Every finding on record at In House Home Health Inc.

This Statement of Deficiencies was generated as a result of an Emergency Preparedness Survey for Home Health Agencies conducted at your agency from November 5, 2024, through November 8, 2024, in accordance with the requirements of 484.22 for Emergency Preparedness for Conditions of Participation for Home Health Agencies. The active census at the time of entry was 64 patients. Eight clinical records were reviewed. Three home visits were conducted. The findings and conclusions of any investigation by the Division of Public and Behavioral Health shall not be construed as prohibiting any criminal or civil investigation, actions or other claims for relief that may be available to any party under applicable federal, state, or local laws. No regulatory deficiencies were identified. No further action is necessary. Please retain a copy of this report for your records.

This Statement of Deficiencies was generated as a result of a Medicare Recertification Survey conducted at your agency from November 5, 2024, through November 8, 2024, in accordance with 42 CFR (Code of Federal Regulations) Part 484 - Home Health Services. The active census at the time of entry was 64 patients. Eight clinical records were reviewed. Three home visits were conducted. The findings and conclusions of any investigation by the Division of Public and Behavioral Health shall not be construed as prohibiting any criminal or civil investigation, actions or other claims for relief that may be available to any party under applicable federal, state, or local laws. The following regulatory deficiencies were identified:

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 record review, interview and policy review, the agency failed to ensure a plan of care included a list of skilled nursing interventions for 1 of 8 sampled patients (Patient #8). Findings include: Patient #8 On 05/26/2023, the agency admitted Patient #8 with pressure ulcer of right buttock, stage 2. The agency certified the patient from 05/26/2023 through 07/24/2023. The agency recertified the patient from 07/25/2023 through 08/03/2023. The agency's plans of care typically displayed sections in the following order: Orders and Treatments, Skilled Nurse Interventions and Goals and Outcomes. The recertification period lacked documented evidence of a section of skilled nurse interventions. On 11/08/2024 at 4:00 PM, the Administrator confirmed the finding. Procedure #3n of the Care Planning, Coordination of Services and Medical Orders policy provided revealed the individualized plan of care would be completed at the time of recertification and would include patient specific interventions and education.

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 record review, interview and policy review, the agency failed to ensure it conducted or discontinued an occupational therapy evaluation for 1 of 8 sampled patients (Patient #1) and failed to ensure skilled nursing visits were conducted as ordered for 1 of 8 sampled patients (Patient #5). Findings include: 1.) Patient #1 On 10/12/2024, the agency admitted Patient #1 with third degree burns of left lower extremity. On 10/20/2024 and again on 10/22/2024, a physician ordered an occupational therapy evaluation. The clinical record lacked documented evidence the agency conducted and documented the evaluation or that a physician cancelled the evaluation. On 11/08/2024 at 3:45 PM, the Administrator and Registered Nurse Director confirmed the evaluation was not addressed. 2.) Patient #5 On10/13/2024, the agency admitted Patient #5 with encounter for surgical aftercare regarding an ostomy. The patient was certified from 10/13/2024 through 12/11/2024. On 10/13/2024, the plan of care revealed a physician ordered skilled nursing visits three times the first week and twice the second week of the episode. For the first week, the clinical record revealed five skilled nursing visits conducted and documented dated 10/13/2024, 10/14/2024, 10/17/2024 x 2 visits and 10/18/2024. For the second week, the clinical record revealed three skilled nursing visits conducted and documented dated 10/21/2024, 10/23/2024 and 10/25/2024. The clinical record lacked documented evidence of a physician order for increased skilled nursing visit frequency for those weeks. On 11/08/2024 at 4:00 PM, the Administrator confirmed the findings. Procedure #3d of the Care Planning, Coordination of Services and Medical Orders policy provided revealed the individualized plan of care would be completed at the time of admission and would include the frequency and duration of visits to be made.

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 record review, interview and policy review, the agency failed to document wound measurements for 1 of 8 sampled patients (Patient #2), skilled nursing visit assessments for 1 of 8 sampled patients (Patient #5) and failed to include a wound care order and calmoseptine on successive plans of care for 1 of 8 sampled patients (Patient #6). Findings include: 1.) Patient #2 On 07/05/2024, the agency admitted Patient #2 with dehiscence of amputated stump. The patient was certified from 07/05/2024 through 09/02/2024. The patient was recertified from 09/03/2024 through 11/01/2024. On 09/03/2024, the plan of care revealed skilled nursing visits twice weekly for wound care. A wound care specialist was ordered to do weekly wound care weekly. The clinical record revealed skilled nursing visits documented wound measurements on skilled nursing visits dated 10/02/2024 and 10/17/2024. The clinical record lacked documented wound measurements on the two skilled nursing visits dated 10/04/2024 and 10/11/2024. On 11/08/2024 at 4:00 PM, the Administrator indicated measurements were completed weekly. The Documentation of Clinical Notes/Reports policy provided revealed weekly measurements were required for wounds. 2.) Patient #5 On10/13/2024, the agency admitted Patient #5 with encounter for surgical aftercare regarding an ostomy. The patient was certified from 10/13/2024 through 12/11/2024. On 10/13/2024, the plan of care revealed skilled nursing visits three times the first week and twice the second week of the episode. The clinical record revealed two skilled nursing visits dated 10/17/2024, and both skilled nursing visits lacked documented evidence of a cardiovascular assessment. The skilled nursing visit dated 10/23/2024 lacked documented evidence of cardiovascular, genitourinary, musculoskeletal, psychosocial and pain assessments. On 11/08/2024 at 4:00 PM, the Administrator indicated nurses were expected to complete and document each assessment area for each visit conducted. 3.) Patient #6 On 10/23/2023, the agency admitted Patient #6 with pressure ulcer of right buttock, stage 2. The patient was certified from 10/23/2023 through 12/21/2023. On 10/23/2023, the plan of care revealed twice weekly skilled nursing visits for 8 weeks and then weekly thereafter. On 10/23/2023, the plan of care revealed wound care as cleanse with normal saline and gauze and apply duoderm. On 12/18/2023, the agency recertified the patient from 12/22/2023 through 02/19/2024. The agency continued weekly skilled nursing visits and performed the same wound care at each visit dated 12/24/2023, 01/01/2024 and 01/08/2024. The clinical record lacked documented evidence the wound care order was carried over from the start of care of episode to the recertification episode as an order, treatment or intervention. The original order appeared under the goals to be addressed with each subsequent skilled nursing visit. The skilled nursing visits dated 12/24/2023, 01/08/2024 and 01/15/2024 demonstrated the nurse was aware caregivers used calmoseptine on the patient, but it was not listed on the plan of care. On 11/08/2024 in the afternoon, the Registered Nurse Director and Administrator confirmed the finding. Procedure #3j of the Care Planning, Coordination of Services and Medical Orders policy provided revealed the individualized plan of care would be completed at the time of recertification and would include all medications and treatments.

A Recertification Survey including a review of the Emergency Preparedness Program was conducted by Healthcare Management Solutions, LLC on behalf of the Nevada Department of Health and Human Services. The survey conducted from 09/13/2021 to 09/15/2021 resulted in a finding of no deficiency citations respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.22.

A Recertification Survey and COVID-19 Focused Infection Control Survey were conducted by Healthcare Management Solutions, LLC on behalf of the Nevada Department of Health and Human Services. The survey conducted from 09/13/2021 to 09/15/2021 resulted in a finding of substantial compliance respective to the applicable Condition of Participation (CoP)under 42 CFR 484, Subparts A through C with the following standard level deficiencies listed below.

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 observation, interview, and medical record review, the home health agency (HHA) failed to ensure the accuracy of the medications and treatment listed on the plan of care (POC) and signed by the physician for two of ten patient's (Patient (P)4 and P6) medical records reviewed. Findings include: 1. During a recertification assessment home visit on 09/14/2021 at 10:00 AM, Registered Nurse (RN) 2 was not observed to physically examine P4's medication bottles. After RN2 left the home, review of the current medication bottles with P4's daughter, whom P4 lives with revealed a bottle labeled, "Aspirin 325 mg (milligrams)." The daughter stated she was giving one tablet daily to P4. Review of medication orders on the current plan of care (POC) signed by the physician revealed, "Aspirin 81 mg. daily." During an interview on 09/15/2021 at 09:30 AM, the Director of Patient Services (DPS) stated the expectation was for the nurse to review the medications by looking at the medication bottles to verify what the patient was taking. The DPS confirmed this would be a medication error since P4 had been taking the wrong dose of aspirin. 2. Review of the medications listed on the POC signed by the physician located in the EMR under "Orders" tab for P6 revealed medications were duplicated on the list with the following errors: a. "Metoprolol Tartrate (used to treat high blood pressure) oral 50 mg 1-tab (tablet) po (by mouth) bid (twice a day)" and "metoprolol tartrate oral 50 mg 1-tab twice a day." b. "levothyroxine sodium (used to treat hypothyroidism) oral 88 mcg (micrograms) 1-tab po qd (daily)" and "Synthroid (brand name for levothyroxine sodium) 88 mcg 1-tab daily." c. "Amiodarone HCl (hydrogen chloride-Used to treat some types of irregular heartbeats) oral 200 mg 1-tab po bid" and "amiodarone HCl oral 200 mg 1-tab twice daily." During an interview on 09/14/2021 at 8:40 AM, the DPS confirmed the above documentation of medications on the POC signed by the physician, confirmed the above were errors, and stated that should have been caught by the office before being sent out to the physician for signature or noted at the physician's office.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on document review and interview, the home health agency (HHA) failed to ensure that it had an effective Quality Assessment and Performance Improvement (QAPI) program that investigated and analyzed adverse patient events capable of demonstrating measurable improvement in patient outcomes and safety. This had the potential to impact the health and safety of all patients receiving home health services. Findings include: On 09/13/2021 at 9:40 AM the Director of Patient Services (DPS) was asked to provide a list of all documentation needed for the survey which included documentation of QAPI information and adverse patient event tracking, trending, and analysis to include infection control, emergent care, and falls. The DPS provided a printout of emergent care data which indicated the number of emergency room visits or acute inpatient hospitalizations that she printed from the computer program based on "OASIS" (Outcome and Assessment Information Set) and stated, "We haven't done anything with that." Review of eight of ten patient (Patient (P)1, P2, P3, P4, P5, P6, P7, and P8) "OASIS" assessments located in the "Nursing" tab in the electronic medical record (EMR) indicated the patient was at risk for falls based on the "Fall Risk Assessment Tool." On 09/13/2021 at 11:50 AM the DPS stated the agency did not track, trend, or analyze fall data. Review of the agency infection control monitoring documentation revealed printed data acquired from the EMR system which identified infection type, date of onset, patient location e.g., Adult Living facility (ALF), Hospital, Patient Home, and the medication prescribed when known. There was no evidence in the infection control documentation provided by the DPS that the data was investigated or analyzed to identify possible contributing factors or trends. In addition, there was no evidence that the information was reviewed as a component of QAPI. During an interview on 09/15/2021 at 2:15 PM, the DPS was unable to locate documentation of QAPI meetings or trend analysis of significant adverse events to include infections, falls, medication errors, or emergent care. The DPS stated the agency had been solely concentrating on COVID-19 since its beginning in 2020. Review of a policy titled, "Incident Report," dated 07/20/99 revealed, "An incident will be defined as any occurrence which ... causes an untoward reaction ... the following is a non-inclusive list of reportable events ...Falls/Burns, Medication Errors ... the QI department will discuss the findings ... a trend analysis will be done quarterly."

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on observation, document review, and policy review, the home health agency (HHA) failed analyze infection tracking data and investigate potential problems, trends, or causative factors that could contribute to the rate or transmission of infection. Findings include: Review of the agency infection control monitoring documentation revealed printed data acquired from the electronic medical record (EMR) system which identified infection type, date of onset, patient location e.g., Adult Living facility (ALF), Hospital, Patient Home, and the medication prescribed when known. There was no evidence in the infection control documentation provided by the Director of Patient Services (DPS) included an investigation and analysis of the data to identify possible contributing factors or trends. In addition, there was no evidence of any Infection Control Committee meetings. During an interview on 09/13/2021 at 3:00 PM, the DPS confirmed there was no documentation that an Infection Control Committee met quarterly and there was no documentation the infection data was investigated or analyzed to identify problems or trends. Review of an undated policy titled, "Infection Control Committee Policy," revealed, "The responsibilities of the committee include ... Analyzing data from infection control surveillance system and taking appropriate actions ... The committee will meet quarterly. Reports from meetings will be forwarded to the PI committee, Administrator, Professional Advisory Committee, and Governing Body. Review of an undated policy titled, "Infection Control Surveillance System: Defined," revealed, "At least quarterly, the infection control logs will be reviewed by the Director of Clinical Services and infection control and PI [Performance Improvement] committees. Data will be aggregated and analyzed. Problems and/or undesirable trends in infections will be identified ... If such problems or undesirable trends are identified, the infection control and PI committees will identify any factors that could have led to the transmission of the infection."

Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency (HHA) failed to monitor, manage, and maintain the equipment used to access the web-based medical record system. This had the potential to result in unauthorized access of patient information for all patients receiving care from the HHA. Findings include: During an interview on 09/13/2021 at 9:40 AM, the Director of Patient Services (DPS) stated the agency used a web-based electronic medical record (EMR) program called "Wellsky" and staff access the program using their personal computers. On 09/13/2021 a log-in and password to access the patient records in the web-based EMR was received. Accessing the EMR revealed it was possible to save the log-in and password information which could allow access to patient information to anyone who might use the staff person's personal computer. Further review of patient information in the EMR revealed documentation, including the patient assessments, plan of care, visit notes, and personal information including address, date of birth, social security number, and insurance information, could be saved to the computer desktop allowing access to patient information when not logged into the EMR. During an interview on 09/15/2021 at 2:15 PM, the DPS confirmed that the agency did not monitor, manage, or maintain the electronic devices owned by staff used to access the EMR. The DPS further confirmed the agency would not know if staff saved the log-in and password used to access patient medical records, lost their personal computers, or saved patient information to the desktop of the computer.