 01/29/2024 revealed, in part, the skilled nurse was to assess the cardiovascular system, identify changes, and report a weight gain of 2-3 pounds in a day or a weight gain of 5 pounds in a week. Review of Patient #3’s record revealed no documented evidence and the agency presented no documented evidence the skilled nurse had weighed Patient #3 nor did the agency have documented evidence of the skilled nurse had reviewed a daily weight log for the certification period of 12/01/2023 to 01/29/2024. In an interview on 01/31/2024 at 2:19 p.m., S3Registered Nurse/Clinical Manager stated Patient #3 was unable to stand for a weight; however, the agency had not notified the physician of inability to weigh Patient #3 nor had the agency obtained alternative methods to monitor weight for weight gain.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient’s physician was notified of auditory hallucinations, headache, and side effects of medication noncompliance for 1 (Patient #7) of 8 (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, and Patient #8) sampled patients reviewed for notification of change. Findings: Review of Patient #7’s Home Health Certification and Plan of Care for certification period of 11/07/2022 to 01/15/2023 revealed, in part, paranoid schizophrenia and generalized anxiety disorder. Review of Patient #7’s Nurse’s Visit Note Report dated 12/19/2022 revealed, in part, Patient #7 had reported something was wrong with his head, reported hearing voices, reported he had a headache. Further review of Patient #7’s Nurse’s Visit Note Report revealed Patient #7’s nurse had assessed Patient #7 with a notable tremor to his bilateral hands and movement of this jaw and tongue. Review of Patient #7’s Nurse’s Visit Note Report revealed Patient #7 was noted to have not been taking his Cogentin (medication used to treat tremors and involuntary movements), Depakote (medication used to treat seizures and/or behaviors), Haldol (medication used to treat psychiatric conditions), Meloxicam (medication used to treat pain/inflammation), and Melatonin (supplement used to improve sleep). Review of Patient #7’s Nurse’s Visit Note Report revealed no documented evidence and the agency presented no documented evidence Patient #7’s physician was notified of the above mentioned findings. In an interview on 01/31/2024 at 1:59 p.m., S4Registered Nurse (RN)/Clinical Manager stated the agency had no documented evidence to present that Patient #7’s physician was notified of the above mentioned findings. S4RN/Clinical Manger acknowledged Patient #7’s physician should have notified of the above mentioned assessment.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to coordinate with the patient’s mental health provider to ensure the patient received his injectable medication as ordered for 1 (Patient #7) of 3 (Patient #1, Patient #7, and Patient #8) sampled patients reviewed for behavioral health services. Findings: Review of Patient #7’s Home Health Certification and Plan of Care for certification period of 11/17/2022 to 01/15/2023 revealed, in part, Patient #7 had a diagnosis of Paranoid Schizophrenia. Further review of Patient #7’s Health Certification and Plan of Care revealed the skilled nurse was to administer Patient #7’s Invega Sustenna (medication used to treat psychiatric conditions) 234 milligrams per 1.5 milliliter injection once every four weeks. Review of Patient #7’s record revealed Patient #7 had received his last Invega Sustenna injection on 11/15/2022. Review of Patient #7’s Client Coordination Note Report dated 12/10/2022 revealed, in part, the skilled nurse informed Patient #7’s sister Patient #7 was to be brought to the mental health facility to receive his injection for the month of December 2022. Further review revealed no documented evidence and the agency presented no documented evidence the skilled nurse or the agency coordinated with the mental health facility regarding administering Patient #7’s Invega Sustenna injection for the month of December 2022. Review of Patient #7’s Progress Note dated 12/13/2022 revealed no documented evidence Patient #7’s Invega Sustenna injection had been administered. In an interview on 01/31/2024 at 1:59 p.m., S4Registered Nurse/Clinical Manager stated the agency had no documented evidence of the agency coordinated with Patient #7’s mental health facility to ensure Patient #7 received his Invega Sustenna injection as ordered.

Initiated/Aborted on 03/16/2020 due to suspension of survey activity on the direction of CMS and State Office. Recertification Survey, Re-licensing Survey, and Covid-19 Focused Infection Control Survey. A COVID-19 Focused Infection Control Survey was conducted on 04/01/2021. The facility has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19. Tag #682 and #684 were cited as a result of the Recertification Survey. Census 140

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, record review, and interview the agency failed to ensure the registered nurse changed her gloves and performed hand hygiene between dirty and clean procedures performed during wound care for 1 of 1 patients (Patient #3) observed during wound care in a total sample of 10. Findings: Review of the CDC's (Center for Disease Control) Article on Hand Hygiene in Healthcare Settings revealed multiple opportunities for hand hygiene may occur during a single care episode. The following are the clinical indications for hand hygiene: Before moving from work on a soiled body site to a clean body site on the same patient; After contact with blood, body fluids or contaminated surfaces; and Immediately after glove removal. Review of Patient #3's Home Health Certification and Plan of Care for certification period of 02/19/2021 to 04/19/2021 revealed Patient #3 had diagnosis, in part: Stage III (stage 3- wound to the fat layer of the skin). Review of Patient #3's Physician Order dated 03/27/2021 revealed the skilled nurse to perform pressure ulcer care to the sacrum. The skilled nurse was to cleanse the wound with normal saline pat dry with gauze, apply gentian violet as a moisture barrier, apply silver alginate (wound dressing used to absorb moisture) to the wound bed, then apply skin prep to the surrounding tissue to help the foam border adhere, then cover with a bordered foam dressing. Observation on 03/31/2021 at 11:20am of Patient #3's sacral wound care revealed, S3RN (Registered Nurse) removed Patient #3's dressing then without changing gloves or performing hand hygiene (washing her hands or using hand sanitizer) proceeded to clean Patient #3's wounds. S3RN then disposed of the gauze used to clean the wound and with the same-gloved hands used to remove the dirty dressing and clean the wound, S3RN applied clean new dressings to the patient's sacral wound. S3RN then disposed of all the dressings and packaging and with the same gloved hands used from the beginning of wound care assisted the patient with repositioning her clothing, without removing the gloves or performing hand hygiene. In an interview on 03/31/2021 at 11:53am, S3RN stated she had forgotten to change her gloves and perform hand hygiene between dirty (removing soiled dressings) procedures and clean (cleaning the wound and applying new dressings) procedures and should have. S3RN further stated gloves should be changed and hand hygiene should be performed between all dirty and clean procedures. In an interview on 03/31/2021 at 12:10pm, S1Administrator/DON (Director of Nursing) was informed of the above observations and stated the breaches in infection control should not have happened and the staff did not follow appropriate infection control techniques for wound care.

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 ensure Infection Reports were completed and/or infections were tracked and trended as required by their infection control program for 2 of 10 sample patients (Patient #1 and Patient #9) reviewed for infection control in a total sample of 10. Findings: Review of the provider's Infection Report revealed a note to employees to please complete this form for any home health patient or employee if: 1. Signs or symptoms of infection are present; or 2. Culture is obtained; or 3. New antibiotic is prescribed; or 4. Client is admitted to the hospital or dies due to a suspected infection. During review of Patient #1-Patient #10's Records revealed Patient #1and Patient #9 had received antibiotics while a patient of the agency. In an interview on 04/01/2021 at 12:08pm, S1Administrator/DON (Director of Nursing) stated she did not have any Infection Reports for Patient #1 or Patient #9. Patient #1 Review of Patient #1's Client Medication Report revealed the following medications were received while being a patient at the agency: Zithromax (antibiotic used to treat infection) 250mg (milligrams) two tablets daily times one dose, then one tablet daily times 4 days (with start date of 02/25/2021 and stop date of 03/02/2021); and Ceftin (antibiotic used to treat infection) 250mg one tablet twice a day for 5 days (with a start date of 02/25/2021 and stop date of 03/02/2021). Review of Patient #1's Physician Order dated 03/12/2021 revealed the following orders: Zithromax 250mg two tablets daily times one dose, then one tablet daily times 4 days; Ceftin 250mg one tablet twice a day for 5 days; and Mucinex 600mg one tablet twice a day for 10 days. There was no documented evidence and the agency did not present any documented evidence that an Infection Report was completed as required. In an interview on 04/01/2021 at 2:50pm, S2Clinical Manager stated the skilled nurse should have completed the infection report to assist with tracking and trending of the agency's infections. Patient #9 Review of Patient #9's Order dated 09/25/2020 revealed Macrobid (antibiotic) 100 mg one tablet twice a day for urinary tract infection (bladder infection). There was no documented evidence and the agency did not present any documented evidence that an Infection Report was completed as required. In an interview on 04/01/2021 at 2:38pm, S2Clinical Manager stated Patient #9's skilled nurse should have completed an infection control report upon receiving the order for the antibiotic and did not. Review of the agency's QI (Quality Incident) Event Report for Infections for the third quarter (July, August, September) of 2020 revealed no documented evidence of Patient #9's infection having reviewed for trending of infections. In interview on 04/01/2021 at 2:20pm, S1Administrator/DON stated the process to obtain information for infection control tracking and trending was as follows: any time a patient had a sign or symptom of infection or was prescribed an antibiotic the nurse was to fill out the infection report form, and then the clinical managers then myself review the forms and look for an increase in infections. S1Administrator/DON stated the case managers should review orders and if a new antibiotic, antiviral, or antifungal was ordered, and if an infection report was not completed the case manager should catch it and update the form during the review. S1Administrator/DON stated she was not sure why the agency did not catch why an infection control report was not completed when Patient #1 and Patient #9 were placed on antibiotics.