Mitchell County Home Health Care/ Public Health

“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 clinical record review, agency policy review, home visit observation and staff interview, the agency failed to ensure staff provided care in accordance with agency expectations and accepted infection control standards of practice observed during a home visit for 3 of 3 sampled patients (Patient #1, #2 and #3) with a home visit observation of staff. Failure to follow agency expectations and accepted standards of practice for infection control may put the patient at risk of receiving unsafe care or care that allows the spread of infection. Findings include: According to the agency policy titled Exposure Control Plan: OSHA Regulations, dated 4/8/22, a barrier may be used under the bag as needed. Upon entering the home, place the bag on a clean surface; a barrier may be used to create a clean area if indicated. Open the hag near the care area and, if possible, near the water supply. Wash hands thoroughly with bacteriostatic foam/liquid/get. Remove all items which will be needed for the visit. Close the bag and give the patient care. If additional items are needed after care has started, wash hands before re-entering bag. Disinfect all items which will be returned to the bag. Wash hands and return equipment to the baf; close bag. Bag will be wiped down with agency approved disinfecting wipe once visit is complete. 1. Patient #1 had a start of care date of 8/21/2020. The Plan of Care (POC), dated 10/5/23 to 12/3/23, included orders for skilled nursing services. On 11/7/23 at 1:15 PM, during a home visit observation, Staff E, Registered Nurse (RN) placed her equipment on a clean barrier. She completed the patient assessment and placed the contaminated equipment on the barrier. She disinfected the equipment and placed the disinfected equipment back on the contaminated barrier. She placed the contaminated equipment into her bag. The agency staff failed to properly sanitize equipment after patient use. 2. Patient #2 had a start of care date of 10/8/2020. The POC, dated 9/23/23 to 11/21/23, included orders for skilled nursing and home health aide services. On 11/7/23 at 12:00 PM, during a home visit observation, Staff D, RN placed her computer tablet on a manilla envelope, used as a barrier. She completed the patient’s nursing visit and documentation on the tablet. Staff D placed the manilla envelope and the tablet into her bag without disinfecting the equipment. The agency staff failed to properly sanitize equipment after patient use. 3. Patient #3 had a start of care date of 11/3/23. The POC, dated 11/3/23 to 1/1/24, included orders for skilled nursing, Physical Therapy and Occupational Therapy services. On 11/7/23 at 9:45 AM, during a home visit observation, Staff C, Occupational Therapist placed his bad directly on the floor in the patient’s home. He placed an non sanitizable paper notebook directly on the patient’s kitchen counter with no barrier and wrote notes during the visit. At the end of the visit he removed the paper notebook and bag from the home. No items sanitized prior to exiting the home. The agency staff failed to properly sanitize equipment after patient use. The above findings shared with the Administrator and the Clinical Manager. The agency provided no further information prior to the end of the survey.”

“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 observation, clinical record, agency policy, patient interview, and staff interview, the agency failed to include all medications in Plans of Care for 4 of 7 patients with home visits (Patient #1, #2, #3 and #4). Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services according to assessed needs and physician orders. Findings include: According to the agency policy titled Plan of Care and Physician Orders dated 3/31/2020, the individualized plan of care must include the following: all medications and treatments and any types of services, supplies and equipment required. 1. Patient #1 had a start of care date of 6/15/23. Clinical record review revealed the following: a. The Plans of Care (POCs), dated 8/6/23 to 10/4/23 and 10/5/23 to 12/3/23, included the following DME (durable medical equipment) used by the patient: grab bars, safety rails, med machine, glucometer, lancets, alcohol swabs, BP cuff, stethoscope, pulse oximeter, thermometer, electric BP machine, glasses, shower chair, hand held shower. b. The skilled nurse visit note, dated 9/15/23, included documentation the patient incontinent of urine and managed by use of incontinent briefs. c. During a home visit observation on 11/7/23 at 1:15 PM with Staff E, Registered Nurse (RN), the surveyor noted the patient had a lifeline and used incontinence products. An interview during the same home visit observation the patient reported the lifeline had been in place over a year and incontinence products utilized for a long time. The Plans of Care failed to identify the DME lifeline and incontinent products. 2. Patient #2 had a start of care date of 12/6/2020. Clinical record review revealed the following: a. The POCs, dated 7/25/23 to 9/22/23 and 9/23/23 to 11/21/23, included the following DME used by the patient: cane, walker, shower chair, hand-held shower, grab bars/safety rails, therapy ball, med box, life alert, denture cup. b. The skilled nurse visit note, dated 9/26/23, included documentation the patient incontinent of urine and managed by use of incontinent briefs. c. During a home observation visit with Staff D, RN on 11/7/23 at 12:00 PM the surveyor noted a bag of Calcium chews 650 milligram (mg). Interview during the same home visit the patient reported he/she takes 1 tablet daily when he/she remembers and had the medication over a year. The Plans of Care failed to identify the DME incontinent products and Calcium chews used by the patient. 3. Patient #3 had a start of care date of 11/3/23. Clinical record review revealed the following: a. The POC, dated 11/3/23 to 1/1/24, included the following DME used by the patient: adult diapers, grab bars, raised toilet seat walker, cane, shower chair, hand held shower. b. The skilled nurse visit note, dated 11/3/23, included documentation the patient utilized a continuous positive airway pressure (CPAP) machine. c. During a home observation visit with Staff C, Occupational Therapist, on 11/7/23 at 9:45 AM the surveyor noted a lift chair, reacher, ice packs, sock aid and CPAP in the patient’s home. Interview during the same home visit observation the patient stated the CPAP for 10 years and the lift chair, reacher and sock aid prior to the admission to the home health agency. The Plans of Care failed to identify the DME CPAP, lift chair, reacher and sock aid products used by the patient. 4. Patient #4 had a start of care date of 1/21/23. Clinical record review revealed the following: a. The POCs, dated 7/30/23 to 9/27/23 and 9/28/23 to 11/26/23, included the following DME used by the patient: came, hand-held shower, grab bars/safety rails. The POCs included orders for the skilled nurse to complete set-up the patients medications. b. The skilled nurse visit note, dated 9/13/23, included documentation the patient required medication set up and used medication planners The Plans of Care failed to identify the DME lifeline and medication planners used by the patient. The above findings were reviewed with the Administrator and Clinical Manager. Agency staff provided no further information prior to the end of the survey.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on agency policy review, clinical record review, and staff interview, the agency failed to maintain a working Plan of Care for patients and update the working Plans of Care with any new verbal/interim physician orders for 2 of 5 sampled patients with new verbal/interim orders. (Patients #2 and #5) Failure to update the Plan of Care increased the potential for medication errors in administration or inaccurate provision of care. Findings include: According to the agency policy titled Plan of Care and Physician orders, dated 3/31, 2020, all patient care orders, including verbal orders must be recorded in the plan of care. The plan will be revised to reflect any verbal order received during the 60-day certification period so that all agency staff are working from a current plan. It is mot necessary for the physician to sign an updated plan of care until the patient is recertified to continue care and the plan of care is updated to reflect all current ongoing orders including any verbal orders received during the 60-day period. 1. Patient #2 had a start of care date of 10/8/2020. Clinical record review revealed: a. The Plan of Care, dated 9/23/23 to 11/21/23, included physician orders for skilled nurse and home health aide services. b. The physician’s order, dated 9/1/23, included order for OT evaluation and treatment for right arm pain and decreased mobility. c. The physician’s order, dated 9/6/23, included the order for OT 1 time a week times 1 week and 2 times a week times 2 weeks. d. The physician’s order, dated 9/12/23, included the order to administer influenza vaccine in the right deltoid. e. Review of the medical record lacked documentation the physician orders added to update the current plan of care. The agency failed to update the patient’s plan of care to include physician orders. 2. Patient #5 had a start of care date of 10/14/23. Clinical record review revealed: a. The Plan of Care, dated 10/14/23 to 12/12/23, included physician orders for skilled nurse and home health aide services. b. The physician’s order, dated 10/25/23, included order to discontinue the medication cephalexin. c. Review of the medical record lacked documentation the physician orders added to update the current plan of care. The agency failed to update the patient’s plan of care to include physician orders. The above information shared with the Administrator and Clinical Manager. Agency staff provided no additional information prior to the end of the survey.”

“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 agency policy review, clinical record review and agency staff interview, the agency failed to provide medications, treatments or services only as ordered by the physician for 2 of 7 sampled patients (Patients #5 and #6). Failure to ensure staff obtain physician orders for administration of medications, treatments or services provided by agency staff placed agency patients at risk for inconsistent care/treatment and possible harm. Findings include: 1. Patient #5 had a start of care date of 10/14/23. Review of the medical record revealed the following: a. The Plan of care (POC), dated 10/14/23 to 12/12/23, included orders for skilled nurse services to provide surgical wound care, cleanse with normal saline, apply mepilex dressing, change every 3 to 5 days and measure the wounds weekly on Tuesdays. b. The skilled nurse visit note, dated 10/14/23 revealed the patient had a left leg/hip incision. The incision wound measured 1 centimeter (cm) by 0.3 cm. The wound failed to include measurements of depth. c. The skilled nurse visit notes, dated 10/18/23 and 10/25/23, failed to include documentation of the wound measurements. The skilled nurse visit note, dated 10/31/23, identified the wound healed. 2. Patient #6 had a start of care date of 9/9/22 and discharge date of 9/16/22. a. The POCs, dated 6/9/22 to 8/7/22 and 8/8/22 to 10/6/23 included orders for skilled nurse services to assess the patient’s skin integrity with special attention to the feet. b. The skilled nurse visit note, dated 7/18, 7/25 and 8/1/23, identified the patient had an open wound to the plantar area of the left foot. The wound measured 0.5 cm by 0.5 cm but lacked documentation of a measurement of wound depth. c. The skilled nurse visit notes the week of 9/11/23 through 9/16/23, dated 9/12, 9/14 and 9/16/23, failed to include documentation of wound measurements. The agency failed to include complete documentation of wound measurements. The above concerns identified with the Administrator and Clinical Manager. The agency staff provided no additional information prior to the end of the survey.”