Every finding on record at Eden Home Health of Bozeman LLC

An Emergency Preparedness Recertification Survey was completed on 3/16/23. The agency was found to be in compliance with the regulatory requirements and with the standards of 42 Code of Federal Regulations (CFR) 484.22 Emergency Preparedness (EP) Final Rule Requirement for Condition of Participation for Home Health Agencies.

A Recertification Survey was completed on 3/16/23. Standard and Condition level deficiencies were cited. Glossary HHA Home Health Aide CNA Certified Nursing Assistant QI Quality Indicator QAPI Quality Assrance Process Improvement

Patient rights CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Due to the manner and degree of the deficient practices, the agency failed to meet the Condition of participation: Patient Rights for Home Health Agencies. Based on interview and record review, the agency failed to: Investigate multiple complaints of a home health aide being rough and inappropriate with patients (G478) Document complaint resolutions for patient complaints (G484) Protect patients during an investigation of complaints (G486) The accumulation of these deficient practices contributed to the adverse patient outcomes, including patients having pain, feeling uncomfortable receiving HHA CNA services, and patient requests to deny future entrance to their home by staff member G.

Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) (i) Investigate complaints made by a patient, the patient's representative (if any), and the patient's caregivers and family, including, but not limited to, the following topics: This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to investigate multiple complaint allegations against staff member G, for being rough and inappropriate with patients. This caused some of the patients to be uncomfortable and request to discontinue her visits for 3 (#s 8, 9, and 10) of 4 sampled patients. Findings Include: Review of the agency policy, Patient Concerns and Grievances Policy, last revised 8/14/2020, showed, "[The Agency] thoroughly investigates complaints made by the patient, the patient's representative (if any), and the patient's caregivers and family, including but not limited to: a. Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately. b. Lack of respect for property and/or person by anyone who is furnishing services on behalf of the agency. c. Mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the agency." Review of the agency document, QI Reports, of patient complaints for the last twelve months showed: -Documented on 7/6/22, for patient #9, “Patient states that bath aide [staff member G] was very rough during his bed bath and is now having pain in his right leg, patient and caregiver also state that [staff member G] made inappropriate and disrespectful comments. Patient and caregiver refuse for bath aide to come back to the house.” Interventions listed as provide education to caregiver, disciplinary counseling, follow-up with client/caregiver/family and prevention as change in staff assignment. No other investigation information was found for the complaint by the end of the survey and none of the listed interventions were documented. -Documented on 11/3/22, for patient #9, “Patient called and stated shower aide [staff member G] seemed inappropriate during his bed bath, he said he did not need help using his urinal but [staff member G] insisted. Patient felt uncomfortable that ‘[staff member G] just wanted to see his junk.’ Patient states he does not want [staff member G] to come anymore and requests different shower aide if possible.” [sic] Interventions listed were to provide education to staff member and prevention as change in staff assignment. No other investigation information was found for the complaint by the end of the survey. -Documented on 1/19/23, for patient #8, “Patient’s spouse stated that aide [staff member G] is very rough and ‘throws him in the shower and slaps stuff on.’” Intervention was education to staff member and prevention was change in staff assignment. No other investigation information was found for the complaint by the end of the survey. -Documented on 1/19/23, for patient #10, “Patient’s spouse states that shower aide [staff member G] is ‘rough and he isn’t any cleaner than before he got his bath.’” Intervention as education to staff member. No other investigation information was found for the complaint by the end of the survey. Review of staff member G’s employee file showed: -No education specific to the complaints by patients #8, #9, and #10. -No discipline specific to the complaints by patients #8, #9, and #10. -An unrelated disciplinary warning on 12/31/22 specified weekly co-visits to be completed with a supervisor. The co-visits were not documented in the employee file and could not be found by agency staff by the end of the survey. During an interview an 3/15/23 at 2:35 p.m., staff member B stated she did not know where the co-visits were documented or how many were done for staff member G. Staff member B checked her desk and staff member G's employee file and the co-visits were not located. During an interview on 3/16/23 at 11:27 a.m., staff member B stated she did not document who or when she interviewed patients and their caregivers for the complaints. Staff member B stated the complaint education provided was only verbal for staff member G. Staff member B stated staff member G was reassigned for the patients that requested. Other patients were asked to give one more chance for staff member G and if issues continued, they would reassign staff member G. Staff member B stated, there were no other patients interviewed for the complaints. During an interview on 3/16/23 at 11:43 a.m., staff member A stated, the agency had a Work Improvement Plan in place for staff member G, regarding being gentle and for time management. Staff member A stated nothing was formally documented or specific to the complaints from patients #8, #9, and #10.

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 interview and record review, the agency failed to document complaint allegations and the corresponding complaint resolutions of staff member G being rough and inappropriate with patients for 3 (#s 8, 9, and 10) patients of 4 sampled patients. Findings Include: Review of the agency admission packet Grievances procedure, page 27, provided on 3/13/23, showed, “We have a formal grievance procedure that ensures your concerns are reviewed and an investigation is started… You will be informed by telephone regarding the status of the investigation and receive a written report when a resolution is determined.” Review of agency QI Reports for complaints against staff member G showed: -7/6/22 for patient #9's complaint, "Resolution Comments" was not completed. -11/3/22 for patient #9's complaint, "Resolution Comments" was not completed. -1/19/23 for patient #8's complaint, "Resolution Comments" was not completed. -1/19/23 for patient #10's complaint, "Resolution Comments" was not completed. During an interview on 3/16/23 at 10:47 a.m., staff members A, B, C and F concurred they did not provide a resolution letter to the complainants as the agency procedure stipulates and did not document a resolution for any of the complaints for staff member G being rough and inappropriate with patients #8, #9, and #10.

Protect patient during investigation CFR(s): 484.50(e)(1)(iii) (iii) Take action to prevent further potential violations, including retaliation, while the complaint is being investigated. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to protect patients from further potential harm, after the first complaint was made to the agency, for staff member G being rough and inappropriate with patients, and during further complaint allegations by patients for 3 (#s 8, 9, and 10) of 4 sampled patients. Findings Include: Review of the agency policy, Reporting of Abuse, Neglect, or Exploitation Policy, last revised 4/28/21, showed, “To provide a consistent process for identifying, assessing, and reporting victims of alleged or suspected abuse… To protect and uphold patients’ rights to be free from neglect or exploitation and verbal, mental, physical, and sexual abuse while receiving care, treatment, and/or services from the organization.” Review of agency QI reports for the last twelve months showed: -7/6/22 patient #9 made a complaint about staff member G being rough and inappropriate during a shower, and requested she not return to the home. -11/3/22 patient #9 made another complaint for staff member G, being inappropriate, was sent back to his home after the first complaint requesting her not to come back. -1/19/23 patient #10 made a complaint about staff member G being rough during showers. -1/19/23 patient #8 made a complaint about staff member G being rough during showers. -None of the complaints had an investigation or appropriate interventions to protect the patients’ who made the complaints or protected other patients that had services by staff member G. Review of patient #8's home health aide visits in the electronic health record, showed staff member G continued to go to the home after the 1/19/23 complaint was made on: 1/23/23, 1/26/23, 1/30/23, 2/2/23, 2/6/23, and 2/9/23. During an interview on 3/13/23 at 3:40 p.m., staff member A stated, the agency abuse training did not go over staff to resident abuse because they were not with patients all the time. Staff member A stated, for complaints and grievances the agency filled out a complaint form and reviewed it in QAPI. During an interview on 3/16/23 at 11:27 a.m., staff member B stated she did not document her interviews with the patients or staff for the complaints against staff member G. Staff member B stated staff member G was changed to different patients in some of the complaints but was not suspended.

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, and record review, the agency failed to ensure staff followed standards of practice for infection control for 1 (#6) of 3 sampled patients. Findings include: During an observation on 3/15/23 at 11:00 a.m., staff member B performed a dressing change to patient #6's left and right hip. Staff member B greeted the patient upon arrival at the home. Staff member B placed a reusable pad on the floor and placed her bag onto the pad. Staff member took a blood pressure cuff, thermometer, and pulse ox monitor to assess the patient's vital signs. When staff member B was finished with each of the items, she placed them on the pad with her bag, which had the potential to contaminate her bag and any other supplies in the bag. Staff member cleaned the equipment with an alcohol wipe. Staff member B sanitized her hands and donned clean gloves. Staff member B placed a disposable pad on the patient's bed and placed all the supplies for the dressing change on the pad. Staff member B removed the dressing from the patient's left hip and measured with a disposable measuring tape. Staff member B then cleansed the wound with wound cleanser. Staff member B removed her gloves and donned clean gloves. Staff member B did not sanitize her hands between glove changes. Staff member B applied an ointment on the patient's wound with a cotton tipped applicator. Staff member B then placed a clean dressing on the patient's wound. Staff member B removed her gloves and sanitized her hands. Staff member B donned clean gloves and removed the dressing off of the patient's right hip, removed gloves and donned clean gloves. Staff member B did not sanitize her hands between glove changes. Staff member B cleansed the wound on the patient's right hip and put a clean dressing on the wound. Staff member B did not change gloves between cleansing the wound and applying a clean dressing. Staff member removed her gloves, sanitized her hands, and donned clean gloves. Staff member B disposed of trash and cleaned the reusable barrier and cleaned it with an alcohol wipe. During an interview on 3/15/23 at 2:35 p.m., staff member B stated sanitizing hands should be done before contact with patient, before glove changes, and between clean and dirty tasks. Staff member B stated she used an alcohol wipe to clean her equipment. During an interview on 3/16/23 at 9:48 a.m., staff member A stated the agency used sani wipes to clean equipment. Review of the agency's policy, titled Hand Hygiene, showed staff were to change gloves when going from a contaminated body site to a clean site body site. The policy also showed staff were to sanitize immediately after glove removal.