Every finding on record at Healthkeeperz

L0514 Based on agency policy, clinical record review, and staff interviews, the agency failed to accept a patients right to refused care or treatment for 1 of 1 patient refusing care. (patient #6) Findings included: --- A policy Client Bill of Rights (revised 10/06/2021) received on 03/18/2025 at 5:41 PM from the agency director stated, ";All company staff and contract personnel shall be knowledgeable of the clients rights and responsibilities, the policies and procedures pertaining to these rights, and shall assume responsibility for their implementation... Participate in, be informed about, and consent or refuse care in advance or during treatment..." Patient #6 was admitted on 02/05/2025 with a diagnosis of age-related physical disability. The plan of care for 02/05/2025-05/05/2025 included orders for medical social work (MSW) visits 2 times a month for 2 months, 3 times a month for 1 month, and 5 PRN (as needed). The patient is a resident of a facility. During the MSW visit on 02/18/2025 MSW #6 documented, ";Social worker emphasized to continuously try to feed the patient and not just accepted his refusal." A home visit at the facility was conducted on 03/18/2025 at approximately 10:45 AM with RN #3. Patient #6 was alert and able to make their needs known and stated that they did not like the food at the facility. An interview conducted on 03/18/2025 at 3:20 PM with MSW #6 revealed that MSW #6 was aware of the patients right to refuse.

Based on agency policy, clinical record review, and staff interviews, the agency failed to include a complete medication list in the plan of care for 2 of 2 patients with registered nurse home visits. (patients #3 and 6) Findings included: --- A policy, Medication Review and Reconciliation (revised 08/18/2021) received on 03/17/2025 at 4:29 PM from the agency director stated, ";A thorough medication review will be conducted on all Home Health and Hospice clients during admission and with each visit thereafter." Patient #3 was admitted on 06/13/2024 with a diagnosis of age-related disability. Patient #3 was a facility resident. The plan of care for 02/08/2025-04/08/2025 included orders for skilled nurse visits 2 times a week for 8 weeks, 1 time a week for 1 week, and 5 PRN (as needed). A home visit was conducted on 03/17/2025 at approximately 2:05 PM with registered nurse (RN) #2. A comprehensive review of the medications found the hospice medical record included orders for ";lorazepam [anxiety medication] 2MG/ML oral concentrate 0.25mL oral every 4 hours/PRN" and ";Trazadone [antidepressant] 50 MG 1 tablet oral at bedtime." A review of the facility medication orders revealed that there were no orders for lorazepam or Trazadone. Further review of the facility medication orders found orders for ";POT CLORIDE TAB 20MEQ by MOUNTH everyday [potassium chloride tablets 20 milliequivalent], VESICARE [bladder control] 5mg take one tablet by mouth every day, OLANZAPINE [antipsychotic] take 1 tablet by mouth every 6 hours, and clonidine [increases blood pressure] 0.1 mg tabs take 1 tablet by mouth once a day as needed." Further review of the hospice clinical record revealed that potassium chloride, Vesicare, olanzapine and clonidine were not included in the plan of care. 2. Patient #6 was admitted on 02/05/2025 with a diagnosis of age-related physical disability. The plan of care for 02/05/2025-05/05/2025 included orders for skilled nurse visits 3 times a week for 13 weeks, 1 time a week for 1 week, and 5 PRN. Patient #6 was a facility resident. A home visit was conducted on 03/18/2025 at approximately 10:45 AM with RN #3. A comprehensive review of the medications found the hospice medical record included orders for ";lorazepam [anxiety medication] 0.5mg tablet 1 tablet every oral every 4 hours/PRN" A review of the facility medication orders revealed that there were no orders for lorazepam. Further review of the facility medication orders found orders for ";Sertraline HCL [antidepressant] tablet 25mg give 1 tablet by mouth one time a day" and ";Gabapentin [treats nerve pain] 300 MG give 1 capsule by mouth 3 times a day." Further review of the hospice clinical record revealed that Sertraline and Gabapentin were not included in the plan of care. During an interview conducted on 03/17/2025 at 2:56 PM RN #2 stated, ";I try do it [medication review] every couple months." During an interview conducted on 03/18/2025 at 10:55 AM the agency director stated, ";Each visit [nurse] should have a medication reconciliation."

Based on agency policy, observation, and staff interviews, the agency failed to take precautions to prevent the spread of infection for 2 of 2 patients with registered nurse observation visits conducted. (patients #3 and 6) Findings included: --- A policy, Nursing Bag Technique (revised 0/26/2021) received on 03/17/2025 at 4:32 PM from the agency director stated, ";Prepare a receptacle for disposal of used supplies... Close the bag and leave it closed during the visit." A policy, Standard Infection Control Procedures for Home Care (not dated) received on 03/18/2025 at 5:40 PM from the agency director stated, ";Donning/Doffing PPE [putting on and taking off personal protective equipment] stated, ";Discard gloves in waste container." Patient #3 was admitted on 06/13/2024 with a diagnosis of age-related disability. Patient #3 was a facility resident. The plan of care for 02/08/2025-04/08/2025 included orders for skilled nurse visits 2 times a week for 8 weeks, 1 time a week for 1 week, and 5 PRN (as needed). A home visit at the facility was conducted on 03/17/2025 at approximately 2:05 PM with registered nurse (RN) #2. RN#2 performed hand hygiene and removed items from the clinical bag. The clinical bag remained open for the entire visit. An interview conducted on 03/18/2025 at 4:06 PM with RN #2 revealed that the clinical bag is not normally left open while providing care. During an interview on 03/18/2025 at 4:08 PM the agency director stated, ";We [all staff] should keep the bag closed during the visit." 2. Patient #6 was admitted on 02/05/2025 with a diagnosis of age-related physical disability. The plan of care for 02/05/2025-05/05/2025 included orders for skilled nurse visits 3 times a week for 13 weeks, 1 time a week for 1 week with 5 PRN. Patient #6 was a facility resident. A home visit was conducted at the facility on 03/18/2025 at approximately 10:45 AM with RN #3. RN #3 donned clean gloves, performed a skin assessment of patient #6s sacrum (lower back near) and buttocks, removed the contaminated gloves and placed them into the RNs pocket. An interview conducted on 03/18/2025 at 3:22 PM with RN #3 revealed that the contaminated gloves were placed into a pocket because the trash can did not have a liner in it. An interview on 03/18/2025 at 3:27 PM with the agency director revealed that soiled gloves should not be placed in the clinicians pocket.

Based on clinical record review and staff interviews, the agency failed to provide spiritual counseling for 2 of 12 patients. (patients #1 and #6) Findings included: --- Patient #1 was admitted on 05/15/2024 with a diagnosis of chronic obstructive pulmonary disease (lung disease). The plan of care for 05/15/2024-07/13/2024 included orders for skilled nurse visits 2 times a week for 9 weeks with 5 PRN (as needed) and medical social work visits 2 times a month for 2 months, 1 time a month for 1 month with 5 PRN. Clinical record review revealed that a chaplain [spiritual] assessment was not conducted. Further review revealed that there was no documentation of the patient refusing chaplain visits. 2. Patient #6 was admitted on 02/05/2025 with a diagnosis of age-related physical disability. The plan of care for 02/05/2025-05/05/2025 included orders for skilled nurse visits 3 times a week for 13 weeks, 1 time a week for 1 week with 5 PRN and medical social work visits 2 times a month for 2 months, 1 time a month for 1 month with 5 PRN. Clinical record review revealed that a chaplain [spiritual] assessment was not conducted. Further review revealed that there was no documentation of the patient refusing chaplain visits. An interview conducted on 03/18/2025 at approximately 4:30 PM with the chaplain revealed that initial chaplain [spiritual] assessments are conducted as assigned by the scheduler. An interview with the agency director on 03/17/2025 at approximately 1:15 PM revealed that if a patient refuses it should be documented in the clinical record.

Based on policy review, clinical record review, satisfaction survey review, and staff interview, the agency failed to document grievances received from patients or their responsible parties for 1 of 16 active clinical records reviewed (Patient #8) and for 3 of 4 patient satisfaction surveys that were returned with documented concerns. Findings included: Policy Grievances/Complaints, revised 10/20/21, was received from the agency director on 05/17/22 at 2:11 PM. This policy revealed, " ...Upon receipt of the complaint, the departmental manager (or designee) shall take the following steps: Contact the individual voicing the complaint of the status of the complaint/grievance within 24 hours. During the contact, the departmental supervisor will obtain all additional necessary information on the nature of the complaint. He or she will also assure the client that the complaint will be reviewed, and further contact will be forthcoming ...Speak with involved employees, as appropriate, to obtain further clarification, and to allow the employee an opportunity to respond to allegations. If required, discuss ways to prevent future similar incidents with involved employee. Plan corrective action plans with employee to address behavior and implement. If required, initiate the disciplinary process. Document all activities on the Complaint/Grievance form. The Supervisor will report status of activities to client/responsible party within three (3) business days following receipt of complaint. Once the investigation of the complaint is completed, the Supervisor will notify the client/responsible party and review the findings..." 1. Patient #8 was admitted to the agency on 03/04/22 with a diagnoses including congestive heart failure and epilepsy. Plan of Care from 05/03/22 to 07/01/22 revealed orders for skilled nursing 1 time per week for 9 weeks and 4 PRN (as needed) for pain and symptom management, and medical social worker 2 times per month for 2 months and 4 PRN for psychosocial support. Employee #6, a medical social worker, conducted a visit with Patient #8 on 04/18/22. This visit note revealed, " ...SW discussed patient's care and patient responded that she dismissed RN due to RN and her getting into a verbal conversation addressing patient's beliefs ..." There was no evidence that this grievance was documented, no evidence of any follow-up contact with Patient #8, and no evidence that an investigation took place. In an interview with Employee #1, the agency director, on 05/18/22 at approximately 12:15 PM, Employee #1 stated, " ...[Patient #8] was adamant that she did not want oxygen in her home ... and said she did not want that nurse to come back ..." Employee #1 stated that the nurse assignment was changed as Patient #8 requested but confirmed that the complaint was not documented and there no evidence of follow-up, including with the complainant, at the time of survey. 2. Patient #18 was on service with the agency from 09/03/20 to 09/07/20. The satisfaction survey was completed by Patient #18's husband and returned to the agency on 12/21/20. This survey revealed, "When my wife died, I was unable to contact the hospice personnel. I called several times no answer [sic]. So I called the [sic] 911. Answering service may need upgrade." There was no evidence that this grievance was documented, no evidence of follow-up contact with Patient #18's husband, and no evidence that an investigation took place. In an interview with Employee #1, the agency director, on 05/18/22 at approximately 12:15 PM, Employee #1 confirmed that the complaint was not documented and there no evidence of follow-up with the complainant at the time of survey. 3. Patient #19 was on service with the agency from 01/21/21 to 02/01/21. The satisfaction survey was completed by Patient #19's daughter and returned to the agency on 05/25/21. This survey revealed, "I would hate for another family try [sic] to reach out to On Call Nurse and not get an answer when your [sic] loved one is in distress. No or slow to return calls." There was no evidence that this grievance was documented, no evidence of follow-up contact with Patient #19's daughter, and no evidence that an investigation took place. In an interview with Employee #1, the agency director, on 05/18/22 at approximately 12:15 PM, Employee #1 confirmed that the complaint was not documented and there no evidence of follow-up with the complainant at the time of survey. 4. Patient #20 was on service with the agency from 08/23/21 to 08/25/21. The satisfaction survey was completed by Patient#19's daughter and returned to the agency on 12/14/21. This survey revealed, "This company was the worst, people need to get a company that cares ..." There was no evidence that this grievance was documented, no evidence of follow-up contact with Patient #20's daughter, and no evidence that an investigation took place. In an interview with Employee #1 on 05/18/22 at approximately 12:20 PM, Employee #1 stated that Patient #20 was only on service with the agency for a very short period of time and that Patient #20's family had a difficult time coping with the patient's rapid decline. Employee #1 also stated that Patient #20's daughter called the office to voice her dissatisfaction while the patient was still receiving services and, "I did not call her [after receipt of the Patient Satisfaction Survey] because it [the complaint] was addressed when it [Patient #20's daughter contacted the office to voice her dissatisfaction with services] occurred ..." Employee #1 confirmed that the complaint was not documented and there no evidence of follow-up, including with the complainant, at the time of survey.