Every finding on record at Carteret Home Health Services

An unannounced on-site recertification survey was conducted on 01/06/2025-01/08/2025. No deficiencies to the Medicare Conditions of Participation for emergency preparedness were identified.

An unannounced on-site recertification survey was conducted on 01/06/2025-01/08/2025. Standard level deficiencies to the Medicare Conditions of Participation were identified.

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 agency policy, observation, and staff interviews, the agency failed to perform hand hygiene prior to entering the clinical bag for 1 of 3 skilled nurse home visits. (patient #13) Findings included: A policy, Nursing Bag Technique (approved 09/13/2024) received on 01/07/2025 from the branch director at approximately 2:34 PM stated, “Perform hand hygiene before entering bag at any time… if additional supplies from the nursing bag are needed during the visit, perform hand hygiene before entering bag.” Patient #13 was admitted on 12/27/2024 with a diagnosis of Infect/inflm [inflammation]] reaction due to internal r [right] knee prosth [prothesis] (infection of the right knee following joint replacement). The plan of care for 12/27/2024-02/24/2025 included orders for skilled nurse visits 2 times a week with 2 PRN (as needed). During a home visit conducted on 01/07/2025 at 9:30 AM registered nurse (RN) #4 removed items from the clinical bag, performed an assessment of patient #13, and failed to perform hand hygiene before removing additional items from the clinical bag. During an interview conducted on 01/08/2025 at 9:22 AM RN #4 stated, “I knew at that moment that I should have changed my gloves and washed my hands” [before removing a thermometer from the bag] During an interview conducted on 01/07/2025 at 10:10 AM the clinical operations manager stated, “They [all staff] should clean their hands with sanitizer before they go into the bag.”

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 agency policy, clinical record review, and staff interviews, the RN failed to provide services/treatments in accordance with the Plan of Care for 1 of 2 patients with a PICC [peripherally inserted central catheter-form of intravenous access that can be used over an extended period] line [#16]. The findings included: The policy Peripherally Inserted Central Catheter (PICC) Dressing Change, Home Care [8/21/23] was provided by the Clinical Director on 1/6/25 at 4 pm. The policy stated, “...Documentation associated with a PICC dressing change include: condition and length of the external catheter...” Patient # 16 had a Start of Care [SOC] date of 12/7/24 and an admitting diagnosis of cellulitis and abscess of the mouth. Review of the clinical record revealed the patient had a PICC line [peripherally inserted central catheter-form of intravenous access that can be used over an extended period] inserted prior to admission to the agency. Review of the Plan of Care [POC] for the certification period 12/7/24-2/4/25 included orders for SN [skilled nursing] 1 time a week for 6 weeks and “SN to perform PICC line dressing and cap changes weekly and PRN [as needed] ...Assess insertion site and measure external length of catheter (if greater than 2 cm migration from baseline external length at insertion notify MD)...” Review of the clinical record revealed the patient received 5 weekly SN visits from 12/7/24-12/30/24. Review of the visit documentation revealed no PICC line measurements in accordance with the POC. During an interview with the agency director on 1/8/25 at approximately 9:15 am, the director confirmed the nursing staff failed to follow the POC related to PICC line management.

An unannounced, onsite recertification survey was conducted 01/18/22 to 01/20/22. Deficiencies to the Medicare Conditions of Participation were identified. -MHB An unannounced, onsite recertification survey was conducted 01/18/22 to 01/20/22. No deficiencies to the Emergency Preparedness program were identified.-MHB

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 clinical record review, policy and procedure review, and staff interview the agency failed to follow the plan of care for assessing vital signs for 3 of 18 records reviewed (#3, #5, and #14) and failed to follow the plan of care for assessing hypo/hyperglycemia (low/high blood glucose level) for 1 of 5 records reviewed (#10) with diabetes. Findings included: A policy, “Patient Plan of Care”, revised 07/18 was received from the clinical operations director on 01/20/22 at approximately 8:30 a.m. The policy stated, “All home health services are furnished under a physician’s order, based on the patient’s plan of care that is established in collaboration with the patient, the physician and Agency staff…” and “… the individualized plan of care includes parameters for physician notification of vital signs... ” 1. Patient #3 had a soc (start of care) of 12/30/21 and included diagnoses of hemiplegia (paralysis on one side of the body) following a cerebral infarction (stroke) right side, essential hypertension, long term use of aspirin, and history of falling. The plan of care from 12/30/22 to 02/27/22 had an order for physical therapy 2 times a week for 3 weeks. Orders included clinician to report vital signs outside of the following established parameters: (temperature96.8-100.4) , (pulse 60- 100), (respiration 12-20), (blood pressure 95/60 and 140/90). Review of the physical therapy visit notes for 12/31/21 and 01/17/22 revealed no vital signs were documented in the record for these visits. Interview with the clinical operations director on 01/20/22 at 2:55 p.m. revealed, “the clinician forgot to document the vital signs in the system”. 2. Patient #5 had a soc of 11/23/21 and included diagnoses of lymphoma, malignant neoplasm of the head, face, and neck, hypothyroidism, and a history of falling. The plan of care from 11/23/21 to 1/21/22 had an order for physical therapy 2 times a week for 3 weeks, and 1 time a week for 1 week. Orders included clinician to report vital signs outside of the following established parameters: (temperature 96.8-100.4) , (pulse 60- 100), (respiration 12-20), (blood pressure 95/60 and 140/90). Review of the physical therapy note for 11/26/21 revealed no vital signs were documented in the record for that visit. Interview with the clinical operations director on 01/20/22 at 2:55 p.m. revealed, “the clinician forgot to document the vital signs in the system”. 3. Patient #14 had a soc of 01/14/22 and included diagnoses of parkinson’s disease (degenerative disease of the nervous system), hypertension, and age-related osteoporosis fracture to femur. The plan of care from 01/14/22 to 03/14/22 had an order for physical therapy 2 times a week for 3 weeks, and 1 time a week for 1 week. Orders included clinician to report vital signs outside of the following established parameters: (temperature 96.8-100.4) , (pulse 60- 100), (respiration 12-20), (blood pressure 95/60 and 140/90). Review of the physical therapy evaluation visit note for 01/14/22 revealed no vital signs were documented in the record for that visit. Interview with the clinical operations director on 01/20/22 at 2:55 p.m. revealed, “the clinician forgot to document the vital signs in the system”. 4. Patient #10 was admitted to the agency on 10/01/21 with diagnoses including sciatica, osteoarthritis, Type 2 diabetes, and hypertensive heart disease with heart failure. Plan of Care from 10/01/21 to 11/29/21 revealed discipline orders for physical therapy 2 times per week for 4 weeks and interventions included, “…Assess for untoward s/s (signs and symptoms) pain, edema (swelling), shortness of breath, heart failure, depression, constipation, sciatica (pain starting in the low back that travels to the legs), hypoglycemia/hyperglycemia (low blood glucose level/high blood glucose level) that interfere with therapy…” Employee #12, Physical Therapy Assistant, completed a physical therapy visit on 10/13/21. This visit note revealed, “Pt (patient) presents sitting in chair. He states he is not doing well. Pt had a fall ‘off of bed’ on Monday night. He woke up in [sic] the floor and did not know how he got there. He was in [sic] the floor for a few hours…He states he has not felt well and did not sleep much since the accident...” There is no evidence of an assessment for hypoglycemia or hyperglycemia in this visit note. Employee #12 also completed a physical therapy visit on 10/15/21. This visit note revealed, “…Pt states that he fell again yesterday during the day he ‘tripped over his O2 tubbing’ [sic] He was on the floor for awhile [sic], but able to pull himself up on the coffee table…Pt states he is in too much pain to do any therapy today…” There is no evidence of an assessment for hypoglycemia or hyperglycemia in this visit note. A Transfer Summary dated 10/26/21 was completed by Employee #4, Physical Therapist and Case Manager, and revealed, “…Pt. transferred to (name of hospital emergency department) on 10/26/21 with subsequent admission for Dx (diagnosis) Hypoglycemia and Pneumonia…” In an interview with Employees #4 and #12 on 01/20/22 at 2:46 PM, Employee #12 stated, “I am not sure why I would not have done that…I did not assess it because he had assessed his own…He checked his own sugar (blood glucose level that would reveal evidence of hypoglycemia or hyperglycemia). We would go over his numbers.” Employee #4 stated, “He had a logbook where he would write down his blood sugars.” Employee #4 confirmed that there was no evidence in the clinical record on 10/13/21 or 10/15/21 regarding assessment for hypoglycemia or hyperglycemia and agreed that it should have been documented.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, observation, and staff interview, the agency failed to document the accurate wound location on the Plan of Care for 1 of 4 patients (#13) with wounds. Findings included: The Home Care Clinical Record Policy, revised 12/2021, was received from the Employee #2, the Clinical Operations Director, on 01/20/22 at 4:00 PM. This policy revealed, “A detailed and accurate record is maintained for each patient admitted to the home care department that reflects all services provided…” Patient #13 was admitted to the agency on 10/30/21. Plan of Care from 12/29/21 to 02/26/22 revealed diagnoses including sepsis (a severe, systemic infection), gastroenteritis (an inflammation/infection of digestive tract), chronic myelomonocytic leukemia (a type of blood cancer), pressure ulcer of sacral region, and laceration without foreign body of the left lower leg. Discipline orders on this Plan of Care included skilled nursing 1 time per week for 1 week, 2 times per week for 2 weeks, and 1 time per week for 2 weeks. Additional services orders revealed, “Skin Tear/Right Lower Leg Shin: Cleanse with wound wash, pat dry, cover with Vaseline (brand name) guaze [sic]. Apply nonstick pad, wrap with Kerlix (brand name) and secure tape. Change every 3 days and PRN (as needed).” Employee #14, the Registered Nurse Case Manager, visited Patient #13 on 01/19/22 at 11:45 AM. This visit was observed via video. Employee #14 was observed performing a wound assessment and treatment of a wound to the right lower leg. There was no evidence of a wound to the left lower leg. In an interview on 01/19/22 at 3:45 PM, Employee #2 confirmed that Patient #13’s wound is to the right leg and stated, “We looked at the record and it is coded incorrectly.” Employee #2 agreed that the Plan of Care contained inaccurate documentation regarding Patient #13’s wound location and this error should have been identified and corrected.