Distinguished Home Health Care Services Inc.

“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 review of the Home Health Agency (HHA)’s Policy and Procedure, record review, Interview and observation, the Home Health Agency failed to maintain infection control measures to prevent potential cross contamination during Insulin administration and during an Intravenous Antibiotic administration for 2 of 3 sampled patients (Patient #1 and #2). The findings included: The findings included: Review of the HHA policy titled “Exposure Control Plan: OSHA Regulations” revised 03/2018 documents “…blood pressure cuffs will be cleaned with Agency approved disinfectant after each use by the employee…”. Review of the HHA policy titled “Specific Procedures for Employee and Patient Infection Control Training” revised 03/2018 documents “…all employees …wash hands before and after wearing gloves…” Review of the HHA policy titled “Hand Hygiene Policy and Compliance Program” revised 03/2018 documents “indications for staff performing hand hygiene are:…before re-entering patient’s clean supplies…CDC hand hygiene guidelines: indications for handwashing and hand antisepsis-after removing gloves…” 1)Review of Patient #1’s clinical record revealed a start of care on 10/06/20 with a Home Health Certification and Plan of Care (POC) dated 01/19/24 to 03/18/24. The patient’s diagnosis was Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. The POC orders documents a Skilled Nurse two (2) times daily for 60 days for Insulin administration; skilled nurse will assess blood sugar levels via a glucometer before insulin administration… the professional nurse will administer insulin per MD (physician) orders. On 02/20/24 at 4:00 PM, a home visit to Patient #1 accompanied by Staff B, Licensed Practical Nurse and the HHA Alternate Director of Nursing (A-DON) was conducted. On 02/20/24 at 4:09 PM, observation revealed Staff B performed hand hygiene, donned gloves and performed Patient #1’s blood glucose fingerstick. Staff B then proceeded to disinfect the Levemir insulin vial rubber top with an alcohol pad, drew 22 units of the insulin and with the same alcohol pad used to disinfect the insulin vial, Staff B disinfected the patient’s skin. On 02/20/24 at 4:28 PM, an interview was conducted with Staff B who was asked why she used the same alcohol pad to disinfect the insulin vial and then disinfect/clean the patient’s skin. Staff B replied, “was I supposed to use three alcohol pads”? Staff B was apprised of cross contamination and to check with the HHA DON regarding infection control. 2) Review of Patient #2’s clinical record revealed a start of care on 02/08/24 with a Home Health Certification and Plan of Care (POC) dated 02/08/24 to 04/07/24. The patient’s diagnosis was Secondary Malignant Neoplasm of Left Lung, Shortness of Breath and Secondary Malignant Neoplasm of Right Lung. The POC documents a “skilled nurse twice a day for 47 days to IV (intravenous) antibiotics administration …via PICC (Peripherally Inserted Central Catheter)…”. On 02/22/24 at 8:25 AM, a home visit accompanied by the HHA A-DON and the Administrator was conducted for Patient #2. A joint interview was conducted with the A-DON and the administrator. The A-DON stated the visit was scheduled to administer Patient #2’s Imipenem (antibiotic) 500 mg IV. On 02/22/24 at 8:35 AM, Observation revealed the A-DON performed hand hygiene and proceeded to gather the IV supplies. At 8:38 AM, the A-DON donned gloves, flushed Patient #2’s PICC line with 10 cc of saline solution and connected the IV antibiotic infusion. At 8:41 AM, the A-DON retrieved a wrist blood pressure cuff from her pocket and placed it on the Patient #2’s wrist and then back to her pocket without disinfecting it. The A-DON was asked about disinfecting her reusable equipment and stated she disinfects her blood pressure and reusable equipment at her home once a week. Observations revealed the A-DON removed her pair of gloves, documents and then without gloves removed Patient #2’s socks and checks her pedal pulses by placing her bare finger on top of the patients foot. Further observation revealed the A-DON then proceeded to search through the patients IV supplies bag without performing hand hygiene before. At 9:11 AM, observation revealed the A-DON donned gloves without performing hand hygiene and proceeded to prime Patient #2’s second IV antibiotic line. The A-DON then disconnect the IV line and connects the second line. The A-DON removed her pair of gloves and proceeded to document the intervention. At 9:42 AM, the A-DON donned gloves without hand hygiene and proceeded to disconnect the patients IV line and removed her pair of gloves. At 9:45 AM, the A-DON left Patient #2 home without performing hand hygiene. Consequently, a joint interview was conducted with the A-DON and the Administrator. The A-DON stated she washed her hand once at the beginning of the visit. The A-DON was apprised that she removed the patient’s socks and touched the patient’s feet and did not do hand hygiene. The A-DON replied, “I should of wash my hands after that, I did not.”. They both were apprised of the infection control concerns during the home visit for Patient #2.”

“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 review of the Home Health Agency (HHA)’s Policy and Procedure, record review, interview and observation, the Home Health Agency failed to follow physicians’ orders for drugs and treatments for 3 of 7 sampled patients (Patient #1, #2 and #3). The findings included: 1) Review of the HHA’s Policy titled, “Physician Orders-Verbal Orders” revised on 03/18 documents, “Drugs and Treatment are administered by the agency staff only as ordered by the physician…orders are obtained prior to the provision of any care, including changes in the plan of care.” Review of Patient #1’s clinical record reveals a “Start of Care” on 10/06/2020 with a Home Health Certification and Plan of Care (POC) dated 01/19/24 to 03/18/2024. The patient’s diagnoses were Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. Review of the POC orders included Levemir (type of Insulin) subcutaneous 100 UNIT/ML (millimeters)10 ml Subcutaneous every AM and 20 Units subcutaneous every PM and Skilled Nurse two (2) times daily for 60 days for Insulin administration. The POC documents, “Skilled nurse will assess blood sugar levels via a glucometer before Insulin administration… the professional nurse will administer Insulin per MD (physician) orders. On 02/20/2024 at 4:00 PM, a home visit to Patient #1, accompanied by Staff B, Licensed Practical Nurse and the HHA’s Alternate Director of Nursing (A-DON) was conducted; during an interview on 02/20/24 at 4:00 PM, the patient stated the nurse was visiting twice a day every day and the patient was not able to state how many units of Insulin they were receiving. On 02/20/2024 at 4:09 PM, observation reveals Staff B performed hand hygiene, donned gloves and performed Patient #1’s blood glucose fingerstick; Staff B then proceeded to draw Levemir from the Insulin vial and drew 22 units of the insulin into the syringe; Staff B disinfected the patient’s skin and administered the Levemir 22 units subcutaneously. On 02/20/2024 at 4:25 PM, a joint interview was conducted with Staff B and the A-DON; Staff B stated Patient #1 was receiving Levemir Insulin 22 units twice a day for over a year. Staff B was asked to provide the physician’s order for Levemir 22 units and stated that “the office has it;” Staff B and the A-DON were apprised that Patient #1’s POC documents Levemir 20 units twice a day and not 22 units as she administered during the visit today. On 02/21/2024 at 9:48 AM, an interview was conducted with the HHA’s Intake Coordinator who stated that HHA received a physician’s order for Patient #1’s Insulin 22 units. Review of the physician’s order dated, 01/15/2024 documents, “Tresiba 22 units daily.” On 02/22/2024 at 1:46 PM, a side-by-side review of Patient #1’s POC dated 01/19/24 to 03/18/24 and the physician’s order dated 01/15/2024 for, “Tresiba 22 units daily” was conducted with the A-DON; the A-DON stated Tresiba is a long acting Insulin, but it is not Levemir; added that she did not know why the physician did not send a prescription for it ; the A-DON stated that the HHA staff saw the “22” units and did not get a prescription for it and the A-DON stated Patient #1 does not have Tresiba insulin at home. 2) Review of Patient #2’s clinical record reveals a “Start of Care” on 02/08/24 with a Home Health Certification and Plan of Care (POC) dated 02/08/24 to 04/07/2024. The patient’s diagnoses were Secondary Malignant Neoplasm of Left Lung, Shortness of Breath and Secondary Malignant Neoplasm of Right Lung; the POC documents a “Skilled nurse twice a day for 47 days to (for) IV (intravenous) antibiotics administer IV: Imipenem 500mg. (milligrams) every 12 hours, Ondansetron (for nausea and vomiting) 8mg. in NS (Normal Saline) 50mL. (milliliters) every 12 hours…skilled nurse frequency 2 times daily for 47 days (Assessment and IV ABX (antibiotic)…via PICC (Peripherally Inserted Central Catheter) …after infusion, flush the (PICC) lumen with 10 ml. of Normal Saline solution followed by 5 ml. Heparin flush (10 units/ml) …” Review of Patient #2’s Skilled Nurse visit dated, 02/08/2024, 02/12/2024, 02/17/2024 and 02/20/2024 documents that the patient’s PICC lumen was flushed after the antibiotic administration with Normal Saline and not Heparin as per the physician’s order. Further review reveals these notes lack written documentation that the PICC lumen was flushed with Heparin after the infusion. Furthermore, review of the Skilled Nurse Notes lack written evidence of communicating with Patient #2’s physician regarding the lack of Heparin flushes after the IV infusion. There was no evidence of a physician’s order on file to discontinue the PICC line Heparin flushes. On 02/22/2024 at 8:25 AM, a home visit accompanied by the HHA A-DON, and the Administrator was conducted for Patient #2 and a joint interview was conducted with the A-DON and the Administrator. The A-DON stated the visit was scheduled to administer Patient #2’s Imipenem (antibiotic) 500 mg .IV.; the A-DON provided Patient’s #2’s hospital discharge medication list for Imipenem; the A-DON was asked if she was provided with a copy of the HHA POC (form 485) for Patient #2 and replied, “what is that; the A-DON stated she follows the hospital discharge orders not the HHA ‘s physician’s POC. On 02/22/2024 at 8:31 AM, an interview was conducted with Patient #2 who stated that the HHA’s nurses started coming twice a day for the IV antibiotics; that her spouse was taught on how to do the evening dose and the nurses are only coming once a day. On 02/22/2024 at 8:35 AM, observation reveals the A-DON asked Patient #2 for the Heparin flushes and the patient replied the nurses were not using the Heparin flushes, (they) were using the (Normal) Saline flushes; on 02/22/2024At 8:38 AM, the A-DON flushed Patient #2’s PICC line with 10 cc of (Normal) Saline solution and connected the IV antibiotic infusion. On 02/22/2024 at 9:11 AM, observation reveals the A-DON disconnected the IV line and without flushing the IV line, connected the second antibiotic (Tigecycline) to Patient #2’s PICC line; at 9:42 AM, observation reveals Patient #2’s IV infusion was completed, and the A-DON disconnected the patient’s IV line and flushed it with 10 cc. of (Normal) Saline solution and further observation on 02/22/2024 at 9:11 AM reveals that the A-DON did not communicate with Patient #2’s physician regarding Heparin flushes not been done as per the physician’s order. 3) Review of Patient #3’s clinical record reveals a “Start of Care” on 01/26/2024 with a Home Health Certification and Plan of Care (POC) dated 01/26/2024 to 03/25/2024. The patient’s diagnoses include Malignant Neoplasm of Prostate, Essential Hypertension and Hydronephrosis (a condition characterized by excess fluid in a kidney due to urine backup). The POC documents a “skilled nurse frequency of four (4) times a week to assess the patient and notify the physician of Systolic (top Blood Pressure reading) Blood Pressure greater than 160 or less than 90 and diastolic (bottom reading) Blood Pressure greater than 90 or less than 60….to assess all body systems with a special attention to the cardiovascular system…report to MD (physician) if the patient’s Blood Pressure is more than 160/90 or less than 90/60…”. Review of Patient #3’s clinical record reveals “Skilled Nurse Notes,” dated 01/29/2024 that document a Blood Pressure of 185/78…skilled intervention: re-educated patient for Blood Pressure medication compliance…”. Review reveals the “Skilled Nurse Note” lacks written evidence of communicating with the physician regarding a systolic Blood Pressure greater than 160 as ordered. Review of Patient #3’s clinical record reveals the Skilled Nurse Notes dated 01/31/2024 documents a Blood Pressure of 173/83…skilled intervention: re-educated patient for Blood Pressure medication compliance…”. Review reveals the “Skilled Nurse Note” lacks written evidence of communicating with the physician regarding a systolic Blood Pressure greater than 160 as ordered. Review of Patient #3’s clinical record reveals the “Skilled Nurse Notes” dated 02/08/2024 documents a Blood Pressure of 180/91…”taking only Nifedipine but not the Beta Blocker (medication used to treat high Blood Pressure) …skilled intervention: re-educated patient for Blood Pressure medication compliance…” Review reveals the “Skilled Nurse Note” lacks written evidence of communicating with the physician regarding a systolic Blood Pressure greater than 160 as ordered. Review of Patient #3’s clinical record reveals the “Skilled Nurse Notes” dated 02/09/2024 documents a Blood Pressure of 172/92 …”taking only Nifedipine but not the Beta Blocker (Metoprolol)…skilled intervention: re-educated patient for Blood Pressure medication compliance…” Review reveals the “Skilled Nurse Note” lacks written evidence of communicating with the physician regarding a systolic Blood Pressure greater than 160 as ordered. Review of Patient #3’s clinical record reveals the “Skilled Nurse Notes” dated 02/16/2024 documents a Blood Pressure of 150/90…taking only Nifedipine but not the Beta Blocker…skilled intervention: re-educated patient for Blood Pressure medication compliance…” Review reveals the “Skilled Nurse Note” lacks written evidence of communicating with the physician regarding a systolic Blood Pressure greater than 160 as ordered. Review of Patient #3’s clinical record reveals the “Skilled Nurse Notes” from 01/29/2024 through 02/16/2024 documents a systolic Blood Pressure greater than 160. Furthermore, review reveals “Skilled Nurse Notes” dated 02/08/2024 and 02/09/2024 documents a systolic Blood Pressure greater than 160 and a diastolic Blood Pressure greater than 90. Review of Patient #3’s clinical record lacks written evidence of communication with the patient’s physician regarding a systolic Blood Pressure greater than 160 for five consecutive Skilled Nurse visits and a diastolic Blood Pressure greater than 90 for two consecutive Skilled Nurse visits. Review of Patient #3’s POC for medications includes the following: Amlodipine oral 10-20 mg (milligrams) take one capsule by mouth daily- Antihypertensive; Metoprolol 25 mg take one tablet (25 mg) by mouth daily (Beta Blocker) and Nifedipine ER 60 mg 20 (tablets) take 1 tablet (90) mg by mouth every morning. On 02/21/2024 at 5:22 PM, a telephone interview was conducted with Staff C, Registered Nurse (RN) who stated she has visited Patient #3 since 01/2024; Staff C stated she checks the patient’s vital signs and added that the patient’s Blood Pressure was not well controlled; stated she educated the patient’s son emphasizing the importance of taking the Blood Pressure medications; stated that the patient was supposed to take Coreg (Beta Blocker) and was out of the medication; Staff C was asked if she communicated with Patient #3’s physician regarding his Blood Pressure reading and not taking the medication as ordered; Staff C replied she was told during orientation to communicate with the (HHA’s) office and the (HHA’s) office would call the physician; Staff C stated she “texted” the HHA ‘s office main number and always gets a response; stated she has never made a telephone call to Patient #3’s physician related to his Blood Pressure readings and not being compliant with his Blood Pressure medications. On 02/22/2024 at 1:59 PM, a side-by-side review of Patient #3’s “Skilled Nurse Notes” and the patient’s Blood Pressure readings was conducted with the Alternate Director of Nursing (A-DON); the A-DON confirmed the physician’s order related to Blood Pressure range and stated she did not see a communication with the Physician related to the patient’s Blood Pressure readings. On 02/22/2024 at 2:17 PM, a joint interview was conducted with the Administrator and the A-DON; the Administrator stated that if the DON calls the physician for any reason, he will write a note under the clinical record communication tab; the Administrator was apprised there were no communication notes on Patient #3’s clinical record related to communicating with the physician regarding the Blood Pressure being out of range.”

“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 the Home Health Agency (HHA)’s Policy and Procedure, record review, interview and observation, the Home Health Agency failed to maintain an up-to-date Medication Profile for 2 of 3 sampled patients as evidenced by a new prescription for Patient #2 noted on top of the patient’s table not added to the patient’s Medication Profile and Patient #3 not taking Blood Pressure medications as per the Medication Profile in the patient’s home and at the HHA’s office (Patient #2 and #3). The findings included: 1) Review of the HHA’s Policy titled, “Medication Reconciliation” revised on 03/2018 documents, “…medications ordered while the patient is receiving care will be compared to the medication list/profile. The medications list/profile will be updated with each new or changed medication. The patient’s medication list in the home will also be updated…” Review of the HHA’s Policy titled, “Medication Profile” revised on 03/2018 documents “…The nurse or therapist will add new/changed medication (s) to the medication profile. Discontinued (D/C) medications will be documented and dated. The medication profile will be reviewed every home visit and updated as changes occur…” Review of the HHA’s Policy titled, “Medication Orders” revised on 03/2018 documents “…agency staff will verify with the physician any …unclear medication orders prior to…providing patient education about the medication…” Review of Patient #2’s clinical record reveals a “Start of Care” on 02/08/2024 with a Home Health Certification and Plan of Care (POC) dated 02/08/2024 to 04/07/2024. The patient’s diagnoses were Secondary Malignant Neoplasm of Left Lung, Shortness of Breath and Secondary Malignant Neoplasm of Right Lung; the POC documents a “Skilled nurse twice a day for 47 days to (administer) IV (intravenous) antibiotics and Ondansetron (for nausea and vomiting) 8mg. in Normal Saline intravenous (IV) 50mL. (milliliters) every 12 hours. On 02/22/2024 at 8:25 AM, during a home visit accompanied by the HHA’s Alternate Director of Nursing (A-DON) and the Administrator for Patient #2, a joint interview was conducted with the A-DON and the Administrator; the A-DON stated the visit was scheduled to administer Patient #2’s Imipenem (antibiotic) 500 mg. IV only. On 02/22/2024 at 9:00 AM, observation reveals a bottle of Prochlorperazine (used to treat nausea) 10 mg.(milligram) one tablet every 6 hours as needed for nausea and vomiting on top of the table by the patient’s side; subsequently, an interview was conducted with Patient #2 who stated she was seen by the surgeon on 02/19/24 who changed the Ondansetron IV to Prochlorperazine by mouth. Review of Patient #2’s Medication Profile, in the patient’s home was conducted and reveals that the Medication Profile was not up to date with Ondansetron being discontinued and Prochlorperazine tablets added to her medication regimen. On 02/22/2024 at 9:45 AM, Patient #2’s home visit was completed, and the A-DON was observed to leave the patient’s home without reviewing the patient’s Medication Profile. On 02/22/2024 at 9:48 PM, a joint interview was conducted with the A-DON and the Administrator who were apprised that Patient #2’s had a new medication, Prochlorperazine that was on top of the patient’s table and the Medication Profile, in the patient’s home was not updated as per the HHA’s policy; the A-DON stated she did not see it ( Prochlorperazine tablets) and added that she asked the patient if she was feeling nauseated. 2) Review of Patient #3’s clinical record reveals a s “Start of Care” on 01/26/24 with a Home Health Certification and Plan of Care (POC) dated 01/26/2024 to 03/25/2024. The patient’s diagnoses include Malignant Neoplasm of Prostate, Essential Hypertension and Hydronephrosis (a condition characterized by excess fluid in a kidney due to urine backup). The POC documents a “skilled nurse frequency of four (4) times a week to assess the patient and notify the physician of Systolic (top Blood Pressure reading) Blood Pressure greater than 160 or less than 90 and diastolic (bottom reading) Blood Pressure greater than 90 or less than 60….to assess all body systems with a special attention to the cardiovascular system…report to MD (physician) if the patient’s Blood Pressure is more than 160/90 or less than 90/60…”. Review of Patient #3’s POC Medications include the following: Amlodipine (for high Blood Pressure) oral 10-20 mg. (milligrams) take one capsule by mouth daily- Antihypertensive; Dorzolamide- Timolol (for increased eye pressure)1 drop into both eyes 2 times daily; Latanoprost 9for increased eye pressure) 1 drop into both eyes nightly.; Metoprolol 25 mg take one tablet (25 mg) by mouth daily (for increased Blood Pressure) and Nifedipine ER (for high Blood Pressure) 60 mg 20 (tablets) take 1 tablet (90) mg by mouth every morning. On 02/22/2024 at 11:00 AM, a home visit accompanied by the HHA’s Administrator and Staff D, Registered Nurse (RN) for Patient #3 was conducted; observation reveals Staff D checked Patient #3’s Blood Pressure with the patient’s own device and stated it was 165/89; Staff D rechecked the patient’s Blood Pressure with her own wrist Blood Pressure device and stated it was 182/98; Staff D sated she will go by the patient’s Blood Pressure device reading; during the review, the patient stated he had not taken his blood pressure medication and review of the patient’s medication profile at home documents the following medications: Amlodipine oral 10-20 mg (milligrams) take one capsule by mouth daily- Antihypertensive; Dorzolamide- Timolol 1 drop into both eyes 2 times daily; Latanoprost 1 drop into both eyes nightly; Metoprolol 25 mg take one tablet (25 mg) by mouth daily (Beta Blocker) and Nifedipine ER 60 mg 20 (tablets) take 1 tablet (90) mg by mouth every morning. Subsequently during an interview, on 02/22/2024 at 11:00 AM, Staff D was asked when she checks the Medication Profile and stated that is usually done once a week; Staff D was asked to review the Medication Profile with the patient; during the review, Patient #3 stated he was only taking Nifedipine, a Baby Aspirin and the Eye Drops; the patient stated he did not have any refills for Amlodipine and Metoprolol; during an interview, Patient #3’s son stated the Cardiologist will not refill the patient’s medications until he sees the patient and the son stated it has been a year since the last cardiologist appointment. On 02/22/2204 at 2:17 PM, a joint interview was conducted with the Administrator and the A-DON; the Administrator stated that if the DON calls the physician for any reason, he will write a note under the clinical record communication tab; the Administrator was apprised there was no communication notes noted on Patient #3’s clinical record related to communicating with the physician regarding the patient’s Blood Pressure out of range order or medications not available in the home.”

“Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This Element is not met as evidenced by: Based on review of the Home Health Agency (HHA)’s Policy and Procedure, record review and interview, the Home Health Agency failed to monitor and evaluate the Licensed Practical Nurse (LPN)’s performance in the provision of services and treatments for 1 of 7 sampled patient reviewed (Patient #1). The findings included: Review of the HHA’s policy provided by the Administrator titled, “Nursing Services” revised on 03/2018 documents, “…the LPN (Licensed Practical Nurse) will be supervised by the RN (Registered Nurse) as required by applicable state rules and regulations (every 28 days).” Review of Patient #1’s clinical record documents a “Start of Care on 10/06/2020 with a Home Health Certification and Plan of Care from 11/20/2203 to 01/18/2024 and 01/19/2024 to 03/18/2024. The Plan of Care documents, “Skilled Nurse Frequency two (2) times daily for 60 days (Insulin Administration). Review of Patient #1’s “Skilled Nurse Visits Note” reveal that the patient was seen by an LPN during both certification periods. Further review of Patient #1’s “Skilled Nurse Visit Notes” from 11/20/2023 through 02/19/2024 reveal a lack of written evidence of documentation of the LPN’s supervision by the RN. Review of Patient #1’s “Skilled Nurse Visit Calendar Schedule” from 11/20/2023 through 02/19/2024 lacks evidence of visits scheduled for the LPN’s supervision by the RN. On 02/22/2024 at 9:38 PM, a joint interview was conducted with the HHA Alternate Director of Nursing (A-DON) and the Administrator; the A-DON stated she did not do the LPN’s supervisory visits; the Administrator stated that the Director Of Nursing (DON), who was out of the office at the time of the survey, was performing supervisory visits. On 02/22/2024 at 2:05 PM, during an interview, the HHA Intake/Scheduler stated that she has not scheduled any LPN supervisory visits to be done for Patient #1.”