Myrtue Med Center Home Health

“Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This Standard is not met as evidenced by: Based on clinical record review, agency policy review, and agency staff interview, the agency failed to provide individualized and specific written patient care instructions from a registered nurse (RN) to agency home health aides for 1 of 2 sampled patients receiving home health aide services (Patient #3). Failure to ensure agency registered nurses provided patient specific written instructions directing the care provided by the agency’s home health aides for each patient increased the risk agency patient’s would receive inappropriate or inconsistent home health aide services. Findings include: According to the agency policy, titled Home Health Aide Assignment, dated 4/2011, the home care aide will be assigned by the Home Care Aide (HCA) supervisor or a designated Registered Nurse (RN) when services are ordered by the physician. During an interview on 12/4/23 at 3:30 PM the Administrator/Clinical Manager stated the HCA care plan created by the RN case manager or the RN who completes the patient’s admission. Patient #3 had a start of date of 11/15/23. The Plan of Care, dated 11/15/23 to 1/13/24, included orders for skilled nursing services one to two times per week home health aide services 2 times a week. The POC also included orders for Nystatin 1000,000 unit/gram topical powder 2 times a day. Clinical record review revealed: a. The home health aide care plan, dated 11/15/23, included the RN assigned tasks of perform systolic and diastolic blood pressure, assist shower with chair, shampoo, partial assist dressing, apply ointment as instructed by RN, notify of problems or changes, apply lotion to skin, check skin for redness and open areas, report changes in skin condition to RN and rollers to hair. b. The RN assigned tasks to the aide of apply ointment as instructed by RN did not define what type of ointment was to be completed by the aide. c. The home care aide notes, dated 11/17, 11/20, 11/24, 11/28 and 12/1/23, included documentation the aide completed the task of applying ointment to the patient. d. During an interview on 12/5/23 at 3:05 PM Staff E, Home Care Aide stated she applies Nystatin power under the patient’s breast as he/she requests. She confirmed she did not apply ointment to the patient. The agency failed to ensure the home health aide assignment specific and individualized to meet the needs of the patient. The above stated finding shared with the Administrator/Clinical Manager and Staff C, RN and Staff D, RN. The agency provided no further information prior to the end of the survey.”

“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 clinical record review, policy review and agency staff interview, the agency failed to ensure completion of signature to include discipline credentials for routine visit notes were completed for 3 of 3 sampled patients with occupational therapy services. (Patients #1, #3 and #6). Failure to maintain appropriately authenticated clinical record documentation increased the risk that agency staff provided services without up to date information related to the patient’s condition, and decreased the ability of agency staff to communicate effectively in order to coordinate patient care. Findings include: According to the agency policy titled Clinical Documentation, dated 7/2018, when assessment is completed, the will electronically sign & lock it (document). Sign form and date. The date signifies the date the nurse signed the form. During an interview on 12/6/23 9:30 AM the Administrator stated the agency had 2 Occupational Therapist (OT). During review of the documentation she concurred 1 OT did not have the discipline title included in the signature but the other OT did have the discipline title included. 1. Patient #1 had a start of care date of 11/22/23. Clinical review revealed the following: a. The Plan of Care (POC), dated 11/22/23 to 1/20/24, included orders for skilled nursing, physical therapy and occupational therapy services. b. The OT visit notes, dated 11/27/23 and 11/29/23, included an electronic signature with name, date and time of completion. The agency failed to include the disciplinary title of the staff who completed the service. 2. Patient #3 had a start of care date of 11/15/23. Clinical review revealed the following: a. The POC, dated 11/15/23 to 1/13/24, included orders for skilled nursing, physical therapy, occupational therapy and home health aide services. b. The OT visit notes, dated 11/16, 11/20, 11/27 and 11/29/23, included an electronic signature with name, date and time of completion. The agency failed to include the disciplinary title of the staff who completed the service. 3. Patient #6 had a start of care date of 1/18/22 and discharge date of 2/21/22. Clinical review revealed the following: a. The POC, dated 1/18/22 to 3/18/22, included orders for skilled nursing, physical therapy and occupational therapy services. b. The OT visit note, dated 1/25/22, included an electronic signature with name, date and time of completion. The agency failed to include the disciplinary title of the staff who completed the service. The above findings shared with the Administrator/Clinical Manager, Staff C, Registered Nurse (RN) and Staff D, RN. The agency provided no additional information prior to the end of the survey.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on clinical record review, agency policy review, and agency staff interview, the agency failed to comprehensively provide wound assessments for 2 of 3 sampled patients with wounds (Patients #4 and #7) and failed to provide a comprehensive patient assessment with recertification assessments 2 of 2 patients (Patients #4 and #5). The agency reported a current patient census of 31 patients. Failure to accurately and thoroughly complete wound assessments or provide a comprehensive assessment placed patients at an increased risk of unidentified condition changes. Findings include: According to the agency’s undated policy, Staging the Wound, revealed no direction for wound assessment criteria or treatment. According to the agency policy, Clinical Documentation, dated July 2018, in pertinent part, all integrated assessment areas are to be completed including weight and findings for wounds. On 12/5/23 at 3:30 PM, when asked about wound assessments components, the Administrator agreed that assessment should include depth, wound base, and drainage; that the agency was in the process of having an updated policy computer program available. In the same interview, the Administrator agreed that a recertification assessment was a time point for a comprehensive assessment to include weight and wound assessment. 1. Patient #4 had a start of care date of 8/20/19 and received home health services from the agency. Clinical record review revealed the following: Skilled Nurse Recertification visit held on 11/22/3 with a comprehensive assessment that did not include the patient’s weight. 2. Patient #5 had a start of care date of 5/4/23 and received services from the agency. Clinical record review revealed: Skilled Nurse Recertification Visit held on 10/27/23 with a comprehensive assessment that did not include: a. The patient’s weight. b. Wound assessment. 3. Patient #7 had a start of care date of 5/4/22 and was discharged from home health services on 6/16/22. Clinical record review revealed: a. POC dated 5/4/22 revealed that Physical Therapy (PT) managed the patient’s sacral wound. b. PT visit lacked complete wound assessment on 5/16/22 with no depth measurement documented. c. Skilled Nurse Visits lacked complete assessment on: 1. 5/4/22 with no length. 2. 6/1/22 with no wound bed assessment. 3. 6/16/22 with depth not measured. The assessment lacked documentation of the presence or absence of drainage, odor, or under mining. The above findings were reviewed with the Administrator/Clinical Manager prior to exit. The agency provided no additional 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 Durable Medical Equipment (DME) in Plans of Care for 5 of 7 sampled patients (Patients #1, #2, #3, #5, and #7). 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. 4. Patient #1 had a start of care date of 11/22/23 and received services from the agency. Clinical record review revealed: The Plan of Care, dated 11/22/23 to 1/2/24, included the following DME supplies used by the patient: quad cane, walker, wheeled walker, walker basket, chair lift, grab bars, hand held shoer, long handled shoe horn, reachers, gait belt, shower chair, leg lift, back brace, elevated toilet, motorized wheelchair and scooter. During a home observation visit on 12/5/23 at 9:00 AM with Staff B, Registered Nurse (RN), the patient observed to have a wheelchair ramp. The patient identified he/she used the wheelchair ramp when exiting/returning to the home. The agency failed to identify the DME the patient required to include the wheelchair ramp. 5. Patient #3 had a start of care date of 11/15/23 and received services from the agency. Clinical record review revealed: The Plan of Care, dated 11/15/23 to 1/13/24, included the following DME required by the patient: single point cane, walker, chair lift, raised toilet seat, grab bars, hand held shower, reacher, gait belt, tub transfer, medset, bedrail and ted hose. The skilled nurse visit note, dated 11/15/23, identified the patient incontinent of bladder. During the observation home visit on 12/5/23 at 8:00 AM with Staff C, RN, the surveyor observed the patient current medication regimen included Vitamin D3 50 micrograms (mcg). The agency medication list, dated 12/4/23, lacked identification of the medication Vitamin D3 50 mcg. During an interview on 12/5/23 at 2:32 PM the patient’s family member stated the patient takes the medication Vitamin D3 50 mcg once a day. The family member also stated the medication not new and had been taking awhile. The agency failed to include the DME incontinent supplies and the medication Vitamin D3 50 mcg required by the patient on; the plan of care. The above findings shared with the Administrator/Clinical Manger, Staff C, RN and Staff D, RN. The agency did not provide additional information prior to the and of the survey. Findings include: According to the agency policy, OASIS/Comprehensive Assessment Guidelines, dated July 2018, in pertinent part, revealed the comprehensive assessment tool incorporates equipment management. On 12/5/23 at 3:30 PM, when asked about including all DME on the plan of care (POC), the Administrator agreed that all DME should be listed on the POC. 1. Patient #2 had a start of care date of 11/25/23 and received services from the agency. Clinical record review revealed: The Plan of Care dated 11/25/23 revealed the patient was incontinent of bowel/bladder and the list of DME did not include incontinence care supplies. 2. Patient #5 had a start of care date of 5/4/23 and received services from the agency. Clinical record review revealed: The Plan of Care signed by a physician on 10/31/23 revealed that the patient was incontinent of bowel/bladder and the list of DME did not include incontinence care supplies. 3. Patient #7 had a start of care date of 5/4/22 and received services from the agency. Clinical record review revealed: The Plan of Care signed by a physician on 5/12/22 revealed that the patient was incontinent of bowel/bladder and the list of DME did not include incontinence care supplies.”

“HH aide supervision elements CFR(s): 484.80(h)(4)(i-vi) Home health aide supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to, the following elements: (i) Following the patient’s plan of care for completion of tasks assigned to a home health aide by the registered nurse or other appropriate skilled professional; (ii) Maintaining an open communication process with the patient, representative (if any), caregivers, and family; (iii) Demonstrating competency with assigned tasks; (iv) Complying with infection prevention and control policies and procedures; (v) Reporting changes in the patient’s condition; and (vi) Honoring patient rights. This Element is not met as evidenced by: Based on clinical record review, agency policy review and staff interview, the agency failed to ensure registered nurses supervising home health aides maintained documentation of a review of all required supervisory elements including following the patient plan of care, maintaining open communication with patient/caregiver, demonstrating competency of all assigned tasks, complying with infection prevention and control policies, reporting changes in the patient condition and honoring patient rights for 1 of 1 sampled patients receiving home health aide services with required 14 day supervision (Patients #3). Failure to ensure the supervision of home health aides by registered nurses maintained documentation of a review of all required supervisory elements increased the risk of agency staff not meeting the patients’ personal care needs. Findings include: According to the agency policy titled Home Health Aide Supervision, dated 6/2017, when skilled nursing care is being furnished to a client, a Registered Nurse must make a supervisory visit tot he client’s residence at least every 2 weeks (either when the Home Health Aide is present to observe and assess care delivery, or when the Home Health Aide si absent) to assess relationships and determine whether goals are being met. During an interview on 12/4/23 at 3:30 PM the Administrator/Clinical Manager stated the aide supervision completed by the Registered Nurse (RN) and documented in the skilled nurse visit note. Patient #3 had a start of care date of 11/15/23. Clinical record review revealed the following: The Plan of Care, dated 11/15/23 to 1/13/24, included orders for skilled nursing and home health aide services. The skilled nurse visit note, dated 11/28/23, included documentation of home health aide supervision. The clinical note lacked documentation the nurse assessed the aides ability to meet the following required supervisory elements: following the patient’s plan of care, open communication, demonstrating competency, comply with infection prevention and control policies and procedure, The above findings shared with the Administrator//Clinical Manager, Staff C, RN and Staff D, RN. The agency provided no further information prior to the end of the survey.”

“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 agency policy review, clinical record review and agency staff interview, the agency failed to provide complete discharge instructions for 1 of 2 sampled patients with discharges (Patient #7) The agency reported a census of 31 patients. Failure to give patients complete discharge instructions may result in inadequate or inappropriate follow-up after discharge. Findings include: The agency policy, Clinical Documentation, dated July 2018, in pertinent, revealed discharge instruction will be documented on discharge instruction form. In an interview on 12/5/23 at 3:30 PM, the Administrator reported that the patient and caregiver were aware of what was required for wound care as the wound required daily dressing changes, but agreed that the lack of detailed instructions could be problematic for care of the wound after home health discharge. Patient #7 had a start of care date of 5/4/22 and was discharged from the agency on 6/16/22. Clinical record review for Patient #7 revealed the following: a. Home health discharge summary, dated 6/16/22, identified that the patient had wound care and to “continue wound care as ordered”. b. The Discharge Instructions lacked what the orders were for wound care. The above findings were reviewed with the agency Administrator/Clinical Coordinator. The agency provided no additional information prior to the end of the survey.”