Medallion Medical Care

“Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to develop policy and procedures to address the use of volunteers in an emergency or address other emergency staffing strategies, including the process and role for the integration of health care professionals to address surge needs during an emergency. This deficient practice has the potential to affect all patients and staff in an emergency. Findings include: During an interview on 11/20/24 at 3:00 p.m., staff member C stated the agency did not have policy and procedures developed which addressed the need and use of volunteers in an emergency. Review of the agency policy and procedure titled Emergency Preparedness, with a revision date of 5/2024; the policy did not address the use of volunteers in an emergency or address other emergency staffing strategies which included the process and role for the integration of health care professionals to address surge needs during an emergency.”

“EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure staff member H was trained on emergency preparedness policies and procedures upon hire. Findings include: Review of staff member H’s personnel records and the agency’s training logs on 11/20/24, showed no training was completed on emergency preparedness policies and procedures. Staff member H’s personnel records showed an agency hire date of 12/27/23. During an interview on 11/20/24 at 12:42 p.m., staff member A stated staff member H had received emergency preparedness training but the agency did not have a written verification of the training completion.”

“Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient’s status at the time of assessment. This Standard is not met as evidenced by: Based on record review and staff interview, the agency failed to accurately code the SOC OASIS to reflect clinically significant medication issues identified during the drug regimen review as part of the comprehensive assessment for 2 (#s 5 and 8) of 8 sampled patients. Findings include: A review of the agency’s policy and procedures, titled OASIS Assessment Documentation, with a revision date of 5/2024, showed: - “Process: … J. The encoded OASIS data must accurately reflect the patient’s status at the time of the assessment…” 1. Review of patient #5’s skilled nursing SOC OASIS, dated 4/11/24, showed (M2001) the drug regimen review did not identify any potentially significant medication issues were identified during the review. Review of patient #5’s DRR for clinically significant medication interactions showed: - Drug Interactions: “Intervention required for: potassium chloride ER oral capsule and oxybutynin chloride oral...” This severe interaction was not accurately coded on the patient’s SOC OASIS. 2. Review of patient #8’s skilled nursing SOC OASIS, dated 4/4/24, showed (M2001) the drug regimen review did not identify any potential significant medication issues were identified during the review. Review of patient #8’s DRR for clinically significant medication interactions showed: - “Drug Interactions: Intervention Required for: potassium chloride ER and oxybutynin chloride oral tablet…” This severe interaction was not accurately coded on the patient’s SOC OASIS. During an interview on 11/20/24 at 2:45 p.m., staff member A stated the SOC OASIS should reflect the patient’s status at the time of the SOC assessment. The patient’s medications should be run through the EHR’s medication interaction checker, if there were medication interactions on the review that should be noted in the SOC OASIS.”

“Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure staff member H was trained on infection prevention and control policies and procedures upon hire and annually thereafter. Findings include: Review of staff member H’s personnel records and the agency’s training logs on 11/20/24, showed no training was completed on infection prevention and control policies and procedures upon hire or annually. Staff member H’s personnel records showed an agency hire date of 12/27/23. During an interview on 11/20/24 at 12:42 p.m., staff member A stated staff member H had not received any specific training on infection prevention and control practices at the agency.”

“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 interview and record review, the agency failed to complete a medication regimen review in order to identify any potential adverse medication side effects, including significant medication interactions, and duplicate therapy; and failed to notify the provider of the significant medication interactions for 3 (#s 5, 6, and 8) of 8 sampled patients. This deficient practice had the potential to affect all patients receiving medication management by the agency. Findings include: A review of the agency’s policy and procedure titled, Medication Profiles, with a revision date of 5/2024, showed: “... Process... D. RN will enter all medications a patient may be taking into the EHR to identify possible ineffective drug therapy, adverse drug reactions, drug allergies, significant side effects, significant drug interactions, duplicate drug therapy, contraindicated medications, and noncompliance with drug therapy. The RN shall promptly report any identified “intervention required” to the physician by faxing a Drug Interaction form along with the medications causing the interaction. RN will print fax verification sheet to be filed in the patient’s chart. If RN does not hear from the physician w/in the next calendar day the RN will call physician office to inquire. Documentation of follow-up will be in a communication in patients EHR...” 1.Patient #5 had a SOC date of 4/11/24, with a primary diagnosis of local infection of the skin and subcutaneous tissue. Review of patient #5’s Medication Interactions, in the agency’s EHR Medication Interaction Checker, showed the following duplicate medication therapy and drug interactions with intervention required: “Duplicate Therapy: - Invega Intramuscular Suspension Prefilled Syringe 234 MG/1.5ML - risperidone oral tablet 1 MG - risperidone oral tablet 3 MG - olanzapine oral tablet 2.5 MG - duloxetine oral capsule delayed release particles 60 MG - bupropion ER oral tablet extended release 24 Hour 150 MG - risperidone oral tablet 1 MG - risperidone oral tablet 3 MG - olanzapine oral tablet 2.5 MG - gabapentin (once-daily) oral tablet 300 MG - gabapentin oral tablet 600 MG Drug Interactions Intervention Required: Drug-Drug: potassium chloride ER oral capsule extended release 10 MEQ and oxybutynin chloride oral tablet 5 MG: Co-administration of anticholinergics (oxybutynin chloride oral tablet 5 MG) and solid dosage forms of potassium chloride (Klor-Con) may increase the risk of potassium-induced gastrointestinal mucosal damage.” Review of patient #5’s Patient Medication Record, dated 4/16/24, showed: - Physician contacted regarding medication discrepancies: NA (no discrepancies). - Physician notified of severe medication interactions: NA (no interactions). The agency failed to notify the physician of the duplicate medication therapy and severe drug interactions with interventions required for patient #5. 2.Patient #6 had a SOC date of 10/21/24, with a primary diagnosis of Parkinsonism. Review of patient #6’s Medication Interactions, in the agency’s EHR Medication Interaction Checker, showed the following duplicate medication therapy: “Duplicate Therapy - propranolol oral tablet 20 MG - amlodipine besylate oral tablet 5 MG - lisinopril oral tablet 5 MG - furosemide oral tablet 20 MG” Review of patient #6’s Patient Medication Record, dated 10/21/24, showed: - Physician contacted regarding medication discrepancies: NA (no discrepancies). - Physician notified of severe medication interactions: NA (no interactions). The agency failed to notify the physician of the duplicate medication therapy for patient #6. 3. Patient #8 had a SOC date of 4/4/24, with a primary diagnosis of collapsed lumbar vertebrae. Review of patient #8’s Medication Interactions, in the agency’s EHR Medication Interaction Checker, showed the following duplicate medication therapy and drug interactions with intervention required: “Duplicate Therapy - hydromorphone injection solution 0.2 MG/ML - hydromorphone injection solution 1 MG/ML - hydromorphone injection solution 0.2 MG/ML -hydromorphone injection solution 1 MG/ML -potassium chloride ER oral tablet extended release 10 MEQ -potassium chloride ER oral tablet extended release 20 MEQ -famotidine oral tablet 10 MG -omeprazole oral capsule delayed release 20 MG Drug Interactions -Intervention Required Drug-Drug potassium chloride ER oral tablet 10 MEQ and oxybutynin chloride oral tablet 5 MG: Co-administration of anticholinergics (oxybutynin chloride) and solid dosage forms of potassium chloride (Klor-Con) may increase the risk of potassium-induced gastrointestinal mucosal damage. -Intervention Required Drug-Drug Potassium Chloride ER Oral Tablet 20 MEQ and oxybutynin chloride oral tablet 5 MG: Co-administration of anticholinergics (oxybutynin chloride) and solid dosage forms of potassium chloride (Klor-Con) may increase the risk of potassium-induced gastrointestinal mucosal damage.” Review of patient #8’s Patient Medication Record, dated 4/8/24, showed: - Physician contacted regarding medication discrepancies: NA (no discrepancies). - Physician notified of severe medication interactions: NA (no interactions). The agency failed to notify the physician of the duplicate medication therapy for patient #8. During an interview on 10/20/24 at 2:45 p.m., staff member A stated it was the expectation for staff to complete a full medication reconciliation with the patient at the start of care. The medications were to be entered into the patient’s chart and then staff would run the medication reconciliation checker to check for duplicate medication therapy or severe medication interactions. If there were any duplicate medication therapies or severe medication interactions with intervention required, staff were to notify the provider immediately and document any changes to the medication regimen.”

“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 interview and record review, the agency failed to develop an individualized plan of care which included the ordered frequency and duration of visits, modality interventions, measurable outcomes, and goals for therapy services for 3 (#s 4, 6, and 7) of 8 sampled patients. This deficient practice had the potential to affect all patients receiving therapy services. Findings include: A review of the agency’s policy and procedures titled, Plan of Care, with a revision date of 4/2024, showed: “…Process: … 2. The Plan of Care shall be completed in full to include: c. Type, frequency, and duration of all visits/services d. Specific procedures and modalities for therapy services. 3. If a physician refers a patient under a Plan of Care which cannot be completed until after an assessment visit, the physician shall be consulted to approve additions or modifications to the original plan. The skilled assessment visit order will be documented on a Doctor’s Order Form and faxed to the physician for signature. Physician’s orders transmitted by fax shall be followed by the original signed and dated orders and filed in the clinical record and/or uploaded into the patient’s EHR. 4. Orders for therapy services shall include the specific procedures and modalities to be used and the amount, frequency, and duration…” 1. Patient #4 had a SOC date of 5/1/24, with a primary diagnosis of cellulitis of lower extremity. Review of patient #4’s PT Evaluation, dated 5/6/24, showed: “…Treatment Goals: 1. Instruct in an HEP for ROM/strengthening in 2 weeks. 2. Provide written copy of HEP in 2 weeks. 3. Ambulate x 1 block with cane with supervision on even/uneven terrain in 3 weeks. 4. Fair with dynamic standing balance with transfers, gait, reaching and turning in 4 weeks. 5. Independent with HEP and up ad lib with patient able to access community for shopping, medical appointments, demonstrating good balance in 4 weeks…. Treatment Plan: - Therapy Exercises, establish or Upgrade HEP, gait Training, range of motion, balance training, muscle re-education, home safety training…” Review of patient #4’s Plan of Care, with a certification period of 5/1/24 to 6/29/24, showed: - Orders and Treatments: PT: two times a week for four weeks effective 5/1/24. - Goals and Outcomes: Home exercise program will be established by physical therapist. Patient #4’s Plan of Care did not include modality interventions, measurable outcomes, and goals for the ordered physical therapy services. 2. Patient #6 had a SOC date of 10/21/24, with a primary diagnosis of Parkinsonism. Review of patient #6’s Physical Therapy Evaluation, dated 10/22/24, showed: “…Patient Goals: Would like to build up his strength and improve his walking… Treatment Goals: 1: Set up an instruct patient and an HEP for general strengthening and conditioning in 2 weeks. 2: Provide written HEP as reference in 2 weeks. 3: Increase strength throughout by one half grade in order to facilitate improved balance and gait quality in 3 weeks. 4: Fair plus dynamic standing balance with reaching, turning, transfers and gait in 3 weeks. 5: Independent was established HEP in 5 weeks. 6: Demonstrate safe and efficient gait with good step through, no loss of balance and good activity tolerance in 5 weeks… Treatment Plan: - Therapy exercises, establish or upgrade HEP, gait training, range of motion, balance training, muscle re-education, home safety training…” Review of patient #6’s OT Evaluation, dated 10/28/24, showed: - “Patient Goals: Patient would like to increase a safety within the home and increase his safety during ADLs… Treatment Goals: 1. Patient will be provided with home exercise program at next occupational therapy visit in 2 weeks. 2. Patient will increase safety during shower transfers indicated by clinical observation and/or patient verbal report in 3 weeks. 3: Patient will increase independence in donning socks with use of sock aid in 4 weeks… Treatment Plan: - Therapy exercise, establish or upgrade HEP, transfer training, balance training, stairs/steps training, strength/endurance training, fine motor coordination training, home safety training, independent living/ADL training…” Review of patient #6’s Plan of Care, with a certification period of 10/21/24 to 12/19/24, showed: Orders and Treatments: - PT: two times a week for one week, three times a week for weeks, effective 10/21/24. Home exercise program will be established by physical therapist. Patient’s mobility will be improved with assistance of physical therapist. - OT: one times a week for four weeks, effective 10/21/24. Home exercise program will be established by occupational therapist. Patient #6’s Plan of Care did not include the established modality interventions, measurable outcomes, and goals for the ordered physical and occupational therapy services. 3. Patient #7 had a SOC date of 11/4/24, with a primary diagnosis of wedge compression fracture of the lumbar spine. Review of patient #7’s Physical Therapy Evaluation, dated 11/4/24, showed: - “Patient Goals: Patient’s goals are to improve strength, returned to her prior level of function and not need to use an assistive device… Treatment Goals: 1. Educate/instruct [patient] on correct body mechanics for good adherence to spinal precautions in two weeks. 2. Set up and instruct in ROM/stretching and strengthening HEP. Provide written copy as reference in two weeks. 3. Gait trials with lesser restrictive assistive device (cane or no [Assistive Device]), good- balance, no increase in reports of back pain in three weeks. 4. Independent with HEP in four weeks. 5. Up ad lib with or without least restrictive assistive device, good activity tolerance and good balance in four weeks… - Treatment Plan: therapeutic exercise, establish or upgrade HEP, gait training, range of motion, muscle re-education, stairs/steps training, home safety training…” Review of patient #7’s Occupational Therapy Evaluation, dated 11/15/24, showed: - “Patient Goals: Complete laundry, dishes, and cooking tasks while maintaining precautions… - Treatment Goals 1: Patient’s home will be assessed for DME/AD necessary to maintain precautions and promote aging in place, in one week. 2: Patient and daughter (caregiver) will be educated on IADL modifications to ensure modified independence and maintenance of spinal precautions, in one week. 3: Will be provided with a handout of the modifications to support independence and task modifications during IADL management, in two weeks. 4: Will be independent to complete laundry tasks (light load) while maintaining precautions and using AD as necessary, in two weeks. 5: Will be provided with education/training on task modifications/energy conservation strategies to improve independence during IADL/ADL tasks, in two weeks. - Treatment Plan: home safety training, independent living/ADL training… - Frequency and Duration: one time a week for two weeks with evaluation…” Review of patient #7’s Plan of Care, with a certification period of 11/4/24 to 1/2/25, showed: Orders and Treatments: - PT: One time a week for four weeks, effective 11/4/24. - Physical therapy to evaluate week of 11/04/2024. - OT: Two visits effective 11/04/2024. - Occupational therapy to evaluate week of 11/04/2024. Patient #7’s Plan of Care did not include the established modality interventions, measurable outcomes, and goals for the ordered physical and occupational therapy services, or the frequency and duration for occupational therapy. During an interview on 11/20/24 at 2:45 p.m., staff member A stated it was the expectation that the plan of care reflected the current services being provided for the patient. Staff were expected to follow the agency’s procedure for ensuring the accuracy of the plan of care for each patient.”

“In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure current cardiopulmonary resuscitation certifications were completed for three staff, members E, I, and J, of six sampled personnel records. Findings include: A. Review of staff member E’s personnel records on 11/20/24, showed no current CPR certification. Review of staff member E’s most recent job description, signed on 8/19/24, showed: -...”Requirements -...Current CPR certification...” B. Review of staff member I’s personnel records on 11/20/24, showed no current CPR certification. Review of staff member I’s most recent job description, signed on 8/15/24, showed: -...”Education -...CPR certification...” C. Review of staff member J’s personnel records on 1120/24, showed her CPR certification had expired on 11/7/24. No documentation of any current certification was included in the records. Review of staff member J’s most recent job description, signed on 8/15/24, showed: -...”Requirements -...Current BCLS certification...” During an interview on 11/20/24 at 12:25 p.m., staff member A stated staff member E was attempting to obtain her current CPR certification from her previous employer. Staff member A stated there was not a current CPR certification on file for staff members I and J. No current CPR certification was obtained from the agency, for staff member E, prior to the exit of the survey.”