Every finding on record at Stella Maris, Inc.

A recertification survey of Stella Maris Home Health agency was conducted November 6-8, 2023. After the review of the agency's emergency preparedness program and plan, the agency was found to be in compliance with all Conditions of Participation and related standards found at 42 CFR (Code of Federal Regulations) Part 484.102.

A standard home health agency re-certification survey was conducted at Stella Maris Home Health agency on November 6-8, 2023. The survey included the following: a review of clinical records; a review of the complaint/incident reports; a review of on-call documentation; a review of admission documentation including patient bill of rights; a review of personnel files including professional licenses and expiration dates; a review of Quality Assurance Project Plan and Reports (QAPI) & Potentially Avoidable Event Report; a review of the organizational chart; a review of the CLIA waiver, and interviews with the agency's administrative. The agency's emergency preparedness program and plan were reviewed. Three home visit observations were conducted during the survey. One initial start of care, one routine skilled nursing, and one routine Physical Therapy visit. A total of sixteen randomly selected patient records were reviewed during the survey. The scope of services included the following: Skilled Nursing Services - Ten Physical Therapy Services – Thirteen Occupational Therapy Services - Eight Medical Social Worker - Zero Home Health Aide Services - Zero Speech-Language Services - Zero Findings in this report were based on data present in the clinical record at the time of the reviews. The agency's administrative and clinical staff were kept informed of the survey findings as the survey progressed. The agency's staff were given the opportunity to present information relative to the findings during the course of the survey. The exit conference was conducted with agency personnel on November 8, 2023. The findings of the Medicare re-certification survey were reviewed; a copy of the patient identification key-code and a signed plan of correction verification form were provided to the agency's administrator.

Rights of the patient CFR(s): 484.50(c) The patient has the right to- This STANDARD is not met as evidenced by: Patients have the right to confidentiality of medical records and care. This did not occur. Based on observation, on 11/7/2023, the care information of patient #14 was discussed in a public area within hearing distance of others not directly related to the care of the patient. Failure to maintain privacy of patient care information places the patient at risk for negative healthcare outcomes. Patient: #14 On 11/7/2023, after providing care to patient #14, who resides in an Assisted Living Facility (ALF), the HHA staff nurse proceeded to locate the facility nurse. After the HHA staff nurse inquired and confirmed with the ALF Concierge the facility nurse was caring for patient #14, the ALF Concierge summoned the nurse to the lobby area via the unit wireless call system. The facility nurse appeared shortly, and the HHA staff in the lobby area, approximately 2 feet from the ALF Concierge desk, began discussing Patient #14. The patient's current status, mobility, hygiene, and compliance with care were discussed. Approximately 3 minutes into the exchange of information about the patient, the ALF Concierge, who was within hearing distance of the conversation, suggested that the nurses may want to move their conversation to a private area. The nurses then went into an unoccupied room to discuss the patient further. When asked for the HHAs Patient Privacy policy, the agency staff presented policy HR.6D Privacy of Resident/Patient Information. The policy states that employees are under strict guidelines to protect the confidentiality of information regarding patients and residents. Including but not limited to written, verbal, and non-verbal means. Procedure #4 of this policy states, "Information concerning patients and/or residents is not to be discussed in public areas, e.g., elevators, canteen, cafeteria, hallways, etc."

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 the review of patient records and interview with agency staff, physician orders were not followed for 1 out of 16 patients reviewed. Failure to follow all treatment orders placed the patient at risk for inadequate health care. Patient: #2 1.The skilled nurse (SN) has an obligation to follow all physician’s orders. This did not occur, as evidenced by the findings of the record review on 11/7/2023. On 11/7/2023 during the review of the patient #2 record, it was noted that the physician ordered SN for wound care at the frequency of three times per week for five weeks starting 10/14/2023. On 10/23/2023 the SN noted that the patient and the caregiver were “competent” in the dressing change and furthermore that the patient had agreed to decrease visit frequencies. However, there was no documentation of the physician being notified of the patient status as of the 10/23/2023 visit or a request order for change in the frequency of care. When asked the agency staff were unable to provide any additional documentation.

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: 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. Failure to comply with regulations places patients at risk for inadequate health care. During interdisciplinary team meetings, all HHA staff involved in the patient care must be present for, and, where appropriate, should contribute to, any discussion regarding patient care. This did not occur. On 11/6/23, during review of the agency’s interdisciplinary team meetings attendance records for 10/3/23, 10/4/23, 10/10/23, 10/11/23, 10/12/23, 10/17/23, 10/19/23, 10/24/23, 10/25/23, 10/26/23, 10/31/23, and 11/2/23 there is no evidence of the home health aides attending. When asked, the agency staff was unable provide any documentation of the home health aides attending any interdisciplinary team meetings.