Celebrity Home Health

“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 record review, the facility failed to ensure patient medical supplies were appropriate for use when multiple supplies were expired, not removed from the storage area, and were available for use on patients. This failure resulted in jeopardizing the supplies sterility (infection control) and integrity (quality control) of the medical supplies available for use (as needed) for 4 of 4 patients (Patients 1, 2, 3, and 4) on service with the agency. During an interview on March 5, 2024, at 1:20 PM, with the Director of Patient Care Services (DPCS), the DPCS stated she was the staff responsible for visiting and caring for the patients. The DPCS further stated the facility kept medical supplies (available for use on patients) in the facility’s supply room stored inside two metal cabinets. During a concurrent observation and interview on March 5, 2024, at 1:23 PM, with the Medical Secretary (MS), the facility’s supply room was observed to have two black metal cabinets. The MS stated the cabinets contained supplies which were used for patients. The contents of the cabinets were reviewed and included the following expired supplies: -five of five foley catheter insertion trays (without catheter) (a tray of sterile supplies used to insert a urinary catheter) with a “use by” date of November 30, 2021. -nine of nine foley catheter trays (with urinary catheter): five with a “use by” date of December 31, 2021, three with a “use by” date of March 31, 2022, and one with a “use by” date of April 30, 2022. -two of two boxes containing a total of 20 hydrogel impregnated gauze dressings (a sterile gauze dressing that has a gel in it to promote moist wound healing) expired July 2022. -one box of povidine-iodine swab sticks (antiseptic swabs) containing a total of 31 swab sticks with an expiration date of November 5, 2022. -two urinary drainage bags (a sterile urinary collection bag): one with a “use by” date of July 2020, and the other with a “use by” date of September 2020. The MS confirmed the supplies reviewed were past their expiration and/or “use by” date and were in cabinets used to store supplies available for use on patients. The MS stated “they [supplies] are expired.” During an interview on March 8, 2024, at 1:16 PM, with the Assistant Administrator (Asst. Admin), the Asst. Admin stated the facility had supplies stored and available for use on patients as needed. The Asst. Admin further stated it was the Director of Patient Care Services (DPCS) responsibility to check the supplies but that their usual DPCS was on medical leave for the last couple months, and they have had a new DPCS filling in the role. The Asst. Admin stated the DPCS should be making sure supplies are “rotated” to ensure they are not expired and if any supply is found to be expired, it should be disposed of and not available for use in the supply area. During a review of the facility’s policy and procedure titled, “Safe and Appropriate Use of Medical Equipment and Supplies,” revised November 2023, the policy indicated, “all home medical equipment and medical supplies will be managed in a safe and appropriate manner…Home Care supplies: Those disposable items used by home care personnel, patient/and/or family/caregiver to meet the patient’s home care needs (i.e., dressings, syringes, catheters, tubing gloves, etc.)…The office may provide a storage area for home care supplies…” The facility did not have any other policy and procedure regarding expired supplies.”

“Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This Standard is not met as evidenced by: Based on interview and record review, the facility failed to provide evidence one of five sampled staff members (Physical Therapist 1- PT 1) was screened for tuberculosis (a potentially serious infectious bacterial disease that mainly affects the lungs) as specified in the facility’s policy and procedure. This failure had the potential to place all four of the facility’s patients at risk for unnecessary exposure to tuberculosis. During a review of the facility document titled, “[name of facility],” undated, the document indicated the Physical Therapist 1 (PT 1) was hired on June 12, 2007. During a concurrent interview and record review on March 8, 2024, at 12:38 PM, with the Medical Secretary (MS), evidence of PT 1’s tuberculosis screening was requested. After reviewing PT 1’s employee file, the MS stated the facility did not have any evidence of a tuberculosis skin testing, chest x-rays or tuberculosis screening on file for PT 1. The MS further stated the facility was supposed to have documentation of tuberculosis testing on file at the facility but did not. The MS further stated she contacted a branch location of the facility’s and they (the branch location) was also not able to find evidence of TB screening for PT 1. During an interview on March 8, 2024, at 3:52 PM, with the Assistant Administrator (Asst. ADMIN), the Asst. ADMIN stated she also looked for, but was unable to find documented evidence of tuberculosis testing, screening or chest x-rays for PT 1. During a review of the facility’s policy and procedure titled, “Tuberculosis Exposure Control Plan,” revised November 2023, the policy indicated, “…C. Upon hire, personnel must provide the organization evidence of a baseline TB skin or blood test, if there is no evidence of a baseline TB skin or blood test conducted at any point in the past. If the personnel is unable to provide evidence of a baseline TB skin or blood test, then the organization will conduct TB testing. D. Where required by state and/or local regulations, a two (2)-step TST skin test will be given to all personnel upon hire, if no TST has been performed within 12 months of hire date, and thereafter, according to risk assessment…F. The testing procedure, reading, documentation and record keeping of TST will be kept in compliance with applicable law and regulation…””

“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 observation, interview, and record review, the facility failed to ensure nursing staff performed a review and reconciliation of all medications for three of three sampled patients (Patients 1, 2, and 3). This failure resulted in the facility and patient’s to not have an updated “Plan of Care” (patient treatment plan), or “Medication Profile” (a comprehensive summary of all medications taken by the patient), when compared to the actual medications the patient’s were taking in the home which may contribute to medication administration errors, discrepancies, or non-compliance with physician’s orders. 1. A review of Patient 1’s face sheet (a document that gives a summary of patient information), undated, indicated Patient 1 had a start of care date of January 19, 2023, and diagnoses which included heart failure, chronic kidney disease, presence of a cardiac pacemaker (an artificial device for stimulating the heart muscle and regulating its contractions), other specified disorders of parathyroid gland (a disorder which affects the gland responsible for regulating calcium levels). During a concurrent observation and record review on March 6, 2024, at 10:00 AM, at Patient 1’s home, with the Director of Patient Care Services (DPCS), and in the presence of Patient 1, an observation of Patient 1’s medication bottles (which she was actively taking) were compared with her (Patient 1’s) most current “Medication Profile”, dated January 12, 2024, and “Plan of Care”, with a certification period of January 14, 2024 through March 13, 2024. The following discrepancies were noted: 1a. Patient 1’s home medications (that she was actively taking) included Carvedilol (a medication for high blood pressure) 25 milligrams (mg- unit of measure) 1 tab, 2 times daily. The patient’s medication profile and plan of care indicated Carvedilol 12 mg 1 tab 2 times daily (discrepancy in dose). 1b. Patient 1’s home medications (that she was actively taking) included Cinacalcet HCL (a medication used to treat hyperparathyroidism or a disorder of the parathyroid gland which results in weakening of the bones through loss of calcium) 30 mg. This medication was not on Patient 1’s medication profile or plan of care. 1c. Patient 1’s medication profile and plan of care indicated the patient was taking amlodipine besylate (a medication used to treat high blood pressure) 10 mg 1 tablet daily, Repaglinide (a medication used to treat diabetes) 2 mg tablet daily, and Furosemide (a diuretic medication used to treat edema [swelling]) 40 mg 1 tablet daily. However, neither of these three medications were in Patient 1’s home medications supply. During an interview on March 6, 2024, at 10:30 AM, with the DPCS, the DPCS acknowledged there were multiple discrepancies when comparing the actual medication’s Patient 1 was taking, the medication profile, and the plan of care. DPCS 1 stated she was responsible for reconciling Patient 1’s medications and was the nurse who regularly visited Patient 1. The DPCS stated she should have reconciled Patient 1’s medications more closely. The DPCS further stated the medication profile, and plan of care should match the medications Patient 1 was taking but stated she must have missed the discrepancies. During a review of Patient 1’s “Plan of Care,” dated with a certification period of January 14, 2024 through March 13, 2024, the plan indicated, “SN [skilled nursing] medication management interventions: Assess: medication compliance…instruct pt [patient]/pcg [patient care giver]: medication actions, uses, frequency, dose, side effects, interactions of all new/change meds…” 2. A review of Patient 2’s face sheet (a document that gives a summary of patient information), undated, indicated Patient 2 had a start of care date of November 8, 2023, and diagnoses which included bilateral osteoarthritis of knee (cartilage of both knees wears away), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities), and hyperlipidemia (high cholesterol). During a concurrent observation, interview, and record review on March 6, 2024, at 11:28 AM, at Patient 2’s home, with the Director of Patient Care Services (DPCS), and in the presence of Patient 2, an observation of Patient 2’s medication bottles (which she was actively taking) were compared with her (Patient 2’s) most current “Medication Profile”, dated January 3, 2024, and “Plan of Care”, with a certification period of January 7, 2024, through March 6, 2024. The following discrepancies were noted: 2a. Patient 2’s home medications (that she was actively taking) included amlodipine (a medication used to treat high blood pressure) 5 mg tab, 1 tab daily. This medication was not on Patient 2’s medication profile or plan of care. 2b. Patient 2’s home medications (that she was actively taking) included ibuprofen (pain medication) 600 mg tablet, 1 tablet by mouth every 6-8 hours as needed for pain. This medication was not on Patient 2’s medication profile or plan of care. Patient 2 stated her doctor had prescribed her the ibuprofen approximately 3 months ago. 2c. Patient 2’s medication profile and plan of care indicated the patient was taking Calcium Carb-cholecalciferol 600-500 mg-units (a medication which treats low calcium and vitamin D levels) 2 tablets daily, diclofenac sodium 1% external (topical) (an anti-inflammatory medication) as needed, and acetaminophen (a medication commonly used to treat pain) 500 mg tablets, 1 tablet daily. However, neither of these three medications were in Patient 1’s home medications supply. During an interview on March 6, 2024, at 11:49 AM, with the DPCS, the DPCS stated she was aware Patient 2 was taking Ibuprofen and was no longer taking Acetaminophen and acknowledged the medication profile and plan of care did not reflect the change. The DPCS stated she had not been reconciling the patients medications like she should have. During a review of Patient 2’s “Plan of Care,” dated with a certification period of January 7, 2024, through March 6, 2024, the plan indicated, “,…interventions…Assess patient’s knowledge, ability, resources, and adherence to medication regimen…Provide medication education…” 3. A review of Patient 3’s face sheet (a document that gives a summary of patient information), undated, indicated Patient 3 had a start of care date of April 29, 2023, and diagnoses which included Chronic Obstructive Pulmonary Disease (a condition involving constriction of the airways and difficulty breathing), hypertension (high blood pressure), wedge compression fracture of the vertebra (fracture of a part of the vertebra of the spine) and human immunodeficiency virus (HIV- a chronic immune system disease). During a concurrent observation, interview, and record review on March 6, 2024, at 1:40 PM, at Patient 3’s home, with the Director of Patient Care Services (DPCS), and in the presence of Patient 3, an observation of Patient 3’s medication bottles (which she was actively taking) were compared with her (Patient 3’s) most current “Medication Profile”, dated February 22, 2024, and “Plan of Care”, with a certification period of February 23, 2024, through April 22, 2024. The following discrepancies were noted: 3a. Patient 3’s home medications (that she was actively taking) included ritonavir (a medication used to treat HIV) 100 mg tablet, 1 tablet twice daily. The patient’s medication profile and plan of care indicated ritonavir 100 mg capsule, 1 daily (discrepancy in frequency). 3b. Patient 3’s home medications (that she was actively taking) included fluoxetine (an antidepressant medication) 40 mg capsule, 1 capsule daily. The patient’s medication profile and plan of care indicated fluoxetine 20 mg capsule daily (discrepancy in the dose). 3c. Patient 3’s medication profile and plan of care indicated the patient was taking CBD cream (cannabidiol – a cream commonly used to treat pain or inflammation) 250 mg, hydrocodone-acetaminophen (a medication used to treat pain) 5-325 mg tablet, 1 tablet as needed, and cholecalciferol (vitamin D3) 50,000 unit capsule, 1 tablet daily. However, neither of these medications were in Patient 3’s home medication supply and Patient 3 stated she did not have them and was not actively taking them. During an interview on March 6, 2024, at 2:06 PM, with the DPCS, the DPCS stated she needed to reconcile Patient 3’s medications and update the patient’s medication profile and plan of care to reflect her current medication regimen. During a review of Patient 3’s “Plan of Care,” dated with a certification date of February 23, 2024, through April 22, 2024, the plan indicated, “…Interventions…SN [skilled nursing] Medication Management Goals: Pt/Pcg [patient/patient caregiver] will verbalize/demonstrate knowledge of and compliance with medication management: dose, route, and schedule/actions, interactions and contraindication/administration and compliance with prefilled medications…” During an interview on March 8, 2024, at 1:20 PM, with the Assistant Administrator (Asst. ADMIN), the Asst. ADMIN stated RNs should be reconciling patients medications any time there is a new medication and upon every recertification period. The Asst. ADMIN further stated RNs should be making updates to the plan of care as needed and the plan of care should match the medications the patient is taking as prescribed by the physician. During a review of the facility’s policy and procedure titled, “Medication Profile,” revised November 2023, the policy indicated, “Purpose – To define the use of the medication profile in evaluating a patient’s medication regimen, including over-the-counter (OTC) medications, nutrition supplements, herbal remedies, vitamins and minerals. Policy…Medication profiles will be updated for each change to reflect current medications, new and/or discontinued medications…2. A drug regimen review will be performed at the time of admission, when updates to the comprehensive assessments are performed…and with the addition of a new medication. 3. During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver as well as other clinicians understand the medication regimen. This includes, but will not be limited to: A. Using the medication profile to evaluate the use of medications in the home setting. The medication profile includes, but is not limited to: all current medications, date prescribed, name of medication, dose, frequency, drug classification, date discontinued, and durg and/or food allergies. B. Using the medication profile to teach purpose of medication, dosages, routes, administration times, side effects, and contraindications. C. Using the medication profile as a communication tool for other clinicians involved in the care.”

“Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This Element is not met as evidenced by: Based on interview and record review, the facility failed to ensure criminal background checks for 3 of 5 sampled staff were performed on employees as specified in their policy and procedure when the facility utilized a background check service which included a disclaimer specifying it was not to be used for employment verification purposes. This failure resulted in the facility hiring of individuals without first ensuring their criminal history wouldn’t have restricted them from providing care for the facility’s patients. This had the potential to place all 4 of the facility’s patients at risk to mistreatment or harm. During an interview on March 8, 2024, at 1:30 PM, with the Assistant Administrator (Asst. Admin), the Asst. Admin stated the facility owner (CEO) used “[name of an online service provider 1]” to perform background checks on employees. During a review of the facility document titled, “[name of facility],” undated, the document indicated the Registered Nurse 1 (RN 1) was hired on December 6, 2014. During a review of RN 1’s employee file with the MS, the MS provided the background report titled, “[name of online service provider 1]” dated March 8, 2024 [current date of survey]. The report included a disclaimer which indicated, “The information contained in any report and on our website is not necessarily 100% accurate, complete or up to date, nor a substitute for your own due diligence, especially concerning such sensitive items as criminal history…[name of online service provider 1] mission is to give people easy and affordable access to public record information, but [name of online service provider 1] does not provide private investigator services or consumer reports…You may not use our site or service or the information provided to make decisions about employment…” During a review of the facility document titled, “[name of facility],” undated, the document indicated the Director of Patient Care Services (DPCS) was hired on March 1, 2011. During a review of DPCS 1’s employee file, with the Medical Secretary (MS), the MS provided the background report titled, “[name of online service provider 1]” undated. The report included a disclaimer which indicated, “[name of online service provider 1]’s mission is to give easy and affordable access to public record information, but [name of online service provider 1] does not provide private investigator services or consumer reports…You may not use our site or service, or the information provided to make decisions about employment…” During a review of the facility document titled, “[name of facility],” undated, the document indicated the Physical Therapist 1 (PT 1) was hired on June 12, 2007. During a review of PT 1’s employee file, with the MS, the MS provided the background report titled, “[name of online service provider 1]” undated. The report included a disclaimer which indicated, “Disclaimer: While we are constantly updating and refining our database and service, we do not represent or warrant that the results provided will be 100% accurate and up to date. [name of online service provider 1] is a database of publicly available sources of information aggregated for your convenience…this information should not be used for employment…related purposes…” During an interview on March 8, 2024, at 11:30 AM, with the MS, the MS stated the facility did not have any other background reports or background information for RN 1, the DPCS, and PT 1 and the only background reports they had for them was from [name of online service provider 1]. During a review of the facility’s policy and procedure titled, “Internal Control Systems/Accountabilities,” Revised November 2023, the policy indicated, “Celebrity Home Health is committed to prevention, detection, and to taking all appropriate action to assure compliance with all legal and regulatory statutes and to promote honest and ethical behavior in all work-related activities…2. Human Resources (HR) Department…A. [Name of agency] will conduct an annual audit to assure that the Standards of Conduct and the agency personnel policies and procedures are being followed. The audit will include but is not limited to: …2. Criminal background completed on all new employees…””