Every finding on record at Tri County Home Health & Services Inc

An onsite unannounced Emergency Preparedness Program Survey was conducted at Tri-County /Medical Services of America Home Health from 04/01/2024 to 04/04/2024. The home health is in substantial compliance with the Medicare Conditions at 42 CFR 484.102 (Establishment of the Emergency Program).

An unannounced onsite Recertification Survey was conducted at Tri-County /Medical Services of America Home Health from 04/01/2024 to 04/04/2024. The facility is in substantial compliance with the Medicare Conditions at 42 CFR PART 484. Standard level deficiencies were cited.

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on record review and interview, the Home Health Agency (HHA) failed to provide proper written notice in advance of discharge for 2 of 5 records reviewed for discharge (Patients #9 and #10). Review of Patient #9's (P9) record on 4/3/24 at 3:20 PM revealed P9 was admitted to the HHA on 11/16/23 with a diagnosis of pancreatitis (inflammation of the pancreas). The Home Health Certification and Plan of Care indicated P9 received Physical Therapy (PT) and Occupational Therapy (OT) services. The Discharge Summary indicated P9 was discharged on 1/15/24. There was no documented evidence provided prior to the notice that was given to P9 of the discharge. In an interview with the Administrator on 4/4/24 at 10:10 AM, she/he reviewed P9's record and confirmed there was no prior notice of discharge given to P9 and she/he stated, "There should have been one." She/he confirmed a Notice of Medicare Non-coverage (NOMNC) should have been provided to P9 no less than 48 hours before discharge. Review of Patient #10's (P10) record on 4/3/24 at 3:37 PM revealed P10 was admitted to the HHA on 12/3/2023, with a diagnosis of atherosclerotic heart disease (thickening and hardening of the arteries). The Home Health Certification and Plan of Care indicated P10 received PT services. The Discharge Summary indicated P10 was discharged on 1/31/2024. There was no documented evidence that the discharge notice was provided to P10 prior to discharge. In an interview with the Administrator on 4/4/2024 at 10:13 AM, she/he reviewed P10's record and confirmed there was no prior notice of discharge provided to P10. She/he confirmed a NOMNC should have been provided to P10 no less than 48 hours before discharge.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency failed to provide assessments within 48 hours of physician orders for Start of Care (SOC) or Resumption of Care (ROC) for 4 out of 17 patients (Patient #2, #4, #16 and #17). Findings included Review of Patient #2’s medical record showed physician orders for Skilled Nurse (SN) dated 02/27/2024 for wound care evaluation. A SN evaluation is documented on 03/13/2024, 15 days after the physician order. During an interview on 04/04/2024 at 11:25 AM, the Administrator stated, "The delay could have been due to staffing". Review of Patient #4’s medical record showed physician orders for Physical Therapy (PT) evaluation on the admission 485. PT evaluation for SOC was completed on 03/24/2024, with no documentation in the chart to explain the delay of 11 days. During an interview on 04/04/2024 at 11:45 AM,the Administrator stated, "The delay could have been due to staffing". Review of Patient #16’s medical record showed Pt 16 was transferred to the hospital on 03/07/2024 with a ROC scheduled for 03/22/2024. Records showed the Registered Nurse (RN) called the caregiver to schedule the ROC visit on 03/22/2024 but the caregiver declined and requested the RN follow up with the patient’s granddaughter to schedule. The RN left a voice message with the granddaughter to return the call to schedule a visit. There is no further documentation of attempts to connect with the granddaughter. During an interview on 04/04/2024 at 11:56 AM, the Administrator stated, "The documentation should not have been listed as a missed visit and it would not have been forwarded to the scheduler". Review of Patient #17’s medical record on 04/03/2024 showed a referral for home health service dated 02/08/2024. The initial assessment SOC by the PT was done on 02/14/2024. There is no documentation in the chart to explain the delay of 6 days. During an interview on 04/04/2024 at 12:05 PM, the Administrator verified the findings.

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 observations, interviews and record reviews the home health agency (HHA) failed to ensure the patient medication lists were updated and accurate for 3 of 7 home visits reviewed for medications (Patients #2, #3, #4 and #7). During a home visit to Patient #7 (P7) with skilled nurse 4 (SN4) on 4/3/24 at 8:30 AM, SN4 stated she/he reconciled P7’s medications “yesterday” and stated she/he reconciles medications “every visit.” A current medication list was requested and received from the assisted living facility (ALF). During review of the ALF Medication Review Report dated 4/3/24 and the HHA Medication Profile dated 3/18/24-5/16/24 on 4/3/24 at 10:30 AM, the following discrepancies were found: The HHA list indicated Isosorbibe Dinatrate Oral 10 mg (milligram) daily but the ALF list indicated Isosorbibe Mononitrate Oral 10 mg daily. The HHA list indicated Ducosate Sodium Oral 100 mg tablet two times a day for constipation prevention but the ALF list indicated Sennosides-Ducosate Sodium Tablet 8.6-50 mg tablet two times a day for constipation. The HHA list indicated Ventolin HFA Inhalation two puffs every six hours as needed and Enulose Oral 10 mg/15 ml 30 ml daily but these medications were not on the ALF list. The HHA list indicated Dapagliflozin Propanediol Oral 10 mg tablet daily for diabetes. The ALF list did not have this medication. The ALF list indicated the following medications which were not on the HHA list: Clotrimazole External Cream 1% topical to fingertips every 24 hours as needed for skin infection with an order date of 12/26/23, Cyanocobalamin 1000 mcg (micrograms) tablet every Monday through Friday with an order date of 3/22/24, Dulcolax Rectal Suppository 10 mg with an order date of 2/5/24, Forosemide 20 mg with an order date of 3/6/24, Lidoderm External Patch with an order date of 12/20/23, Oxycodone 7.5 mg with an order date of 1/30/24, Potassium Chloride ER 10 MEQ (milliequivalents) with an order date of 3/22/24, and Pregabalin 25 mg with an order date of 12/20/23. During an interview with the Administrator on 4/4/24 at 10:45 AM she/he reviewed the ALF and HHA medication lists and confirmed the findings. The Administrator stated the nurses are supposed to reconcile the medications every visit. Findings included Observation in Patient #2’s home on 04/01/2024 from 3:45 PM to 4:45 PM showed Oxybutynin Chloride ER 15 mg 1 tablet daily via feeding tube on agency medication list. Caregiver reports Oxybutynin Chloride ER 5 mg twice a day via feeding tube. Agency medication list reports Dorzolamide HCL-Timolol Mal Ophthalmic 22.3-6.8 Mg/ml, 1 drop each eye twice a day. Caregiver reports Dorzolamide HCL-Timolol Mal Ophthalmic 22.3-6.8 Mg/ml, 1 drop each eye once a day.During an interview on 04/04/2024 at 11:25 AM, Administrator stated medications should have been updated and verified the findings. Observation in Patient #3’s home on 04/02/2024 from 9:45 AM to 10:25 AM showed on Agency medication list Docusate Sodium 100 mg, 1 capsule by mouth twice a day. Patient #3 reports no longer taking this medication. Agency medication list reports Insulin Aspart subcutaneous 100 units/ml into skin 3 times a day per sliding scale. There is no documentation of dosage for sliding scale. During an interview on 04/04/2024 at 11:42 AM, Administrator stated sliding scale dosing should have been listed. Observation in Patient #4s home on 04/02/2024 from 912:05 PM to 12:37 PM showed on Agency medication list Scopolamine Transdermal 1 mg/3 days, 1 patch apply patch topically to the skin every 3 days. Patient #4 reports no longer taking this medication. During an interview on 04/04/2024 at 11:45 AM, Administrator stated list should have been updated and verifies the finding.

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 record review, the Home Health Agency (HHA) failed to provide a full comprehensive assessment of the patients psycho-social status for 2 out of 17 patients (Patient #13 and #17). Findings included Review of Patient #13’s medical record on 04/03/2024 showed under psychosocial assessment on Plan of Care (POC), marked as “not applicable”. During an interview on 04/04/2024 at 12:01 PM, Administrator stated it should have been completed. Review of Patient #17’s medical record on 04/03/2024 showed under psychosocial assessment on Plan of Care (POC), marked as “not applicable”. During an interview on 04/04/2024 at 12:05 PM, Administrator stated it should have been completed.

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 record review, the Home Health Agency (HHA) failed to obtain physician orders for Skilled Nurse (SN) visits for 1 of 17 patients (Patient #15). Findings included Review of Patient #15’s medical record on 04/03/2024 showed documentation of Skilled Nurse (SN) visits on 03/08/2024 and 03/12/2024. Physician orders for SN visits are dated as effective 03/17/2024. There are no orders for SN visits prior to that date. During an interview on 04/04/2024 at 12:10 PM, the Administrator stated she/he was unable to find orders for these visits and verified the finding.

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, interview and policy review, the Home Health Agency (HHA) staff failed to follow standard precautions to prevent the spread of infection by failing to perform hand hygiene when doffing gloves, switching gloves between contaminated areas, using poor barrier technique, using poor bag technique, and sanitizing used equipment for 2 out of 7 patients (Patient #2, and #5). Patient #5’s (P5’s) wound care and dressing changes were observed during a home visit with Skilled Nurse 3 (SN3) on 4/2/24 at 10:05 AM. SN3 put on gloves and used a tape measure and pen to measure the wounds to P5’s lower legs (two on the left lower leg and three on the right lower leg). Then SN3 cleansed all of the wounds, cut open a dressing package, cutting the dressing into pieces and placed the pieces on the leg wounds. SN3 then grabbled the rolled gauze package, cut open a non-stick dressing package, and applied the nonstick dressing to the wounds and wrapped the legs in the rolled gauze. SN3 then removed the dressings to both the right and left forearms except for one that was stuck on the left forearm. SN3 did all of this with the same gloves on. SN 3 did not remove the gloves and perform hand hygiene after removing the soiled dressings. SN3 then removed the gloves, performed hand hygiene and put on clean gloves and removed the dressing that was stuck to the left forearm. With the same gloves on she/he cleansed the wound and applied a clean dressing. SN3 did not remove the gloves and perform hand hygiene after removing the soiled dressing. SN3 did not provide wound care to each wound separately. In an interview with SN3 at 11:00 AM, immediately after leaving P5’s home, she/he confirmed the findings. In an interview with the Administrator on 4/4/24 at 11:15 AM, she/he stated the nurse is “…supposed to change each dressing separately” and “remove gloves and alcohol” (hand sanitizer) after removing the soiled dressings. Findings included Observation in Patient #2’s home on 04/01/2024 from 3:45 PM to 4:45 PM showed Skilled Nurse (SN) #1 placing clean and dirty equipment on the same barrier, reaching into bag to retrieve scissors, gloves and tape wearing soiled gloves. During an interview on 04/04/2024 at 11:25 AM, Administrator stated agreement that proper technique was not performed.

A survey of the Home Health Agency's (HHA) Emergency Preparedness Program (EPP) was conducted from 08/30/2021 to 09/02/2021. Based on observations, record reviews, interviews, and review of the HHA's EPP and policies and procedures, it was determined that no deficiencies resulted from the Emergency Preparedness Program Survey.

The Home Health Agency's (HHA) Recertification Survey was conducted in conjunction with the COVID-19 focused Infection Control requirements from 08/30/2021 to 09/02/2021. Based on observations, record reviews, interviews, review of the COVID -19 requirements, and review of the HHA's policies and procedures, it was determined the HHA is in compliance with the COVID - 19 focused Infection Control requirements, and determined that standard level deficiencies resulted from the HHA's Recertification Survey.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record reviews, interviews, and review of the facility's policies and procedures, the Home Health Agency (HHA) staff failed to document wound measurements when completing the initial nursing assessment for one of four patients with wounds (Patient #8) and failed to document wound measurements for multiple visits with Patient #12. Patient 12 On 09/01/ at 12:45 PM, the review of the patient’s record revealed the patient was seen on 07/09/21 for a diagnosis of “Laceration without foreign body of left forearm and laceration without foreign body of right hand.” Wound measurements were obtained on the visit. The patient was seen two (2) times weekly for six (6) weeks with no wound measurements obtained. The findings were verified by the administrator on 09/02/21 at 9:16 AM. On 9/1/2021 at 12:04 PM, a review of Patient #8’s chart reveals the Registered Nurse (RN) failed to document wound measurements on an open pressure ulcer located on the buttock on the initial nursing assessment dated 7/27/2021. This finding is verified by the Administrator at 12:04 PM on 9/1/2021. On 9/2/2021 at 11:55 AM, a review of the agency’s policy and procedure for Wound Care Standards states, “Any patient with an open area will have the sites measured and documented weekly.” This finding is verified by the Administrator at 11:55 AM on 9/2/2021.

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on record review, interview, and agency policy and procedure, the agency staff failed to document wound measurements in three out of four patients with wounds (Patient #11, #12, and #17). On 9/1/2021 at 1:12 PM, a review of Patient #17’s chart reveals the Registered Nurse (RN) assessed a new wound on the left great toe. There is no documentation of the measurements of the wound in the chart. On 9/2/2021 at 11:55 AM, a review of the agency’s policy and procedure for Wound Care Standards states, “Any patient with an open area will have the sites measured and documented weekly.” This finding is verified by the Administrator at 11:55 AM on 9/2/2021.

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, interview, and agency policy and procedure, the agency staff failed to obtain wound care orders prior to performing wound care in one out of four patients with wounds reviewed (Patient #17). On 9/1/2021 at 1:12 PM, a review of Patient #17’s chart reveals the Registered Nurse (RN) assessed a new wound (left great toe ) on a visit dated 7/15/2021. The nurse documents wound care and the type of dressing applied. There are no orders found for the wound care applied during this visit. This finding is verified by the Administrator at 10:17 AM on 9/2/2021.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record reviews and interview, the Home Health Agency staff failed to follow physician orders such as missed visits, services, and consults for 5 of 17 patient charts reviewed for care and services. (Patient #5, #6, #7, #9, and #11) Patient 11 On 09/01/21 at 11:02, the review of the patient’s record revealed there was a nurse visit scheduled for 05/31/21 with a comment “Patient will be seen tomorrow” without notifying the physician or the supervisor. The findings were verified by the administrator on 09/02/21 at 9:05 AM. He/she stated “The nurse didn’t explain why the visit was missed.” Patient #6 On 8/31/2021 at 12:50 PM, a review of Patient #6’s chart reveals an order for a Dietician consult for assistance with weight loss needs. There is no documentation in the chart to show the Dietitian made the consult and no order canceling the Dietitian service. This finding is verified by the Administrator at 9:35 AM on 9/2/2021. Patient #7 On 8/31/2021 at 1:15 PM, a review of Patient #7’s chart reveals the Aide’s frequency of one time a week for four weeks, effective 7/14/2021. There is no documentation of a visit by the Aide on the week of 7/14/2021 and no documentation of a missed visit. This finding is verified by the Administrator at 9:40 AM on 9/2/2021. Patient #5 On 8/31/2021 at 1:57 PM, a review of Patient #5’s chart reveals the Aide has a frequency for 2 times a week for three weeks effective 7/18/2021.There is no documentation within the chart of any Aide visits for this patient nor was there an order to cancel the Aide service. There are no missed visits documented. The chart shows a frequency for the Medical Social Worker (MSW) of one time a week for one week effective 7/15/2021. There is no documentation of a MSW visit on the week of 7/15/2021. There is a missed visit by the MSW on 7/22/2021. There is no documentation the MSW did an evaluation on the patient nor was there an order to cancel the MSW evaluation. These findings are verified by the Administrator at 9:23 AM on 9/2/2021. Patient #9 On 9/1/2021 at 11:24 AM, a review of Patient #9’s chart reveals the Skilled Nurse’s (SN) frequency as one time a week for one week, effective 7/15/2021, then one time a week for seven weeks, effective 7/19/2021. The patient was admitted with Unspecified Atrial Flutter with a secondary diagnosis of Chronic Kidney Disease with Stage Five Kidney Disease or End Stage Renal Disease (ESRD). The patient receives hemodialysis on Monday, Wednesday, and Friday. On the week of 8/8/2021, the SN has documentation of a missed visit on Friday, August 13, 2021 stating the reason “Doctor-Clinic Appointment.” On Monday, 8/16/2021, the RN documents a missed visit stating the reason being “miscommunication with scheduling.” The next visit by the SN staff was on 8/27/2021. In summary, the patient was seen on 8/3/2021 and again on 8/27/2021, a period of 23 days without SN assessments. These findings are verified by the Administrator at 10:00 AM on 9/2/2021.

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, interview, and agency policy and procedure, the agency staff failed to document the notification to the Physician (missed visits, blood pressure outside of range specified, and consults/services) in 8 out of 17 records reviewed (Patient #5, #6, #7, #8, #9, #10, #11, and #15). Patient #6 On 8/31/2021 at 12:50 PM, a review of Patient #6’s chart reveals an order for a Dietician consult for assistance with weight loss needs. There is no documentation the Physician was notified of the Dietitian’s missed consult. This finding is verified by the Administrator at 9:35 AM on 9/2/2021. Patient #7 On 8/31/2021 at 1:15 PM, a review of Patient #7’s chart reveals there is no documentation of a visit by the Aide on the week of 7/14/2021 and no documentation of the Physician being notified of the missed visit. This finding is verified by the Administrator at 9:40 AM on 9/2/2021. Patient #5 On 8/31/2021 at 1:57 PM, a review of Patient #5’s chart reveals the Aide has a frequency for 2 times a week for three weeks effective 7/18/2021. There is no documentation within the chart of any Aide visits for this patient and no documentation the Physician was notified of the missed visits. There is a missed visit by the Medical Social Worker (MSW) on 7/22/2021 and the Physician was not notified per the chart documentation. These findings are verified by the Administrator at 9:23 AM on 9/2/2021. Patient #15 On 9/1/2021 at 9:44 AM, a review of Patient #15’s chart reveals the orders state “to notify the Physician if the systolic blood pressure is greater than 160”. The Physical Therapist (PT) made a visit on 8/16/2021 and obtained a blood pressure of 180/70. There is no documentation of notifying the Physician. The Occupational Therapist (OT) made a visit on 8/16/2021 and obtained a blood pressure of 162/72. There is no documentation of notifying the Physician. These findings are verified by the Administrator at 10:14 AM on 9/2/2021. Patient #10 On 9/1/2021 at 10:55 AM, a review of Patient #10’s chart reveals orders “to notify the Physician for a systolic blood pressure greater than 160 and a diastolic blood pressure greater than 90”. On 8/6/2021, the OT made a visit and obtained a blood pressure of 184/99. There is no documentation the Physician was notified. This finding is verified by the Administrator at 10:03 AM on 9/2/2021. Patient #9 On 9/1/2021 at 11:24 AM, a review of Patient #9’s chart reveals the Skilled Nurse’s (SN) frequency as one time a week for one week, effective 7/15/2021, then one time a week for seven weeks, effective 7/19/2021. The SN had documentation of a missed visit on Friday, August 13, 2021 and states the Physician was not notified. This finding is verified by the Administrator at 10:00 AM on 9/2/2021. Patient #8 On 9/1/2021 at 12:04 PM, a review of Patient #8’s chart reveals the Aide had a missed visit on 8/6/2021. The chart documentation shows the Physician was not notified. This finding is verified by the Administrator at 9:45 AM on 9/2/2021. On 9/2/2021 at 11:55 AM, a review of the agency’s policy and procedure for Patient Visits-Scheduling states, “When a visit is missed the clinician will notify the Physician of the missed visit and the reason for the missed visit.” This finding is verified by the Administrator at 11:55 AM on 9/2/2021.