Every finding on record at Nhc/Op, LP

An onsite unannounced Emergency Preparedness Program Survey was conducted at NHC Aiken Home Health from 04/22/2024 to 04/24/2024. The Home Health Agency is in compliance with Medicare Conditions at 42 CFR 484.102 (Establishment of the Emergency Program).

An onsite unannounced Recertification Survey was conducted at NHC Aiken Home Health from 04/22/2024 to 04/24/2024. The Home Health Agency is in substantial compliance with the Medicare Conditions at 42 CFR Part 484 with standard level deficiencies cited.

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 observation, record review and interview, the Home Health Agency (HHA) failed to ensure 1 of 1 Registered Nurse (RN) #1 obtained physician orders for wound care for 1 of 7 patient charts reviewed. (Patient #4). Findings include: Home observation on 04/23/2024 from 11:55 AM to 12:30 PM of Patient #4 showed RN #1 applying skin protectant around a Stage 3 peripheral sacral wound prior to performing wound care. Review of the chart revealed no documentation of physician orders for skin protectant on the peri-wound. During an interview on 04/23/2024 at 12:30 PM, RN #1 stated that he/she thought that this was included in the orders.

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 and interview, the Home Health Agency (HHA) failed to ensure 1 of 1 Registered Nurse (RN) #1 observed followed standard infection control procedures to prevent spread of communicable disease when performing wound care for 1 of 2 observed home patients. (Patient #4). Findings include Home observation on 04/23/2024 from 11:55 AM to 12:30 PM of Patient #4 showed RN #1 reaching into his/her uniform pocket twice with ungloved hands, retrieved an ink pen and replaced the ink pen into his/her uniform pocket without performing hand hygiene and/or sanitizing the ink pen. During an interview on 04/23/2024 at 12:30 PM, RN #1 stated that he/she didn’t realize that he/she was doing that.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the Home Health Agency (HHA) failed to ensure 1 of 1 Registered Nurse (RN) #1 observed failed to follow physician orders for wound care for 1 of 7 patient charts reviewed. (Patient #4). Findings include: Home observation on 04/23/2024 from 11:55 AM to 12:30 PM of Patient #4 showed RN #1 performed wound care to Pt #4's sacrum by removing the old dressing, cleansing the wound with normal saline, applying saline moistened gauze to the wound bed, covering with an ABD (abdominal) pad, and securing the ABD pad with paper tape. Review of physician wound care orders dated 04/18/2024 report “SN to cleanse unstageable wound coccyx with wound clenser (sic) or normal saline pack with normal saline on sterile gauze cover with sterile gauze tape using clean technique 2Xweek”. SN #1 covered the new dressing area with an ABD pad which was not part of this order. During an interview on 04/24/2024 at 9:45 AM, the Administrator stated that the ABD was not part of the order and verified the finding.

A survey of the Home Health Agency's (HHA) Emergency Preparedness Program (EPP) was conducted from 08/16/2021 to 08/19/2021. Based on observations, record reviews, interviews, and review of the HHA's EPP and policies and procedures, it was determined that standard level deficiencies resulted from the Emergency Preparedness Program Survey.

EP Training Program CFR(s): 484.102(d)(1) *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on interviews. the review of personnel files and the review of Emergency Preparedness and Covid training, the Home Health Agency (HHA) failed to ensure staff knowledge of the emergency plan for four (4) of seven (7) contract employees credentialing files reviewed. The findings are: On 08/19/21 at 9:45 AM, the review of the HHA Emergency Preparedness Manual, interview and review of personnel files, the HHA failed to provide documentation of staff training regarding Emergency Preparedness and Covid for 4 of 7 contract employees. The findings were verified by the business manager. He/she stated “We don’t train our contract employees. They are trained by their company, No, we don’t ask for a copy of their training.” The facility’s policy and procedure titled “Teaching and Training” reads “Staff Education Emergency Preparedness is a part of the continuing education plan for all staff (employed and contracted). Emergency preparedness training is provided: in orientation; annually, as a part of the routine, recurring continuing education plan; prior to known impending disasters; when an after action review has been completed post real or actual emergency, to include factors limiting success, opportunities for improvement, and a corrective action plan….”.

The Home Health Agency's (HHA) Recertification Survey was conducted in conjunction with the COVID-19 focused Infection Control requirements from 08/16/2021 to 08/19/2021. Based on observations, record reviews, interviews, review of the COVID -19 requirements, and review of the HHA's policies and procedures, it was determined the HHA is in compliance with the COVID - 19 focused infection control requirements, and determined that standard level deficiencies resulted from the HHA's Recertification Survey.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record reviews and interview, the home health agency staff failed to ensure all patient goals had measurable outcomes for seven of seven patient records reviewed for care plans.(Patient #1, #2, #3, #4, #5, #6, and -#7) Patient #1 On 8/17/2021 at 9:03AM, a review of Patient #1’s chart reveals goals are not measurable (A plan of care will be established; Cardiovascular exacerbations will be identified; Respiratory exacerbations will be identified; and Abnormal oxygen saturation levels.) The findings are verified by the Alternate Administrator and the Regional Director at 11:17 AM on 8/18/2021. Patient #2 On 8/17/2021 at 10:03AM, a review of Patient #2’s chart reveals goals are not measurable (A physical therapy plan of care will be ordered.) The findings are verified by the Alternate Administrator and the Regional Director at 11:24 AM on 8/18/2021. Patient #6 On 8/17/2021 at 10:23 AM, a review of Patient #6’s chart reveals goals are not measurable (A plan of care will be established; A physical therapy evaluation will be completed; and An occupational therapy evaluation will be completed.) The findings are verified by the Alternate Administrator and the Regional Director at 11:26 AM on 8/18/2021. Patient #7 On 8/17/2021 at 11:02 AM, a review of Patient #7’s chart reveals goals are not measurable (A physical therapy plan of care; and Changes in patient co-morbid status will be.) The findings are verified by the Alternate Administrator and the Regional Director at 11:36 AM on 8/18/2021. Patient #3 On 8/17/2021 at 11:27 AM, a review of Patient #3’s chart reveals goals are not measurable (A plan of care will be established; Cardiovascular exacerbations; Abnormal oxygen saturation levels; Respirator exacerbations; and Increased pain or ineffective pain control.) The findings are verified by the Alternate Administrator and the Regional Director at 11:44 AM on 8/18/2021. Patient #4 On 8/17/2021 at 12:52 PM, a review of Patient #4’s chart reveals goals are not measurable (A plan of care will be established; Abnormal oxygen saturation levels; Changes in patient c-morbid status; and A physical therapy plan of care.) The findings are verified by the Alternate Administrator and the Regional Director at 11:45 AM on 8/18/2021. Patient #5 On 8/17/2021 at 1:23 PM, a review of Patient #5’s chart reveals goals are not measurable (A physical therapy plan of care; Changes in skin integrity; and Patient will demonstrate compliance with medications.) The findings are verified by the Alternate Administrator and the Regional Director at 11:49 AM on 8/18/2021.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review and interview, the agency staff failed to provide the visits (skilled nursing) ordered by the patient’s plan of care in two out of seven records reviewed (Patient #4 and #6). Patient #6 On 8/17/2021 at 10:23 AM, a review of Patient #6’s chart reveals an order for skilled nursing frequency of one time a week for nine weeks. On the week of 6/20/2021 there is no documentation of a nursing visit or missed nursing visit. This finding is verified by the Alternate Administrator and the Regional Director at 11:26 AM on 8/18/2021. Patient #4 On 8/17/2021 at 12:52 PM, a review of Patient #4’s chart reveals an order for skilled nursing frequency effective 6/27/2021 as three times a week for one week, two times a week for two weeks, and one time a week for one week. On the week of 6/27/2021, the chart does not show documentation of a skilled nursing visit nor a skilled nursing missed visit. The week of 7/4/2021, the chart shows only one skilled nursing visit on 7/9/2021. The week of 7/11/2021, the chart shows only one skilled nursing visit dated 7/14/2021. The findings are verified by the Alternate Administrator and the Regional Director at 11:45 AM on 8/18/2021.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to provide services (occupational therapy evaluation) as ordered on the plan of care in one out of three charts with occupational therapy orders (Patient #6). Patient #6 On 8/17/2021 at 10:23 AM, a review of Patient #6’s chart reveals an order for an occupational therapy evaluation. There is no documentation in the chart that an occupational therapy evaluation was completed. This finding is verified by the Alternate Administrator and the Regional Director at 11:26 AM on 8/18/2021.