Every finding on record at Alternate Solutions Homecare of Dayton, LLC

SUBSTANTIAL ALLEGATION SURVEY SUBSTANTIAL ALLEGATION 61041 COVID 19 INFECTION CONTROL SURVEY The following deficiency is based on the COVID 19 Focused Infection Control Survey and Substantial Allegation Survey completed on 11/22/21. Kettering Homecare 367778, is not in compliance with the requirements found at 42 CFR Part 484, Subpart B, C 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 and staff interview, the agency failed to properly follow standard precautions to prevent the transmission of COVID-19 for one of three patients reviewed (Patient #1). This could affect all patients receiving services from the agency. The agency census was 2644. Findings include: Review of the plan of care for Patient #1 revealed he was admitted to the home health agency on 09/16/21 and was discharged on 10/13/21. The services provided were for Physical therapy (PT) one time a week times one week, two times a week times three weeks and one time a week times one week. The patient's primary diagnosis was aftercare following joint replacement therapy. Secondary diagnoses included osteoarthritis of the left hip, hypertension, anxiety, high cholesterol, hypothyroidism, insomnia, history of falling, right artificial joint and right artificial knee. Review of a client communication note dated 09/27/21 revealed the patient was made aware that one of the employees that provided his services tested positive for COVID-19. Patient #1 was informed his risk was minimal as staff wore proper personal protective equipment (PPE) including mask, gloves and goggles. There were no further questions or concerns at this time. Review of the education COVID-19 letter that was provided to patients upon admission revealed the clinicians were screened daily for COVID symptoms, wore face masks and gloves throughout each visit, equipment was disinfected, patients/household member screened as at risk for COVID and clinicians wore full protective equipment including facemask, gloves, gowns and face shields/goggles. Interview with Staff B the afternoon of 11/19/21 revealed he had plenty of PPE which was provided to him when he needed it from the agency. Staff B also revealed he primarily saw the patient in the home and wore a mask and goggles, but did not wear gloves. He stated he would wear gloves with a COVID positive patient. This finding was confirmed with Staff A prior to the exit conference on 11/22/21. This citation substantiates Substantial Allegation 61041.

Substantial Allegation Survey Substantial Allegation OH00121224 The following deficiencies are based upon Substantial Allegation OH00121224 completed on 04/08/21. Kettering Homecare is not in compliance with the requirements found at 42 CFR Part 484, Subpart B, C, Home Health Agencies.

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on medical record review, facility policy review, and staff interview, the facility failed to ensure patients received the wound care outlined in the plan of care. This affected three (Patient #1, Patient #3, and Patient #4) of five patients reviewed. Findings include: 1. Review of the medical record of Patient #1 revealed the patient was admitted for services of the agency on 01/06/21. According to the intake documentation, the patient was found by local police on 01/02/21 walking on the highway, barefoot. The patient was diagnosed with trench foot (serious condition that results from feet being wet for too long). Imaging revealed soft tissue injuries of the first through third digits of both the left and right feet. Although the CT of the head was negative, the patient was noted to have altered mental status with confusion, forgetfulness, and some hallucinations observed by staff. The patient was admitted with diagnoses including non-pressure ulcers of left and right feet with fat layer exposed, trench foot, opioid abuse in remission, and history of falling. The physician ordered skilled nurse visits to perform perform wound care or teach client/caregiver to perform wound care to left and right toes. Nurses were ordered to cleanse toes with normal saline, apply Aqua Cell, cover with gauze wrap with kerlix and ace bandage. Dressing was ordered to be changed at a daily frequency. The order stated, "Daily skilled services for wound care, projected endpoint to daily visits is end of episode." The frequency of the visits were one time for one week, three times a week for one week, four times a week for one week, six times a week for one week, two times a week for one week, and one time a week for the remaining four weeks. The first week, an admission assessment was performed on 01/06/21 and no subsequent visits were noted although documentation of a missed visit was noted on 01/09/21, the last day of the week. The medical record lacked documentation education was provided to the patient or spouse on how to perform wound care. The second week, skilled nursing visits for wound care were performed on 01/10/21, 01/15/21, and 01/16/21. Documentation of missed visits were noted for the four remaining days of 01/11/21, 01/12/21, 01/13/21, and 01/14/21. The medical record lacked documentation of any training being provided to the patient or family member on how to perform wound care. The third week, skilled nursing visits for wound care occurred on 01/17/21, 01/18/21, 01/21/21, and 01/23/21. Missed visits were noted on 01/19/21, 01/20/21, and 01/22/21. A skilled visit note on 01/25/21 stated the patient's caregiver was unable to assist with wound care. The fourth and fifth weeks of the certification period noted daily nursing visits except for the missed visits on 01/24/21, 01/31/21, and 02/02/21. The patient received only two skilled nursing visits week six of the certification period, 02/07/21 and 02/08/21. 2. Review of the medical record of Patient #3, the Specified Patient, revealed the patient was admitted for services of the agency on 03/18/21. This skilled patient was admitted with diagnoses that included hypokalemia, diarrhea, pneumonia, history of falling, gastric esophageal reflux disease, and long term use of systemic steroids. The certification period reviewed was 03/18/21 to 05/16/21. Among other tasks, the skilled nurse was ordered to perform wound care or teach client/caregiver to perform wound care to right lower abdomen which included cleaning with normal saline, applying Calcium Alginate with Silver and covering with foam dressing daily. The patient was ordered to receive services of a nurse three times for a week, six times for a week, then once a week for seven weeks. Although the plan of care was signed by a registered nurse, there was no signature of a physician noted. Documentation of an admission assessment was noted on 03/18/21 and subsequent skilled visits were conducted from 03/19/21 through 03/26/21. The medical record lacked documentation of any visits that occurred after 03/26/21. The medical record also lacked documentation the patient or caregiver was educated on how to perform wound care, or any missed visit notes. 3. Review of the medical record of Patient #4 revealed the patient was admitted for services of the agency on 01/03/21. The patient was admitted with diagnoses including COVID-19, pneumonia due to coronavirus disease, type 2 diabetes mellitus with foot ulcer, and cellulitis of left lower limb. The certification period reviewed was 01/03/21 to 03/03/21. The patient was ordered to receive services of an aide two times a week for two weeks. Skilled nursing was ordered four times week one, three times week two, and once for the remaining seven weeks. Among other tasks, agency nurses were ordered to perform wound care every other day or as needed for drainage. Agency nurses were ordered to clean with normal saline, apply Opticel AG at wound bed, cover with abdominal pad and secure with kerlix times two and ace 6 inches times two. A Coordination Note on 01/08/21 stated the patient refused the services of an aide due to having an appointment for wound care that same day. An admission assessment occurred on 01/03/21. Subsequent skilled nursing visits occurred on 01/04/21 and 01/06/21. The medical record lacked documentation the fourth ordered skilled nursing visit occurred. There was no documentation the patient was educated on how to perform wound care. A coordination note dated 01/11/21 stated that the nurse that was supposed to see him/her on Friday, 01/08/21, didn't show up and did not call. Skilled nursing visits occurred the second week on 01/12/21 and 01/15/21. The third week, skilled nursing visits occurred twice, on 01/18/21 and 01/21/21. The fourth week, skilled nursing visits also occurred twice, on 01/25/21 and 01/28/21. The medical record lacked documentation the patient was educated on performing wound care during the first six weeks of the certification period. Skilled nursing visits didn't occur every other day, as ordered, until the seventh week of the certification period. Skilled nursing visits occurred on 02/15/21 and 02/15/21. Every other day dressing changes continued through the remainder of the certification period. Staff A was interviewed on 04/07/21 at 3:10 P.M. and confirmed that neither of the three patients received the wound care outlined in the plan of care. The facility's Patient Rights revealed patients have a right to participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate with respect to any changes in the care to be provided and establishing the care that the patient will receive (The Plan of Care). This deficiency substantiated Substantial Allegation OH00121224.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on medical record review, facility policy review, and staff interview, the facility failed to ensure staff alerted physicians to changes in the plan of care. This affected three (Patient #1, Patient #3, and Patient #4) of five patients reviewed. Findings include: 1. Review of the medical record of Patient #1 revealed the patient was admitted for services of the agency on 01/06/21. According to the intake documentation, the patient was found by local police on 01/02/21 walking on the highway, barefoot. The patient was diagnosed with trench foot (serious condition that results from feet being wet for too long). Imaging revealed soft tissue injuries of the first through third digits of both the left and right feet. Although the CT of the head was negative, the patient was noted to have altered mental status with confusion, forgetfulness, and some hallucinations observed by staff. The patient was admitted with diagnoses including non-pressure ulcers of left and right feet with fat layer exposed, trench foot, opioid abuse in remission, and history of falling. The physician ordered skilled nurse visits to perform perform wound care or teach client/caregiver to perform wound care to left and right toes. Nurses were ordered to cleanse toes with normal saline, apply Aqua Cell, cover with gauze wrap with kerlix and ace bandage. Dressing was ordered to be changed at a daily frequency. The order stated, "Daily skilled services for wound care, projected endpoint to daily visits is end of episode." The frequency of the visits were one time for one week, three times a week for one week, four times a week for one week, six times a week for one week, two times a week for one week, and one time a week for the remaining four weeks. The first week, an admission assessment was performed on 01/06/21 and no subsequent visits were noted although documentation of a missed visit was noted on 01/09/21, the last day of the week. The medical record lacked documentation education was provided to the patient or spouse on how to perform wound care. The second week, skilled nursing visits for wound care were performed on 01/10/21, 01/15/21, and 01/16/21. Documentation of missed visits were noted for the four remaining days of 01/11/21, 01/12/21, 01/13/21, and 01/14/21. The medical record lacked documentation of any training being provided to the patient or family member on how to perform wound care. The third week, skilled nursing visits for wound care occurred on 01/17/21, 01/18/21, 01/21/21, and 01/23/21. Missed visits were noted on 01/19/21, 01/20/21, and 01/22/21. A skilled visit note on 01/25/21 stated the patient's caregiver was unable to assist with wound care. The fourth and fifth weeks of the certification period noted daily nursing visits except for the missed visits on 01/24/21, 01/31/21, and 02/02/21. The patient received only two skilled nursing visits week six of the certification period, 02/07/21 and 02/08/21. 2. Review of the medical record of Patient #3, the Specified Patient, revealed the patient was admitted for services of the agency on 03/18/21. This skilled patient was admitted with diagnoses that included hypokalemia, diarrhea, pneumonia, history of falling, gastric esophageal reflux disease, and long term use of systemic steroids. The certification period reviewed was 03/18/21 to 05/16/21. Among other tasks, the skilled nurse was ordered to perform wound care or teach client/caregiver to perform wound care to right lower abdomen which included cleaning with normal saline, applying Calcium Alginate with Silver and covering with foam dressing daily. The patient was ordered to receive services of a nurse three times for a week, six times for a week, then once a week for seven weeks. Although the plan of care was signed by a registered nurse, there was no signature of a physician noted. Documentation of an admission assessment was noted on 03/18/21 and subsequent skilled visits were conducted from 03/19/21 through 03/26/21. The medical record lacked documentation of any visits that occurred after 03/26/21. The medical record also lacked documentation the patient or caregiver was educated on how to perform wound care, or any missed visit notes. 3. Review of the medical record of Patient #4 revealed the patient was admitted for services of the agency on 01/03/21. The patient was admitted with diagnoses including COVID-19, pneumonia due to coronavirus disease, type 2 diabetes mellitus with foot ulcer, and cellulitis of left lower limb. The certification period reviewed was 01/03/21 to 03/03/21. The patient was ordered to receive services of an aide two times a week for two weeks. Skilled nursing was ordered four times week one, three times week two, and once for the remaining seven weeks. Among other tasks, agency nurses were ordered to perform wound care every other day or as needed for drainage. Agency nurses were ordered to clean with normal saline, apply Opticel AG at wound bed, cover with abdominal pad and secure with kerlix times two and ace 6 inches times two. A Coordination Note on 01/08/21 stated the patient refused the services of an aide due to having an appointment for wound care that same day. An admission assessment occurred on 01/03/21. Subsequent skilled nursing visits occurred on 01/04/21 and 01/06/21. The medical record lacked documentation the fourth ordered skilled nursing visit occurred. There was no documentation the patient was educated on how to perform wound care. A coordination note dated 01/11/21 stated that the nurse that was supposed to see him/her on Friday, 01/08/21, didn't show up and did not call. Skilled nursing visits occurred the second week on 01/12/21 and 01/15/21. The third week, skilled nursing visits occurred twice, on 01/18/21 and 01/21/21. The fourth week, skilled nursing visits also occurred twice, on 01/25/21 and 01/28/21. The medical record lacked documentation the patient was educated on performing wound care during the first six weeks of the certification period. Skilled nursing visits didn't occur every other day, as ordered, until the seventh week of the certification period. Skilled nursing visits occurred on 02/15/21 and 02/15/21. Every other day dressing changes continued through the remainder of the certification period. Staff A was interviewed on 04/07/21 at 3:10 P.M. and confirmed that the medical records of Patient #1, Patient #3, and Patient #4 lacked documentation a physician was notified of the change in the plan of care related to the provision of wound care. The facility policy titled "Standards of Skilled Nursing (05-001)", effective 10/14, revealed RN's and LPN's are responsible for providing direct nursing care. Responsibilities of the registered nurse includes informing the physician and other personnel of changes in the patient's status and needs, or changes to the plan of care and collaborating/communicating with patient, family, caregiver, physician and other disciplines to ensure a comprehensive approach to patient care, including patient's progress towards goals and outcomes. This deficiency substantiated Substantial Allegation OH00121224.

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on medical record review, facility policy review, and staff interview, the agency failed to ensure patients reviewed received training on wound care. This affected three (Patient #1, Patient #3, and Patient #4) of five patients reviewed. Findings include: 1. Review of the medical record of Patient #1 revealed the patient was admitted for services of the agency on 01/06/21. According to the intake documentation, the patient was found by local police on 01/02/21 walking on the highway, barefoot. The patient was diagnosed with trench foot (serious condition that results from feet being wet for too long). Imaging revealed soft tissue injuries of the first through third digits of both the left and right feet. Although the CT of the head was negative, the patient was noted to have altered mental status with confusion, forgetfulness, and some hallucinations observed by staff. The patient was admitted with diagnoses including non-pressure ulcers of left and right feet with fat layer exposed, trench foot, opioid abuse in remission, and history of falling. The physician ordered skilled nurse visits to perform perform wound care or teach client/caregiver to perform wound care to left and right toes. Nurses were ordered to cleanse toes with normal saline, apply Aqua Cell, cover with gauze wrap with kerlix and ace bandage. Dressing was ordered to be changed at a daily frequency. The order stated, "Daily skilled services for wound care, projected endpoint to daily visits is end of episode." The frequency of the visits were one time for one week, three times a week for one week, four times a week for one week, six times a week for one week, two times a week for one week, and one time a week for the remaining four weeks. The first week, an admission assessment was performed on 01/06/21 and no subsequent visits were noted although documentation of a missed visit was noted on 01/09/21, the last day of the week. The medical record lacked documentation education was provided to the patient or spouse on how to perform wound care. The second week, skilled nursing visits for wound care were performed on 01/10/21, 01/15/21, and 01/16/21. Documentation of missed visits were noted for the four remaining days of 01/11/21, 01/12/21, 01/13/21, and 01/14/21. The medical record lacked documentation of any training being provided to the patient or family member on how to perform wound care. The third week, skilled nursing visits for wound care occurred on 01/17/21, 01/18/21, 01/21/21, and 01/23/21. Missed visits were noted on 01/19/21, 01/20/21, and 01/22/21. A skilled visit note on 01/25/21 stated the patient's caregiver was unable to assist with wound care. The fourth and fifth weeks of the certification period noted daily nursing visits except for the missed visits on 01/24/21, 01/31/21, and 02/02/21. The patient received only two skilled nursing visits week six of the certification period, 02/07/21 and 02/08/21. 2. Review of the medical record of Patient #3, the Specified Patient, revealed the patient was admitted for services of the agency on 03/18/21. This skilled patient was admitted with diagnoses that included hypokalemia, diarrhea, pneumonia, history of falling, gastric esophageal reflux disease, and long term use of systemic steroids. The certification period reviewed was 03/18/21 to 05/16/21. Among other tasks, the skilled nurse was ordered to perform wound care or teach client/caregiver to perform wound care to right lower abdomen which included cleaning with normal saline, applying Calcium Alginate with Silver and covering with foam dressing daily. The patient was ordered to receive services of a nurse three times for a week, six times for a week, then once a week for seven weeks. Although the plan of care was signed by a registered nurse, there was no signature of a physician noted. Documentation of an admission assessment was noted on 03/18/21 and subsequent skilled visits were conducted from 03/19/21 through 03/26/21. The medical record lacked documentation of any visits that occurred after 03/26/21. The medical record also lacked documentation the patient or caregiver was educated on how to perform wound care, or any missed visit notes. 3. Review of the medical record of Patient #4 revealed the patient was admitted for services of the agency on 01/03/21. The patient was admitted with diagnoses including COVID-19, pneumonia due to coronavirus disease, type 2 diabetes mellitus with foot ulcer, and cellulitis of left lower limb. The certification period reviewed was 01/03/21 to 03/03/21. The patient was ordered to receive services of an aide two times a week for two weeks. Skilled nursing was ordered four times week one, three times week two, and once for the remaining seven weeks. Among other tasks, agency nurses were ordered to perform wound care every other day or as needed for drainage. Agency nurses were ordered to clean with normal saline, apply Opticel AG at wound bed, cover with abdominal pad and secure with kerlix times two and ace 6 inches times two. A Coordination Note on 01/08/21 stated the patient refused the services of an aide due to having an appointment for wound care that same day. An admission assessment occurred on 01/03/21. Subsequent skilled nursing visits occurred on 01/04/21 and 01/06/21. The medical record lacked documentation the fourth ordered skilled nursing visit occurred. There was no documentation the patient was educated on how to perform wound care. A coordination note dated 01/11/21 stated that the nurse that was supposed to see him/her on Friday, 01/08/21, didn't show up and did not call. Skilled nursing visits occurred the second week on 01/12/21 and 01/15/21. The third week, skilled nursing visits occurred twice, on 01/18/21 and 01/21/21. The fourth week, skilled nursing visits also occurred twice, on 01/25/21 and 01/28/21. The medical record lacked documentation the patient was educated on performing wound care during the first six weeks of the certification period. Skilled nursing visits didn't occur every other day, as ordered, until the seventh week of the certification period. Skilled nursing visits occurred on 02/15/21 and 02/15/21. Every other day dressing changes continued through the remainder of the certification period. Staff A was interviewed on 04/07/21 at 3:00 P.M. and confirmed that the medical records of Patient #1, Patient #3, and Patient #4 all lacked documentation of education for wound care being provided as ordered. The facility policy titled "Education on Supplies and Medical Gases (06-009)", effective 03/06/17, was reviewed on 04/07/21 at 01:55 PM. According to the policy, staff are instructed that documentation of patient/family/caregiver/representative instruction in the medical record should include: *Information taught *Patient/Family/Caregiver understanding *Return demonstrations *Response to teaching This deficiency substantiated Substantial Allegation OH00121224.