Interim Healthcare

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on record review, policy and procedure review, and staff interview, the agency failed to ensure the patient’s medication orders on the Plan of Care and the medication profile (a real-time document used by the agency that lists the patient’s medications) were accurate for 1 or 5 patient records reviewed (Patient 4). The total sample size was 5. The census was 160. Findings are: A. Review of the agency’s policy and procedure titled Initial Comprehensive Assessment, dated 4/2/21, revealed: 1. The comprehensive assessment was to accurately reflect the individual’s status at the time of the assessment. 2. The assessment may include gathering information from a variety of sources, including discharge information and orders from a facility. B. Review of the agency’s policy and procedure titled Plan of Care and Revision to Plan of Care Requirements for Medications and Treatments, dated 1/5/21 revealed, the Registered Nurse (RN) was to include all prescription medications and over the counter medications on the clients [sic] plan of care. C. Transfer orders from Southlake Village to the agency, dated 6/20/24, included orders for: 1. Simvastatin (a medication to treat high cholesterol), 40 (mg), 0.5 tablet, orally, at bedtime. 2. Carboxymethylcellulose Sodium Ophthalmic Solution (a medication to treat dry and itching eyes), 0.5%, 1 drop in both eyes, 4 times daily (QID) as needed (PRN), for dry eyes. D. Review of Patient 4’s clinical record revealed: 1. The Home Health Certification and Plan of Care (POC) for the certification period 6/25/24 through 8/23/24, and the Patient’s medication profile, included: a. Simvastatin, 40 milligrams (mg),1 tab, orally, at bedtime. b. Carboxymethylcellulose Sodium Ophthalmic Solution 0.5%, 1 drop, Ophthalmic (related to the eyes), once a day PRN for itching. E. During an interview on 8/8/24 at 3:30 PM, the Director of Health Care Services confirmed, Patient 4’s medication orders on the POC and the medication profile did not match the transfer orders from Southlake Village.”

“Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on record review, policy and procedure review, and staff interview, the agency failed to obtain required information from an emergency department (ED) visit for 7/2/24, failed to update the physician of a patient fall, and failed to follow up with the prescribing practitioner to ensure accuracy of a medication order for 1 of 1 patient (Patient 5). The total sample size was 5. The census was 160. Findings are: A. Review of the agency’s policy and procedure titled Coordination of Care/Services, dated 4/2/21, revealed: 1. There was to be regular communication with the patient/client and with others providing patient/client care services. 2. Skilled Professionals who provide services to the patient, directly or under arrangement, participate in the coordination of care. 3. Employees were to coordinate patient/client care/services from admission to discharge. 4. The Clinical Manager was to coordinate care/services among all disciplines involved in the care of the patient/client. 5. The Clinical Manger was to ensure coordination of care/service and ongoing interdisciplinary assessment of the patient, including medication name, dosage, and frequency. 6. The Clinical Manager was to confer with the patient’s caregiver and the patient’s physician when there was a change in the patient’s/client’s condition, when the patient’s /client’s response to care/treatments is not as expected, and when changes in the patient’s/client’s environment impacts the plan of care service plan. 7. The agency was to coordinate care delivery to meet the patient’s needs, and involve the patient, the patient representative, and caregivers, in coordination of care activities. B. Review of the agency’s policy and procedure titled Plan of Care and Revisions to the Plan of Care Requirement for Medications and Treatments, dated 1/5/21, revealed: 1. Changes or additions of any medication during the home health care episode were to be reported to the office staff. 2. The Clinical Manager was to ensure the plan of care was created and revised when there were changes or additions of any medications, update the medication list in the electronic medical record, and update the home health medication addendum on the clients [sic] care plan if applicable. C. Review of Patient 5’s Home Health Certification and Plan of Care (POC) for certification date 6/14/24 through 8/12/24 included orders for Skilled Nursing (SN) 3 times weekly for wound care. D. Review of the agency’s internal email notes revealed: 1. On 6/19/24, the patient was admitted to the hospital due to a fall. 2. On 6/21/24, the patient was to be discharged from the hospital either on 6/21/24 or 6/22/24. SN will resume services and Physical Therapy (PT) and Occupational Therapy (OT) will be added when the patient returns home. 3. On 6/24/24, SN services were resumed. 4. On 6/25/24, PT evaluated the patient and planned to see 2 times a week x 3. 5. On 6/26/24, OT evaluated the patient and planned to see 1 time a week x 3. 6. On 7/3/24, at 1:28 PM, the Assist Living Facility (ALF) staff reported to the agency’s physical therapy assistant (PTA), the patient had an unwitnessed fall on 7/2/24 during the night and was transferred to the Emergency Department (ED). The agency failed to request an ED note for the patient visit on 7/2/24, and failed to update the physician of the patient’s fall on 7/2/24. E. Review of a SN visit note, dated 7/5/24, revealed: 1. The patient was having severe pain in right rib area. 2. The ALF staff reported the patient had a fall a few days prior to SN visit. 3. The ALF staff had faxed the patient’s physician for pain medication orders. The agency failed to follow up to confirm if pain medication was ordered on 7/5/24, failed to request an ED note for the patient visit on 7/2/24, and failed to notify the physician of the patient fall on 7/2/24. F. Review of an office visit note, dated 7/9/24, revealed: 1. The patient was seen by an Advanced Practice Registered Nurse (APRN) for a follow up for the 7/2/24 ED visit due to a fall. 2. The APRN prescribed Tramadol (medication to treat moderate to severe pain) 50 mg, 1 tablet, orally, every 6 hours PRN for pain, on 7/8/24. The agency failed to obtain information for the 7/2/24 APRN office visit until 8/8/24. G. During an interview on 8/8/24 at 3:30 PM, the Director of Health Care Services confirmed, the agency failed to follow their policies and procedures to request the ED note for Patient 5’s visit on 7/2/24, to update the physician of Patient 5’s fall on 7/2/24, and to ensure accuracy of medication orders for Patient 5.”

“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 record review, policy and procedure review, observation of the provision of cares, and staff interview, the agency failed to ensure 7 of 7 staff (Staff C, D, E, F, G, H, and I), observed during the provisions of care to 7 of 7 patients (Patients 1, 2, 3, 4, 5, 6, and 7) , performed proper hand hygiene, cleaning of equipment, and/or bag technique according to the agency’s policies and procedures. The sample size was 17. The census was 160. Findings are: A. Review of the agency policy and procedure, titled, Handwashing, no date indicated, revealed: 1. When washing hands at the sink, staff are to dry hands with a paper towel and turn off the faucet with a paper towel. 2. Handwashing was to be performed when entering and leaving the patient’s home, before obtaining supplies from the supply bag, and before applying and after removing gloves. The policy did not include washing hands after contact with contaminated items, after contact with bodily secretions, non-intact skin, or after handling soiled items. B. Review of the agency policy and procedure, titled, Equipment/Supply Bag Technique, effective date 3/13/2015, revealed: 1. The supply bag was to be placed on a clean, dry surface. A barrier was to be placed under the supply bag when a clean, dry surface is not visible. The supply bag was to be closed when not in use. 2. Hands were to be sanitized prior to entering the supply bag. 3. The inside of the supply bag and its contents are considered clean, and staff are to clean all items removed from the supply bag and before returning items to the bag. C. Review of the clinical records revealed: 1. Patient 1’s Home Health Certification and Plan of Care (POC), for the certification period 10/7/23 through 12/5/23, and 12/6/23 through 2/3/24, included orders for a Skilled Nurse (SN) 3 times per week to change wound vac dressing (vacuum-assisted device and dressing to promote wound healing) to right breast. 2. Patient 2’s POC, for the certification period 11/4/23 through 1/2/24, included orders for Physical Therapy (PT) 2 times per week for 2 weeks, then 1 time per week for 1 week, to assist with and teach home exercises to promote mobility. 3. Patient 3’s POC, for the certification period 11/29/23 through 1/27/24, included orders for Occupational Therapy (OT) 2 time per week for 2 weeks, then 1 time per week for 1 week, to assess ability/tolerance to perform activity of daily living (ADLs) and teach patient therapeutic exercises for upper body. 4. Patient 4’s POC, for the certification period 9/28/23 through 11/26/23, included orders for Home Health Aide (HHA) 1 to 3 visits per week, to assist with personal cares. 5. Patient 5’s POC, for the certification period 10/18/23 through 12/16/23, included orders for HHA 1 to 2 visits daily, to assist with medications. 6. Patient 6’s POC, for the certification period 10/2/23 through 11/30/23, and 12/1/23 through 1/29/24, included orders for SN 2 times per week, for skilled assessment and change urostomy bag and tubing (a bag and tubing used to drain urine from the bladder through an opening in the abdomen). 7. Patient 7’s POC, for the certification period 11/22/23 through 1/20/24, included orders for SN 3 times per week, for skilled assessment and perform wound cares to left lower extremity. D. The observation of the provision of cares to Patient 1, on 12/6/23 at 12:00PM, revealed Staff C failed to: 1. Sanitize hands prior to entering the supply bag to obtain supplies. 2. Clean supplies after use, and prior to placing the supplies back into the supply bag. 3. Close the supply bag when not in use during the visit. E. The observation of provision of cares to Patient 2, on 12/6/23 at 2:00 PM, revealed Staff D failed to: 1. Place the supply bag on a cleaned surface or barrier. 2. Sanitize hands prior to entering the supply bag to obtain supplies for patient use and prior to returning the supplies back into the supply bag. 3. Clean the oximeter (a device placed on a finger to measure oxygen level) that was retrieved from Staff D’s pants pocket prior to and after use on patient. 4. To clean the oximeter after removing it from Staff D’s pants pocket and prior to returning it to the supply bag. 5. Clean the tablet (electronic device used to document the visit) after documentation of the visit and signing by the patient and prior to returning it to the supply bag. 6. Close the supply bag when not in use during the visit. 7. Sanitize hands prior to leaving home. F. The observation of provision of cares to Patient 3, on 12/6/23 at 3:00 PM, revealed Staff E failed to: 1. Sanitize hands prior to entering the supply bag to obtain supplies for patient use and prior to returning the supplies back into the supply bag. G. The observation of provision of cares to Patient 4, on 12/11/23 at 9:25 AM, revealed Staff F failed to: 1. Place the supply bag on a cleaned surface or a barrier. 2. Use a paper towel to dry hands and to turn off faucet after washing hands at sink. H. The observation of provision of cares to Patient 5, on 12/7/23 at 11:15 AM, revealed Staff G failed to: 1. Place supply bag on cleaned surface or barrier. 2. Sanitize cell phone after use for documentation and prior to placing it into Staff G’s pants pocket. I. The observation of provision of cares to Patient 6, on 12/7/23 at 1:00 PM, revealed Staff H failed to: 1. Place supply bag and iPad for documentation on a cleaned surface or a barrier. 2. Sanitize hands prior to entering the supply bag to obtain supplies and prior to returning supplies to the supply bag after use. 3. Sanitize iPad after use for documentation and obtaining patient signature and prior to returning it to the supply bag. 4. Close the supply bag when not in use during the visit. 5. Sanitize hands prior to leaving the home. J. The observation of provision of cares to Patient 7, on 12/7/23 at 3 PM, revealed Staff I failed to: 1. Sanitize hands prior to returning supplies used during visit into the supply bag. 2. Remove gloves and sanitize hands prior to touching patient’s walker after assessing and touching the patient’s buttocks. 3. Sanitize hands after removing gloves and leaving the patient’s home. K. During an interview, on 12/6/23 at 2:40 PM, Staff D confirmed the inside of the supply bag was to be considered clean and has had training on the agency’s bag technique policy and procedure. L. During an interview, on12/11/23 at 11:00 AM, the Director of Nursing confirmed that Staff C, D, E, F, G, H, and I failed to follow the agency’s policies and procedures for hand hygiene, cleaning of equipment and/or bag technique during the provision of cares to Patients 1, 2, 3, 4, 5, 6, and 7, respectively.”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on record review, policy and procedure review, and staff interview, the agency failed to ensure verbal orders received for patient care and services were documented on a physician order form or similar form to allow for physician validation and signature of the order for 2 of 17 clinical records reviewed (Patient 16 and Patient 17). The census was 160. Findings are: A. Review of the agency policy and procedure titled, Chapter 6: When Orders for Care/Services Are Required, copyright 2021, revealed when a qualified staff obtains a verbal order for care/services, the staff member was to complete a verbal physician’s order at the time the order was given. B. Review of the agency policy and procedure titled, Chapter 3: Entries Into the Patient/Client Record, copyright 2021, defines a verbal order as an order that is spoken to appropriate personnel and later put in writing for the purpose of documenting and revising the patient’s plan of care. It also required the physician’s order/verbal order to be sent to the physician for signature in a timely manner. C. Review of Patient 16’s clinical record revealed: 1. A Skilled Nurse (SN) Note dated 7/5/23 documented the physician was notified of a change in patient condition and the SN was waiting for a return call from the physician’s office. 2. An email communication note dated 7/5/23 to the patient’s care team reported the physician’s office returned the SN phone call and requested the patient go to the emergency room for evaluation. 3. There was no documentation a physician’s verbal order form was completed and sent to the patient’s physician for validation and signature of the verbal order given on 7/5/23. D. Review of Patient 17’s clinical record revealed: 1. The Home Health Certification and Plan of Care for the certification period of 7/20/23 through 9/17/23 included an order for hydrofera blue (a topical wound dressing) and mepilex (a non-stick form dressing) with Ace wrap to wound on left shin. 2. An email communication note dated 9/13/23 to the patient’s care team reported the nurse was using hydrofera blue, mepilex, and tubigrip (a type of compression sock) to two open blisters on the left foot. 3. An update dated 9/15/23, to the 9/13/23 email communication note, revealed the nurse was now using aquacel (a topical wound dressing) to the blisters on the left foot. 4. There was no documentation a physician’s verbal order form was completed and sent to the patient’s physician for validation and signature of the order indicated in the emails dated 9/13/23 and 9/17/23. E. During an interview on 12/13/23 at 1:00 PM, the Director of Nursing confirmed there was no documentation in the clinical record of a physician’s order/verbal order completed and sent to the patient’s physician for validation and signature for verbal orders received for Patient 16 and Patient 17.”