Every finding on record at The Evangelical Lutheran Good Samaritan Society

A survey for compliance with CMS Appendix Z Emergency Preparedness Requirements, was conducted 5/3/21 through 5/6/21, during a recertification survey. The facility was in full compliance and no deficiencies were issued.

A partial extended survey was conducted at the Good Samaritan Society Home Care on May 03, 04, 05 and 06, 2021 and was found to have not met the requirements at 42 CFR. Part 484 for Home Health Agencies. BRANCH OFFICES: None NUMBER OF HOME VISITS MADE: 3 NUMBER OF RECORDS REVIEWED: 07 HOURS OF OPERATION: 8:00 a.m. to 4:30 p.m.

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, interview, and document review, the agency failed to complete a comprehensive drug regimen review to ensure the accuracy of all medications/dosages for 2 of 3 patients (P3, P5) whose medications were reviewed during home visits and record review. Findings include: P3's plan of care (POC) indicated start of care (SOC) date of 11/22/20. The (POC) for the certification period 4/7/21 to 6/5/21, included diagnoses of heart disease, chronic kidney disease with heart failure, kidney and pancreas transplant status and history of transient ischemic attack. The POC further indicated P3 received skilled nurse visits every two weeks for various assessments and education, including to assess/instruct patient knowledge of medications, use, actions, side effects and response to medications, drug interactions and side effects to report. P3's POC included the following medications: allopurinol (to treat gout) 100 milligrams (mg) po (by mouth) q (every) am; enteric coated aspirin 81 mg po daily (currently on hold); atorvastatin (to lower cholesterol) 40 mg po bedtime; calcium carbonate with cholecalciferol (calcium with vitamin D) 600-400 mg-unit 2 capsules q am; ferrous sulfate 325 mg 1 tablet po daily; magnesium 400 mg q am; Plavix (platelet inhibitor to prevent blood clots) 75 mg po q am; Prednisone 5 mg po q am; Prograf (an anti-rejection med) 1 mg po BID (am and pm); Protonix 40 mg po q am; refresh tears one drop in both eyes four times per day; Xalatan ophthalmic solution one drop to right eye q evening; dorzolamide HCl-Timolol ophthalmic solution one drop to both eyes BID; Cardura 2 mg po at bedtime; Lovenox one unit daily subcutaneous injection stop after international normalized ratio (a lab value measuring how long it takes blood to clot) (INR) is greater than two for two consecutive days; Coumadin two mg daily, recheck on Monday 3/1/21; Coreg 12.5 mg po BID; Prograf 0.5 mg po BID. During a home visit conducted on 5/4/21, at 11:00 a.m. P3's current medication bottles and medications setup in P3's medication boxes by the registered nurse (RN)-A for daily medication administration were compared to the medications listed on the POC, however, several of the medication labels differed from the directions on the POC. RN-A was observed to setup P3's medication boxes for a one week setup. Two Prograf medication bottles were observed among P3's medications. One bottle was labeled Prograf 0.5 mg BID and the other bottle was labeled Prograf 1 mg BID, this bottle had a hand written note "do not take" on the label. Two bottles of carvedilol (generic for Coreg) were also observed among P3's medications. One bottle was labeled carvedilol 12.5 mg and the other bottle was labeled carvedilol 6.25 mg. Both bottle labels indicated P3 was to take one tablet po BID. RN-A indicated P3 was no longer taking the Prograf one mg tablet as indicated by the handwritten notation on the label and P3's carvedilol dosage had been changed from 6.25 mg to 12.5 mg tablets BID. He was no longer taking the 6.25 mg dosage. Vitamin E capsules were observed to be setup in P3's medication setup, however was not listed on his current POC. Coumadin was observed setup in P3's medication setup as 4 mg 5/4/21, 3 mg 5/5/21 through 5/9/21, and 2 mg on 5/10/21, however 2 mg daily was listed on his current POC. RN-A stated P3 did have a medication list in his home, however, it was not regularly updated. When medication changes were made she tried to bring a new one out to the home. RN-A indicated she used the computer medication administration record (MAR) to setup medications in the home. RN-A indicated the medications P3 was not currently taking would be better stored in a different cupboard from his current medication bottles to prevent medication errors. Review of P3's Medication Evaluation Report for medication setup during skilled nurse visits 4/7/21, 4/22/21, 4/29/21, and 5/4/21, indicated medications were setup per the MAR, however the report did not identify the name, dosage or frequency of the medications that were setup. Review of P3's current agency Careplan printed 5/6/21, indicated P3's Lovenox had been ordered on 2/25/21 and was to end after the INR was greater than 2 for 2 consecutive days. P3's carvedilol dose was changed to 12.5 mg on 3/25/21 and his Prograf dose was changed to 0.5 mg on 4/7/21. P5's (POC) indicated a (SOC) date of 3/20/21. The POC for the certification period 3/20/21 to 5/18/21, included diagnoses of hypertension, atrial fibrillation, diabetes, kidney disease and a history of malignant neoplasm of the large intestine. The POC further indicated P5 received skilled nurse visits one time a week for one week, then two times per week for four weeks then one time per week for four weeks for various assessments with three visits as needed (prn) for ostomy complications. P5's POC included the following medications; acetaminophen 325 mg two tablets po q four hours prn; albuterol inhaler 108 mcg one to two puffs inhalation q four hours prn; aspirin 81 mg po q bedtime; coenzyme q 10 100 mg po daily; cranberry 400 mg po daily; fish oil 1200 mg po daily; furosemide (a diuretic) 40 mg 1/2 tablet po daily; hydralazine 10 mg po BID; isosorbide extended release (ER) 60 mg po daily; loratadine 10 mg po daily; melatonin 5 mg po q bedtime; metformin 500 mg po q am; metoprolol 50 mg po BID; omeprazole 20 mg po q bedtime; senna 8.6-50 mg po BID; vitamin D 3 125 mcg po daily. Review of P5's Eldercare Nursing Home Discharge Summary dated 3/18/21, included the following medications; Crestor 5 mg take 1/2 tablet po q Monday, Wednesday and Friday, levothyroxine 25 mcg po q day, Spiriva inhaler one capsule into the lungs one time a day, which were not listed on P5's POC. Hydralazine 10 mg take 2 tablets po BID, and melatonin 2.5 mg q bedtime, were listed as different strengths on P5's POC. During a home visit conducted on 5/6/21, at 9:00 a.m. RN-B assisted P5 with a shower and colostomy cares and assessed vitals, pain and edema. RN-B stated P5's furosemide had been recently increased due to increase edema (swelling). RN-B did not review medications, weights or lung sounds. RN-B completed the visit and left P5's home. When questioned about her medications, P5 stated she setup her medications and brought out her medication bottles, pill setup boxes and a medication list her daughter had written that she used to set her medications. P5 stated she took levothyroxine 25 mcg every day, Crestor 5 mg 1/2 tab every Monday, Wednesday and Friday, and the Spiriva inhaler every morning. All of which were not listed on the POC. P5 indicated she only took melatonin 5 mg when she felt she needed it, hydralazine 10 mg 1/2 tablet twice a day, not the whole 10 mg tab as listed on the POC or the two tablets ordered on her discharge orders 3/18/21, and she had been taking the newly increased dose of furosemide 60 mg as instructed but had went back to the original 40 mg dose yesterday because the increase dose caused her frequent urination and she did not like that. All of which was different than what was listed on P5's current POC. When interviewed on 5/6/21, at 11:00 a.m. the clinical manager (CM)-A indicated the nurses were to ask each visit regarding medications, if there were any problems, new medications or changes. Their computer program automatically generates an order when medication changes were made and the order would be faxed to the primary provider. When the nurse sets medications there is a comment section at the bottom of the MAR to add comments on how long they setup the medications. The agency's computer system does not allow to check off each medication and dosage that is setup. During interview on 5/6/21, at 2:00 p.m. the administrator stated the computer MAR was what was used to setup client's medications in the home. If there were discontinued medications or changed dosages, the changed dose or discontinued medication should be taken off the MAR and the agency certification and POC. The administrator stated inactive or discontinued medication bottles should be removed from the active medication bottles to a different area or cupboard. This would be important to prevent medication errors. Review of the agency's policy, Medication Setup with revision date of 3/18/21, indicated nurses were to document medication setup with use of the agency's MAR. Dosage, route of administration and frequency of administration and time of day medication was to be taken, was to be entered in to the medication record profile Review of the agency's policy Medication Management with review date 2/2/21, indicated medication management included medication regimen review, identification of clinically significant drug issues, reconciliation of medication issues and discrepancies as appropriate and education of the client or caregiver. At minimum, client medications would be assessed at time of initial assessment, following a physician appointment, after a change in client condition, at time of recertification and discharge from the agency and whenever there is a concern about the medications the client may/may not be taking. Ongoing assessments are made during visits and include changes in the client's medications, client's compliance with the medication regimen, response to medication, side effects experienced by the patient, laboratory values, needed refills and check of medication containers on refilled prescriptions. All prescribed and over the counter medications should be listed initially on the 485 POC.

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on interview and document review, the agency failed to complete a comprehensive reassessment the last 5 days of two 60 day certification periods, for 1 of 1 patients (P2) currently receiving home care services. Findings include: P2 plan of care (POC) indicated start of care (SOC) date of 11/26/19. P2's certification periods of 5/24/20 to 7/22/20, and 9/21/20 to 11/19/20, indicated P2 received skilled nurse visit (SNV) weekly for medication set up, teaching, assessments, home health aide supervision, international normalized ratio (INR), and home health aide visits three times per week to assist with showering. Review of P2's POC indicated the comprehensive assessment was completed on 5/18/20 (at day 55), and 9/14/20 (at day 54), instead of every 56-60 days, as required. POC dated 5/24/20 to 7/22/20, revealed in the recertification summary note, "recert early as ct is only scheduled once weekly." POC dated 9/21/20 to 11/19/20, revealed in the recertification summary note, "recert happening 6 days early as ct has weekly visits and next visit is scheduled in next VF." When interviewed on 5/6/21, at 11:00 a.m. clinical manager indicated, recertification visits are scheduled at the SOC. The computer generates the next cert visit. A notification pops up to remind nurses to do a cert visit. A warning pops up if the visit is outside the window. She stated, "sometimes the nurses complete the recert visits early, and they will document why is it being done early in the note. The nurse manually putting in the next recert visit and prompts them to. Cert dates remain the same from the start of care regardless of when the cert visit was made." When interviewed on 5/6/21, at 2:00 p.m. agency administrator indicated, recertification's are done within five days before the 60th day. She stated, "We do them as close as we can and if we have to do them early we put a note of why it was done, when it was done, whether early or late. Cert dates don't change, it is generated at the start of care by the computer system, then it generates all following cert dates. The agency is unable to make changes to the programming. We enter the reason it was done outside of the cert dates, like if they will be out of town or unavailable. We would never schedule it outside of the window due to the nurse visit schedule." Review of the agency's policy, Comprehensive Assessment-Home Health, Therapy & Rehab, dated 1/26/21, indicated the "comprehensive assessment must be updated and revised (including the OASIS) as frequently as the client's condition warrants due to major decline or improvement in the client's health status, but no less frequently then: the last five days of every 60 days beginning with the start of care date, unless there is a beneficiary elected transfer, significant change in condition or discharge and return to the agency during the 60 day episode."

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 interview and document review, the agency failed to ensure the plan of care (POC) included a description of safety measures to protect against injury for 5 of 7 patients (P3, P4, P6, P7, P1) and the risk for emergency department visits and hospital re-admission for 1 of 7 patients (P1), whose records were reviewed. Findings include: P3's plan of care (POC) indicated start of care (SOC) date of 11/22/20. The (POC) for the certification period 4/7/21 to 6/5/21, included diagnoses of heart disease, chronic kidney disease with heart failure, kidney and pancreas transplant status and history of transient ischemic attack. The POC further indicated P3 received skilled nurse visits every two weeks for various assessments and education. P3 had poor vision, unsteady gait, taking anticoagulant medications and lived alone. The POC failed to identify a description of safety measures to protect P3 against injury. P4's POC indicated SOC date of 4/19/21. The POC for the certification period 4/19/21 to 6/17/21, included diagnoses of diabetes, use of hypoglycemic medications, repeated falls and abnormal gait and mobility. The POC further indicated P4 received skilled nurse visits one time per week for two weeks then every two weeks for various assessments and education. P4 had unsteady gait, ambulated with a walker, was at high risk for emergent care and had frequent falls. The POC listed basic home safety under safety measures and failed to identify a description of safety measures to protect P4 against injury. P6's POC indicated SOC date of 2/28/21. The POC for the certification period 2/28/21 to 4/28/21, included diagnoses of cerebral vascular accident (CVA) with right sided weakness, and heart disease. The POC further indicated P6 received skilled nurse visits two times per week for one week and then every two weeks for various assessments and education. P6 had right sided weakness, uses a wheelchair for mobility, weakness and received anticoagulant medication. The POC listed basic home safety under safety measures and failed to identify a description of safety measures to protect P6 against injury. P7's POC indicated SOC date of 11/2/20. The POC for the certification period 11/2/20 to 12/31/20, included diagnoses of pressure ulcer, lymphedema, atrial fibrillation and kidney disease. The POC further indicated P7 received skilled nurse visits one time per week for four weeks and then every two weeks for four weeks for various assessments and education. P7 had weakness, urinary urgency, had short term memory impaired and lived alone. The POC listed P7's durable medical equipment and supplies under the safety measures and failed to identify a description of safety measures to protect P7 against injury. P1's POC indicated SOC date of 4/10/21. P1's certification period of 4/10/21 to 6/08/21, included diagnoses of lumbar intervertebral disc degeneration, type 2 diabetes mellitus including kidney disease and polyneuropathy (nerve damage), and congestive heart failure. The POC indicated P1 received skilled nurse visits one time per week for one week and every two weeks for eight weeks for assessment and education, and physical and occupational therapy for evaluation. P1's POC included an area titled "PATIENT AT RISK FOR EMERGENT CARE OR HOSPITALIZATION (BASED ON COMPREHENSIVE ASSESSMENT):" However, the area was answered with "med," and did not indicate P1's risk for risk for emergency department visits and hospital readmission, including all necessary interventions to address the underlying risk factors as required. The POC also included an area titled "Safety Measures:" The area was answered with "Basic Home Safety." P1's comprehensive assessment indicated high risk and history of falls, weakness, prescribed blood thinners, lifeline, ambulation with walker and lives alone. The POC failed to identify a description of the individualized safety measures to protect P1 against injury. During interview on 5/6/21, at 11:00 a.m. clinical manager (CM)-A stated the POC information was generated by what the nurses input manually at the SOC visit. Basic home safety was the agency's way of saying no throw rugs, electrical cords, general safety guidelines and things like that, rather than typing the whole thing out. If there were other risk factors, she would expect the nurse to address that on the care plan, such as bleeding risks. During interview on 5/6/21, at 2:00 p.m. the administrator stated basic home safety measures was an option if there was nothing specific needed. Safety measures should be addressed in the POC and the hospital/emergency risk for patients should include why the patient was at risk.

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 interview and document review, the agency failed to perform home health aide (HHA) visits, only as ordered by a physician, for 1 of 7 patients (P5), reviewed for home care services. Findings include: P5's plan of care (POC) indicated start of care (SOC) date of 3/20/21. The POC for the certification period 3/20/21 to 5/18/21, included diagnoses of hypertension, atrial fibrillation, diabetes, kidney disease and a history of malignant neoplasm of the large intestine. The POC further indicated P5 received skilled nurse visits one time a week for one week, then two times per week for four weeks then one time per week for four weeks for various assessments with three visits as needed (prn) for ostomy complications. Physical therapy (PT) one time per week for one week. Occupational therapy one time per week for one week and HHA one time per week for three weeks to assist with activities of daily living, shower, bathing, and dressing/undressing. Review of P5's service agreement dated 3/20/21 indicated P5 had been informed and agreed to the following services; skilled nursing visits two times per week for 4 weeks then one time per week for four weeks, therapies per POC and HHA visits one time per week for three weeks. Review of P5's physician orders revealed the HHA visits were discontinued on 4/22/21, however, the medical record lacked additional orders for the extra HHA visits for week four and five. During interview on 5/6/21, at 11:00 a.m. clinical manager (CM)-A indicated if visits were missed or more visits were needed, a fax was sent to the doctor, all disciplines were to fill out their own. There was a frequency of visits form and the service agreement if more services were needed. If changes to visit frequency, a new order was generated regardless. During interview on 5/6/21, at 2:00 p.m. the administrator stated any changes in services would require a new service agreement and to send an order to the physician. The facility's policy Physician Notification with revision date of 3/19/21, indicated if the home health agency provided visits at different intervals than the physician orders, the physician would be notified by the agency with an interim order.