Every finding on record at Hga Homecare, LLC

A recertification survey was conducted on 2/11/25 to 2/13/25 and Huntsville Hospital Homecare was found to be in substantial compliance with the Conditions of Participation for Emergency Preparedness.

A recertification survey was conducted on 2/11/25 to 2/13/25 at Huntsville Hospital Homecare. Standard level deficiencies were cited and will require an approved Plan of Correction.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on observation, review of medical records (MR), agency policy and procedure, and staff interviews, it was determined the agency failed to ensure staff developed an individualized Plan of Care (POC) to care for a patient's gastrostomy tube (g-tube). This deficient practice affected Home Visit (HV # 4), and one of one open records reviewed of a patient with a g-tube and had the potential to affect all patients with g-tubes served by the agency. Findings include: Agency policy: Plan Of Care Policy number: 2.1.007 Revised date: 09/01/24 Purpose: To assure an appropriate POC is developed...for each patient... Policy: Each patient has an individualized POC developed in consultation with the patient, physician or authorized practitioner, and staff that integrates comprehensive assessment findings to address patient problems, needs, and goals, as well as to address specific services being provided. Procedure: ...2. The POC includes: ...Patient specific interventions... HV # 4 was admitted to the agency on 1/14/25 with diagnoses of Essential (Primary) Hypertension and Hypothyroidism, Unspecified. A HV was conducted on 2/11/25 at 3:02 PM with Employee Identifier (EI) # 3, Licensed Practical Nurse (LPN) to observe care provided. During the observation, it was noted that HV # 4 was receiving liquid nutrition through a gastrostomy tube. EI # 3 inspected the insertion site of the g-tube during the visit. No care was provided to the site. Review of the Home Health Certification (HHC) and POC dated 1/14/25 revealed documentation of DME (Durable Medical Equipment) and Supplies...DME-Feeding Pump, ... Feeding Tube Supplies. Further review of the HHC and POC revealed Nutritional Requirements: Tube Feeds. There was no documentation in the POC for care of the patient's g-tube. An interview was conducted on 2/13/25 at 12:02 PM with EI # 1, Executive Director, who confirmed there was no documentation in the POC for care of the patient's g-tube.

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 review of agency policies, observation, and staff interview, it was determined the agency failed to ensure staff followed infection control policies in one of seven home visits including Home Visit (HV) # 1. This deficient practice had the potential to negatively affect all patients served by the agency. Findings include: Agency Policy: Hand Hygiene Policy Number: 8.004 Date: 5/1/19 Purpose: To help prevent the spread of microorganisms and infection by cross contamination... Policy: Staff are required to perform hand hygiene prior to, at specified time points during, and following patient contact. Procedure: Staff performs hand hygiene by washing with soap and water or using an alcohol-based hand sanitizer: ...after contact with blood, bodily fluids or excretions, mucous membranes, non-intact skin, wound dressings HV # 1 was admitted to the agency on 1/30/25 with a primary diagnosis of Encounter for Surgical Aftercare Following Surgery on Digestive System. A Home Visit was conducted on 2/11/25 from 12:15 PM to 1:30 PM with Employee Identifier (EI) # 4, Registered Nurse, performing wound care for HV # 1. After removing the soiled wound dressing, EI # 4 failed to remove his/her gloves and perform hand hygiene. With the same gloves used to remove the old wound dressing and clean the wound, EI # 4 reached into the patient's box of clean wound care supplies multiple times to retrieve supplies needed to perform wound care. An interview was conducted on 2/13/25 at 1:00 PM with EI # 1, Executive Director, who confirmed staff failed to follow the hand hygiene policy during the home visit.

Based on review of the agency Emergency Preparedness Plan and interview it was determined Huntsville Hospital HomeCare was in substantial compliance with 484.102 Conditions of Participation: Emergency Preparedness.

A recertification survey was conducted at Huntsville Hospital HomeCare on 2/1/22 to 2/3/22. Standard level deficiencies were cited and will require a plan of correction.

Patient's needs CFR(s): 484.55(c)(4) The patient's medical, nursing, rehabilitative, social, and discharge planning needs; This ELEMENT is not met as evidenced by: Based on review of on-call logs, policies and procedures, and interview, it was determined the agency failed to ensure the staff met the needs of patients 24 hours a day per agency policy. This affected 2 of 5 on-call log patients reviewed including unsampled (US) # 3, and US # 4, and had the potential to negatively affect all patients receiving services by this agency. Findings include: Agency Policy: Admission Process Policy Number: 2.1.001 Revised Date: 1/1/21 Policy: Patients admitted to home care services must be under the care of a physician, meet admission criteria, and have reasonable expectations that needs can be met safely in the home. Procedure: 1. Patient admission criteria: ...c. The agency: ...Must be able to meet the patient's needs. Agency Policy: On-Call Process (To Include During and After Hours Care) Policy Number: 5.008 Revised Date: 3/1/19 Policy: The agency ensures that patients... have access to a staff clinician 24 hours -a-day by means of providing an on-call nurse during and after office hours... Procedure: 1. The agency will provide each client, upon admission to services, a designated on-call telephone number and will instruct each client to call this number to access care from the agency after regular business hours. ...5. Clinicians will document responses and outcomes of appropriate calls on the On-Call Event Coordination note. 6. Clinicians will submit the On-Call Event Coordination note and any supporting patient documentation by next business day and verbally communicate all on-call issues to appropriate Executive Director/Clinical Director and/or Patient Care Manager. Agency Policy: Operations For Patient Care Delivery Policy Number: 5.004 Revised Date: 1/1/18 Policy: Leadership, ...provides organization direction and staffing for patient care services according to the scope of care or services offered... Procedure: ...2. Services are provided in a timely manner to meet patient's needs. Review of the agency's on-call logs from December 2021 through January 2022 was conducted on 2/3/22 at 9:00 AM with the following findings for 2 of 5 on-call log documentation requested: 1. Review of US # 3 on-call log dated 12/9/21 at 7:19 PM revealed, "Pt (Patient) has a high fever/chills/body ache." Further review of US # 3 on-call log dated 12/9/21 at 9:28 PM revealed, "Fever, Body Aches/Has PICC (Peripherally Inserted Central Catheter) Line and Catheter." The surveyor requested the On-call Event Coordination notes and any supporting patient documentation for the 12/9/21 at 7:19 PM and 9:28 PM after hour calls for US # 3. There were none provided. The staff failed to meet the needs of the patient per policy. An interview was conducted on 2/3/22 at 10:32 AM with Employee Identifier (EI) # 1, Registered Nurse (RN) Executive Director, who stated, "There are no notes and there was no visit made". The surveyor asked EI # 1, if the patient's needs were met and EI # 1 stated, "It's not documented". 2. Review of US # 4 on-call log dated 1/2/22 at 1:53 PM revealed, "Wound VAC (Vacuum Assisted Closure) Keeps Beeping. Question about if I could do something about that beep or can I turn it off." Further review of US # 4 on-call log dated 1/2/22 at 4:53 PM revealed, "Pt has pulled Wound VAC loose and can't get back connected." The surveyor requested the On-call Event Coordination notes and any supporting patient documentation for the 1/2/22 at 1:53 PM and 4:53 PM after hour calls for US # 4. There were none provided. The staff failed to meet the needs of the patient per policy. An interview was conducted on 2/3/22 at 10:32 AM with EI # 1 who stated, "There are no notes and there was no visit made". The surveyor asked EI # 1, if the patient's needs were met and EI # 1 stated, "It's not documented".

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on review of medical records (MR), agency policy and procedure, observations, and interviews, it was determined the agency failed to ensure staff reconciled medications for 5 of 7 Home Visits (HV) conducted. This affected HV # 7, HV # 6, HV # 2, HV # 4, HV # 1, and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Monitoring Medications Policy Number: 10.008 Revision Date: 05/01/19 Purpose: To provide a process to ensure continuous monitoring of medications in the patient's home. Policy: A drug regimen review will be performed on all patients in conjunction with all comprehensive assessments. Additionally, all clinicians will participate in medication review and reconciliation throughout the episode. For patients receiving skilled nursing and therapy services, the skilled nurse is responsible for medication review and reconciliation throughout the episode... For patients receiving only therapy services, the therapist is responsible to facilitate drug regimen review and medication reconciliation throughout the episode... The physician is contacted immediately if any discrepancies between agency information and patient medications are found. Procedure: 1. The discipline responsible for the drug regimen review will: a. Compare medication list obtained from the facility from which the patient was transferred and /or active physician orders to actual medications patient is taking. b. Review all medications including over the counter (OTC) medications, vitamins, herbs and herbal products, creams and topical ointments.... 2. All clinicians participating in the patient's care are responsible to assist with the maintenance of accurate patient medication information throughout the episode of care. During the patient's episode of care the following will occur: a. Through a collaborative process the care team will: i. Compare medications patient is currently taking with medications ordered for the patient in order to identify and resolve discrepancies... 5. HV # 1 was admitted to the agency on 12/3/21, and recertified for care 2/1/22 to 4/1/22, with diagnoses including Malignant Neoplasm of Uterus, Part Unspecified, and Anemia in Neoplastic Disease. A HV was conducted on 2/1/22 at 11:10 AM to observe care provided by EI # 8, RN. EI # 3, RN, Clinical Manager, was also present on the HV. Review of the Home Health Certification and Plan of Care dated 2/1/22 to 4/1/22 revealed a SN frequency of 1 WK 3. Prior to the HV, the surveyor received a CMR, printed on 2/1/22 at 10:03 AM. The CMR was compared to the medications in the home, and the following discrepancies were observed: Gabapentin 300 mg, 1 capsule, 3 times daily was listed on the CMR. The bottle in the home, date filled 1/6/22, read 2 times daily, and was confirmed by the patient. Phenazopyridine 100 mg tablet, 1 tablet every 8 hours was listed on the CMR. The bottle in the home, date filled 1/6/22, read 1 tablet twice a day, and was confirmed by the patient. Potassium Chloride 20 mEq/ ml oral liquid, 7.5 ml daily was listed on the CMR. There was none in the home and HV # 1 stated stated she/he had not taken potassium in over 1 month. Vitamin C 1000 mcg (micrograms) tablet, 1 daily, was in the home and not on the CMR. HV # 1 confirmed taking Vitamin C for over 1 month. An interview was conducted on 2/3/22 at 11:49 AM with EI # 2, who confirmed staff failed to reconcile medications per policy. 3. HV # 2 was admitted to the agency on 1/5/22 with diagnoses including Encephalopathy, Unspecified and Long Term (Current) Use of Anticoagulants. A HV was conducted on 2/1/22 at 1:23 PM to observe care provided by EI # 6, RN. EI # 1, RN, Executive Director, was also present during the HV. Prior to the HV, the surveyor received a current CMR printed 2/1/22 at 10:14 AM. The CMR was compared to the medications in the home, and the following discrepancies were observed: Amlodipine 10 mg tablet 1 tablet daily was on the CMR. The bottle in the home, date filled 12/8/21, read 5 mg 1 tablet daily. The patient's caregiver confirmed he/she had been taking it for several months. Extra Strength Tylenol for Adults 500 mg 1 as needed was found in the home, but not listed on the CMR. The caregiver stated she had been taking the Extra Strength Tylenol for 4-5 years. The CMR discrepancy was confirmed at the time of the visit by EI # 1. 4. HV # 4 was admitted to the agency on 11/3/21 and recertified from 1/2/22 to 3/2/22 with diagnoses including Type 2 Diabetes with Diabetic Peripheral Angiopathy Without Gangrene and Long Term (Current) Use of Anticoagulants. A HV was conducted on 2/1/22 at 11:55 AM to observe care provided by EI # 5, RN. EI # 1, was also present during the HV. Prior to the HV, the surveyor received a current CMR printed 2/1/22 at 10:43 AM. The CMR was compared to the medications in the home, and the following discrepancies were observed: Enoxaparin 100 mg /ml subcutaneous 90 mg 2 times daily was listed on the CMR. There was none found in the home and the patient stated it was discontinued about 2 weeks ago. The CMR discrepancy was confirmed at the time of the visit by EI # 1. 1. HV # 7 was admitted to the agency on 1/7/22 with diagnoses including Other Pneumonia, Unspecified Organism, Amaurosis Fugax, and Type 2 Diabetes With Unspecified Diabetic Retinopathy Without Macular Edema. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated1/7/22 to 3/7/22 revealed an ordered SN (Skilled Nurse) visit frequency of 1WK (week) 5, beginning 1/7/22, PT (Physical Therapist) ordered frequency of 2WK1, 1WK3, beginning 1/9/22, and OT (Occupational Therapist) ordered frequency of 1WK5 beginning 1/9/22. A HV was conducted on 2/1/22 at 2:40 PM to observe care provided by Employee Identifier (EI) # 9, PT. EI # 2, RN (Registered Nurse) Clinical Director was also present during the visit. During the HV, a comparison was made between medications observed in the home and the Client Medication Report (CMR) printed 2/1/22 at 10:46 AM provided to the surveyor prior to the HV. The following medications were observed in the home, and not listed on the CMR: a. Bottle of OTC Complete Multivitamin (MVI) supplement. The patient's caregiver (cg) stated he/she had been taking the vitamin supplement daily for years. b. Bottle of OTC Omeprazole 20 milligram (MG) tablets. The patient's cg stated he/she had been taking as needed for heartburn for a long time. c. Bottle of OTC Miralax powder. The patient's cg stated he/she had been taking as needed for constipation for more than six months. The following discrepancies were observed between the medications observed in the home and what was listed on the CMR: a. Novolin R (regular) insulin, 100 units per ml (milliliter), 30 units three times daily was listed on the CMR. The patient's cg stated the dose administered was based on what the current blood sugar result was at the time of administration, and that the patient had been dosing this way for six years. b. Lantus insulin, 100 units per ml, 40 units at bedtime, was listed on the CMR. The patient's cg stated the dose administered was based on what the current blood sugar result was at the time of administration, and that the patient had been dosing this way for six years. EI # 2, RN Clinical Director, confirmed at the time of the HV the CMR was not reconciled with the patient's current medications. 2. HV # 6 was admitted to the agency on 1/12/22 with diagnoses including Cerebral Infarction Due To Unspecified Occlusion or Stenosis of Right Middle Cerebral Artery and Hypertensive Chronic Kidney Disease With Stage 1-4 Unspecified. Review of the HHC and POC dated 1/12/22 to 3/12/22 revealed an ordered SN visit frequency of 1WK9, beginning 1/12/22, PT ordered frequency of 2WK3, 1WK1, beginning 1/16/22, OT ordered frequency of 1WK5, beginning 1/16/22, and ST (Speech Therapist) ordered frequency of 1WK1, 2WK2, 1WK4, beginning1/12/22. A HV was conducted on 2/1/22 at 12:03 PM to observe care provided by EI # 4, Licensed Practical Nurse (LPN). EI # 2, RN Clinical Director, was also present during the visit. During the HV, a comparison was made between medications observed in the home and the CMR printed 2/1/22 at 10:45 AM provided to the surveyor prior to the HV. Hydralazine 25 MG tablet, 1 tablet 3 times daily was listed on the CMR. The patient's cg stated that the hydralazine was changed to 2 times daily on 1/13/22. The CMR discrepancy was confirmed at the time of the visit by EI # 2.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on review of medical records (MR), policy and procedure, and interviews, it was determined staff failed to develop the plan of care to include: 1. Wound care frequency. 2. Port-A-Cath care instructions. This affected 2 of 12 MR's reviewed, including MR # 4, Home Visit (HV) # 1, and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Plan of Care (POC) Policy Number: 2.1.007 Revision Date: 12/01/21 Purpose: To assure an appropriate plan of care is developed and revised in a timely manner for each patient. To assure that physician/authorized practitioner's orders are followed. Policy: Each patient has an individualized POC developed in consultation with the patient, physician or authorized practitioner, and staff... to address patient problems, needs and goals, as well as to address specific services being provided. Procedure: 1. A POC is developed for all patients... 2. The POC includes: ...f. Medications and treatments. ...i. Patient specific interventions. ...n. All patient care orders. 1. MR # 4 was admitted to the agency on 1/13/22 with diagnoses including Type 2 Diabetes Mellitus with Diabetic Neuropathy, Unspecified, and Unspecified Atrial Fibrillation. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 1/13/22 to 3/13/22 revealed no documentation or orders for care for the patient's midline neck wound, post tracheotomy. Review of the physician's order dated 1/21/22 revealed an order for wound care to # 4 Midline Neck: Remove old dressing and discard using biohazard protocol. Cleanse with saline and gauze. Apply dry gauze. Secure with tape using clean technique. There was no documentation of a frequency for the wound care. An interview was conducted on 2/3/22 at 11:56 AM with Employee Identifier (EI) # 2, RN (Registered Nurse), Clinical Director, who confirmed staff failed to include wound care in the initial POC, and failed to include a frequency for the wound care on the subsequent order. 2. HV # 1 was admitted to the agency on 12/3/21, and recertified for care 2/1/22 to 4/1/22, with diagnoses including Malignant Neoplasm of Uterus, Part Unspecified, and Anemia in Neoplastic Disease. A HV was conducted on 2/1/22 at 11:10 AM to observe care provided by EI # 8, RN. EI # 3, RN, Clinical Manager, was also present on the HV. Review of the HHC and POC dated 12/3/21 to 1/31/22 revealed a SN frequency of 1 WK (Week) 1, 2 WK 1, and 1 WK 7. Review of the HHC and POC dated 2/1/22 to 4/1/22 revealed a SN frequency of 1 WK 3. During the HV, the patient referred to her/his port, and stated she/he sure wanted to keep it. Review of both HHC and POC's referenced above, revealed no documentation the port was included in the POC. A review of the RN Oasis Admission note, dated 12/3/21, revealed the following documentation for the question, 'Does patient have an infusion access' "No." In the Narrative note, the RN documented the following, "...Patient has a Port-A-Cath to the right chest wall that is de-accessed at this time and has not been flushed since October. Patient will follow up on Tuesday with her/his physician to determine if she/he will continue treatments and keep the port in, or have the port removed..." The surveyor requested follow up information and/or physician orders for the care of the port, and none was received. An interview was conducted on 2/3/22 at 11:49 AM with EI # 2, who confirmed staff failed to include the Port-A-Cath in the POC.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on review of medical records (MR), agency policies and procedures, observations, and interviews, it was determined the agency failed to ensure staff followed physician orders to: 1. Notify the physician of weight gain of 5 pounds in 7 days as ordered. 2. Instruct on new medications as ordered. 3. Obtain body measurement of calf circumference every visit as ordered. 4. Collection and testing of a stool specimen for Clostridium Difficile (C-Diff) as ordered. 5. Assess lower extremities for presence of lesions on every visit, as ordered. This affected 4 of 12 open records reviewed, which included MR # 2, MR # 3, Home Visit (HV) # 2, MR # 4 and had the potential to affect all persons served by the agency. Findings include: Agency Policy: Plan of Care (POC) Policy Number: 2.1.007 Revision Date: 12/01/21 Purpose: To assure an appropriate plan of care is developed and revised in a timely manner for each patient. To assure that physician/authorized practitioner's orders are followed. Policy: Each patient has an individualized POC developed in consultation with the patient, physician or authorized practitioner, and staff... to address patient problems, needs and goals, as well as to address specific services being provided. Procedure: 1. A POC is developed for all patients... 2. The POC includes: ...i. Patient specific interventions and education: measurable outcomes and goals... ...n. All patient care orders. Agency Policy: Patient Education Policy Number: 3.001 Revision Date: 11/01/17 Purpose: To describe patient and/or caregiver interactions designed to promote and maximize patient health and safety. Policy: The agency plans, supports, and coordinates patient and caregiver education designed to promote patient health and safety. Patients receive oral and written information for this purpose on an ongoing basis... Procedure: ...6. ...patients and caregivers receive oral and written information on medication education to include: a. Dosage, route, duration b. Description, purpose, expected action c. Potential side effects, contraindications, avoidance of interactions, reactions to report... 7. Using the progress/Visit note, the clinician documents the level of patient/caregiver comprehension... 4. MR # 4 was admitted to the agency on 1/13/22 with diagnoses including Type 2 Diabetes Mellitus with Diabetic Neuropathy, Unspecified, and Unspecified Atrial Fibrillation. Review of the HHC and POC dated 1/13/22 to 3/13/22 revealed frequency orders for the PT (Physical Therapist) for 1 WK 1, 2 WK 1, 1 WK 7, and orders for the therapist to assess lower extremities for presence of lesions on every visit. Review of the PT Oasis Admission note dated 1/13/22 revealed the PT documented the patient had 0 (zero) wounds, and for integumentary findings documented "No problems identified." Review of the PT VNR dated 1/17/22 revealed the PT documented the following intervention: "Assess lower extremities for the presence of skin lesions every visit... Assessment findings none." Review of the PT VNR dated 1/19/22 revealed the PT documented the following intervention: "Assess lower extremities for the presence of skin lesions every visit... No skin lesions." Review of the Nurse Practitioner Progress Note, dated 1/20/22 revealed the following documentation, "...The wounds to his bilateral second toes have deteriorated since I last saw him/her... Today, the dressings were so dry, we had to moisten them to remove them. The skin is red and angry looking with discharge. Significant concern for osteo (osteomyelitis) starting with current care (or lack there of) being provided to areas... Wounds have deteriorated in the previous 2 weeks..." An interview was conducted on 2/3/22 at 11:56 AM with EI # 2, RN, Clinical Director, who confirmed the PT failed to assess lower extremities every visit as ordered, and identify the patient's wounds. 3. HV # 2 was admitted to the agency on 1/5/22 with diagnoses including Encephalopathy, Unspecified and Long Term (Current) Use of Anticoagulants. Review of a physician's order dated 1/17/22 at 8:09 AM read, "SN/CG (Caregiver) to collect and test stool for C-Diff". There was no documentation in the MR the stool specimen was collected and tested for C-Diff as directed per the physicians orders. An interview was conducted on 2/3/22 at 11:26 AM with EI # 1, who verified the staff failed to collect and test a stool specimen on HV # 2 for C-Diff per physician orders. 1. MR # 2 was admitted to the agency on 1/11/22 with diagnoses including Hypertensive Heart Disease With Heart Failure, and Permanent Atrial Fibrillation. Review of the Home Health Certification (HHC) and POC for 1/11/22 to 3/11/22 revealed a SN (Skilled Nurse) visit frequency of 1WK (week) 5, with orders for the physician to be notified of weight gain or loss of 5 pounds within 7 days, and to instruct the patient to weigh daily and keep a weight log. Review of the 1/11/22 SN (Skilled Nurse) Visit Note Report (VNR) revealed a documented weight of 104 pounds. Review of the 1/17/22 SN VNR revealed a documented weight of 109 pounds, which was a gain of 5 pounds in 6 days. There was no documentation the SN notified the physician of the 5 pound weight gain in 7 days. Further review of the HHC and POC revealed orders for the SN to instruct on new and changed medications. A new order, dated 1/20/22, was written for furosemide 40 MG (milligrams) daily, and potassium chloride 10 MEQ (milliequivalents) daily. Review of the SN VNR's dated 1/20/22, 1/24/22, and 2/1/22 revealed there was no documentation the new medications ordered on 1/20/22 were instructed to the patient or caregiver by the SN. In an interview conducted 2/3/22 at 11:35 AM, Employee Identifier (EI) # 1, RN (Registered Nurse) Executive Director confirmed the SN should have notified the physician of the 5 pound weight gain as ordered, and provided instructions for the new medications. 2. MR # 3 was admitted to the agency on 1/20/22 with diagnoses including Non Displaced Bicondylar Fracture Right Tibia, Subsequent For Closed Fracture With Routine Healing, and Hypertensive Heart Disease With Heart Failure. Review of the HHC and POC for 1/20/22 to 3/20/22 revealed a SN visit frequency of 1 WK 9, which included orders for the SN to instruct on new and changed medications, perform body measurement of calf circumference every visit, and to notify the physician of 2 CM (centimeter) increase in 7 days. Review of the SN VNR's dated 1/20/22 and 1/26/22 revealed no documentation a calf circumference measurement was obtained as ordered. Further review of the MR revealed new medication, pantoprazole 20 MG (Milligrams) delayed release tab, 20 MG daily, was ordered 1/25/22. Review of the SN VNR's dated 1/26/22 and 2/1/22 revealed no instruction/education was provided to the patient or caregiver by the SN on the new medication. In an interview conducted 2/3/22 at 11:17 AM, EI # 1, RN Executive Director, confirmed the calf circumference should have been obtained and documented as ordered for the SN visits and was not, and that the new medication pantoprazole should have been taught, and was not.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on review of medical records (MR), agency policies and procedures, and staff interview, it was determined, the staff failed to ensure physician orders were obtained for all labs performed. This deficient practice affected 1 of 12 active records reviewed including Home Visit (HV) # 4, and had the potential to negatively affect all patients served by the agency. Findings include: Agency Policy: Physician Orders Policy Number: 2.1.008 Revised Date: 11/01/21 Policy: No medications, treatments, diagnostic studies or therapeutics will be administered without the order of a qualified physician or authorized practitioner... Procedure: ...10. Services are provided according to the most recent orders updating the patient's Plan of Care. Agency Policy: Plan of Care Policy Number: 2.1.007 Revised Date: 12/01/21 Policy: Each patient has an individualized Plan of Care (POC) developed... to address patient problems, needs, and goals, as well as address specific services being provided. Procedure: 2. The POC includes: ...n. All patient care orders. 1. HV # 4 was admitted to the agency on 11/3/21 and recertified from 1/2/22 to 3/2/22 with diagnoses including Type 2 Diabetes with Diabetic Peripheral Angiopathy Without Gangrene and Long Term (Current) Use of Anticoagulants. Review of the Home Health Certification and Plan of Care dated 1/2/22 to 3/2/22 revealed a Skilled Nurse (SN) frequency of 1 times week for 9 weeks. Review of the 1/4/22 SN Visit Note Report revealed, "The following labs were obtained: PT/INR (Prothrombin Time/International Normalized Ratio)". There was no physicians order in the MR or POC for the PT/INR obtained by the SN on 1/4/22 per agency policy. An interview was conducted on 2/3/22 at 11:31 AM with Employee Identifier # 1, Registered Nurse Executive Director, who verified the staff failed to ensure physician orders were obtained for all labs performed.

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 review of medical records (MR), agency policy and procedure, and interview with staff, it was determined the agency failed to notify the physician of changes in the patient's assessment. This affected 2 of 12 open records reviewed, including MR # 2, MR # 3, and had the potential to negatively affect all patients served by the agency. Findings include: Agency Policy: Coordination of Care, From Admit Through Discharge Policy Number: 2.1.017 Revision Date: 8/1/19 Policy: The agency provides care and services within an integrated continuum of care system. This is accomplished by: Identifying patient needs through assessment and communications with other health care providers. Procedure: ...4. Coordination of care with physician: At admission, throughout care, and at discharge, coordination of services is promoted through routine communication with the patient's physician: a. When changes occur in the patient's condition... e. When there is a need to change the patient's plan of care. 1. MR # 2 was admitted to the agency on 1/11/22 with diagnoses including Hypertensive Heart Disease With Heart Failure, and Permanent Atrial Fibrillation. A review of the 1/17/22 Skilled Nurse (SN) Visit Note Report (VNR) Vital Signs revealed a documented weight of 109 pounds. Review of the 1/20/22 SN VNR Vital Signs revealed a documented weight of 113 pounds. The SN Narrative for the same visit documented the patient had bilateral fine crackles to bases (of lungs). There was no documentation the SN notified the physician of the change to physical assessment. In an interview conducted on 2/3/22 at 11:35 AM, Employee Identifier (EI) # 1, Registered Nurse (RN) Executive Director, confirmed the physician was not notified of the 4 pound weight gain in 3 days, and the fine crackles noted in the patient's assessment, and should have been. 2. MR # 3 was admitted to the agency on 1/20/22 with diagnoses including Non Displaced Bicondylar Fracture Right Tibia, Subsequent For Closed Fracture With Routine Healing, and Hypertensive Heart Disease With Heart Failure. A review of the 1/26/22 SN VNR revealed the patient reported he/she took the medications lasix and potassium as needed. Review of the Home Health Certification and Plan of Care for 1/20/22 to 3/20/22 revealed lasix and potassium were not listed with the medications ordered at start of care. Review of the Client Medication Record (CMR) printed on 2/1/22 at 12:40 PM provided by the agency, revealed lasix and potassium were not listed on the CMR. In an interview conducted on 2/3/22 at 11:17 AM, EI # 1 confirmed the physician was not notified the patient was taking lasix and potassium as needed, and should have been, and that the medications were not listed on the CMR.

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 observations, policies and procedures, Aspira Drainage System Manufacturer's Guidelines, agency protocols, and interviews, it was determined the agency failed to ensure staff: 1. Performed hand hygiene as directed per policy. 2. Performed Aspira Drainage System dressing change per manufacturer's guidelines. 3. Brought sharps container to the area where the procedure using sharps was performed. This affected 4 of 7 Home Visits (HV), including HV # 4, HV # 1, HV # 6, HV # 5, and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Hand Hygiene Policy number: 8.003 Date revised: 10/1/15 Purpose: To help prevent the spread of microorganisms and infection by cross-contamination and to provide practice guidelines. Policy: Staff are required to perform hand hygiene prior to, at specified time points during, and following patient contact... Procedure: 1. Staff performs hand hygiene ... c. after contact with a patient's intact skin (e.g., when taking a pulse or blood pressure...) f. after contact with inanimate objects ( including medical equipment) in the immediate vicinity of the patient. g. before and after glove use. Aspira Drainage System Manufacturer's Guidelines ...How to Care for and Dress Your Aspira Drainage Catheter ...Supplies you will need: 1 Dressing Kit ...a. Carefully remove the clear dressing, gauze and split gauze pad from your catheter. b. Wash your hands... c. Peel open the pouch with the dressing kit. Note: The gloves and items in the dressing kit are sterile. Do not touch any non-sterile surface such as your skin, clothing, or furniture with your gloves. d. Remove the gloves from the pouch. ...f. Remove the sterile sheet from the pouch... Agency Protocol Sharps Storage and Disposal: ...6. Label the sharps container...and move it to the area where the procedure using sharps will be performed. ...8. Immediately following any procedure that uses sharps, remove the lid from the container, place the used sharp in the disposal container... 3. HV # 6 was admitted to the agency on 1/12/22 with diagnoses including Cerebral Infarction Due To Unspecified Occlusion or Stenosis of Right Middle Cerebral Artery and Hypertensive Chronic Kidney Disease With Stage 1-4 Unspecified. A HV was conducted on 2/1/22 at 12:03 PM to observe care provided by EI # 4, Licensed Practical Nurse (LPN), that included obtaining vital signs and drawing a BMP (basic metabolic profile) requiring venipuncture. EI # 2, RN Clinical Director, was also present during the visit. EI # 4 performed hand hygiene, donned gloves, and obtained vital signs. EI # 4 then used disinfecting wipes to clean vital sign equipment wearing the same gloves worn while obtaining vital signs. EI # 4 failed to remove gloves and perform hand hygiene prior to disinfecting vital sign equipment per policy. Also during the visit, the surveyor observed EI # 4 attempt times 3 to obtain the blood specimen ordered utilizing a 23 gauge butterfly needle set. After each attempt, EI # 4 laid the used needle on the white paper barrier placed at the beginning of the visit. At the completion of the visit, EI # 4 wrapped the 3 used butterfly needle sets loosely in the paper barrier, carried them out to his/her vehicle, and disposed of them in a sharps container located in his/her trunk. EI # 2 confirmed at the time of the HV that agency protocol was to take the sharps container inside for the visit. In an interview conducted 2/3/22 at 11:11 AM, EI # 1, RN Executive Director, confirmed EI # 4 should have changed gloves and performed hand hygiene before cleaning vital sign equipment, and that the used needles should not have been carried to the vehicle wrapped in the paper barrier, instead the sharps container should have been carried into the home for the visit. 4. HV # 5 was admitted to the agency on 12/13/21 with diagnoses including Other Intra Articular Fracture Low End Right Radius, Subsequent For Closed Fracture with Routine Healing, and Essential Primary Hypertension. A HV was conducted on 2/1/22 at 1:49 PM to observe care provided by EI # 7, Occupational Therapist (OT), which included obtaining vital signs. EI # 2, RN Clinical Director was also present during the visit. EI # 7 performed hand hygiene, donned gloves, and obtained vital signs. EI # 7 then used disinfecting wipes to clean vital sign equipment wearing the same gloves worn while obtaining vital signs. EI # 7 failed to remove gloves and perform hand hygiene prior to disinfecting vital sign equipment per policy. In an interview conducted 2/3/22 at 11:30 AM, EI # 1 confirmed the gloves should have been removed, hand hygiene performed, and new gloves donned before cleaning equipment. 2. HV # 1 was admitted to the agency on 12/3/21, and recertified for care 2/1/22 to 4/1/22, with diagnoses including Malignant Neoplasm of Uterus, Part Unspecified, and Anemia in Neoplastic Disease. A HV was conducted on 2/1/22 at 11:10 AM to observe care provided by EI # 8, RN. EI # 3, RN, Clinical Manager, was also present on the HV. EI # 8 performed hand hygiene and opened the Aspira Dressing Kit. EI # 8 donned the sterile gloves in the kit, removed the old dressing over the Aspira drainage tube, discarded the dressing and doffed the sterile gloves. EI # 8 performed hand hygiene and retrieved multiple non-sterile exam gloves and placed them on the sterile field. EI # 8 donned the non-sterile gloves and cleaned around the tube site with alcohol preps. EI # 8 failed to maintain the sterile field and use the sterile gloves to clean and dress the site per manufacturer's guidelines. An interview was conducted on 2/3/22 at 11:49 AM with EI # 2, RN, Clinical Director, who confirmed staff failed to follow manufacturer's guidelines for changing the Aspira Drainage System dressing. 1. HV # 4 was admitted to the agency on 11/3/21 and recertified from 1/2/22 to 3/2/22 with diagnoses including Type 2 Diabetes with Diabetic Peripheral Angiopathy Without Gangrene and Long Term (Current) Use of Anticoagulants. A HV was conducted on 2/1/22 at 11:55 AM to observe wound care and obtain lab's for PT/INR (Prothrombin Time/International Normalized Ratio) via venipuncture by Employee Identifier (EI) # 5, RN (Registered Nurse). EI # 1, RN Executive Director, was also present during the HV. EI # 5 performed hand hygiene, applied his/her gloves, then stated, "I forgot to get the lab tube out of my car". EI # 5 then removed his/her gloves and proceeded to his/her car and obtained the lab tube needed to collect the PT/INR lab specimen without performing hand hygiene after removing gloves per agency policy. An interview was conducted on 2/3/22 at 11:31 AM with EI # 1, who verified the staff failed to perform hand hygiene after removing gloves per agency policy. .

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on review of agency policies and procedures, medical records (MR) and interviews, it was determined the agency failed to ensure medical record documentation was complete and accurate with all events and treatments which included: 1. Assessment of a patient's genitourinary system with a foley catheter. 2. Wound measurements. 3. Wound care. This affected 3 of 12 open MR's reviewed including MR # 5, MR # 3, MR # 4, and 1 of 5 closed records reviewed, including MR # 9, and had the potential to negatively affect all patients served by this agency. Findings include: Agency Policy: Home Care Record Policy Number: 7.003 Revised Date: 11/1/21 Purpose: To define the contents and requirements of the clinical home care record. Policy: A medical record is maintained for all patients receiving services and care from the agency. All entries in the patient care record will also reflect date and time care performed. Procedure: ...2. The patient home care record shall contain the following clinical information: a. Patient’s current comprehensive assessment including all of the assessments from the most recent admission. ...e. Interventions, including medication administration, treatments, and services, and responses to those interventions. Agency Policy: Wound Assessment, Documentation, and Photography Policy Number: 2.2.001 Revision Date: 12/01/21 Purpose: To ensure the accurate and consistent assessment and documentation of wounds. Policy: Upon initial visit ...all wounds will be assessed with appropriate documentation within the medical record. Wound location and description documentation is completed on all patients with wounds at the time of admit... Procedure: ...3. Document the following in the medical record: ...c. Wound size: Length, Width and Depth ... 3. MR # 4 was admitted to the agency on 1/13/22 with diagnoses including Type 2 Diabetes Mellitus with Diabetic Neuropathy, Unspecified, and Unspecified Atrial Fibrillation. Review of the physician order dated 1/21/22 revealed the following wound care: Wound # 1 Left Upper 2nd Toe: Daily. Cleanse with saline and gauze. Paint with betadine. Leave open to air using clean technique... Wound # 2 Left Second Toe and Wound # 3 Right Second Toe: Every other day... Cleanse with saline and gauze. Apply silver alginate. Cover with dry gauze and secure with tape using clean technique... Review of two SN Visit Note Reports (VNR's), dated 1/21/22 and 1/28/22, revealed the SN documented the following wound care for wound # 1, "...Performed procedure of wound care to right 2nd toe and left second toe lesion. Cleansed with saline and gauze. Applied silver alginate. Covered with dry gauze..." Further review of the two SN VNR's dated 1/21/22 and 1/28/22, revealed the SN documented the following wound care for wound # 2, "...Performed procedure of wound care to left upper second toe lesion. Cleansed with saline and gauze. Painted with betadine. Left open to air..." Further review of the SN VNR dated 1/2822 revealed the SN documented in interventions, "... Assess lower extremities for the presence of skin lesions every visit... Assessment findings No lesions noted. An interview was conducted on 2/3/22 at 11:56 AM with EI # 2, RN, Clinical Director, who confirmed the errors in documentation by the SN, and was unable to determine if the correct wound care was performed on the correct wounds. 4. MR # 9 was admitted to the agency on 9/17/21 and discharged to hospice care on 10/13/21. Admitting diagnoses included Covid 19, and Pneumonia due to Covid 19. Review of the physician order dated 9/25/21 revealed the following wound care order: SN to perform/teach wound care to wound # 1 Right Lower Buttock and # 2 Left Lower Buttock Stage 2 pressure ulcer. Cleanse with saline and gauze, apply foam dressing... Old dressing to be disposed per hazardous protocol. Review of the SN VNR dated 9/25/21 revealed the nurse documented the following in the narrative note, "...SN instructed cg (caregiver) on new wound care..." For wound # 1 the SN documented the following wound care provided, "Performed/ taught wound care to wound # 1 right lower buttock and # 2 left lower buttock stage 2 pressure ulcer. Cleansed with saline and gauze, applied foam dressing. Used clean technique. Old dressing disposed per hazardous protocol..." Further review of the SN VNR dated 9/25/21 revealed the nurse documented the following wound care provided for wound # 2, "Performed/ taught wound care to wound # 1 right lower buttock and # 2 left lower buttock stage 2 pressure ulcer. Cleansed with saline and gauze, applied foam dressing. Used clean technique. Old dressing disposed per hazardous protocol..." The surveyor was unable to determine if wound care was performed twice, and if the new wounds already had a dressing. Review of the MR revealed a physician's order dated 9/29/21 for the following wound care: SN to perform/ teach wound care to wound # 3 right greater trochanter and # 4 coccyx... Cleanse with saline and gauze, apply foam dressing... Review of the SN VNR dated 9/29/21 revealed two new wounds: Wound # 3 Right Greater Trochanter, and Wound # 4 Coccyx. The following wound care was documented as provided for wound # 3, "Performed/ taught wound care to wound # 3 right greater trochanter and # 4 coccyx stage 2 pressure ulcer. Cleansed with saline and gauze, applied foam dressing... Old dressing disposed per hazardous protocol..." Further review of the SN VNR dated 9/29/21 revealed the following wound care was documented for wound # 4, "Performed/ taught wound care to wound # 3 right greater trochanter and # 4 coccyx stage 2 pressure ulcer. Cleansed with saline and gauze, applied foam dressing... Old dressing disposed per hazardous protocol..." The surveyor was unable to determine if wound care was performed twice, and if the newly discovered wounds already had a dressing. Review of the MR revealed the following physician's order dated 10/5/21: Wound to right greater trochanter healed, discontinue wound care. Review of the SN VNR dated 10/5/21 revealed the nurse documented for wound # 3 right greater trochanter, "Inactivate wound- healed." For wound # 4 coccyx, the SN documented the following wound care, "Perform wound care to wound # 3 right greater trochanter and # 4 coccyx stage 2 pressure ulcer. Cleansed with saline and gauze, applied foam dressing..." The SN documented wound care to the healed wound # 3. Review of the RN Discharge from Agency VNR dated 10/13/21 revealed the SN documented the following wound care to wound # 4, "Perform wound care to wound # 3 right greater trochanter and # 4 coccyx... Cleansed with saline and gauze, applied foam dressing..." The SN documented wound care to the healed wound # 3. An interview was conducted on 2/3/22 at 11:53 AM with EI # 2, who confirmed the errors in documentation. 2. MR # 3 was admitted to the agency on 1/20/22 with diagnoses including Non Displaced Bicondylar Fracture Right Tibia, Subsequent For Closed Fracture With Routine Healing, and Hypertensive Heart Disease With Heart Failure. Review of the 1/20/22 SN Admission Assessment revealed MR # 3 had a Stage 1 Pressure Ulcer on the coccyx. The SN documented under measurements taken, "no." The SN did not follow agency policy to assess and document the wound size at time of admission. In an interview conducted 2/3/22 at 11:17 AM, EI # 1 confirmed the SN did not measure the wound and should have. 1. MR # 5 was admitted to the agency on 1/7/22 with diagnoses including Sepsis Due to Escherichia Coli (E. Coli), Urinary Tract Infection, Site Not Specified, Retention of Urine, Unspecified and Personal History of Malignant Neoplasm of Prostate. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 1/7/22 to 3/7/22 revealed a SN (Skilled Nurse) frequency of 1 wk 9 (1 times week for 9 weeks). SN nurse for instructions/reinforcement of care of indwelling catheter... Review of the 1/7/22 SN Admission Visit Note Report revealed the patient had a foley catheter, size 18, which had been inserted on 12/20/21. Review of the weekly SN visit notes dated 1/13/22, 1/19/22 and 1/24/22 revealed, "Genitourinary: No problems identified... Instructed pt/cg (patient/caregiver) on urinary catheter bag care". There was no documentation the patient had a foley catheter or the size of the foley catheter. The SN failed to document a complete assessment of the patient's genitourinary system with a foley catheter per agency policy. An interview was conducted on 2/3/22 at 11:39 AM with Employee Identifier (EI) # 1, Registered Nurse (RN) Executive Director, who verified MR # 5 continued to have his/her foley catheter on the above mentioned dates. EI # 1 verified the staff failed to document a complete and accurate assessment which assessment of MR # 5's genitourinary system with a foley catheter.