Every finding on record at The Village at Morrisons Cove

Based on the findings of an onsite unannounced Medicare recertification and State relicensure survey conducted 12/14/2021 through 12/20/2021, Village In Place Services was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies – Emergency Preparedness.

Based on the findings of an onsite unannounced Medicare recertification and state relicense survey conducted 12/14/2021 through 12/20/2021, Village In Place Services was found not to be in compliance with the following requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

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 a review of agency policy, medical record (MR) and staff (EMP) interview, it was determined that the agency failed to maintain an accurate medication profile to ensure review of all medications the patient was taking in order to identify and address potential adverse effects, drug reactions, ineffective drug therapy, significant side effects, drug interactions and noncompliance for two (2) of seven (7) MR's reviewed (MR1 and MR2). Findings Included: Review of the agency policy and procedures on 12/23/2021 at approximately 11:00 AM revealed, Policy “SUBJECT: MEDICATION MONITORING…PURPOSE: To ensure that the medication therapy ordered is appropriate to meet the patient’s clinical needs, thereby promoting achievement of positive patient outcomes. To minimize the occurrence of adverse events relative to medication administration either by (Agency)…staff or by the patient/family/caregiver. POLICY: The patient’s response to medications is monitored by the skilled nurse on a regular basis. The results of the monitoring process are communicated to the ordering physician, licensed independent practitioner and (Agency) staff involved in the patient’s care, treatment, and/or services. PROCEDURE: The skilled nurse monitors the patient’s response to medications during each skilled visit, based on the patient’s clinical needs and/or services. The monitoring process includes at least the following elements: Eliciting from the patient/family/caregiver a determination of the effectiveness of the medication regimen and whether or not any side effects have occurred *Reviewing and evaluating laboratory results, if applicable *Reviewing and evaluating the medication profile *Objectively assessing the patient’s clinical response to medications, The findings, conclusions and recommendations of medication monitoring are communicated to the physician. The findings, conclusions and recommendations of medication monitoring are documented in the patient’s medical record.” Review of MR1 on 12/15/2021 at approximately 11:45 AM revealed, "Home Health Certification and Plan of Care" with a start of care date of 9/29/2021 and a current certification period starting 11/28/2021 and ending 1/26/2022. The primary diagnosis was "Acute Kidney Failure, unspecified" The Home Health Certification and Plan of Care and Medication Profile did not list any allergies under categories “Substance” or “Reaction”. The surveyor requested any H&P (history and physical) available for the patient from a start of service. A faxed document with a fax date of 11/28/2021 revealed “Community Provider Services…Allergies erythromycin [boils to skin]; Inderal [dyspnea]; morphine [Euphoria]; TraZODone Hydrochloride [Euphoria]…” The allergies listed on the documents did not match. Review of MR2 on 12/15/2021 at approximately 2:07 PM revealed, "Home Health Certification and Plan of Care" with a start of care date of 4/9/2021 and a current certification period starting 4/9/2021 and ending 6/7/2021. The primary diagnosis was "COVID-19 acute respiratory disease" Review of a skilled nursing note dated 4/27/2021 revealed under section "Respiratory...O2 at: 2L (Liters) LPM (Liters Per Minute) via: NC (Nasal Cannula) The Home Health Certification and Plan of Care Listed under section “Secondary/Other Diagnosis…Dependence on supplemental oxygen…” The Medication Profile was also review. An order for oxygen was not listed on either document. An exit interview was conducted with the administrator and the director on 12/20/2021 at approximately 11:40 AM which confirmed the above findings.

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 review of agency policy and procedure, observations (OBV) during home visits and staff (EMP) interview, the agency failed to ensure staff followed infection control standards of practice per agency policy and procedure for one (1) of two (2) observations providing direct care to patients (OBV1). Findings Included: Review of the agency policy and procedures on 12/23/2021 at approximately 11:00 AM revealed, "SUBJECT: NURSING BAG TECHNIQUES ...PURPOSE: To maintain a clean nursing bag and prevent transmission of infection to patients ...PROCEDURE: The bag should be placed on a barrier, i.e. disposable profession towels, paper towels, in the employee ' s care and in the patient ' s home. Contaminated supplies/equipment are contained/disposed of as necessary. Reusable equipment is cleaned using alcohol, antiseptic wipes, and/or soap and water as appropriate: Stethoscope (bell and diaphragm): Cleaned with alcohol/antiseptic wipe, Bandage scissors: Cleaned with alcohol/antiseptic wipe, Blood pressure cuff: Cleaned according to the manufacturer and whenever the cuff has been soiled with blood or other potentially infectious materials..." Observations (OBV#1) during a visit to MR1 residence on 12/17/2021 at 8:54 AM revealed: EMP provided direct patient care. EMP7 placed three chuck/barriers on the patient's table. The nursing bag was place on one of the chuck/barriers but the strap to the bag was hanging off the chuck/barrier and laying against a tablecloth on the side of the patient's table. An exit interview was conducted with the administrator, agency director and home care director on 12/20/2021 at approximately 11:40 AM which confirmed the above findings.