Every finding on record at Northwest Colorado Visiting Nurse Association

A recertification survey was completed on 6/11/26. One deficiency was cited.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on the record review and interview, the agency failed to develop and maintain an emergency preparedness plan. Specifically, the agency did not have an annual updated and reviewed community-based risk assessment. Findings include: 1. Record review completed on 6/11/26, revealed an emergency preparedness plan provided to surveyors by the agency. Further review revealed the agency did not have a current emergency plan or an updated community-based risk assessment. a.The agency failed to ensure the agency's emergency preparedness plan contained an updated and completed assessment of hazards or potential emergencies the agency could encounter. During an interview on 6/11/26 at 11:58 a.m., when questioned specifically regarding the lack of an updated plan, Personnel #7 and Personnel #9 reviewed the emergency preparedness plan with surveyors. Upon review, they stated the plan was last reviewed on 3/26/26; however, this was not documented anywhere. They further stated they did not have an updated risk assessment, and the agency was aware of the regulatory requirement. During continued interview, Personnel #7 and Personnel #9 stated the agency was securing further funding and was working with the agency staff to establish a more robust emergency preparedness plan, including an updated community-based risk assessment.

A recertification survey was completed on 7/12/23. Two deficiencies were 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 interview and record review, the agency failed to ensure wound care treatments were administered by agency staff only as ordered by a physician for 1 of 2 patients reviewed who had wound care ordered (Patient #1). Findings include: AGENCY POLICY According to the agency policy dated 10/10/22, titled, Orders for Home Health and Hospice Services, (read in pertinent parts): "Medical provider orders are required to provide skilled care to Home Health and Hospice patients. -Verbal orders within approved scope of practice are put in writing, signed and dated with the date of receipt by the Registered Nurse or qualified therapist responsible for furnishing or supervising the ordered services." 1. The clinical record for Patient #1 was reviewed on 7/10/23. The plan of care for the certification period 6/7/23 to 8/5/23 revealed a start of care date of 6/7/23; diagnoses included type 2 diabetes mellitus (DM) with foot ulcer, non-pressure ulcer of right heel and midfoot with bone involvement, osteomyelitis, dementia, intervertebral disc degeneration of lumbar region, hypothyroidism, hyperlipidemia, history of TIA (transient ischemic attack), history of falling and history of urinary tract infections. The plan of care orders included: skilled nursing (SN) services one time a week for one week, three times a week for for two weeks, and two times a week for six weeks for assessment and evaluation, medical management, DM teaching, DM ulcer wound care to right heel and vital signs; physical therapy services two times a week for two weeks and one time a week for one week for assessment and evaluation, strengthening and balance training; occupational therapy services for assessment and evaluation of activities of daily living and instrumental activities of daily living; and medical social worker services for assessment and evaluation for community services. a) The agency failed to ensure wound care was provided only as ordered by the physician. Review of Patient #1's plan of care, dated 6/7/23 to 8/5/23 revealed the following wound care order for Patient #1's right heel wound: "Wash hands, put on gloves and remove old dressing. Clean the wound with wound cleanser. Moisten the center of sterile gauze with sterile saline leaving the outer portion of gauze dry. [p]lace moistened gauze into wound bed. Secure with dry gauze and gauze wrap or Coban [a self-adherent elastic wrap that functions like a tape, but sticks to itself]. Dressing to be changed 2X [two times] a day." Effective 6/14/23, Patient #1's wound care orders changed to the following order and were documented on a verbal order as well as the plan of care: "Wash hands, don clean gloves, remove old dressing. Remove gloves, wash hands, don new gloves. Do not wash out wound bed. Wipe out excess alginate [a type of wound care dressing known for it's ability to absorb drainage] with gauze moistened with saline wound wash. Apply skin prep [forms a barrier between the patient's skin and adhesives to help preserve skin integrity] to the peri-wound area, allow to dry. Apply thin layer of Medihoney [a wound care substance with antibacterial and anti-inflammatory properties] in wound bed. Cut Maxorb calcium alginate (silver not necessary) [an alginate dressing that contains calcium used for wounds with moderate to heavy drainage] to fit and place inside wound bed over medi-honey [sic]. Cover with Optifoam [a wound dressing used to cover a wound which has absorbent properties and a waterproof outerlayer] (note: cut a slit in dressing border on each of 4 sides in order to better secure dressing over shape of heel). Wound care dressing change provided every 1 to 7 days per week, depending on drainage." Review of a SN note dated 6/16/23, revealed SN #9 documented Patient #1's right heel wound dressing had been in place for two days and the maceration (occurs when skin has been exposed to moisture for too long) of Patient #1's right heel wound was worse. SN #9 documented "Dressing to be changed 1 to 2 times daily until maceration improves." SN #9 documented she educated Patient #1's husband on how to change Patient #1's right heel dressing, his understanding and comfort with the dressing change, and the importance of reducing maceration. SN #9 also documented "When dressing is changed tomorrow morning, [Patient #1's husband] will switch the outer dressing to dry gauze. Wound Care to wound bed to be performed daily, and dry gauze to be changed BID [twice a day]." Review of Patient #1's chart failed to show evidence of a physician order to change Patient #1's right heel dressing one to seven times a week using Optifoam as the outer wound care dressing (the wound care ordered) to changing the outer dressing two times a day using dry gauze instead of Optifoam as ordered. Review of a SN note dated 6/19/23, revealed SN #7 documented she performed wound care to Patient #1's right heel, applying Medihoney and calcium alginate and covering the wound with gauze and Kerlex [sic](a type of dry gauze roll). SN #7 also documented, "[Patient #1's husband] applies DRSG [wound care dressings] as directed during the AM (dry gauze and kerlex [sic]) and changes DRSG to Optifoam in the evening as it stays in place better throughout the night. This appears to be effective and will continue." Patient #1's record failed to show evidence of a physician order to change Patient #1's right heel dressing from one to seven times a week using Optifoam as the outer wound care dressing (the wound care ordered) to changing the outer dressing two times a day using dry gauze and Kerlix for the morning change and Optifoam for the evening change. Review of supplemental orders revealed a verbal order written 7/11/23, by SN #9, effective 7/5/23, for Patient #1's right heel wound care: "Daily dressing changes. Wash hands, don clean gloves, remove old dressing, wipe out excess alginate with gauze, do not wash wound bed. Remove gloves, wash hands, don new gloves. Apply skin prep to peri-wound area. If wound bed is moist, cut Silver Alginate [alginate wound dressing with silver embedded] to fit, and place inside wound bed. If wound bed is dry and alginate that was removed was fibrous and not gelled, apply thin layer of Thera-honey [a wound care substance with antibacterial and anti-inflammatory properties] before placing new alginate. Cover with super absorbent Dressing." Review of Patient #1's record failed to reveal further orders for Patient #1's right heel wound care. Review of a SN note dated 7/5/23, revealed SN #7 documented she cleaned Patient #1's right heel wound with dry gauze, applied skin prep and silver alginate and covered the wound with Optifoam and Kerlix. SN #7 also documented "Per Pt's [patient's] husband, they had a f/u [follow up] with the wound care specialist. New orders for skin prep to edges, silver infused alginate to wound bed, medihoney [sic] is DC'd [discontinued], cover with optifoam [sic] and wrap with (kerlex [sic]) if needed. Continuing with no wound wash and dry DRSG's. Change once daily." Patient #1's record revealed the physician order for the wound care provided by SN #7 on 7/5/23 was not obtained until 7/11/23, six days later, and the order had not included using Kerlix to secure the Optifoam dressing as SN #7 documented. During an interview on 7/11/23 at 4:18 p.m., SN #9 acknowledged on 6/16/23 she failed to obtain an order from Patient #1's wound care specialist to change the frequency of wound care provided to Patient #1's right heel wound from one to seven times, using Optifoam as the outer wound dressing to applying the Medihoney and alginate in Patient #1's right heel wound one time a day and using dry gauze as the outer wound dressing with frequency of changing the outer wound dressing from one to two times a day. SN #9 stated she was aware of the regulation requiring all wound care orders to be provided by a physician, physician assistant (PA) or nurse practitioner (NP) prior to providing the wound care. SN #9 stated she thought she spoke with the NP at the wound care clinic who was overseeing Patient #1's wound care and had obtained the order for the change in wound care she provided to Patient #1 on 6/16/23; but acknowledged she failed to document this conversation in Patient #1's record and failed to write a verbal order for the change in Patient #1's wound care. During a home visit on 7/10/23 at 10:31 a.m., SN #7 confirmed the first time she provided Patient #1 care, including wound care, was on 6/19/23. SN #7 stated she spoke with SN #9 on the telephone prior to her 6/19/23 visit and SN #9 informed SN #7 on how to perform the wound care for Patient #1. During continued interview, SN #7 stated when a patient and/or their family reported to her the patient's wound care order had been changed after the patient was seen by their physician/NP/PA, if SN #7 trusted the patient and/or their family, she would perform the new order and then call the physician/NP/PA to confirm the order and obtain new documentation of the new orders. If SN #7 did not trust the patient and/or their family, then SN #7 would call the physician/NP/PA to confirm the orders had changed prior to performing the new wound care order. SN #7 stated she trusted Patient #1's husband, and on 7/5/23 she performed the wound care as Patient #1's husband directed. SN #7 stated on 7/6/23, she left a phone message for Patient #1's wound care NP to attempt to obtain a verbal order for the changes to Patient #1's right heel wound care as reported by Patient #1's husband but had not received a call back. During an interview on 7/11/23 at 4:18 p.m., SN #9 stated Patient #1's wound care NP left her a voice message on 7/3/23 with the wound care orders as written on the 7/11/23 verbal order, but SN #9 did not listen to the voicemail message which included the order until 7/5/23 and she had forgotten to enter the new order until 7/11/23. During an interview on 7/12/23 at 1:10 p.m., the interim administrator reviewed Patient #1's chart and acknowledged Patient #1 had three wound care orders: the first one written on and effective 6/7/23, the second one written and effective on 6/14/23, and a the third one effective 7/5/23, but had not been entered into Patient #1's chart until 7/11/23. The interim administrator reviewed Patient #1's SN notes and acknowledge SN #9 performed wound care on 6/16/23 without an order for the wound care she provided and SN #7 performed wound care on 6/19/23 and 7/5/23 without an order for the wound care she provided those two visits. The interim administrator stated the agency expectation was for SNs to perform wound care only as ordered by a physician. If a patient and/or family reported a change in the wound care orders and/or if a SN felt the wound care should be changed based on their assessment, the agency expectation was the SN was to obtain an order for the change prior to providing the new wound care. The interim administrator stated she would reeducate the agency's SNs on this expectation.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure certified nurse aides (CNAs) provided services as ordered by the physician and on the plan of care for 1 of 3 patients who required CNA services (Patient #1). Findings include: AGENCY POLICY According to the agency policy dated 9/8/21, and titled, Certified Nurse Aide Scope of Practice, (read in pertinent parts): "Physician orders for aide services must identify the type of service to be provided, the frequency of service required, and the duration of services. -There will be a specific plan of care on all CNA patients written by a RN [registered nurse] and will include consumer input on tasks to be performed." 1. The clinical record for Patient #1 was reviewed on 7/10/23. The plan of care for the certification period 6/7/23 to 8/5/23 revealed a start of care date of 6/7/23; diagnoses included type 2 diabetes mellitus (DM) with foot ulcer, non-pressure ulcer of right heel and midfoot with bone involvement, osteomyelitis, dementia, intervertebral disc degeneration of lumbar region, hypothyroidism, hyperlipidemia, history of TIA (transient ischemic attack), history of falling and history of urinary tract infections. The plan of care orders included: skilled nursing (SN) services one time a week for one week, three times a week for for two weeks, and two times a week for six weeks for assessment and evaluation, medical management, DM teaching, DM ulcer wound care to right heel and vital signs; physical therapy services two times a week for two weeks and one time a week for one week for assessment and evaluation, strengthening and balance training; occupational therapy services for assessment and evaluation of activities of daily living and instrumental activities of daily living; and medical social worker services for assessment and evaluation for community services. Review of a supplemental order for Patient #1 revealed a verbal order written on 6/22/23 by the interim director of clinical services for CNA services one time a week for one week and two times a week for six weeks for assistance with bed baths. Review of a CNA care plan dated 6/22/23, developed by the interim director of clinical services revealed CNAs were to assist Patient #1 with dressing, bed baths, perineal care and skin care without a frequency provided. a) The agency failed to ensure the CNA provided services as ordered by the physician and directed on the care plan. Review of CNA notes completed by CNA #6 from 6/23/23 to 7/10/23, revealed CNA #6 provided Patient #1 with care five times (6/23/23, 6/26/23, 6/29/23, 7/6/23 and 7/10/23), and documented she assisted Patient #1 with transfers at all five visits, a task not assigned on her care plan or ordered by the physician. Further review of a CNA note written on 7/6/23, showed CNA #6 documented Patient #1's daughter was present for the visit and informed CNA #6 Patient #1 was approved for showers (versus a bed bath), but Patient #1 required a protective boot. Further review of a CNA note written on 7/10/23, showed CNA #6 documented she and Patient #1's husband assisted Patient #1 to transfer in and out of the shower and assisted Patient #1 with a shower (not a bed bath as ordered and care planned). During a home visit on 7/11/23 at 9:30 a.m., the surveyor observed Patient #1 to have three lift systems: one to use for transfers from a hospital bed located in her living room to/from a reclining chair or wheelchair; another lift system in Patient #1's bathroom to assist her with transferring on and off the toilet and in and out of the shower from her wheelchair; and a third lift system located in Patient #1's bedroom to assist with transferring her from the wheelchair to/from the bed in her bedroom. The surveyor also observed a waterproof foot and lower leg covering in Patient #1's bathroom. During a home visit on 7/11/23 at 9:30 a.m., Patient #1's husband confirmed CNA #6 provided care to Patient #1 two days a week. Patient #1's husband stated CNA #6 assisted Patient #1 with a variety of tasks including bed baths and transfers using Patient #1's lift systems with the husband's assistance. Patient #1's husband stated on 7/10/23, CNA #6 provided Patient #1 with the waterproof foot and lower leg covering and assisted Patient #1's husband to transfer Patient #1 in and out of the shower and CNA #6 provided Patient #1 with a shower (not a bed bath as ordered). During an interview on 7/11/23 at 4:11 p.m., CNA #6 confirmed she provided care to Patient #1. CNA #6 stated she knew what tasks to perform with Patient #1 as she looked at Patient #1's care plan and she spoke with the interim director of clinical services prior to her first visit with Patient #1, who informed CNA #6 what tasks were care planned for Patient #1. CNA #6 stated the the tasks assigned on Patient #1's care plan were skin care, perineal care, dressing and bed baths; but the care plan needed to be updated as CNA #6 had recently been approved to assist Patient #1 with showers instead of a bed bath. CNA #6 confirmed she helped Patient #1's husband to transfer Patient #1 at each visit using the lift systems in Patient #1's home. CNA #6 stated she thought transfers were a care planned task for Patient #1. CNA #6 stated sometimes she gets comfortable in her role of assisting patients and did not always review the care plan to ensure she was only providing tasks as care planned prior to visits. CNA #6 stated she did not inform Patient #1's nurse case manager that Patient #1 required assistance with transfers. During further interview, CNA #6 stated she informed the lead CNA (CNA #10) on 7/11/23, Patient #1 was approved for showers and CNA #6 provided Patient #1 a shower on 7/10/23, instead of a bed bath as care planned. CNA #6 also stated she provided Patient #1 with the waterproof foot and leg cover from her personnel supplies to use in the shower as she had purchased it for another patient who had not used it and CNA #6 knew Patient #1 needed to protect her right heel wound from getting wet in order to take a shower instead of a bed bath. During an interview on 7/12/23 at 11:49 a.m., the lead CNA, CNA #10, stated part of her job responsibilities as the lead CNA was to complete scheduling for the CNAs and to assist with communication between the CNAs and SN. The lead CNA stated the agency expectation was if a CNA was asked by a patient or family to complete a task not assigned on the care plan, the CNA was to communicate with either the lead CNA and/or nurse case manager for the patient to see if the task could be added to the CNA care plan prior to assisting the patient with the task. The lead CNA stated CNA #6 informed her on 7/11/23 that CNA #6 assisted Patient #1 with a shower on 7/10/23 as she was approved for showers versus a bed bath, and requested Patient #1's care plan be updated. The lead CNA stated she had not communicated with Patient #1's nurse case manager regarding CNA #6's request to update Patient #1's care plan. The lead CNA also stated she was not aware CNA #6 had provided Patient #1 with the water proof foot and leg cover from her personal supplies. During an interview on 7/11/23 at 5:21 p.m., SN #11 confirmed she was Patient #1's nurse case manager. SN #11 stated she was not aware Patient #1 received skilled CNA services. SN #11 stated she thought CNA #6 provided unskilled personal care and homemaking services to Patient #1. SN #11 stated she was new to nursing and home health and struggled to understand the difference between skilled CNA services versus unskilled personal care/homemaking services and CNA #6 provided both types of services to patients in the agency. During an interview on 7/11/23 at 11:21 a.m., the interim director of clinical services confirmed she created the CNA care plan for Patient #1. The interim director of clinical services stated Patient #1's husband called her and stated he required assistance with Patient #1's activities of daily living, in particular bed baths. The interim director of clinical services called Patient #1's physician for CNA orders and created the CNA care plan to assist SN #11. The surveyor attempted to complete a follow up interview with the interim director of clinical services on 7/12/23 at 11:18 a.m., but was informed the interim director of clinical services went home sick for the day. During an interview on 7/12/23 at 12:50 p.m., the interim administrator reviewed Patient #1's CNA care plan and notes, acknowledging CNA #6 documented she assisted Patient #1 with transfers, a task not care planned. The interim administrator also acknowledged CNA #6 documented she assisted Patient #1 with a shower, also a task not care planned. The interim administrator stated the agency expectation was, if a CNA was asked by a patient and/or family to complete a task not care planned, the CNA was to contact the patient's nurse case manager prior to completing the non-care planned task to see if the nurse case manager agreed the task was appropriate. The interim administrator stated she would educate the entire staff on the need for improved communication and re-educate the CNA's on following the patient's care plan, and if a patient and/or family requested a non-care planned task be completed, the CNA needed to reach out to the nurse case manager for the patient to receive approval prior to providing the non-care planned task.