Every finding on record at Peacehealth Dba Sacred Heart - Univ. Distric

An unannounced Federal recertification survey was completed at this agency on 7/24/2024. The agency was surveyed for compliance with 42 CFR Conditions of Participation for Home Health Agencies, Part 484.102 Emergency Preparedness. An entrance conference was held on 7/8/2024 at 12:09 PM with the Home Health Director and Program Manager. The purpose of the survey and the survey needs were explained. An opportunity was provided for questions, answers, and comments. Definitions and abbreviations: CFR - Code of Federal Regulations

An unannounced Federal recertification survey was completed at this agency on 7/24/2024. The agency was surveyed for compliance with 42 CFR Conditions of Participation for Home Health Agencies, Part 484. An entrance conference was held with the Director of Home Health and Program Manager on 7/8/2024 at 12:09 PM. The purpose of the survey and the survey needs were explained. An opportunity was provided for questions, answers, and comments. Definitions and abbreviations: CFR - Code of Federal Regulations CHF - Congestive Heart Failure COPD - Chronic Obstructive Pulmonary Disease HHA - Home Health Aide OASIS - Outcome and Assessment Information Set MD - Medical Doctor MSW - Medical Social Worker OT - Occupational Therapist pt - Patient PT - Physical Therapist RN - Registered Nurse SLP - Speech Language Pathologist SN - Skilled Nurse SOC - Start of Care s/p - Status post

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on observation, interview, and review of documentation in 2 of 17 patient records (Patients #1 and #3), it was determined the agency failed to provide home health aide services outlined in the plan of care and physician order. Findings: Patient #1: Review of Patient #1's medical record, "3/29/2024 SN OASIS Start of Care" revealed "Patient will be seen by SN, PT, OT, MSW and home health aide. Proposed plan of care reviewed with patient and spouse and patient admission handbook provided and reviewed." Review of Patient #1's medical record, "All Conversations" written on 3/30/2024 at 3:58 PM by the admitting registered nurse revealed "Disciplines needed: PT, OT, SLP, HHA, MSW. Disciplines ordered but not needed: n/a. Next visit needed: Monday or Tuesday 4/1 or 4/2." On 7/24/2024 at 10:16 AM this Surveyor requested to see a document that proved Patient #1 received home health aide services as indicated in the care plan. Review of Patient #1's medical record titled "Skilled Nursing Visit Summary" on 4/3/2024 at 1109 and filed on 4/3/2024 at 1629 did not reveal anything about Patient #1 declining home health aide services. The addendum to the above nursing visit from 4/3/2024 and filed on 7/23/2024 at 1609 by RN Care Manager revealed "Pt and spouse declined HHA. Agreeable to PT, SN, OT visits. Updated care plan." During an interview and record review with Employee #1 and Employee #2 on 7/23/2024 beginning at 10:30 AM, Employee #1 and Employee #2 were made aware of the findings. On 7/24/2024 at 12:47 PM Employee #2 in an email message stated "The addendum was completed on 7/23/2024 at 1609 as indicated in the first screenshot. The nurse had stated [the nurse] had thought [the nurse] had included that the patient/spouse declined HHA in [the nurse's] note originally but [the nurse] had not, so [the nurse] addended the note to add that information after [Employee #1 and Employee #2] made [the nurse] aware of [the findings] yesterday." In the same email, Employee #2 stated "I do not have an updated care plan to share." Patient #3: Review of Patient #3's medical record revealed Start of Care of 7/2/2024. Patient #3's medical record titled "New Visit Order For Aide" revealed "1 visit every week for 2 weeks from 7/7/20024 to 7/20/2024." Review of Patient #3's medical record "Home Health Plan of Care 7/2/24" revealed, "Aide visits ... For bathing assistance." However, the agency failed to provide home health aide services for Patient #3. During an interview and record review with Employee #1 and Employee #2 on 7/23/2024 beginning at 10:30 AM, Employee #1 and Employee #2 were made aware of the findings. In the follow-up email, Employee #2 wrote "No aide visits have occurred for this patient. I do see an order and care plan in place."

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on observation, interview, and review of documentation in 1 of 17 patient records (Patient #1), it was determined the agency failed to implement physician orders that wound measurement be taken every week and documented. Findings: Review of Patient #1's medical record, "5/23/2024 SN OASIS Recertification" reflected a "Measure and photo wound every week. Signed by [physician's name] MD on 5/6/2024." Review of Patient #1's medical record, "Homecare Wound Left Posterior" flowsheet with "SOC date of 3/29/2024" and "Current Cert Period 5/28/24 - 7/26/2024" revealed missing wound care measurements for weeks of 4/22/2024, 6/10/2024, 6/17/2024 (measured only wound depth), and 7/1/2024. During an interview and record review with Employee #1 and Employee #2 on 7/23/2024 beginning at 10:30 AM, Employee #1 and Employee #2 confirmed the findings. There was no additional documentation provided.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on interview and medical record review, it was determined the agency failed to ensure an onsite supervisory visit of home health aide services was conducted at least every 14 days for 1 of 17 patient records reviewed (Patient #5). Findings: Patient #5: The review of document titled "Home Health Plan of Care 6/19/24" revealed under "Visit Sets," "Aide visits: 1 visit every week for 3 weeks. Dates: 6/19/2024 to 7/6/2024." The supervisory visit was completed on 7/16/24 by a registered nurse, 27 days after the first home health aide visit on 6/19/24. During interview and record review with Employee #1 and Employee #2 on 7/23/2024 beginning at 10:30 AM, the findings were discussed. In a follow-up email by Employee #2 on 7/24/2024 at 10:16 AM, Employee #2 verified "This [completed on 7/26/24] is the only supervisory visit."