Every finding on record at Baycare Home Care Inc

During the recertification survey conducted from 5/12/21 to 5/14/21 at Baycare Home Care Inc. a Home Health Agency., Emergency Preparedness was reviewed. Baycare Home Care Inc. is in compliance with Emergency Preparedness per Code of Federal Regulations (CFR) 42, Part 484.22, Condition of Participation for Home Health Agencies.

A recertification survey was conducted at Baycare Home Care from 5/12/21 to 5/14/21. Baycare Home Care Inc, ,was not in compliance with 42 CFR Part 484 Requirements 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: This STANDARD is NOT MET: Based on observations, interviews and record reviews the agency failed to ensure proper hand hygiene before and after glove use and to ensure staff followed aseptic technique with patient equipment for 2 (#5,#7) patients out of 7 sampled during home care visits. 2) A review of the medical record for Patient #7 revealed a home care admission date of 4/10/2021 to provide wound care to right below the knee amputation (BKA). The current patient certification of care from 4/10/2021 to 6/08/2021 with a primary diagnosis of cellulitis of the right lower limb and diabetes mellitus. SN (skilled nurse) 1wk1, 2wk2, 1wk6, and 3 PRN (as needed) visits for alteration in cardiovascular/integumentary status. A home visit was conducted on 5/13/2021 at noon for Patient #7. Staff B, Registered Nurse (RN), was waiting in the lobby with Patient #7, sitting in his wheelchair. Staff B rolled the resident to the elevator and then to his apartment. Patient #7 unlocked his door and self-propelled himself into his home. Staff B put a barrier on the floor and then put her bag on top of it. Staff B unzipped the top opening of the backpack-type bag and entered the bag, and pulled out a bottle of hand sanitizer. Staff B cleaned her hands and then pulled out a BP cuff, stethoscope, temporal Thermometer, and a pulse oximeter finger probe. Staff B then donned a pair of gloves. After taking the patient's vital signs with her gloves on and a small alcohol pad cleaned the bell of the stethoscope, sprayed the outer cover of the blood pressure cuff with an antiseptic spray, took off her gloves, and placed all of the equipment back in the center open area of her bag without washing or sanitizing her hands. Staff B then used hand sanitizer and then began to pull out wound care dressing supplies from a plastic container sitting on a dresser in the room. Staff B donned gloves, cleaned the open area to Patient #7's right BKA with saline spray, and dried it with gauze. Then with her gloves still on, Staff B went back into the basket of clean wound care supplies, pulled out a couple of packs of skin prep, and applied skin prep to the patient's wound to his right BKA. Staff B then removed her gloves and went into the center of her bag for a pair of scissors. Using the scissors, she cut a piece of a medicated dressing, then donned a pair of gloves, placed the medicated dressing on the patient's right BKA, and wrapped the area with a stretch bandage. Staff B removed her gloves, cleaned her scissors, put them back in her supply bag, put the old dressing supplies in the trash, and sanitized her hands. On 5/13/2021 at 12:25 p.m., Staff B, RN, confirmed she had not sanitized after removing her gloves and that she should have cleaned the equipment when she took it out of her nursing bag and before she put the equipment back in her bag. An interview was conducted on 5/13/2021 at approximately 2:40 p.m., with Agency Administrator, who said, "Staff are to clean their patient equipment before and after they use it. Hands are to be washed or sanitized before and after glove use. I expect that Staff should clean a wound, remove their gloves, sanitize their hands, and then don a new pair of gloves. If needed, they should sanitize their hands again." Patient #5 was an elderly patient admitted to the agency on the Start of Care date 4/22/2021. The Certification Period for the patient was 4/22/2021 to 6/20/2021. The Patient #5 had Orders to begin Physical Therapy (PT) and Occupational Therapy (OT) 4/22/2021, 1W1, 2W3; Evaluation and Treatment, Therapeutic Exercises, Transfer Training, Establish/Upgrade Home Exercise Program, and Progressive Gait Training. The Occupational Therapist (OT) took out his Thermometer and took temperature of patient-97.2 and 02 sat: 97%, P-76, R- BP-128/77. OT took out BP cuff and cleaned it, took patient’s Blood pressure. The OT rolled up the blood pressure cuff, thermometer, 02 sat monitor and stethoscope when done and returned it to the bag without cleaning. OT asked patient if she ate breakfast. She stated yes. He asked if patient has any pain. And patient placed her hand onto her right side under her arm. Then OT asked Patient #5 to start exercises. In an interview with the Occupational Therapist-Staff Member A at 10:30 a.m. on 5/13/2021, surveyor asked what the policy and procedure was for cleaning the visit tools they use in the home. He paused and didn’t respond. Then stated I clean the instruments upon removing them from my bag. Surveyor stated it was to clean tools before and after use. OT stated yes, you are right. In an interview at 9:16 a.m. on 5/14/2021, the Administrator stated that the proper way to clean instruments was cleaning them before and after use. She agreed that putting the equipment back in the bag without cleaning re-contaminated them. Record review of the policy and procedure titled “Skills-Medical Equipment : Cleaning and disinfecting (Home Health Care) Published: October 2020, stated under the topic Noncritical Equipment- 1. Stethoscope: Wipe he bell, diaphragm, and tubing with an alcohol or disinfectant wipe after patient use. Let the alcohol dry before placing the stethoscope into the nursing bag. 2. Blood pressure cuff: wipe all surfaces thoroughly with an alcohol or antiseptic wipe, making sure to clean the inside and outside of the cuff, all the tubing, and the blood pressure gauge. Let the alcohol dry before placing the cuff into the nursing bag. 4. Meters (glucometers, coagulometers, and pulse oximeters): wipe the outside of the monitor with an alcohol or disinfectant wipe after patient use. Follow the manufacturer’s specific recommendations for cleaning. 5. Temporal and tympanic thermometers: Wipe thermometers with an alcohol or antiseptic wipe before patient use. Use thermometer covers, if available, and discard them after use in an appropriate trash receptacle. Wipe thermometers with an alcohol or antiseptic wipe after patient use.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician as indicated in the plan of care; This ELEMENT is not met as evidenced by: This ELEMENT is NOT MET: Based on observations, interviews, and record reviews the agency failed to 1) Monitor the respiratory status and report abnormal oxygen saturation levels to the physician for 1 (#16) active patient out of 2 patients sampled with a diagnosis of COVID-19 and 2) Failed to assess and monitor weights for a patient with a history of heart failure and a new diagnosis of Atrial Fibrillation for 1(#3) patients out of 17 patients sampled. Findings included: A review of the agency policy titled Assessment/Reassessment with an original issue date of 6/99 and a revision date of 3/20 Policy: To determine the care and services to be provided to meet the Patient's needs. "Purpose: A comprehensive assessment/reassessment of the relevant physical and psychosocial needs of the Patient includes the collection and analysis of data about the Patient to determine the Patient's plan of care. Guidelines: 1.Assess Patient upon admission and with each skilled visit throughout care. On page 3 of 5: #7. Initial Comprehensive Assessment includes: A. Physical assessment/review of systems S. Reassess patient with each home visit to evaluate current problems, change in condition, and/or needs to adjust care/services provided, as indicated. i. Reassessment's findings/concerns document on discipline-specific visit notes ii. Notify physician and collaborate with Patient's team of clinicians involved in Patient's care. iii. Document collaboration in the electronic medical record. 9. Reassess Patient if/when the following occurs: A. A significant change in condition, diagnosis, care, environment, or support system occurs. B. Physician orders more frequent reassessments ... 10. Identify and prioritize patient needs and problems from analyzing data from assessments and reassessments to direct care/services and modify the plan of care.." A review of the agency COVID-19 Homecare Pathway provided by the Regional Clinical Director, without an implementation or revision date reflected: Skill Nurse (SN) to install Tele monitor to perform daily monitoring of weight, pulse ox, pulse, and blood pressure from home care after when the telemonitoring unit is installed. Instruct patient to monitor temperature twice a day: alteration and cardiopulmonary status. Perform pulse oximetry as needed for respiratory assessment. Notify physician for oxygen saturation's less than 92%..." 1. A record review was conducted for Patient #16 reflected a hospitalization date of 4/23/2021 with the diagnosis of COVID-19 and admission to home care on 4/30/2021 with a current physician-ordered plan of care (POC) for the certification period 4/30/2021 to 6/28/2021 with a primary diagnosis of COVID-19 and a secondary diagnosis of pneumonia due to Coronavirus Disease., Acute respiratory failure and Dependence on supplemental oxygen. Online 21: Orders for Discipline and Treatments of the POC the physician ordered SN 1wk2, 2wk1, 1wk6 3 PRN (as needed) visits for concerns, cardiopulmonary complications or change in condition. Observe, assess, intervene, and instruct in disease(s). Management per POC DX (diagnosis) COVID-19. Effective 5/01/2021, virtual/telephonic visits equal to 5-5 times a week alternating with SN visits for full 7- day coverage for two weeks. Instruct in medication regime/therapeutic actions/side effects, food/drug interactions and safety. SN to install telemonitor and perform daily telemonitoring of weight, pulse ox, pulse, and blood pressure from home care after installing the telemonitoring unit. Notify MD for 02 sat less than 95%.." A review of the medication profile revealed pertinent medications: Dexamethasone (steroid) Oral Tablet 2mg taper: 3 pills 1x day7 days, two pills 1 x day seven days. 1pill 1 x day seven days, then stop oral. Tessalon Perles (cough) oral capsule 100 mg 1 capsule oral three times a day and Albuterol Inhalation Aerosol Solution (bronchodilator) 80 MCG/ACT 2 puffs inhalation every 6 hours as needed for dyspnea, oxygen at 2 liters via nasal cannula at bedtime as needed for SOB (shortness of breath) ... A review of the initial nursing assessment dated 4/30/2021 on page 34 of 37 Reason for homecare/Chief Complaint/Injury: COVID-19, Pneumonia due to Coronavirus Disease 2019, Acute respiratory failure with Hypoxia. Significant Clinical Findings: Respirations 22. The initial nursing comprehensive assessment revealed the nurse did not document the Patient's oxygen saturation under Significant Clinical Findings. A review of the narrative part of the initial nursing assessment note under Skilled Treatment/Procedure/Teaching: Proper PPE (personal protective equipment) donned and doffed for COVID patient per protocol. Patient in the yellow zone for cardiopulmonary status, Patient with wheeze in LUL (left upper lung) and dry cough with occasional clear mucus. The Patient endorses SOB upon exertion, home oxygen available. Spouse directed to obtain a pulse ox to monitor Patient's oxygen saturation and call home health care for any oxygen below 95%..." There is no documentation of the Patient's oxygen saturation percentage on the initial comprehensive nursing assessment. A review of the nursing visit notes on 5/07/2021, 5/11/2021 revealed no documentation that the nurse assessed the Patient's pulse ox status. A review of Patient #16's home telemonitoring reports readings registered pulse oximeter readings below the 95% parameters established on the physician ordered POC: 4/30/2021: The medical record revealed no documentation that the nurse contacted the physician 93% at 2:43 p.m. 84% at 11:23 p.m. 93% at 2:59 p.m. 94% t 3:09 p.m. The nursing visit notes for 5/01/2021, 5/02/2021 revealed no pulse ox results. 5/03/2021: The medical record revealed no documentation that the physician was contacted regarding the oxygen saturation readings of: 94% at 6:32 p.m. 93% at 8:43 a.m. 89% at 2:17 p.m., 92 % at 2:35 p.m. 94% at 2:37 p.m. 92 % at 4:42 p.m. p.m. 5/04/2021: The medical record revealed no documentation that the physician was contacted. 93% at 9:40 a.m. 5/05/2021: The medical record revealed no documentation that the physician was contacted. 94% at 12:08 p.m. 5/06/2021: The medical record revealed no documentation that the physician was contacted. 93% at 10:56 a.m. 5/07/2021: The medical record revealed no documentation that the physician was contacted. 92% at 9:20 a.m. 93% at 9:21 a.m. 5/10/2021: The medical record revealed no documentation that the physician was contacted. 94% No pulse ox results for 5/11/2021 or 5/12/2021. 5/13/2021: The medical record revealed no documentation that the physician was contacted. 94% at 9:51 a.m. Interviewed the Regional Clinical Director on 5/13/2021 at 2:05 p.m., and the Regional Clinical Director confirmed no pulse ox documented on the admission visit on 4/30/2021. "I would expect them to get a baseline in the admission. The nurse should have assessed the oxygen saturation rate since it is part of the comprehensive assessment. I do not see that the telehealth results were called to the physician either." Interviewed the Agency Administrator on 5/14/2021 at 8:59 a.m., said, "The nurse should always report abnormal vital signs to the physician." Interviewed the Director of Nursing (DON) on 5/14/2021 at 9:55 a.m., when the Director of Nursing (DON) said, "O2 levels below the parameters, we would expect the nurses to call the physician". 2) A review of the medical record for Patient #3 reflected admission to home care on 4/24/2021. A current physician ordered POC for the certification period 4/24/2021 to 6/22/2021 with a primary diagnosis of Acute Diastolic (Congestive Heart Failure), Chronic kidney disease with heart failure, and unspecified Atrial fibrillation. On line 21: Orders for Discipline and Treatments of the POC, the physician ordered SN 2wk3, 1wk6 Observe, assess, intervene, and instruct in disease(s). Management per plan of care diagnosis(DX), Instruct in medication regime/therapeutic actions/side effects, food/drug interactions, and safety. Instruct on appropriate activity level and energy conservation techniques for CHF (congestive heart failure). SN may visit PRN x 2 for a weight increase of 2LB in one day or 5LB in one week. Perform pulse oximetry PRN respiratory assessment. COPD (Chronic Obstructive Pulmonary Disease) SN may visit PRN x 2 for increased SOB, mucus, ankle edema, and coughing. SN to install telemonitor. Perform daily telemonitoring of weights, pulse ox, pulse, and blood pressure from homecare after telemonitoring unit installed. May perform 3 PRN home visits for alteration in cardio-pulmonary status, perform pulse oximetry PRN respiratory assessment. Notify MD for 02 less than 88%..." A review of the medication profile revealed appropriate medications: Albuterol Inhalation Aerosol Solution (bronchodilator) 80 MCG/ACT 2 puffs inhalation every 4 hours as needed, Amlodipine Besylate 2.5 mg 1 tab oral daily, Bumetanide 0.5mg 1 tab daily as needed for shortness of breath, Spironolactone 25mg ½ tab orally daily. A review of the initial nursing assessment dated 4/24/2021 revealed no documentation of the Patient's actual weight. A review of the nursing visit notes for 4/25/2021 and 4/26/2021 revealed no documentation of the Patient weight. However, a review of the telemonitoring report reflected electronic recordings of the Patient's weights starting on 4/28/2021. A home visit was conducted on 5/12/2021 at 2:15 p.m. for Patient #3 with Staff C, Registered Nurse (RN). Staff C performed a complete head-to-toe assessment that included vital signs that Staff C compared her manual readings against the telemonitoring system readings at 2:27 p.m., from the earlier electronic readings on at 9:58 a.m. Staff C did not get a weight on Patient #3 during the home visit. A review of the telemonitoring report for 5/12/2021 confirms that the nurse did not weigh the Patient during the home visit. An interview was conducted on 5/13/2021 at 2:30 p.m., the Regional Clinical Director said, "Yes, as part of the initial assessment, the nurse should have weighed the patient." An interview was conducted on 5/13/2021 at 3:00 p.m., the Agency Administrator said, "The weight we have documented is 150 pounds. That is the weight that was put in by central intake when the referral came over. I do not see another weight documented by the nurse on admission or the two nursing visits, 4/25/2021 or 4/26/2021. The Patient's weights were documented once the telemonitoring was put in on 4/28/2021 by the home health aide. The nurses should be weighing the Patient on each home visit and documenting the weights. If nothing more than to make sure the telemonitoring machine is calibrated and working correctly." test

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: This ELEMENT is NOT MET: Based on observations, interviews, and record reviews the agency failed to notify the physician with significant changes in a patients respiratory status for 1 (#16) patient out of 17 total patients sampled and failed to notify the physician of an injury to a foot for a diabetic patient for 1 (#8) of 17 total patients reviewed. Findings included: A review of the agency policy titled Assessment/Reassessment with an original issue date of 6/99 and a revision date of 3/20 Policy: To determine the care and services to be provided to meet the patient's needs. "Purpose: A comprehensive assessment/reassessment of the relevant physical and psychosocial needs of the patient includes the collection and analysis of data about the patient to determine the patient's plan of care. Guidelines: 1.Assess patient upon admission and with each skilled visit throughout course of care. On page 3 of 5: #7. Initial Comprehensive Assessment includes: A. Physical assessment/review of systems S. Reassess patient with each home visit to evaluate current problems, change in condition, and/or needs to adjust care/services provided, as indicted. i. Reassessment's findings/concerns document on discipline specific visit notes ii. Notify physician and collaborate with patient's team of clinicians involved in patient's care. iii. Document collaboration in electronic medical record. 9. Reassess patient if/when the following occurs: A. A significant change in condition, diagnosis, care, environment, or support system occurs. B. Physician orders more frequent reassessments ... 10. Identify and prioritize patient needs and problems from analyzing data from assessments and reassessments to direct care/services and modify plan of care.." 1. A record review was conducted for Patient #16 reflected a hospitalization date of 4/23/2021 with the diagnosis of COVID-19 and admission to home care on 4/30/2021 with a current physician-ordered plan of care (POC) for the certification period 4/30/2021 to 6/28/2021 with a primary diagnosis of COVID-19 and a secondary diagnosis of pneumonia due to Coronavirus Disease., Acute respiratory failure and Dependence on supplemental oxygen. Online 21: Orders for Discipline and Treatments of the POC the physician ordered SN 1wk2, 2wk1, 1wk6 3 PRN (as needed) visits for concerns, cardiopulmonary complications or change in condition. Observe, assess, intervene, and instruct in disease(s). Management per POC DX (diagnosis) COVID-19. Effective 5/01/2021, virtual/telephonic visits equal to 5-5 times a week alternating with SN visits for full 7- day coverage for two weeks. Instruct in medication regime/therapeutic actions/side effects, food/drug interactions and safety. SN to install telemonitor and perform daily telemonitoring of weight, pulse ox, pulse, and blood pressure from home care after installing the telemonitoring unit. Notify MD for 02 sat less than 95%.." A review of the medication profile revealed pertinent medications: Dexamethasone (steroid) Oral Tablet 2mg taper: 3 pills 1x day7 days, two pills 1 x day seven days. 1pill 1 x day seven days, then stop oral. Tessalon Perles (cough) oral capsule 100 mg 1 capsule oral three times a day and Albuterol Inhalation Aerosol Solution (bronchodilator) 80 MCG/ACT 2 puffs inhalation every 6 hours as needed for dyspnea, oxygen at 2 liters via nasal cannula at bedtime as needed for SOB (shortness of breath) ... A review of the initial nursing assessment dated 4/30/2021 on page 34 of 37 Reason for homecare/Chief Complaint/Injury: COVID-19, Pneumonia due to Coronavirus Disease 2019, Acute respiratory failure with Hypoxia. Significant Clinical Findings: Respirations 22. The initial nursing comprehensive assessment revealed the nurse did not document the Patient's oxygen saturation under Significant Clinical Findings. A review of the narrative part of the initial nursing assessment note under Skilled Treatment/Procedure/Teaching: Proper PPE (personal protective equipment) donned and doffed for COVID patient per protocol. Patient in the yellow zone for cardiopulmonary status, Patient with wheeze in LUL (left upper lung) and dry cough with occasional clear mucus. The Patient endorses SOB upon exertion, home oxygen available. Spouse directed to obtain a pulse ox to monitor Patient's oxygen saturation and call home health care for any oxygen below 95%..." There is no documentation of the Patient's oxygen saturation percentage on the initial comprehensive nursing assessment. A review of the nursing visit notes on 5/07/2021, 5/11/2021 revealed no documentation that the nurse assessed the Patient's pulse ox status. A review of Patient #16's home telemonitoring reports readings registered pulse oximeter readings below the 95% parameters established on the physician ordered POC: 4/30/2021: The medical record revealed no documentation that the nurse contacted the physician 93% at 2:43 p.m. 84% at 11:23 p.m. 93% at 2:59 p.m. 94% t 3:09 p.m. The nursing visit notes for 5/01/2021, 5/02/2021 revealed no pulse ox results. 5/03/2021: The medical record revealed no documentation that the physician was contacted regarding the oxygen saturation readings of: 94% at 6:32 p.m. 93% at 8:43 a.m. 89% at 2:17 p.m., 92 % at 2:35 p.m. 94% at 2:37 p.m. 92 % at 4:42 p.m. p.m. 5/04/2021: The medical record revealed no documentation that the physician was contacted. 93% at 9:40 a.m. 5/05/2021: The medical record revealed no documentation that the physician was contacted. 94% at 12:08 p.m. 5/06/2021: The medical record revealed no documentation that the physician was contacted. 93% at 10:56 a.m. 5/07/2021: The medical record revealed no documentation that the physician was contacted. 92% at 9:20 a.m. 93% at 9:21 a.m. 5/10/2021: The medical record revealed no documentation that the physician was contacted. 94% No pulse ox results for 5/11/2021 or 5/12/2021. 5/13/2021: The medical record revealed no documentation that the physician was contacted. 94% at 9:51 a.m. Interviewed the Regional Clinical Director on 5/13/2021 at 2:05 p.m., and the Regional Clinical Director confirmed no pulse ox documented on the admission visit on 4/30/2021. "I would expect them to get a baseline in the admission. The nurse should have assessed the oxygen saturation rate since it is part of the comprehensive assessment. I do not see that the telehealth results were called to the physician either." Interviewed the Agency Administrator on 5/14/2021 at 8:59 a.m., said, "The nurse should always report abnormal vital signs to the physician." Interviewed the Director of Nursing (DON) on 5/14/2021 at 9:55 a.m., when the Director of Nursing (DON) said, "O2 levels below the parameters, we would expect the nurses to call the physician". 2. Review of the record for Patient # 8 revealed that he was admitted to home care on 3/7/21 with a Primary Diagnosis of Chronic Diastolic ( Congestive) Heart Failure and a pertinent diagnosis of Type 2 Diabetes Mellitus without complications. Patient # 8 received skilled nursing services and physical therapy services. Review of a physical therapy evaluation , completed 3/24/21, revealed under "Sensation/ Coordination/ Muscle Tone/ Other" that the patient had " Decreased /Absent sensation to bilateral plantar feet. " Review of a physical therapy visit note, dated 4/12/21 revealed that Patient # 8 reported " I think I stepped on something last Friday night and the bottom of my left foot is a little sore:" The physical therapist assessment revealed " No wounds present, very small ( less than 2 MM ) of a healed abrasion with no blood, on the lateral toe pad area." There was no documentation that the physical therapist reported the injury to the agency, the skilled nurse or the physician. Review of a " Transfer to an inpatient facility " form revealed that the patient was admitted to a hospital and the last home health visit was 4/12/21 by physical therapy. Review of a "HH Addendum" from , dated 4/16/21 revealed " Patient to PCP ... on 4/16. Patient not feeling well. Patient reports to Dr. that he is noncompliant with diabetic management, alcohol Consumption frequently. Patient reports home has been under renovation and patient reports to That he stepped on something causing toe to bleed. . Patient direct admitted to ( Hospital) with Left Great Toe Cellulitis. Last billable home care visit was 4/12/21. " Interview with the Regional Clinical Director, on 5/13/21 at 3: 10 p.m., revealed that she was unable to find any documentation that the wound on the foot was reported to the physician or the agency supervisor. She stated it should have been written up as an incident. The DON and the Administrator, on 5/14/21 at 10: 01 a.m. stated that the foot injury was not addressed and the physician and supervisor should have been informed