Every finding on record at Palmeira Home Health

This Statement of Deficiencies was generated as a result of an Emergency Preparedness Survey for Home Health Agencies conducted at your agency from November 19, 2024 through November 27, 2024, in accordance with 42 CFR (Code of Federal Regulations) Part 484 - Home Health Services. The active census at the time of entry was 307 patients. Seventeen clinical records were reviewed. Seven home visits were conducted. The findings and conclusions of any investigation by the Division of Public and Behavioral Health shall not be construed as prohibiting any criminal or civil investigation, actions or other claims for relief that may be available to any party under applicable federal, state, or local laws. No regulatory deficiencies were identified. No further action is necessary. Please retain a copy of this report for your records.

This Statement of Deficiencies was generated as a result of a Medicare Recertification Survey and Complaint Investigation for Home Health Agencies conducted at your agency from November 19, 2024 through November 27, 2024, in accordance with 42 CFR (Code of Federal Regulations) Part 484 - Home Health Services. The active census at the time of entry was 307 patients. Eighteen clinical records were reviewed. Seven home visits were conducted. Two complaints were investigated and completed. Complaint #96875 was substantiated (See Tags G514 and G590). Complaint #102707 was substantiated (See Tag G596). The investigation of the complaints included: Interview with Clinical Manager and Administrator. Document Review included facility policy and procedures, grievance logs and patient clinical records including the patients of concern. The findings and conclusions of any investigation by the Division of Public and Behavioral Health shall not be construed as prohibiting any criminal or civil investigation, actions or other claims for relief that may be available to any party under applicable federal, state, or local laws. The following the regulatory deficiencies were identified:

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure its admission booklet contained the correct home health hotline phone number for all patients. Findings include: On 11/19/2024 in the afternoon, a home visit was conducted. On 11/20/2024, five home visits were conducted throughout the day. On 11/21/2024 in the morning, a home visit was conducted. On 11/19-20/2024 during the home visits conducted, the surveyor contacted the home hotline phone number provided in the agency's booklet. Instead of the complaint line, the surveyor was solicited with an elder alert system. On 11/26/2024 in the agency's office, the surveyor contacted the home health hotline number in front of the Clinical Manager and Administrator, using the number provided in an admission booklet from the office and the same solicitation was received. The finding was confirmed.

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure it documented the existence and resolution of complaints for 1 of 18 patients (Patient #15). Findings include: Patient #15 On 8/20/2022, the agency admitted Patient #15 with diabetes mellitus II with foot ulcer and history of infectious diseases. The agency recertified the patient continuously with a focus episode of 10/14/2023 through 12/12/2023. On 11/17/2023, a physician ordered a resumption of care with skilled nursing visits three times weekly. On 11/28/2023, a licensed practical nurse (LPN) conducted and documented a skilled nursing visit, revealing the Clinical Manager accompanied the LPN on the visit. The LPN documented the patient conveyed numerous grievances to the Clinical Manager. The agency's grievance log lacked documented evidence correlating with any complaints conveyed at or in near proximity to 11/28/2023. On 11/27/2024 in the afternoon, the Clinical Manager indicated the complaints were addressed as routine issues.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a start of care was conducted within 48 hours of discharge for 1 of 18 patients (Patient #1). Findings include: Patient #1 On 3/19/2023, the agency admitted Patient #1 with hypertensive encephalopathy and pneumonia due to methicillin resistant Staphylococcus aureus. On 3/13/2023, the hospital referred the patient for home health services. On 3/14/2023, an unsigned phone message revealed the spouse agreed to the start of care on 3/18/2023. This was contradicted by a complaint the bureau received in real time regarding the availability of a nurse on 3/16-17/2023. Someone at the agency documented a later referral date on the patient's face sheet as 3/17/2023. On 3/18/2023, the nurse was a no call/no show at the patient's house, none of which was documented at the agency. The patient was unable to get through to the agency until 3/19/2024. On 11/27/2024 in the afternoon, the Clinical Manager and Administrator were unable to provide documented evidence of any other information addressing the late start of care. Procedure #4 of the Care Planning Process policy (4-001) provided revealed the registered nurse informed the patient's physician of any changes that suggested a need to change the plan of care. Changes must be written, dated and signed by the professional making the changes and forwarded to the physician for approval and signature. The patient/family was informed of changes in the plan of care and the registered nurse documented in the chart if the patient understood and was agreeable to the revised plan of care. Complaint #96875

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 record review, observation and interview, the agency failed to ensure a patient's allergies were addressed for 2 of 18 patients (Patient #5 and #9) and failed to ensure an accurate medication profile for 2 of 18 patients (Patient #13 and #14). Findings include: Patient #5 On 11/8/2023, the agency admitted Patient #5 with failure to thrive and altered mental status. On 11/8/2023, the plan of care and medication profile both lacked documented evidence the patient's allergies were listed or whether the patient did not have allergies. On 11/27/2024 in the afternoon, the Clinical Manager and Administrator confirmed the finding. Patient #9 On 11/25/2023, the agency admitted Patient #9 with atherosclerotic heart disease of the coronary artery. On 11/25/2023, the plan of care and medication profile both lacked documented evidence the patient's allergies were listed or whether the patient did not have allergies. On 11/27/2024 in the afternoon, the Clinical Manager and Administrator confirmed the finding. Patient #13 On 11/14/2024, the agency admitted Patient #13 with hemiplegia. On 11/14/2024, the agency certified the patient from 11/14/2024 through 1/12/2025. On 11/14/2024, the plan of care revealed a physician ordered a home health aide once the week of 11/17/2024 through 11/23/2024. On 11/21/2024, a home visit was conducted with a home health aide. During the visit, a medication reconciliation was conducted. Of note were two medications, one of which was neither on the plan of care nor the medication profile provided. The other was listed at a different dose. The plan of care and medication profile lacked documented evidence of Hydralazine. A container was identified in the home, filled on 11/12/2024, with Hydralazine 25 milligrams three times daily. The plan of care and medication profile both listed Amlodipine at 10 milligrams daily. A container was identified in the home, filled on 11/12/2024, with Amlodipine 2.5 milligrams nightly at 9:00 PM. On 11/21/2024, a skilled nursing visit was conducted and documented after the visit with the home health aide. The medication profile was updated to include Hydralazine 25 milligrams three times daily, but the Amlodipine 10 milligrams daily was still listed. On 11/27/2024 in the afternoon, the Clinical Manager and Administrator confirmed the finding. Patient #14 On 11/6/2014, the agency admitted Patient #14 with encounter for surgical wound dressing. On 11/6/2024, both the plan of care and medication profile listed Citalopram 10 milligrams daily. On 11/20/2024, a home visit was conducted with a physical therapist for a discharge. A medication reconciliation revealed the medication Citalopram (Celexa) was actually Escitalopram (Lexapro) according to the container's label. After the visit, the difference between the two medications was mentioned to the therapist. The medication profile was not corrected.

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 record review, interview and policy review, the agency failed to ensure it conducted and documented skilled visits as ordered for 8 of 18 patients (Patient #1, #3, #4, #5, #7, #14, #15 and #16). Findings include: Procedure #4 of the Care Planning Process policy (4-001) provided revealed the registered nurse informed the patient's physician of any changes that suggested a need to change the plan of care. Changes must be written, dated and signed by the professional making the changes and forwarded to the physician for approval and signature. The patient/family was informed of changes in the plan of care and the registered nurse documented in the chart if the patient understood and was agreeable to the revised plan of care: Patient #1 On 3/19/2023, the agency admitted Patient #1 with hypertensive encephalopathy and pneumonia due to methicillin resistant Staphylococcus aureus. On 3/19/2023, the plan of care revealed a physician ordered skilled nursing visits four times for the first week of the episode. The clinical record lacked documented evidence the agency conducted and documented skilled nursing visits aside from the start of care visit on 3/19/2023. The clinical record lacked documented evidence a physician changed, discontinued or reduced the frequency. On 11/27/2024 in the afternoon, the Clinical manager confirmed the finding. Patient #3 1) On 10/13/2024, the agency admitted Patient #3 with open wound of the left wrist. On 10/13/2024, the plan of care revealed a physician ordered an occupational therapy evaluation. On 10/17/2024, a physician ordered late occupational therapy evaluation. The clinical record lacked documented evidence an occupational therapy evaluation was conducted and documented or that the order was changed or discontinued. 2) On 11/3/2024, a physician ordered every other week skilled nursing visits due to patient request. The clinical record contained documented evidence of weekly skilled nursing visits dated 11/7/2024, 11/14/2024 and 11/19/2024. On 11/26/2024 in the afternoon, the Clinical Manager and Administrator confirmed the above findings. 3) On 10/13/2024, the plan of care revealed a physician ordered twice weekly skilled nursing visits and to cleanse left wrist area with wound cleanser, apply dry gauze to wound and secure in place daily. On 10/16/2024, a registered nurse conducted and documented a skilled nursing visit with wound care as cleansed with betadine, applied xeroform and dressed with adhesive foam. The nursing goals included the original plan of care order as current on the obverse side of the skilled nursing visit form. On 11/26/2024 in the afternoon, the Clinical Manager and Administrator confirmed the finding the order was not followed. Patient #4 On 10/3/2024, the agency admitted Patient #4 with stage 2 pressure ulcer of left heel. On 10/3/2024, the plan of care revealed a physician ordered an occupational therapy evaluation and a social services evaluation. The clinical record revealed an occupational therapy evaluation was conducted and documented on 10/15/2024, and a social services evaluation was conducted and documented on 10/16/2024. The clinical record lacked documented evidence why the evaluations were so delayed. The orders were not changed or discontinued. On 11/26/2024 at 12:55 PM, the Administrator indicated secondary discipline evaluations ordered were expected to be conducted within five days and confirmed the findings. Patient #5 On 11/8/2023, the agency admitted Patient #5 with failure to thrive and altered mental status. On 11/10/2023, an occupational therapy evaluation was conducted and documented. On 11/8/2023, the plan of care lacked documented evidence a physician ordered an occupational therapy evaluation. On 11/10/2023 the patient was transferred to acute care for altered mental status. On 11/22/2023, the agency resumed home health care for the patient. A physician ordered twice weekly skilled nursing visits to begin the following week. For the week of 11/26/2023 through 12/2/2023, the clinical record contained documented evidence only one skilled nursing visit was conducted and documented on 11/29/2023. On 11/27/2024 in the afternoon, the Clinical Manager and Administrator confirmed the findings. Patient #7 On 8/5/2024, the agency admitted Patient #7 with stage 3 pressure ulcer of the sacral region, complicated urinary tract infection and fitting and adjustment of urinary device. The agency certified the patient from 8/5/2024 through 10/3/2024. On 8/5/2024, a physician wrote an order for monthly Foley catheter change as needed for leakage/dislodgement. On 9/30/2024, the agency recertified the patient from 10/4/2024 through 12/2/2024. On 8/5/2024 and 10/4/2024, the plans of care lacked documented evidence a physician ordered a monthly Foley catheter change or sized the Foley catheter in place. On 10/4/2024, the plan of care revealed a physician ordered twice weekly weekly skilled nursing visits. On 10/11/2024, a skilled nursing visit revealed urinary tract infection symptoms were present, the provider called and waiting for a urinalysis order. On 10/14/2024, a skilled nursing visit revealed urinary tract infection symptoms were present, the provider called and waiting for a urinalysis order. On 10/16/2024, a skilled nursing visit revealed urinary tract infection symptoms were present, the provider called and waiting for a urinalysis order. On 10/20/2024, an "as needed" skilled nursing visit revealed a nurse changed the Foley catheter due to nonfunction. The Foley size was 24 french and 30 milliliter balloon. On 10/21/2024, a skilled nursing visit revealed urinary tract infection symptoms were present, the provider called and waiting for a urinalysis order. On 10/25/2024, a skilled nursing visit revealed urinary tract infection symptoms were present, the provider called and waiting for a urinalysis order. On 10/28/2024, a skilled nursing visit revealed urinary tract infection symptoms were present and a urine specimen was collected. On 10/29/2024, the lab result revealed the patient was positive for urinary tract infection. On 10/30/2024, a physician ordered 24 french and 30 milliliter balloon for the monthly changes. On 10/30/2024, an "as needed" skilled nursing note revealed a nurse documented the new Foley as 24 french and 15 milliliter balloon. On 11/1/2024, a skilled nursing visit revealed the visit nurse obtained the lab result confirming the infection and antibiotic ordered at pharmacy for pick-up. On 11/13/2024, a skilled nursing note revealed a nurse documented a new Foley catheter change as 22 french and 30 milliliter balloon. The monthly Foley catheter change order (8/5/2024) was not transferred to the plans of care. The size of the Foley catheter was not identified per order change until 10/30/2024. The Foley catheter changes performed and documented on 10/30/2024 and 11/13/2024 were the wrong size. The plan of care lacked documented evidence for the extra "as needed" skilled nursing visits conducted and documented on 10/20/2024 and 10/30/2024. On 11/27/2024 in the afternoon, the Clinical Manager and the Administrator confirmed the findings, indicating the agency was reliant upon using specific requisition forms for labs which had to be physician signed prior to establishing an order for the lab, despite appearing on the plan of care. The catheter size should be physician-ordered. Procedure #1 of the Foley Catheter Care and Management policy (4-007) provided revealed for nurses to verify the doctor's order. Patient #14 On 9/28/2024, the agency admitted Patient #14 with secondary malignant neoplasm of bone. On 9/28/2024, the plan of care revealed a physician ordered an occupational therapy evaluation and a social services evaluation. The clinical record revealed an occupational therapy evaluation was conducted and documented on 10/2/2024. On 10/2/2024, the occupational therapy evaluation revealed a physician ordered occupational therapy weekly for six weeks. The clinical record revealed occupational therapy visits were conducted and documented weekly until the week of 11/3/2024 through 11/9/2024. On 11/10/2024, a physician order was obtained to discharge the patient during the coming week, which was conducted and documented on 11/13/2024. The clinical record lacked documented evidence why the occupational therapy discharge visit was not conducted between 11/3/2024 and 11/9/2024. The clinical record lacked documented evidence of a missed visit, communication note, change or discontinuation order between 11/3/2024 and 11/9/2024. The order to discharge the following week was written after the fact. The social services evaluation, ordered 10/2/2024, was conducted and documented on 10/15/2024. The clinical record lacked documented evidence why the evaluation was so delayed. The order was not changed or discontinued. On 11/26/2024 at 12:55 PM, the Administrator indicated secondary discipline evaluations ordered were expected to be conducted within five days and confirmed the above findings. Patient #15 On 8/20/2022, the agency admitted Patient #15 with diabetes mellitus II with foot ulcer and history of infectious diseases. The agency recertified the patient continuously with a focus episode of 2/16/2023 through 4/16/2023. On 2/16/2023, the plan of care revealed a physician ordered three times weekly (Tuesday, Thursday and Saturday) throughout the care episode for a chronic diabetic foot ulcer. The clinical record revealed skilled nursing visits were conducted on those mornings without fail the first half of March with the exception of 3/9/2023. The clinical record lacked documented evidence of a missed visit. On 3/9/2023 at 6:24 PM, a registered nurse obtained a physician order to reduce the skilled nursing visits to two times for that week with no reason specified, but the agency cannot reduce visit frequency as a means to cover a missed visit after an undocumented missed, scheduled skilled nursing visit. The agency recertified the patient continuously with a focus episode of 10/14/2023 through 12/12/2023. On 10/14/2023, the plan of care revealed a physician ordered skilled nursing visits daily for wound care. The clinical record lacked documented evidence of a skilled nursing visit conducted and documented on 10/16/2023. The clinical record lacked documented evidence of a physician order that changed, modified or discontinued the skilled nursing visit. The clinical record lacked documented evidence of a missed visit for 10/16/2023. On 10/14/2023, the plan of care revealed a physician ordered home health aide visits twice weekly throughout the care episode. On 10/25/2023, a physician ordered twice weekly home health aide visits to continue. The clinical record revealed the last home health aide visit conducted and documented dated 10/30/2023. The clinical record lacked documented evidence of a physician order that changed, modified or discontinued the home health aide visits. The clinical record lacked documented evidence of any missed home health aide visits after 10/30/2023. On 11/17/2023, the agency resumed patient care after an acute care stay. The comprehensive assessment revealed an intent to order an occupational therapy evaluation. On 11/28/2023, a physician ordered an occupational therapy evaluation. The clinical record lacked documented evidence an occupational therapy evaluation was conducted and documented, addressed with a missed visit or that the order was changed or discontinued. On 11/26/2024 at 12:55 PM, the Administrator indicated secondary discipline evaluations ordered were expected to be conducted within five days and confirmed the findings. On 11/27/2024 in the afternoon, the Clinical Manager and Administrator confirmed all the above findings. Patient #16 On 8/6/2024, the agency admitted Patient #16 with encounter for non-surgical wound dressing. On 8/6/2024, the clinical record lacked documented evidence a physician ordered home health aide visits. On 8/6/2024, a home health aide plan of care revealed twice weekly home health aide visits. The clinical record contained documented evidence of unordered home health aide visits conducted on 8/12/2024 and 8/23/2024, which constituted weekly visits. On 11/26/2024 in the afternoon, the Clinical Manager and Administrator confirmed the findings.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review, interview and agency practice guidelines, the agency failed to ensure it notified a physician or the discharging hospital regarding the need for orders to address the presence of an intravenous line for three days after the start of care for 1 of 18 patients (Patient #1). Findings include: Patient #1 On 3/19/2023, the agency admitted Patient #1 with hypertensive encephalopathy and pneumonia due to methicillin resistant Staphylococcus aureus. The start of care OASIS assessment revealed the Registered Nurse documented and was aware the physician ordered intravenous antibiotic management without any orders to maintain the intravenous line or any antibiotics. The intravenous line dressing was clean, dry and intact. On 3/19/2023, the plan of care revealed a physician ordered intravenous antibiotic management and was aware the patient had an intravenous line in the left arm. The intravenous line dressing was clean, dry and intact. On 3/19-21/2023, the clinical record lacked documented evidence anyone contacted a physician or the hospital to obtain orders to change the dressing, maintain the intravenous line or have it discontinued. The clinical record lacked documented evidence of orders for intravenous medication. On 3/21/2023, a physical therapist documented a communication note from an evaluation conducted, revealing the patient was wondering about the intravenous line and if it could be removed. On 3/22/2023, the Case Manager at the hospital was contacted regarding the intravenous line and what to do. On 3/24/2023, the Clinical Manager contacted the patient/spouse regarding awaiting an answer from the case manager at the hospital. On 3/24/2023, the agency finally received a faxed reply from the hospital case manager to remove the intravenous line at the next skilled nursing visit. On 3/26/2023, a skilled nursing visit documented removal of the intravenous line. On 11/27/2024 in the afternoon, the Clinical Manager indicated there was a wait to hear about what to do with the intravenous line. There was no documented evidence anyone contacted the case manager at the hospital for three days. The agency's Guide To Line Care provided revealed for the patient's intravenous line: transparent dressing change was required weekly and as needed. Flushing agents included Heparin 3 milliliters of 100 units/milliliter Heparin daily and 3 milliliters of Normal Saline daily when the intravenous line was not in use. The clinical record lacked documented evidence any of the Guide To Line Care items were ordered or administered between 3/19-26/2023. Complaint #96875

Revisions communicated to patient and MDs CFR(s): 484.60(c)(3)(i) (i) Any revision to the plan of care due to a change in patient health status must be communicated to the patient, representative (if any), caregiver, and all physicians or allowed practitioner's issuing orders for the HHA plan of care. This ELEMENT is not met as evidenced by: Based on record review, interview, policy review and contract review, the agency failed to ensure a missed visit was documented clearly as to why the visit was missed and notify the physician accordingly for 1 of 18 patients (Patient #2) and failed to document a missed visit and notification of a change to the plan of care for 1 of 18 patients (Patient #15). Findings include: Patient #2 On 10/31/2024, the agency admitted Patient #2 with right-sided hemiplegia. On 10/31/2024, the plan of care revealed a physician ordered a physical therapy evaluation. On 11/5/2024, a physical therapy evaluation revealed a physician ordered twice weekly physical therapy visits starting the following week. On 11/13/2024, a physical therapy assistant (PTA) documented a missed visit because of a scheduling conflict. The supervisor was notified by fax. The scheduling conflict failed to distinguish whether or not the patient had the conflict or the PTA. The visit was not made up, nor was the physician notified. The physical therapy assistant was contracted and followed the contracted language of notifying the agency. On 11/27/2024 in the afternoon, the Clinical Manager and Administrator confirmed the finding. The agency's Missed Visit policy provided revealed physician notification was required with a missed visit. The intake team would provide another visit if another visit was available. [The agency's policy was out of sync with what contracted personnel were required to do for missed visits]. Patient #15 On 8/20/2022, the agency admitted Patient #15 with diabetes mellitus II with foot ulcer and history of infectious diseases. The agency recertified the patient continuously with a focus episode of 2/16/2023 through 4/16/2023. On 2/16/2023, the plan of care revealed a physician ordered skilled nursing visits for wound care three times weekly (Tuesday, Thursday and Saturday) throughout the care episode for a chronic diabetic foot ulcer. On 3/7/2023, a skilled nursing visit revealed the patient complained about the third party wound care provider not calling or showing up to provide wound care on 3/6/2023. The clinical record revealed skilled nursing visits were conducted on March mornings before noon without fail the first half of March with the exception of 3/9/2023. The clinical record lacked documented evidence of a missed visit. On 3/9/2023 at 6:24 PM, a registered nurse obtained a physician order to reduce the skilled nursing visits to two times for that week with no reason specified, but the agency cannot reduce visit frequency as a means to cover a missed visit after an undocumented missed, scheduled skilled nursing visit. The clinical record lacked documented evidence the agency contacted the patient regarding 3/9/2023. The clinical record lacked documented evidence of an attempt to conduct a make-up visit on 3/10/2023. On 3/11/2023, a skilled nursing visit revealed the patient had respirations of 22 and temperature of 101.5 Fahrenheit. The patient stated being upset about no nursing visit on 3/9/2023. The licensed practical nurse documented the patient had a raised abscess in the diabetic ulcer. The patient also had a thick layer of purulent drainage on the left shin wound. The physician was contacted and immediately ordered Augmentin and Doxycycline twice daily for a week and for the patient to come for an office visit on 3/13/2023, as the patient refused the recommended emergency department visit. On 11/27/2024 in the afternoon, the Clinical Manager and Administrator confirmed the findings but thought they were covered with a physician order, but it was explained the agency changed the plan of care, failed to document a missed visit in real time and the reason for the missed visit and failed to document patient notification. Complaint #102707

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure it arranged for a mobile physician in a timely manner for 1 of 18 patients (Patient #18). Findings include: Patient #18 On 10/14/2024, the agency admitted Patient #18 with hypertension, anxiety disorder and long term opiate analgesic use. On 10/14/2024, the clinical record revealed a request for a mobile primary care physician. The clinical record lacked documented evidence the above request was ever addressed. On 11/20/2024, a skilled nursing home visit was conducted with a registered nurse. During the visit, it was identified the patient did not take the ordered blood pressure medication Lisinopril 20 milligrams daily. The patient was completely out of ordered Alprazolam 0.5 milligrams and Hydrocodone/Acetaminophen 5/325 milligrams as needed. The patient had a blood pressure of 164/94 with a radial pulse of 110 and demonstrated anxiety and depressed mood during the visit. Although the registered nurse was able to obtain a visit with a physician appointment for the following day for high blood pressure and medication refills, the patient did not have transportation and/or was unable to drive, as expressed during the visit, and was forced to contact someone immediately to secure transportation to the appointment the next day. The plan documented for the next skilled nursing visit was still (after five weeks) to arrange for a mobile physician for continuity of care. On 11/26/2024 in the afternoon, the Clinical Manager and Administrator indicated a mobile physician could usually be obtained within a few days, but there was no documented evidence in five weeks why a mobile physician could not be obtained for the patient prior to the home visit conducted on 11/20/2024.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation and interview, the agency failed to ensure it notified a patient of a missed visit in a timely manner for 1 of 18 patients (Patient #3). Findings include: On 10/13/2024, the agency admitted Patient #3 with open wound of the left wrist. On 10/13/2024, the plan of care revealed a physician ordered twice weekly skilled nursing visits. On 11/3/2024, the physician ordered a reduction in skilled nursing visits to one every other week. On 11/19/2024 in the afternoon, a skilled nursing home visit was conducted with a registered nurse. During the visit, the spouse and patient indicated they had been waiting most of the day for the visit. They were told 10:00 AM to Noon for the visit, but the home visit with the surveyor commenced at 3:00 PM. The agency did not inform them of the missed visit until setting up the surveyor's home visit after the 2-hour window of time lapsed. On 11/21/2024 in the afternoon, the Clinical Manager and Administrator indicated a licensed practical nurse called off for a family emergency after 11:00 AM on 11/19/2024. The process was someone from the agency was supposed to contact the patient to cancel.

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, interview and policy review, the agency failed to ensure it delivered services specified in the plan of care for 1 of 18 patients (patient #7). Findings include: Patient #7 On 8/5/2024, the agency admitted Patient #7 with stage 3 pressure ulcer of the sacral region, complicated urinary tract infection and fitting and adjustment of urinary device. The agency certified the patient from 8/5/2024 through 10/3/2024. On 8/5/2024, a physician wrote an order for monthly Foley catheter change as needed for leakage/dislodgement. On 9/30/2024, the agency recertified the patient from 10/4/2024 through 12/2/2024. On 8/5/2024 and 10/4/2024, the plans of care lacked documented evidence a physician ordered a monthly Foley catheter change or sized the Foley catheter in place. On 10/4/2024, the plan of care revealed a physician ordered twice weekly skilled nursing visits. On 10/11/2024, a skilled nursing visit revealed urinary tract infection symptoms were present, the provider called and waiting for a urinalysis order. On 10/14/2024, a skilled nursing visit revealed urinary tract infection symptoms were present, the provider called and waiting for a urinalysis order. On 10/16/2024, a skilled nursing visit revealed urinary tract infection symptoms were present, the provider called and waiting for a urinalysis order. On 10/20/2024, an "as needed" skilled nursing visit revealed a nurse changed the Foley catheter due to nonfunction. The Foley size was 24 french and 30 milliliter balloon. On 10/21/2024, a skilled nursing visit revealed urinary tract infection symptoms were present, the provider called and waiting for a urinalysis order. On 10/25/2024, a skilled nursing visit revealed urinary tract infection symptoms were present, the provider called and waiting for a urinalysis order. On 10/28/2024, a skilled nursing visit revealed urinary tract infection symptoms were present and a urine specimen was collected. The clinical record lacked documented evidence why it took 17 days to collect a urine specimen. The plan of care at recertification revealed a nurse could go ahead and collect a urine specimen if urinary tract infection symptoms were present. The clinical record lacked documented evidence why the nurse did not collect a urine specimen. On 10/29/2024, the lab result revealed the patient was positive for urinary tract infection. On 10/30/2024, a physician ordered 24 french and 30 milliliter balloon for the monthly changes. On 10/30/2024, an "as needed" skilled nursing note revealed a nurse documented the new Foley as 24 french and 15 milliliter balloon. On 11/1/2024, a skilled nursing visit revealed the visit nurse obtained the lab result confirming the infection and antibiotic ordered at pharmacy for pick-up. On 11/13/2024, a skilled nursing note revealed a nurse documented a new Foley catheter change as 22 french and 30 milliliter balloon. The monthly Foley catheter change order (8/5/2024) was not transferred to the plans of care. The size of the Foley catheter was not identified per order change until 10/30/2024. The Foley catheter changes performed and documented on 10/30/2024 and 11/13/2024 were the wrong size. On 11/27/2024 in the afternoon, the Clinical Manager and the Administrator confirmed the findings, indicating the agency was reliant upon using specific requisition forms for labs which had to be physician signed prior to establishing an order for the lab, despite appearing on the plan of care. The catheter size should be physician-ordered. Procedure #1 of the Foley Catheter Care and Management policy (4-007) provided revealed for nurses to verify the doctor's order.

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 a physician order was clear, complete and appropriately authenticated and dated for 1 of 18 patients (Patient #14) and failed to ensure a home health aide documented vital signs for 1 of 18 patients (Patient #15). Findings include: Patient #14 On 9/28/2024, the agency admitted Patient #14 with secondary malignant neoplasm of bone. The agency certified the patient from 9/28/2024 through 11/26/2024. On 9/30/2024 at 1:19 PM, a physician ordered skilled visit frequency weekly for four weeks every other week until discharge. The nurse signed the order 11/30/2024, which had not occurred yet in the timing of the survey 11/19/2024 through 11/27/2024. Aside from the above anachronism, the order was invalid due to failing to indicate a skilled discipline in the order. None of the disciplines with documented skilled visits even remotely resembled the ordered frequency. On 11/26/2024 in the afternoon, the Clinical Manager and Administrator confirmed the finding. Patient #15 On 8/20/2022, the agency admitted Patient #15 with diabetes mellitus II with foot ulcer and history of infectious diseases. The agency recertified the patient continuously with the current focus episode of 10/14/2023 through 12/12/2023. On 10/14/2023, the plan of care revealed a physician ordered home health aide visits twice weekly throughout the care episode. The latest home health aide plan of care revealed the home health aide was to take and document vital signs each visit. On 10/20/2023, a home health aide conducted and documented a home health aide visit, indicating a complete set of vital signs were taken, but the home health aide failed to document the vital signs. For every documented home health aide visit of the above care episode, the home health aide visits lacked documented evidence of temperatures taken for each visit, despite the home health aide noting a complete set of vital signs were taken on each visit. On 11/27/2024 in the afternoon, the Clinical Manager and Administrator confirmed the findings.

This Statement of Deficiencies was generated as a result of an Emergency Preparedness survey conducted at your agency from June 7, 2022 through June 16, 2022, in accordance with 42 Code of Federal Regulations (CFR) and the State Operations Manual (SOM), Appendix Z- Emergency Preparedness for All Provider and Certified Supplier Types. The findings and conclusions of any investigation by the Division of Public and Behavioral Health shall not be construed as prohibiting any criminal or civil investigations, actions or other claims for relief that may be available to any party under applicable federal, state, or local laws. No regulatory deficiencies were identified. No further action is necessary, Retain a copy of this report for your records.

This Statement of Deficiencies was generated as a result of the Medicare Recertification survey, Healthcare Worker (HCW) Vaccine Mandate, and Complaint Investigation conducted at your agency from June 07, 2022 through June 16, 2022 , in accordance with 42 CFR (Code of Federal Regulations) Part 484 - Home Health Services. The census on the first day of the survey was 416 patients. Eighteen clinical records were reviewed. Seven home visits were conducted. The investigation of regulatory compliance for COVID-19 Vaccination of Facility Staff included: - Review of Infection Control Surveillance plans. - Review of Vaccination policies including staff members vaccination status, exemptions, (medical and non-medical), temporary delays for vaccinations, additional precautions for unvaccinated staff, contingency plans for unvaccinated staff and additional precautions to prevent the spread of Covid -19. Review of the facility's Healthcare Worker Vaccination policies and facility documentation revealed the facility was at 100% compliance with Healthcare Worker vaccination requirements. One complaint was investigated. Complaint #61478 with the following allegations was unsubstantiated. Allegation 1) The allegation an RN left gauze in the patient’s wound causing an infection could not be substantiated because the patient was diagnosed with a wound infection prior to the agency admitting the patient, and the agency actively treated the patient for the infection during the stay with intravenous antibiotics. Allegation 2) The allegation an RN left the wound vac tube up too far in the wound, causing the resident to hemorrhage was unsubstantiated because there were many mitigating factors to identify the RN had caused this situation: The patient had a stage iv sacral pressure ulcer but was known to prefer positioning on the back. Both positioning on the back and moving the patient to and from the back and/or up or down in the bed could all contribute to the wound vac tubing becoming misplaced. Additionally, the patient was taking an anticoagulant medication daily and was being heparinized via a PICC line in between intravenous antibiotics, creating a high risk for any kind of hemorrhaging. The subsequent hospital record did not identify any insidious causes aside from the patient's own chronic conditions. The findings and conclusions of any investigation by the Division of Public and Behavioral Health shall not be construed as prohibiting any criminal or civil investigation, actions or other claims for relief that may be available to any party under applicable federal, state, or local laws. The following regulatory deficiencies were identified:

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 clinical record review, observation, interview and policy review, the agency failed to ensure as needed pain medication had specific time range limitations ordered for 1 of 18 patients (Patient #12). Findings include: Patient #12 On 6/4/2022, the agency admitted Patient #12 with right femur fracture aftercare. On 6/4/2022, the plan of care showed the following pain medications ordered without a time reference: Hydrocodone-Acetaminophen oral 5-325 milligrams 1 tablet as needed for pain. Advil oral 200 milligrams 1 tablet as needed for pain. The medication profile had the same listings. On 6/8/2022 at 10:00 AM, a home visit was conducted with a skilled nurse. A container of Hydrocodone was observed without a time range limitation on the label. On 6/15/2022 at 12:30 PM, a Clinical Manager confirmed the above findings. The Clinical Manager was unable to locate a policy regarding maintaining a medication profile.

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 clinical record review and interview, the agency failed to follow a skilled wound provider's wound care order for 2 of 18 patients (Patient #1 and #3), failed to follow skilled nurse frequency orders for 1 of 18 patients (Patient #11) and failed to ensure contact regarding or completion of initial evaluations within 5 days for 2 of 18 patients (Patient #2 and #17). Findings include: Patient #1 On 4/15/2022, the agency admitted Patient #1 with cellulitis of left lower limb and wound care for the left lower extremity. On 5/13/2022, a wound care Nurse Practitioner ordered Aquacel AG application for wound care. On 6/8/2022, the clinical record lacked documented evidence any skilled nurse applied Aquacel AG to the wound bed from 5/15/2022 through 6/6/2022. On 6/10/2022 in the afternoon, a Clinical Manager confirmed the finding. Patient #3 On 1/7/2022, the agency admitted Patient #3 with chronic peripheral venous insufficiency. The agency continuously recertified Patient #3 through the current care episode of 5/7/2022 to 7/5/2022. On 5/7/2022, the plan of care showed a physician ordered skilled nursing visits twice weekly for wound care. On 5/25/2022, a wound care clinic ordered hydrofera blue application to wound bed with twice weekly skilled nursing visits. The wound care clinic faxed the order to the agency at 1:37 PM on 5/26/2022. On 5/27/2022 at 12:30 PM, a skilled nursing visit documented the use of hydrogel to the wound bed. Patient #11 On 11/26/21, the agency admitted Patient #11 with change/removal of surgical dressing. The agency continued to recertify the patient to the last care episode of 3/26/2022 to 5/24/2022. On 3/26/2022, the plan of care showed a physician ordered skilled nursing visits six times for the week of 3/27/2022 to 4/2/2022 and daily each week thereafter. The clinical record lacked documented evidence of skilled nursing visits on 4/4/2022 and 4/5/2022. The clinical record lacked documented evidence of missed visits, order change, order discontinuation or patient refusal. On 6/15/2022 at 12:25 PM, a Clinical Manager confirmed the findings. Patient #2 On 3/23/2022, the agency admitted Patient #2 with change or removal of surgical dressing. On 3/23/2022, the plan of care documented a physician ordered a physical therapy evaluation. The clinical record showed a physical therapist conducted the evaluation on 3/29/2022. The clinical record lacked documented evidence there was an attempt to contact the patient within the first five days following the start of care date of 3/23/2022, a reason why the evaluation could not be completed within five days, or why the evaluation was delayed. On 6/15/2022 at 10:15 AM, a Clinical Manager verified the above findings. Patient #17 On 3/3/2022, the agency admitted Patient #17 with orthopedic aftercare. On 3/3/2022, the plan of care documented a physician ordered a physical therapy evaluation. On 3/9/2022, a physician ordered the physical therapy evaluation for the week of 3/13/2022. The clinical record showed a physical therapist conducted the evaluation on 3/14/2022. The clinical record lacked documented evidence there was any attempt to contact the patient within the first five days following the start of care date of 3/3/2022, a reason why the evaluation could not be completed within five days, or why the evaluation was delayed. On 6/15/2022 in the late afternoon, a Clinical Manager verified the above findings. Section 5 of the Coordination of Care policy, last reviewed 12/10/2021, revealed skilled evaluations would be completed within five days after the 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 clinical record review, interview and policy review, the agency failed to ensure it conducted skilled nursing visits only as ordered by a physician for 2 of 18 patients (Patient #3 and #4). Findings include: 1) Patient #3 was admitted to the agency on 1/7/2022, with chronic peripheral venous insufficiency. The agency continuously recertified Patient #3 through the current care episode of 5/7/2022 to 7/5/2022. On 5/7/2022, the plan of care showed a physician ordered skilled nursing visits twice weekly for wound care. The clinical record had documented evidence of three skilled nursing visits the week of 5/8/2022 to 5/14/2022: 5/9/2022, 5/11/2022 and 5/13/2022. The clinical record lacked documented evidence a physician ordered the additional visit. On 6/15/2022 at 10:15 AM, a Clinical Manager confirmed the finding. 2) Patient #4 was admitted to the agency on 5/20/2022, with cutaneous abscess of the foot. On 5/20/2022, the plan of care showed a physician ordered skilled nursing visits every 72 hours (3 days) and intravenous antibiotics via Peripherally inserted Central Catheter (PICC) line. The clinical record showed documented evidence of skilled nursing visits dated 5/20/2022, 5/21/2022, 5/22/2022, and 2 visits on 5/23/2022. The clinical record lacked documented evidence a physician ordered the additional skilled nursing visits. On 6/15/2022 at 11:30 AM, a Clinical Manager confirmed the finding and indicated the agency generally conducted daily visits for teaching the first three days when a patient received intravenous antibiotics. The Medical Management of Home Care Patients policy, last reviewed 12/20/2021, revealed physician orders were individualized, based on patients' needs, including treatments and/or procedures to be done, including type, frequency, and duration.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on clinical record review and interview, the agency failed to ensure a physician was notified regarding a diastolic blood pressure reading below the ordered parameter for 1 of 18 patients (Patient #5). Findings include: Patient #5 On 3/16/2022, the agency admitted Patient #5 with metabolic encephalopathy. On 3/16/2022, the plan of care showed a physician ordered skilled nursing visits twice weekly the first two weeks and then weekly thereafter, and nurses were to report diastolic blood pressure readings less than 60. On 4/6/2022, a skilled nurse documented a skilled nursing visit with a diastolic blood pressure reading of 56. The clinical record lacked documented evidence the nurse notified a physician as ordered. On 6/15/2022 at 11:40 AM, a Clinical Manager confirmed the finding.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on clinical record review and interview, the agency failed to identify pressure wounds and demonstrate that the agency had continued to assess and monitor the wounds on a regular basis for 1 of 18 patients (Patient #18). Findings include: Patient #18 On 7/29/2021, the agency admitted Patient #18 with stage iv sacral pressure ulcer (#1) and stage iii right buttock pressure ulcer (#2). On 8/9/2021, an acute care facility admitted Patient #18 for a worsening and bleeding sacral ulcer (#1). The admitting history and physical also noted bilateral ischial tuberosity ulcers at admission (right ischial tuberosity/buttock #2). There was also a stage ii right posterior thigh pressure sore below and lateral to the ischial tuberosity (#3) identified at admission. The patient received care and treatment in acute care for the left ischial tuberosity (#4). On 8/17/2021, the agency's resumption of care OASIS documented three pressure sore areas, not four. On 8/19/2021 and 8/22/2021, the agency's skilled nursing visits did not document an assessment or monitoring regarding either one of the two additional pressure sores identified at the acute care facility. On 8/22/2021, an acute care facility admitted Patient #18 for wheezing and shortness of breath. During the stay, the wound previously identified as wound #3 was assessed as a closed stage ii. The wound previously identified as wound #4 was assessed as a subacute stage ii pressure injury and received care and treatment. In addition, wound #5 was identified at the acute care facility as an anterior peri area wound present on admission. On 9/3/2021, the agency's resumption of care OASIS documented the same three pressure sore areas it documented on the resumption OASIS dated 8/17/2021. Wounds #4 and #5 were not identified. On 9/7/2021, the agency's skilled nursing visit did not document an assessment or monitoring regarding either one of the two additional pressure sores identified by the acute care facility. On 6/16/2022 in the late afternoon, the Clinical Manager indicated the agency's assessments were consistent with identifying and caring for wounds #1 and #2.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on clinical record review, interview and policy review, the agency failed to ensure the clinical record included a current/complete order for 2 of 18 patients (Patient #1 and #3) and provider clinical notes for 2 of 18 patients (Patient #1 and #16). Findings include: Patient #1 On 4/15/2022, the agency admitted Patient #1 with cellulitis of left lower limb and a left lower extremity wound for wound care. On 4/15/2022, the plan of care showed a physician failed to order a wound medication application for the patient's wound. The physician ordered skilled nursing visits twice weekly for the first two weeks and then weekly thereafter. On 6/8/2022 at 11:30 AM, a home visit was conducted with a registered nurse for continued wound care. The latest documented order was hydrogel. The registered nurse spoke with the patient who indicated some nurses used hydrogel and some used the other product present: Aquacel AG Extra. The registered nurse contacted the wound care provider, a Nurse Practitioner (NP), who responded by text that the Aquacel AG was the current order. The registered nurse performed the wound care. On 6/8/2022 in the afternoon, it was identified the NP did not provide notes or orders until contacted by a Clinical Manager to do so on 6/9/2022 and 6/10/2022. The notes and orders were dated 5/3/2022, 5/13/2022, 5/20/22, 5/27/2022 and 6/3/2022. On 6/10/2022 in the afternoon, a Clinical Manager indicated the orders/notes could not be opened when originally sent but were not followed up on until now. Patient #3 On 1/7/2022, the agency admitted Patient #3 with chronic peripheral venous insufficiency. The agency continuously recertified Patient #3 through the current care episode of 5/7/2022 to 7/5/2022. On 5/7/2022, the plan of care showed a physician ordered skilled nursing visits twice weekly for wound care. On 6/8/2022, a registered nurse initiated an order for an as needed (prn) skilled nursing visit which was conducted and documented. The order itself consisted of "PRN" which did not refer to nursing, wound care, or anything else. On 6/15/2022 at 10:30 AM, a Clinical Manager agreed "PRN" was not a complete order. Patient #16 On 7/4/2020, the agency admitted Patient #16 with stage iv right buttock pressure ulcer. The agency recertified Patient #16 to the current care episode of 4/25/2022 through 6/23/2022. During clinical record review, it was identified a wound care provider conducted home visits for Patient #16. On 6/15/2022 late in the afternoon, a Clinical Manager indicated the wound care provider saw the patient on Mondays but could not verify the frequency. The Clinical Manager provided two sets of provider notes dated 3/21/2022 and 5/30/2022. The Clinical Manager was unable to verify the frequency of provider visits and the wound care order changes. On 6/2/2022, a communication note documented the wound care provider conducted home visits every Monday. On 6/15/2022 in the late afternoon, the Clinical Managers were unable to provide any other clinical notes from the wound care provider and documented evidence of a clinical documentation policy.

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 clinical record review, interview and policy review, the agency failed to ensure a physician signed the plan of care in a timely manner for 1 of 18 patients (Patient #18). Findings include: Patient #18 On 7/29/2021, the agency admitted Patient #18 with stage iv sacral pressure ulcer. On 6/16/2021 in the afternoon, the plan of care showed a physician signed the plan of care dated 5/11/2022. On 6/16/2022 in the late afternoon, the Clinical Manager confirmed the above finding. The Medical Management of Home Care Patients policy, last reviewed 12/20/2021, revealed the physician signed the plan of care /treatment within 21 working days of the start of care.

A complaint survey and focus infection control survey was conducted by Healthcare Management Solutions, LLC on behalf of the Nevada Department of Health and Human Services. An unannounced on-site Complaint Survey (ASPEN #TOUD11) at the above-named Home Health Agency (HHA) from 02/16/21 to 02/18/21 resulted in a finding of no deficiency respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.22, related to E0024(b)(5).

This Statement of Deficiencies was generated as a result of a complaint investigation and a focus infection control survey conducted in your facility from 02/16/21 to 02/18/21 in accordance with 42 Code of Federal Regulations (CFR), 484, Subparts A through C - Requirements for Home Health Agencies. Citations G608 and G706 substantiates complaint NV00060571. The census at the time of the survey was 361. The sample size was 7.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review and staff interview, the home health agency failed to ensure the skilled nurse coordinated care delivery to meet patient's needs and involve the patient and caregiver in the coordination of care activities in order to minimize patient discomfort and maximize the effectiveness of the patient plan of care for 1 of 4 record (Patient (P) 6) reviews conducted where wound care and assessment was required. Failure to coordinate care could potentially negatively affect patient safety and treatment effectiveness provided by all disciplines. This had the potential to affect the 361 patients who were currently receiving home health services and all future home health patients. Findings include: Review of P6's "Plan of Care (POC)," located in the medical record, revealed an admission date of 02/18/20 and diagnoses of surgical wound infection after spinal fusion. The medical record also indicated that P6 lived in a private residence, was ambulatory, alert and oriented, and had skilled nursing services two times weekly to monitor patient safety, to provide medication teaching, and complete wound assessment, which included a wound vacuum (VAC) (device with canister which produces negative pressure over the wound surface to assist in healing). On the "Start of Care (SOC) for P6 the Comprehensive Assessment," dated 2/18/20, located in the medical record, the admitting Registered Nurse (RN) 3 documented "Pt (patient) has a wound VAC on her back, it was placed by Dr ... after patient underwent excision debridement lumbar skin, soft tissue and fascia. No wound care done this visit. Wound VAC is to be kept intact till 2/22/20 per MD's order." The RN 3 failed to include an assessment of the appearance of the dressing or assessment of wound VAC device functioning on the SOC comprehensive assessment for P6. In addition, there was no evidence on the SOC comprehensive assessment or the POC as to whether the RN or the surgeon was responsible for discontinuing the wound VAC on 02/22/20. There was no evidence RN 3 completing the SOC assessment contacted the admitting physician to determine who would be responsible for discontinuing the wound VAC. There was no evidence RN 3 completing the SOC assessment ascertained if the patient had a physician appointment on 02/22/20 for wound VAC removal or follow up. There was also no evidence that RN 3 completing the SOC assessment educated the patient about the physician's order prohibiting removal of the wound VAC dressing until 02/22/20, or provided education regarding the patient's role and responsibility in monitoring the wound VAC while at home. There was no evidence in the medical record that RN 3 coordinated care delivery with the admitting physician or with the patient and patient caregiver for P6 at the start of care to meet patient's needs regarding care of the wound VAC. During an interview on 02/18/21 at 3:00 PM, the above observations were discussed at length with Clinical Manager (CM) and the Regional Clinical Manger (RCM) at which time both the CM and RCM confirmed that the above observations did not reflect coordination of care by the RN responsible for this start of care comprehensive assessment for P6. This citation substantiates complaint NV00060571.

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 during home visit, review of agency policy, and staff interview, the home health agency failed to maintain an effective infection control program that protected patients, families, visitors, and home health personnel in 2 of 2 survey joint home visits conducted with a home health patient (Patient (P)1, P 2), where wound care was completed. Failure to maintain separation of clean and dirty during wound care increases the risk for cross contamination and has the potential of exposure to bloodborne pathogens. This had the potential to affect the 361 patients who were currently receiving home health services and all future home health patients. Findings include: 1. Review of P1's "Plan of Care (POC)," located in the medical record, revealed an admission date of 02/09/21 and diagnoses of multiple sclerosis and multiple pressure ulcers. The medical record also indicated that P1 resided at a group home setting, was bedbound, alert and oriented, and had skilled nursing services three times weekly for wound care, which included a wound vacuum (VAC) (device with canister which produces negative pressure over the wound surface to assist in healing). On 02/17/21 at 12:30 PM, a joint survey home visit was conducted with Licensed Practical Nurse (LPN) 1 and this surveyor. During this visit to the home, LPN 1 was observed completing wound care to eight different wounds covering P1's body, including changing the wound VAC dressing over a large lower back and sacral pressure ulcer. The following observations were made: a. After donning two pair of clean gloves, LPN 1 began by removing the soiled dressing over the large sacral pressure ulcer. When the dressing had been removed, LPN 1 took off the top layer of gloves and replaced with another pair of gloves. LPN 1 failed to remove both pair of gloves and complete hand hygiene before proceeding to apply the clean dressing. b. After completing the wound VAC dressing change, LPN 1 hand swept the floor with the gloves used for the dressing change in order to pick up soiled dressings that had been dropped on the floor. After cleaning the floor, LPN 1 took off the top layer of gloves and replaced with another pair of gloves. LPN 1 failed to remove both pair of gloves and complete hand hygiene before proceeding to the next dressing change. c. As LPN 1 moved from one wound to another, for a total of ten separate wounds and a period of two hours, the outer most pair of gloves were removed, always leaving the initial gloves that were donned in place. LPN 1 never removed the initial pair of gloves that were donned at the beginning of the visit to complete hand hygiene at any time during the visit until leaving the home. At the conclusion of this home visit, LPN 1 was interviewed about hand hygiene practices. LPN 1 stated "we were told that we must keep a pair of unsterile gloves on whenever we are in the home due to new infection control policies." When asked if the non-sterile gloves were meant to replace hand hygiene, LPN 1 stated "no, they are not." 2. Review of P2's "POC," located in the medical record, revealed an admission date of 11/11/20 and diagnoses of cellulitis with open wound. The medical record also indicated that P2 resided at a private residence, was wheelchair bound, alert and oriented, and had skilled nursing services three times weekly for wound care, which included a wound vacuum (VAC). On 02/18/21 at 10:30 AM, a joint survey home visit was conducted with Registered Nurse (RN) 1 and this surveyor. During this visit to the home, RN 1 was observed completing a physical assessment and wound care to a large open, draining lower left leg traumatic wound which was covered with a wound VAC. The following observations were made: a. After donning two pair of clean gloves, RN 1 began by removing the soiled dressing over the large leg wound. When the dressing had been removed, RN 1 took off the top layer of gloves and replaced with another pair of gloves. RN 1 failed to remove both pair of gloves and complete hand hygiene before proceeding to apply the clean dressing. b. When RN 1 completed the wound VAC change, which was oozing drainage, RN 1 removed the outer most pair of gloves, leaving the initial gloves that were donned at the beginning of the wound care, replaced them with another pair of clean gloves and began other tasks such as checking lung sounds and bowel sounds. RN 1 failed to remove both pair of gloves and complete hand hygiene after completing wound care. The agency policy titled "Handwashing," dated 10/24/18, stated "Personnel providing care/service in the home setting will wash their hands: before and after EACH contact with a patient ... before and after gloves are used." The agency policy titled "Wound Care/Dressing Change," dated 10/25/18, stated "Always wash hands before and after changing the dressing because good hand washing will help keep the wound clean and prevent the spread of germs." During an interview on 02/18/21 at 4:00 PM, the above observations were discussed at length with Clinical Manager (CM) and the Regional Clinical Manger (RCM) at which time both the CM and RCM confirmed that the above observations were in violation of the agency's infection control policy.

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on personnel file review, staff interview, and review of agency policy, it was determined the home health agency failed to ensure that annual infection control education had been documented for each staff member providing patient care services in four of 6 personnel files (Clinical Coordinator (CC) 1, CC2, Registered Nurse (RN) 2, and Physical Therapist (PT)1) reviewed. This could potentially allow employees who had not been educated to fail in implementing current infection prevention and treatment practices and in providing adequate, safe care in the home setting. This had the potential to affect the 361 patients who were currently receiving services and all future home health patients. Findings include: 1. CC1: The employee's date of hire was 01/07/20. At the time of the personnel file review conducted on 02/18/21, there was no evidence of a completed annual infection control education in the personnel file provided. 2. CC2: The employee's date of hire was 02/15/15. At the time of the personnel file review conducted on 02/18/21, there was no evidence of a completed annual infection control education in the personnel file provided. 3. RN2: The employee's date of hire was 10/21/19. At the time of the personnel file review conducted on 02/18/21, there was no evidence of a completed annual infection control education in the personnel file provided. 4. PT1: The employee's date of hire was 09/11/17. At the time of the personnel file review conducted on 02/18/21, there was no evidence of a completed annual infection control education in the personnel file provided. The agency policy titled "Infection/Exposure Control Plan," dated 10/17/18, stated "The Home Health Care, LLC. educates all personnel on infection control policies and procedures and their responsibilities for implementation ...Infection control in-services will be scheduled no less than annually .... Attendance will be mandatory and will be documented .... Records of in-service attendance will be maintained." During an interview after the personnel file review was completed on 02/18/21 at 3:30 PM, the Clinical Manager (CM) verified these findings and stated, "I think we are educating, but not documenting. Human Resource documentation is an area in which we need improvement." The CM acknowledged that per agency policy, each employee was required to complete annual infection control education ... and that documentation of successful completion of the education program should be retained in the employee's personnel file.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on record review and staff interview, the home health agency failed to ensure the skilled nurse provided ongoing interdisciplinary assessment of the patient in 1 of 4 record (Patient (P) 6) reviews conducted where wound care and assessment was required. Failure to communicate with other members of the interdisciplinary team could potentially negatively affect patient safety and treatment effectiveness provided by all disciplines. This had the potential to affect the 361 patients who were currently receiving home health services and all future home health patients. Findings include: Review of P6's "Plan of Care (POC)," located in the medical record, revealed an admission date of 02/18/20 and diagnoses of surgical wound infection after spinal fusion. The medical record also indicated that P6 lived in a private residence, was ambulatory, alert and oriented, and had skilled nursing services two times weekly to monitor patient safety, to provide medication teaching, and complete wound assessment, which included a wound vacuum (VAC) (device with canister which produces negative pressure over the wound surface to assist in healing). On the "Start of Care (SOC) Comprehensive Assessment," dated 2/18/20, located in the medical record of P6, the admitting Registered Nurse (RN) 3 documented "Pt (patient) has a wound VAC on her back, it was placed by Dr ... after patient underwent excision debridement lumbar skin, soft tissue and fascia. No wound care done this visit. Wound VAC is to be kept intact till 2/22/20 per MD's order." There was no evidence on the "SOC Comprehensive Assessment" or the "POC" as to whether the RN or the surgeon was responsible for discontinuing the wound VAC on 02/22/20 for P6. There was no evidence RN 3 completing the SOC assessment contacted the admitting physician to determine who would be responsible for discontinuing the wound VAC. There was no evidence RN 3 completing the SOC assessment ascertained if the patient had a physician appointment on 02/22/20 for wound VAC removal or follow up. There was also no evidence that RN 3 completing the SOC assessment educated the patient about the physician's order prohibiting removal of the wound VAC dressing until 02/22/20 or provided education regarding the patient's role and responsibility in monitoring the wound VAC while at home. There was no evidence in the medical record that the RN coordinated care delivery for P6 with the admitting physician or with the patient and patient caregiver at the start of care to meet patient's needs regarding care of the wound VAC. On the following home visit note for P6 dated 02/21/20 and located in the medical record, the licensed practical nurse (LPN) 2 documented "Wound VAC intact. Pt (patient) states that wound VAC is full and constantly beeping. No beeping noted during visit. Attempted to call Dr ... re: wound VAC and all went to voice mail. Pt stable on departure." There was no evidence that LPN 2 contacted the RN Case Manager, or supervising RN, from the home to seek advice on wound VAC troubleshooting or cause of wound VAC frequent alarming. There was no evidence that LPN 2 researched, or requested assistance to research, the wound VAC directions for use to determine the cause of frequent alarming, such as low battery alert. No further attempts, later that day, to contact the admitting physician were documented in the medical record. A "Patient Communication" dated 02/22/20 and located in the medical record of P6, documented "Patient called extremely upset with our company, ... had a wound vac and both nurses that came out didn't touch it or help with concerns, they both seemed not to know what they were doing ... went to hospital and does not want anyone else coming out from our office. I apologized and said I would have a manager reach out to discuss what went wrong." There was no evidence in the medical record that a return call or contact was made with P6 by a manager to "discuss what went wrong." There was no evidence that a supervisor was aware of P6's request to discontinue home health services. The next notation in this medical record of P6 was a missed visit note, dated 02/26/20, which documented "no answer to phone call." The next notation in this medical record was a second missed visit note, dated 02/29/20, which documented "no answer to locked door." There was no evidence in the medical record that the home health agency provided ongoing communication with all members of the interdisciplinary team to coordinate care delivery and meet this patient's needs regarding wound care and assessment. During an interview on 02/18/21 at 3:00 PM, the above observations were discussed at length with Clinical Manager (CM) and the Regional Clinical Manger (RCM) at which time both the CM and RCM confirmed that the above observations did not reflect coordination of care for P6 by the home health care team. This citation substantiates complaint NV00060571.