Every finding on record at Nhc/Op, L.P.

A Health Emergency Preparedness survey was conducted along with the Recertification survey on 8/7/2023 through 8/8/2023. This agency complies with all Health Emergency Preparedness Regulations.

A Recertification survey was conducted 8/7/2023 through 8/8/2023. An entrance conference was held with the Administrator. An exit conference was held with the Administrator and Office Manager on 8/8/2023; the Regional Administrator joined the conference via telephone. They were afforded the opportunity to ask questions of the surveyor.

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 policy review, medical record review, observations and interview the agency failed to ensure current medications were recorded for 3 of 3 (Patient #1, #2, and #3) sampled patients with home visits. The findings included: 1. Review of the agency's policy titled, "Clinical Services - Best Practices" revised on 8/18/2029 revealed, "...Medication reconciliation will occur on every SN [Skilled Nurse] and therapy visit, to include medication review and report of any new medications..." 2. Medical record review for Patient #1 revealed a Start of Care (SOC) date of 2/10/2021 with diagnoses which included Stage 3 Pressure Ulcer of the Lower Back, Paraplegia, and Neurogenic Bladder. Review of the Client Medication Report revealed, "Trazodone 50 mg [milligrams] Tablet" with instructions to take 1 tablet by mouth at bedtime, and "Alendronate 70 mg Tablet" with instructions to take 1 tablet once a week." Observations in Patient #1's home on 8/8/2023 at 10:30 AM, revealed Trazodone and Alendronate were not in the patient's home. In an interview on 8/8/2023 at 10:31 AM, Patient #1 verified she was no longer taking the Trazodone and Alendronate, but the patient could not recall how long ago she had stopped the medications. 3. Medical record review for Patient #2 revealed a SOC date of 7/17/2023 with diagnoses which included Hemiplegia, Aphasia, Hypertension, and Major Depressive Disorder. Observations in Patient #2's home on 8/8/2023 at 1:30 PM revealed, Docusate Sodium 100 mg tablet to be taken two time a day; Aspirin 81 mg tablet to be taken once a day; Lactobacillus supplement to be taken once a day; and Restless Leg Syndrome supplement to be taken once a day. None of the medications were on the Client Medication Report. In an interview on 8/8/2023 at 2:02 PM, the Assisted Community Living Facility (ACLF) Nurse verified Patient #2 was taking the above medications in addition to the other medications listed on her Client Medication Report. 3. Medical record review for Patient #3 revealed a SOC date of 7/29/2023 with diagnoses which included Atherosclerotic Heart Disease, Hypertension, Congestive Heart Failure, and Nontraumatic Aortic Valve Failure. Observations in Patient #3's home on 8/8/2023 at 8:10 AM revealed Diphenhydramine 25 mg Sleep Aide to be taken at bedtime. The medication was not on the Client Medication Report. In an interview on 8/8/2023 at 8:12 AM, Patient #3's spouse verified the patient had been taking the medication for "quite some time." 4. In an interview on 8/8/2023 at 3:25 PM, the Administrator was asked how often patient medications were reviewed for accuracy. The Administrator stated, "Every Visit."

Review and revision of the plan of care CFR(s): 484.60(c) Standard: Review and revision of the plan of care. This STANDARD is not met as evidenced by: Based on policy review, medical record review and interview, the agency failed to ensure wounds were measured weekly for 1 of 3 (Patient #5) sampled patients with wounds. The findings included: Review of the agency's policy titled, "Documenting Wounds and Wound Care" revised January 2020 revealed, "...Document measurements of each wound At Least Weekly..." Medical record review for Patient #5 revealed a Start of Care (SOC) date of 1/25/2020 with diagnoses which included Stage 3 Pressure Ulcer of the Sacral Region, Spina Bifida, Paraplegia, Type 2 Diabetes and Hypertension. Review of the Visit Notes dated 5/9/2023 through 7/7/2023 revealed Patient #5's sacral wound was not measured from 5/25/2023 through 6/8/2023, a total of 2 weeks. In an interview on 8/8/2023 at 12:50 PM, the Administrator stated "Wounds should be measured weekly."

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 policy review, medical record review, observation and interview, the agency failed to ensure measures to prevent infection were followed when 1 of 1 (Nurse #1) nurses observed performing wound care failed to perform hand hygiene between glove changes. The findings included: 1. Review of the agency's policy titled, "Quality Assurance Performance Improvement (QAPI) Program: Infection Prevention and Control" revised 6/23 revealed, "...Hand Hygiene is a general term that applies to hand washing, antiseptic hand wash, or antiseptic alcohol-based rub...It cannot be emphasized strongly enough that good hand hygiene is the single most important patient care activity that a home care staff member can do to prevent cross-contamination and home-acquired infections. Hand Hygiene is Indicated, at least...After glove removal...Before performing an aseptic task (e.g. [such as]...performing wound care)...After removal of personal protective equipment (PPE), including gloves...Wearing gloves is not a substitute for hand hygiene..." Medical record review for Patient #1 revealed a Start of Care (SOC) date of 2/10/2021 with diagnoses which included Stage 3 Pressure Ulcer of the Lower Back, Paraplegia and Neurogenic Bladder. Review of the Plan of Care (POC) dated 7/30/2023 through 9/27/2023 revealed the Skilled Nurse (SN) "...To perform/teach wound care to right lower back wound...using clean/aseptic technique..." Observations in Patient #1's home on 8/8/2023 beginning at 10:30 AM revealed Nurse #1 performed hand hygiene, donned gloves, removed the dressing from Patient #1's lower back wound and placed it in the sink. The nurse removed the soiled gloves and applied new gloves without performing hand hygiene. Nurse #1 continued and cleaned the wound with a gauze soaked in Dakin's solution, applied skin prep to the peri wound area, placed a piece of Dakin's moistened calcium alginate with silver rope gauze into the wound bed using a Q tip and covered the entire area with a boarder foam dressing. The nurse gathered the soiled supplies and discarded them in a trash bag inside the garbage can. Without removing the gloves and performing hand hygiene, the nurse cleaned the patient's scissors with an alcohol swab and placed them back in the bin of wound care supplies along with the bottle of Dakin's solution. The nurse continued and picked up the zip lock bag of clean gloves and placed them back into her supply bag. While continuing to wear the same pair of gloves, the nurse gathered the trash out of the garbage bag, placed it into the garbage bag in the kitchen, then removed all of the trash and carried it out of the patient's home. Nurse #1 came back inside the patient's home, discarded the gloves and performed hand hygiene. Nurse #1 failed to perform hand hygiene before donning new gloves and performing wound care. Nurse #1 also failed to remove the soiled gloves and perform hand hygiene after completing the wound care and before handling the clean supplies and placed them back into the patient's bin and her supply bag. 2. In an interview on 8/8/2023 at 3:35 PM, the Administrator was asked when hygiene should be performed. The Administrator stated, "Hand hygiene should be performed before they reach in the bag, before they put gloves on; after they remove gloves and before they put on new gloves. My expectation is you can't do too much hand hygiene."

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on policy review, medical record review and interview, the agency failed to ensure a Registered Nurse (RN) provided oversite and supervision of a Licensed Practical Nurse (LPN) providing skilled nursing services for 1 of 5 (Patient #1) sampled patients. The findings included: Review of the agency's policy titled, "Supervision" revised 3/2020 revealed, "...The RN must make a visit to every patient receiving even a single visit from an LPN, at least every 30 calendar days (with or without the LPN present); documentation of the supervision is maintained in the patient's Medical Record..." Medical record review for Patient #1 revealed a Start of Care (SOC) date of 2/10/2021 with diagnoses which included Stage 3 Pressure Ulcer of the Lower Back, Paraplegia and Neurogenic Bladder. Review of the Plan of Care (POC) dated 5/31/2023 through 7/29/2023 revealed the patient was to have services provided by a skilled nurse. Review of the Visit Notes dated 5/31/2023 through 7/24/2023 revealed the skilled nursing visits were provided by Nurse #1, a Licensed Practical Nurse. There was no documentation a Registered Nurse performed a supervisory visit the entire 55 days. In an interview on 8/8/2023 at 3:25 PM, the Administrator stated LPN supervisory visits should have been performed by a Registered Nurse every 30 days.