Pruitthealth Home Health-Columbia

“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 and interview, the Home Health Agency (HHA) failed to ensure staff followed infection control practices for three of seven home visits observed, Patients #12, #14 and #15. A home visit by the Speech Language Pathologist (SLP) #1 to Patient #12 was observed on 6/10/24 from 2:24 PM to 4:15 PM. While providing care to Patient #12 and the patient’s vital signs, SLP #1 re-entered the medical bag multiple times without performing hand hygiene. After using the vital signs equipment, SLP #1 placed all vital signs equipment, including a box of thermometer probe covers, on a clear plastic bag which was under the medical bag. After completing patient care, SLP #1 gave the patient the electronic tablet and Patient #12 held the tablet and signed. The SLP #1 took the tablet back from the patient and then picked up all of the soiled vital signs equipment and the box of thermometer probe covers and placed them all in the clear plastic bag that was used as a dirty barrier under the equipment. SLP #1 then did not perform hand hygiene. SLP #1 zipped up the medical bag and picked up the soiled plastic bag and the medical bag, then placed the soiled plastic bag back down on the table and went to wash her/his hands. SLP #1 washed her/his hands and turned off the faucet with her/his left elbow and with wet hands went back to the table and picked up the soiled plastic bag and left the home. During an interview on 6/10/24 at 4:15 PM, SLP #1 immediately after exiting the home, she/he confirmed the breaches in infection control, including re-entering the medical bag without performing hand hygiene multiple times, using the soiled barrier to place the vital signs equipment in and taking it with her/him when exiting the home, and not disinfecting the electronic tablet. During an interview with the Administrator on 6/13/24 at 1:45 PM, she/he confirmed the findings and stated, “SLP #1 should have performed hand hygiene before re-entering the medical bag, should have dried her/his hands after handwashing, should have either disinfected the vital signs equipment and placed it back in the medical bag or used a clean plastic bag to place it in before exiting the home and should have disinfected the electronic tablet”. A home visit by Physical Therapy Assistant (PTA) #2 to Patient #15 was observed on 06/12/24 from 9:34 AM to 10:36 AM. With gloved hands, PTA #1 provided hands on physical assistance to Patient #15 in the completion of exercises and ambulation. With the same gloved hands, PTA #1 reconciled the medications, handling the patient’s medication bottles. Then, with the same gloves on, PTA #1 unzipped a pocket of the medical bag and took out a small closed clear plastic bag, opened it, obtained a wipe and used the wipe to clean the soiled vital signs equipment. In an interview with PTA #1 immediately after exiting Patient #15’s home, PTA #1 confirmed the breach in infection control. In an interview with the Administrator on 06/13/24 at 2:00 PM, she/he stated PTA #1 should have removed the gloves and performed hand hygiene before entering the medical bag. A home visit by Registered Nurse (RN) #2 to Patient #14 was observed on 06/12/24 from 12:10 PM to 1:13 PM. With gloved hands, RN #2 removed the stocking and dressing from Patient #14’s right ankle, then picked up the electronic tablet without doffing and without performing hand hygiene. During wound care, RN #2 placed an unopened dressing package on top of the soiled vital signs equipment. After patient care was completed, RN #2 placed the dressing package in the medical bag. In an interview with RN #2 immediately after exiting Patient #14’s home, she/he confirmed the breaches in infection control. In an interview with the Administrator on 06/13/24 at 2:10 PM, she/he stated RN #2 should have removed the soiled gloves and performed hand hygiene after removing the stocking and dressing from Patient #14’s right ankle, and should not have placed the dressing package in the medical bag after it was on the soiled vital signs equipment. Review of the HHA policy titled, “Bag Technique Policy for Home Health & Hospice” on 06/13/24 revealed, “...Always observe the principles of Standard Precautions. The inside of the bag should be regarded and maintained as a clean area...If additional equipment or supplies are needed from the bag during the visit, the handwashing procedure must be repeated...After providing care, clean all equipment with a home health agency approved disinfectant before returning it to the bag...Never place...soiled equipment, or dressings in the clinical bag...” Review of the HHA policy titled, Infection Control Plan - Home Health” on 06/13/24 revealed, “...Hand hygiene must be performed at least in the following instances...Prior to donning...non-sterile gloves...After removing gloves...Hand hygiene is performed at a sink with soap and water...Dry thoroughly with a paper towel...turn of faucets with a paper towel...Standard precautions will be followed in all patient care...””

“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, record review and interviews, the facility failed to ensure that medication lists in the patients’ homes are accurate and updated regularly for 5 of 7 patient records reviewed during home visits to reflect the medications the patient is currently taking. (Patients #12, #13, #14, #15, and #16). A home visit with Speech Language Pathologist (SLP) #1 to Patient #12 was observed on 06/10/24 from 2:24 PM to 4:15 PM. SLP #1 reconciled the patient’s home medications with the home health agency (HHA) Client Medication Report and the following discrepancies were revealed: Oxybutynin Chloride 5 mg (milligram) tablet was in the home and Patient #12 stated she/he used to take it three times a day but “about a month ago” her “family doctor” changed it to twice a day. The Medication Report indicated, “...OXYBUTYNIN CHLORIDE 5 MG TABLET...Dose...1 mg...DAILY...” Patient #12 was taking AREDS 2, “two tablets once a day” but the HHA Medication Report indicted, “...AREDS2...TABLET...DAILY...” Patient #12 was taking certrizine 10 mg “since last Wednesday” and stated prior to that she/he took a different “allergy medicine.” There was no allergy medication on the HHA Medication Report. Patient #12 was using a transdermal (through the skin) patch of Rivastigmine 13.3 mg and the package had a fill date of 5/6/24 but the Medications Report indicated the dose was 9.5 mg. Patient #12 was taking Zinc 50 mg daily but the Medication Report indicated, “Zinc...15 mg...DAILY.” Patient #12 was taking Aleve PRN (as needed) “for right knee pain.” Aleve was not on the Medication Report. In an interview with SLP #1 immediately after exiting Patient #12’s home, SLP #1 confirmed the HHA Medication Report was not accurate. A home visit with Physical Therapy Assistant (PTA) #2 to Patient #15 was observed on 06/12/24 from 9:34 AM to 10:36 AM. PTA #2 reconciled Patient #15’s home medications with the HHA Medication Report and the following discrepancies were revealed: Patient #15 was taking Coenzyme Q10 200 mg daily but the HHA Medication Report indicated, “...100 mg Daily...” Patient #15 was taking Amlodipine 2.5 mg daily but Amlodipine was not on the HHA Medication Report. The family caregiver (FCG) stated, “...Probably been on it at least a year...they dropped the dosage from 5 to 2.5 (mg) probably a month ago...” Patient #15 was taking Atorvastatin 20 mg one-half tablet daily but the HHA Medication Report indicated one (whole) tablet daily. The FCG stated it was decreased to one-half tablet “about three years ago” and the fill date on the bottle was 9/18/23. In an interview with PTA #2 immediately after exiting Patient #15’s home he/she confirmed the HHA Medication Report was not accurate. A home visit with Registered Nurse (RN) #2 to Patient #14 was observed on 06/12/24 from 12:10 PM to 1:13 PM. RN #2 reconciled Patient #14’s home medications with the HHA Medication Report and the following discrepancies were revealed: Patient #14 was taking Sinemet 25 mg-250 mg tablets, one and one-half tablets at 7:00 AM and 1:00 PM, and one tablet at 10:00 AM, 4:00 PM and 7:00 PM. Patient #14 said he/she thought the dose changed from 100 mg to 250 mg “about one and one half years ago.” Patient #14 was taking Garlic extract 1000 mg daily and he uses it when he runs out of aspirin and has done this for “about 20 years.” Garlic was not on the HHA Medication Report. Patient #14 was taking Vitamin C 1000 mg daily and had been for “a long time” but Vitamin C was not on the HHA Medication Report. Patient #14 was taking Vitamin D3 5,000 units but the HHA Medication Report indicated, “50,000 units.” Meloxican was on the HHA Report but Patient #14 stated he/she was not taking it and had no bottle for it. In an interview with RN #2 immediately after exiting Patient #14’s home, she/he confirmed the HHA Medication Report was not accurate. Findings included: Observation on a home visit 06/10/24 at 2:30 PM for Patient #13, showed the patient medication list is inaccurate. Record review showed the patient is ordered to take 40 milligram (mg) Lasix per day and patient reports taking 60 mg per day. The patient is ordered to use Gentamicin 0.1% ointment on a toe wound and Mupirocin 2% ointment on a lower leg wound three times per week which the patient reports not using. The patient confirms taking 75 milligrams (mg) Vitamin C, 2000 International units (IU) of Vitamin D3, 600 IU Vitamin D12, 25 mg Spirolactone, and 40 mg of Atorvastatin daily, plus 1000 mg Meringa twice daily. In an interview with Physical Therapist #1 on 06/10/24 3:10 PM while present in the home, this information is confirmed. In an interview with the Administrator on 06/13/24 at 1:13 PM the information is further confirmed. Observation on a home visit 6/10/24 at 11:00 AM for Patient #16 showed the patient medication list is inaccurate. Record review showed the patient is ordered to take 40 mg Lasix daily but the patient reports none has been taken over the past 6 months. The patient is ordered to take 50 mg Myrbetriq XR, 60 mg Dexilant and 10 milliequivalents Klor-Con daily but the patient reports not using the drugs for several months if at all. In an interview with the Registered Nurse #3 present during the home visit it is confirmed the medication list is inaccurate. In an interview with the Administrator on 06/13/24 at 1:13 PM this information is further confirmed.”

“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 record review and interview the Home Health Agency (HHA) failed to ensure all information was included in the plan of care for two of 17 records reviewed, Patients #9 and #12. Findings include: Review of Patient #9’s medical record and plan of care dated 4/06/24 to 6/04/24 on 6/13/24 at 10:40 AM revealed Patient #9’s diagnoses included, “TYPE 2 DIABETES” [elevated blood sugar/glucose levels]...”. The plan of care indicated...”SKILLED NURSE FOR INSTRUCTIONS/REINFORCEMENT OF DIABETIC CARE TO INCLUDE...BLOOD GLUCOSE TESTING...”. The plan of care did not include parameters for what blood glucose levels should be reported to the physician. In an interview with the Administrator on 6/13/24 at 1:36 PM, she/he reviewed Patient #9’s record and confirmed the plan of care should include parameters for what blood glucose levels should be reported to the physician. Review of Patient #12’s medical record and plan of care dated 4/29/24 to 6/27/24 on 6/13/24 at 9:45 AM revealed, “...Nutritional Requirements...N/A...” In an interview with the Administrator on 6/13/24 at 1:54 PM, she/he reviewed Patient #12’s record and confirmed the findings stating the Nutritional Requirements should be completed and should not be “N/A.””

“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 observations, interview and record review, the Home Health Agency (HHA) staff failed to follow physician orders regarding therapy evaluations, weights, glucose monitoring and visit schedules for 8 out of 17 charts (Patient #1, #2, #8, #9, #11, #12, #14 and #17). A home visit by Registered Nurse (RN) #2 to Patient #14 was observed on 06/12/24 from 12:10 PM to 1:13 PM. While providing wound care to Patient #14’s left lower leg, RN #2 applied what appeared to be skin prep to the skin surrounding the wound and applied a dressing with an adhesive border on the wound. Patient #14 stated, “My skin is thin” to which RN #2 replied, “I used skin prep, so it should be fine.” Patient #14’s record was reviewed on 06/13/24 at 9:00 AM. The physician’s order dated 06/12/24 indicated, “IRRIGATE WITH WOUND CLEANSER. PAT DRY. APPLY CALCIUM ALGINATE TO WOUND BED. COVER WITH 4X4 AND SECURE WITH KLING...” Review of the plan of care dated 04/17/24 to 06/15/24 revealed Patient #14’s diagnoses included Peripheral Vascular Disease and Chronic Venous Insufficiency. In an interview with the Administrator on 06/13/24 at 2:05 PM she/he reviewed Patient #14’s record and confirmed the findings stating RN #2 should not have used skin prep or a bordered adhesive dressing because they were not ordered by the physician. Review of Patient #12’s record on 06/13/24 at 9:45 AM revealed the plan of care dated 04/29/24 to 06/27/24 indicated the ordered Speech Language Pathology (SLP) visit frequency was one time a week for 9 weeks. Review of the SLP visits conducted during the certification period revealed no SLP visit was done the week of May 12th and there was no documentation of a missed visit or physician notification. In an interview with the Administrator on 06/13/24 at 1:56 PM she/he reviewed Patient #12’s record and confirmed the findings. Review of Patient #2’s record on 06/13/24 at 8:45 AM revealed a physician’s order dated 01/31/24 for Physical Therapy (PT) to visit Patient #2 effective 01/28/24, “1W1” and then “2Q2W”. Review of the PT visits for the months of January and February 2024 revealed there were no PT visits the week of 01/11/24. In an interview with the Administrator on 06/13/24 at 1:20 PM she/he reviewed Patient #2’s record and confirmed the findings, stating PT should have visited Patient #2 two times the week of 01/11/24 but no PT visits were done that week and there were no missed visit notes and no evidence the physician was notified of the missed visits. Review of Patient #9’s record and plan of care dated 04/06/24 to 06/04/24 on 06/13/24 at 10:40 AM revealed Patient #9’s diagnoses included, “TYPE 2 DIABETES” [elevated blood sugar levels]...” The plan of care indicated...”SKILLED NURSE FOR INSTRUCTIONS/REINFORCEMENT OF DIABETIC CARE TO INCLUDE...BLOOD GLUCOSE TESTING...” Review of all of the nursing visit notes from 05/10/24 to 06/06/24 revealed no documented evidence of any blood glucose monitoring. In an interview with the Administrator on 06/13/24 at 1:36 PM she/he reviewed Patient #9’s record and confirmed based on the plan of care, nursing should have been monitoring Patient #9’s blood glucose and stated, “I don’t see any documentation of why there was no monitoring (of the blood glucose).” Record review for Patient #17 on 06/13/24 11:00 AM showed the Occupational Therapist received orders on 04/29/24 from the Physician “to evaluate for Occupational services and develop a plan of care for the Physician’s signature to include physical and psychosocial test results”. There is no evidence found in the record that psychosocial test results were sent to the Physician. In an interview with the Administrator on 06/13/24 at 2:00 PM this information is confirmed. Findings included Review of Patient #1’s medical record on 06/10/24 at 11:47 AM showed orders for Occupational Therapy (OT) visit starting 04/28/24 1 visit for 1 week, 3 visits for 1 week, 2 visits for 3 weeks. There are 2 documented visits for the second week beginning 05/05/24. During an interview on 06/13/24 at 12:51 PM, Administrator stated that OT visit was documented on 05/07/24, OT missed visit on 05/09/24 and verified the finding. Review of Patient #8’s medical record on 06/10/24 at 12:45 PM showed physician orders for OT evaluation week of 04/28/24. OT evaluation was documented on 05/07/24. During an interview on 06/13/24 at 12:42 PM, Administrator stated that there is no documentation why the evaluation was delayed and verified the finding. Review of Patient 11’s medical record on 06/12/24 at 10:35 AM showed at Resumption of Care (ROC) on 05/17/24, physician orders for Physical Therapy (PT) evaluation, daily weights and Skilled Nurse (SN) visit schedule 1visit every week for 2 weeks, 2 visits every week for 3 weeks. There is no documentation in the medical record that a PT evaluation was completed. There are no weights documented from SN visits on 05/21/24, 05/23/24, 05/28/24, 05/30/24, 06/04/24 and 06/10/24. SN visits are documented twice the week of 05/19/24 and once the week of 06/02/24. During an interview on 06/13/24 at 12:55 PM, Administrator stated that weights were not being recorded, SN visit schedule is “backwards” and PT evaluation was not completed.”

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on observation, record review and interview, the Home Health Agency (HHA) failed to ensure the Licensed Practical Nurse (LPN) reported a new wound to the Registered Nurse (RN) or Clinical Manager (CM) for one of two patients observed for wound care, Patient #14. A home visit by RN #2 to Patient #14 was observed on 6/12/24 from 12:10 PM to 1:13 PM. RN #2 removed a stocking and dressing from Patient #14’s right lower leg which Patient #14 said was there for “about a week,” The wound was observed to be approximately less than or equal to 0.5 cm and circular in the shape of a crater with a pink wound bed. RN #2 applied betadine and a bandaid and told Patient #14 she/he could not perform any wound care because this was a new wound and there were no physician’s orders for wound care for it. On 6/13/24 at 9:00 AM, Patient #14’s record was reviewed. The plan of care dated 4/17/24 to 6/15/24 indicated Patient #14 was admitted to the HHA on 4/17/24 with diagnoses including Peripheral Vascular Disease (PVD) (decreases the circulation of blood in the legs and feet). The nursing visit note by a Licensed Practical Nurse (LPN) dated 6/06/24 indicated there was a “small” “new skin tear noted” to Patient #14’s “right ankle” and the patient was instructed to “keep covered with foam bandage and monitor until next SNV (skilled nursing visit).” There was no documented evidence the LPN notified an RN or the Clinical Manager of the new skin tear. Review of the nursing visit note from the observed visit on 6/12/24 indicated, “...NEW WOUND NOTED TO RIGHT LOWER LEG. SKIN TEAR...CHANGE IN STATUS...NONE...MEASUREMENTS TAKEN...NO...DEPTH DESCRIPTION...PART THICK...EXUDATE [i.e. drainage] TYPE BLOODY...EXUDATE AMOUNT...SCANT...” In an interview with the Administrator and the Clinical Manager on 6/13/24 at 2:15 PM, they stated the LPN who visited Patient #14 on 6/06/24 should have notified the RN or the Clinical Manager and another visit should have been scheduled to reassess the wound before the next nursing visit a week later on 6/12/24.”