Every finding on record at Eh Health Home Health of the Northwest, LLC

An unannounced Emergency Preparedness survey was conducted on 10/21/24 at Enhabit Health Home Health. The facility was found to be in compliance with 42 CFR 484.102, Emergency Preparedness Requirements for Medicare Participating Providers and Suppliers. State of Alaska Department of Health Division of Health Care Services Health Facilities Licensing and Certification 4601 Business Park Blvd, Building K Anchorage, AK 99503

The following deficiencies were noted during an unannounced Federal Recertification survey conducted 10/14-21/24 at Enhabit Health Home Health. Census: 31 Active Patients 284 skilled unduplicated census for the past 12 months 8 Records reviewed (6 active and 2 discharged.) 3 home visits observed (1 Registered Nurse Visit, 1 Licensed Practical Nurse visit, and 1 Physical Therapy visit). State of Alaska Department of Health Health Facilities Licensing and Certification 4601 Business Park Blvd, Building K Anchorage, AK 99503

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: (1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on record review and interview, the facility failed to ensure the comprehensive assessment accurately reflected the patient's status for one patient (#3) out of six active patient records reviewed. This failed practice had the potential to affect the skilled professionals’ knowledge of immediate needs of the patient, placing the patient at risk for improper or less than optimal care which had the potential to effect the patient's overall physical, mental, and psychosocial well-being. Findings: Record review on 10/14-21/24 revealed Patient #3 had a primary diagnosis of unspecified open wound of left upper arm with a Start of Care date of 9/4/24 and a Home Health Certification and Plan of Care for the certification period of 9/6/24 to 11/4/24. A Billable Admission OASIS (the Outcome and Assessment Information set) Data Collection Visit Note Report dated 9/6/24 and completed by the Clinical Team Lead failed to include an accurate infusion assessment in this assessment report. This report failed to include the presence of a central venous catheter (a device that's inserted into a large vein and used for hemodialysis, a treatment provided to filter waste and extra fluid from the blood) in place on the patient's right chest. During a home visit observation on 10/16/24 at 8:00 AM, Patient #3 was observed to have a Central Venous Catheter positioned on the right chest area. During an interview on 10/21/24 at 11:37 AM, the Clinical Team Lead stated, when asked if the initial/comprehensive assessment included a description or assessment of the Central Venous Catheter, that there was no assessment of the Central Venous Catheter on the patient's right chest area on the Billable admission, OASIS Data Collection Visit note report, dated 9/6/24. Review of the agency policy "Admission Process and Patient Assessment," revised date 10/20/2023 revealed, "The initial admission evaluation/assessment will be performed in the patient's home by the appropriate licensed professional within 48 hours of the referral or patient's return from an inpatient stay or on the physician's ordered start of care...During the initial evaluation/assessment, the admitting professional evaluates the patient and situation, using the admission criteria, and decides to admit or decline the patient for services...as part of the admission process, the admitting professional completes the medication profile and OASIS assessment, and selects the appropriate nursing diagnosis problems."

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 record review, observation, and interview, the home health agency failed to ensure acceptable professional standards for infection control occurred. Specifically, the facility failed to ensure Licensed Nurse (LN) #1 performed acceptable professional standards for hand hygiene and glove use during wound care for one patient (#3), out of one patient observed for wound care. This failed practice placed this patient at risk for the spread of infectious diseases during wound care, which could affect the patient's overall health and wellbeing. Findings: Record review on 10/14-21/24 revealed Patient #3 had a primary diagnosis of unspecified open wound of left upper arm with a Start of Care date of 9/4/24. During a home visit observation on 10/16/24 at 8:00 AM, LN #1 was observed to sanitize hands, apply gloves, and then remove a dressing from Patient #3’s left upper arm. After this dressing removal and while wearing the same gloves, LN #1 was observed to cleanse the wound area with wound wash. Then LN #1 discarded his/her gloves and sanitized his/her hands before proceeding to dress the wound with a xerofoam dressing and then cover with a gauze dressing. During an interview on 10/17/24 at 10:47 AM, the Clinical Team Lead stated that LN #1 should have removed the soiled gloves and cleansed his/her hands after removing a soiled dressing and proceeding to a clean task. Review of the agency policy "Hand Hygiene," revised 7/10/24, revealed, "It is the policy that Agency's employees and contracted staff will follow the CDC Guidelines regarding hand hygiene...At a minimum, personnel will perform hand hygiene in the following instances...After any contact with patient excretions [feces, urine] or secretions [from wounds...] or with articles/surfaces contaminated by secretions or excretions." Review of the agency policy "Infection Surveillance Exposure Control Plan," dated 10/9/23, revealed, "Disposable gloves will be replaced as soon as possible when contaminated."

This visit was for an Emergency Preparedness Survey. Provider #: 027022 Facility ID: HHA-002 Visit dates: 1/25/22 - 1/28/22 Skilled Unduplicated Census past 12 months: 361 State of Alaska DHSS/ HCS Health Facilities Licensing & Certification 4601 Business Park Blvd. Bldg K Anchorage, AK 99503

Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the communication plan contained contact information for Federal, State, Tribal and / or local emergency preparedness staff for 1 of 1 agency emergency preparedness plan. This failed practice placed all Patients (based on an active census of 50) at risk for receiving less than optimal or a delay in care during an emergency. Fiindings: Review on 1/27/22 of the agency's undated emergency preparedness plan titled "Agency Specific Preparedness Plan" failed to include a communication plan that contained the contact information for Federal, State, Tribal, and / or local emergency preparedness staff. Review of the Emergency Preparedness Plan revised on 4/16/21 stated, "Communication during a disaster will be maintained via telephones, email, and pagers. Local radio and TV stations may be utilized for communication purposes, if telephone services are interrupted. The Branch Director or designee will maintain communication with the administrator or alternate. 4.2.7.1. Emergency Telephone numbers…Police / Fire / ambulance 911…Poison Control 800-764-7661. Guidelines to follow include those from...Law Enforcement Agencies...Civil Defense Organizations...Other local / state / federal organizations deemed responsible for Emergency Preparedness and Response...the Administrator or alternate or BD [branch director] will notify state and local emergency preparedness [including the Agency State licensing department of the implementation of the agency preparedness plan..." During an interview on 1/27/22 at 2:30 PM, the clinical manager and the acting temporary administrator, when asked about the communication plan, stated the required contacts including Federal, state, tribal, regional and local emergency contacts was embedded in the Community Resource list. Review on 1/27/22 of the Community Resource List, revised 3/08, included Varied Resources such as Alaska 211, American Red Cross, and Boy Scouts. These contacts included phone numbers but no personnel names were included on the list. .

This visit was for a Federal Recertification Survey. Provider #: 027022 Facility ID: HHA-002 Visit dates: 1/25/22 - 1/28/22 Skilled Unduplicated Census past 12 months: 361 4 home visits were conducted. 3 visits were to observe skilled nursing home visits and 1 visit was to observe an occupational therapy home visit. State of Alaska DHSS/ HCS Health Facilities Licensing & Certification 4601 Business Park Blvd. Bldg K Anchorage, AK 99503

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 policy review, the agency failed to ensure infection control practices were properly implemented at 1 of 3 home visits observed with a skilled nurse (Patient #5 with Skilled Nurse #3). Specifically, the agency failed to ensure the skilled nurse placed a clean field on a soiled surface prior to placing supplies for wound care. This failed practice had the potential to place the patient at risk of transmission of pathogens and exposure to infectious organisms. Findings: During an observation on 1/27/22 at 12:10 PM, Skilled Nurse #3 was observed to prepare for a wound care treatment for Patient # 5's buttocks wound. Prior to completing this wound care treatment, Skilled Nurse # 3 was observed to place wound care treatment supplies including wound cleanser, a border foam dressing, a tube of Gel Honey, and sterile cotton tipped applicators on a blanket on the Patient's couch. Skilled Nurse #3 removed the old dressing and discarded this dressing. After discarding his/her gloves and cleansing his/her hands with hand sanitizer, Skilled Nurse # 3 donned clean gloves. Skilled Nurse #3 cleansed the buttock wound with wound cleanser, prepared the skin with skin protectant, applied the honey gel with an applicator and applied the new dressing. Skilled Nurse #3 picked up each item from the soiled surface of the blanket with his / her gloved hands and used the items in that order to complete the wound care and dressing change. Skilled Nurse #3 removed his/her gloves and cleansed his/her hands with hand sanitizer. During an interview on 1/27/22 at 12:30 PM, after asking Skilled Nurse #3 if a clean field should have been placed on top of the blanket and if this blanket was potentially soiled, Skilled Nurse #3 agreed that the best practice would be to place a clean field under the wound care / dressing supplies and then complete the wound care and dressing change with clean gloves and clean supplies. During an interview on 1/27/22 at 2:14 PM, the Clinical Manager agreed that Skilled Nurse #3 needed a clean field between the blanket and the wound care supplies as wound care was completed on the Patient's wound as best practice to prevent cross contamination between the supplies, the nurse's gloved hands, and the wound during wound care and the dressing change. A review of the policy on 1/28/22 at 3:30 PM titled "Infection Prevention and control plan" with revised date of 11/18/21 revealed, "1.0 Purpose 1.1 To reduce cross contamination that may occur through staff / patient contact with provider care and to safeguard the health of the staff, care giver and the patient." A review of the procedure on 1/28/22 at 3:30 PM titled "Wound Dressing application, home care" revised February 18, 2021 revealed, "Organize equipment and supplies on a clean surface … arrange the equipment and supplies according to the order of use to avoid cross - contamination while performing wound care." .