Every finding on record at Spiritrust Lutheran Home Care & Hospice

Based on the findings of an onsite unannounced home health agency Medicare recertification survey conducted January 10, 2023 through January 13, 2023 and extended off-site through January 25, 2023, Spiritrust Lutheran Home Care & Hospice, 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 onsite unannounced home health agency Medicare recertification survey conducted January 10, 2023 through January 13, 2023 and extended off-site through January 25, 2023, Spiritrust Lutheran Home Care & Hospice, was found not to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies

Minimum hours of training CFR(s): 484.80(b)(2) A minimum of 16 hours of classroom training must precede a minimum of l6 hours of supervised practical training as part of the 75 hours. This ELEMENT is not met as evidenced by: Based on review of Personnel files (PF), agency’s policies, home health aide job description and an interview with the Agency Administrator, the agency failed to ensure complete documentation that the home health aides completed a minimum of sixteen (16) hours of classroom instruction that precedes a minimum of sixteen (16) hours of supervised practical training as a part of seventy-five (75) hours in three (3) out of four (4) home health aide personal files (PF). (PF #3, #7, and #12) Findings: Review of Spiritrust Lutheran Home Care & Hospice Orientation Education policy on 1/13/23 at approximately 11:00 AM revealed: “1. Purpose: A. To provide performance objectives for a planned orientation for all new employees or current employees changing positions. B. To document the objectives which were satisfactorily met by the employee during orientation. C. To comply with orientation policy. 2. Procedures: A. Standard orientations have been developed and will be used, along with the job description, to develop the orientation schedule for new hires…D. Education staff and hiring managers will collaborate to develop the orientation using the applicable standard orientations, the job description for the position and the policy and procedure reading list as a guideline. F. As each objective is satisfactorily met by the employee, the designated instructor, supervisor, or preceptor will enter hours, date and initial the objective…” Review of Spiritrust Lutheran Home Care & Hospice Competency Assessment for Personal Care Assistants/Certified Nursing Assistants Education policy on 1/13/23 at approximately 11:00 AM revealed: “1. Purpose: A. To define the process of assessing competency for Personal Care Assistants (PCA) and Certified Nursing Assistants (CNA). B. To fulfill the requirements of the Orientation and Continuing Education policies. C. To meet regulatory oversight requirements. 2. Procedure: A. PCA and CNA skills and training will be verified….” Review of Spiritrust Lutheran Home Care & Hospice New Employee Orientation Home Health Aide/Hospice Aide on 1/10/23 at approximately 2:00 PM revealed: All classroom learning and Nurse Preceptor and Home Health Aide Preceptor requirements for a new home health aide employee are listed with columns for date/signature of instructor or preceptor, time, and hours of instruction. A. Supervisor Acknowledgement: “This schedule has been reviewed and all signatures are complete.” An area noted for Supervisor signature and date. B. An interview with the Agency Administrator on 1/11/23 at approximately 11:00 AM revealed: “I know the updated the form sometime in 2020 but I’m not sure of the exact date but here is the updated form that should be used now.” Surveyor was given a copy of the last page of the orientation packet that revealed an added section that states “The following must be completed before independent visits: 1. Seventy-five (75) hours of orientation 2. Sixteen (16) hours providing care under supervision of a Registered Nurse (RN) with at least one (1) year of experience supervising aides 3. All Relias training 4. Second meeting with supervisor with an area for the supervisor’s signature.” Review of Spiritrust Lutheran Home Care & Hospice Home Health Aide/Hospice Aide job description on 1/25/23 revealed: Basic Qualifications: “Aide certification as required by federal and state regulations in the state(s) served by Spiritrust Lutheran Home Care & Hospice; Essential Duties: “3. Provide safe, effective home health aide/hospice aide services under the supervision and guidance of a registered nurse…g. performs specific health procedures as instructed by the registered nurse/therapist. Job Description Acknowledgement: “I understand the education and training requirements…” Review of Personnel files on 1/10/23 between 1:40 PM-3:45 PM and 1/11/23 between 10:30 AM-11:00 AM revealed: PF # 3, Date of Hire (DOH): 6/15/20, orientation packet was incomplete: hours of training not documented, signatures of preceptors missing, not filled in. Only twenty-two (22) hours with preceptor documented. Agency Administrator was only able to find a total of forty-eight (48) hours when she conducted a review of total orientation hours. PF # 7, Date of Hire (DOH): 4/2/18, orientation packet was incomplete: hours of training not documented, signatures of preceptors missing, not filled in. Agency Administrator was only able to find a total of thirty-three (33) hours when she conducted a review of total orientation hours. PF # 12, Date of Hire (DOH): 11/7/16, orientation packet was incomplete: hours of training not documented, signatures of preceptors missing, not filled in. Agency Administrator was only able to find a total of fifty-four (54) hours when she conducted a review of total orientation hours. An interview with the Agency Administrator on 1/13/23 at 11:45 AM confirmed the above findings.

HHA maintains documentation of training CFR(s): 484.80(b)(4) The HHA must maintain documentation that demonstrates that the requirements of this standard have been met. This ELEMENT is not met as evidenced by: Based on review of Personnel files (PF), agency’s policies, home health aide job description and an interview with the Agency Administrator, the agency failed to ensure complete documentation that the home health aides completed a minimum of sixteen (16) hours of classroom instruction that precedes a minimum of sixteen (16) hours of supervised practical training as a part of seventy-five (75) hours in three (3) out of four (4) home health aide personal files (PF). (PF #3, #7, and #12) Findings: Review of Spiritrust Lutheran Home Care & Hospice Orientation Education policy on 1/13/23 at approximately 11:00 AM revealed: “1. Purpose: A. To provide performance objectives for a planned orientation for all new employees or current employees changing positions. B. To document the objectives which were satisfactorily met by the employee during orientation. C. To comply with orientation policy. 2. Procedures: A. Standard orientations have been developed and will be used, along with the job description, to develop the orientation schedule for new hires…D. Education staff and hiring managers will collaborate to develop the orientation using the applicable standard orientations, the job description for the position and the policy and procedure reading list as a guideline. F. As each objective is satisfactorily met by the employee, the designated instructor, supervisor, or preceptor will enter hours, date and initial the objective…” Review of Spiritrust Lutheran Home Care & Hospice Competency Assessment for Personal Care Assistants/Certified Nursing Assistants Education policy on 1/13/23 at approximately 11:00 AM revealed: “1. Purpose: A. To define the process of assessing competency for Personal Care Assistants (PCA) and Certified Nursing Assistants (CNA). B. To fulfill the requirements of the Orientation and Continuing Education policies. C. To meet regulatory oversight requirements. 2. Procedure: A. PCA and CNA skills and training will be verified….” Review of Spiritrust Lutheran Home Care & Hospice New Employee Orientation Home Health Aide/Hospice Aide on 1/10/23 at approximately 2:00 PM revealed: All classroom learning and Nurse Preceptor and Home Health Aide Preceptor requirements for a new home health aide employee are listed with columns for date/signature of instructor or preceptor, time, and hours of instruction. A. Supervisor Acknowledgement: “This schedule has been reviewed and all signatures are complete.” An area noted for Supervisor signature and date. B. An interview with the Agency Administrator on 1/11/23 at approximately 11:00 AM revealed: “I know the updated the form sometime in 2020 but I’m not sure of the exact date but here is the updated form that should be used now.” Surveyor was given a copy of the last page of the orientation packet that revealed an added section that states “The following must be completed before independent visits: 1. Seventy-five (75) hours of orientation 2. Sixteen (16) hours providing care under supervision of a Registered Nurse (RN) with at least one (1) year of experience supervising aides 3. All Relias training 4. Second meeting with supervisor with an area for the supervisor’s signature.” Review of Spiritrust Lutheran Home Care & Hospice Home Health Aide/Hospice Aide job description on 1/25/23 revealed: Basic Qualifications: “Aide certification as required by federal and state regulations in the state(s) served by Spiritrust Lutheran Home Care & Hospice; Essential Duties: “3. Provide safe, effective home health aide/hospice aide services under the supervision and guidance of a registered nurse…g. performs specific health procedures as instructed by the registered nurse/therapist. Job Description Acknowledgement: “I understand the education and training requirements…” Review of Personnel files on 1/10/23 between 1:40 PM-3:45 PM and 1/11/23 between 10:30 AM-11:00 AM revealed: PF # 3, Date of Hire (DOH): 6/15/20, orientation packet was incomplete: hours of training not documented, signatures of preceptors missing, not filled in. Only twenty-two (22) hours with preceptor documented. Agency Administrator was only able to find a total of forty-eight (48) hours when she conducted a review of total orientation hours. PF # 7, Date of Hire (DOH): 4/2/18, orientation packet was incomplete: hours of training not documented, signatures of preceptors missing, not filled in. Agency Administrator was only able to find a total of thirty-three (33) hours when she conducted a review of total orientation hours. PF # 12, Date of Hire (DOH): 11/7/16, orientation packet was incomplete: hours of training not documented, signatures of preceptors missing, not filled in. Agency Administrator was only able to find a total of fifty-four (54) hours when she conducted a review of total orientation hours. An interview with the Agency Administrator on 1/13/23 at 11:45 AM confirmed the above findings.

Based on the findings of an unannounced onsite home health agency complaint investigation survey conducted on 4/25/2022, Spiritrust Lutheran Home Care and Hospice, was found to be not 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 or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on review of agency policy, medical records (MR), interview with office manager (EMP # 1), agency failed to include all complete orders in POC for one (1) of three (3) records reviewed. (MR # 2). Findings included: Review of agency policy on 4/25/2022 between approximately 12:30 PM-3:00 PM titled “Clinical Policies- SLHCH” stated “(C.3) The provider certifies that the client is in need of the services included on the 485/POT {plan of treatment} by signing and dating the 485/POT.” Request for policy regarding contents of 485 made on 4/25/2022 between approximately 12:30 PM-3:00 PM and not produced by agency. Review of MR on 4/25/2022 between approximately 10:00 AM-12:00 PM and 12:30 PM-1:00 PM revealed: MR # 2, SOC 10/5/2021; sixteen (16) year old male with diagnoses of pressure ulcer stage 4 left buttock {wound down to muscle, bone, or supporting tissue}, sepsis {life threatening complication of an infection}, lumbar spina bifida with hydrocephalus {birth defect of spinal cord and water on the brain}. Physician orders 12/4/2021-2/1/2022 for “Skilled Nursing {SN} 1x/wk x 9 wks (12/5/2021-2/1/2022) PRN {as needed} x6 no charge-scheduled call; PRN x 6 complications/med changes ..focus on 1. Infection prevention 2. Fall prevention 3.pressure ulcer formation prevention. Skilled observation and assessment of GU {genitourinary} status, integument status, s/sx {signs/symptoms} infection, s/sx UTI {urinary tract infection}, safety. Assess head to toe. Assess patient pain… Patient identified steps toward personal goal: 1. Do my dressing changes every day 2. Eat a good diet 3. See my doctor when I need to…. Respiratory screening completed every visit….Teach cl/SO {client/significant other} importance of continued follow-up with physician. Wound # 2 traumatic wound on sacrum. Wound care supplies …. Teach integument disease process, s/sx wound infection. .. Wound # 1- left ischial wound-pressure ulcer-dressing changes 3x/day. Cleanse wound and pack with Dakins moistened Kerlix, cover with ABD {abdominal wound dressing}, and secure with medipore tape.” No physician orders for specific wound care to wound # 2 on sacrum, no order for weights or minimal intake of food or fluids, no parameters to contact physician but order to monitor for infection. No documentation of discussion or interim order changes with physician regarding wound care. Interview with (EMP # 1) on 4/25/2022 at approximately 3:00 PM confirmed above findings.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on review of agency policy, medical records (MR), interview with office manager (EMP # 1), agency failed to obtain and include verbal orders for one (1) of three (3) records reviewed. (MR # 2). Findings included: Review of agency policy on 4/25/2022 between approximately 12:30 PM-3:00 PM titled “Clinical Policies- SLHCH” stated “(C.3) The provider certifies that the client is in need of the services included on the 485/POT {plan of treatment} by signing and dating the 485/POT.” Review of MR on 4/25/2022 between approximately 10:00 AM-12:00 PM and 12:30 PM-1:00 PM revealed: MR # 2, SOC 10/5/2021; sixteen (16) year old male with diagnoses of pressure ulcer stage 4 left buttock {wound down to muscle, bone, or supporting tissue}, sepsis {life threatening complication of an infection}, lumbar spina bifida with hydrocephalus {birth defect of spinal cord and water on the brain}. Physician orders 12/4/2021-2/1/2022 for “Skilled Nursing {SN} 1x/wk x 9 wks (12/5/2021-2/1/2022) PRN {as needed} x6 no charge-scheduled call; PRN x 6 complications/med changes ..focus on 1. Infection prevention 2. Fall prevention 3.pressure ulcer formation prevention. Skilled observation and assessment of GU {genitourinary} status, integument status, s/sx {signs/symptoms} infection, s/sx UTI {urinary tract infection}, safety. Assess head to toe. Assess patient pain… Patient identified steps toward personal goal: 1. Do my dressing changes every day 2. Eat a good diet 3. See my doctor when I need to…. Respiratory screening completed every visit….Teach cl/SO {client/significant other} importance of continued follow-up with physician. Wound # 2 traumatic wound on sacrum. Wound care supplies …. Teach integument disease process, s/sx wound infection. .. Wound # 1- left ischial wound-pressure ulcer-dressing changes 3x/day. Cleanse wound and pack with Dakins moistened Kerlix, cover with ABD {abdominal wound dressing}, and secure with medipore tape.” No physician orders for specific wound care to wound # 2 on sacrum, no order for weights or minimal intake of food or fluids, no parameters to contact physician but order to monitor for infection. No documentation of physician interim order for wound care changes or orders for new wound # 3. Interview with (EMP # 1) on 4/25/2022 at approximately 3:00 PM confirmed above findings.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on review of agency policy, medical records (MR), interview with office manager (EMP # 1), agency staff failed to conform to physician orders for two (2) of three (3) records reviewed. (MR # 1-2). Review of agency policy on 4/25/2022 between approximately 12:30 PM-3:00 PM titled “Clinical Policies- SLHCH” stated “(C.3) The provider certifies that the client is in need of the services included on the 485/POT {plan of treatment} by signing and dating the 485/POT.” Review of MR on 4/25/2022 between approximately 10:00 AM-12:00 PM and 12:30 PM-1:00 PM revealed: MR # 1, Start of Care (SOC) 9/27/2021; seventy-six (76) year old female with diagnoses of Chronic Obstructive Pulmonary Disease (COPD), hyper heart and chronic kidney disease with heart failure {long term problem related to high blood pressure}, heart failure {heart doesn’t pump blood as well as it could}. Physician orders 3/26/2021-5/24/2021 for Physicial Therapy (PT) “ ..measures focusing on: fall prevention/home safety education; therapeutic exercises to address balance, strength, and endurance…Assess patient pain. Energy Conservation/Endurance activities. Evaluate and/or validate medication regimen…perform HEP, Respiratory screening completed every visit… teach interventions to monitor and mitigate pain… Daily weight.” Review of PT visit note 3/30/2022, only one visit conducted during physician order 3/26/2022-5/24/2022, respiratory screening “ not performed” and no documentation of daily weight. MR # 2, SOC 10/5/2021; sixteen (16) year old male with diagnoses of pressure ulcer stage 4 left buttock {wound down to muscle, bone, or supporting tissue}, sepsis {life threatening complication of an infection}, lumbar spina bifida with hydrocephalus {birth defect of spinal cord and water on the brain}. Physician orders 12/4/2021-2/1/2022 for “Skilled Nursing {SN} 1x/wk x 9 wks (12/5/2021-2/1/2022) PRN {as needed} x6 no charge-scheduled call; PRN x 6 complications/med changes ..focus on 1. Infection prevention 2. Fall prevention 3.pressure ulcer formation prevention. Skilled observation and assessment of GU {genitourinary} status, integument status, s/sx {signs/symptoms} infection, s/sx UTI {urinary tract infection}, safety. Assess head to toe. Assess patient pain… Patient identified steps toward personal goal: 1. Do my dressing changes every day 2. Eat a good diet 3. See my doctor when I need to…. Respiratory screening completed every visit….Teach cl/SO {client/significant other} importance of continued follow-up with physician. Wound # 2 traumatic wound on sacrum. Wound care supplies …. Teach integument disease process, s/sx wound infection. .. Wound # 1- left ischial wound-pressure ulcer-dressing changes 3x/day. Cleanse wound and pack with Dakins moistened Kerlix, cover with ABD {abdominal wound dressing}, and secure with medipore tape.” Wound care provided to wound # 2 on sacrum, without orders. Order to monitor infection but when temperature increased no call to physician. Addition of wound # 3 with no documentation of a call to physician. Interview with (EMP # 1) on 4/25/2022 at approximately 3:00 PM confirmed above findings.

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 review of agency policy, medical records (MR), interview with office manager (EMP # 1), agency staff failed to promptly alert physician to changes in patient condition for one (1) of three (3) records reviewed. (MR # 2). Review of agency policy on 4/25/2022 between approximately 12:30 PM-3:00 PM titled “Clinical Policies- SLHCH” stated “(II.A.8) " Observing recording, and reporting to the provider the client's reaction to treatment and any changes in the client's condition per agency guidelines." Review of MR on 4/25/2022 between approximately 10:00 AM-12:00 PM and 12:30 PM-1:00 PM revealed: MR # 2, SOC 10/5/2021; sixteen (16) year old male with diagnoses of pressure ulcer stage 4 left buttock {wound down to muscle, bone, or supporting tissue}, sepsis {life threatening complication of an infection}, lumbar spina bifida with hydrocephalus {birth defect of spinal cord and water on the brain}. Physician orders 12/4/2021-2/1/2022 for “Skilled Nursing {SN} 1x/wk x 9 wks (12/5/2021-2/1/2022) PRN {as needed} x6 no charge-scheduled call; PRN x 6 complications/med changes ..focus on 1. Infection prevention 2. Fall prevention 3.pressure ulcer formation prevention. Skilled observation and assessment of GU {genitourinary} status, integument status, s/sx {signs/symptoms} infection, s/sx UTI {urinary tract infection}, safety. Assess head to toe. Assess patient pain… Patient identified steps toward personal goal: 1. Do my dressing changes every day 2. Eat a good diet 3. See my doctor when I need to…. Respiratory screening completed every visit….Teach cl/SO {client/significant other} importance of continued follow-up with physician. Wound # 2 traumatic wound on sacrum. Wound care supplies …. Teach integument disease process, s/sx wound infection. .. Wound # 1- left ischial wound-pressure ulcer-dressing changes 3x/day. Cleanse wound and pack with Dakins moistened Kerlix, cover with ABD {abdominal wound dressing}, and secure with medipore tape.” Review of skilled nursing visit notes revealed: Baseline temperature obtained on 10/5/2021 was 98.4 degrees Fahrenheit. Visit on 12/14/2022 new wound # 2 developed and no call to physician. No documentation of temperature taken. No order for wound care for this newly developed wound but nurses documented same wound care as completed for wound # 1, Cleanse wound and pack with Dakins moistened Kerlix, cover with ABD {abdominal wound dressing}, and secure with medipore tape.” Visit on 1/3/2022 temperature was 99.1 and no documentation of call placed to physician. Visit on 1/12/2022 temperature was 99.1. Wound # 1 on buttock documented slight odor to wound and no documentation of call placed to physician. Visit on 1/25/22022 temperature was 101.7 and new wound # 3 developed and no documentation of call placed to physician. Interview with (EMP # 1) on 4/25/2022 at approximately 3:00 PM confirmed above findings.