Every finding on record at Providence at Home With Compassus Hh Anchorage

E000 A Recertification Survey was conducted by Healthcare Management Solutions, LLC on behalf of the State of Alaska, Department of Health and Social Services. An unannounced on-site Recertification Survey at the above-named Home Health Agency (HHA) from 11/15/21 to 11/19/21 resulted in a finding of no deficiency citations respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.102.

G000 The following deficiency was noted during an unannounced Medicare/Medicaid Recertification Survey conducted 11/15/21 to 11/19/21 at Providence In Home Services. Sample Size: 17 sampled patients, 0 non-sampled patients, and 5 closed records. State of Alaska Department of Health and Social Services Health Facilities Licensing and Certification 4601 Business Park Blvd. Building K Anchorage, AK 99503

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on record review, observation, and interview, the agency failed to document the correct wound site in 1 of 12 active records reviewed. This failed practice placed the patient at risk for not having his / her wound treated and care planned for appropriately and accurately. Findings: Record review from 11/15-11/19/21 revealed Patient # 3, start of care 10/15/21 with a certification period of 10/15/21 - 12/13/21, was admitted to the agency with diagnoses that included unspecified open wound right lower leg subsequent encounter; pressure ulcer of sacral region, unstageable and collapsed vertebra, not elsewhere classified, lumbosacral region, subsequent healing for fracture with routine healing. Further review revealed these wounds on the right leg were documented on the start of care assessment in error. The wounds were on the left leg. An observation on 11/15/21 at 1:01 PM at revealed no wounds on Patient # 3's right lower leg. Patient #3's left lower leg had dressing in place. Occupational Therapist #1 was observed to complete a home visit with this patient. During an interview on 11/15/21 at 1:01 PM, Patient # 3 and the Occupational Therapist #1 stated the patient had a left leg wound and not a right leg wound. Review of a PT [Physical Therapy] - Oasis Start of Care document dated 10/15/21 and 5:26 PM completed by PT # 2 revealed a diagnoses of an unspecified open wound on the right lower leg. An encounter note in the document stated, "Patient referred to home health following a MD referral due to pressure sores in [his / her] lower leg [R] and L sacral ulcer as well as deconditioning. There were no measurements or description of the wound on the document. During an interview on 11/19/21 at 11:30 AM, the current Home Health Director stated that this is a problem. Review of a policy titled "Regulatory, Compliance and Governance - Providence Home Health Alaska" revised 1/21 stated, "Medicare Regulations Oasis … A. Clinician: 1. Completes the start of care OASIS within 5 days of the Start of Care."

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a licensed nurse had completed a review of medications to identify any adverse effects and drug reactions or interactions, duplicate drug therapy, and noncompliance with drug therapy for 4 of 7 records reviewed (#1, #6, #7, #10) when a physical therapist completed the start of care assessment. This failed practice had the potential to affect patients with a start of care assessment completed by a physical therapist a complete review of medications and potential for ineffective drug therapy or adverse effects from drug therapy. Review of clinical records #1, # 6, # 7, # 10 from 11/15 - 11/19/21 revealed the licensed nurse failed to complete a review of all medications in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy after the physical therapist had completed a start of care assessment upon admission to the agency's care. Review of Patient #1's Start of Care (SOC) assessment dated 9/14/21 indicated PT # 2 completed the admission assessment. The medical record did not include documentation that a Licensed Nurse (LN) completed a review of all medications in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. Review of Patient #6's SOC assessment dated 11/12/21 indicated PT # 1 completed the admission assessment. The medical record did not include documentation that LN completed a review of all medications in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. Review of Patient #7's SOC assessment dated 11/9/21 indicated PT # 2 completed the admission assessment. The medical record did not include documentation that a LN completed a review of all medications in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. Review of Patient #10's SOC assessment dated 11/11/21 indicated PT # 7 completed the admission assessment. The medical record did not include documentation that a LN completed a review of all medications in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. During an interview on 11/19/21 at 10:45 AM, the current Home Health Director stated that physical therapists had completed the above start of care assessments and these records failed to show a licensed nurse had reviewed the medications at start of care assessments. A review of the policy titled "Nursing Service - Home Health Alaska" revised 4/21 stated, "Functions of the RN … complements comprehensive assessments [start of care, resumption of care, recert ] updated assessments … within the time frame defined by regulations and the plan of care."

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure a comprehensive assessment was updated after 1 of 1 active records (#17) reviewed had a completed reassessment after a change of condition occurred. This failed practice placed the patient at risk for his / her altered physical needs for not being addressed in a timely manner and therefore placed the patient at risk for a potential decline in health and functioning. Findings: Review from 11/15/21 - 11/19/21 of the clinical record for Patient #17 evidenced a change of condition after a fall with injury to the right clavicle area occurred on 11/9/21. After the fall, Patient # 1 visited the emergency department for an evaluation and treatment and then returned home. There was no comprehensive assessment completed after the patient's fall and change of condition. A SN (Skilled Nurse) repeat visit note dated 11/9/21 that Licensed Nurse (LN) # 1 completed 11/10/21 at 6:21 AM revealed a SN visit. Patient # 1 had pain to the right side of neck, clavicle, shoulder and arm at a level '8' out of '10' after a fall from bedside commode. Bruises were noted on right side of neck / clavicle and the patient was unable to lift his / her arm. LN # 1 advised the patient and family to take the patient to the emergency room for evaluation. An emergency room visit note dated 11/9/21 was generated on 11/10/21 and revealed Patient #1 had a fall at home and then was found to have a closed displaced fracture of the right clavicle. A sling was applied to the right arm. A SN [Skilled Nurse] repeat visit note for 11/12/21 was signed and completed by Licensed Nurse (LN) # 1 on 11/15/21 at 5:40 PM. This note revealed the patient's family member had taken the patient to the emergency room for evaluation. The patient had been treated for a displaced right clavicle. The patient was found to have a sling in place that was not applied correctly and the LN # 1 instructed the patient on correct sling usage and corrected the problem. There was a discussion with the patient and nurse about possibly consider going to a skilled nursing facility or assisted living facility. There was a new wound found on the left upper shin. The agency policy titled "Assessment - Adult, HH 207-5" revised 11/2021 stated, "The comprehensive assessments are appropriate to the type of care and services provided by the organization and the patient's needs. As appropriate, the assessments [as part of the medical record] include the evaluation and documentation of ... pertinent physical findings." Review of a policy titled "Regulatory, Compliance and Governance - Providence Home Health Alaska" revised 1/21 stated, "Medicare Regulations Oasis … A. Clinician … Completes a follow - up OASIS [SCIC] within 24 hours of an unexpected significant change in condition or within 2 days of becoming aware of the change a. 'Significant change' is a decline or improvement in a patient's status that I. will not normally resolve itself without further intervention by staff or by implementing standard disease related clinical interventions … impacts on more than one area of the patient's health status iv. requires interdisciplinary and / or revision of the existing plan of care … ii. a fall resulting in a new fracture with weight bearing status or pain change but no inpatient admission."

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 observation, record review and interview, the agency failed to ensure a plan of care was accurate for 1 of 17 records reviewed (#3). This failed practice had the potential to affect all patients with a plan of care for accuracy on the plan of care. Record review from 11/15-11/19/21 revealed Patient # 3, start of care 10/15/21 with a certification period of 10/15/21 - 12/13/21, was admitted to the agency with diagnoses that included unspecified open wound right lower leg subsequent encounter; pressure ulcer of sacral region, unstageable and collapsed vertebra, not elsewhere classified, lumbosacral region, subsequent healing for fracture with routine healing. A plan of care for this certification period had wound management with a start date of 10/20/21 for the right medial calf and right posterior calf. This plan of care document stated, "Wound care [each visit, start 10/19/21. Wound type # 2 traumatic location right posterior calf. Wound care remove old dressing, note amount and character of exudate [drainage], cleanse with wound cleanser, apply xeroform, apply abdominal pad if weeping is present, apply stockinette, wrap with kerlix. Frequency: weekly." This wound care was also to a wound on the right medial calf. An observation on 11/15/21 at 1:01 PM at revealed no wounds on Patient # 3's right lower leg and no dressing in place on left lower leg. This visit was for an Occupation Therapist visit. During an interview on 11/15/21 at 1:01 PM, Patient # 3 and the Occupational Therapist #1 stated the patient had a healed sacral wound and left leg wounds. Review of a PT [Physical Therapy] - Oasis Start of Care document dated 10/15/21 and 5:26 PM completed by PT # 2 revealed a diagnoses of an unspecified open wound on the right lower leg. An encounter note in the document stated, "Patient referred to home health following a MD referral due to pressure sores in [his / her] lower leg [R] and L sacral ulcer as well as deconditioning. There were no measurements or description of the wound on the document. During an interview on 11/19/21 at 11:30 AM, the current Home Health Director stated that this is a problem. Review of a policy titled "Regulatory, Compliance and Governance - Providence Home Health Alaska" revised 1/21 stated, "Medicare Regulations Oasis … A. Clinician: 1. Completes the start of care OASIS within 5 days of the Start of Care." The agency policy titled "Certification and Plan of Care, HH 307 - B" revised 11/2021 stated, "Care follows a written plan of care established by each discipline following their initial visit and in consultation with the provider ... The plan of care should include all pertinent diagnosis ... medications and treatments ... The plan of care must include 484.60 (a) Standard: Plan of are. 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 ... B. Plan of care components: The individualized plan of care must include the following ... all medications and treatments."

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, policy review and interview, the agency failed to ensure infection control practices were properly implemented at 1 of 2 home visits observed with a skilled nurse (Patient # 4 with Licensed Nurse # 1). Specifically, the agency failed to ensure the skilled nurse removed gloves and then performed hand hygiene after the skilled nurse's gloves were soiled. This failed practice had the potential to place the patient at risk of transmission of pathogens and exposure to infectious organisms. Findings: During an observation on 11/16/21 at 2:15 PM, Licensed Nurse (LN) # 1 was observed to complete an assessment and wound care at a home visit with Patient # 4. After donning gloves, the LN was observed to remove the Patient's dressing on the lower left leg. The dressing was removed. The LN was observed to remove his / her gloves and then did not wash or sanitize his / her hands before donning clean gloves. The LN proceeded to wash the wounds on the left leg and left heel with wound wash. The LN removed the gloves and donned new gloves without washing or sanitizing his / her hands prior to donning new gloves prior to applying a wound treatment to the wounds and applying a dressing over the wounds. During an interview on 11/17/21 at 2:15 PM, the current Home Health Director stated that hand hygiene or handwashing should follow after removing gloves and then applying clean gloves. The agency policy titled "PSJH - Clin-1205 Hand Hygiene Policy" implemented, revised and reviewed on 9/2019 stated, "Gloves are a protective barrier for the healthcare worker and patients according to Standard Precautions ... b. Gloves are removed when the need for protection no longer exists and hand hygiene should be practiced immediately after removal of gloves."

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to provide skilled nursing services in a timely manner for 1 of 17 records reviewed ( #1). This failed practice denied the patient the services necessary to maintain the highest practicable level of well-being. Findings: Review on 11/15/21 - 11/19/21 of the clinical record of Patient #1 evidenced a start of care date of 9/14/21 with a certification period of 9/14/21 - 11/12/21 and diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting left nondominant side. During this certification period, the patient was receiving physical therapy and occupational therapy. The review further revealed a new skilled nursing service was ordered on 10/12/21 and was not started until 10/26/21. A review of Clinical Record #1 evidenced an order for skilled nursing 1 -3 visits per week for 9 weeks for Foley care per HH [home health] protocol and 3 as needed visits to troubleshoot issues related to care needs for catheter care. This order was entered on 10/12/21 at 1:34 PM by the Clinical Resource Nurse. The first skilled nurse visit in response to this order occurred on 10/26/21 at 6:43 AM by Licensed Nurse #1. During an interview on 11/17/21 at 2:39 PM when asked about the delay in nursing service care, the current Home Health Director stated that this is not what we aim for. A review on 11/19/21 of the agency policy titled "Provider Roles, Responsibilities, Verbal Orders, Written Orders and Plan of Care - Home Health Alaska" reviewed 4/21 stated, "Policy … follow all applicable Federal, state, local regulations or ordinance or standards outlined within our accreditation organization." A review on 11/19/21 of the agency policy titled "Nursing Service - Home Health Alaska" reviewed on 4/21 stated, "Functions of the RN … 4. Initiates changes in the plan of care based on patient response, in conjunction with the patient, caregiver, and provider."