Every finding on record at Essential Medical Services Inc

A recertification survey was completed on 12/12/24. Seven deficiencies were cited.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to develop an emergency preparedness plan. Findings Include: 1.On 12/11/24 at 11:59 a.m., an interview with the administrator/director of nursing revealed the agency did not have an emergency preparedness plan. She found a binder that stated emergency preparedness, but the binder was empty. She went on to state she had been with the agency since September 2024 and did not have time to develop an emergency preparedness plan for the agency.

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on interview and record review the agency failed to develop and implement policies and procedures based on the emergency plan and risk assessment. Findings Include: 1.On 12/11/24 at 11:59 a.m., an interview with the administrator/director of nursing revealed the agency did not have an emergency preparedness policies and procedures based on the risk assessment. She found a binder that stated emergency preparedness, but the binder was empty. She went on to state she had been with the agency since September 2024 and did not have time to develop an emergency preparedness policies and procedures for the agency.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on interview and clinical record review, the agency failed to ensure the comprehensive assessment was updated and revised at the time of patient discharge for 1 of 1 patient records reviewed that had been discharged (Patient #7). Findings include: 1. The clinical record for Patient #7 was reviewed on 12/11/24. The plan of care for the certification period dated 9/6/24 to 11/4/24, revealed a start of care date of 1/18/08; diagnoses included quadriplegia and neurogenic bladder. The plan of care included a skilled nurse (SN) visit once per week for medication management and once per month for suprapubic catheter change; and certified nursing assistant (CNA) visits three times a day for nine weeks for assistance with activities of daily living (ADL's). a) The agency failed to document a comprehensive assessment upon Patient #7's discharge. Clinical review of agency discharge list showed Patient #7 was discharged on 10/16/24. Further review of the record for Patient #7 failed to reveal any further information regarding the discharge on 10/16/24. There was no documentation or evidence that a comprehensive assessment had been completed for Patient #7. During an interview on 12/11/24 at 11:31 a.m., the director of nursing (DON) stated the agency had not completed a comprehensive assessment of Patient #7 at the time of discharge. The DON went on to state she was not aware she had to complete a comprehensive assessment when a patient discharged.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on interviews and record review the agency failed to provide services in accordance with clinical practice guidelines and accepted professional standards of practice. Findings Include: 1.The clinical record for Patient #6 was reviewed on 12/11/24. Plan of care orders for the certification period dated 10/19/24 to 12/17/24 revealed a start of care date of 10/19/24; diagnoses included head trauma, sleep apnea, dizziness and giddiness, and a disorder of the muscles. Plan of care orders included skilled nurse visits eight (8) times a week for nine (9) weeks, Monday through Friday, twice a day. Saturday and Sunday twice a day for medication set up and gastronomy tube (g-tube) administration. a. The agency failed to provide services in accordance with clinical practice guidelines; specifically the handling of a medication. Record review revealed the skilled nurses for Patient #6 have been crushing a medication and administering it via the g-tube. On 12/11/24 at 11:58 a.m., an interview with the administrator/director of nursing revealed she did not know the medication could not be crushed. She initially thought the mother was administering the medication until a review of the plan of care. She went on to say that she would notify the physician and ask for a liquid version of the medication that was meant for g- tube medication administration. She further acknowledged the agency had failed to provide services according to the clinical practice guidelines for this medication handling.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on interviews and a review of records, the agency failed to maintain clinical documentation of patient assessment findings for 1 of 7 active patients. (Patient #6) Findings Include: 1.The clinical record for Patient #6 was reviewed on 12/11/24. Plan of care orders for the certification period dated 10/19/24 to 12/17/24 revealed a start of care date of 10/19/24; diagnoses included head trauma, sleep apnea, dizziness and giddiness, and a disorder of the muscles. Plan of care orders included skilled nurse visits eight (8) times a week for nine (9) weeks, Monday through Friday, twice a day. Saturday and Sunday twice a day for medication set up and gastronomy tube (g-tube) administration. a. The agency failed to maintain documentation of patient assessments. A review of Patient #6's record failed to show the assessments being performed by the skilled nurses. The charting was sparse and some boxes were left unchecked. On 12/11/24 at 11:54 a.m., an interview with the administrator/director of nursing revealed the electronic medical record (EMR) was new to the agency. She went on to say that she had a plan to get the staff trained on documentation in the EMR . She believed the assessments were performed but just not documented in the patient record to meet compliance. On 12/12/24 at 9:00 a.m., an interview with Patient #6's mother showed that she was happy with the skilled nurse services from the agency and that she had no concerns with the skilled nurses.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on interviews and a review of records, the agency failed to maintain clinical documentation of all interventions, including medication administration, treatments, services, and patient responses to those interventions for 1 of 7 active patients. (Patient #6) Findings Include: 1.The clinical record for Patient #6 was reviewed on 12/11/24. Plan of care orders for the certification period dated 10/19/24 to 12/17/24 revealed a start of care date of 10/19/24; diagnoses included head trauma, sleep apnea, dizziness and giddiness, and a disorder of the muscles. Plan of care orders included skilled nurse visits eight (8) times a week for nine (9) weeks, Monday through Friday, twice a day. Saturday and Sunday twice a day for medication set up and gastronomy tube (g-tube) administration. a. The agency failed to maintain clinical documentation of the medication administration and the patient's response to the intervention. A review of Patient #6's medication administration record failed to show documentation of the dates, times, and the patient's responses to the medications administered by the skilled nurses providing care. On 12/11/24 at 11:50 a.m., an interview with the administrator/director of nursing revealed that she is new to the company and had not started doing record audits so she was unaware that the skilled nurses for Patient #6, were forgetting to chart medication administration. She also acknowledged that if the skilled nurse did not chart care, treatment, and services then they were not provided to the patient.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure a discharge summary was sent to the primary care practitioner within five business days of discharge for 1 of 1 patients records reviewed requiring a transfer or discharge summary (Patients #7). Findings include: 1. The clinical record for Patient #7 was reviewed on 12/11/24. The plan of care for the certification period dated 9/6/24 to 11/4/24, revealed a start of care date of 1/18/08; diagnoses included quadriplegia and neurogenic bladder. The plan of care included a skilled nurse (SN) visit once per week for medication management and once per month for suprapubic catheter change. Certified nurse aide (CNA) visits for four hours, three times a week and two hours, four days a week. CNA also visits one hour mid-day seven days a week and two hours every night, seven days a week. 2. Clinical review of agency discharge list showed that Patient #7 was discharged on 10/16/24. Further review of the record for Patient #7 failed to reveal any further information regarding the discharge on 10/16/24. The agency failed to send Patient #7's discharge summary to the physician within five business days of the patient's discharge. 3. During an interview on 12/11/24 at 11:31 a.m., the director of nursing (DON) stated the discharge summary was not sent to the MD and that was her mistake.

A recertification survey was completed on 1/27/22. Four deficiencies were cited.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure nursing staff promptly alerted the physician of changes in the patient's condition or needs that suggested outcomes were not being achieved or the plan of care (POC) needed to be altered for 1 of 3 patients observed during a home visit (Patient #1). Findings include: AGENCY POLICY: According to a policy dated December 2017, titled, Coordination of Care, (in pertinent parts): "Essential Medical Services Inc. shall assure coordination of care with patients by doing the following: -Assure communication with all physicians involved in the plan of care. -Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregivers(s), as appropriate, the coordination of care activities." 1. The clinical record for Patient #1 was reviewed on 1/24/22. The Plan of Care (POC) for the certification periods dated 10/3/21 to 12/01/21 and 12/2/21 to 1/30/22, showed a start of care date of 2/2/16. Diagnoses included quadriplegia, pressure ulcers to right and left heels and neuromuscular dysfunction of the bladder. POC orders included skilled nurse (SN) visits two times per week to assess and monitor vital signs, medication reactions and effectiveness, lung congestion, skin integrity, patency of suprapubic catheter, change suprapubic catheter (a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder) and irrigate monthly. The SN was also ordered to change wound dressings to left and right heels, two times per week, and included the cleansing of the wounds with normal saline, apply compounding ointment and cover with mepilex. a) The agency registered nurse (RN) failed to notify Patient #1’s physician of record regarding a change to the patient's condition and impaired skin integrity, thereby affording the physician the opportunity to alter the patient's plan of care. A home visit was conducted on 1/24/22 at 5:00 P.M. for Patient #1. During the home visit, the surveyor observed a large amount of swelling in the patient’s ankle and feet areas, bilaterally. The right ankle and foot were observably much larger than the left ankle and foot. Patient #1 stated both feet had been swollen for at least a month and that he had contacted an urgent care company that made house calls in December because he was concerned. Patient #1 went on to state the home urgent care provided a visit to him in his home and was prescribed a medication to reduce the swelling. RN #2 was present during the home visit with the surveyor on 1/24/22 and stated the home urgent care provider prescribed a medication to help decrease the swelling to his lower extremities, however, she (RN #2) advised Patient #1 not to take the medication because it was not appropriate due to the patient's past medical history. RN #2 went on to state she was in the patients home sometime in December for a scheduled SN visit and was present when the home urgent care had returned to the patient's home for follow up care and that she (RN #2) asked the urgent care provider to discontinue the medication. RN #2 also stated Patient #1 had followed up with his hematology specialist during a scheduled appointment and that the specialist completed an ultrasound and addressed the patient's lower extremity swelling. Documentation review showed RN #2 completed 38 SN visits between 10/1/2021 and 1/20/22 and had only noted the presence of swelling to the patient’s left lower extremity (LLE) during one of the 38 SN visits, on 12/23/21. There was no documentation of swelling to the right lower extremity. RN #2 also documented the patient had a doctor's appointment on 12/21/21 to address the LLE swelling and had an ultrasound that was negative for the presence of a blood clot but had an enlarged lymph node in the groin. Further record review failed to show any documentation the SN had contacted the patient's physician of record regarding the swelling to the lower extremities, ankles or feet. Furthermore, there was no documentation to show the physician of record was aware another provider had been in the home to provide urgent care or that the patient had followed up with his hematology specialist for further evaluation of the LLE swelling. During an interview on 1/26/22 at approximately 4:00 P.M., RN #2 stated she did not contact Patient #1’s physician of record because the patient had already addressed the swelling with his hematologist. RN #2 acknowledged she did not understand the need for further communication with the patient's physician of record with the agency.

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 the skilled nurse (SN) followed accepted standard infection control practices to prevent the transmission of infections and communicable diseases for 1 of 1 patients observed receiving wound care during a home visit (Patient #1). Findings include: PROFESSIONAL REFERENCE: According to Potter et al. (2013), Fundamentals of Nursing (8th edition), page 411, "The effectiveness of infection prevention practices depends on the conscientiousness and consistency in using effective aseptic technique by all health care providers. They cautioned that failure to comply with the basic procedures places the patient at risk for an infection that can seriously impair recovery or lead to death." AGENCY POLICY: According to a policy dated July 1, 1997, titled, "[Woundcare] is performed without incidence of infection," (in pertinent parts): "Intent: To dress, change and care for a wound without incidence of infection. -Education (with follow-up) is the mainstay of proper wound care in the home and should include: -Indications for handwashing -Indications for clean vs sterile technique -Signs and symptoms of wound infections -Proper storage and maintenance of supplies -Disposal of soiled dressings -Disease transmission" 1. The clinical record for Patient #1 was reviewed on 1/24/22. The Plan of Care (POC) for the certification periods of 10/3/21 to 12/01/21 and 12/2/21 to 1/30/22, showed a start of care date of 2/2/16. Diagnoses included; quadriplegia, pressure ulcers to right and left heels and neuromuscular dysfunction of the bladder. POC orders included skilled nurse (SN) visits three times per week to assess and monitor vital signs, medication reactions and effectiveness, lung congestion, skin integrity, patency of suprapubic catheter, change suprapubic catheter and irrigate monthly. POC orders also included the registered nurse (RN) to provide supervision of the certified nurse aid(e) (CNA) in the home. Additional review of the POC dated 12/2/21 revealed the SN was to change wound dressings to left and right heels, cleanse with normal saline, apply compound ointment and cover with mepilex, three times per week. Further record review of an interim physicians order completed by RN #2, effective 12/20/21, showed a decreased frequency of SN visits and dressing changes to the bilateral heels from three times per week to two times per week, however no other changes were noted to the wound care procedures in the interim physician's order. a) Observations showed RN #2 failed to utilize appropriate infection control procedures during the provision of wound care for Patient #1. A home visit was conducted on 1/24/22 at 5:00 P.M. for Patient #1. The surveyor observed RN #2 providing wound care to Patient #1's left and right heel wounds. The surveyor observed RN #2 gather gloves, normal saline, gauze pads, scissors, foam dressing contained in a clear peel pouch and the compound ointment. RN #2 then performed initial hand hygiene, applied gloves and placed a clean barrier below the footrests of the patient's wheelchair. RN #2 then cut two pieces of foam from the opened peel pouch, large enough to fit each heel wound, and laid them on the clean barrier below. With her gloved hands, RN #2 then peeled back the used mepilex dressing from the patient's right heel, but did not remove the mepilex completely, and left it dangling from the patient's right heel. RN #2 removed the contaminated foam from the right heel wound and cleansed the wound with normal saline using a clean gauze, with the same gloved hands as she had used to remove the contaminated foam and peel back the used mepilex to the right heel. With the same gloved hands, RN #2 then removed the cap from the syringe that contained the compound ointment and squirted a small amount of the compound on the clean foam and placed it directly to the open right heel wound. The RN then reapplied the same used mepilex dressing that was already attached to the patient's right heel. RN #2 then repeated the exact same wound care procedure to the left heel as she had just completed for the right using the same gloved hands. When the wound care was completed, RN #2 removed her gloves and disposed of the barrier and soiled wound contents in a plastic bag. At no time during the wound care procedure observation did the surveyor observe RN #2 stop to perform hand hygiene or apply clean gloves after the removal of the contaminated dressings and prior to the cleansing or the redressing of the open wounds. Additionally, RN #2 was observed using the same contaminated gloves throughout the entire wound care procedure for both the right and left heels. Furthermore, RN #2 placed the used mepilex dressings over both the right and left heel wounds. During the procedure, RN #2 stated she was using the same mepilex during wound care because the patient was running low on supplies. During an interview on 1/26/22 at 4:08 p.m., RN #2 acknowledged she did not change her gloves at all or wash her hands throughout the wound care provided to Patient #1 during the home visit observed by the surveyor. RN #2 stated the reason she reused the same Mepilex on each of Patient #1's heel wounds was RN #2 did not consider the previously used Mepilex dirty. RN #2 stated the previously used Mepilex on each of Patient #1's heel wounds may have had a bit of dry skin on them, but they were not dirty as they did not come in direct contact with Patient #1's wounds as the foam she applied to the wound bed provided a barrier between the wound and the Mepilex. RN #2 acknowledged Patient #1 had six Mepilex available that she could have used during the wound care provided during the home visit, but she was trying to conserve the Mepilex for Patient #1. RN #2 stated Patient #1 has not had any infections since she has been caring for his wounds, but RN #2 acknowledged reusing dressing could potentially lead to a Patient developing an infection. During an interview on 1/27/22 at 12:09 p.m., the administrator/DON stated the agency expectation was that universal precautions be used and doctors orders be followed during all wound care provided by agency RN's. The administrator stated she was not aware that RN #2 had reused Mepilex for Patient #1's bilateral heel wounds. The administrator stated she had never heard of the practice of reusing a dressing, she stated basic nursing practice indicates when a wound care dressing change is performed the RN removes the old dressing and applies a new dressing at the end of the wound care. The administrator stated the agency has a closet with supplies available to agency RN's to access. If a patient is running low on supplies, agency RN's can access the agency supply closet if needed. The administrator stated she would address this issue with RN #2.

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 observation, interview and record review, the agency failed to ensure the patient received care in conformance with physician's orders and as indicated in the plan of care for 1 of 5 active patient records reviewed (Patients #1). 2. The clinical record for Patient #1 was reviewed on 1/24/22. The Plan of Care (POC) for the certification periods of 10/3/21 to 12/01/21 and 12/2/21 to 1/30/22, showed a start of care date of 2/2/16. Diagnoses included; quadriplegia, pressure ulcers to right and left heels and neuromuscular dysfunction of the bladder. POC orders included skilled nurse (SN) visits three times per week to assess and monitor vital signs, medication reactions and effectiveness, lung congestion, skin integrity, patency of suprapubic catheter, change suprapubic catheter and irrigate monthly. POC orders also included the registered nurse (RN) to provide supervision of the certified nurse aid(e) (CNA) in the home. Additional review of the POC dated 12/2/21 revealed the SN was to change wound dressings to left and right heels, cleanse with normal saline, apply compound ointment and cover with mepilex, three times per week. Further record review of an interim physicians order completed by RN #2, effective 12/20/21, showed a decreased frequency of SN visits and dressing changes to the bilateral heels from three times per week to two times per week, however no other changes were noted to the wound care procedures in the interim physician's order. a) The agency failed to ensure Patient #1's wound care was provided as ordered. A home visit was conducted on 1/24/22 at 5:00 P.M. for Patient #1. The surveyor observed RN #2 providing wound care to Patient #1's left and right heel wounds. The surveyor observed RN #2 gather gloves, normal saline, gauze pads, scissors, foam dressing contained in a clear peel pouch and the compound ointment. RN #2 then cut two pieces of foam from the opened peel pouch, large enough to fit each heel wound, and laid them on the clean barrier below the patient’s feet. The RN then peeled back the used mepilex dressings from the patient's right and left heels, removed the contaminated foam dressings and cleansed the wounds with normal saline using clean gauze. RN #2 then applied a small amount of the compound ointment to the clean foam dressing pieces and placed them directly to the open wounds on each heel. The RN completed the wound care procedure and reapplied the same used mepilex dressings to each heel. Documentation review for Patient #1 showed no record of a physician's order for the foam dressing or procedure for the application. During an interview on 1/26/22 at 4:08 P.M., when asked to locate the wound care orders for Patient #1 that included the addition of the foam dressing, RN #2 stated she did not obtain orders for the foam because it was just an added layer of padding and did not feel it was necessary. RN #2 further acknowledged she should have obtained an order from the physician. Findings include: AGENCY POLICY According to a policy dated December 2017, titled, "Conformance with Physician Orders," (in pertinent parts): "Essential Medical Services, Inc. shall conform to all physician orders after consulting with the physician and as they are written. -Drugs, services, and treatments are administered only as ordered by a physician." According to a policy dated December 2017, titled " Plan of Care," (in pertinent parts): "Essential Medical Services Inc. shall ensure that a written individualized care plan identifies patient- specific measurable outcomes and goals, and which is established, periodically reviewed, and [signs] by a doctor of medicine, osteopathy, or podiatry acting within the scope of [her or her] state license, certification, or registration. " 1. The clinical record for Patient #2 was reviewed on 1/25/22. The Plan of Care for the certification periods dated 11/10/21 to 1/8/22 and 1/9/22 to 3/9/22 revealed a start of care date of 1/27/00 with a restart of care date of 7/13/21; diagnoses included quadriplegia C5-C6 incomplete, perforation of intestine (nontraumatic), pressure ulcer of right buttocks, unspecified stage, and colostomy. Plan of Care orders included skilled nursing (SN) visits two times a week for nine weeks and two pro re nata (PRN) visits per month to perform assessment of medication reaction and effectiveness, suprapubic catheter (a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder) changes every two to three weeks, assess patency of suprapubic catheter, change colostomy bag twice per week and prn, and supervise home health aides (HHA); and HHA visits 21 times a week for nine weeks for range of motion, empty colostomy bag, showers, hair care, oral care, dressing, transfers, meal preparation, catheter care and empty drainage bag, irrigate suprapubic catheter with distilled water seven days a week and delegated wound care to right hip on Tuesdays, Thursdays and Saturdays after showers. Further review of the Plan of Care revealed orders for suprapubic catheter irrigation were as follows: "Supplies -pre-packaged irrigation tray -30-50 cc syringe -normal saline, sterile water, or distilled water Procedure -wash hands with soap and water -open pre-packaged irrigation tray -put on gloves -prepare 50 cc syringe with room temperature solution, leave filled syringe in tray. -disconnect the catheter from connector of drainage tubing -place sterile cap on connector, while holding catheter tip over irrigation tray -insert prepared 50 cc syringe into catheter and slowly instill solution into the catheter -contact RN as specified on the delegation record if patient demonstrates any of these -instill the second syringe into the catheter, and pull the solution (only 50cc) back immediately; instill again, withdraw, instill again, withdraw using a forceful "pumping" action. (This action helps to "stir up" the sediment in the bladder.) The remaining 50 cc solution will drain when the catheter is connected to drainage tubing. -wipe catheter tip and connector of the drainage tubing with Betadine (a medicine used for skin disinfection) prior to reconnecting catheter to drainage bag. -dispose of tray, solution container and syringe in appropriate covered trash container. -remove gloves and wash hands." a) The agency failed to ensure Patient #2's suprapubic catheter irrigation was provided as ordered. Specifically, the agency failed to ensure new irrigation trays and syringes were used as ordered each time Patient #2's suprapubic catheter was irrigated. Review of HHA notes from 11/9/21 to 12/3/21 revealed HHA # 6 documented completing catheter irrigation nine times, HHA #7 documented completing catheter irrigation 12 times, and HHA #8 documented completing catheter irrigation one time for Patient #2. During a home visit on 1/26/22 at 8:22 a.m., HHA #7 showed the surveyor the equipment used for irrigating Patient #2's suprapubic catheter which included two plastic containers and a syringe. The syringe was not dated nor were either of the containers. HHA #7 stated when she finished irrigating Patient #2's suprapubic catheter she would clean all of the equipment with hot water. HHA #7 stated she would obtain a new syringe to use every two to three weeks. During an interview on 1/27/22 at 12:52 p.m., HHA #6 stated she would reuse syringes and plastic containers for irrigating Patient #2's suprapubic catheter. She stated she would prefer to use new supplies, but Patient #2 did not like to waste supplies so she reused supplies per his request. After using the previously used syringes and plastic containers to hold the sterile water, HHA #6 stated she would clean the syringe and plastic container by rinsing them with water. HHA #6 stated she had not seen a date on a previously used syringe or container to know how many times that syringe or container had been used. During an interview on 1/27/22 at 11:30 a.m., the alternate administrator (Patient #2's RN) stated the HHAs should be using a new syringe each time they performed irrigation of Patient #2's suprapubic catheter. The alternate administrator stated Patient #2 had a large box of new syringes in his home. During an interview on 1/27/22 at 12:09 p.m., the administrator/director of nursing (DON) stated patients can have limited access to supplies at times and it is not uncommon to reuse supplies when performing suprapubic irrigation. She acknowledged Patient #2's Plan of care orders failed to have instructions on how many times the syringe or irrigation containers could be reused. She also acknowledged the Plan of Care orders failed to instruct the HHA on how to clean the syringe or containers between use and the orders failed to instruct the HHAs to date the syringe and containers to know how many days the syringe and containers have been used.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure home health aides (HHAs)/certified nursing aides (CNAs) provided services permitted to be performed under state law for 1 of 1 active patients reviewed who received delegated wound care by HHA (Patient #2). Findings include: REGULATORY REFERENCE According to the Colorado Nurse and Nursing Aide Practice Act (Title 12-255-131), dated 2021, (read in part): " Any licensed practical nurse, registered nurse, or advanced practice registered nurse may delegate any task included in the nurse's licensed scope of practice, subject to the requirements of this section. A licensed practical nurse, registered nurse, or advanced practice registered nurse may delegate nursing tasks to licensed, certified, registered, or unlicensed or unregulated assistive personnel. In no event may a registered nurse delegate to another person the authority to select medications if the person is not, independent of the delegation, authorized by law to select medications. -Delegated tasks shall be within the area of responsibility of the delegating nurse and shall not require any delegatee to exercise the judgment required of a nurse." According to the Colorado Nurse and Nursing Aide Practice Act (Title 12-255-206), dated 2021 (pertinent in parts): " (1) In addition to any nursing tasks delegated to a certified nurse aide pursuant to section 12-255-131, a certified nurse aide who is deemed competent by a registered nurse licensed pursuant to part 1 of this article 255 may perform the following tasks: Digital Stimulation, insertion of a suppository, or use of an enema, or any other medically acceptable procedure to stimulate a bowel movement; Gastrostomy-tube and jejunostomy-tube feeding; Placement in a client's mouth of presorted medication that has been boxed or packaged by a registered nurse, a licensed practical nurse, or a pharmacist or, in the case of a client who is a minor, presorted medication that has been sorted by the minor's parent or guardian; Administration of oxygen to clients; and Changing ostomy bags. (2) The board shall promulgate rules concerning the competency requirements for a certified nurse aide to perform the task listed in subsection (1) of this section. (3) The duties performed by a certified nurse aide as specified in subsection (1) of this section are not considered a delegation of nursing tasks pursuant to section 12-255-131." AGENCY POLICY According to a policy dated July 10, 2001, titled, "Nurse Delegation in the Home," (in pertinent parts): "The Colorado Nurse Practice Act allows for delegation by RNs(registered nurse) to LPNS (licensed practical nurse), CNAs (certified nurse assistant) or non-nursing personnel in individual situations: to a specific delegatee for a specific client and within a specific time frame. Any nursing task delegated by the professional nurse shall be: -Within the area of responsibility of the nurse delegating the task -Within the knowledge, skills, and ability of the nurse delegating the task -Of a routine repetitive nature and shall not require the delegate to exercise nursing judgment or intervention. -A task that a reasonable and prudent nurse would find to be within generally accepted nursing practice. -An act consistent with the health and safety of the client. -Limited to a specific delegate, for a specific client and within a specific time frame." 1. During an interview on 1/24/22 at 1:25 p.m., the administrator/DON stated the agency did allow registered nurses (RNs) to delegate tasks to HHAs. The DON stated the process for the RN to delegate to the HHA was the RN would write step by step instructions for the HHA, instruct the HHA on how to complete the steps, and then ensure the HHA was competent to complete the delegated task. The DON stated if a delegated task changed at all from the original instructions, for example, a doctor ordered a new dressing to be used on a wound, the RN would rewrite the step by step instructions for the HHA, go back out to the patient's home and instruct the HHA on the changes for the delegated task. The DON stated RN could delegate "simple" wound care to a HHA. During an interview on 1/26/22 at 4:08 p.m., the DON defined "simple" to mean a wound care dressing that involved cleaning the wound and applying a bandage. The DON stated any task that required the use of a medication could not be delegated or completed by a HHA. 2. The clinical record for Patient #2 was reviewed on 1/25/22. The Plan of Care for the certification periods dated 11/10/21 to 1/8/22 and 1/9/22 to 3/9/22 revealed a start of care date of 1/27/00 with a restart of care date of 7/13/21; diagnoses included quadriplegia C5-C6 incomplete, perforation of intestine (nontraumatic), pressure ulcer of right buttocks, unspecified stage, and colostomy. Plan of Care orders included skilled nursing (SN) visits two times a week for nine weeks and two pro re nata (PRN) visits per month to perform assessment of medication reaction and effectiveness, suprapubic catheter (a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder) changes every two to three weeks, assess patency of suprapubic catheter, change colostomy bag twice per week and prn, and supervise home health aides (HHA); and HHA visits 21 times a week for nine weeks for range of motion, empty colostomy bag, showers, hair care, oral care, dressing, transfers, meal preparation, catheter care and empty drainage bag, irrigate suprapubic catheter with distilled water seven days a week and delegate wound care to right hip on Tuesdays, Thursdays and Saturdays after showers. Further review of Plan of Care orders for the certification period dated 11/8/21 to 1/8/22 revealed delegation to HHA of wound dressing changes to Patient #2's right hip on Tuesdays, Thursdays, and Saturdays after showers as follows: Wash hands and put gloves on, remove old dressing and discard. Cleanse wound with normal saline and apply Santyl (a medicine that removes dead tissue from wounds) ointment. Cover with Hydrofera Blue Ready Border (a type of antibacterial wound bandage). Review of wound care clinic notes for Patient #2 revealed an order, written on 12/10/21 by NP #9, which stated, "Essential Home Health: Right trochanter (a portion of a hip) -clean with wound cleanser, apply Iodosorb paste (a topical medication used to treat persistent weeping wounds) to wound bed, cover with Mepilex (an absorbent foam dressing), change every other day." a) The RN failed to ensure that only tasks permitted by state law were delegated to the HHA for Patient #2. Review of delegated HHA notes dated 11/9/21 to 12/9/21, completed by HHA #6, revealed HHA #6 documented she completed the following wound care for Patient #2 eleven times (11/9/21, 11/11/21, 11/13/21, 11/18/21, 11/20/21, 11/23/21, 11/25/21, 11/27/21, 12/2/21,12/7/21, and 12/9/21): "Wash hands and put gloves on. Clean wound with NS (normal saline). Apply Santyl ointment. Cover with Hydrofera Blue Ready Border." Review of delegated HHA visit notes dated 12/14/21 to 12/23/21, completed by HHA #6, revealed HHA #6 documented she completed the following wound care for Patient #2 four times (12/14/21, 12/16/21, 12/21/21, and 12/23/21): "Wash hands and put gloves on. Remove old dressing and discard. Cleanse wound with NS. Apply Iodosorb calcium alginate, cover with Mepilex." Review of delegated HHA visit notes dated 1/1/22 to 1/6/22, completed by HHA #6, revealed HHA #6 documented she completed the following wound care for Patient #2 three times (1/1/22, 1/4/22, and 1/6/22): "Wash hands and put gloves on. Remove old dressing and discard. Cleanse wound with NS. Apply Iodosorb. Cover with Mepilex." During an interview on 1/27/22 at 12:52 p.m., HHA #6 confirmed she performed wound care with Patient #2. HHA #6 stated RN #2 taught her how to perform the wound care and would educate her each time the wound care changed. During an interview on 1/24/22 at 3:21 p.m., RN #2 stated had delegated wound care to HHA #6 for Patient #2. RN #2 stated she educated HHA #6 each time Patient #2 wound care orders changed. During an interview on 1/26/22 at 4:08 p.m., RN #2 stated the only wound care she delegated was simple wound care. She defined simple as wound care requiring dressing change and/or application of medication to the wound bed. RN #2 stated she would not delegate complex wound care such as wound care that required the use of a wound vac (a wound care treatment that decreases air pressure around a wound to assist in the healing) to a HHA. RN #2 stated she did not always have HHA #6 return a demonstration of how to complete the wound care for Patient #2 when the wound care orders changed. RN #2 stated most of the time she would call HHA #6 on the phone and educate HHA #6 regarding the change and then have HHA #6 repeat the change back to her. RN #2 stated she did not have HHA #6 return a demonstration of how to complete the wound care for Patient #2 after the orders changed as RN #2 considered the care to Patient #2's wound to be simple application of medication and dressing changes.