In August, the Department of Inspections, Appeals & Licensing (DIAL) had 3 complaint surveys and 3 recertification surveys available for review. All of the complaint surveys didn’t result in any deficiencies identified. The recertification surveys had an average of 8 deficiencies cited. All 3 of the recertification surveys were conducted 34 months since the last recertification survey. There are currently no home health agencies that are more than 36 months since their last recertification.
There were 2 deficiencies cited for emergency preparedness which were both E037 related to training. During review of employee files in each survey, a staff member lacked documentation of training on the emergency preparedness plan (EPP) in the last 12 months.
The deficiency cited during each survey was G0574 related to items that must be included in the plan of care (POC). Examples include:
- Ibuprofen was included in the medication set-up but was not in the POC.
- The POC didn’t accurately reflect current medications and equipment including a scale, blood pressure cuff, and pill splitter.
- A lifeline pendant and wound care orders weren’t included in the POC.
Other deficiencies cited more than once included:
- G0374 when the start of care date wasn’t correct and a pressure ulcer wasn’t included in the OASIS.
- G0536 when a drug regimen review (DRR) wasn’t included on discharge and there were discrepancies between the POC and what was included in the medication planner.
- G0798 when the home health aide care plan directed staff to apply hydrocortisone cream to the patient’s itchy areas, but the patient had cognitive impairment. Another example was when the POC lacked oxygen and crutches, but the aide plan of care included using adaptive equipment during ambulation which included oxygen and crutches.
- G0808 related to home health aide supervisory visits that exceeded the 14 day requirement.