Every finding on record at Redstone @ Home

Based on the findings of an unannounced state re-licensure and Medicare recertification survey conducted onsite 10/24/23 and completed 10/30/23, Redstone at Home was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.

Based on the findings of an unannounced state re-licensure and Medicare recertification survey conducted onsite 10/24/23 and completed 10/30/23, Redstone at Home was found not to be in compliance with the following requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

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 a review of policies, home visit observations (HV), and interviews (EMP), the agency’s staff did not follow accepted clinical practice standards to prevent the transmission of infections and communicable diseases related to disposal of sharps and sterile dressing IV dressing technique for one (1) of five (5) home visit observations made (HV 2). In addition, based on supply room tour observations, the agency did not follow current clinical practice standards for reviewing medical supplies. Findings include: CDC “Guidelines for Environmental Infection Control in Health-Care Facilities…Management of Regulated Medical Waste in Health-Care Facilities” states, "Medical wastes require careful disposal and containment before collection and consolidation for treatment. OSHA has dictated initial measures for discarding regulated medical-waste items. These measures are designed to protect the workers who generate medical wastes and who manage the wastes from point of generation to disposal… Puncture-resistant containers located at the point of use (e.g., sharps containers) are used as containment for discarded slides or tubes with small amounts of blood, scalpel blades, needles and syringes, and unused sterile sharps…. To prevent needlestick injuries, needles and other contaminated sharps should not be recapped, purposefully bent, or broken by hand. …Transporting and storing regulated medical wastes within the health-care facility prior to terminal treatment is often necessary…. Any facility that generates regulated medical wastes should have a regulated medical waste management plan to ensure health and environmental safety as per federal, state, and local regulations.” https://www.cdc.gov/infectioncontrol/pdf/guidelines/environmental-guidelines A review of agency policy “Infusion Therapy Policies and Procedures” on 10/26/23 between approximately 12:30 pm – 2:00 pm revealed: “Intermittent Injection Port Change…1. Adhere to Standard Universal Infection Control Guidelines/Precautions…13. Remove old injection port…20. Discard soiled supplies in appropriate containers…Dressing Change Equipment…Procedure…3. Open sterile dressing kit using sterile technique…use the outer bag as a trash bag… 20. Discard soiled supplies in appropriate containers.” A Home Visit Observation (HV) completed on 10/25/23 between approximately 9:00 am – 9:15 am revealed the following: HV#2, EMP8 performed Intermittent Injection Port needle and site dressing change. During the visit EMP8 created a sterile field for the port but placed the non-sterile plastic surface of a container upon the sterile field. After the port was changed EMP8 gathered all syringes and the port needle into their gloved hand then doffed the glove while grasping the needle and syringes in a closed fist. A sharps disposal container was not present nearby during the dressing change. The above home visit observation findings were discussed with EMP 2, Executive Director, and EMP 4, Clinical Team Lead during onsite interviews on October 26, 2023, between approximately 1:00 pm - 3:00 pm. During a tour of the agency’s supply room located within the Annex on 10/24/23 at approximately 12:30 pm the following supplies were found: 9 Opsite dressings with an expiration date of 07/2019 2 boxes (144 packets) of Triple Antibiotic Ointment with an expiration date of 09/22 19 providone iodine swab sticks with an expiration date of 4/2020 1 box (144 count) Lubricating Jelly 3 gm packets with an expiration date of 5/13/22 15 IV 3000 Smith and Nephew 2 3/8in x 2 ¾ in dressings with an expiration date of 1/2021 9 Telfa nonadherent sterile dressings with an expiration date of 7/2020 74 NSS 5mL Portex saline “bullets” with an expiration date of 6/2/22 17 Puritan DM sticks (sterile measuring device) with an expiration date of 12/2019 10 Medline collagen dressings with silver with an expiration date of 3/31/23 The expired supplies were shown to EMP4, Clinical Team Lead, and then discarded. EMP4 confirmed that there was a need for routine stock/supply review and rotation. Findings were also discussed at an exit debriefing on 10/24/23 at approximately 3:30pm with EMP2, Executive Director.

Based on the findings of an unannounced onsite Medicare Re-certification survey completed on January 8, 2021, Redstone @ Home, was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Condition of Participation: Home Health Agencies- Emergency Preparedness.

Based on the findings of an unannounced onsite Medicare Re-certification survey completed on January 8, 2021, Redstone @ Home, was found not to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

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 may choose to include. This ELEMENT is not met as evidenced by: Based on review of agency policy, clinical records (CR), and staff (EMP) interview, it was determined that the agency failed to ensure the Plan of Care (POC) included all prescribed medications for three (3) of fourteen (14) CR's reviewed (CR 1,10, & 13). The agency also failed to ensure all ordered interventions were included on the POC for five (5) of fourteen (14) CR's reviewed (CR1, 3, 4, 9, & 10) Findings included: Review of agency policy on January 8, 2021 at approximately 12:15pm revealed: "Policy # C-2.0 Acceptance of Patients, Plan of Care, and Medical Supervision...Procedure...2. Plan of Care...B. The plan of care includes i. all pertinent diagnosis ii. All patient care orders, including verbal orders...x. All medications and treatments..." Review of clinical records on January 5, 2021 between approximately 11:50am and 3:30pm, January 6, 2021 between approximately 1:30pm and 3:30pm, January 7, 2021 between approximately 1:20pm and 3:30pm, and January 8, 2021 between approximately 9:15am and 12:00pm revealed: CR1, start of services (SOS) 11/13/2020, period reviewed 11/13/2020-1/11/2021, CR revealed upon discharge from hospital patient on Oxygen 3Liters via Nasal Canula. Initial Comprehensive Assessment conducted by the registered nurse on 11/13/2020 noted patient to be on Oxygen at 3 Liters via Nasal Canula (NC). Oxygen not listed on patient medication list. POC also revealed patient to have Type 2 Diabetes and be taking insulin on a sliding scale. equipment documented upon admission includes Glucometer, glucose monitoring strips, and lancets. No orders for blood glucose monitoring on POC or included in patient record. CR3, SOS 10/16/2020, period reviewed 10/16/2020-12/14/2020, CR revealed patient to have Type 2 Diabetes and equipment documented upon admission includes Glucometer, glucose monitoring strips, and lancets, admission narrative also notes patient to be attempting to check blood sugar prior to hospitalization. No orders for blood glucose monitoring on POC or included in patient record. patient hospitalized while on services, 11/1/2020. Discharge records note blood sugar to be checked at 9:00pm. No orders written or POC updated post hospitalization. CR4, SOS 11/28/2020, period reviewed 11/28/2020-1/26/2021, CR revealed patient to have Type 2 Diabetes and be taking insulin on a sliding scale. Equipment documented upon admission includes Glucometer, glucose monitoring strips, and lancets. Admission narrative documented that patient and son were educated on checking blood sugars. No orders for blood glucose monitoring on POC or included in patient record. CR9, SOS 8/21/2020, period reviewed 8/21/2020-10/15/2020, CR revealed patient to have a diagnosis on POC of urinary catheter. Equipment documented upon admission included Foley Cath insertion tray, foley Cath irrigation set, Indwelling foley catheter, Urinary drainage bag, 16F, 30cc balloon [foley catheter size/balloon volume], and Catheter supplies. Admission narrative documented Foley catheter to be changed in approximately 1 month. No orders for foley catheter change/care on POC or included in patient record. CR10, SOS 6/26/2020, period reviewed 10/24/2020-12/22/2020, POC revealed patient to require Oxygen concentrator and portable Oxygen. Order dated 6/26/2020-Oxygen via NC continuous 1-6L/min to maintain 88% SaO2 [Oxygen saturation]. Oxygen not documented on patient medication list. POC also revealed patient diagnosis of Type 2 Diabetes. Equipment documented upon admission includes Glucometer, glucose monitoring strips, and lancets. No orders for blood glucose monitoring on POC or included in patient record. CR13, SOS 8/10/2020, period reviewed 12/8/2020-2/5/2020, CR revealed order for Oxygen 2 Liters per minute via NC as needed for shortness of breath on 10/8/2020. Oxygen not on medication list. Interview on January 5, 2020 at approximately 4:00pm EMP2 reported that the agency requirement is that the nurse put oxygen either on an order or med list. EMP2 also confirmed agency lack of knowledge that blood glucose checks need added to POC. Findings confirmed during exit interview on January 8, 2021 at approximately 12:30pm with Administrator, Clinical Director, Quality Manager, and Contracted Therapy Director.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on review of agency policy, clinical records (CR), and staff (EMP) interview, it was determined that the agency failed to ensure verbal orders were signed and dated by ordering physician within 30 days for three (3) of fourteen (14) CR's reviewed. (CR 1, 9, & 13) Findings included: Review of agency policy on 1/8/2021 at approximately 12:15pm revealed: "Policy #C-7.0 Physician Verbal/Telephone Orders...Procedure: ...c. All verbal orders will be monitored to ensure countersignature is received within 30 days to be compliant with the Department of Health..." Review of clinical records on January 5, 2021 between approximately 11:50am and 3:30pm, January 6, 2021 between approximately 1:30pm and 3:30pm, January 7, 2021 between approximately 1:20pm and 3:30pm, and January 8, 2021 between approximately 9:15am and 12:00pm revealed: CR1, start of services (SOS) 11/13/2020, period reviewed 11/13/2020-1/11/2021, CR contained Plan of Care (PC) with a verbal order date of 11/30/2020. Doctor signature on POC dated 1/4/2021, 52 days later. CR9, SOS 8/21/2020, period reviewed 8/21/2020-10/15/2020, CR contained POC with a verbal order date of 8/21/2020. Doctor signature on POC dated 9/30/2020, 40 days later. CR13, SOS 8/10/2020, period reviewed 12/8/2020-2/5/2021, CR contained POC with a verbal order date of 12/3/2020. Doctor signature not yet obtained on POC. Review of POC on 1/8/1021 is 36 days later. Interview with EMP1, EMP2, and EMP3 on January 5, 2020 at approximately 4:00pm revealed that the agency has identified a delay in the timeframe from obtaining verbal order approval of POC to getting the POC sent to the doctor for signature. EMP3 reports that the agency had piloted a trial admission nurse program to streamline the SOC review process but that has since absolved and did not result in a fix and the process continued to be prolonged. Findings confirmed during exit interview on January 8, 2021 at approximately 12:30pm with Administrator, Clinical Director, Quality Manager, and Contracted Therapy Director.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on review of agency policy, clinical records (CR), and staff (EMP) interview, it was determined that the agency failed to ensure wounds were assessed and measured weekly for two (2) of fourteen (14) CR's reviewed. (CR2 & 10) Findings included: Review of agency policy on January 8, 2021 at approximately 12:15pm revealed: "Policy # N-7.09 Dressing Changes...Procedure: ...6.A.Wound size including length, width, and depth. document weekly and when needed. B. Drainage characteristics...C. Evidence of wound healing or deterioration. Symptoms of infection including redness.... E. Development of undermining..." Review of clinical records on January 5, 2021 between approximately 11:50am and 3:30pm, January 6, 2021 between approximately 1:30pm and 3:30pm, January 7, 2021 between approximately 1:20pm and 3:30pm, and January 8, 2021 between approximately 9:15am and 12:00pm revealed: CR2, start of services (SOS) 9/24/2020, period reviewed 9/24/2020-11/22/2020, CR contained nurse visit frequency of 1 time a week. Visit conducted on 10/29/2020 for week dated 10/25/2020-10/31/2020. No wound measurement documented this visit. CR10, SOS 6/26/2020, period reviewed 10/24/2020-12/22/2020, CR contained nurse visit frequency of 1 time a week. Visit conducted on 11/5/2020 for week dated 11/1/2020-11/7/2020. No wound assessment documented this visit. Visit conducted on 11/14/2020 for week dated 11/8/2020-11/14/2020. No wound assessment documented this visit. Visit conducted on 11/18/2020 for week dated 11/15/2020-11/21/2020. No wound assessment documented this visit. Findings confirmed during exit interview on January 8, 2021 at approximately 12:30pm with Administrator, Clinical Director, Quality Manager, and Contracted Therapy Director.