Every finding on record at Kit Carson County Memorial Hospital Home Health

A recertification survey was completed on 1/26/22. Two deficiencies were cited.

Documentation of competency evaluation CFR(s): 484.80(c)(5) The HHA must maintain documentation which demonstrates that the requirements of this standard have been met. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to maintain documentation which demonstrated certified nurse aides (CNA) received the required observed competency evaluation in accordance with regulation prior to assignment of CNA services for 1 of 1 CNA personnel records reviewed (Employee # 3). Findings include: 1. On 1/25/22, a review of the personnel record for Employee #3 revealed a hire date of 11/11/20. a) The agency failed to maintain a complete personnel record for Employee #3. Review of the personnel record for Employee #3, failed to reveal that an initial or annual competency had been completed. Further review of Employee #3's record revealed no documented evidence Employee #3 performed a competency assessment before beginning to provide care to patients. During an interview on 1/25/22 at 3:46 p.m. the interim administrator stated she could not find the competencies or any training for Employee #3. During an interview on 1/25/22 at 4:10 p.m. the chief clinical officer stated she would check with the nurse educator because she was not able to find any competencies for Employee #3. During an interview on 1/26/22 at approximately 8:26 a.m. the interim administrator stated she could see the competencies in their EMR but the file was locked. She further stated had a call into EMR help staff, however no competencies were ever presented to the surveyor.

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 interview and record review, the agency failed to ensure clinical records contained accurate documentation of patient's clinical notes for 1 of 2 patients reviewed, who received certified nursing aide (CNA) services (Patient #4). Finding include: AGENCY POLICY According to the agency policy titled Clinical/Service Data Collection with an unknown date; "7. The clinical/service note will include: A. What care/services was provided B. Treatment and/or invasive procedures performed D. The date the service was provided (month, day, year)". 1. The clinical record for Patient #4 was reviewed on 1/25/22. The plan of Care for the certification period dated 8/26/21 through 10/24/21 revealed a state of care date of 8/26/21; diagnosis included alcohol dependence, and post-traumatic stress disorder. Plan of care orders included skilled nurse (SN) visits one time a week during the weeks of 8/26/21, 8/29/21, 9/12/21, and 9/26/21 and CNA visits once a week for one week and then twice a week for eight weeks for assisting with personal care, activities of daily living (ADL's), and light housekeeping. a) The agency failed to document any CNA clinical notes, including who provided service, what days and times services were provided, or what services were provided. Record review of Patient #4's clinical record revealed three SN visit notes on 8/26/21, 9/1/21, and 9/14/21. There was also a missed visit note on 10/1/21. However, there were no CNA clinical notes. Per the care plan the client was to receive CNA visits twice a week from the week of 8/29/21 until the end of the certification period. Further review of the clinical record revealed during the SN visits on 9/1/21 and 9/14/21, the nurse provided supervisory visits of the CNA. This documents the CNA was in the home of Patient #4 and providing services. However, no CNA clinical notes were found in the record. During interview on 1/25/22 at 1:08 p.m., the interim administrator stated she could not locate any of the CNA clinical notes for Patient #4. She went on to state they are not located in the electronic medical record (EMR) system of the agency, nor were they located in the paper files for Patient #4.