Every finding on record at Community Nurses Home Health and Hospice, Inc

Based on review of agency policy, medical records (MR) and staff (EMP) interviews, the agency failed to maintain an accurate medication profile to ensure review of  potential adverse effects, side effects for one (1) of fourteen (14) medical records reviewed (MR8).  Findings included: Review of the agency policy and procedures was conducted on 4/25/2025 at approximately 1:20 PM revealed, “Patient Record Content…PROCEDURE 1. (Agency) will initiate and maintain an individual and accurate patient record containing past and current findings for each patient receiving care in compliance with all federal state laws and regulations.  The record must contain correct clinical information that is available to the patient’s attending physician and (Agency) staff.  The record may be maintained electronically.  (Agency) will use a standardized format for records.  The format will be periodically reviewed and updated, as necessary…3. Each patient record will contain the following as applicable…*Care/services provided by Hospice, including contracted staff  (evaluations, treatments and progress notes)…*A current medication profile to include medication/allergies/sensitivities and  every medication, dose, frequency and route of administration for prescription and  non-prescription medications, herbal products and home remedies. *Responses to medications, symptom management, treatments and services. *Outcome measure data elements.  *Actual or potential drug/food or drug/drug interactions. * The dose, route, time, date and any adverse drug reaction of every dose of medication administered by (Agency) staff and identification of  individual administering the medication…”  Review of MR8 was conducted on 4/23/2025 at approximately 2:12 PM revealed, "Physician’s Orders/Plan of Care" with a start of care date of 2/1/2023 and a current certification period starting 3/22/2025 to 5/20/2025. The primary diagnosis was "Malignant neoplasm of right ovary." The Physician’s Orders/Plan of Care medication list under section “Allergies: ASA OXYCODONE…”  Listed on page three (3) of four (4) was the medication list “Aspirin By Mouth Tablet Chewable 81 MG 1 tablet(s) three times a day PO…Start Date 09-28-2023…” An exit interview was conducted on 4/25/2025 at approximately 2:00 PM with the operations manager, performance improvement manager and manager which confirmed the above findings.

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 and agency policy and procedure for two (2) of three (3) observations providing direct care to patients (OBV1 and OBV3).  Findings Included: Review of the agency policy and procedures was conducted on 4/25/2025 at approximately 1:20 PM revealed, “Infection Control: Preparation of Work Area and Bag Technique…PURPOSE: To prevent contamination of bag and equipment, avoid cross infection, and establish a clean work area…PROCEDURE: 1. Adhere to Standard Precautions. 2. Select a flat surface to place bag and set up work area. Use discretion and consideration when placing bag on patient’s furniture. Never place bag on floor.  Keep bag closed when not in use.  3. Place a barrier (paper towels, clean newspaper or other appropriate material) on flat surface before setting bag down…”  Observations (OBV1) on 4/25/2025 at approximately 9:32 AM revealed:  EMP5 provided direct patient care.  EMP5 placed a chuck/barrier on a bench.  The strap of the equipment bag laid to one side extending below the barrier and rested on the legs of the bench.   Observations (OBV3) on 4/25/2025 at approximately 12:13 AM which revealed:  EMP6 provided direct patient care.  EMP6 placed chucks/barriers on couch.  The equipment bag was placed on the chuck/barrier, and two (2) top zippers of the equipment bag remained open while services was being provided to the patient.    Based on agency policy, volunteer files, staff (EMP) interviews, Centers for Disease Control and Prevention CDC guidance, and agency policy the agency failed to ensure volunteers were screened for TB (tuberculosis) upon hire for one (1) of one (1) volunteer files (VF) reviewed. Findings Included: Review of the agency policy and procedures was conducted on 4/25/2025 at approximately 1:20 PM revealed, “Occupational Exposure to Tuberculosis/Prevention of Transmission of TB Plan…PURPOSE To protect exposed employees and patient care volunteers against TB…PROCEDURE 1. Responsibility for the TB infection control program is assigned to the Director, who is given the authority to  implement and enforce TB infection control policies and procedures…11. All employees and patient care volunteers will receive education regarding TB that is relevant to their particular occupational group, before initial assignment and annually…14…*During the pre-employment physical, employee’s and patient care volunteer who have potential for exposure to M. tuberculosis, including those with a history of BCG vaccination, will have baseline PPD skin testing performed. *For employees or patient care volunteers who have not had a documented negative PPD test during the proceeding 12 months, the baseline PPD testing will include the two step method…” Review of the Centers for Disease Control and Prevention CDC guidance was conducted on 4/30/2025 at approximately 2:30 PM revealed, "Clinical Testing Guidance for Tuberculosis: Health Care Personnel...TB screening programs in health care setting, TB screening programs should  include anyone working or volunteering in health care settings, including: *Inpatient settings *Outpatient settings..." A review of VF1 was completed on 4/24/2025 at approximately 2:42 PM. VF1 start date was  1/10/2024. An “Employee Tuberculosis Screening Review Questionnaire” was completed on 3/12/2025. No documentation was provided by the agency to confirm TB testing per policy and CDC guidance was completed at the time of  hire. An exit interview was conducted on 4/25/2025 at approximately 2:00 PM with the operations manager, performance improvement manager and manager which confirmed the above findings.