Every finding on record at Pasco/SW Home Health - Grand Junction

A complaint survey, prompted #CO2966788 was completed on 4/2/26. One deficiency was cited.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure skilled nursing (SN) services were provided in accordance with the plan of care for 1 of 3 patients reviewed (Patient #3). Findings include: AGENCY POLICY According to the agency policy titled, “Provision of Care and Record Management”, dated 4/21 (in pertinent parts), “The plan of care will be based upon the physician’s (or other authorized licensed independent practitioner’s) orders and will encompass the equipment, supplies, and services required to meet the patient’s needs.” 1. The clinical record for Patient #3 was reviewed on 3/31/26. Plan of care orders for the certification period dated 2/4/26 to 4/8/26 revealed a start of care date of 12/5/25; diagnoses included type 2 diabetes mellitus, morbid (severe) obesity, and bariatric surgery. Plan of care orders included skilled nursing (SN) visits twice a week for wound care, Peripheral Intravenous Central Catheter (PICC) line management, and instruction in diabetic care including diet, diabetic foot care, and blood glucose testing. a) The agency failed to ensure Patient #3 was receiving blood glucose testing or education on testing according to the plan of care. Review of the clinical record for Patient #3 revealed a SN visit note dated 2/9/26 by RN #1 failed to include blood glucose testing results or documentation of education provided on blood glucose testing. Review revealed a SN visit note dated 2/11/26 entered by RN #1 failed to reveal blood glucose testing or documentation showing education was provided to Patient #3 on blood glucose testing. Review of SN visit notes completed by RN #1 dated on 2/16/26, 2/18/26, 3/4/26, 3/16/26, 3/25/26, and 3/27/26 failed to reveal blood glucose testing or education on blood glucose testing was completed during these visits. Review of coordination notes entered by RN #1 on 2/16/26, 2/18/26, 2/28/26, 3/4/26, 3/26/26, and 3/27/26 failed to include a reason blood glucose testing or education for blood glucose testing was not completed during the visits completed by RN #1 for Patient #3. Review of SN visit notes completed by LPN #1 on 3/6/26 and 3/13/26 failed to include blood glucose testing results or documented education on blood glucose testing provided to Patient #3. Review of coordination notes dated 3/6/26 and 3/13/36 entered by LPN #1 gave the reason for not including blood glucose testing as does not check. During an interview conducted on 4/1/26 at 12:41 p.m., LPN #1 confirmed Patient #3’s blood glucose testing was not completed during the visits on 3/6/26 and 3/13/26. LPN #1 stated Patient #1 did not have a glucose monitor in the home that she was aware of. LPN #1 verbalized failure to notify the RN case manager or office of the missing glucose monitor. Further, LPN #1 revealed the missing glucose monitor was not documented in Patient #3’s record. An interview was completed on 4/1/26 at 12:00 p.m. with RN #1. RN #1 confirmed blood glucose testing was not concluded for Patient #3 during the visits indicated. RN #1 stated Patient #3 did not consider herself a diabetic. Interview revealed the plan of care was confirmed by the physician of record for Patient #3. Further, RN #3 acknowledged failure of not following the plan of care and poor documentation as to why the blood glucose testing was not completed. During an interview on 4/2/26 at 9:30 a.m., the agency admitted blood glucose testing was not completed per the plan of care for Patient #3. The agency confirmed the plan of care was signed by the physician and counted as physician orders.

A recertification in conjunction with a COVID-19 infection control survey was completed on 8/4/21. Three deficiencies were cited.

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 interview and record review, the agency failed to ensure the registered nurse (RN) conducted an initial assessment visit to determine the immediate care and support needs of the patient within 48 hours of referral, or on the physician ordered start of care date, for 1 of 2 clinical records reviewed receiving wound care (Patient #1). Findings include: 1. The clinical record for Patient #1 was reviewed on 8/4/21. The Plan of Care for the certification period dated 7/14/21 to 9/11/21 revealed a start of care date of 7/14/21; diagnoses included chronic ulcer of the lower leg, diabetes mellitus (DM), obesity, major depressive disorder, and long term current use of insulin. Plan of Care orders included skilled nurse (SN) visits three times weekly and as needed (PRN) for assessment, education, and management of wound care and DM. Wound care orders on the Plan of Care, dated 7/14/21, were to measure the wound weekly on Monday, cleanse with saline bullet, apply clobetasol to the outside of the wound edges, instill five to six drops of Timolol solution into the wound bed, apply vaseline to wound bed, cover wound bed with adaptic and ABD (Army Battle Dressing) pad, wrap with kerlix, and secure dressing with tubigrip using clean technique. a) The agency failed to start services for Patient #1 within 48 hours of the referral. Review of the referral received on 7/9/21, revealed Patient #1 was ordered to have a SN evaluation for wound care. The referral failed to reveal a frequency or specific wound care orders. Review of the Start of Care (SOC) Assessment, dated 7/14/21, completed by the assistant director of clinical services (ADCS) revealed Patient #1 started services on 7/14/21, five days after receipt of the referral. During an interview on 8/4/21 at 1:56 p.m., the ADCS stated the agency received the referral on 7/9/21, which was a Friday. She stated Patient #1 had a wound clinic appointment on Monday 7/12/21, and since her orders were for three times a week, the agency did not initiate services until Wednesday 7/14/21. During an interview on 8/4/21 at 2:47 p.m., the director of clinical services (DCS) confirmed there was no documented communication in Patient #1's chart regarding the wound clinic appointment or the reason for the delay of initiation of services. She stated an order to delay the SOC was supposed to have been received by the agency, but confirmed there was no order from the physician authorizing a delayed SOC.

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 interview and record review, the agency failed to ensure care was provided according to each patient's individualized written plan of care, in conformance with physician orders, for 1 of 3 patients receiving CNA services (Patient #6). Findings include: 1. The clinical record for Patient #6 was reviewed on 8/4/21. The Plan of Care for the certification period dated 4/3/21 to 6/1/21 revealed a start of care date of 12/4/20; diagnoses included heart disease, hypertension, and pulmonary embolism. Plan of care orders included certified nurse assistant (CNA) services twice a day Monday through Friday for bathing and grooming assistance, home exercise program, skin care, transfer and ambulation assistance, aspiration precautions, and meal assistance. a) The agency failed to ensure the CNA provided care and services as ordered by the physician. Review of the Visit Notes dated 5/3/21 to 7/15/21 revealed Patient #6 had physician orders for CNA services twice a day Monday through Friday. Review of Patient #6's calendar dated 6/1/21 to 7/15/21 revealed on 6/8/21 the afternoon visit was missed with no documentation for the reason for the missed visit, and no communication with the physician regarding the missed visit. Further review of the calendar revealed on 7/14/21 both visits were missed with no reason documented and no communication with the physician regarding the missed visits. During an interview on 8/4/21 at 1:35 p.m., Employee #2 stated she had looked in Patient #6's record and had not found documentation of the missed visits for the patient. She further stated she knew the family had cancelled the afternoon visit on 7/14/21, but could not find the documentation for the missed visit.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation and interview, the agency failed to ensure staff followed accepted standard infection control practices to prevent the transmission of infections and communicable diseases for 1 of 1 patient observed receiving wound care during a home visit (Patient #1). Findings include: 1. The clinical record for Patient #1 was reviewed on 8/4/21. The Plan of Care for the certification period dated 7/14/21 to 9/11/21 revealed a start of care date of 7/14/21; diagnoses included chronic ulcer of the lower leg, diabetes mellitus (DM), obesity, major depressive disorder, and long term current use of insulin. Plan of Care orders included skilled nurse (SN) visits three times weekly and as needed (PRN) for assessment, education, and management of wound care and DM. Wound care orders on the Plan of Care, dated 7/14/21, were to measure the wound weekly on Monday, cleanse with saline bullet, apply clobetasol to the outside of the wound edges, instill five to six drops of Timolol solution into the wound bed, apply vaseline to wound bed, cover wound bed with adaptic and ABD (Army Battle Dressing) pad, wrap with kerlix, and secure dressing with tubigrip using clean technique. a) Observations showed Registered Nurse (RN) #4 failed to utilize appropriate infection control procedures during the provision of wound care for Patient #1. A home visit was conducted on 8/4/21 at 8:29 a.m. for Patient #1. The surveyor observed RN #4 providing wound care to Patient #1's left lower extremity wound. A barrier with a saline bullet, two clear plastic bags containing pill bottles, gauze pads, gloves, scissors, tape, a tubigrip sock, and adaptic and ABD dressings was on the kitchen table. RN #4 was observed to be wearing gloves and was removing the kerlix wrap. She removed the old ABD and adaptic dressing and placed it on the corner of the barrier away from the wound care supplies. She opened the adaptic dressing, the ABD pad and the saline bullet, removed her gloves, placed them with the soiled dressing and donned new gloves from one of the clear bags on the barrier. RN #4 did not wash her hand or use an alcohol based sanitizer prior to donning new gloves. RN #4 squeezed saline onto a gauze pad that she used to clean the wound three times and placed the used gauze and saline bullet with the soiled dressing on the barrier. She did not change her gloves. She reached into one of the clear bags and retrieved a tube and two pill bottles. She opened the adaptic packaging and cut a small piece off and placed it within the adaptic packaging. RN #4 opened the tube of clobetasol propionate ointment and squeezed directly from the tube onto the outer raised edge of the wound, briefly touching the tube end to the wound edge in several places. She placed the tube on the barrier and opened a pill bottle, retrieved the bottle of Timolol that was inside the pill bottle, opened the Timolol and placed multiple drops around the inside of the raised wound edge. RN #4 then opened another pill bottle and scooped out vaseline ointment onto the index finger of her right gloved hand and spread the vaseline on the wound bed. Without changing her soiled gloves, RN #4 then placed the previously cut piece of adaptic onto the wound and covered the wound with the ABD pad, requesting the patient hold it in place. RN #4 removed her right glove and placed it on the barrier. She retrieved a package of kerlix wrap from a box and donned a new glove on her right hand. She opened the kerlix, removed it from the packaging and wrapped the kerlix from the patient's ankle to her knee, covering the ABD pad. She requested the patient hold the kerlix wrap in place while she cut a small piece of tape from the roll. She cut the kerlix and secured the end with the cut piece of tape and donned the tubigrip sock. She then took the trash previously placed on the barrier and placed it into her left gloved hand, doffed her left glove and placed the glove on the barrier. Using her right gloved hand, RN #4 capped the clobetasol ointment tube and Timolol bottle, placed the Timolol bottle back in the pill bottle, secured the caps on the two pill bottles containing the Timolol bottle and vaseline and placed the bottles and tubes in one of the clear plastic bags. Still using her right gloved hand, RN #4 placed both clear plastic bags into a cloth drawstring bag, pulled the drawstrings closed with both hands, placed it on the kitchen table, removed the barrier and its contents from the table, walked to the trash can, doffed her right glove and disposed of the soiled barrier and contents and her right glove in the trash. RN #4 was then observed washing her hands at the kitchen sink. During an interview on 8/4/21 at 10:20 a.m., RN #4 stated she had been with the agency since May 2021. She stated when she started, she trained with the assistance director of clinical services (ADCS) including observing the ADCS and the ADCS then observing RN #4 providing care to patients. RN #4 stated she had been providing wound care to Patient #1 since she started working for the agency. RN #4 stated her wound care process including washing her hands, getting all supplies ready, and going through the wound care orders step by step. She stated she always changed her gloves following removal of the old dressing and when putting on a new dressing. She stated she usually sanitized her hands between glove changes, but stated she had a new home health bag and did not have any sanitizer with her. She stated she could have washed her hands at the kitchen sink but did not. RN #4 further stated it would "make sense" to change gloves after cleaning the wound and before putting on the new wound dressing, but she had been taught previously by a different employer there were "always two glove changes" during the completion of wound care. During an interview on 8/4/21 at 1:28 p.m., the ADCS stated she believed RN #4 was nervous during the home visit but needed to improve her glove technique and overall infection control during the provision of wound care services. She stated RN #4 washed her hands at the end of the visit, but confirmed there was no handwashing between glove changes. The ADCS further stated she had been in contact with the agency's wound care specialist who acknowledged RN #4's breach of infection control and the agency would be creating a performance improvement project (PIP) for the Quality Assurance Performance Improvement (QAPI) program and providing additional training to clinical staff regarding infection control processes. During an interview on 8/4/21 at 1:38 p.m., the director of clinical Services (DCS) stated clinical staff should be washing their hands when entering and exiting the home and between tasks. She stated staff could also use hand sanitizer in place of soap and water. Specifically, the DCS stated when performing wound care, the RN should always move from "clean to dirty" and anytime contact was made with anything "dirty" or soiled, the clinician should de-glove, wash or sanitize their hands, and re-glove.