Every finding on record at Mason District Hospital Home Health

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 1/29/2026. The Agency was in compliance with the Condition, 42 CFR 484.102, Establishment of the Emergency Program for this survey.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 1/29/2026. The Agency was not in compliance with the standards of 42 CFR 484, Conditions of Participation for Home Health Agencies, for this survey.

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, staff interview, and document review, the facility failed to ensure cleaned equipment was placed on a clean barrier or returned to the bag and failed to ensure the reusable barrier was cleaned prior to returning it to the bag. Findings include: During the observed home visit for a patient (Pt #2) on 1/27/2026 at approximately 1:30 pm, the Occupational Therapist (E #2) was observed setting contaminated equipment back on the barrier after use, then cleaning the equipment and placing it directly back on the same barrier. At approximately 1:50 pm, E #2 was observed folding the reusable barrier and placing it back into the bag without cleaning it. In an interview with E #2 on 1/27/2026 at approximately 2:05 pm, E #2 verbally confirmed the equipment was placed directly on the same barrier after cleaning, and the barrier was not cleaned prior to placing it back in the bag. In an interview with the Registered Nurse/Clinical Manager/Director (E #5) on 1/27/2026 at approximately 2:20 pm, E #5 confirmed that, per the facility's policy, the equipment should not have been placed back on the barrier after cleaning, and the reusable barrier should have been cleaned prior to placing it back in the bag.Review of the facilities “Home Care Bag” policy states “4. Remove all articles for patient care and place on barrier. Following patient use, clean all equipment before returning it to the bag.”

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 interview, it was determined that the Facility failed to ensure that all outdated supplies were removed from potential use in patient care. Findings include: A tour of the storage areas was completed on 1/28/2026 at approximately 3:00 pm. During the tour, the following outdated supplies were found and were available for patient use:1 box of UltraFlo Safety Winged Blood Collection Set 25G x ¾” x 12”. Expired 8/9/20241 box of BD Vacutainer Safety-Lok Blood Collection Set 21G x ¾” x 12”. Expired 2/28/20251 box Dover Male External Catheter 1- 3/8”. Expired 10/31/202410 boxes of ostomy supplies. Expired 10/1/20251 Female Cath Kit with Gloves and Swabs 6/30/20251 box with 5 out of 10 ConvaTec Esteem Ostomy pouches. Expired 5/2022 2. On 1/28/2025 at approximately 3:45 PM, the policy “Home Health Supplies” was reviewed. The policy stated, “…1. Staff shall verify the expiration date: Upon receipt of supplies and prior to patient use. 2. Any supply with: An expired date, Illegible expiration date. Damaged or opened packaging shall not be used.” 3. The Policy Disposal of Outdated Medical Supplies (approved 10/5/2009) was reviewed at approximately 3:50pm. The policy stated “...Disposal of outdated, obsolete, or damaged medical supplies: a. Any and all medical supplies found to be outdated, obsolete, or damaged will be documented on the form, 'Disposition of Outdated, Obsolete or Damaged Medical Supplies and Equipment,' with all the information provided, and turned into the Purchasing Department”. 4. On 1/28/2025 at approximately 3:30 PM, an interview was conducted with the Director (E #5). E #5 verbally agreed that the supplies had expired.

The Emergency Preparedness requirements were evaluated in conjunction with the recertification survey on 02/24/23. The Home Health Agency was in compliance with the Condition, 42 CFR 484.102, Establishment of the Emergency Program, for this survey.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 02/24/23. The Agency was in compliance with the requirements for Emergency Preparedness. The Agency was not in compliance with the Standards, 42 CFR 484, for Home Health Agencies, as evidenced by. Abbreviations: E- Employee mg- milligram ml- milliliter POC- Plan of Care Pt- Patient SN- Skilled Nurse SOC- Start of Care

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 document review and interview, it was determined for 1 of 10 (Pt #7) patients records reviewed, the Agency failed to ensure drugs were administered as ordered. This has the potential to affect all patients who receive service by the Agency with a current census of 75 patients. Findings include: 1. Pt #7 SOC: 11/21/22 and 01/05/23 Diagnosis: Aftercare following colon surgery. The record was reviewed on 02/22/23 at approximately 11:00 AM. The Physician's Office note dated 01/11/23 noted, "Discontinued or Completed: metroNIDAZOLE (FLAGYL) 500 mg (milligram) tablet... Discontinued or Completed: oxyCODONE (ROXICODONE) 5 mg immediate release tablet." The Active Medication(s) list dated 01/05/23 - 03/05/23 noted "Oxycodone 5 mg oral tablet 1 tab (tablet every 6 hours as needed for severe pain". The Active nor the Discontinued Medication(s) list dated 01/05/23 - 03/05/23 noted Metronidazole as an active or discontinued medication. 2. During an interview on 02/23/23 at approximately 9:00 AM, the Director/Clinical Manager (E#1) reviewed Pt #7's record and verbally agreed the Agency failed to ensure drugs were administered as ordered and should have been.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on document review and interview, it was determined for 1 of 10 (Pt #7) patients records reviewed, the Agency failed to ensure the Plan of Care (POC) was updated. This has the potential to affect all patients who receive care by the Agency with a current census of 75 patients. Findings include: 1. Pt #7 Start of Care (SOC): 11/07/23 Diagnosis: Aftercare following Colon Surgery. The record was reviewed on 02/22/23 at approximately 11:00 AM. The record noted Pt #7 had been treated for bilateral lower legs deep vein thrombosis (blood clots) in October 2022 and medications for the DVT's were discontinued prior to admission. 15 of 15 Skilled Nurse Visit notes between 11/21/233 and 02/22, noted, "Medical Necessity for Care Patient with new diagnosis of bilateral DVT's requiring prescribed treatment regimen changes and need for plan of care for instructions and evaluation of efficacy/complications of changes to treatment regimen." 2. During an interview on 02/23/23 at approximately 9:00 AM, the Director/Clinic Manager reviewed Pt #7's record and verbally agreed the Plan of Care had not been updated and should have been.