Every finding on record at Blessed Trinity Home Care, Inc

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site Recertification Survey (5F80E-H1) at the above-named Home Health Agency (HHA) from 04/03/23 to 04/07/23 resulted in the following deficiencies respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.22.

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: Based on observation, interview, record review, document review, and policy review, it was determined that the agency failed to provide individualized emergency preparedness plans for 4 (Patient 1, Patient 2, Patient 3, and Patient 4) of 4 patient observations. This failure created the potential for patients and staff being unclear on how to protect the patients and respond during a natural or man-made disaster. Findings Include: Review of the agency policy titled, “Admission Criteria and Process,” revised in 12/2010, showed the patient and family/caregiver was to be provided with a brochure and various educational materials providing sufficient information on emergency management plans. Patient 1 Review of Patient 1’s “Home Health Certification and Plan of Care” (POC), dated 03/27/23, showed the agency admitted Patient 1 on 03/27/23 with diagnoses that included a stage 4 (a deep wound reaching the muscles, ligaments, or bones) pressure ulcer of the sacral region, and a colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall). During an observation conducted in Patient 1’s home on 04/03/23 at 2:00 PM, showed the undated “[Agency] Admission Packet” provided to the patient did not include the patient emergency preparedness plan and information section. Patient 2 Review of Patient 2’s “Home Health Certification and Plan of Care” (POC), dated 02/28/23, showed the agency admitted Patient 2 on 02/28/23 with diagnoses that included complications due to an orthopedic procedure (a procedure that involved bones, joints, ligaments, tendons, muscles, nerves, and skin) and acute posthemorrhagic anemia (lowered red blood cell count due to rapid loss of blood). During an observation conducted in Patient 2’s home on 04/04/23 at 9:50 AM, showed the undated “[Agency] Admission Packet” provided to the patient did not contain the patient emergency preparedness plan and information section. Patient 3 Review of Patient 3’s “Home Health Certification and Plan of Care” (POC), dated 03/09/23, showed the agency completed an assessment and admitted Patient 3 on 03/09/23 with diagnoses that included bilateral primary osteoarthritis of the knees (a condition where both knee joints have cartilage damage that causes pain, stiffness, and swelling) and chronic pain syndrome (a condition of persistent or intermittent pain that lasts for more than three months). During an observation conducted in Patient 3’s home on 04/04/23 at 11:15 AM, showed the undated “[Agency] Admission Packet” provided to the patient did not contain the patient emergency preparedness plan and information section. Patient 4 Review of Patient 4’s “Home Health Certification and Plan of Care” (POC), dated 02/28/23, showed the agency admitted Patient 4 on 02/28/23 with diagnoses that included primary generalized (osteo)arthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down) and cervical disc disorder with myelopathy (a compression of the spinal cord at the cervical level of the spinal column resulting in spasticity such as sustained muscle contractions, hyperreflexia, pathologic reflexes, digit/hand clumsiness, and/or gait disturbance). During an observation conducted in Patient 4’s home on 04/04/23 at 1:25 PM, showed the undated “[Agency] Admission Packet” provided to the patient did not contain the patient emergency preparedness plan and information section. During an interview on 04/07/23 at 10:06 AM, Staff A, Regional Director of Clinical Services (RDCS), stated that the agency expected staff to provide patients with an individualized emergency preparedness plan at the time of admission by completing the patient emergency preparedness plan and information section in the “[Agency] Admission Packet” given to each patient on admission. Staff A, RDCS, stated that these plans were not uploaded to the patient’s electronic medical record. Staff A, RDCS, confirmed that if a patient’s admission packet did not contain the patient emergency preparedness plan and information, the agency was not following their policy.

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site Recertification survey (5F80E-H1) conducted at the above-named Home Health Agency (HHA) from 04/03/23 to 04/07/23 resulted in a finding of substantial compliance respective to applicable Condition of Participation (CoP) under 42 CFR 484, Subpart A through C with the following standard-level deficiencies cited.

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on observation, interview, record review, document review, and policy review, it was determined that the agency failed to provide administrator contact information to 2 (Patient 1 and Patient 2) of 4 patient observations. This failure created the potential that patients would not know who and how to contact the administrator about service concerns and unmet service needs. Findings Include: Review of an agency policy titled, “Admission Criteria and Process,” revised in 12/2010, showed the patient and family/caregiver were to be provided with an organization brochure and various educational materials providing sufficient information on the complaint and grievance process. The policy did not indicate administrator contact information was to be provided. Patient 1 Review of Patient 1’s “Home Health Certification and Plan of Care” (POC), dated 03/27/23, showed the agency admitted Patient 1 on 03/27/23 with diagnoses that included a stage 4 (a deep wound reaching the muscles, ligaments, or bones) pressure ulcer of the sacral region, and a colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall). Concurrent observation and interview conducted in Patient 1’s home on 04/03/23 at 2:00 PM, showed the undated “[Agency] Admission Packet” did not contain contact information for the agency administrator. Patient 1’s family member stated they did not know who to contact over the weekend should the need arise. Patient 2 Review of Patient 2’s “Home Health Certification and Plan of Care” (POC), dated 02/28/23, showed the agency admitted Patient 2 on 02/28/23 with diagnoses that included complications due to an orthopedic procedure (a procedure that involved bones, joints, ligaments, tendons, muscles, nerves, and skin) and acute posthemorrhagic anemia (lowered red blood cell count due to rapid loss of blood). During a concurrent observation and interview conducted in Patient 2’s home on 04/04/23 at 9:50 AM, the undated “[Agency] Admission Packet, did not contain contact information for the agency administrator. Patient 2 stated they would call the agency administrator with any concerns but did not know the agency administrator’s name. During an interview on 04/06/23 at 1:05 PM, Staff B, Administrator (ADM), stated that the agency expected staff to provide patients with the administrator's name and contact information at the time of admission by documenting the administrator's name and contact information in the “[Agency] Admission Packet” given to each patient on admission. Staff B, Administrator, confirmed that if a patient’s admission packet did not contain the administrator's name and contact information, the agency was not following their policy.

Patient's or legal representative's signature CFR(s): 484.50(a)(2) Obtain the patient's or legal representative's signature confirming that he or she has received a copy of the notice of rights and responsibilities. This ELEMENT is not met as evidenced by: Based on interview, record review, and policy review, it was determined that the agency failed to obtain a patient’s signature confirming receipt of the notice of rights and responsibilities for 1 (Patient 9) of 10 patient records reviewed. This failure created the potential for the patient being unaware of their rights. Findings Include: Review of the agency policy titled, “Admission Criteria and Process,” revised in 12/2010, showed the patient or his/her representative was to sign the required forms indicating acceptance of services and receipt of patient rights and privacy information. Patient 9 Review of Patient 9’s “Home Health Certification and Plan of Care” (POC) dated 05/20/22, showed the agency admitted Patient 9 on 05/20/22, with diagnoses that included pressure ulcers (wounds caused by pressure) on the buttocks, sacral area, and left heel, and heart failure. Further review showed that Patient 9 was oriented to person, place, and time and did not have a legal guardian. Review of Patient 9’s entire clinical record showed that the agency had not obtained Patient 9’s signature confirming that the agency had provided a copy of the patient’s notice of rights and responsibilities. During an interview on 04/05/23 at 1:30 PM, Staff A, Regional Director of Clinical Services (RDCS), stated that the agency policy was for staff to provide patients or their legal guardian with a copy of the patient’s notice of rights and responsibilities and to obtain the patient's or legal guardian's signature confirming that the agency had provided them with the notice. During an interview on 04/07/23 at 12:30 PM, Staff A, RDCS, stated that the agency was unable to provide documentation showing the agency had obtained a signature from Patient 9 indicating receipt of the notice of rights and responsibilities, and acknowledged the agency was not following their policy.

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on interviews, document review, and policy review, it was determined that the agency failed to document the investigation and outcome for 1 of 1 complaint reviewed. This failure created the potential for other patients to have similar experiences or concerns remain unresolved. Findings Include: Review of the agency policy titled, “Complaint/Grievance Process,” revised June 2021, showed, “Complaints and any action taken will be documented on a complaint form.” Review of the agency's 2021 complaint log showed the agency received a complaint on 01/28/21 regarding a delay in service provision. Further review of the complaint log revealed the log failed to show documentation that the complaint was investigated, any findings related to the complaint, or any information to address the resolution status of the complaint. During an interview on 04/05/23 at 9:00 AM, Staff A, Regional Director of Clinical Services (RDCS), stated that the agency expectation was that complaint logs should include documentation of the complaint investigation and resolution. Staff A, RDCS, further stated that the agency did not have additional documentation regarding the investigation and resolution of the 01/28/21 complaint. During an interview on 04/07/23 at 12:30 PM, Staff A, RDCS, acknowledged the agency was not following their complaint process.

Standard: Initial assessment visit. CFR(s): 484.55(a) Standard: Initial assessment visit. This STANDARD is not met as evidenced by: Based on interview, record review, and policy review, it was determined that the agency failed to complete initial assessments within 48 hours of receipt of referrals for 3 (Patient 1, 3, and 4) of 10 patient records reviewed. This failure created the potential for the patients to not receive necessary care and services. Findings Include: Review of the agency policy titled, “Admission Criteria and Process,” revised in 12/2010, showed the initial visit must be performed either within 48 hours of the referral, within 48 hours of the patient’s return home, or on the start of the care date ordered by the healthcare professional (or other authorized licensed independent practitioner). Patient 1 Review of Patient 1’s “Home Health Certification and Plan of Care" (POC), dated 03/27/23, showed the agency admitted Patient 1 on 03/27/23 with diagnoses that included a stage 4 (a deep wound reaching the muscles, ligaments, or bones) pressure ulcer of the sacral region and a colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall). Review of Patient 1’s demographic record showed the agency received a referral on 03/23/23 to provide Patient 1 with agency services. Review of Patient 1’s entire clinical record showed the agency did not assess Patient 1 within 48 hours of receiving Patient 1’s referral for service and there was no documented agency communication with Patient 1 related to the delayed assessment. The agency did not provide any additional documentation related to the delayed assessment. Patient 3 Review of Patient 3’s “Home Health Certification and Plan of Care" (POC), dated 03/09/23, showed the agency completed an assessment and admitted Patient 3 on 03/09/23 with diagnoses that included bilateral primary osteoarthritis of the knee (a condition where both knee joints have cartilage damage that causes pain, stiffness, and swelling) and chronic pain syndrome (a condition of persistent or intermittent pain that lasts for more than three months). Review of Patient 3’s demographic record showed the agency received a referral on 03/06/23 to provide Patient 3 with agency services. Review of Patient 3’s entire clinical record showed that the agency did not assess Patient 3 within 48 hours of receiving Patient 3’s referral for service and there was no documented agency communication with Patient 3 related to the delayed assessment. The agency did not provide any additional documentation related to the delayed assessment. Patient 4 Review of Patient 4’s “Home Health Certification and Plan of Care" (POC), dated 02/28/23, showed the agency admitted Patient 4 on 02/28/23 with diagnoses that included primary generalized (osteo)arthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down) and cervical disc disorder with myelopathy (a compression of the spinal cord at the cervical level of the spinal column resulting in spasticity such as sustained muscle contractions, hyperreflexia, pathologic reflexes, digit/hand clumsiness, and/or gait disturbance). Review of Patient 4’s demographic record showed the agency received a referral on 02/16/23 to provide Patient 4 with agency services “on or around 02/22/23.” Review of Patient 4’s entire clinical record showed that the agency did not assess Patient 4 within 48 hours of the physician’s ordered start date and there was no documented agency communication with Patient 4 related to the delayed assessment. The agency did not provide any additional documentation related to the delayed assessment. During an interview on 04/05/23 at 4:00 PM, Staff A, Regional Director of Clinical Services (RDCS), stated that she was aware the agency had delayed initial assessments due to the volume of referrals the agency had received. Staff A stated that if the agency did not have a clinician to complete a patient’s initial assessment within 48 hours of receiving a referral for service, she would contact the physician to delay the initial assessment date. Staff A further stated that if the patient’s initial assessment date could not be delayed, the agency would refuse the referral. During an interview on 04/07/23 at 12:30 PM, Staff A, RDCS, confirmed that Patient 1, Patient 3, and Patient 4, had delayed initial assessment dates and acknowledged that the agency was not following their policy.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on interview, record review, and policy review, it was determined the agency failed to ensure a registered nurse (RN), or other authorized personnel licensed in the state of Kansas, received and transcribed a telephone physician's order for 1 (Patient 2) of 10 patient records reviewed. This failure created the potential for lack of order clarification and/or accuracy based on the transcriptionist's lack of qualification to engage in order transcription in the state of Kansas. Findings Include: Review of the agency policy titled, “Verification of Healthcare Professional Orders,” revised in 09/2017, showed orders were to be taken only by professional, licensed home health personnel. Document review of Kansas Home Health licensing regulation 28-51-100 (tt), dated 05/05/22, showed a "Registered Nurse" means an individual who is licensed by the state board of nursing as a registered professional nurse or an individual who has a multistate license as a registered nurse specified in K.S.A. 65-1166, and amendments thereto" ... Patient 2 Review of Patient 2’s “Home Health Certification and Plan of Care" (POC), dated 02/28/23, showed the agency admitted Patient 2 on 02/28/23 with diagnoses that included complications related to an orthopedic procedure (a procedure that involved bones, joints, ligaments, tendons, muscles, nerves, and skin) and acute post hemorrhagic anemia (lowered red blood cell count due to rapid loss of blood). Review of Patient 2’s demographic record showed the agency received a referral on 02/24/23 to provide Patient 2 with agency services. Review of a “Patient Communication,” dated 02/24/23, showed Staff A, Regional Director of Clinical Services (RDCS), received a verbal order from Patient 2’s physician to change Patient 2’s start of care date to 02/28/23. During an interview on 04/03/23 at 9:30 AM, Staff A, RDCS, stated that she was a registered nurse (RN), resided in Ohio, had oversight of home health agencies in four states, and functioned as the alternate administrator performing the duties of the administrator when the administrator was not available. Review of an online "Nursys" a nurse licensure verification website, showed Staff A, RDCS, had a single state RN license in the state of Ohio, and no RN license in the state of Kansas. During an interview on 04/03/23 at 10:05 AM, Staff B, Administrator (ADM), stated that the RDCS functioned as the clinical manager for the agency. A concurrent agency personnel file review and interview, conducted on 04/07/23 at 10:00 AM, with Staff G, Human Resources Specialist (HRC), showed that the RDCS did not have a current Kansas RN license. Staff G, HRC, confirmed the RDCS did not have a current Kansas RN license. During an interview on 04/07/23 at 1:00 PM, Staff A, RDCS, confirmed she did not have a Kansas RN license.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on observation, interview, record review, and policy review, it was determined that the agency failed to provide clinical manager contact information for 4 (Patient 1, 2, 3, and 4) of 4 patient observations. This failure created the potential for the patients to not be able to contact the clinical manager about service concerns and unmet service needs. Findings Include: Review of the agency policy titled, “Admission Criteria and Process,” revised in 12/2010, showed the patient and family/caregiver were to be provided with an organization brochure and various educational materials providing sufficient information on the complaint and grievance process. Patient 1 Review of Patient 1’s “Home Health Certification and Plan of Care" (POC), dated 03/27/23, showed the agency admitted Patient 1 on 03/27/23 with diagnoses that included a stage 4 (a deep wound reaching the muscles, ligaments, or bones) pressure ulcer of the sacral region and a colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall). Concurrent observation and interview conducted in Patient 1’s home on 04/03/23 at 2:00 PM, showed the undated “[Agency] Admission Packet” did not contain contact information for the clinical manager. Patient 1’s family member stated they did not know who to contact over the weekend should the need arise. Patient 2 Review of Patient 2’s “Home Health Certification and Plan of Care" (POC), dated 02/28/23, showed the agency admitted Patient 2 on 02/28/23 with diagnoses that included complications due to an orthopedic procedure (a procedure that involved bones, joints, ligaments, tendons, muscles, nerves, and skin) and acute posthemorrhagic anemia (lowered red blood cell count due to rapid loss of blood). Concurrent observation and interview conducted in Patient 2’s home on 04/04/23 at 9:50 AM, showed the undated “[Agency] Admission Packet” did not contain contact information for the agency clinical manager. Patient 2 stated they would call the agency administrator with any concerns but did not know the agency administrator’s name. Patient 3 Review of Patient 3’s “Home Health Certification and Plan of Care" (POC), dated 03/09/23, showed the agency admitted Patient 3 on 03/09/23 with diagnoses that included bilateral primary osteoarthritis of the knees (a condition where both knee joints have cartilage damage that causes pain, stiffness, and swelling) and chronic pain syndrome (a condition of persistent or intermittent pain that last for more than three months). Observation conducted in Patient 3’s home on 04/04/23 at 11:45 AM, showed the undated “[Agency] Admission Packet” did not contain contact information for the agency clinical manager. Patient 4 Review of Patient 4’s “Home Health Certification and Plan of Care" (POC), dated 02/28/23, showed the agency admitted Patient 4 on 02/28/23 with diagnoses that included primary generalized (osteo)arthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down) and cervical disc disorder with myelopathy (a compression of the spinal cord at the cervical level of the spinal column resulting in spasticity such as sustained muscle contractions, hyperreflexia, pathologic reflexes, digit/hand clumsiness, and/or gait disturbance). Observation conducted in Patient 4’s home on 04/04/23 at 2:20 PM, showed the undated “[Agency] Admission Packet” did not contain contact information for the agency clinical manager. During an interview on 04/06/23 at 2:44 PM, Staff A, Regional Director of Clinical Services (RDCS), stated that the agency expected staff to provide patients with the clinical manager’s name and contact information at the time of admission by documenting the clinical manager’s name and contact information in the “[Agency] Admission Packet” given to each patient on admission. Staff A, RDCS, confirmed that if a patient’s admission packet did not contain the clinical manager’s name and contact information, the agency was not following their policy.

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, interview, record review, document review, and policy review, it was determined that the agency failed to follow accepted standards of practice to prevent transmission of infection and communicable diseases for 3 (Patients 1, 2, and 4) of 4 patient observations. This failure created the potential for patients to be at risk for increased infections and communicable diseases. Findings Include: Document review of the agency policy titled, "Hand Hygiene," revised in 07/2011, showed hand decontamination using an alcohol-based hand rub should be performed after removing gloves. The policy also showed that when hands were washed using soap and water staff were to rinse with water and dry the hands with a disposable towel. Document review of the agency policy titled, "Bag Technique," revised in 02/2021, showed that prior to administering care and before opening a patient care supply bag, hand hygiene should be performed. In addition, the policy showed the bag will contain a designated clean and dirty area; the clean area is designated for unused or clean supplies/equipment; the dirty area is for contaminated materials (i.e., used equipment, etc.). When the visit is completed, the policy showed agency staff hands will be decontaminated, reusable equipment including reusable barriers, will be cleaned using alcohol and will be returned to the bag. Patient 1 Review of Patient 1’s “Home Health Certification and Plan of Care” (POC), dated 03/27/23, showed the agency admitted Patient 1 on 03/27/23 with diagnoses that included a stage 4 (deep wound reaching the muscles, ligaments, or bones) pressure ulcer of the sacral region, and a colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall). Observations on 04/03/23 at 2:00 PM, conducted in Patient 1’s home, showed Staff C, Registered Nurse (RN), did not conduct hand hygiene prior to reaching into the clean section of the bag. After retrieving assessment equipment from the bag, Staff C, RN, held the equipment against her scrub top during transfer to the patient. After obtaining vital signs, Staff C, RN, placed the used equipment on the computer’s keyboard and did not sanitize the keyboard after removing the equipment. Staff C, RN, did not clean the blood pressure cuff after the cuff fell onto the computer keyboard, and before placing it in the bag. While conducting a wound dressing change, Staff C, RN, did not use hand sanitizer after doffing gloves and before donning a new pair of gloves and applying a clean dressing. Staff C, RN, used the patient’s cloth towels in the bathroom after washing her hands rather than using disposable towels to dry her hands. Patient 2 Review of Patient 2’s “Home Health Certification and Plan of Care” (POC), dated 02/28/23, showed the agency admitted Patient 2 on 02/28/23 with diagnoses that included complications due to an orthopedic procedure (a procedure that involved bones, joints, ligaments, tendons, muscles, nerves, and skin) and acute posthemorrhagic anemia (lowered red blood cell count due to rapid loss of blood). Observation on 04/04/23 at 9:20 AM, conducted in Patient 2’s home, showed Staff D, Licensed Practical Nurse (LPN), reaching into the clean section of the bag without first doffing gloves and conducting hand hygiene using an alcohol-based hand rub. Patient 4 Review of Patient 4’s “Home Health Certification and Plan of Care” (POC), dated 02/28/23, showed the agency admitted Patient 4 on 02/28/23 with diagnoses that included primary generalized (osteo)arthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down) and cervical disc disorder with myelopathy (a compression of the spinal cord at the cervical level of the spinal column resulting in spasticity such as sustained muscle contractions, hyperreflexia, pathologic reflexes, digit/hand clumsiness, and/or gait disturbance). Observation on 04/04/23 at 1:25 PM, conducted in Patient 4’s home, showed Staff F, Physical Therapy Assistant (PTA), using a pulse oximeter on the patient’s finger. After removing the pulse oximeter from the patient's finger, Staff F, PTA, placed the pulse oximeter in his scrub pocket without first cleansing or sanitizing the device. Staff F, PTA, repeated this procedure five times before decontaminating the pulse oximeter and returning it to the bag. During an interview on 04/04/23 at 2:15 PM, Staff F, PTA, confirmed the pulse oximeter was considered “dirty” after it was placed on a patient's finger. Staff F, PTA, confirmed the device was not cleansed or sanitized before it was placed in a scrub pocket and prior to reusing the device. Staff F, PTA, stated this was typical practice during his patient visits. During an interview on 04/06/23 at 1:45 PM, Staff A, Regional Director of Clinical Services (RDCS), stated that the agency expected staff to sanitize hands between glove changes and use disposable paper towels rather than a patient’s cloth towels. Staff A, RDCS, did not indicate if a pocket would be considered clean or dirty after placing used equipment in the pocket. Staff A, RDCS, confirmed that if staff members completed hand hygiene and bag technique as observed and described above, the agency was not following their policy.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on interview, record review, and policy review, it was determined that the agency failed to provide services as ordered by a physician for 1 (Patient 7) of 10 patient records reviewed. Failure to provide services as ordered and indicated in the plan of care places patients at risk for not receiving needed care and services. Findings Include: Document review of an agency policy titled “Care Planning Process,” revised in 09/2017, showed care, treatment or services will be provided using the most recent patient order(s). Patient 7 Review of Patient 7’s “Home Health Certification and Plan of Care" (POC), dated 02/22/23, showed the agency admitted Patient 7 on 10/29/22 with diagnoses that included displaced simple supracondylar fracture without intercondylar fracture of right humerus (a break in the upper bone of the right arm) and type 2 diabetes mellitus with diabetic neuropathy (a condition where high blood sugar levels damage the nerves over time). Review of a “Patient Communication,” dated 03/13/23, showed Patient 7 was admitted at a local hospital on 03/10/23 with an altered mental status (a change in brain function). Review of Patient 7’s “Post Hospital Orders,” dated 03/17/23, showed the agency resumed providing services for Patient 7 on 03/17/23, and the agency was to provide a speech therapy (ST) evaluation to Patient 7. Review of Patient 7’s entire clinical record from 03/17/23 through 04/07/23 showed the agency did not provide an ST evaluation for Patient 7. During an interview on 04/07/23 at 12:30 PM, Staff A, Regional Director of Clinical Services (RDCS), stated that the agency was unable to provide documentation showing the agency provided a ST evaluation for Patient 7 or documentation indicating the reason the evaluation had not occurred. Staff A, RDCS acknowledged the agency did not follow their policy.