John Ed Chambers Memorial Inc. HHA

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on Clinical Records and the Agency Final Validation Reports review, the Agency failed to transmit Outcome and Assessment Information Set (OASIS) patient data within 30 days of the assessment completion date for 53 (5.8%) patients in the 12-month period dated 07/01/23 - 06/28/24. This failed practice prevented the Agency from accurately reporting the information necessary to protect the integrity of the Prospective Payment System and other public reporting mechanisms (patient outcomes). Findings follow: 1. The Agency Final Validation Reports indicated the agency failed to transmit 53 (5.8%) of the patient’s comprehensive assessment within 30 days as required. 2. On 10/10/24, Home Health acting Director stated, “We’ve had about 3 different people that were responsible for this duty during that time frame.””

“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 clinical record review and interview, it was determined the agency failed to ensure current medications were reviewed for potential adverse reactions, side effects, and drug interactions for 2 (#2, #6) of 10 (#1 - #10) clinical records reviewed. This failed practice posed a risk of potential harm for all patients on census by inhibiting the agency’s Skilled Nurse and Physician to make informed decisions regarding the patient’s medication regimen related to potential adverse effects, drug reactions, significant side effects or significant drug interactions. Findings follow: Review of Clinical Record #2 revealed a patient with a diagnosis of Chronic Pain, Pressure Ulcer of right buttock and a start of care date of 05/02/24 and certification period of 08/30/24 - 10/28/24. There was no evidence of a medication regimen review to include potential adverse effects and drug interactions. Review of Clinical Record #6 revealed a patient with a diagnosis of Emphysema and a start of care date of 07.09/24 and certification period of 09/07/24 - 11/05/24. There was no evidence of a medication regimen review to include potential adverse effects and drug interactions. On 10/10/24 the Home Health acting Director was not able to locate the medication review documentation for clinical records #2 and #6.”

“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 record review and interview, it was determined the Agency failed to ensure the care plans were detailed and specific to the needs of the individual patient for 10 of 10 (#1-#10) clinical records reviewed. This failed practice had the potential to affect all patients on census as the direct-care staff does not have specifics in order to provide that individualized direct care. Findings follow: Review of Clinical Records #1 - #10 revealed patients with non-specific and non-individualized care plans. The care plans did not include frequency and duration of visits to be made, all medications and treatments, types of services, supplies and equipment required. On 10/10/24, the acting Director of Home Health was interviewed and asked if there was any additional information for the care plans and there was none provided.”

“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 observation, record review, and interview, it was determined the Agency failed to ensure there was an original order for an indwelling catheter in use for 1 of 1 (#4) patients with an indwelling catheter observed on the case mix and that the most current wound treatment order was followed for 2 of 2 (#3, #4) patients with a wound dressing observed on the case mix. This failed practice had the potential to affect all patients on census with the use of an indwelling catheter and those with a wound dressing ordered in that the direct caregivers would not be aware of interventions to implement and the family/caregiver in the home would not receive proper education. Findings follow: 1. Review of Clinical Record #4 with a start of care date of 09/07/24 and certification period of 09/07/24 - 11/05/24 revealed a patient with a diagnosis of disruption of external operation (surgical wound). The patient was sent to the hospital and returned to care of the Agency on 09/22/24. a. A Resumption of Care (ROC) assessment dated 09/22/24 documented an indwelling catheter was in place (no specifics on type, size) and a urology appointment scheduled on 10/08/24. There was no order for the catheter, and this was not on the care plan. b. On 10/09/24, during a home visit, an indwelling catheter was observed. c. On 10/10/24, the acting Director of Home Health was asked to provide the original order for the catheter. An order dated 10/08/24 was provided. This was from the urology appointment. The order documented, “...Foley catheter exchange, Voiding trial....” This did not include the size and bulb size of the catheter to be used. 2. Review of Clinical Record #3 with a start of care date of 07/24/24 and certification period of 09/22/24 - 11/20/24 revealed a patient with a diagnosis of Pressure Ulcer of Sacral Region, unstageable. a. On 10/09/24 at 12:50 p.m., during a home visit wound care observation it was noted that Collagen/Promogran Prisma was used as the treatment. b. The Home Health Care Certification and Plan of Care documented, “... hydrofera blue to wound bed...effective date 09/17/24...start date 09/22/24...” 3. Review of Clinical Record #4 with a start of care date of 09/07/24 and certification period of 09/07/24 - 11/05/24 revealed a patient with a diagnosis of Disruption of external operation. a. The Home Health Care Certification and Plan of Care documented, “...Surgical Incision/ Left leg knee perform wound care/dressing change: cleanse wound to left knee with wound cleanser ...pack using wet to dry technique...effective date 09/07/24...Interventions...Perform wound VAC (vacuum-assisted wound closure) dressing change Monday, Wednesday and Saturday...” b. There was a Resumption of Care (ROC) dated 09/22/24 after a hospital stay with amputation to the left leg. The patient had a below the knee amputation. c. On 10/09/24 at 10:30 a.m., the patient received a Paint with Betadine and cover with bordered gauze dressing change. d. On 10/10/24, the acting Director of Home Health was asked to provide any other orders for the wound care. A copy of an order was obtained which was dated 10/09/24 at 11:28 which documented, “leave incision area open to air. Betadine paint incision daily until sutures are removed.” There was no order provided to accurately reflect the orders from readmission on 09/22/24 until the order on 10/09/24 at 11:28 a.m.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on observation, record review and interview, it was determined the agency failed to ensure an air mattress was provided for 1 of 1 (#3) observed with an unstageable pressure wound. This failed practice had the potential to affect all patients on census with unstageable pressure ulcers and those that need specialized equipment to meet their health needs and promote recovery. Findings follow: Review of Clinical Record #3 with a start of care date of 07/24/24 revealed a patient with a diagnosis of Pressure Ulcer of sacral region unstageable. The certification and plan of care with a certification period of 09/22/24 - 11/20/24 documented an order “...Perform wound care/dressing change; cleanse with wound cleanser, apply collagen to wound bed and pack with dampened conform, cover with calcium alginate and bordered dressing 3 x [times] weekly...effective date 07/24/24...” It also included an order change dated 09/17/24 noted as, “...Cleanse coccyx with wound cleanser, apply hydrofera blue to wound bed, cover with bordered dressing 3x weekly...” There were no orders, care plan, or coordination for the patient to receive a pressure relieving mattress. On 10/09/24 12:50 p.m., during a home visit observation, it was observed there was no pressure relieving mattress. The RN was asked what type of mattress the patient was lying on and she stated, “It looks like a mattress on a mattress” but concurred there was no special mattress. On 10/09/24, during the home visit, the caregiver asked if she could get someone to help her get an over-the-bed table since the patient doesn’t get out of the bed since she’s been back from the hospital. There was no special bed or over-the bed table observed in the home. On 10/10/24 at 1:00 p.m., the acting Director of Home Health was asked about obtaining a specialty mattress for those with a pressure ulcer. She stated, “I believe the criteria is they have to have an unstageable or multiple ulcers on the trunk of the body.””

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on review of medications during home visits, clinical record review and interview, it was determined the agency failed to ensure there were accurate medication lists in the home for 2 (#3 and #4) of 4 (#3, #4, #5, and #7) of clinical records reviewed. This failed practice had the potential to affect all patients on census in that the patients could possibly take or exclude medications in error. Findings follow: Review of Clinical Record #3 revealed a patient with a diagnosis of pressure ulcer, sacral region, unstageable and had a start of care date of 07/24/24 and certification period of 09/22/24 - 11/20/24. During the home visit, it was noted the medication profile as compared to the hand-written medication list used by the caregiver and family member were not the same. The medication profile did not match the medication list in the SN (Skilled Nurse) system. Brilinta was stopped on 09/01/24, Ferrous sulfate, Vitamin C, Zinc were also stopped. Vitamin D was not on the medication list in the home. Metoprolol Succinate ER 100 mg 1 tablet daily was on the medication profile, but the caregiver stated, “She takes two a day.” The medication list in the home listed Metoprolol Tartrate 100 mg 2 times daily. Additionally, Multivitamin and probiotic gummy were on a list in the home and not on the agency’s medication profile. Review of Clinical Record #4 revealed a patient with a diagnosis of disruption of external operation (surgical) wound and had a start of care date of 09/07/24 and certification period of 09/07/24 - 11/05/24. During the home visit, it was noted the medication profile as compared to the medication list (recent hospital discharge paperwork) used in the home did not match. The medication profile had Eliquis 5mg tablet 2 times a day and the patient and family stated that she is not on this medication. Amlodipine 5 mg daily was on the list, but the family stated this was stopped, the nurse stated, “Her blood pressure hasn’t been over 110 since we admitted her this time.” The Medication Profile has the following: “Clonazepam 1 mg tablet 2 times a day as needed for anxiety; Take 1/2 to 1 tablet by mouth once daily as needed for anxiety for 30 days”. The Skilled Nurse (SN) list had 1/2 table as needed daily. The patient stated, “I take one of them.” Buspar was listed as 10 mg 1 tablet 3 times a day, the SN had it listed as two times a day, and the family member brought a medication bottle dated 09/17/24 which had instructions as, “1/2 to 1 tablet 2 times a day”. Doxepin 25 mg was on the medication list, but the family stated it was stopped. Novolin R sliding scale was not on the medication list from the hospital discharge paperwork. Vitamin D3 and Miralax are being used by the patient but are not on the agency’s medication profile. The caregiver stated they are using the most recent hospital discharge paperwork as their medication list. During the home visits, the SN reviewed the medication lists as well and had no other information. The medication lists and care plans provided by the agency and placed in the home were not current and accurate. On 10/10/24, the acting Home Health Director had no additional information regarding the medication list not being up to date and current.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on record review and interview, it was determined the Agency failed to ensure the discharge/transfer summary was completed and sent to the physician within 2 business days for an unplanned transfer for 1 (#8) and subsequently 5 business days of discharge for 1 (#8). Additionally, there was no transfer summary within 2 days of a planned transfer for 1 (#10) of 3 (#8, #9, #10) closed records reviewed. This failed practice had the potential to affect all patients on census as there may be a delay in a proper transition to home or another care setting. Findings follow: Review of Clinical Record #8 with a start of care date of 05/15/24 and certification period of 07/14/24 - 09/11/24 revealed a patient with a diagnosis of Pressure Ulcer of sacral region, stage IV. A Registered Nurse (RN) Transfer visit documentation dated 08/12/24 noted the patient was sent to an inpatient facility. There was no transfer summary within 2 business days for an unplanned transfer. The patient has not returned. There was no discharge summary. The acting Director of Home Health was interviewed on 10/10/24 and she stated she could not locate a discharge summary sent to the physician within 5 business days of discharge. Review of Clinical Record #10 with a start of care date of 05/07/24 and certification period of 07/06/24 - 09/03/24 revealed a patient with a diagnosis of Displaced Intertrochanter fracture right femur. The Discharge Summary completed and signed on 07/23/24 documented the discharge effective date as 07/16/24. This was on day 7 rather than within the 2 days as required for a planned discharge. The acting Director of Home Health was interviewed on 10/10/24 and there was no further information provided.”