Hamilton County Public Health Nursing Services

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on clinical record review, agency policy review and agency staff interview, the agency failed to provide an initial assessment visit within 48 hours of receipt of referral for 2 of 7 sampled patients (Patients #1 and #5). Failure to provide an initial assessment visit within 48 hours put agency patients at risk for not having immediate care needs met. Findings include: 2. Patient #6 had a start of care date of 3/6/24 and discharge date of 6/28/24. Review of the clinical record revealed the following: a. The POCs, dated 3/6/24 to 5/4/24, documented the patient had orders for skilled nurse and physical therapy visits. b. The referral, dated 2/29/24, included documentation of referral for services by the physician’s clinic. c. The skilled nurse visit note at the start of care, dated 3/6/24, included documentation of the initial assessment visit. d. The clinical record failed to include documentation of a physician’s order for services to start on 3/6/24. e. The agency failed to conduct the initial assessment within 48 hour after the physician’s referral. The above findings shared with the Clinical Manager. The agency provided no further information prior to the end of the survey. The agency policy, Initial Visit and Comprehensive Assessment reviewed February 2018, revealed in pertinent part, the initial visit must be held within 48 of referral or within 48 hours of clients return to home or on the physician ordered start of care date. In an interview on 5/15/24 at 11:30 AM, the Clinical Manager reported she was unable to find a physician order to start home care services within 48 hours of Patient #1’s start of care date of 4/25/24. Patient #1 had a start of care date of 4/25/24 and received services from the agency. Clinical record review revealed the following: The physician’s initial referral order, dated 4/19/24 and sent to the agency by facsimile (fax) on 4/19/24, ordered skilled nursing home health services but did not identify a specific start of care date. The Plan of Care (POC), dated 4/25/24 to 6/23/24, identified the start of care date was 4/25/ 24. Lacked documentation of any skilled nursing visit prior to 4/25/24 and lacked documentation of any case communication notes or notes in the electronic medical record (EMR) explaining the delay of the start of care. Lacked documentation of any follow up with the referring physician to report the delay in start of care. The clinical record lacked documentation of any physician’ s order to delay the home health services. The patient was not admitted to service until 5 days after receiving the referral.”

“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 1 of 1 sampled patients with wounds (Patient #1). Failure to accurately and thoroughly complete wound assessments placed patients at an increased risk of unidentified condition changes. Findings include: According to the agency’s policy, Assessment and Documentation of Wounds last reviewed July 2018, revealed in pertinent part, to document the following on the visit report: the treatment and condition of the wound (each visit), appearance of the wound, wound measurements (at least weekly) including the length, depth, and width of the wound in centimeters, depth and location of undermining in centimeters, skin around the wound, color, odor, and estimated amount of drainage, and compare the progress of the wound with the goals of therapy. Wound care is covered by Medicare as long as the need for skilled care and treatment is clearly and precisely documented on the visit report. In an interview on 5/15/24 at 11:30 AM, the Clinical Manager reported she was unable to find wound measurements for Patient #1’s wound for the week of 4/28/24. The Clinical Manager was able to find visit notes of wound assessment, but the wound assessments failed to include measurements. Patient #1 had a start of care date of 4/25/24 and received services from the agency. Clinical record review revealed the following: Orders that included skilled nursing visits for admission, then two visits per week for two weeks, then weekly visits. Each nursing visit was ordered to include wound treatment and dressing changes. The skilled nursing visits on 4/30/24 and 5/3/24 failed to include a comprehensive wound assessment with no wound measurements documented. The above findings were reviewed with the Clinical Manager and no further information provided 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 required components of the Plan of Care (POC) for 6 of 7 sampled patients (Patients #1, #2, #3, #4, #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. Findings include: 4. Patient #4 had a start of care date of 4/19/24. Clinical review revealed the following: a. The POC, dated 4/19/24 to 6/17/24, included the following DME: Shower chair, hospital bed, front-wheeled walker, 4 x 4 split gauze, IV pole, peg tube supplies, urinal, wheelchair, scale and commode. b. The skilled nurse visit note at the start of care, dated 4/19/24, included documentation the patient used the DME ramp, mepilex dressing, medication planner and gait belt. The POC failed to include the patient’s DME use of a ramp, mepilex dressing, medication planner and gait belt. 5. Patient #5 had a start of care date of 8/15/23. Clinical review revealed the following: a. The POC, dated 4/12/24 to 6/10/24, included the following DME: cane, 4 wheeled walker, bed rail, shower grab bars, shower chair, med planners, toilet seat riser, dentures, eye glasses, hearing aids and lift reclining chair. b. The skilled nurse visit note, dated 3/12/24, included documentation the patient used the DME medication planner. The POC failed to include the patient’s DME use of a medication planner. 6. Patient #7 had a start of care date of 1/3/21. Clinical review revealed the following: a. The POC, dated 4/28/23 to 6/26/23 and 6/27/23 to 8/25/23, included orders for skilled nursing services. b. The clinical record included a copy of the patient’s advanced directives, dated 9/30/20. The POC failed to include the patient’s advanced directives. The above findings shared with the Clinical Manager. The agency failed to provide additional information prior to the end of the survey. Agency policy, titled Care Planning, Coordination of Services, and Quality Care dated January 2018, revealed in pertinent part, that each client must receive the home health services that are written in an individualized plan of care that must include the following: types of services, supplies, and equipment required, information related to any advance directives, and any additional items HCPH (Hamilton County Public Health) or the physician may choose to include. In an interview on 5/15/24 at 10:15 AM, the Clinical Manager reported that she was not sure why the POC’s did not show the advance directive status. The Clinical Manager asked the nurses, who all reported they are discussing advanced directives with patients at admission, but will need to look into the electronic health record (EHR) system the agency uses to determine the cause of the lack of this entry on the POC. During the same interview, when asked about Patient #1’s medication reconciliation at admission, the Clinical Manager requested assistance in understanding how to perform medication reconciliation at admission when the agency has a medication list on file and the agency has a medication list included with the referral. 1. Patient #1 had a start of care date of 4/25/24 and received services from the agency. In a concurrent observation and interview with the patient on 5/14/24 at 1:30 PM, disposable briefs were observed in the patient’s bathroom. The patient reported he started wearing them prior to starting home health care and wears the disposable briefs all of the time for incontinence. The patient reported discussion regarding advance directives occurred with his admission to home health care and that full code was his result of this discussion. Medications were reviewed with the patient finding the patient reporting that no longer takes furosemide (to remove excess fluid). The patient reported he was ordered to take furosemide at the clinic visit that his doctor ordered home health. The patient reported he no longer took lisinopril (treats high blood pressure), that he stopped taking that a year ago when he had a hip replacement procedure and had home health care. Ciclopirox (prescription topical solution to treat nail fungus) was observed next to his other medications, the date it was filled on the medication label was c4/17/24, the patient reported he took that medication prior to starting home care and takes the medication as prescribed. Clinical record revealed: a. The Summary of Care sent via facsimile (fax) with referral documents from the referring clinic on 4/19/24 included a medication that included ciclopirox and did not lisinopril. b. The POC from 4/25/24 to 6/23/24 did not have any documentation in the advance directive area, did not list incontinence supplies in the durable medical equipment section, included lisinopril, and did not list ciclopirox. 2. Patient #2 had a start of care date of 12/1/23 and received services from the agency. In a concurrent observation and interview with the patient on 5/14/24 at 8:45 AM, when asked if the patient wore incontinence products, she replied that she has worn a pad for over a year for incontinence. When asked if she used a Cpap (continuous positive airway pressure) or BiPap (bilevel positive airway pressure) to treat obstructive sleep apnea, the patient reported that she has used a BiPAP for over a year. The patient reported discussion regarding advance directives occurred with her admission to home health care and she was undecided as to whether or not she would like to be a full code or a DNR (do not resuscitate). Medications were reviewed with the patient finding the patient reporting that she did not know she was ordered to take amoxicillin 1 hour prior to a procedure as a result of the knee replacement she had in October 2023. The patient reported she had postoperative complications and had a challenging time managing her health needs. The patient reported to Staff D, Registered Nurse (RN), that she was no longer taking benzonatate, she had this medication refilled a few times, but she no longer had the cough she needed the medication for. The 4/18/24 was the date last filled on the medication label for benzonatate. Clinical record review revealed: a. The POC from 3/30/24 to 5/28/24 did not have any documentation in the advance directive section, did not list incontinence supplies or BiPap in the DME section, and did not list benzonatate or amoxicillin. b. The POC included the patient’s diagnoses of generalized anxiety disorder and obstructive sleep apnea, that the patient has outpatient psychiatric services, and that the patient’s mental statuses included depression and schizophrenic disorder. 3. Patient #3 had a start of care date of 2/2/24 and received services from the agency. In a concurrent observation and interview with the patient on 5/13/24 at 3:15 PM, when asked if the patient wore incontinence products, she replied that she has worn a pad for over a year for incontinence. When asked if she has any allergies, the patient reported that she has one allergy to scented soaps. The patient reported discussion regarding advance directives occurred with her admission to home health care and DNR (do not resuscitate) was her advance directive Medications were reviewed with the patient finding the patient reporting that she was unable to keep her lidocaine patch in place, that it wouldn’t stick and move, the patient obtained a prescription for lidocaine gel in October 2023, has refilled the medication several times, and uses the medication. The agency medication list included orders for a bedtime dose of lorazepam (treats anxiety), the patient reported she no longer took this dose because at her hospitalization she was prescribed temazepam to take instead. During review of temazepam, it was discovered that the agency medication list contained a 15 milligram (mg) dose and the medication bottle label dose was 22.5 mg. The patient reported that temazepam 15 mg was originally prescribed while hospitalized and then at a follow up clinical visit, the medication was increased to 22.5 mg. Clinical record revealed: The POC from 4/2/24 to 5/31/24 did not have any documentation in the advance directive section, did not include documentation in the allergy section, did not list incontinence supplies in the DME section, and the medication list did not include lidocaine gel, the updated dosing for lorazepam or temazepam.”

“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 #4 and #7). 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: According to agency policy, titled Care Planning, Coordination of Services and Quality Care, dated 1/2018, drugs, services and treatments are administered only as ordered by the physician. 1. Patient #4 had a start of care date of 4/19/24. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 4/19/24 to 6/17/24, documented the patient had nutritional requirements of a general diet and percutaneous endoscopic gastrostomy (PEG) tub supplemental feeding. The Plan lacked any orders for supplemental feeding, formula, amount or rate of administration. b. The skilled nurse visit note on admission, dated 4/19/24, included documentation the patient had feedings of Nestle Nutren 1.5 through the PEG tube by gravity. The clinical record lacked physician orders for PEG tube formula, amount or rate of administration. 2. Patient #7 had a start of care date of 1/3/21 and discharge date of 6/29/23. Review of the clinical record revealed the following: a. The POCs, dated 2/27/23 to 4/27/23, 4/28/23 to 6/26/23 and 6/27/23 to 8/25/23, documented the patient had orders for skilled nurse visits to set up medications in a medication planner. The orders included the medication Belsomra to aide in sleep. b. The skilled nurse visit note, dated 2/3/23, included documentation the nurse set up medications for the patient for 10 day supply. Belsomra called into the pharmacy for refills. c. The visit report, dated 2/4/23, included documentation a phone call made to the on call nurse by the patient. The patient identified he/she hurt his/her eye and had been having bad post traumatic stress disorder (PTSD) last night and today. He/she stated he/she would quit taking medications until a nurse will come look at his/her medications. d. The skilled nurse visit report, dated 2/4/23, revealed a visit made to the patient’s home and set up medications for 3 days for the remaining weekend. c. During an interview on 5/15/34 at 8:50 AM, Staff D, RN stated she was the nurse on call and received a call from the patient. The patient upset about the medications not set up correctly and the sleeping medication not in the medication planner. She stated she made a visit to the patient’s home and found the medication Belsomra not in the medication box for Saturday, Sunday, Monday, Tuesday, Wednesday or Thursday but were in the following weekend for Friday Saturday and Sunday holders instead. She further stated she took all of the medications out of the medication planner for the week and re-set up the medications for the weekend. She placed the sleeping medication in the planner for Saturday, Sunday and Monday. The sleeping medication had been requested for a refill and would set up the remaining medications on Monday. The agency failed to provide medication set up according to physician orders. The above findings were reviewed with the Clinical Manager. The agency provided no further information prior to the end of the survey.”

“Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This Element is not met as evidenced by: Based on agency policy review, clinical record review and staff interview, the agency failed to ensure home health aides provided care to agency patients only as ordered by the physician, permitted under state law and/or as directed by the skilled professional assigning the home health aide to the patient for 2 of 2 sampled patients receiving home health aide services (Patients #4 and #5). The agency reported 38 patients who received home health aide services. Failure to ensure that home health aide services are provided only as ordered by the physician, permitted under state law and/or as directed by the skilled professional assigning the home health aide to the patient and according to the home health aide care plan increased the risk that patients’ personal care needs were not adequately met. Findings including: According to the agency policy, titled Home Health Aide Services, dated 3/20/24, home health aides are assigned to specific clients by a registered nurse or other appropriate skilled professional, with written client care instructions for a home health aide prepared by the registered nurse or other appropriate skilled professional. 1. Patient #4 had a start of care date of 4/19/24. The Plans of Care, dated 4/19/24 to 6/17/24, included physician orders for skilled nursing services for assessment every other week and home health aide services 2 times per week to assist with personal care. Clinical record review revealed: a. The Aide Care Plan for the months of March, April and May included direction to the aide to perform the following: Clean tub/shower, dressing change, help with dressing, shave, shower bath, skin care lotion to extremities and topical application Calmoseptine to peri area of peg at each visit after shower. b. Home health aide visit notes, dated 4/24, 4/30, 5/2, 5/7 and 5/9/24, failed to include documentation the aide performed the task of shaving and failed to document why the task was not performed. The home health aide failed to provide services that are ordered by the physician, included in the plan of care, permitted under state law, and consistent with home health aide training. 2. Patient #5 had a start of care date of 8/15/23. The POCs, dated 2/12/24 to 4/11/24 and 4/12/24 to 6/10/24, included physician orders for skilled nursing services for assessment every other week and home health aide services 2 times per week to assist with personal care. Clinical record review revealed: a. The Aide Care Plan for the months of March, April and May included direction to the aide to perform the following: exercise program, help with dressing, help with walking, shower bath, skin care lotion to arms, legs and back and topical application Nystatin to groin. b. Home health aide visit notes, dated 3/22, 3/26, 3/29, 4/2, 4/5, 4/26, 4/30 and 5/3/24, failed to include documentation the aide performed the task of exercise program and failed to document why the task was not performed. The home health aide failed to provide services that are ordered by the physician, included in the plan of care, permitted under state law, and consistent with home health aide training. The above findings were reviewed with the Clinical Manager. The agency failed to provide additional prior to the end of the survey.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on clinical record review, agency aide supervision guidelines and agency staff interview, the agency failed to ensure a registered nurse or other appropriate health care professional completed home health aide supervision at least every 14 days for 2 of 2 sampled patients who received hands on personal care services in conjunction with a skilled service provision (Patients #4 & #5). The agency reported 29 patients who received home health aide services with every 14 day supervision. Failure to supervise home health aide services, at least every 14 days increased the risk that patients received unsatisfactory or inappropriate care from home health aides. Findings include: According to the agency’s policy titled Home Health Aide Services, dated 3/20/24, when home health aide services are provided to a client who is receiving skilled nursing, a registered nurse or other appropriate skill professional who is familiar with the client, the clients plan of care and the written client instructions must make a supervisor visit to the client’s home one every 14 days. During an interview on 5/14/24 at 8:24 AM the Clinical Manager stated the nurse completes aide supervision and documents under the episode tab. 1. Patient #4 had a start of care date of 4/19/24. The Plan of Care (POC), dated 4/19/24 to 6/17/24, included physician orders for skilled nursing and home health aide services. Review of the clinical record included the following: a. The supervision report, dated 4/25/24, included documentation of home health aide supervision. b. Review of the clinical record on 5/13/24, lacked additional documentation of home health aide supervision (2 days late). The agency failed to provide home health aide supervision every 14 days. 2. Patient #5 had a start of care date of 4/19/24. The POCs, dated 2/12/24 to 4/11/24 and 4/12/24 to 6/10/24, included physician orders for skilled nursing and home health aide services. Review of the clinical record included the following: a. The supervision report, dated 2/28/24, included documentation of home health aide supervision. b. The supervision report, dated 4/9/24, included documentation of home health aide supervision (27 days late). c. Review of the clinical record lacked additional documentation of home health aide supervision. The agency failed to provide home health aide supervision every 14 days The above information were reviewed with the Clinical Manager. No additional information provided prior to the end of the survey.”