Every finding on record at Piggott Community Hospital

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 06/11/2025. During the survey it was determined the home health provider is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Providers.

An extended survey for Medicare recertification for the home health was completed on 06/11/2025. The provider had 59 current patients. One condition-level deficiency was identified during this survey. A condition-level deficiency is identified at §484.60 Condition of Participation: Care Planning, Coordination of Services, and Quality of Care. A home health provider that is found out of compliance with any Condition of Participation evaluated as part of a standard survey may not train or competency evaluate their home health aides for a period of two (2) years following the date of this survey. A deficiency has been cited at §484.80(f)(3) – see Tag G0782.

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 policy review, record review, home visit observation, and interview, the home health provider failed to ensure staff performed a complete medication review in three of five full records reviewed (Records/Patients #1, #2, and #3). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Medication Reconciliation,” dated February 2024, showed in part: - At the time of admission, the admitting registered nurse, physical therapist, or speech-language pathologist will create and document a complete list of medications that the patient is taking at home, including dose, strength, route, and frequency: * Any concerns or discrepancies will be reconciled by a registered nurse with the patient’s physician/practitioner; * Discrepancies include duplications, omissions, changes, contraindications and/or unclear information; * The provider provides the patient and/or caregiver with written patient medication schedule/instructions, including medication name, dose, strength, route, and frequency as well as which medications will be administered by the provider’s staff and staff acting on behalf of the provider; * In therapy only cases, the therapist submits a list of medications collected during the comprehensive assessment to the registered nurse for review, who contacts the physician/practitioner if indicated; and - Medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medications. The patient’s medication list in the home will also be updated. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 02/16/2024 with a primary diagnosis of a urinary tract infection (an infection that affects any part of the urinary system, including the kidneys, bladder, ureters, and urethra (UTI)). Observation and interview on 06/09/2025 at 12:30 PM, showed the following discrepancies between the patient’s home medications and the provider’s medication profile: -The provider’s profile showed the patient took duloxetine hydrochloride (HCl) (used to treat depression and anxiety) 60 milligrams (mg) by mouth daily. The patient stated he/she no longer took this medication; -The provider’s profile showed the patient took lyrica (used to treat nerve pain) 50 mg by mouth once daily. The patient stated he/she no longer took this medication; and -The patient took acetaminophen 1000 mg by mouth as needed for pain. The provider’s profile failed to include this medication. During an interview on 06/10/2025 at 2:00 PM, the home health administrator stated that he/she would expect the medications that the patient was taking to match the provider’s medication list. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health service on 06/04/2025 with a primary diagnosis of acute cystitis (a type of urinary bladder infection) and had additional diagnoses including pneumonia (lung infection), low back pain, and hypertensive heart disease (a condition where heart problems develop due to prolonged high blood pressure). He/she lived at home alone. Review of the patient's hospital discharge medication list, dated 06/02/2025, compared to the provider's admission medication list showed two additional medications listed on the provider's medication list; cetirizine hydrochloride (used to treat allergies) 10 milligram (mg) one tablet daily as needed for allergies, and Tylenol Extra Strength (used to treat mild to moderate pain or fever) 500 mg one or two tablets every six hours as needed for pain. Review of the document titled, "OASIS-E1 (Outcome and Assessment Information Set) Start of Care", dated 06/04/2025, showed the document failed to include communication with the patient's attending provider to clarify if the patient should use these additional medications. Observation and interview on 06/10/2025 at 11:45 AM, showed the following discrepancies between the patient’s home medications and the provider’s medication profile. The provider’s profile showed the patient took Tylenol (acetaminophen) Extra Strength 500 mg one or two tablets every six hours as needed for pain. The patient had a bottle of acetaminophen 650 mg in the home and stated that he/she was using this medication. During an interview on 06/10/2025 at 1:40 PM, the home health administrator stated he/she expected communication about the meds (medications) found in the home if different than the hospital discharge list, and a request for orders from the physician (attending provider). The administrator was unable to find additional information in the clinical record to clarify the discrepancies. ECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 05/29/2025 with a primary diagnosis of heart failure (a decrease in the ability of the heart to pump blood). The patient had secondary diagnoses of diabetes (a group of diseases that results in too much sugar in the blood), chronic kidney disease (a condition where the kidneys are damaged and can't filter blood effectively, leading to a buildup of waste and fluid in the body), traumatic subarachnoid hematoma (a condition where bleeding occurs in the space between the brain and the tissue covering it), fractures of the second cervical (neck), first lumbar (lower back), and fourth thoracic (chest) vertebrae, atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular heartbeat), atherosclerotic heart disease (ASHD; thickening of the arterial wall that results in decreased supply of blood flow), and convulsions. The patient resided in his/her own home with the assistance of his/her spouse. Observation and interview on 06/10/2025 at 9:30 AM, showed the following discrepancies between the patient's home medications and the provider's medication profile: - Ferrous sulfate (an iron supplement) one tablet daily. The patient stated he/she had been taking for several years; and - Folic acid (a vitamin supplement) one tablet daily. The patient stated he/she had been taking since his/her return from the hospital. During an interview on 06/11/2025 at 10:00 AM, the administrator and clinical manager stated that they would expect the clinicians to reconcile the medications at each visit.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on policy review, record review, home visit observation, and interview, the home health provider failed to: -Ensure individualized plan of care included patient-specific interventions and education were included in the plan of care (G0574); -Ensure a copy of the visit schedule, including frequency of visits, was provided to the patient (G0614); -Ensure a current copy of the patient’s medication schedule/instructions, was provided to the patient (G0616); -Ensure a copy of pertinent instructions related to the patient’s care and treatments was provided to the patient (G0620); and -Ensure the name and contact information of the clinical manager was provided to the patient (G0622). The cumulative effects of these deficient practices have the potential to affect all the patients served by the provider.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on policy review, record review, home visit observation, and interview, the provider failed to ensure the plan of care (POC) included all required treatments and interventions in three of five records reviewed (Records/Patients #1, #2, and #4). This deficient practice has the potential to affect the provision of care for all the patients served by the provider. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 05/29/2025 with a primary diagnosis of heart failure (a decrease in the ability of the heart to pump blood). The patient had secondary diagnoses of diabetes (a group of diseases that results in too much sugar in the blood), chronic kidney disease (a condition where the kidneys are damaged and can't filter blood effectively, leading to a buildup of waste and fluid in the body), traumatic subarachnoid hematoma (a condition where bleeding occurs in the space between the brain and the tissue covering it), fractures of the second cervical (neck), first lumbar (lower back), and fourth thoracic (chest) vertebrae, atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular heartbeat), atherosclerotic heart disease (ASHD; thickening of the arterial wall that results in decreased supply of blood flow), and convulsions. The patient resided in his/her own home with the assistance of his/her spouse. Review of the document titled, “Home Health Certification and Plan of Care,” dated 05/29/2025, showed in part the document failed to contain orders and interventions for: - The monitoring of the patient’s weight and physician notification of weight gain associated with heart failure; - The frequency that the patient self-monitored his/her blood sugars, and need to assess the patient’s findings each visit to report readings outside of physician assigned parameters; and - An identification of the location of the patient’s pain or orders for the length of therapy for the use of warm or cold compresses. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home heath services on 10/03/2025 with a primary diagnosis of respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions). The patient had secondary diagnoses of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe), diabetes, atherosclerotic heart disease, cancer of the larynx (voice box), trachea (windpipe), and lung, and dysphagia (difficulty swallowing). The patient utilized a ventilator for breathing, a PEG tube (enteral feeding tube; a tube placed surgically through the abdominal wall into the stomach for the administration of food, fluids, and medication), and a PureWick system (a system used to control urine incontinence). The patient resided in his/her own home with the assistance of his/her spouse and adult children. Review of the document titled, “Home Health Certification and Plan of Care,” dated 05/31/2025, showed in part the document failed to contain orders for assessment and interventions for: - The patient’s tracheostomy; - The patient’s ventilator; - The care and use of the PEG tube; - The use of the PureWick system; - The frequency that the patient self-monitored his/her blood sugars and need to assess the patient’s findings each visit. Identification of physician assigned parameters for blood sugar readings; and - The length of therapy for the use of warm or cold compresses. During an interview on 06/11/2025 at 10:00 AM, the administrator and clinical manager stated that: - They would expect the plans of care to contain orders for assessments interventions to: * Monitor the patient’s weight for a patient with heart failure; * Assess the patient’s self-reported blood sugar readings; * Define parameters related to the patient’s blood sugar monitoring; * Manage a patient with a tracheostomy, ventilator, PEG tube, and PureWick system; * An identification of the length of therapy for the use of warm or cold compresses; and - They were unable to find the above interventions on the patients plans of care. Findings included: Review of the provider’s policy titled, “Plan of Care,” dated February 2024, showed in part the individualized plan of care must include the following: - All pertinent diagnosis; - The patient’s mental, psychosocial, and cognitive status; - The types of services, supplies, and equipment required; - The frequency and duration of visits to be made; - Prognosis; - Rehabilitation potential; - Functional limitations; - Activities permitted; - Nutritional requirements; - All medications and treatments; - Safety measures to protect against injury; and - Patient-specific interventions and education, measurable outcomes and goals identified by the provider and the patient. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health service on 06/04/2025 with a primary diagnosis of acute cystitis (a type of urinary bladder infection) and had additional diagnoses including pneumonia (lung infection), low back pain, and hypertensive heart disease (a condition where heart problems develop due to prolonged high blood pressure). He/she lived at home alone. Review of the POC dated 06/04/2025 to 08/02/2025, showed an order for the skilled nurse (SN) to instruct the patient/caregiver regarding strategies to mitigate pain including medication administration, recording and reporting pain, non-pharmacological (managing without medications) treatments, including positioning, massage, visualization, distraction and cold or warm compresses. During an observation visit with the registered nurse (RN) on 06/10/2025 at 11:45 AM, the patient was observed to have a heating pad in his/her recliner. The patient stated that he/she used the heating pad several times a day and applied it to his/her neck and back. The RN assisted the patient in positioning the heating pad to the patient's neck and down to the lower part of the patient's back. The patient turned on the heating pad, and the caregiver in the home stated the heating pad has a timer on it, and it shuts off automatically after about 15 or so minutes. The POC failed to include a complete order for the heat treatment used by the patient. During an interview on 06/10/2025 at 1:40 PM, the home health administrator stated that if the patient is using a heat treatment, he/she would expect the order for the treatment to include a location, how long to use it and the frequency.

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 policy review, record review, home visit observation, and interview, the provider failed to ensure the patient was provided with a written visit schedule, including the frequency of visits by all personnel, in two of three home visit observations conducted (Records/Patients #2 and #3). This deficient practice has the potential to affect all the patients served by the provider. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 02/16/2024 with a primary diagnosis of a urinary tract infection (an infection that affects any part of the urinary system, including the kidneys, bladder, ureters, and urethra (UTI)). Review of the patient’s home folder showed the folder failed to contain a visit schedule, including frequency of visits for all disciplines seeing the patient. During an interview on 06/10/2025 at 2:00 PM, the home health administrator stated that he/she would expect the visit schedule of the disciplines to be present in the home folder. Findings included: Review of the provider’s policy titled, “Coordination of Patient Care,” dated February 2024, showed in part the provider would coordinate care with the patient by providing a copy of written instructions outlining the patient’s visit schedule including the frequency of visits. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health service on 06/04/2025 with a primary diagnosis of acute cystitis (a type of urinary bladder infection) and had additional diagnoses including pneumonia (lung infection), low back pain, and hypertensive heart disease (a condition where heart problems develop due to prolonged high blood pressure). He/she lived at home alone. During a home visit observation, on 06/10/2025 at 11:45 AM, with the registered nurse (RN), the home admission folder (a packet of information given to the patient at the time of admission to home health) was reviewed. The folder failed to contain a written visit schedule. The caregiver in the home stated that would be nice to have, to help coordinate visits. The RN confirmed that the patient did not have a visit schedule in the home.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on policy review, record review, home visit observation, and interview, the provider failed to ensure the patient was provided a written medication schedule/list, in three of three home visit observations conducted (Records/Patients #1, #2, and #3). This deficient practice has the potential to affect all the patients served by the provider. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 02/16/2024 with a primary diagnosis of a urinary tract infection (an infection that affects any part of the urinary system, including the kidneys, bladder, ureters, and urethra (UTI)). Review of the patient’s home folder showed a medication list dated 02/16/2024 – 04/15/2024. The folder failed to contain an accurate and updated medication list. During an interview on 06/10/2025 at 2:00 PM, the home health administrator stated that he/she would expect the updated medication list to be present in the home folder. Findings included: Review of the provider’s policy titled, “Coordination of Patient Care,” dated February 2024, showed in part the provider would coordinate care with the patient by providing a copy of the written patient medication schedule/instructions. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health service on 06/04/2025 with a primary diagnosis of acute cystitis (a type of urinary bladder infection) and had additional diagnoses including pneumonia (lung infection), low back pain, and hypertensive heart disease (a condition where heart problems develop due to prolonged high blood pressure). He/she lived at home alone. During a home visit observation on 06/10/2025 at 11:45 AM with the registered nurse (RN), the home admission folder (a packet of information given to the patient at the time of admission to home health) was reviewed. The folder failed to contain a written medication schedule with instructions (six days after admission). The RN confirmed that the patient did not have a written medication schedule in the home and stated the provider mails this (medication schedule/list) to the patient. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 05/29/2025 with a primary diagnosis of heart failure (a decrease in the ability of the heart to pump blood). The patient had secondary diagnoses of diabetes (a group of diseases that results in too much sugar in the blood), chronic kidney disease (a condition where the kidneys are damaged and can't filter blood effectively, leading to a buildup of waste and fluid in the body), traumatic subarachnoid hematoma (a condition where bleeding occurs in the space between the brain and the tissue covering it), fractures of the second cervical (neck), first lumbar (lower back), and fourth thoracic (chest) vertebrae, atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular heartbeat), atherosclerotic heart disease (ASHD; thickening of the arterial wall that results in decreased supply of blood flow), and convulsions. The patient resided in his/her own home with the assistance of his/her spouse. Observation on 06/10/2025 at 9:30 AM, during the patient’s home visit: - A review of the documentation in the patient information folder in the patient’s home failed to contain a written list of the patient’s medications; - The visiting clinician confirmed the folder failed to contain a written list of the patient’s medications; and - The patient stated he/she had not received a written list of his/her medications. During an interview on 06/11/2025 at 10:00 AM, the administrator stated they would expect the clinicians to provide a written list of medications to their patients.

Other pertinent instructions CFR(s): 484.60(e)(4) Any other pertinent instruction related to the patient's care and treatments that the HHA will provide, specific to the patient's care needs. This ELEMENT is not met as evidenced by: Based on policy review, record review, home visit observation, and interview, the provider failed to ensure the patient and caregiver received a copy of written instructions specific to the patient’s needs in one of three home visit observations conducted (Record/Patient #1). This deficient practice has the potential to affect the quality of care for all the provider’s patients. Findings included: Review of the provider’s policy titled, “Coordination of Patient Care,” dated February 2024, showed in part the agency would coordinate care with the patient by providing a copy of written instructions outlining pertinent instruction related to the patient’s care and treatments specific to the patient’s care needs. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 05/29/2025 with a primary diagnosis of heart failure (a decrease in the ability of the heart to pump blood). The patient had secondary diagnoses of diabetes (a group of diseases that results in too much sugar in the blood), chronic kidney disease (a condition where the kidneys are damaged and can't filter blood effectively, leading to a buildup of waste and fluid in the body), traumatic subarachnoid hematoma (a condition where bleeding occurs in the space between the brain and the tissue covering it), fractures of the second cervical (neck), first lumbar (lower back), and fourth thoracic (chest) vertebrae, atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular heartbeat), atherosclerotic heart disease (ASHD; thickening of the arterial wall that results in decreased supply of blood flow), and convulsions. The patient resided in his/her own home with the assistance of his/her spouse. Review of the document titled, “Home Health Certification and Plan of Care,” dated 05/29/2025, showed in part the patient’s primary diagnosis was heart failure. Observation and interview on 06/10/2025 at 9:30 AM, showed: - A review of the documentation in the patient information folder in the patient’s home failed to contain written instructions on the management of heart failure; - The visiting clinician confirmed the folder failed to contain written instructions on the management of heart failure; and - The patient stated that he/she had not received written information on the management of heart failure. During an interview on 06/11/2025 at 10:00 AM, the administrator stated that they would expect the clinicians to provide written instructions to their patients on the management of the primary diagnosis for care.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on policy review, record review, home visit observation, and interview, the provider failed to ensure the contact information for the clinical manager was provided to the patient in two of three home visit observations conducted (Records/Patients #2 and #3). This deficient practice has the potential to affect all the patients served by the provider. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 02/16/2024 with a primary diagnosis of a urinary tract infection (an infection that affects any part of the urinary system, including the kidneys, bladder, ureters, and urethra (UTI)). Review of the patient’s home folder showed the folder failed to contain the contact information for the clinical manager. During an interview on 06/10/2025 at 2:00 PM, the home health administrator stated that he/she would expect the contact information for the clinical manager to be present in the home folder. Findings included: Review of the provider’s policy titled, “Coordination of Patient Care,” dated February 2024, showed in part the provider would coordinate care with the patient by providing the name and contact information of the provider’s director of clinical services. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health service on 06/04/2025 with a primary diagnosis of acute cystitis (a type of urinary bladder infection) and had additional diagnoses including pneumonia (lung infection), low back pain, and hypertensive heart disease (a condition where heart problems develop due to prolonged high blood pressure). He/she lived at home alone. During a home visit observation on 06/10/2025 at 11:45 AM with the registered nurse (RN), the home admission folder (a packet of information given to the patient at the time of admission to home health) was reviewed. The folder failed to contain the contact information for the clinical manager. During an interview on 06/11/2025 at 10:00 AM, the home health administrator confirmed that the contact information for the clinical manager was missing from the admission folder and stated he/she planned to add that information to the admission folder.

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 policy review, record review, home visit observation, and interview, the provider's staff failed to follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases in one of three home visit observations conducted (Record/Patient #2). This deficient practice has the potential to affect all of the patients served by the provider. Findings included: Review of the provider’s policy titled, “Exposure Control Plan,” dated February 2024, showed in part, before entering the home, make sure the bag is stocked with bacteriostatic foam/fluid/gel and plastic trash bags (preferable in a side pocket). Upon entering the home, place the bag on a clean surface; paper towels or plastic bag may be used to create a clean area if indicated. Open the bag near the care area and, if possible, near the water supply: - Wash hands thoroughly with bacteriostatic foam/liquid/gel; - Remove all items which will be needed for the visit; * Place items on one of the paper towels. Close the bag and give the patient care; * If additional items are needed after care has started, wash hands before re-entering the bag; * Clean any visibly soiled items which will be returned to the bag; * Wash hands and return equipment to the bag; close the bag; and * Tidy up the work area disposing of wastes. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 06/04/2025 with a primary diagnosis of acute cystitis (a type of urinary bladder infection) and had additional diagnoses that included pneumonia (lung infection), low back pain, and hypertensive heart disease (a condition where heart problems develop due to prolonged high blood pressure). He/she lived at home alone. Observation on 06/10/2025 at 11:45 AM, showed the registered nurse (RN) assembled the equipment used for vital sign assessment on a single barrier along with his/her nursing bag (placed in the middle of the barrier). The RN completed the vital sign assessment and placed the dirty equipment on the right side of the barrier (now the dirty side). The RN applied hand gel, then applied gloves and began cleaning the equipment, placed some of the clean equipment on the left side of the barrier (clean side) and the patient asked a question. The RN walked over to the patient while he/she was still cleaning the equipment, answered the question and walked back to the barrier. The RN finished cleaning his/her stethoscope, and the blood pressure cuff and then placed it back on the right side (dirty side) of the barrier beside the black bag that holds the blood pressure cuff. The RN did not clean the black bag. The RN removed his/her gloves, failed to clean his/her hands, picked up the blood pressure cuff and placed it into the black bag, placed the black bag and the rest of his/her equipment into the nursing bag and then applied hand gel to his/her hands. The computer tablet used by the RN to document the visit was handed to the patient and the patient signed the tablet. The RN failed to wipe the tablet prior to leaving the patient's home and failed to clean it in his/her car. After leaving the patient's home, the observed process was discussed with the RN related to the failure to observe the clean and dirty side of the barrier, the failure to clean his/her hands after removing gloves, the failure to clean the tablet, and he/she agreed the process was incorrect. During an interview on 06/10/2025 at 1:40 PM, the administrator stated that the tablet (computer) should be wiped down and the staff should follow their policy (infection control).

Eligible training/competency evaluation orgs. CFR(s): 484.80(f) A home health aide training program and competency evaluation program may be offered by any organization except by an HHA that, within the previous 2 years: (1) Was out of compliance with the requirements of paragraphs (b), (c), (d), or (e) of this section; or (2) Permitted an individual who does not meet the definition of a "qualified home health aide" as specified in paragraph (a) of this section to furnish home health aide services (with the exception of licensed health professionals and volunteers); or (3) Was subjected to an extended (or partially extended) survey as a result of having been found to have furnished substandard care (or for other reasons as determined by CMS or the state); or (4) Was assessed a civil monetary penalty of $5,000 or more as an intermediate sanction; or (5) Was found to have compliance deficiencies that endangered the health and safety of the HHA's patients, and had temporary management appointed to oversee the management of the HHA; or (6) Had all or part of its Medicare payments suspended; or (7) Was found under any federal or state law to have: (i) Had its participation in the Medicare program terminated; or (ii) Been assessed a penalty of $5,000 or more for deficiencies in federal or state standards for HHAs; or (iii) Been subjected to a suspension of Medicare payments to which it otherwise would have been entitled; or (iv) Operated under temporary management that was appointed to oversee the operation of the HHA and to ensure the health and safety of the HHA's patients; or (v) Been closed, or had its patients transferred by the state; or (vi) Been excluded from participating in federal health care programs or debarred from participating in any government program. This STANDARD is not met as evidenced by: Based on the results of this extended level survey resulting in noncompliance with one Condition of Participation: Care Planning, Coordination of Services, and Quality of Care, the provider may not train, or competency evaluate their home health aides for a period of two (2) years following the date of this survey. The restriction ends 06/11/2027.

Aides are members of interdisciplinary team CFR(s): 484.80(g)(4) Home health aides must be members of the interdisciplinary team, must report changes in the patient's condition to a registered nurse or other appropriate skilled professional, and must complete appropriate records in compliance with the HHA's policies and procedures. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview the home health provider failed to ensure the aide reported changes in the patient’s condition to a registered nurse (RN) or other skilled professional in three of three reviewed records of patient's receiving home health aide services (Records/Patients #2, #3, and #4). This deficient practice has the potential to affect the care of all the provider’s patients. Findings included: Review of the provider’s policy titled, “Home Health Aide Services and Training Program,” dated February 2024, showed in part the duties of a home health aide include reporting changes in the patient’s condition to a registered nurse or other appropriate skilled professional. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home heath services on 10/03/2025 with a primary diagnosis of respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions). The patient had secondary diagnoses of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe), diabetes (a group of diseases that results in too much sugar in the blood), atherosclerotic heart disease (ASHD; thickening of the arterial wall that results in decreased supply of blood flow), cancer of the larynx (voice box), trachea (windpipe), and lung, and dysphagia (difficulty swallowing). The patient resided in his/her own home with the assistance of his/her spouse and adult children. Review of home health aide documentation for the dates of 04/30/2025 to 05/28/2025 showed in part the patient refused for the aide to perform oral care, cleaning of dentures, assistance with bedpan/urinal, incontinence care, dangling on the side of the bed, use of the Hoyer lift, equipment care, and changing of the patient’s linens. The visit notes failed to include documentation that the HHA reported the refusals of care to the registered nurse or other skilled professional. During an interview on 06/11/2025 at 10:00 AM, the administrator and clinical supervisor stated they would expect the home health aide to report patient refusals of care. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 02/16/2024 with a primary diagnosis of a urinary tract infection (an infection that affects any part of the urinary system, including the kidneys, bladder, ureters, and urethra (UTI)). Review of the home health aide (HHA) visits dated 04/08/2025 – 06/03/2025 showed the patient refused to have the HHA shampoo and comb the patient’s hair. The HHA failed to report the refusals of care to the registered nurse (RN). During an interview on 06/10/2025 at 2:00 PM, the home health administrator stated that he/she would expect the refusals of care to be reported to the RN and those tasks taken off the aide care plan. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health service on 06/04/2025 with a primary diagnosis of acute cystitis (a type of urinary bladder infection) and had additional diagnoses including pneumonia (lung infection), low back pain, and hypertensive heart disease (a condition where heart problems develop due to prolonged high blood pressure). He/she lived at home alone. Review of the home health aide care plan dated 06/04/2025 showed the aide was tasked with notifying the registered nurse (RN) of refusal of care and had a list of tasks to complete that included apply lotion, comb hair, change linens, and clean/file nails at every visit. Review of the home health aide (HHA) visit note dated 06/05/2025 showed the patient refused to have the HHA apply lotion, comb hair, or change linens. The HHA marked not applicable (N/A) to the task of clean/file nails. The visit note failed to include documentation that the HHA reported the refusals of care to the RN and the box on the visit note for notifying the case manager of problems/concerns was not marked. During an interview on 06/10/2025 at 1:40 PM, the home health administrator stated that he/she would expect the refusals of care to be reported to the RN so the task plan (aide care plan) could be updated, would expect a communication note in the chart (clinical record) and would expect the notified case manager of problems/concerns box to be marked.

HH aide supervision elements CFR(s): 484.80(h)(4)(i-vi) Home health aide supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to, the following elements: (i) Following the patient's plan of care for completion of tasks assigned to a home health aide by the registered nurse or other appropriate skilled professional; (ii) Maintaining an open communication process with the patient, representative (if any), caregivers, and family; (iii) Demonstrating competency with assigned tasks; (iv) Complying with infection prevention and control policies and procedures; (v) Reporting changes in the patient's condition; and (vi) Honoring patient rights. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure an accurate home health aide (HHA) supervision included ensuring the HHA reported changes in the patient’s condition in one of three reviewed records of patient's receiving home health aide services (Record/Patient #4). This deficient practice has the potential to affect the home health aide services for all of the provider’s patients. Findings included: Review of the provider’s policy titled, “HHA Supervisory Visit,” dated February 2024, showed in part home health aide supervision must ensure that aides furnish care in a safe and effective manner, including but not limited to: - Following the patient’s plan of care for completion of tasks assigned to an HHA by the registered nurse or other appropriate skilled professional; and - Reporting changes in the patient’s condition. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 10/03/2025 with a primary diagnosis of respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions). The patient had secondary diagnoses of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe), diabetes (a group of diseases that results in too much sugar in the blood), atherosclerotic heart disease (ASHD; thickening of the arterial wall that results in decreased supply of blood flow), cancer of the larynx (voice box), trachea (windpipe), and lung, and dysphagia (difficulty swallowing). The patient resided in his/her own home with the assistance of his/her spouse and adult children. Review of HHA documentation for the dates of 04/30/2025 to 05/28/2025, showed in part the HHA failed to notify the registered nurse or other skilled professional of the patient’s refusal to allow the HHA to perform oral care, clean dentures, assist with bedpan/urinal, provide incontinence care, dangle on the side of the bed, use the Hoyer lift (a mechanical lift used for transferring patients), equipment care, and change the patient’s linens. Review of the documents titled, “HHA Supervisory visit,” with the dates of 05/08/2025 and 05/23/2025, showed in part: - The aide followed the plan of care for completion of tasks as assigned; - Informed the supervisor of client’s needs and changes in the patient’s condition as required; and - The supervisory visit documentation failed to address the HHA’s failure to notify the registered nurse or other skilled professional of the patient’s refusal for the HHA to perform tasks. During an interview on 06/11/2025 at 10:00 AM, the administrator and clinical manager stated that they would expect the HHA supervision documentation to reflect the HHA’s failure to report that the patient had refused the provision of tasks listed on the HHA assignment sheet.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on the Missouri statute review, employee file review, and interview, the home health provider failed to ensure Missouri Family Care Safety Registry (FCSR) results were obtained prior to patient contact in two of three employee records reviewed (Employees #1 and #2). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Section 192.2495 RSMo, requires employees of licensed home health agencies under contract with the Missouri Department of Health and Senior Services, to register with the Family Care Safety Registry regardless of hire date. This section also requires home health agencies to conduct criminal background screenings by checking the Family Care Safety Registry. Review of Section 192.2495.6, RSMo: “A provider is guilty of a class A misdemeanor if the provider knowingly hires or retains a person to have contact with patients or residents and the person has been found guilty in this state or any other state or has been found guilty of a crime, which if committed in Missouri would be a class A or B felony violation of chapter 565, 566 or 569, or any violation of subsection 3 of section 198.070 or section 568.020.” Review of Section 192.2495.7, RSMo (effective August 28, 2018): “Any in-home services provider agency or home health agency shall be guilty of a class A misdemeanor if such agency knowingly employs a person to provide in-home services or home health services to any in-home services client or home health patient and such person either refuses to register with the family care safety registry or if such person: (1) Has any of the disqualifying factors listed in subsection 6 of this section; (2) Has been found guilty of or pleaded guilty or nolo contendere to any felony offense under chapter 195 or 579; (3) Has been found guilty of or pleaded guilty or nolo contendere to any felony offense under section 568.045, 568.050, 568.060, 568.175, 570.023, 570.025, 570.030, 570.040 as it existed prior to January 1, 2017, 570.090, 570.145, 570.223, 575.230, or 576.080; (4) Has been found guilty of or pleaded guilty or nolo contendere to a violation of section 577.010 or 577.012 and who is alleged and found by the court to be an aggravated or chronic offender under section 577.023; (5) Has been found guilty of or pleaded guilty or nolo contendere to any offense requiring registration under section 589.400; (6) Is listed on the department of health and senior services employee disqualification list under section 192.2490; (7) Is listed on the department of mental health employee disqualification registry under section 630.170; or (8) Has a finding on the child abuse and neglect registry under sections 210.109 to 210.183.” EMPLOYEE #1: Review of the employee record showed: -Date of first patient contact: 03/23/2022; and -The provider failed to show a FCSR result prior to 03/23/2022. EMPLOYEE #2: Review of the employee record showed: -Date of first patient contact: 12/07/2022; and -The provider failed to show a FCSR result prior to 12/07/2022. During an interview on 06/10/2025 at 1:21 PM, the administrator stated that he/she did not have the FCSR result for the two employees, he/she only had a copy of the request, not the results.

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 policy review, record review, and interview, the home health provider failed to ensure the timeliness of documentation in one of five full records reviewed (Record/Patient #3). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Timely Submission of Patient Documentation,” dated February 2024, showed in part that itineraries, with all visit reports attached, must be submitted the next scheduled workday, not exceeding three business days. All patient visit reports from contract personnel must be submitted within three business days from the date of the visit. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 02/16/2024 with a primary diagnosis of a urinary tract infection (an infection that affects any part of the urinary system, including the kidneys, bladder, ureters, and urethra (UTI)). Review of the clinical record showed the following: -A certified occupational therapy assistant (COTA) visit was made on 05/28/2025 and signed/completed by the clinician on 06/03/2025 (six days later); -A COTA visit was made on 05/30/2025 and signed/completed by the clinician on 06/04/2025 (five days later); -A COTA visit was made on 06/02/2025 and signed/completed by the clinician on 06/10/2025 (eight days later); and -A COTA visit was made on 06/06/2025 and signed/completed by the clinician on 06/10/2025 (four days later). During an interview on 06/10/2025 at 2:00 PM, the administrator stated that he/she would expect the clinicians to have documentation completed within 24 hours of the visit during the week or up to 72 hours over the weekend.

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 07/13/22. During the survey it was determined the home health provider is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Agencies.

A partial extended survey for Medicare recertification for the home health provider was completed on 07/13/2022. The agency had 42 current patients.

Written notice within 4 business days CFR(s): 484.50(a)(4) Provide written notice of the patient's rights and responsibilities under this rule and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section to a patient-selected representative within 4 business days of the initial evaluation visit. This ELEMENT is not met as evidenced by: Based on review of the agency’s current patient rights information and interview, the agency failed to provide the written notice of patient rights that included the patient’s right to have a copy of the patient’s rights and responsibilities and the agency’s transfer and discharge policies provided to a patient-selected representative within four business days of the initial evaluation visit. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all patients served by the agency. Findings included: Review of the admission folder, provided by the agency's administrator on 07/11/2022, showed that the notice of patient rights, and other information given to a patient during the initial visit, failed to contain written information regarding the right to have a copy of the patient’s rights and responsibilities and the agency’s transfer and discharge policies provided to a patient-selected representative within four business days of the initial evaluation visit. During an interview on 07/11/2022 at 11:35 AM, the regional administrator stated that he/she reviewed packet given to patients on admission, including the patient rights information, and could not find where the agency informs the patient of this right. He/she stated the missing language needs to be added.

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 review of the agency's current patient rights information, home visit observation, and interview, the agency failed to ensure staff provided written notice of patient rights to include that the Missouri state toll free home health telephone hotline hours of operation were 7:00 AM to 8:00 PM daily in three (Records/Patients #1 #2, and #3) of three home visit observations conducted. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities for all patients/representatives served by the agency. Findings included: The administrator provided an admission packet for review on 07/11/2022. The agency’s notice of patient rights and other information given to a patient during the initial visit showed that calls to the Missouri state toll free home health telephone hotline number are accepted 24 hours per day, seven days a week. Observations during Patient #1's home visit on 07/11/2022 at 2:00 PM, Patient #2's home visit on 07/12/2022 at 2:15 PM, and Patient #3's home visit on 07/12/2022 at 9:50 AM, showed the written patient rights information in their home folders failed to include the correct hotline hours. Findings were reviewed with the agency administrator and the regional administrator on 7/11/2022 at 11:25 AM. During the interview, the agency administrator stated that he/she was not aware that the hotline hours had changed. The regional administrator stated that they would get the correct hours of operation into the admission packets.

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 policy review, record review, home visit observation, and interviews, the agency failed to ensure a complete/accurate medication review and/or update of the patient's medications was completed in, but not limited to, two (Records/Patients #1 and #2) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, “Medication reconciliation”, dated/revised February 2021 showed in part: -- At time of admission, the admitting registered nurse (RN), physical therapist (PT), or speech language pathologist (SLP) will create and document a complete list of medications that patient is taking at home, including dose, strength, route, and frequency; -- In therapy only cases, the therapist submits a list of medications collected during the comprehensive assessment to the RN for review, who contacts physician/practitioner if indicated; and -- Medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication. The patient's medication list in the home will also be updated. RECORD/PATIENT #1: RECORD/PATIENT #2: Observation and interview on 07/12/2022 at 2:30 PM, during the patient’s home visit, showed the following medication discrepancies with the agency medication profile: - The agency medication profile showed an order for Lyrica (nerve pain) one capsule twice a day. The patient’s spouse stated that the patient discontinued taking this medication on Sunday; - The agency medication profile showed an order for gabapentin (restless leg and/or nerve pain) 100 milligrams (mg) one capsule, take one to two at bedtime. The patient’s spouse stated that the patient stopped taking on 06/22, about a month ago; - The agency medication profile showed an order for Klor-con (mineral supplement) M20 (dosage) one tablet daily. The patient’s spouse stated that the patient took two tablets every morning since June 22nd; - The agency medication profile showed an order for furosemide (fluid reduction) 20 mg one tablet daily. Patient’s spouse stated that the patient took two tablets every morning since June 22nd; - The agency medication profile showed an order for fluticasone (runny nose) 50 microgram (mcg)/inhalation, one spray twice a day. The patient’s spouse stated that the patient uses only on an as needed basis; and - The agency medication profile showed an order for prednisone (support the body system e.g. arthritis relief) 5 mg daily. The patient’s spouse stated that the patient was no longer taking this medication. During an interview with RN A, immediately following the home visit, the RN stated that he/she failed to check the patient’s medication bottles in the home, and that the patient and the patient’s spouse failed to tell the RN of the medication changes. RECORD/PATIENT #1: Review of the plan of care and the medication profile, both dated 06/18/2022 – 08/16/2022, showed the patient took the following medications: - Xarelto (a blood thinner) 10 milligrams (mg), one tablet daily by mouth; and - Cholecalciferol (vitamin D3) 25 micrograms (mcg) take two tablets daily by mouth. Review of the patient’s medications, during a home visit on 07/11/2022 at 2:00 PM, showed the following: - Xarelto 20 mg one tablet, by mouth, daily; - Cholecalciferol 25 mcg one tablet, by mouth, daily; and - The agency failed to clarify the medication dosage with the physician. During an interview on 07/12/2022 at 2:30 PM, the regional administrator stated that the patient was taking Xarelto 10 mg and two Cholecalciferol tablets when they did the patient’s recertification but the nurse should have called for clarification on the medication dosage. The nurses should have checked the medication bottles with each home visit. During an interview on 07/13/2022 at 10:45 AM, the regional administrator stated that he/she spoke with the nurses and discovered the cholecalciferol dosage had been changed from one tablet to two tablets at a physician office visit and the nurses should have put in an order for the dosage change so there was a documentation trail of what had occurred.

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 policy review, record review, and interview, the agency failed to ensure prompt notification of the physician of changes in the patient’s condition or needs in, but not limited to, two (Records/Patients #1 and #4) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency’s policy titled, “Plan of Care – CMS #485 and Physician/Practitioners Orders,” dated/revised February 2022, showed, in part, the following: - Care and services provided will be provided according to physician/practitioner orders; - Orders are current and updated; - Any revision to the plan of care due to a change in patient health status must be communicated to the patient, caregiver, and all physicians issuing orders for the agency’s plan of care; - Changes in the patient’s condition that require a change in the plan of care must be documented in the patient’s clinical record; - Consultation with the physician on any modification in the plan of care will be documented; and - If the agency misses a visit or a treatment or services as required by the plan of care, which results in any potential for clinical impact upon the patient, then the agency must notify the responsible physician of such missed treatment or service. RECORD/PATIENT #1: Review of the recertification assessment, dated 06/13/2022, showed: - The patient had numerous falls, most recent was two days prior to assessment; - A left upper forearm laceration (a deep cut or tear in the flesh); and - Skilled nurse (SN) cleansed wound with normal saline, patted the wound dry, applied Telfa (a type of bandage that doesn’t stick to the wound), covered and secured with Kerlix (a wrap gauze). Review of the plan of care, dated 06/18/2022 – 08/16/2022, showed: - SN to notify the physician if heart rate is greater than 120 beats per minute (bpm) or less than 60 bpm; - SN to perform wound care to laceration on left forearm to include; * Cleanse wound with normal saline; * Pat dry; * Apply Telfa; and * Cover and secure with Kerlix or ace (elastic) bandage. Review of SN note dated 06/20/2022, showed: - Wound care to the left forearm was not performed because the wound was healed; - The patient’s heart rate was recorded at 59 bpm (under the physician ordered parameters); - The agency failed to notify the physician that the left forearm laceration had healed; and - The agency failed to notify the physician that the patient’s heart rate was outside the ordered parameters. During an interview on 07/13/2022 at 11:03 AM, the regional administrator stated that the nurse should have notified the physician that the arm laceration had healed so wound care orders could be discontinued and the nurse should have reported the heart rate to the physician. RECORD/PATIENT #4: Review of the plan of care, dated 05/31-2022 – 07/29/2022 showed orders for SN visits once a week for nine weeks. Review of the SN notes showed a missed visit for the week of 07/04/2022 through 07/10/2022. Findings were reviewed with the regional administrator on 07/13/2022 at 11:00 AM. He/she stated that the physician should have been notified of the missed visit for that week but the nurse forgot to put in a missed visit note to send to the physician.

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 nationally-recognized standards, policy review, home visit observation and interview the agency failed to ensure staff followed acceptable standards of practice for infection control in two (Records/Patients #1and #2) of three home visit observations. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the centers for disease control (CDC) website (cdc.gov/hand hygiene in healthcare settings) showed in part that gloves are not a substitute for hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, before touching the patient or the patient environment and perform hand hygiene immediately after removing gloves. Review of the CDC’s 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, as well as other professional publications Rhinehart & McGoldrick, 2006 showed as long as the principles of preventing the transfer of microorganisms are observed by staff, patient infections can be prevented. Bag Technique showed in part: - Place the hand-carried bag on a clean, dry surface or keep the rolling bag on the floor; - Perform hand hygiene; - Remove the supplies from the bag and place them on a clean, dry surface or on a surface barrier as needed; - Do not reenter the bag with gloves on. Remove the gloves if worn, perform hand hygiene and then reenter the bag; and - Remove personal protective equipment (PPE) if worn, and perform hand hygiene. Guidance went on to say “One of the myths regarding the home care bag is that there should be a designated “clean side” and “dirty side” of the nursing bag". The term “dirty” infers that there are items that are soiled that will be placed inside the bag. Nothing inside the bag should be “dirty” and, as such, there does not have to be a designated “clean” and “dirty” side of the bag. Review of the agency's policy titled, "Exposure Control Plan: OSHA (Occupational Safety and Health Administration) Regulations, dated/revised March 2018 showed that bags used by nurses, and other staff which contain equipment, and brought into the home are classified as clean on the inside. Review of the agency's policy titled, "Hand Hygiene Policy and Compliance Program", dated/reviewed March 2018, showed in part: - Indications for staff performing hand hygiene are before and after direct patient care; - After any contact with contaminated materials; - Before re-entering nursing bag or patient's clean supplies and - Hand hygiene after removing gloves was recommended. RECORD/PATIENT #2: Observation on 07/12/2022 at 2:15 PM, during the patient’s home visit showed: - The registered nurse (RN) wore gloves during the patient assessment; - The RN removed his/her gloves and placed them in his/her nursing bag; - The RN obtained another pair of gloves from his/her nursing bag and put them on; and - The RN failed to perform hand hygiene when he/she entered the nursing bag and prior to applying the new pair of gloves. During an interview with RN A, immediately following the home visit, RN A stated that he/she should have performed hand hygiene before and after putting on gloves. RN A stated that he/she have always had a “clean”/”dirty” side in his/her nursing bag, had been doing this for years. When “clean”/”dirty” side further discussed, RN A stated that he/she had never thought about the meaning of “dirty” side before. RECORD/PATIENT #1: Observations during a home visit on 07/11/2022 at 1:55 PM showed: - The physical therapist A (PT) donned gloves, checked the patient’s vital signs, and provided treatment to the patient; - PT A completed patient treatment and failed to remove gloves or perform hand hygiene; and - PT A wore the soiled gloves while cleaning the blood pressure cuff, thermometer, and gait belt with sanitizing wipes. An interview was conducted with PT A during the home visit. He/she stated that he/she did not think about touching the equipment with the same gloves worn during treatment but was appreciative of learning ways to do better. During an interview on 07/12/2022 at 10:00 AM, the agency administrator and the regional administrator stated that the nurse should have removed gloves and performed hand hygiene prior to cleaning the equipment.

Must have a written agreement CFR(s): 484.105(e)(2)(i-iv) An HHA must have a written agreement with another agency, with an organization, or with an individual when that entity or individual furnishes services under arrangement to the HHA's patients. The HHA must maintain overall responsibility for the services provided under arrangement, as well as the manner in which they are furnished. The agency, organization, or individual providing services under arrangement may not have been: (i) Denied Medicare or Medicaid enrollment; (ii) Been excluded or terminated from any federal health care program or Medicaid; (iii) Had its Medicare or Medicaid billing privileges revoked; or (iv) Been debarred from participating in any government program. This ELEMENT is not met as evidenced by: Based on review of the agency’s contractual agreement and interview, the agency failed to ensure that the contract agreements between the home health agency and the agency contracted for services contained the statements that the agency, organization, or individual providing services under arrangement may not have been: (i) Denied Medicare or Medicaid enrollment, (ii) Been excluded or terminated from any federal health care program or Medicaid, (iii) Had its Medicare billing privileges revoked, or (iv) Been debarred from participating in any government program. This deficient practice has the potential to affect the contracted services for all of the agency patients. Findings included: Review of the undated services agreement titled, “Amended and Restated Personnel Agreement,” showed the contract did not contain statements that the agency, organization, or individual providing services under arrangement may not have been: (i) Denied Medicare or Medicaid enrollment, (ii) Been excluded or terminated from any federal health care program or Medicaid, (iii) Had its Medicare billing privileges revoked, or (iv) Been debarred from participating in any government program. During an interview on 07/12/2022, at 3:00 PM, the regional administrator stated that he/she understood why the regulatory language is required and why it needs to be added to the contract. He/she would have the attorneys update the contract to ensure compliance.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on review of Missouri State Code of Regulations, employee record review, and interview, the agency failed to provide evidence of dementia specific training about Alzheimer’s disease in one (Employee #1) of four employee records reviewed. The agency also failed to check the Employee Disqualification List (EDL) prior to hire date on one (Employee #2) of four employee records reviewed. This deficient practice has the potential to affect the safety of all patients served by the agency. Findings included: Review of 19 CSR 30-26.010 (1) (B) required: "Licensed home health agencies shall provide dementia-specific training about Alzheimer's disease and related dementias to their employees and those persons working as independent contractors who provide direct care to or may have daily contact with residents, patients, clients or consumers with Alzheimer's disease or related dementias. 1. The training for persons providing direct care shall address the following areas, at a minimum: (A) An overview of Alzheimer's disease and related dementias; (B) Communicating with persons with dementia; (C) Behavior management; (D) Promoting independence in activities of daily living; and (E) Understanding and dealing with family issues. 2. Employees or independent contractors who do not provide direct care for, but may have daily contact with, persons with Alzheimer's disease or related dementias shall receive dementia-specific training that includes, at a minimum: (A) An overview of Alzheimer's disease and related dementias; and (B) Communicating with persons with dementia. 3. Dementia-specific training about Alzheimer's disease and related dementias shall be incorporated into orientation for new employees with direct patient contact and independent contractors with direct patient contact. The training shall be presented by an instructor who is qualified by education, experience, and knowledge in the current standards of practice regarding individuals with Alzheimer's disease and other related dementias. The training shall be provided annually and updated as needed. Review of Employee #1’s filed showed the agency failed to ensure the employee received dementia specific training about Alzheimer’s disease on orientation. Review of Section 192.2490.12 RSMo: “No person, corporation, organization, or association who received the employee disqualification list under subdivisions (1) to (7) of subsection 11 of this section shall knowingly employee any person who is on the employee disqualification list.” Review of the agency’s undated policy titled, “Criminal Background Checks,” showed prior to allowing any person who has been hired in a full time, part time or temporary position to have contact with any patient or client, the agency will initiate the following background checks: * The Office of Inspector General Exclusion List; * National Sex Offender Registry; * EDL (requirement is to check prior to employee hire, not prior to patient contact); and * Family Care Safety Registry. Review of Employee #2’s file showed: * Employee’s date of hire was 05/17/2021; * Date of EDL check was 5/17/2021; and * The agency failed to ensure an EDL check was completed prior to hire. During an interview on 07/13/2022 at 11:25 AM, the agency administrator stated that the EDL was to be completed prior to patient contact then stated that it was to be completed prior to hire. He/she remembered that the Alzheimer’s training was completed but he/she could not find the form showing completion and the completion date wasn’t recorded in the employee’s file.