Atrium Health at Home Cleveland

“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 clinical record review and staff interviews the agency failed to ensure the accuracy of OASIS [The Outcome and Assessment Information Set-used to collect and report patient outcome data] question N0415 [related to high-risk medications] for 7 of 17 patients [# 1, 4, 5, 13, 14, 15 and 17]. The findings included: 1. Patient # 1 had a Start of Care [SOC] date of 2/9/25 with an admitting diagnosis of type 2 diabetes mellitus with diabetic chronic kidney disease. Review of the Plan of Care for the certification period 2/9/25-4/9/25 revealed the patient was ordered clopidogrel [anticoagulant-slows down the overall blood clotting process] 75 mg daily. RN [registered nurse] # 8 completed the SOC OASIS [The Outcome and Assessment Information Set-used to collect and report patient outcome data] on 2/9/25. Review of the OASIS documentation revealed question N0415 [related to high-risk medications] was answered incorrectly. RN # 8 had indicated the patient was receiving an antiplatelet [prevents platelets from sticking together] rather than an anticoagulant at the time of admission. 2. Patient # 4 had a Start of Care [SOC] date of 2/3/25 with an admitting diagnosis of essential hypertension. Review of the Plan of Care [POC] for the certification period 2/3/25-4/3/25 revealed no antipsychotic medication on the POC. PT [physical therapist] # 7 completed the SOC OASIS [The Outcome and Assessment Information Set-used to collect and report patient outcome data] on 2/3/25. Review of the OASIS documentation revealed question N0415 [related to high-risk medications] was answered incorrectly. PT # 7 had indicated the patient was receiving an antipsychotic medication at the time of admission. ST [speech therapist] # 9 completed the DC [discharge] OASIS on 3/28/25. Review of the DC OASIS documentation revealed N0415 was answered incorrectly as well. ST [speech therapist] # 9 indicated the patient was receiving an antipsychotic medication at the time of discharge. 3. Patient # 5 had a Start of Care [SOC] date of 5/21/24 with admitting diagnoses of chronic obstructive pulmonary disease [COPD-breathing condition] and type 2 diabetes mellitus with diabetic polyneuropathy [numbness, tingling, pain [burning or shooting], muscle weakness and loss of sensation, particularly in the hands and feet]. Review of the Plan of Care for the certification period 5/21/24-7/19/24 revealed the patient was ordered metformin [used to lower blood sugar] 500 mg daily and oxycodone [opioid] 5 mg every 6 hours as needed for pain. Further review of the clinical record revealed RN [registered nurse] # 6 completed the discharge OASIS [The Outcome and Assessment Information Set-used to collect and report patient outcome data] on 7/2/24. There was no supplemental order noted in the clinical record to stop the metformin or the oxycodone. Review of the OASIS documentation revealed question N0415 [related to high-risk medications] was answered incorrectly. RN # 6 failed to capture the use of a hypoglycemic[metformin] medication and oxycodone [opioid] when answering N0415. 4. Patient # 13 had a Start of Care [SOC] date of 5/15/25 with an admitting diagnosis of malignant neoplasm [cancer] of temporal lobe [brain]. Review of the Plan of Care for the certification period 5/15/25-7/13/25 revealed the patient was ordered clopidogrel [anticoagulant-slows down the overall blood clotting process] 75 mg daily. RN [registered nurse] # 4 completed the SOC OASIS [The Outcome and Assessment Information Set-used to collect and report patient outcome data] on 5/15/25. Review of the OASIS documentation revealed question N0415 [related to high-risk medications] was answered incorrectly. RN # 4 indicated the patient was receiving an antiplatelet [prevents platelets from sticking together] rather than an anticoagulant at the time of admission. 5. Patient # 14 had a Start of Care [SOC] date of 5/14/25 with an admitting diagnosis of type 1 diabetes mellitus without complications. Review of the Plan of Care for the certification period 5/14/25-7/12/25 revealed no antipsychotic medication on the POC. Review of the clinical record revealed PT [physical therapist] 7 completed the SOC OASIS [The Outcome and Assessment Information Set-used to collect and report patient outcome data] on 5/14/25. Further review of the OASIS documentation revealed question N0415 [related to high-risk medications] was answered incorrectly. PT # 7 indicated the patient was ordered/receiving an antipsychotic medication at the time of admission. 6. Patient # 15 had a Start of Care [SOC] date of 5/19/25 with an admitting diagnosis of type 2 diabetes mellitus with hyperglycemia [high blood sugar]. Review of the Plan of Care [POC] for the certification period 5/19/25-7/17/25 revealed the patient was not ordered an opioid. PT [physical therapist] # 7 completed the SOC OASIS [The Outcome and Assessment Information Set-used to collect and report patient outcome data] on 5/19/25. Review of the OASIS documentation revealed question N0415 [related to high-risk medications] was answered incorrectly. PT # 7 indicated the patient was receiving an opioid at the time of admission. 7. Patient # 17 had a Start of Care [SOC] date of 6/2/25 with an admitting diagnosis of pressure ulcer of sacral [lower back] region, stage 4 [full thickness tissue loss with exposed bone, tendon or muscle]. Review of the Plan of Care for the certification period 6/2/25-7/31/25 revealed the patient was ordered tramadol [opioid] 30 mg three times per day. Review of the SOC OASIS [The Outcome and Assessment Information Set-used to collect and report patient outcome data] revealed RN [registered nurse] # 4 completed the OASIS on 6/2/25. Further review of the OASIS documentation revealed question N0415 [related to high-risk medications] was answered incorrectly. RN # 4 failed to capture the tramadol [opioid] when answering the question.”

“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 direct observation and staff interviews the agency failed to ensure clinicians used proper infection control practices during 3 of 7 home visits [#6, 9, and 12]. The findings included: 1. Patient # 6 had a Start of Care date of 4/3/25 with an admitting diagnosis of type 2 diabetes mellitus with foot ulcer. Review of the Plan of Care for the certification period 6/2/25-7/31/25 included orders for SN [skilled nursing] 3 times a week for 8 weeks, 2 times a week for 1 week. A supplemental order was noted on 6/2/25 to “Cleanse left top foot with anasept or dakin’s ¼ strength...apply black foam...cover with transparent occlusive draping. Attach trac pad. Set continuous suction at 125 mmhg...” On 6/16/25 at approximately 11:30 am a joint visit was made with RN # 4. During the visit the RN completed wound care/negative pressure wound therapy to the left foot. RN # 4 donned gloves and initiated the dressing change. During the dressing change the wound on the left foot had a moderate amount of bloody drainage. The RN removed 4x4’s from the large pack of 4x4’s noted to be located on the patient’s table several times wearing the same gloves as wiping away bloody drainage. After placing the wound vac on, RN # 4 requested the patient pass the tubing attached to the canister to the RN. The tubing attached to the canister had been laying on the patient’s floor. The RN then connected the tubing attached to the canister to the tubing attached to the trac pad without wiping the tubing with an alcohol prep. During an interview with the agency director and the accreditation coordinator on 6/19/25 at 11:30 am, it was confirmed RN # 4 failed to practice acceptable infection control related to the dressing change. 2. Patient # 9 had a Start of Care date of 6/4/25 with an admitting diagnosis of unspecified fracture third lumbar [lower back] vertebra [forms the spine]. Review of the Plan of Care [POC] for the certification period 6/4/25-8/2/25 included orders for PT [physical therapy] 1 time a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 2 weeks. On 6/17/25 at approximately 2:30 pm, a joint visit was conducted with PT # 2. At the conclusion of the visit, PT # 2 donned clean gloves and proceeded to wipe vital signs equipment down with alcohol prep pads. After wiping equipment down with the pads, still wearing the same gloves, PT # 2 opened the container of disinfection wipes by removing the lid. She then placed her gloved hand into the container to attempt to thread the wipes into the top of the lid. During an interview with RN # 5, who was present for the visit, it was confirmed PT # 2 failed to use proper infection control techniques by placing gloved hand into the wipes container after wiping vital sign equipment down with the alcohol prep pad using the same gloved hand. 3. Patient # 12 had a Start of Care date of 6/3/25 and an admitting diagnosis of encounter for surgical aftercare following surgery on the digestive system. Review of the Plan of Care [POC] for the certification period 6/3/25-8/1/25 included orders for SN [skilled nursing] 1 time a week for 1 week with a supplemental order for 1 time a week 4 weeks. On 6/18/25 at 3 pm a joint visit was made with RN # 3. During the joint visit RN # 3 obtained an INR [International Normalized Ratio-a blood test that measures how long it takes for a person’s blood to clot] reading via finger stick using an INR test meter. After performing the finger stick for the test, RN # 3 was noted to place the used test strip [blood noted on the strip] into a sharps container which was placed in the clean section of the nursing bag. The sharps container was stored in the same section of the bag as clean gloves. During an interview with RN # 5, who was present for the visit, it was confirmed RN # 3 did not use proper infection control practices by storing the sharps container inside the clean section of the nursing bag.”

“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 agency policy review, home visit observations, clinical record review, and interviews with staff/patients/caregivers the plan of care failed to include all the current/correct medications the patient was taking for 3 of 7 home visits [#7, 9 and 12]; and the plan of care failed to include weight loss parameters for 1 of 1 patients with a diagnosis of severe protein-calorie malnutrition [a form of malnutrition characterized by a significant deficiency in protein and calorie intake, leading to weight loss and muscle wasting] [#16]. The findings included: The policy, Medication Reconciliation [revised 8/7/24], was provided by the accreditation coordinator on 6/18/25 at 3:44 pm. The policy stated, “At time of comprehensive assessment, the clinician will create and document a complete list of medications...The medication list/profile will be revised with each new, changed, or discontinued medication...” 1. Patient # 7 had a Start of Care date of 3/21/15 with an admitting diagnosis of pressure ulcer of left ankle-stage 2 [partial thickness skin loss involving the dermis]. Review of the Plan of Care [POC] for the certification period 5/20/25-7/18/25 included orders for SN [skilled nursing] 2 times a week for 1 week, 3 times a week for 7 weeks, 2 times a week for 1 week and “skilled nurse to review medication profile and reconcile medications as needed...” On 6/16/25 at approximately 1:30 pm, a joint visit was made with LPN # 1. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: The patient presented a bottle of magnesium [supplement] 400 mg. The patient reports taking 1 tablet each day and states she has been taking the magnesium “about a month or so”. The medication profile provided by the agency did not include magnesium. The medication profile listed Trintellix [antidepressant] 10 mg daily. The patient reports the last time she saw the provider, she was told she could take 20 mg each day. LPN # 1 confirmed during the visit that the POC did not include all the current medications the patient was taking. 2. Patient # 9 had a Start of Care date of 6/4/25 with an admitting diagnosis of unspecified fracture third lumbar [lower back] vertebra [forms the spine]. Review of the Plan of Care [POC] for the certification period 6/4/25-8/2/25 included orders for PT [physical therapy] 1 time a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 2 weeks and “Therapist to monitor and follow up regarding management of medications”. On 6/17/25 at approximately 2:30 pm a joint visit was made with PT # 2. During the visit a medication review was completed using a medication profile provided by the agency. The following discrepancies were noted: The patient reported taking the following medications since before her admission to home health: Ferrous sulfate [iron supplement] 325 mg each day, nifedipine [blood pressure] 90 mg each day and donepezil [used to treat Alzheimer’s disease] 10 mg at bedtime. None of the previous medications were included on the POC. During an interview with PT # 2 she confirmed the POC did not include all the medications the patient was using. 3. Patient # 12 had a Start of Care date of 6/3/25 and an admitting diagnosis of encounter for surgical aftercare following surgery on the digestive system. Review of the Plan of Care [POC] for the certification period 6/3/25-8/1/25 included orders for SN [skilled nursing] 1 time a week for 1 week with a supplemental order for 1 time a week 4 weeks. On 6/18/25 at 3 pm a joint visit was made with RN # 3. During the joint visit a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: Metoprolol Tartrate [blood pressure] 50 mg 2 times a day was listed on the medication profile. During an interview with the patient, the patient reported, “I only take ½ of a pill in the morning and ½ in the evening. The doctor changed it a couple weeks ago.” During an interview with RN # 3 it was confirmed the POC did not include all the correct medications the patient was taking. 4. Patient # 16 had a Start of Care date of 5/17/25 with an admitting diagnosis of unspecified severe protein-calorie malnutrition [a form of malnutrition characterized by a significant deficiency in protein and calorie intake, leading to weight loss and muscle wasting]. Review of the Plan of Care [POC] for the certification period 5/17/25-7/15/25 included orders for SN [skilled nursing] 1 time a week for 1 week, 3 times every 2 weeks for 2 weeks, 2 times a week for 2 weeks, 1 time a week for 4 weeks and “...monitor weight and report weight gain of 3 pounds in 24 hours or 5 pounds in a week...” Further review of the POC revealed the following documentation, “...She presented to the ED [emergency department] at _________ [name of ED] ...Patient was severely malnourished with a weight of 72 pounds per patient...” Review of the clinical record revealed, at the time of admission, a weight of 122 pounds was documented by RN # 8. On 5/20/25 the patient weighed 116 pounds. On 5/26/25 the RN documented a weight of 112 pounds. On 6/9/25 the patient weighed 100.5 pounds. During an interview with the agency director on 6/19/25 at approximately 12 pm, it was confirmed the POC should have included weight loss parameters based on the comprehensive assessment findings.”