Every finding on record at Bridges Home Health

A Recertification Survey was conducted by Healthcare Management Solutions, LLC on behalf of the Nevada Department of Health and Human Services. An unannounced on-site Recertification Survey at the above-named Home Health Agency (HHA) from 03/22/23 to 03/23/23 resulted in a finding of no deficiency citations respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.102.

A Recertification Survey was conducted by Healthcare Management Solutions, LLC on behalf of Nevada Department of Health and Human Services. An unannounced on-site recertification survey conducted at the above-named Home Health Agency (HHA) facility from 03/22/23 to 03/23/23 resulted in a finding of substantial compliance respective to the applicable Condition of Participation (CoP) under 42 CFR 484, Subparts A through C with the following standard-level deficiencies listed below.

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 document review, policy review, and interview, the agency failed to provide the patient with the name of the Administrator to contact in the event the patient had a complaint or concern. Failure to provide the required information could potentially discourage the patient, family, or caregiver from calling the agency with a concern. Findings include: Review of the patient rights information provided to the patient on admission revealed, report any complaints or grievances with respect to care that is furnished (without interference, coercion, discrimination or reprisal) to the Home Health Administrator. A phone number was included but the document did not include the name of the Administrator. During an interview at 1:40 PM on 03/23/23, the Administrator reviewed the document and confirmed the administrator's name was not identified. Review of the policy provided by the agency titled, Complaint Resolution, dated 2014, documented to provide a mechanism for use by the patient or employee to ensure response and, if possible, resolution of a complaint in a timely manner. To provide administrative persons an opportunity to review responses to complaints as indicated. The policy did not include the requirement to provide the patient with the name of the Administrator.

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 record reviews, policy reviews, and interviews, the home health agency (HHA) failed to ensure aide visits were performed as ordered in the patient's plan of care (POC) for one (Patient (P) 2) of three patient records reviewed with aide services from a sample of seven patients. This deficient practice had the potential for P2 to have unmet care needs. Findings include: Review of the undated policy titled Patient Admission Criteria, documented "Care follows a written plan of care established and reviewed at least every 60 days by the physician . . ." Review of the undated policy titled Home Health Aide Services and Training Program, documented "The duties of the HHA [home health aide] are to provide services that are physician ordered in the plan of care. . ." Review of P2's Home Health Certification and Plan of Care, for the period of 11/30/22 to 01/28/23 indicated physician orders for home health aide two times a week for nine weeks. Review of a physician order, dated 11/25/22 indicated an aide frequency of two times a week times eight weeks. Review of the calendar of visits made, indicated P2 received home health aide visits two times a week for eight weeks rather than nine weeks as ordered in P2's POC. In an interview on 03/23/23 at 12:11 PM, Administrator (who is a registered nurse) stated P2's POC was dated after the physician order of 11/25/22. Administrator stated P2's aide should have seen P2 for nine weeks.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on record reviews, policy reviews, and interviews, the home health agency (HHA) failed to ensure the Registered Nurse (RN) provided patient care instructions for the home health aide to follow for two (Patient (P) 1, P6) of three patient records reviewed with aide services provided from a sample of seven patient records. This had the potential for P1 and P6 to have unmet care needs. Findings include: Review of the undated policy titled Home Health Aide Services and Training Program, documented ". . . The duties of the HHA [home health aide] are to provide services that are physician ordered in the plan of care. . . The Home Health Aide is assigned to a specific patient by a RN. Written patient care instructions must be prepared by the RN or other appropriate professional who is responsible for supervising the HHA. . ." 1. Review of P1's Home Health Certification and Plan of Care, for the certification period of 01/13/23 to 03/13/23 indicated aide services were to be provided three times a week for eight weeks. Review of P1's Home Health Aide Plan of Care dated 01/12/23, indicated no abnormal temperature, blood pressure, pulse, and respiration results that were to be reported to the RN. There was a space on the aide care plan for the RN to document the "greater than" and "less than" value for each vital sign. 2. Review of P6's Home Health Certification and Plan of Care for the certification period of 01/03/23 to 03/03/23, indicated aide services were to be evaluated for frequency. Review of P6's EMR indicated a physician order dated 01/04/23 documented an aide frequency of three times a week for two weeks then two times a week for seven weeks. Review of P6's Home Health Aide Plan of Care dated 01/03/23, indicated no abnormal temperature, blood pressure, pulse, and respiration results that were to be reported to the RN. There was a space on the aide care plan for the RN to document the "greater than" and "less than" value for each vital sign. In an interview on 03/22/23 at 9:15 AM, Administrator, who is an RN, stated the aide care plan should include instructions/ranges for vital signs out of range to be reported to the RN. In an interview on 03/23/23 at 12:21 PM, Administrator confirmed the aide care plan for P1 and P6 did not include instructions for the aide to know when out-of-range vital signs were to be reported to the RN.

Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This STANDARD is not met as evidenced by: Based on record review, policy review, and interview, the agency failed to monitor, manage and maintain the equipment used to access the web-based medical record system. This failure had the potential to result in unauthorized access to patient information for all patients receiving home health care from the agency. Findings include: During the entrance conference at 9:40 AM, the Office Manager stated the agency uses a web-based electronic medical record (EMR) program called Data Soft Logic. The Office Manager stated only full-time employees are given an electronic device owned by the agency to access the web-based electronic medical record system and that other staff, which includes part time and contract staff use their personal devices. Review of Patient (P)1's referral form showed that the web-based program called Data Soft Logic allowed users to save the document to a desktop as a Portable Document Format (PDF). Other documents containing patient information could be saved to the computer desktop also allowing access to the information without logging into the web based EMR. During an interview at 1:40 PM on 03/23/23, the Administrator confirmed that the agency cannot monitor or maintain the staff's personal electronic devices. The Administrator also confirmed the agency would not know if an employee saved patient information to their computer or if the employees device was lost or stolen. Review of the agency policy titled, Information Confidentiality, Security and Data Integrity dated 2014 revealed, the agency will observe the patient's right to confidentiality of information and will implement process that assure confidentiality, security and data integrity.