Every finding on record at Rock Springs Young at Heart

An Emergency Preparedness survey was conducted by Healthcare Licensing and Surveys on 8/15/24. Based upon the findings of the survey, it was determined that no deficiencies were identified pertaining to the Emergency Preparedness Rule.

A recertification survey was conducted by Healthcare Licensing and Surveys from 8/12/24 to 8/15/24.

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on medical record review and staff interview, the agency failed to provide all services outlined in the plan of care for 1 of 7 patients (#2). The findings were: Review of the medical record for patient #2 showed the skilled nurse was to provide services 5 times a week for 9 weeks. The services included medication management and home safety. Review of the patient's diagnosis showed diabetes mellitus type 2, multiple sclerosis, deep vein thrombosis, dementia, and macular degeneration. The patient lived by his/her self. The following concerns were identified: Observation on 8/13/24 at 11 AM showed the registered nurse (RN) restocked the medication minder, assessed the patient, and injected insulin. Interview at that time with the RN revealed the RN comes 5 times a week and injects the patients insulin for him/her. Review of the home visits showed the agency failed to provide services on 7/3/24, then had 7/4/24 and 7/5/24 off for the holiday. Review of the "Missed Visit Note/Order" form showed the physician had not signed the consent for the missed visit. Review of the agency "Holiday 2024" showed 7/4/24 was a paid Holiday off. 7/5/24 showed it was an unpaid day. Review of the letter to patients and families showed "The home health employees will be off to spend time with their families on ...July 4th."

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 medical record review and staff interview, the agency failed to revise the plan of care to reflect the correct information related to advance directives for 1 of 7 patients (#2). The findings were: Review of the 5/8/24 to 7/6/24 Plan of Care (POC) for patient #2 showed the advance directive of Full Code. Review of the 2/6/24 WyoPOLST (Providers Orders for Life Sustaining Treatment) showed Do Not Attempt Resuscitation (DNR). Interview with the Director of Nursing on 8/14/24 at 12 PM revealed it is the expectation for staff to follow the POC. Further, she confirmed the change in the advance directives was missed.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on observation, staff interview, and cleaning product review, the agency failed to ensure the correct cleaning product was used to ensure clean equipment. The findings were: Observation on 8/13/24 at 9:15 AM showed Certified Nursing Assistant (CNA) #1 was finishing his/her home visit. The CNA opened a circular container labeled Purell and wiped his/her blood pressure cuff, thermometer, pulse ox, and stethoscope down observing the wet time. Further, observation showed the Purell product was a hand sanitizer not meant for disinfecting equipment. Interview at that time with the CNA revealed that the container was what the agency provided him/her to clean the equipment and that was all s/he had with him/her. Interview with the Director of Nursing on 8/14/24 at 12 PM revealed it was the agency fault for the CNA having the wrong product to clean with. Further, she stated she did not look at the container when she issued it to the CNA.

A recertification survey and a COVID-19 focused infection control survey, which included a review of emergency preparedness requirements was conducted by Healthcare Licensing and Surveys from 8/2/21 through 8/5/21. The following common abbreviations are used throughout this document: DON: Director of Nursing HHA: Home Health Aide LPN: Licensed Practical Nurse OASIS: Outcome and Assessment Information Set POC: Plan of Care PT: Physical Therapist RN Registered Nurse Less commonly used abbreviations will be annotated in each deficiency.

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on medical record review, staff interview, and policy review the agency failed to ensure patients received service according to the POC for 2 of 7 sample patients (#4, #6) reviewed for frequency of home visits. The findings were: 1. Review of the POC dated 5/9/21 to 7/7/21 for patient #4 showed diagnoses that included repeated falls, non-compliance with medical treatment, peripheral vascular disease, and polyarthritis. Further, it showed the HHA was to provide assistance 5 times a week for 9 weeks. Review of the home visit documentation for the HHA showed they missed 4 visits in the certification period, (5/24/21, 5/27/21, 5/28/21, 5/31/21). 2. Review of the POC dated 6/23/21 to 8/21/21 for patient #6 showed diagnoses that included Crohn's disease, colostomy, dementia, and mild cognitive impairment. Further, it showed the HHA was to provide assistance 5 times a week for 9 weeks. Review of the home visit documentation for the HHA showed they missed 6 visits in the certification period, (6/28/21, 6/30/21, 7/1/21, 7/2/21, 7/7/21, 7/12/21). 3. Interview on 8/4/21 at 2 PM with the DON confirmed there was no documentation showing why the visits were missed. 4. Review of policy "Report a Missed Visit" with no date showed "...the agency will report to the primary care provider of the missed visit the reason for the missed visit and the service missed and the action taken..."

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, staff interview, review of policy and procedure, and review of manufacturer's instructions, the agency failed to implement measures to prevent infection during 1 of 3 home visit observations (patient #1). The findings were: Observation on 8/4/21 at 10 AM showed HHA #4 took patient #1's vitals with a stethoscope, BP cuff, pulse oximeter, and a thermometer. Further observation showed the HHA cleaned the equipment with a quick wipe of Lysol wipes, and placed the items back into his/her bag. Interview with the HHA at that time revealed the equipment only needed a wipe and would be dry by the time s/he got to the next patient. In addition, when asked about the wet time, the HHA was unable to answer. Review of the instructions on the Lysol wipe package on 8/5/21 at 9:55 AM showed "...to disinfect allow to remain wet for 10 minutes. Allow surface to air dry." Review of the policy "Healthcare Bag Technique" with no date, showed "...Process: ... 17. ...then repack and close the health bag after cleaning any equipment used at the patient's home with sani-wipes and allowed to dry before repacking health bag..."

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on observation, review of agency staff meeting notes, and staff interview, agency failed to maintain a program for the surveillance, and identification of infectious and communicable diseases during 1 of 3 home visit observations (patient #5). The findings were: 1. Observation of a home visit on 8/3/2021 at 4:00 PM showed PT #1 was providing care to patient #5. Staff did not screen the patient by taking temperature or asking any infectious disease screening questions during the duration of the home visit. 2. Review of agency staff meeting notes dated 7/22/2020 showed, "Coronavirus (COVID-19) Screening Criteria questionnaire must be filled out and attached to your daily note". Included in the meeting notes was the screening questionnaire that was referenced. 3. Interview with DON 8/4/2021 at 8:35 AM verified that all staff were expected to screen patients for COVID-19 using the screening questions "when they first arrive" at the home visit.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on medical record review and staff interview, the agency failed to ensure HHA supervisory visits were completed every 14 days for 5 of 7 sample patients (#1, #2, #3, #4, #6) who received HHA services. The findings were: 1. Review of the POC for patient #1 dated 6/2/2021-7/31/2021, showed orders for skilled nursing 1 time a week and HHA 2 times a week for the certification period. Further review showed no evidence of HHA supervisory visits between the dates of 6/24/2021 and 7/20/2021, indicating the patient went 30 days without a HHA supervisory visit. 2. Review of the POC for patient #2 dated 6/17/2020-8/15/2020, showed orders for skilled nursing 1 time a week and HHA 2 times a week for the certification period. Further review showed no evidence of HHA supervisory visits during the certification period, indicating the patient went 60 days without a supervisory visit. 3. Interview with the DON on 8/3/2021 at 11:00 AM verified there were no HHA supervisory visits for patient #2 between the dates of 6/17/20-8/15/20. Later interview of the DON on 8/5/2021 at 8:15 AM verified that there were no HHA supervisory visits for patient #1 between the dates of 6/2/21-7/31/21. 4. Review of the POC dated 11/3/20 through 1/1/21 showed patient #3 had skilled nurse and HHA services assigned through the certification period. Review of the POC showed the HHA was to provide services 5 times a week. Review of the supervisory visit documentation showed only a supervisory visit dated 11/4/20, indicating the patient went 25 days without a supervisory visit. The patient was discharged to hospice on 11/30/21. 5. Review of the POC dated 5/9/21 to 7/7/21 showed patient #4 had skilled nurse and HHA services assigned through the certification period. Review of the POC showed the HHA was to provide services 5 times a week. Review of the supervisory visit documentation showed a supervisory visit dated 5/17/21, and then another on 6/9/2, indicating the patient went 22 days without a supervisory visit. 6. Review of the POC dated 6/23/21 to 8/21/21 showed patient #6 had skilled nurse and HHA services assigned through the certification period. Review of the POC showed the HHA was to provide services 5 times a week. Review of the supervisory visit documentation showed a supervisory visit dated 7/14/21, indicating the patient went 21 days without a supervisory visit. 7. Interview with the DON on 8/5/21 at 9:30 AM confirmed the agency could not provide evidence of supervisory visits.