Every finding on record at Eh of Fort Worth, LP

A Recertification Survey entrance conference was conducted on 07/24/23 with the Alternate Administrator, Employee B, at 1:20 p.m. Census: L&C – 94 LHH – 38 An exit conference was conducted on 07/28/23, with the Administrator, Employee A, at 4:45 p.m. The preliminary findings were discussed. This agency was in substantial compliance with 42 CFR Part 492 Part 484.102, Emergency Preparedness Requirements for Home Health Agencies.

A Recertification Survey entrance conference was conducted on 07/24/23 with the Alternate Administrator, Employee B, at 1:20 p.m. Census: L&C – 94 LHH – 38 An exit conference was conducted on 07/28/23, with the Administrator, Employee A, at 4:45 p.m. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies/Violations.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to maintain a coordinated agency wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases, specific to care and services provided in the home setting, which included a method for identifying infectious and communicable disease problems and a plan for the appropriate actions that are expected to result in improvement and disease prevention for 3 of 13 patients (Patient #1, Patient #3 and Patient #10) reviewed for infection control tracking in that the agency form, titled, “Infection Report,” used by the agency nurses to monitor client infections was not fully completed. This failure resulted in the agency utilizing incomplete data, which did not fully track the course of the clients’ infections, which could result in harm to clients related to the ineffective treatment of client infections. The findings included: Record review of an agency form titled, “Infection Report,” for Patient #1, dated 05/15/23, showed the bottom half of the form, which included follow-up information for the infection, including x-rays ordered, type of x-ray ordered, results of x-rays taken, labs ordered, type of lab ordered, results of the lab ordered, other treatment ordered, and other status of patient. (There was no documentation to indicate the status of the patient after the initial treatment was documented to include information such as if the patient finished the medication as ordered, if the patient’s signs and symptoms subsided, if the patient had to go back to the physician for the same infection, if the patient had another medication ordered if the first medication was not effective, and if so, the date the second medication was ordered, if the patient required another x-ray or additional lab work, if there were new wound care orders, or if the patient was admitted to the hospital for this infection.) was not completed. The form indicated, “Please complete this form for any home health patient or employee if: 1) signs and symptoms of infection are present 2) culture is obtained 3) new antibiotic is prescribed 4) client is admitted to the hospital or does due to suspected infection.” Record review of an agency form titled, “Infection Report,” for Patient #1, dated 05/19/23, showed the bottom half of the form, which included follow-up information for the infection, including x-rays ordered, type of x-ray ordered, results of x-rays taken, labs ordered, type of lab ordered, results of the lab ordered, other treatment ordered, and other status of patient (There was no documentation to indicate the status of the patient after the initial treatment was documented to include information such as if the patient finished the medication as ordered, if the patient’s signs and symptoms subsided, if the patient had to go back to the physician for the same infection, if the patient had another medication ordered if the first medication was not effective, and if so, the date the second medication was ordered, if the patient required another x-ray or additional lab work, if there were new wound care orders, or if the patient was admitted to the hospital for this infection.) was not completed. The form indicated, “Please complete this form for any home health patient or employee if: 1) signs and symptoms of infection are present 2) culture is obtained 3) new antibiotic is prescribed 4) client is admitted to the hospital or does due to suspected infection.” Record review of an agency form titled, “Infection Report,” for Patient #3, dated 06/30/23, showed the bottom half of the form, which included follow-up information for the infection, including x-rays ordered, type of x-ray ordered, results of x-rays taken, labs ordered, type of lab ordered, results of the lab ordered, other treatment ordered, and other status of patient (There was no documentation to indicate the status of the patient after the initial treatment was documented to include information such as if the patient finished the medication as ordered, if the patient’s signs and symptoms subsided, if the patient had to go back to the physician for the same infection, if the patient had another medication ordered if the first medication was not effective, and if so, the date the second medication was ordered, if the patient required another x-ray or additional lab work, if there were new wound care orders, or if the patient was admitted to the hospital for this infection.) was not completed. The form indicated, “Please complete this form for any home health patient or employee if: 1) signs and symptoms of infection are present 2) culture is obtained 3) new antibiotic is prescribed 4) client is admitted to the hospital or does due to suspected infection.” Record review of an agency form titled, “Infection Report,” for Patient #10, dated 05/19/23, showed the bottom half of the form, which included follow-up information for the infection, including x-rays ordered, type of x-ray ordered, results of x-rays taken, labs ordered, type of lab ordered, results of the lab ordered, other treatment ordered, and other status of patient (There was no documentation to indicate the status of the patient after the initial treatment was documented to include information such as if the patient finished the medication as ordered, if the patient’s signs and symptoms subsided, if the patient had to go back to the physician for the same infection, if the patient had another medication ordered if the first medication was not effective, and if so, the date the second medication was ordered, if the patient required another x-ray or additional lab work, if there were new wound care orders, or if the patient was admitted to the hospital for this infection.) was not completed. The form indicated, “Please complete this form for any home health patient or employee if: 1) signs and symptoms of infection are present 2) culture is obtained 3) new antibiotic is prescribed 4) client is admitted to the hospital or does due to suspected infection.” Record review of an agency form titled, “Infection Report,” for Patient #10, dated 05/30/23, showed the bottom half of the form, which included follow-up information for the infection, including x-rays ordered, type of x-ray ordered, results of x-rays taken, labs ordered, type of lab ordered, results of the lab ordered, other treatment ordered, and other status of patient (There was no documentation to indicate the status of the patient after the initial treatment was documented to include information such as if the patient finished the medication as ordered, if the patient’s signs and symptoms subsided, if the patient had to go back to the physician for the same infection, if the patient had another medication ordered if the first medication was not effective, and if so, the date the second medication was ordered, if the patient required another x-ray or additional lab work, if there were new wound care orders, or if the patient was admitted to the hospital for this infection.) was not completed. The form indicated, “Please complete this form for any home health patient or employee if: 1) signs and symptoms of infection are present 2) culture is obtained 3) new antibiotic is prescribed 4) client is admitted to the hospital or does due to suspected infection.” Record review of an agency form titled, “Infection Report,” for Patient #10, dated 06/19/23, showed the bottom half of the form, which included follow-up information for the infection, including x-rays ordered, type of x-ray ordered, results of x-rays taken, labs ordered, type of lab ordered, results of the lab ordered, other treatment ordered, and other status of patient (There was no documentation to indicate the status of the patient after the initial treatment was documented to include information such as if the patient finished the medication as ordered, if the patient’s signs and symptoms subsided, if the patient had to go back to the physician for the same infection, if the patient had another medication ordered if the first medication was not effective, and if so, the date the second medication was ordered, if the patient required another x-ray or additional lab work, if there were new wound care orders, or if the patient was admitted to the hospital for this infection.) was not completed. The form indicated, “Please complete this form for any home health patient or employee if: 1) signs and symptoms of infection are present 2) culture is obtained 3) new antibiotic is prescribed 4) client is admitted to the hospital or does due to suspected infection.” During an interview conducted on 07/28/23 at 1:12 p.m., with the Administrator, when asked why the infection report forms were not being completed to include the information listed on the bottom of the form such as documentation to indicate the status of the patient after the initial treatment was documented to include information such as if the patient finished the medication as ordered, if the patient’s signs and symptoms subsided, if the patient had to go back to the physician for the same infection, if the patient had another medication ordered if the first medication was not effective, and if so, the date the second medication was ordered, if the patient required another x-ray or additional lab work, if there were new wound care orders, or if the patient was admitted to the hospital for this infection, she replied, “I am not sure. Let me go get the Director of Nurses.” They both came back to the area where surveyor was working and when asked why these “Infection Reports” were not being completed to include the information listed on the bottom of the form such as documentation to indicate the status of the patient after the initial treatment was documented to include information such as if the patient finished the medication as ordered, if the patient’s signs and symptoms subsided, if the patient had to go back to the physician for the same infection, if the patient had another medication ordered if the first medication was not effective, and if so, the date the second medication was ordered, if the patient required another x-ray or additional lab work, if there were new wound care orders, or if the patient was admitted to the hospital for this infection, the Director of Nurses replied, “We have always completed the upper section since I have worked here.” When asked about any follow up being completed regarding the infection, the Director of Nurses said, “Just that one form is done for the infection.” Record review of the agency’s policy titled, “Infection Surveillance Data Gathering”, revised date 05/16/2023, indicated, “Data gathering is to collect and hold, in confidence, available data regarding the infectious state of current clients. It is the policy of the agency to collect, compile and trend data as related to client infections. Data to include but is not limited to: all patients who have suspected infection as noted on the start of care, post hospitalization history and physician or reported by the client. All patients with known or suspected infections acquired while receiving services from the agency. All patients who have had recent cultures / lab / physician intervention done for the following conditions: A) urinary B) respiratory C) wound or skin lesion D) gastrointestinal E) oral or blood All patients who have had recent antibody and or antigen studies done. All patients who indicate a fever above 100 Fahrenheit for longer than 72 hours, have an elevated white blood count or where documented change may be related to one of the above diagnoses. All patients with a known or suspected infection acquired while receiving services from the agency will have an infection log QI report completed dated with the date of onset of new infection.”