Medi-Plex Healthcare Professionals, LLC

“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 the provider’s policy, observation, and interview, the home health provider failed to ensure their clinicians followed standard precautions, to prevent the transmission of infections and communicable diseases in two of three home visit observations (Records/Patients #2 and #4). This deficient practice has the potential to affect the standard precautions utilized for all of the provider’s patients. Findings included: Review of the provider’s undated policy titled, “Bag Technique Procedure,” showed that the bag technique procedure included, in part: - Observe principles of universal precautions and body substance isolation at all times. The inside of the nursing bag shall be regarded and maintained as a clean area; - Open the nursing bag and remove items that are needed to wash the hands. Handwashing supplies should be kept in the side pocket or at the top of the bag. Close the bag. Open and close the nursing bag as few times as possible; and - Open the nursing bag again and remove items necessary for the visit. Apply personal protective equipment. Keep the bag close during the visit. Provide patient care. If additional equipment or supplies are needed form the bag during the home visit, the handwashing procedure must be repeated. Clean any items from the bag, which have become soiled. Place then on a clean a paper towel. Repeat handwashing procedure and return equipment to bag at the end of the visit. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health on 10/24/2023 for wound care following an exploratory laparotomy (an incision into the abdominal cavity), abdominal mesh removal, and small bowel resection (removal) on 10/16/2023. The patient resided in their own home with the assistance of family and friends. Secondary diagnoses are hypertension, atrial fibrillation, osteoarthritis, anxiety, benign prostatic hypertrophy. During a home visit observation on 12/05/2023 at 3:45 PM, the clinician entered the patient’s home wearing a surgical mask and gloves on both hands. The clinician entered his/her clinical bag wearing the gloves donned prior to entering the home, and without performing hand hygiene. He/she then removed the blood pressure cuff and pulse oximeter from the bag, monitored the patient using the equipment, and returned the equipment to the clinical bag without cleansing the equipment or removing the soiled gloves and performing hand hygiene. During an interview on 12/06/2023 at 4:00 PM, the administrator stated that the bag techniques utilized during this visit failed to follow the agency policy. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 11/14/2023 with a primary diagnosis of non-pressure chronic ulcer on right foot, and secondary diagnosis of lymphedema. The patient resided in their own home. During a home visit observation on 12/05/2023 at 1:36PM, the clinician performed wound care with the following breaks in infection control. The clinician: - Removed the old dressing from the patient’s leg and placed the dressing in the trash. He/she failed to perform hand hygiene or remove his/her gloves before reaching into a package of clean gauze; - Cleansed the patient’s wound with spray wound cleaner, wiped the wound with clean gauze, failed to perform hand hygiene or change gloves, and reached back into the package of clean gauze to get more (this was repeated three times); and - Assessed the patient’s vital signs, failed to wash his/her hands, reached into his/her bag, retrieved a box of alcohol preps (sat the prep box on the table without a drape), cleansed the equipment with an alcohol prep, and returned the equipment and contaminated box of alcohol preps back into the nursing bag. During an interview on 12/06/2023 at 11:42 AM, the administrator stated that the bag techniques utilized during this visit failed to follow the agency policy.”

“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 the provider’s policy, clinical record review, and interview, the home health provider failed to ensure clinicians perform a review of all medications the patient was currently using in two of six records (Records/Patients #1 and #2). This deficient practice has the potential to affect the medication review and reconciliation for all of the provider’s patients. Findings included: Review of the provider’s policy titled, “Medication Reconciliation,” dated February 2021, showed, in part: - At the time of admission, the admitting [clinician] will create and document a complete list of medications that the patient is taking at home, including dose, strength, route, and frequency: * Any concerns or discrepancies will be reconciled by a registered nurse (RN) with the patient’s physician/practitioner; - Discrepancies include duplications, omissions, changes, contraindications and/or unclear information; - The agency provides the patient and/or caregiver with written patient medication schedule/instructions, including medication name, dose, strength, route and frequency as well as which medications will be administered by agency staff and staff acting on behalf of the agency; and - In therapy only cases, the therapist submits a list of medications collected during the comprehensive assessment to [the] RN for review, who contacts physician/practitioner if indicated. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 11/14/2023 with a primary diagnosis of hemochromatosis (genetic disorder that can cause severe liver disease and other health problem), and secondary diagnoses including, but not limited to, gastroesophageal reflux (a condition in which stomach acid repeatedly flows back into the tube connecting your mouth and stomach), hyperlipidemia (elevated levels of lipids (fats) in the blood), and long-term use of antiplatelet agents. The patient resided in their own home with the assistance of family/friends. Comparison of the medication list sent to the provider at the time of referral on 10/13/2023 to the plan of care dated 11/14/2023 showed, in part the following discrepancies: - The referral medication profile listed multiple medications that were not included on the provider’s medication profile including acetaminophen (a non-narcotic pain reliever), clotrimazole (a cream used to treat skin conditions), diazepam (a medication used to treat anxiety and depression), lansoprazole (used to treat gastric reflux), latanoprost (a medication used to treat glaucoma), metronidazole (a medication used to treat skin conditions), and polyethylene glycol (a medication used to treat constipation); and - Multiple medications appeared on the provider’s medication profile and were not listed on the referral medication list including clopidogrel (to prevent blood clots), pantoprazole (used to treat gastric reflux), rosuvastatin (to reduce lipids in the blood), and vitamin B12. Review of the start of care visit dated 11/14/2023 showed the clinician documented that a medication reconciliation was performed and there were no issues found during the medication review. The visit documentation failed to contain documentation that the physician was notified of the discrepancies between the referral medication list and the provider’s medication profile. During an interview on 12/06/2023 at 11:42 AM, the administrator stated that they were unable to locate documentation that the clinician had notified the physician of discrepancies identified during the start of care medication reconciliation. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health on 10/24/2023 for wound care following an exploratory laparotomy (an incision into the abdominal cavity), abdominal mesh removal, and small bowel resection (removal) on 10/16/2023. The patient resided in their own home with the assistance of family and friends. Secondary diagnoses are hypertension, atrial fibrillation (fluttering of the upper portion of the heart), osteoarthritis, anxiety, benign prostatic hypertrophy. Comparison of the medication list sent to the provider at the time of referral on 10/19/2023 to the plan of care dated 10/24/2023 showed, in part the following discrepancies: - The referral medication profile listed medications that were not included on the provider’s medication profile including aspirin (used to prevent blood clots), ketoconazole (used to treat skin conditions), lisinopril 40 milligrams (mg) take one half tablet daily (for high blood pressure), multivitamin, and omega-3 oils; and - Multiple medications appeared on the provider’s medication profile and were not listed on the referral medication list including lisinopril 40mg take one tablet daily, potassium chloride, and sildenafil (for erectile dysfunction). Review of the start of care visit dated 10/24/2023 showed the clinician documented that a medication reconciliation was performed and there were no issues found during the medication review. The visit documentation failed to contain documentation that the physician was notified of the discrepancies between the referral medication list and the provider’s medication profile. During an interview on 12/06/2023 at 4:00 PM, the administrator stated that they were unable to locate documentation that the clinician had notified the physician of discrepancies identified during the start of care medication reconciliation.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on the provider’s policy, clinical record review, and interview, the home health provider failed to ensure the clinicians provided the services that were ordered by the physician as indicated in the plan of care in one of six records reviewed (Record/Patient #4). This deficient practice has the potential to affect the provision of care as ordered for all of the provider’s patients. Findings included: Review of the provider’s undated policy titled, “Missed Visit Policy,” showed: - The agency will ensure accurate documentation of all missed visits and when to report the missed visit to the physician; - To provide written documentation to the physician, when applicable and in the patient’s medical record of when visits are missed within the scheduled visit week (Sunday-Saturday) for all patients; - Procedure: * The clinician will document when scheduled visits are missed due to various reasons and record the reason accurately; * The clinician will make other attempts to visit the patient within the service week to adhere to the patient’s frequency according to the plan of care; * The clinician will report missed visits to the physician when visits are missed excessively; and * MD/Physician and/or wound care clinic appointment(s) may or may not apply to meeting the patient’s frequency for the service week. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 11/14/2023 with a primary diagnosis of non-pressure chronic ulcer on right foot, and secondary diagnosis of lymphedema. The patient resided in their own home. Review of the plan of care dated 11/14/2023 showed the nurse was to visit two times per week for the provision of wound care. The nurse was to cleanse the wound with normal saline, apply gentamycin cream, Algicel Ag (an absorbent dressing impregnated with silver), Hydrofera Blue (a dressing used to reduce bacterial growth), cover with dry dressing, and secure with tape. Apply with two-layer Coflex (a compression dressing). The week of 11/26 the patient did not have any nursing visits for provision of wound care. The clinical record failed to contain documentation that the physician was notified of the missed visits and that the patient did not receive wound care for that week. During an interview on 12/06/2023 at 11:42 AM, the administrator stated that they would expect the clinician to notify the physician of missed visits and that wound care was not provided as ordered.”