Every finding on record at Clayton Hospital Home Care

The following deficiencies were cited as a result of a recertification survey completed on 01/07/2021 for the requirements of 42 CFR 11.02 Federal Requirements for Home Health Agencies. A COVID-19 Focused Infection Control Survey was conducted by the New Mexico Department of Health Division of Health Improvement on 01/07/2021. The facility was found not to be in compliance with 42 CFR §483.80 infection control regulations and has not implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.

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, record review and interview the facility failed to follow good infection control practices, such as use of standard precautions, for 1 (P#2) of 2 patient (P#1, & P#2) of home visits we observed. Staff member failed to perform proper hand washing/hand sanitizing procedures and to perform proper cleaning/sanitizing of reusable equipment. This deficient practice is likely to increase risk for infectious disease transmission to the staff member involved and all patients in contact with that staff member. The findings are: A. On 1/6/2021 at 2:50 pm observation of S4 (Physical Therapy Director- PTD) during a PT (Physical Therapy) home visit at patient P2's home revealed the following: 1. S#4 pet (touched, rubbed) 1 of 2 dogs (considered a dirty object/animal) upon entering patient P#2's home. S#4 did not use hand sanitizer or perform hand washing (HS/HW) after petting the dog, prior to touching his medical equipment or the patient . 2. After greeting the patient (pts) P#2 and introducing surveyors to the patient, S#4 laid a chux (a water proof barrier/sheet) down on the patient's couch, without hand sanitizing or hand washing (HS/HW) prior to touching the chux. The chux is used to provide a clean surface/barrier to reduce the risk of contamination/infection for any object placed on top of it, such as S#4's bag and equipment. 3. S#4 then set his (presumably) clean supply bag directly on the patient's (P#2) couch, which is considered a dirty surface, rather than on the chux he (a clean surface) had laid down. 4. S#4 did not perform HS/HW prior to removing his blood pressure cuff (equipment used to measure blood pressure (b/p) and indicator of cardiac health/disease), stethoscope (used in conjunction with b/p cuff to listen to pts. b/p). S#4 also removed a pulse oximeter (PO- a medical device used to measure percentage of oxygen (O2) being delivered to body tissues- an indicator or respiratory and cardiac function) at the same time. 5. S#4 then placed these items on P#2's skin to obtain the desired b/p and PO information. After performing these assessments, S#4 placed this dirty equipment onto the clean chux without first cleaning/sanitizing the equipment, thereby contaminating his clean chux/surface. 6. S#4 then performed hands on (touching the pts bare skin) assessment on multiple areas of pts. skin without performing HS/HW prior to of after touching the pts. skin. This unnecessarily exposed the pt. to infection from S#4's hands. Hands are considered one of the dirtiest and highest infection risk areas of the human body. 7. S#4 then returned the b/p cuff, stethoscope and pulse oximeter to his supply bag (SB) without cleaning/sanitizing any of this equipment prior to placing items back into SB, thereby potentially contaminating all of the equipment and supplies inside his SB. 8. At no time during the entire visit with P#2 was S#4 observed to perform HS/HW, including prior to leaving the pts. home. 9. At no time during the entire visit with P#2 was S#4 observed to perform cleaning/sanitizing of his used equipment or supply bag, including prior to leaving the pts. home. B. Record review of facility's Policy and Procedure #9-014.1 dated 12/2018, "Bag Technique" reveals: "1. The (supply) bag will be placed on a clean dry surface in the care and in the home." "2. Prior to administering care ...hands will be washed." "3. After hand washing, supplies and/or equipment needed for the visit will be removed from the bag." "5. When the visit is completed, reusable equipment will be cleaned using alcohol and/or soap and water as appropriate, hands will be washed, and equipment and supplies will be returned to the bag." This sentence (5.) goes on to specifically list the following equipment: "A. Stethoscope ..." "E. Blood pressure cuff ..." C. On 1/6/2021 at 11:40 am during interview S#3, Registered Nurse (RN), stated that visiting staff should always wash/sanitize hands- prior to beginning the patient visit, regularly as appropriate during the visit, and after completing the visit. S#3 stated that her supply bag and all clean equipment should be placed on a clean surface, such as a chux. She also stated that all equipment used during the visit needed to be cleaned/sanitized prior to placing it back in the supply bag.

Development and evaluation of plan of care CFR(s): 484.75(b)(2) Development and evaluation of the plan of care in partnership with the patient, representative (if any), and caregiver(s); This ELEMENT is not met as evidenced by: Based on record review and interviews the facility failed to incorporate all clinical participants in care planning and formulation of form CMS-485 (Home health certification and plan of care form that outlines all aspects of treatment that patients are to receive during home care) for 3 out of 7 sampled patients (P#'s 1,2,3) from the past 3 months (October, November, December) This failed practice is likely to lead to fragmented care and does not establish unified goals for the patient's care across each active clinical team member. The findings are: A. On 01/06/2021 record review of facility's "Case Conference/Progress Summary" policy that has been effective since 12/2018 Revealed: 1. Case conference meetings require that all clinicians working with patients will participate, including physician/medical doctor (MD) 2. Care conference is required to meet only every 60 days from the last one. 3. Information discussed by the multidisciplinary team includes status of patient, changes in condition, interventions for all disciplines, current frequency of all disciplines in the case, progress toward goals, and discharge plan. 4. A written summary of case conferences will be sent to the patient's physician at least every 60 days. B. On 01/06/ 2021 Record Review of Case Conferences from 2019-2020 that would incorporate all 7 out of 7 patients revealed that: 1. No MD listed in attendance at any meeting. 2. No group meeting held on the months of April, May, July, September, or November 2020. Giving precedent to host meetings sooner than every 60 days as well. 3. No copy of a written summary that would be sent to the patient's physician found which is required by their policy and signifies that physicians are not being given information on multidisciplinary meetings regarding their patients. C. On 01/07/2021 at 10:15 am Interview with Staff #2 (LMSW (Licensed Mater Social Worker) /Facility Director) stated that case conference meetings are typically only held every 2 months for the discussion of recertifying a patient to the home health program. Staff #2 acknowledged that should a patient's recertification date not fall on the month of the case conference, the patient could miss the chance to have their case discussed with the whole multidisciplinary team. Regarding physician involvement or leading of the case conference, Staff #2 stated that doctors do not attend the case conference and they do not become aware of changes to plan of care until form CMS-485 Home Health Certification and Plan of Care is sent to them for signature. Staff #2 highlights that form CMS-485 serves as 2 purposes, official recertification notification and written summary of the outcome of the case conference. D. On 01/07/2021 at 10:20 am interview with Staff #3 (Registered Nurse) stated that Staff #3 is the one that makes changes to form CMS-485 during case conference meetings in collaboration with physical therapy services. When prompted about physician/MD notification prior to modifying an order, Staff #3 stated that MDs become notified after form CMS-485 is sent and they receive it. When asked about when modified orders are enacted, Staff #3 indicated that changes to CMS-485 take effect immediately even if the physician has not signed them. Personnel without independent ordering ability is modifying the plan of care and enacting these changes without physician input, awareness, or MD authorization. E. On 01/07/2021 record review of P#2's medical record reveled that: 1. Form CMS-485 recertifying home health services from 12/01/2020-01/29/2021 is unsigned by physician. 2. No nursing note in patient's record communicating with physician that patient is to be recertified or that, if changes were made, changes are made to form CMS-485. F. On 01/07/2021 record review of P#1's medical record revealed that: 1. Form CMS-485 recertifying home health services from 11/12/2020-01/10/2021 is unsigned by physician. 2. No nursing note in patient's record communicating with physician that patient is to be recertified or that changes, if changes were made, are made to form CMS-485. G. On 01/07/2021 record review of P#3's medical record revealed that: 1. Form CMS-485 recertifying home health services from 12/5/2020-2/2/2021 is unsigned by physician. 2. No nursing note in patient's record communicating with physician that patient is to be recertified or that changes, if changes were made, are made to form CMS-485. H. On 1/7/2021 at 11:00 am interview with Staff #2 (LMSW/Facility Director) stated that there may not have been a case conference for P#3 as their most recent recertification date did not fall within the typical every 2 months indicated in the "Case Conference/ Progress Summary" policy. Staff #2 stated P#3 was still recertified and form CMS-485 was sent, but no summary of any recommended or performed order changes prior was sent to the physician.

Contents of clinical record CFR(s): 484.110(a) Standard: Contents of clinical record. The record must include: This STANDARD is not met as evidenced by: Based record reviews and interviews the facility failed to record advance directives (information on critical emergent treatment that patient would want if they were unable to make their needs known) for 5 patients (P#'s 1,4,5,6,& 7) of 7 sampled patients for the past 3 months (October, November, & December). This deficient practice is likely to lead to the direct omission of vital pertinent patient information regarding advanced directives and those listed as power of attorney, should the patient be in a critical situation where they are unable to make their wishes known. The findings are: A. On 01/06/2021 Record of review of medical records for 5 (patients 1, 4, 5, 6, 7) of 7 sampled patients for the past 3 months: 1. P#1's "Statement of understanding and authorization"form indicates that patient has a living will and power of attorney. Nor does it specify advanced directives for the patient. Neither document is found in their medical record. 2. P #4's "Statement of understanding and authorization" form indicates that patient has a living will and power of attorney. Neither document is found in their medical record. 3. P #5's "statement of understanding and authorization" forms has inconsistencies as the patient writes down a name under "Power of Attorney", but it is documented as the patient not having one. Legal form designating the Power of Attorney not found in the medical record. 4. P#6's "statement of understanding and authorization" form indicates that the patient has a living will and power of attorney. Neither document is found in their medical record. Nor does it specify advanced directives for the patient. 5. P#7's "statement of understanding and authorization" form indicates that the patient has a living will and power of attorney. Neither document is found in their medical record. Nor does it specify advanced directives for the patient. B. On 01/06/2021 at 3:40 pm during interview with P#2 at a home visit revealed that patient stated they do have advanced directives and a power of attorney. P#2 continued by stating that he told the facility of these directives, but that the facility never requested a copy of them to be retained in the medical record. C. On 01/06/2021 at 2:45 pm, interview with Staff #2 (LMSW, Facility Director) stated that advanced directives are not retained in patient's charts, rather they are maintained in the hospital's medical records department, as the facility's base of operation is within the hospital. Staff #2 acknowledged the likelihood of delay in retrieving advanced directives for each patient and how this could impact patient care in regard to executing advanced directives them during a critical event if they are only held in a separate facility, such as the hospital.