Medi Home Health and Hospice

“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 agency policy, direct observation, and staff interviews the SN [skilled nurse] failed to ensure the nursing bag was closed after removing equipment for the visit for 3 of 6 home visits #6, 7, and 10]; and failed to perform hand hygiene for 2 of 6 patients who received home visits [# 7 and 10]; and failed to place wound care supplies on a barrier for 1 of 2 home visits [#7]; and failed to place syringes/needle used to obtain blood and a syringe full of wasted blood [first blood sample obtained from PICC [type of catheter used to access the large veins in your chest] line is discarded] in a proper receptacle for 1 of 1 patient having PICC line [# 9]. The findings included: 3. Patient #10 had a start of care date of 04/12/2024 with admitting diagnoses of pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time) of left buttock, stage 3 (full thickness skin loss), chronic obstructive pulmonary disease ( a group of lung diseases that block airflow and make it difficult to breathe), chronic atrial fibrillation (an irregular heart rate), pulmonary hypertension (a type of high blood pressure that affects arteries in the lungs and in the heart), peripheral vascular disease (narrowed blood vessels reduce blood flow to the limbs), venous insufficiency (a condition in which the veins fail to return blood efficiently to the heart). Review of the Plan of Care for certification period 06/11/2024-08/09/2024 revealed orders for SN (skilled nursing) 1 time a week for one week, effective 06/11/2024, and two times a week for eight weeks effective 06/17/2024, with four PRN (as needed) visits effective 06/11/2024. The plan of care also included orders for the left buttock to clean with Anasept (skin and wound cleanser) and gauze, apply Prisma (a dressing that creates a moist wound bed and supports wound healing) to wound bed and cover with border foam dressing (a foam dressing that absorbs fluid that leaks out of tissue), change every 2-3 days and PRN for soiling/coming off. On 7/16/24 at 12:30 pm a joint visit was conducted with the Registered Nurse (Employee #4), to observe wound care provided to the patient (Patient #10). During the visit, Employee #4 donned a pair of clean gloves from the nursing bag. Employee #4 removed the old dressing from the wound and removed the gloves. Employee #4 placed a clean pair of gloves on and did not use hand sanitizer between glove changes. In speaking with Employee #4, she was aware that she needed to use hand sanitizer when removing gloves. During an interview with Employee #1 and Employee #2 on 7/17/24 at approximately 1:00 pm, they confirmed Employee #4 should have used hand sanitizer after removing dirty gloves. 4. Patient #10 had a start of care date of 04/12/2024 with admitting diagnoses of pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time) of left buttock, stage 3, chronic obstructive pulmonary disease, chronic atrial fibrillation, pulmonary hypertension, peripheral vascular disease, venous insufficiency. Review of the Plan of Care for certification period 06/11/2024-08/09/2024 revealed orders for SN (skilled nursing) 1 time a week for one week, effective 06/11/2024, and two times a week for eight weeks effective 06/17/2024, with four PRN (as needed) visits effective 06/11/2024. The plan of care also included orders for the left buttock to clean with Anasept (skin and wound cleanser) and gauze, apply Prisma (a dressing that creates a moist wound bed and supports wound healing) to wound bed and cover with border foam dressing (a foam dressing that absorbs fluid that leaks out of tissue), change every 2-3 days and PRN for soiling/coming off. On 7/16/24 at 12:30 pm a joint visit was conducted with Employee #4, to observe wound care provided to the patient (Patient #10). During the visit, Employee #4 retrieved supplies for the visit out of her home health bag and kept the home health bag open during the entire visit. 5. Patient #9 had a start of care date of 06/20/2024 with admitting diagnoses of osteomyelitis (inflammation of bone caused by infection) of vertebrae ( a series of small bone forming the backbone), cervical region (the neck region of your spinal column or backbone), intraspinal abscess (a buildup of pus in the spine caused by infection) and granuloma ( a tiny cluster of white blood cells and other tissue), retropharyngeal and parapharyngeal abscess (infection in the lymph nodes behind the throat and a deep neck infection), extrapyramidal movement disorder (involuntary movements you cannot control), Stiff-man Syndrome (a rare neurological disorder with symptoms of muscle stiffness), type I diabetes mellitus with hyperglycemia, type 1 diabetes mellitus ( a disorder in which the body does not produce enough insulin or respond normally to insulin, that result in too much sugar in the blood) with diabetic neuropathy (nerve damage that can occur with diabetes), and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). Review of the Plan of Care for certification period 06/20/2024-08/18/2024 revealed orders for SN (skilled nursing) one time a week for nine weeks, with 3 PRN (as needed) visits and “SN for IV (intravenous) line care, labs weekly, education on meds and disease process”. A visit was conducted with the Registered Nurse (Employee #3) at the patient’s home on 7/16/24 at 9:20 am. The RN was visiting to perform PICC line (one type of catheter used to access the large veins in your chest) care, dressing change and venipuncture for lab work ordered by the physician. During the visit, the Registered Nurse was observed recapping the needle several times that was used to place blood into the blood collection tubes. The Registered Nurse did not have a sharps container (a container made of rigid plastic to ensure safe containment of sharp objects) available to place the used needle in and placed the recapped needle in a glove and carried it out of the patient’s home in the glove. During the patient visit, the Registered Nurse placed the syringe containing the blood waste from the PICC line directly on the counter and not on the barrier. At the end of the visit, the Registered Nurse carried the syringe containing the blood waste into the patient’s bathroom and disposed of the blood in the patient’s commode and flushed. The RN did not have a mask, eye protection, or a face mask to protect against splashing while disposing of the blood. An interview was conducted with Employee #1 and Employee #2 on 7/17/24 at 1:00 pm, both stated that employees are provided sharps container to dispose of syringes and non-penetrable containers to transport blood. The policy, Hand Hygiene HH4012 [6/24], was provided by the human resource director on 7/16/24 at 11:06 am. The policy stated, “...Indications for Hand Hygiene: Before and after having direct contact with the patient...Before and after use of gloves (or other PPE)…Before and after treatments/procedures...” The policy, Bag Technique HH4020 [6/24], was provided by the human resource director on 7/16/24 at 11:06 am. The policy stated, “...After performing hand hygiene, all the clean supplies and equipment needed for the visit are moved from the bag. The bag is then closed...” Review of the CDC [Centers for Disease Control] best practice guidelines related to sharps container use revealed the following information, “ immediately place the connected needle and syringe into the sharps disposal container. Place contaminated dressings, gauze, cotton materials, tubing, and contaminated cleanup items in biohazard waste disposal bags. Place uncontaminated non-sharps in a standard trash can”. 1. Patient # 6 had a start of care date of 6/22/24 with admitting diagnoses of encounter for orthopedic aftercare following surgical amputation and type 2 diabetes with diabetic polyneuropathy [condition that affects nerves in diabetics]. Review of the plan of care for the certification period 6/22/24-8/20/24 included orders for SN [skilled nursing] 1 time a week for 5 weeks and “SN to obtain wound measurements weekly...Cleanse the wound with wound cleanser daily, apply xeroform to the incision site, wrap with kerlix and ace wrap using figure 8 method. On 7/15/24 at approximately 4 pm, a joint visit was conducted with RN # 7 to observe wound care. After arriving in the patient’s home, the RN placed the nursing bag on a barrier and removed the vital sign equipment. The vital sign equipment was placed on the barrier. The RN failed to close the nursing bag and the nursing bag remained open the entire visit. During an interview with RN # 1 on 7/17/24 at approximately 1 pm, the RN confirmed the nursing bag should have been zipped up after removing the equipment. 2A. Patient # 7 had a start of care date of 4/14/24 and admitting diagnoses of unspecified severe protein-calorie malnutrition, pneumonia, unspecified open wound right lower leg, and unspecified open wound, left lower leg. Review of the plan of care [poc] for the certification period 6/15/24-8/13/24 included orders for SN [skilled nursing] 1 time a week for 9 weeks and “RLE [right lower extremity] trauma wounds clean with anesept, pry dry, apply xeroform, gauze to wound bed...” On 7/15/24, at approximately 3 pm, a joint visit to observe wound care was conducted with LPN # 6. During the visit, the LPN was noted to wash hands upon arrival to the patient’s home. The LPN applied gloves to do the dressing change. After removing the old dressings, the LPN removed the gloves. After removing the old gloves, she applied a new pair of gloves to clean the wounds. She did not do hand hygiene with hand sanitizer. After cleaning the wounds, she removed the old gloves and applied new gloves. She did not use hand sanitizer. During an interview with RN # 1 on 7/17/24 at approximately 1 pm, the RN confirmed the LPN should have used hand sanitizer each time she removed a used pair of gloves. 2B. Patient # 7 had a start of care date of 4/14/24 and admitting diagnoses of unspecified severe protein-calorie malnutrition, pneumonia, unspecified open wound right lower leg, and unspecified open wound, left lower leg. Review of the plan of care [poc] for the certification period 6/15/24-8/13/24 included orders for SN [skilled nursing] 1 time a week for 9 weeks. On 7/15/24, at approximately 3 pm, a joint visit to observe wound care was conducted with LPN # 6. Upon entering the patient’s home, LPN # 6’s nursing bag was unzipped. The LPN placed the nursing bag on a barrier. LPN # 6 removed vital sign equipment and placed it on the barrier. The nursing bag remained open the entire visit. During an interview with RN # 1 on 7/17/24 at approximately 1 pm, the RN confirmed the nursing bag should have been zipped shut after removing the equipment needed for the visit.”

“Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This Standard is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews the SN [skilled nurse] failed to initial/weekly wound measurements for 2 of 4 patients with a wound [ #1 and 6]; and failed to place wound care supplies on a barrier for 1 of 3 home visits receiving wound care [#7]; and failed to use an unused syringe/needle when transferring a blood sample to a blood collection tube for several samples [#9];and failed to clean PICC [a long, flexible plastic tube that’s inserted into a vein in the upper arm and threaded into a large vein above the heart used for long term medication or to obtain blood] line insertion site correctly when doing a PICC line dressing change for 1 of 1 patients [#9]. The findings included: 5. Patient #9 had a start of care date of 06/20/2024 with admitting diagnoses of osteomyelitis (inflammation of bone caused by infection) of vertebrae ( a series of small bone forming the backbone), cervical region (the neck region of your spinal column or backbone), intraspinal abscess (a buildup of pus in the spine caused by infection) and granuloma ( a tiny cluster of white blood cells and other tissue), retropharyngeal and parapharyngeal abscess (infection in the lymph nodes behind the throat and a deep neck infection), extrapyramidal movement disorder (involuntary movements you cannot control), Stiff-man Syndrome (a rare neurological disorder with symptoms of muscle stiffness), type I diabetes mellitus with hyperglycemia, type 1 diabetes mellitus ( a disorder in which the body does not produce enough insulin or respond normally to insulin, that result in too much sugar in the blood) with diabetic neuropathy (nerve damage that can occur with diabetes), and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). Review of the Plan of Care for certification period 06/20/2024-08/18/2024 revealed orders for SN (skilled nursing) one time a week for nine weeks, with 3 PRN (as needed) visits. Per Plan of Care, “SN for IV (intravenous) line care, labs weekly, education on meds and disease process”. A visit was conducted with the Registered Nurse (Employee #3) at the patient’s home on 7/16/24 at 9:20 am. The RN was visiting to perform the PICC line dressing change and venipuncture for lab work ordered by the physician. During the PICC line dressing change, the nurse cleaned the pick line insertion area using a scrubbing motion as opposed to an outward circular motion. The policy, Wound Care Standards [8/23], was provided by the human resource director on 7/16/24 at 11:06 am. The policy stated, “...Any patient with an open area will have the sites measured and documented weekly...” The policy, Central Venous Catheters and Midline Catheters, last revised 2/2023, received from Human Resources 7/16/24 at 11:06 am, stated “open the package of one alcohol swab stick. Clean the area, beginning at the insertion site and working in an outward circular motion about 3 inches (this removes natural oils from the patient’s skin).” 1. Patient # 1 had a Start of Care date of 6/11/24 with admitting diagnoses of copd [chronic obstructive pulmonary disease-lung disease making it difficult to breath], atrial fibrillation [abnormal heart rhythm], heart failure, type 2 diabetes without complications, pressure ulcer right buttock, stage 2 [shallow open wound that indicates partial thickness loss of the skin’s epidermis and dermis], and pressure ulcer left buttock, stage 2. Review of the plan of care [POC] for the certification period 6/11/24-8/9/24 included orders for SN [skilled nursing] 2 times a week for 2 weeks, 1 time a week for 7 weeks and “SN to apply zinc barrier cream to stage 2 on buttocks...” Review of the clinical record revealed the SN made routine visits on 6/13/24, 6/19/24, 6/21/24, 6/26/24, 7/2/24. There were no wound measurements noted in 5 of 5 SN visits. During an interview with RN # 1 on 7/17/24 at approximately 1 pm, RN # 1 confirmed the SN failed to measure the stage 2 decubitus. 2. Patient # 6 had a start of care date of 6/22/24 with admitting diagnoses of encounter for orthopedic aftercare following surgical amputation and type 2 diabetes with diabetic polyneuropathy [condition that affects nerves in diabetics]. Review of the plan of care for the certification period 6/22/24-8/20/24 included orders for SN [skilled nursing] 1 time a week for 5 weeks and “SN to obtain wound measurements weekly...Cleanse the wound with wound cleanser daily, apply xeroform to the incision site, wrap with kerlix and ace wrap using figure 8 method...” Review of the clinical record revealed SN visits on 6/22/24, 6/27/24, 7/5/24, 7/11/24, 7/15/24. Review of the documentation for the visits revealed no wound measurements for 5 of 5 SN visits. During an interview with RN # 1 on 7/17/24 at approximately 1 pm, the RN confirmed the SN failed to obtain wound measurements. 3. Patient # 7 had a start of care date of 4/14/24 and admitting diagnoses of unspecified severe protein-calorie malnutrition, pneumonia, unspecified open wound right lower leg, and unspecified open wound, left lower leg. Review of the plan of care [poc] for the certification period 6/15/24-8/13/24 included orders for SN [skilled nursing] 1 time a week for 9 weeks and “RLE [right lower extremity] trauma wounds clean with anesept, pry dry, apply xeroform, gauze to wound bed...” On 7/15/24, at approximately 3 pm, a joint visit to observe wound care was conducted with LPN # 6 . During the visit, the LPN placed the barrier for her nursing bag on the floor to the left of the patient. The LPN placed plastic bags with wound care supplies directly on the floor without a barrier. During the visit the gauze wrapping came out of the bag and was directly on the floor. The LPN continued with the wound care, using the gauze that was on the floor. During an interview with RN # 1 on 7/17/24 at approximately 1 pm, the RN confirmed the wound supplies should have been on a barrier and the LPN should not have used the rolled gauze that was on the floor. 4. Patient # 9 had a start of care date of 6/20/24 with admitting diagnoses of osteomyelitis [infection of the bone] and stiff man syndrome [progressive neurological disorder that causes muscle stiffness and spasms]. Review of the plan of care for the certification period 6/20/24-8/18/24 included orders for SN [skilled nursing] 1 time a week for 9 weeks and “...SN to obtain labs per orders via PICC [peripherally inserted central catheter used to obtain blood or administer medication over a period of time] …obtain weekly on Monday or Tuesday...” On 7/16/24 at approximately 9:20 am a joint visit was conducted with RN # 3 to observe PICC line care. During the visit RN # 3 was noted to be obtaining blood for the lab sample using a 10 cc syringe and then transferring the blood into the blood tubes using a large bore needle. The RN accessed the PICC line numerous times [3-4] using the same syringe and transferring the blood sample into collection tubes with the same needle. During an interview with RN # 1 on 7/17/24 at approximately 1 pm, the RN confirmed RN # 3 should not have consistently used the same syringe to obtain the blood sample or the same needle to transfer the blood.”

“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, clinical record review, direct observation, and staff interviews the agency failed to obtain orders for wound care for 3 of 4 patients with a wound [#1, 7 and 10]. The findings included: 3. Patient #10 had a start of care date of 04/12/2024 with admitting diagnoses of pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time) of left buttock, stage 3 (full thickness skin loss), chronic obstructive pulmonary disease ( a group of lung diseases that block airflow and make it difficult to breathe), chronic atrial fibrillation (an irregular heart rate), pulmonary hypertension (a type of high blood pressure that affects arteries in the lungs and in the heart), peripheral vascular disease (narrowed blood vessels reduce blood flow to the limbs), venous insufficiency (a condition in which the veins fail to return blood efficiently to the heart). Review of the Plan of Care for certification period 06/11/2024-08/09/2024 revealed orders for SN (skilled nursing) 1 time a week for one week, effective 06/11/2024, and two times a week for eight weeks effective 06/17/2024, with 4 PRN (as needed) visits effective 06/11/2024. The plan of care also included orders for the left buttock to clean with Anasept (skin and wound cleanser) and gauze, apply Prisma (a dressing that creates a moist wound bed and supports wound healing) to wound bed and cover with border foam dressing (a foam dressing that absorbs fluid that leaks out of tissue), change every 2-3 days and PRN for soiling/coming off. On 7/16/24 at 12:30 pm a joint visit was conducted with the Registered Nurse (Employee #4), to observe wound care provided to the patient (Patient #10). During the visit, The RN completed wound care to the patient’s left buttock in accordance to the Plan of Care. The RN assessed the patient’s skin and observed a pressure ulcer to the patient’s right buttock and completed wound care to the right buttock. The RN cleaned the right buttock wound with Anasept and gauze, applied Prisma, and covered it with a border foam dressing. A review of the clinical record revealed no physician’s order for wound care to the right buttock. During an interview with Employee #1 and Employee #2 on 07/17/24 at approximately 1:00 pm, Employee #2 confirmed the RN completed wound care to the right buttock without a physician’s order. The policy, Physician Telephone/Verbal Orders HH2018 [3/24] was provided by the agency administrator on 7/17/24 at 8:30 am. The policy stated, “______[name of agency] provides care, treatment and/or services to patients according to a physician’s or licensed practitioners most recent order...” 1. Patient # 1 had a Start of Care date of 6/11/24 with admitting diagnoses of copd [chronic obstructive pulmonary disease-lung disease making it difficult to breath], atrial fibrillation [abnormal heart rhythm], heart failure, type 2 diabetes without complications, pressure ulcer right buttock, stage 2 [shallow open wound that indicates partial thickness loss of the skin’s epidermis and dermis], and pressure ulcer left buttock, stage 2. Review of the plan of care [POC] for the certification period 6/11/24-8/9/24 included orders for SN [skilled nursing] 2 times a week for 2 weeks, 1 time a week for 7 weeks and “SN to apply zinc barrier cream to stage 2 on buttocks...apply zinc barrier cream to affected area bilateral groins...” Review of the clinical record revealed on 6/13/24 RN # 5 conducted a routine visit and documented the following information, “...Rt [right] groin...area cleaned and antifungal applied...left groin...area cleaned and antifungal applied...buttocks...optifoam applied to open area...”Further review of the clinical record revealed on 6/19/24 and 6/21/24 RN # 5 documented “antifungal applied to bilateral groin”. During an interview with RN # 1 on 7/17/24 at approximately 1pm, the RN confirmed there was no physician’s order for an optifoam or antifungal cream. 2. Patient # 7 had a start of care date of 4/14/24 and admitting diagnoses of unspecified severe protein-calorie malnutrition, pneumonia, unspecified open wound right lower leg, and unspecified open wound, left lower leg. Review of the plan of care [poc] for the certification period 6/15/24-8/13/24 included orders for SN [skilled nursing] 1 time a week for 9 weeks. On 7/15/24, at approximately 3 pm, a joint visit was conducted with LPN # 6 . During the visit, the patient expressed a fall earlier which resulted in 4 new skin tears. The new skin tears were on the bilateral lower legs, right upper arm, and right shoulder. During the visit, the LPN applied a dry dressing. Review of the clinical record revealed no order for a dry dressing. The clinical record revealed the LPN sent a communication note to the physician after the visit asking for wound care orders. During an interview with RN # 1 on 7/17/24 at approximately 1 pm, the RN confirmed the LPN applied the dry dressing without a physician’s order.”

“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 policy review, client record review, and staff interview the agency failed to provide accurate home health aide supervision for 1 of 3 home health aide records reviewed (#8). Findings included: Review of policy “Clinical Supervision HH2036”, revised 11/2023 was received from agency administrator on 07/17/24 at 8:30 a.m. The policy stated,” …shall be supervised by a qualified staff member at least, but not to exceed, every 14 days as specified in the Conditions of Participation…” Patient #8 had a SOC (start of care) of 06/08/24 and included diagnoses of major depressive disorder, atrial flutter, hypertensive heart disease, heart failure, and unspecified hearing loss. Home health aide orders were for 1 time a week for 8 weeks. Review of the weekly home health aide visits revealed a supervisory visit was completed on 06/07/24 by the registered nurse and was not completed again until 07/15/24. Interview with agency administrator on 07/17/24 at 1:51 p.m. revealed, “the aide supervisory visit should have been completed by 07/12/24, we were out of compliance on that one”.”