Every finding on record at Alegent Creighton Health

CHI Health Health at Home Plainview is in compliance with the requirements of 42 CFR 484.102 Condition of Participation for Home Health Agencies.

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 care, and staff interview, the agency failed to ensure 1 of 3 staff (Staff C), observed during the provision of care for 1 of 3 patients (Patient 1), performed proper hand hygiene and bag technique according to the agency's policies and procedures. The total sample size was 7. The census was 39. A. Review of the agency’s policy and procedure titled Bag Technique, reviewed/revised 5/7/24, revealed: 1. Hand hygiene was to be performed before entering/re-entering the clinician bag, and before, and after patient and/or equipment contact. 2. Equipment was to be cleaned prior to returning to the clinician bag. 3. The hard-shell case and the laminated screen protector of the tablet was to be cleaned after patient and caregiver use with a lightly moist sanitizing or alcohol wipe prior to returning it to the clinician bag. B. Review of the agency’s policy and procedure titled Hand Hygiene, revised 8/10/22, revealed hand hygiene was to be performed before re-entering the clinician bag and/or handling clinician or patient's clean supplies, such as, clinician bag, tablet, and clean supplies. C. Review of Patient 1’s Home Health Certification and Plan of Care (POC), for the certification period of 5/20/25 through 7/18/25, included orders for Skilled Nurse (SN) every 2 weeks for Home Health Aide supervision, prefill medication planner, and provide education regarding safety issues, proper oxygen use, preventing falls and provide interventions to reduce fall risk. D. The observation of the provision of care, for Patient 1 on 6/10/25 at 11:00 AM, revealed Staff C: 1. Failed to perform hand hygiene on one occasion prior to entering the clinician bag. 2. Failed to provide cleaning of the tablet prior to returning it to the clinician bag after use by the SN and patient. E. During an interview on 6/10/25 at 1:00 PM, the Home Health Supervisor confirmed Staff C failed to follow the agency’s policy and procedure for hand hygiene and bag technique during the provision of care for Patient 1.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review, policy and procedure review, and staff interview, the agency failed to follow their policy and procedure to ensure transfer information was sent to the receiving facility for 2 of 2 patients who had a transfer (Patients 3 and 5). The total sample size was 7. The census was 39. A. Review of the agency policy and procedure titled Transfer and Discharge-Home Health, revised 10/20/23, revealed the agency was to: 1. Send a transfer summary within two (2) business days of becoming aware of an unplanned transfer to the receiving provider. 2. Maintain a copy in the patient's clinical record of the Transfer or Discharge Summary provided to the receiving provider. B. Review of Patient 3's clinical record revealed: 1. A Home Health Certification and Plan of Care with a start of care date of 10/31/24. 2. A Care Summary - Transfer Client Coordination Note Report, dated 5/12/25, showing Patient 3 was admitted to the hospital on 5/9/25. 3. There was no documentation in the clinical record that a transfer or discharge summary was provided by the agency to the receiving facility. C. Review of Patient 5's clinical record revealed: 1. A Home Health Certification and Plan of Care with a start of care date of 5/8/25. 2. A Care Summary - Transfer Client Coordination Note Report, dated 5/20/25, showing Patient 5 was admitted to the hospital on 5/19/25. 3. There was no documentation in the clinical record that a transfer or discharge summary was provided by the agency to the receiving facility. D. During an interview on 6/11/25 at 2:15 PM, the Home Health Supervisor and the Regional Director of Clinical Services confirmed: 1. There was no documentation in the clinical record that a Patient Transfer Form or Transfer Summary was completed or provided to the receiving facility when Patient 3 and Patient 5 were transferred to the hospital on 5/9/25 and 5/19/25, respectively. 2. The Agency staff failed to follow the agency's policy and procedure to ensure transfer information was sent to the receiving facility for 2 of 2 patients who had a transfer (Patient 3 and 5).

CHI Health Health at Home Plainview is in compliance with the requirements of 42 CFR 484.102 Condition of Participation for Home Health Agencies.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review, policy and procedure review, and staff interview, the agency failed to follow their policy and procedure to ensure transfer information was sent to the receiving provider for 1 of 1 patients who had a transfer (Patient 6). The sample size was 7. The census was 25. Findings are: A. Review of the agency policy and procedure titled Transfer/Referral of Services, revised 6/21/12, revealed the agency was to: 1. Verbally provide information to the appropriate receiving healthcare provider within 48 hours. 2. Complete a Patient Transfer Form or Discharge/Transfer Summary and send a copy to the receiving provider. 3. Maintain a copy in the patient's clinical record of the Patient Transfer Form or Discharge/Transfer Summary provided to the receiving provider. B. Review of Patient 6's clinical record revealed: 1. The Home Health Certification and Plan of Care revealed the patient's start of care date was 12/9/21. 2. A telephone order dated 12/24/21 from the patient's physician to admit the patient to the hospital. 3. A telephone order dated 1/25/22 from the patient's physician to transfer patient to ACH (local hospital) with discharge. 4. There was no documentation in the clinical record that verbal information was provided by the agency to the receiving provider on 12/24/21 and 1/25/22. 5. There was no documentation in the clinical record that the Patient Transfer Form or Discharge/Transfer Summary was completed and sent to the receiving provider on 12/24/21 and 1/25/22. 6. There was no documentation in the clinical record that a copy of the Patient Transfer Form or Discharge/Transfer Summary provided to the receiving provider was included in the clinical record. C. During an interview on 6/16/22 at 10:45 AM, the Home Health Supervisor (Clinical Manager) (CM) confirmed: 1. There was no documentation in the clinical record that a Patient Transfer Form or Transfer Summary was completed and provided to the receiving provider when Patient 6 transferred to the hospital on 12/24/21 and again on 1/25/22. 2. There was no documentation in the clinical record that verbal information was provided to the receiving provider when Patient 6 transferred to the hospital on 12/24/21 and 1/25/22. 3. The agency staff did not follow the policy and procedure to complete and send transfer information to the receiving provider and did not maintain documentation, in Patient 6's clinical record, of the information provided to the receiving provider.