Medical Services of America Home Health

“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 observation, interview and policy review, the Home Health Agency (HHA) staff failed to follow standard precautions to prevent the spread of infection by failing to perform hand hygiene when doffing gloves, switching gloves between contaminated areas, using poor barrier technique, using poor bag technique, and sanitizing used equipment for 2 out of 7 patients (Patient #2, and #5). Patient #5’s (P5’s) wound care and dressing changes were observed during a home visit with Skilled Nurse 3 (SN3) on 4/2/24 at 10:05 AM. SN3 put on gloves and used a tape measure and pen to measure the wounds to P5’s lower legs (two on the left lower leg and three on the right lower leg). Then SN3 cleansed all of the wounds, cut open a dressing package, cutting the dressing into pieces and placed the pieces on the leg wounds. SN3 then grabbled the rolled gauze package, cut open a non-stick dressing package, and applied the nonstick dressing to the wounds and wrapped the legs in the rolled gauze. SN3 then removed the dressings to both the right and left forearms except for one that was stuck on the left forearm. SN3 did all of this with the same gloves on. SN 3 did not remove the gloves and perform hand hygiene after removing the soiled dressings. SN3 then removed the gloves, performed hand hygiene and put on clean gloves and removed the dressing that was stuck to the left forearm. With the same gloves on she/he cleansed the wound and applied a clean dressing. SN3 did not remove the gloves and perform hand hygiene after removing the soiled dressing. SN3 did not provide wound care to each wound separately. In an interview with SN3 at 11:00 AM, immediately after leaving P5’s home, she/he confirmed the findings. In an interview with the Administrator on 4/4/24 at 11:15 AM, she/he stated the nurse is “…supposed to change each dressing separately” and “remove gloves and alcohol” (hand sanitizer) after removing the soiled dressings. Findings included Observation in Patient #2’s home on 04/01/2024 from 3:45 PM to 4:45 PM showed Skilled Nurse (SN) #1 placing clean and dirty equipment on the same barrier, reaching into bag to retrieve scissors, gloves and tape wearing soiled gloves. During an interview on 04/04/2024 at 11:25 AM, Administrator stated agreement that proper technique was not performed.”

“Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This Element is not met as evidenced by: Based on record review and interview, the Home Health Agency (HHA) failed to provide proper written notice in advance of discharge for 2 of 5 records reviewed for discharge (Patients #9 and #10). Review of Patient #9’s (P9) record on 4/3/24 at 3:20 PM revealed P9 was admitted to the HHA on 11/16/23 with a diagnosis of pancreatitis (inflammation of the pancreas). The Home Health Certification and Plan of Care indicated P9 received Physical Therapy (PT) and Occupational Therapy (OT) services. The Discharge Summary indicated P9 was discharged on 1/15/24. There was no documented evidence provided prior to the notice that was given to P9 of the discharge. In an interview with the Administrator on 4/4/24 at 10:10 AM, she/he reviewed P9’s record and confirmed there was no prior notice of discharge given to P9 and she/he stated, “There should have been one.” She/he confirmed a Notice of Medicare Non-coverage (NOMNC) should have been provided to P9 no less than 48 hours before discharge. Review of Patient #10’s (P10) record on 4/3/24 at 3:37 PM revealed P10 was admitted to the HHA on 12/3/2023, with a diagnosis of atherosclerotic heart disease (thickening and hardening of the arteries). The Home Health Certification and Plan of Care indicated P10 received PT services. The Discharge Summary indicated P10 was discharged on 1/31/2024. There was no documented evidence that the discharge notice was provided to P10 prior to discharge. In an interview with the Administrator on 4/4/2024 at 10:13 AM, she/he reviewed P10’s record and confirmed there was no prior notice of discharge provided to P10. She/he confirmed a NOMNC should have been provided to P10 no less than 48 hours before discharge.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on interview and record review, the home health agency failed to provide assessments within 48 hours of physician orders for Start of Care (SOC) or Resumption of Care (ROC) for 4 out of 17 patients (Patient #2, #4, #16 and #17). Findings included Review of Patient #2’s medical record showed physician orders for Skilled Nurse (SN) dated 02/27/2024 for wound care evaluation. A SN evaluation is documented on 03/13/2024, 15 days after the physician order. During an interview on 04/04/2024 at 11:25 AM, the Administrator stated, “The delay could have been due to staffing”. Review of Patient #4’s medical record showed physician orders for Physical Therapy (PT) evaluation on the admission 485. PT evaluation for SOC was completed on 03/24/2024, with no documentation in the chart to explain the delay of 11 days. During an interview on 04/04/2024 at 11:45 AM,the Administrator stated, “The delay could have been due to staffing”. Review of Patient #16’s medical record showed Pt 16 was transferred to the hospital on 03/07/2024 with a ROC scheduled for 03/22/2024. Records showed the Registered Nurse (RN) called the caregiver to schedule the ROC visit on 03/22/2024 but the caregiver declined and requested the RN follow up with the patient’s granddaughter to schedule. The RN left a voice message with the granddaughter to return the call to schedule a visit. There is no further documentation of attempts to connect with the granddaughter. During an interview on 04/04/2024 at 11:56 AM, the Administrator stated, “The documentation should not have been listed as a missed visit and it would not have been forwarded to the scheduler”. Review of Patient #17’s medical record on 04/03/2024 showed a referral for home health service dated 02/08/2024. The initial assessment SOC by the PT was done on 02/14/2024. There is no documentation in the chart to explain the delay of 6 days. During an interview on 04/04/2024 at 12:05 PM, the Administrator verified the findings.”

“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 observations, interviews and record reviews the home health agency (HHA) failed to ensure the patient medication lists were updated and accurate for 3 of 7 home visits reviewed for medications (Patients #2, #3, #4 and #7). During a home visit to Patient #7 (P7) with skilled nurse 4 (SN4) on 4/3/24 at 8:30 AM, SN4 stated she/he reconciled P7’s medications “yesterday” and stated she/he reconciles medications “every visit.” A current medication list was requested and received from the assisted living facility (ALF). During review of the ALF Medication Review Report dated 4/3/24 and the HHA Medication Profile dated 3/18/24-5/16/24 on 4/3/24 at 10:30 AM, the following discrepancies were found: The HHA list indicated Isosorbibe Dinatrate Oral 10 mg (milligram) daily but the ALF list indicated Isosorbibe Mononitrate Oral 10 mg daily. The HHA list indicated Ducosate Sodium Oral 100 mg tablet two times a day for constipation prevention but the ALF list indicated Sennosides-Ducosate Sodium Tablet 8.6-50 mg tablet two times a day for constipation. The HHA list indicated Ventolin HFA Inhalation two puffs every six hours as needed and Enulose Oral 10 mg/15 ml 30 ml daily but these medications were not on the ALF list. The HHA list indicated Dapagliflozin Propanediol Oral 10 mg tablet daily for diabetes. The ALF list did not have this medication. The ALF list indicated the following medications which were not on the HHA list: Clotrimazole External Cream 1% topical to fingertips every 24 hours as needed for skin infection with an order date of 12/26/23, Cyanocobalamin 1000 mcg (micrograms) tablet every Monday through Friday with an order date of 3/22/24, Dulcolax Rectal Suppository 10 mg with an order date of 2/5/24, Forosemide 20 mg with an order date of 3/6/24, Lidoderm External Patch with an order date of 12/20/23, Oxycodone 7.5 mg with an order date of 1/30/24, Potassium Chloride ER 10 MEQ (milliequivalents) with an order date of 3/22/24, and Pregabalin 25 mg with an order date of 12/20/23. During an interview with the Administrator on 4/4/24 at 10:45 AM she/he reviewed the ALF and HHA medication lists and confirmed the findings. The Administrator stated the nurses are supposed to reconcile the medications every visit. Findings included Observation in Patient #2’s home on 04/01/2024 from 3:45 PM to 4:45 PM showed Oxybutynin Chloride ER 15 mg 1 tablet daily via feeding tube on agency medication list. Caregiver reports Oxybutynin Chloride ER 5 mg twice a day via feeding tube. Agency medication list reports Dorzolamide HCL-Timolol Mal Ophthalmic 22.3-6.8 Mg/ml, 1 drop each eye twice a day. Caregiver reports Dorzolamide HCL-Timolol Mal Ophthalmic 22.3-6.8 Mg/ml, 1 drop each eye once a day.During an interview on 04/04/2024 at 11:25 AM, Administrator stated medications should have been updated and verified the findings. Observation in Patient #3’s home on 04/02/2024 from 9:45 AM to 10:25 AM showed on Agency medication list Docusate Sodium 100 mg, 1 capsule by mouth twice a day. Patient #3 reports no longer taking this medication. Agency medication list reports Insulin Aspart subcutaneous 100 units/ml into skin 3 times a day per sliding scale. There is no documentation of dosage for sliding scale. During an interview on 04/04/2024 at 11:42 AM, Administrator stated sliding scale dosing should have been listed. Observation in Patient #4s home on 04/02/2024 from 912:05 PM to 12:37 PM showed on Agency medication list Scopolamine Transdermal 1 mg/3 days, 1 patch apply patch topically to the skin every 3 days. Patient #4 reports no longer taking this medication. During an interview on 04/04/2024 at 11:45 AM, Administrator stated list should have been updated and verifies the finding.”

“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 Home Health Agency (HHA) failed to provide a full comprehensive assessment of the patients psycho-social status for 2 out of 17 patients (Patient #13 and #17). Findings included Review of Patient #13’s medical record on 04/03/2024 showed under psychosocial assessment on Plan of Care (POC), marked as “not applicable”. During an interview on 04/04/2024 at 12:01 PM, Administrator stated it should have been completed. Review of Patient #17’s medical record on 04/03/2024 showed under psychosocial assessment on Plan of Care (POC), marked as “not applicable”. During an interview on 04/04/2024 at 12:05 PM, Administrator stated it should have been completed.”

“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 interview and record review, the Home Health Agency (HHA) failed to obtain physician orders for Skilled Nurse (SN) visits for 1 of 17 patients (Patient #15). Findings included Review of Patient #15’s medical record on 04/03/2024 showed documentation of Skilled Nurse (SN) visits on 03/08/2024 and 03/12/2024. Physician orders for SN visits are dated as effective 03/17/2024. There are no orders for SN visits prior to that date. During an interview on 04/04/2024 at 12:10 PM, the Administrator stated she/he was unable to find orders for these visits and verified the finding.”