Monroe Co Hosp Progressive Hom

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: Based on a review of the agency’s Emergency Preparedness (EP) plan and staff interview it was determined the agency failed to review and update the EP plan every two years. This had the potential to affect all patients served, and all staff members employed by this agency. Findings include: 1. A review of the agency’s EP plan revealed the plan had not been reviewed or updated since April 2022, which is three years and four months since last update. An interview was conducted on 8/21/25 at 10:45 AM with Employee Identifier # 1, Associate Executive Director, who confirmed the agency’s EP plan had not been updated or reviewed since April 2022.”

“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, agency procedure and staff interview it was determined the agency failed to ensure all aide staff followed infection control precautions and bed bath procedure. This affected one of three home visit (HV) patients, including Home Visit (HV) # 1, and had the potential to affect all patients served by this agency. Findings include: Agency Procedure : Briggs Healthcare Infection Control Procedure number: N-140 Agency Review date 1/28/25 ...Required Infection Procedures: ...2. Remove gloves and wash hands after each contact... Agency Procedure: Briggs Healthcare Bed Bath Procedure Number P-140 Agency Review date 1/28/25 Purpose: To cleanse the skin, stimulate circulation, provide mild exercise, and promote comfort... Applies to: Home Health Aides... 16. Cover the patient and change bath water. 17. Remove gloves, wash hands put on new gloves... 21. Remove gloves , wash hands, change bath water, put on clean gloves... 1. HV # 2 was admitted to the agency on 7/13/24 and recertified from 7/11/25 to 9/8/25 with a primary diagnosis of Diabetes with Foot ulcer. A HV was conducted on 8/20/25 at 8:45 AM with Employee Identifier (EI) # 5, Home Health Aide to observe care provided to HV # 2. EI # 1, Associate Executive Director was present during the HV. Review of the Home Health Care Certification and Plan of Care dated 7/11/25 revealed physician’s orders for an Aide to visit one time a week for one week effective week of 7/11/25, and one time a week for nine weeks effective week of 7/14/25 for Hygiene: Bath: Chair with each visit, Safety: standard precautions with each visit. During the HV, EI # 5 washed the perineal area of the patient, then washed and rinsed the lower body with the same basins of water and without changing gloves and performing hand hygiene. When the bath was complete EI # 5 did not change his/her gloves to obtain the patient’s clothing and briefs, and dress the patient. An interview was conducted on 8/21/25 at 10:02 AM with EI # 1, who confirmed staff failed to follow the procedure for a bed bath and the agency infection control procedure.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on the Alabama Board of Nursing Chapter 610-x-6: Standards of Nursing Practice, agency procedure, Medical Record (MR) review, and staff interview, it was determined the agency failed to ensure the staff documented accurately and completely in the MR. This affected three of three wound care MR’s reviewed including Home Visit (HV) # 2, HV # 1, and MR # 1 and had the potential to affect all patients served by this agency. Findings include: Alabama Board of Nursing Chapter 610-x-6: Standards of Nursing Practice 610-X-6-.06 Documentation Standards: (1) The standards of documentation of nursing care provided to patients by registered nurses or licensed practical nurses are based on principles of documentation regardless of the documentation format. (2) Documentation of nursing care shall be: (a) Legible (b) Accurate (c) Complete. Complete documentation includes reporting and documenting on appropriate records a patient’s status, including signs and symptoms, response, treatments, medications, other nursing care rendered, communication of pertinent information to other health team members, and unusual occurrences involving the patient... “ Agency Procedure: Wound Measurement Briggs Healthcare Procedure Number: G-270 Review Date:1/28/25 Procedure: ...f. Wound Measurements are done with routine would care procedures... g. Documentation of wound measurements is part of the required documentation for all wound care procedures. 3. MR # 1 was admitted on 7/6/25 with diagnoses including Type II Diabetes Mellitus with Diabetic Chronic Kidney Disease and Hypertensive Chronic Kidney Disease with Stage 1-4 unspecified Chronic Kidney Disease. A review of the POC dated 7/6/25 revealed physician’s orders for SN two visits per week for four weeks, then one visit per week for five weeks. A further review of the POC revealed an order for SN to perform wound care to clean sacral wound with Normal Saline, allowing time to dry, pack wound lightly with Dakins soaked gauze and cover with Mepilex. A review of the SN Visit Note dated 7/14/25 and 7/21/25 revealed the SN failed to document the depth measurement. An interview was conducted on 8/21/25 at 9:59 AM with EI # 2, Clinical Manager, who confirmed the nurse failed to document the depth measurement. 1. HV # 2 was and admitted to the agency on 7/13/24 and recertified from 7/11/25 to 9/8/25 with a primary diagnosis of Diabetes with Foot ulcer. A review of the POC dated 7/11/25 revealed an order for Skilled Nurse (SN) for one time a week for nine weeks with orders for the SN to assess blood sugar monitoring and results: notifying the Doctor of Medicine (MD) of blood sugar readings greater than 300 or less than 65. A review of the Skilled Nursing Visit notes dated 7/16/25, 7/21/25 and 8/4/25 revealed the nurse failed to document the blood sugar monitoring results. A further review of the POC revealed an order for SN to clean left heel with normal saline, pat dry, apply Santyl ointment (debridement) followed by a wet to dry dressing, wrap with Kerlix (rolled gauze) and secure with Coban (self adherent wrap) daily and as needed. A review of the Skilled Nursing Visit notes dated 7/16/25, 8/4/25, 8/13/25, and 8/18/25 revealed the nurse failed to document the wound care performed during the visit. A review of the Skilled Nursing Visit note dated 7/16/25, 7/21/25, 8/4/25, and 8/18/25 revealed the nurse failed to document the wound measurements. An interview was conducted on 8/21/25 at 10:02 AM with Employee Identifier (EI) # 1 Associate Executive Director, who confirmed the nurse failed to document the blood sugar monitoring results, wound care performed and the measurements. 2. HV # 1 was admitted on 7/13/23 and recertified from 7/2/25 to 8/30/25 with diagnoses including Pressure Ulcer of Right Buttock, Stage 4, Encounter for attention to colostomy, and Encounter for Fitting and Adjustment of Urinary Device. A review of the POC dated 7/2/25 revealed an order for SN one time a week for eight weeks. Further review of the POC revealed SN to perform wound care/dressing change to stage four right buttock gluteal fold. Clean with dial soap and water, pat dry, moisten coarse gauze with 0.125 % Dakin’s Solution and apply directly to right buttock wound. Cover with island dressing or Allevyn ( foam dressing) twice daily and as needed for soilage. SN to instruct caregiver on how to perform wound care twice daily in the SN’s absence. A review of the Skilled Nursing Visit note dated 7/15/25 revealed the nurse failed to document the depth measurement. An interview was conducted on 8/21/25 at 9:45 AM with EI # 1, who confirmed the staff failed to document the depth measurement.”

“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, medical record (MR) review, agency policy and procedure, and interviews with staff, it was determined the agency failed to ensure medications were reconciled each Skilled Nurse (SN) visit per agency policy. This deficient practice affected two of three home visit (HV) patients including HV # 1, HV # 2, and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: Medication Reconciliation Policy Number: 8.15.1 Reviewed: 1/28/25 Policy: The Agency will reconcile patient’s medications at time of admission and on an ongoing basis... Procedure: ...2. ...The medication list/profile will be updated with each new or changed medication. The patient’s medication list in the home will also be updated... 2. HV # 2 was admitted to the agency on 7/13/24 and recertified from 7/11/25 to 9/8/25 with a primary diagnosis of Diabetes with Foot ulcer. Review of the Home Health Care Certification and Plan of Care dated 7/11/25 revealed physician’s orders for SN one visit per week for nine weeks, SN to perform medication reconciliation with each visit. A HV was conducted on 8/20/25 at 8:45 AM to observe care provided by EI # 5, Home Health Aide. During the home visit the medications were reviewed with HV # 2 and compared with the MP dated 8/19/25. The following is a list of the discrepancies: Eliquis 2.5 mg take one tablet twice daily was on the MP but not in the home. HV # 2 stated he/she had not taken the medication in three years. Colace sodium 100 mg oral capsule, take one cap orally twice daily. HV # 2 stated he/she has only taken the medication as needed for greater than three months. Hydrocodone 7.5/325 mg, take one tablet orally every four hours as needed for moderate pain was on the MP but not in the home. HV # 2 stated he/she had not taken the medication for greater than six months. Atorvastatin 40 mg oral table, take one tablet orally once daily was on the MP and in the home. HV # 2 stated he/she had the medication in the home but does currently take the medication. An interview was conducted on 8/21/25 at 10:02 AM with EI # 1 who confirmed the medications were not reconciled per agency policy and physician’s orders. 1. HV # 1 was admitted on 7/13/23 and recertified from 7/2/25 to 8/30/25 with diagnoses including Pressure Ulcer of Right Buttock, Stage IV, Encounter for attention to colostomy, and Encounter for Fitting and Adjustment of Urinary Device. Review of the Home Health Care Certification and Plan of Care dated 7/2/25 revealed physician’s orders for SN one visit per week for eight weeks, SN to perform medication reconciliation with each visit. A HV was conducted on 8/20/25 at 10:15 AM to observe care provided by Employee Identifier (EI) # 4, Registered Nurse (RN). During the home visit, EI # 4 reviewed the medications with HV # 1 and compared the medications with the Medication Profile (MP) dated 8/19/25. The following is a list of the discrepancies: Nitrofurantoin 50 milligrams (mg) take one every day, prescription dated 11/12/24, was in the home but not on the MP. HV # 1 stated he/she was currently taking the medication daily. Terbinafine 250 mg take one daily was on the medication list but not in the home. HV # 1 stated he/she had not been taking the medications for “a while.” Omega 500 mg was in the home and not on the MP. HV # 1 stated he/she had been taking the medication for “a long while.” An interview was conducted on 8/21/25 at 9:50 AM with EI # 1, Associate Executive Director, who confirmed the medications were not reconciled per agency policy and physician’s orders.”

“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 Medical Record (MR) review, agency policy and procedure, and staff interview it was determined the agency failed to ensure all physician orders were complete and accurate. This affected two of seven MR’s reviewed, including Home Visit (HV) # 1 and MR # 4 and had the potential to affect all patients served by this agency. Findings include: Agency Policy: Plan of Care - CMS # 485 and Physician Orders Policy Number: Not Listed Reviewed Date: 1/28/25 Policy: Skilled nursing ... will be in accordance with a Plan of Care... Procedure: ... 4. The individualized plan of care must include the following: ...Patient-specific interventions and education, measurable outcomes and goals identified by the agency... 21. Drugs, services, and treatments are administered by staff only as ordered by physician... 1. HV # 1 was admitted on 7/13/23 and recertified from 7/2/25 to 8/30/25 with diagnoses including Pressure Ulcer of Right Buttock, Stage 4, Encounter for attention to colostomy, and Encounter for Fitting and Adjustment of Urinary Device. A review of the Home Health Certification and Plan of Care (POC) dated 7/2/25 revealed an order for Skilled Nurse (SN) to change Foley catheter as ordered using sterile technique, SN to change size18 French Foley catheter every month at visit week of 5/12/25, 6/16/25, 7/7/25, or PRN due to leaking. An interview was conducted on 8/21/25 at 9:45 AM with Employee Identifier (EI) # 1, Associate Executive Director, who confirmed the staff failed to write an order for the Foley to be changed in August 2025 on the POC. 2. MR # 4 was admitted to the agency on 4/16/24 and recertified from 2/10/25 to 4/10/25 with diagnoses including Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Disorder of the Kidney and Ureter unspecified. A review of the POC dated 2/10/25 revealed an order for the SN to change Foley catheter every three weeks as ordered: week of 2/24/25, week of 3/17/25 and week of 4/7/25. No order was found with the size of the Foley catheter or the balloon size. An interview was conducted on 8/21/25 at 9:54 AM with EI # 1, who confirmed the order for the Foley was not complete on the POC.”

“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 observations, agency policy and procedure, medical record (MR) review, and interviews with staff, it was determined the agency failed to ensure: 1. Wound care was provided as ordered. 2. Patient’s weight was obtained as ordered. 3. Patient’s Blood Sugar (BS) was monitored as ordered. This deficient practice affected four of 7 MR reviewed including Home Visit (HV) # 1, MR # 2, HV # 2, and MR # 1, and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: Plan of Care - CMS # 485 and Physician Orders Policy Number: Not Listed Reviewed Date: 1/28/25 Policy: Skilled nursing ... will be in accordance with a Plan of Care... Procedure: ... 4. The individualized plan of care must include the following: ...All medications and treatments. ...All patient care orders, including verbal orders, must be recorded in the plan of care... 21. Drugs, services, and treatments are administered by staff only as ordered by physician... 4. MR # 1 was admitted on 7/6/25 with diagnoses including Type II Diabetes Mellitus with Diabetic Chronic Kidney Disease and Hypertensive Chronic Kidney Disease with Stage 1-4 unspecified Chronic Kidney Disease. A review of the POC dated 7/6/25 revealed physician’s orders for SN two visits per week for four weeks, then one visit per week for five weeks. Further review of the POC revealed SN to assess blood sugar at each visit and to perform wound care/dressing change to sacral wound every SN visit. Clean with Normal Saline, allowing time to dry, pack wound lightly with Dakin’s soaked gauze and cover with Mepilex. A review of SN Visit Notes dated 7/24/25, 7/28/25, 8/1/25, and 8/5/25 revealed the SN documented covering the sacral wound with Allevyn instead of the ordered Mepilex. A review of SN Visit Notes dated 7/6/25, 7/7/25, 7/10/25, 7/22/25, 7/24/25, and 8/5/25 revealed the SN failed to document blood sugar. An interview was conducted on 8/21/25 at 9:59 AM with EI # 2, Clinical Manager, who confirmed the staff failed to follow the physician’s order for blood sugar assessments and wound care. 3. HV # 2 was admitted to the agency on 11/13/24 and recertified for continued care on 7/11/25 to 9/8/25 with a primary diagnosis of Type Two Diabetes Mellitus with Foot Ulcer. A review of the POC dated 7/11/25 revealed an order for SN for one time a week for nine weeks. SN to clean left heel with normal saline, pat dry, apply Santyl ointment (debridement) followed by a wet to dry dressing, wrap with Kerlix (rolled gauze) and secure with Coban (self adherent wrap) daily and as needed. A further review of the POC revealed an order for SN to assess blood sugar monitoring and results; notifying the MD of blood sugar readings greater than 300 or less than 65. The review revealed no physician orders to obtain a fingerstick blood sugar. A review of the Skilled Nursing Visit note dated 7/21/25 revealed the nurse documented the left heel was cleaned with saline and covered with a Band-Aid. The staff failed to provide wound care to the left heel as ordered. A review of the Skilled Nursing Visit note dated 8/18/25 revealed the nurse documented: SN assessed the blood sugar via fingerstick to right middle finger. An interview was conducted on 8/21/25 at 10:02 AM with EI # 1, who confirmed the nurse did not follow the physicians orders for wound care and had no orders to obtain patient’s blood sugar. 1. HV # 1 was admitted on 7/13/23 and recertified from 7/2/25 to 8/30/25 with diagnoses including Pressure Ulcer of Right Buttock, Stage 4, Encounter for attention to colostomy, and Encounter for Fitting and Adjustment of Urinary Device. Review of the Home Health Care Certification and Plan of Care dated 7/2/25 revealed physician’s orders for Skilled Nurse (SN) one visit per week for eight weeks to perform wound care/dressing change to Stage 4 pressure ulcer to right buttock, clean with dial soap and water, pat dry, moisten coarse gauze with 0.125 % Dakin’s Solution and apply directly to wound. Cover with Island dressing or Allevyn dressing. There were no other orders provided for the wound care. A HV was conducted on 8/20/25 at 10:15 AM to observe wound care provided by Employee Identifier (EI) # 4, Registered Nurse (RN). EI # 4 removed the border dressing from the buttock and approximately 12 inches of gauze packing from inside the wound. EI # 4 then cleaned the wound with Normal Saline and gauze. EI # 4 failed to clean the wound with soap and water as per physician’s orders. EI # 4 then unfolded a 4 x 4 gauze, soaked the gauze with Vashe, packed the wound with the Vashe soaked gauze, then covered the wound with Allevyn dressing. EI # 4 failed to clean the wound with Dakin’s Solution and packed the wound with Vashe soaked gauze without a physician order. An interview was conducted on 8/20/25 at 11:15 AM with EI # 4 who was asked if the wound care was provided as ordered. EI # 4 responded “We switch back and forth from the Dakin’s and Vashe to clean the wound, it depends on the drainage and the smell of the wound. The Dakin’s is better if the wound has an odor to it.” A review of the Skilled Nursing Visit notes dated 7/8/25, 7/15/25, 7/23/25, 7/30/25, 8/6/25 and 8/13/25 revealed the nurse documented cleaning the wound with normal saline instead of the ordered dial soap, and water. An interview was conducted on 8/21/25 at 9:50 AM with EI # 1, Associate Executive Director, who confirmed the wound care was not provided as ordered and there was no physician order for wound packing. 2. MR # 2 was admitted on 7/2/25 with diagnoses including Hypertensive Heart Disease, Heart Failure, and Atherosclerotic Heart Disease. Review of the Home Health Care Certification and Plan of Care dated 7/2/25 revealed physician’s orders for SN one visit per week to assess weight change with each visit. Review of the SN Visit Notes dated 7/18/25, 7/25/25, 8/14/25, and 8/18/25 revealed no documentation the patient weight was obtained. An interview was conducted on 8/21/25 at 9:50 AM with EI # 1 who confirmed the agency failed to ensure the patient’s weight was obtained on each SN visit as ordered.”

“Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This Element is not met as evidenced by: Based on medical record (MR) review, agency policy and procedure, and interview with staff, it was determined the agency failed to ensure a patient received education on a new medication prior to discharge. This deficient practice affected one of one patients with therapy only ordered including MR # 4 and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: Patient Education Policy Number: 9.22.1 Reviewed: 1/28/25 Policy: Agency staff will provide initial and ongoing education to meet each individual patient’s needs. ... Procedure: ... 2. Based on patient’s condition, physician ordered care and assessed needs, patient/family will receive education, as appropriate, about: ...Medications, including safe and effective use... 1. MR # 4 was admitted on 2/24/25 with diagnoses including Multiple Sclerosis and Hemiplegia. Review of the Home Health Care Certification and Plan of Care dated 2/24/25 revealed physician’s orders for Physical Therapy (PT) one visit per week for seven weeks and to reconcile medications with each visit. Review of the Patient Care Order dated 3/25/25 revealed orders for Bactrim 400 milligrams, take 0.5 tablets daily for 14 days. Review of the Physical Therapy Visit Notes revealed no documentation the patient was provided education on the new medication. There was no documentation a Skilled Nurse visit was completed. Review of the Patient Care Order dated 4/15/25 revealed physician’s orders to discharge from physical therapy and all home health services secondary to goals met. An interview was conducted on 8/21/25 at 10:00 AM with Employee Identifier # 1, Associate Executive Director who confirmed there was no patient education provided for the new medication.”