Every finding on record at New Heights Homecare Solutions Inc

Purpose of Visit: Federal Complaint Investigation Entrance Date: 06/08/2021 An entrance conference was conducted with the agency alternate administrator, Employee A at 11:10 a.m. L&CHHS Census: 53 Complaint Investigation Intake number: 270646 Exit Date: 06/10/2021 An exit conference was conducted at 1:50 p.m. with the administrator, Employee A and the alternate administrator, Employee B. The preliminary findings were discussed. The agency was given an opportunity to ask questions and provide additional documentation. Additional documentation, a copy of agency policy and procedure table of contents, was provided. The agency was informed that if violations were cited, the agency would receive the Statement of violations within 10 business days post exit. Written instructions were provided for how to submit an acceptable plan of correction, within 10 days of receipt of the Statement of Deficiencies. Abbreviations: Licensed and Certified Home Health Services-L&CHHS Registered Nurse (RN) Physical Therapist (PT) Licensed Vocational Nurse (LVN) POC- Plan of Care SOC- Start of Care SN- Skilled Nursing QAPI-Quality Assurance Performance Improvement COVID-19- Coronavirus disease 2019

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: This is a continuing deficiency cited at G684 during survey dated 11/19/2019. Based on record review and interview, in one of one Infection Control Program, the HHA failed to enforce a written policy addressing infection control including the prevention of and the spread of infectious and communicable disease. The agency failed to review, annually, all aspects of the agency's infection control program for the years 2019 and 2020. The failure could place the agency patients at an increased risk of the spread of infectious and communicable diseases. The failure could also cause the agency to not identify trends in infections and therefore prevent the agency from developing action plans to prevent the trending infections. FINDINGS INCLUDED: During the entrance conference on 06/08/2021 at 2:10 p.m. the alternate administrator, Employee B stated that the agency had clients and a staff member who had previously tested positive for COVID-19. The surveyor requested all agency infection control records and documents. On 06/08/2021 and 06/09/2021 the agency's infection control binder was provided. Review of the agency's infection control binder, reports and documents did not show that the agency had documented the COVID-19 infections. There were also no reports that showed the agency maintained 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 QAPI program that by reviewing, annually, all aspects of the agency's infection control program for the years 2019 and 2020, including the surveillance of infections. Review of the agency's QAPI records did not show that the agency had conducted a review of the agency's infections, to include clients and staff who had COVID-19 infections. On 06/10/2021 the surveyor requested the agency's infection control surveillance log for 06/01/2020 to 06/10/2021. Record review of the surveillance log only listed Patient # 7 and 19 with a COVID-19 infection. The log did not include any staff member infections. During an interview on 06/10/2021 at approximately 11:45 a.m., with the administrator, Employee A and the alternate administrator, Employee B, the surveyor asked why the agency had not documented the clients and the staff member who had been positive for COVID-19. The alternate administrator, Employee B stated that the lists were on Employee B's desk. Record review of the binder provided by Employee B revealed handwritten lists, dated 12/01/2020; 02/01/2021; 02/19/2021 and 03/16/2021, of patients #6-20 who previously had COVID-19. Only Client # 7 (date of infection 10/29/2020) and Client # 19 (date of infection 09/15/2020) were included in the agency's infection control surveillance log dated 06/01/2020 to 06/10/2021 for COVID-19 infection. The staff member who previously had COVID-19 was not listed. During an interview at approximately 11:45 a.m., with the administrator, Employee A and the alternate administrator, Employee B, the surveyor asked why the agency had not maintained a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that was an integral part of the HHA's quality QAPI program, by conducting a review of all aspects of the agency's infection control program, in accordance with the agency's infection control policy. The alternate administrator, Employee B replied, "We did not do it." Employee B also stated that Employee B was not aware that it was required. Agency policy titled, "INFECTION CONTROL PROGRAM IC.2" revised 070120 read in part: " ...II. The Infection Control Program will include ...C. A system that coordinates: 1. Surveillance of the occurrence of an infection 2. Identification of the occurrence 3. Implementation of appropriate preventive procedures 4. Implementing appropriate measures to control infection 5. Review of data collected to evaluate for trends, patterns ...D. Documentation completed by all staff will include at a minimum: 1. Date the infection was detected 2. Patient's/Client's name 3. Primary diagnosis 4. Signs/symptoms 5. Type of infection 6. Pathogen identified, if any 7. Treatment ...III ...A ...3. Both employee and patient /client infection will be reported and documented as soon as any Agency staff member is aware of it ...D ...4. The Supervising Nurse or designee will review all reports and analyze the data, noting trends or patterns and will report to the QAPI Committee quarterly ...7. Process for Reporting Employee Infections ...c. An "Infection Control Report" will be completed within forty-eight ...hours and submitted to the supervisor ...f. The QAPI Committee will review all reports and analyze the data ...8 ...b. Every patient/client infection will be reported as soon as any Agency staff member is aware of it. C. All reported infections will be documented on appropriate Agency form ...VI. Review A. All aspects of the program will be reviewed and revised annually ..."

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to ensure that all entries to the clinical record were authenticated in four (Patients # 1, 2, 4 and 5) of five records reviewed . The failure could place the patients at risk of harm if care and treatment were not reviewed, approved and authenticated by the primary author. FINDINGS INCLUDED: Clinical Record Review # 1: Patient # 1's record included a POC for the treatment period of 05/23/2021 to 07/21/2021 with a SOC date of 11/24/2020. The POC was signed by supervising nurse, RN C and dated 05/18/2021. The POC included a principal diagnosis of obesity. The POC included an order for SN visits three times per week for eight weeks and two times per week for one week. The record included SN notes dated 05/24/2012; 05/26/2021; 05/28/2021 and 05/31/2021. The SN note dated 05/31/2021 was not completed and authenticated by an agency nurse, there was no signature, title, nor date. The note included documentation for interventions, visit narrative and treatment performed. For Client # 1, in one (SN note 05/31/2021) of four SN notes reviewed for treatment period of 05/23/2021 to 07/21/2021 an agency nurse failed to complete and authenticate the SN note. Clinical Record Review # 2: Patient# 2's record included a POC for the treatment period of 04/06/2021 to 06/04/2021 with a SOC date of 04/17/2019. The POC was signed by supervising nurse, RN C and dated 04/01/2021. The POC included a principal diagnosis of urinary tract infection. The POC included an order for SN visits two times per week for one week and three times per week for eight weeks. The record included SN notes that were randomly selected by the surveyor, dated 04/07/2021; 04/09/2021 and 04/12/2021. None of the randomly selected SN notes were completed and authenticated by an agency nurse, there was no signature, title, nor date. The notes included documentation for interventions and visit narrative. For patient # 2, in three (SN notes 04/07/2021; 04/09/2021 and 04/12/2021) of three SN notes randomly selected for review for treatment period 04/06/2021 to 06/04/2021 an agency nurse failed to complete and authenticate the SN notes. Clinical Record Review # 4: Patient# 4's record included a POC for the treatment period of 03/18/2021 to 05/16/2021 with a SOC date of 03/18/2021. The POC was signed by supervising nurse, RN C and dated 03/18/2021. The POC included a principal diagnosis of urinary tract infection. The POC included an order for SN visits one time per week for eight weeks beginning 03/21/2021. The record included SN notes dated 03/23/2021; 03/29/2021 and 04/05/2021. SN note dated 03/29/2021 was not completed and authenticated by an agency nurse, there was no signature, title, nor date. The note included documentation for interventions and visit narrative. SN notes dated 03/29/2021 and 04/05/2021 only included a visit date, primary diagnosis and secondary diagnosis; the notes were not completed and authenticated by an agency nurse, there was no signature, title, nor date. Review of Patient # 4's discharge summary dated 04/13/2021 showed that Client # 4's last visit date was on 04/06/2021. For Patient # 4, in three (SN notes 03/23/2021; 03/29/2021 and 04/05/2021) of three SN notes reviewed for treatment period 03/18/2021 to 05/16/2021 an agency nurse failed to complete and/or authenticate the SN notes. Clinical Record Review # 5: Patient # 5's record included a POC for the treatment period of 12/28/2020 to 02/25/2021 with a SOC date of 12/28/2021. The POC was signed by supervising nurse, RN C and dated 12/28/2020. The POC included a principal diagnosis of urinary tract infection. The POC included an order for SN visits three times per week for eight weeks and two times per week for one week. The record included SN notes dated 12/28/2020 and 12/30/2020. The SN notes were not completed, in that the notes did not include vital signs, review of Client # 5's body systems, interventions or visit summary. The SN notes were authenticated by LVN H with an electronic signature, title, and date. For Patient # 5, in two (12/28/2020 and 12/30/2020) of two SN notes reviewed for treatment period 12/28/2020 to 02/25/2021 LVN H failed to complete the SN notes. During an interview on 06/10/2021 at approximately 12:00 p.m. the surveyor discussed the above findings and asked why the agency did not ensure that all entries were legible, clear, complete, and appropriately authenticated and dated with a signature and a title of a primary author who had reviewed and approved the entry for Clients # 1, 2, 4 and 5 for authentication. The administrator, Employee A replied, "We should have documented better."