Every finding on record at Tabitha, Inc.

A complaint investigation was completed on 7/25/22. The complaint allegation was substantiated and deficiencies were cited related to the allegation. Agency census was 334. Two condition-level deficiencies were identified during the survey, 484.75 (G700) Skilled Professional Services and 484.105 (G940) Organization and Administration of Services. Findings are: A. An Immediate Jeopardy (IJ) deficient practice was identified during the onsite investigation and the agency was notified on 7/21/22 at 4:00 PM. B. The agency’s IJ began on 7/15/22 when: The agency failed to ensure a skilled nurse was assigned and provided a PRN (as needed) skilled nursing visit, as requested by the patient's caregiver, and approved by the patient’s physician, to assess Patient 1's condition, following the patient's caregiver notifying the agency of the patient’s change in condition on 7/15/22.The agency failed to ensure the needs of Patient 1 were continually assessed and failed to ensure the development of an individualized plan of care and implementation of interventions to meet the needs of the patient. C. The agency's IJ Removal Plan was implemented by the agency on 7/21/22, as confirmed by the surveyor before exiting the agency. This plan included: 1. During the IJ removal process, the agency ensured all phone calls from patients were triaged by the Registered Nurse (RN) Clinical Managers (CM). 2. A specific staff member, an RN or Licensed Practical Nurse (LPN), from each area was scheduled daily to provide PRN visits for their assigned area. 3. If the phone assessment of the situation by the RNCM determined a PRN visit was needed, or the patient/family/caregiver asked for assistance or a PRN visit, the RNCM was to call the staff RN or LPN scheduled to conduct PRN visits that day and notify them of the patient situation and the need for a PRN visit. The PRN visit was to occur within 1 hour. 4. If the PRN nurse could not reach the patient by phone when scheduling a PRN visit, the nurse assigned to complete PRN visits was to call the patient’s family member and the patient's physician. Then, the nurse was to go directly to the patient home for the visit. 5. If the PRN RN/LPN or the on-call staff, due to geography, was not able to make the visit within 1 hour, the RNCM was to notify the patient of the expected time of arrival of the agency staff member and if the situation was determined to be emergent, the RNCM was to either direct the patient to call 911, if their condition changed, or the RNCM was to call 911 for the patient. 6. After hours, all phone calls to the agency from patients were to be triaged through the agency's answering service and PRN visits were to be made by the on-call nurse in each region. An administrative staff member was scheduled on call and available to staff after hours. The administrative staff member was to make an alternate nursing assignment when the on-call nurse was unable to make the visit. 7. All Home Health Agency Staff were to receive education on the new process by the agency administrator and the RN Project Coordinator by email on 7/21/22. Follow up education was to be provided during question-and-answer sessions with staff on 7/27/ 22 and 7/28/22.

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 clinical records and staff interview, the agency failed to conform with physician orders to provide PRN (as needed) skilled nurse visits associated with disease related complications, for 1 of 3 patients reviewed (Patient 1). Agency census was 343 and sample size was 3. Findings are: A. Review of Patient 1’s clinical record and Home Health Certification and Plan of Care for the certification period of 6/9/22 to 8/7/22 revealed the patient had diagnoses of encounter for attention to cystostomy, urinary tract infection, type 2 diabetes mellitus with chronic kidney disease and long term and current use of insulin. The same form revealed physician orders for the patient to receive a skilled nurse visit 1 time every 2 weeks and 3 PRN (as needed) skilled nurse visits for disease related complications. B. Documentation dated 7/15/22 at 11:53 AM revealed the caregiver from Patient 1’s private duty agency had called the Home Health Agency (HHA) and informed them the patient had blood in [gender] urine and the caregiver and requested a HHA nurse call the patient. Documentation dated 7/15/22 at 11:54 AM by Clinical Manager (CM)- L, revealed a phone call from Patient 1’s caregiver was received and the HHA was informed the patient was clammy, and overall, just not [gender] self. The caregiver informed the HHA the patient’s temperature could not be taken due to a nonfunctioning thermometer and the patient had blood in catheter. The patient’s caregiver requested a PRN visit, by the HHA skilled nurse, to assess the patient and the situation. C. Review of Patient 1’s clinical record revealed a PRN visit, as ordered by the patient’s physician for disease related complications and to assess the needs of the patient, was not conducted by the agency and the patient was transferred to the hospital on 7/15/22. D. Interview with the HHA, RN Program Coordinator on 7/21/22 at 10:00 AM confirmed the HHA had not conducted a PRN skilled nursing visit to assess Patient 1, on 7/15/22, as ordered by the patient’s physician, and as requested by the patient's caregiver, to assess the patient for a change in condition. E. The practice of not providing PRN visits as ordered by the patient’s physician to assess the patient's needs when a change in patient condition was identified provided the opportunity for potential harm. This practice had the potential to affect all 343 patients receiving services from the agency.

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: G706: Based on record review, review of policy and procedure and staff interview, the agency failed to ensure a skilled nurse completed an assessment for 1 of 3 patients reviewed (Patient 1), following notification by the patient’s caregiver of a change in the patient’s condition and a request by the caregiver for a skilled nurse to conduct a home visit to assess the patient. Agency census was 343 and sample size was 3. This practice provided the opportunity for a lack of patient assessment and subsequent revisions to the plan of care to prevent adverse patient outcomes. This practice had the potential to affect all 343 patients served by the home health agency. G 710: Based on record review, review of policy and procedure and staff interview, the agency failed to ensure a skilled nurse visit for assessment of the patient was conducted for 1 of 3 patients reviewed (Patient 1), as ordered by the patient’s physician and as requested by the patient's caregiver following the patient's change in condition. Agency census was 343 and sample size was 3. This practice provided the opportunity for skilled nurse visits not to be provided as deemed necessary by the patient's attending physician and resulting in patient's potential decline in condition.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on record review, review of policy and procedure and staff interview, the agency failed to ensure a skilled nurse completed an assessment for 1 of 3 patients reviewed (Patient 1), following notification by the patient’s caregiver of a change in the patient’s condition and a request by the caregiver for a skilled nurse to conduct a home visit to assess the patient. Agency census was 343 and sample size was 3. This practice provided the opportunity for a lack of patient assessment and subsequent revisions to the plan of care to prevent adverse patient outcomes. This practice had the potential to affect all 343 patients served by the home health agency. Findings are: A. Review of agency policy and procedure, titled Reassessment/Recertification with a revision date of 10/10/21, revealed each patient was to be reassessed, using a comprehensive OASIS (Outcome and Assessment Information Set, a comprehensive assessment tool developed for the purpose of gathering data on home health care patients) for review and revision of the plan of care when there is a significant change in the patient’s condition. B. Review of Patient 1’s clinical record and Home Health Certification and Plan of Care for the certification period of 6/9/22 to 8/7/22 revealed the patient had diagnoses of encounter for attention to cystostomy, urinary tract infection, type 2 diabetes mellitus with chronic kidney disease and long term and current use of insulin, and physician orders for a skilled nurse visit 1 time every 2 weeks and 3 PRN (as needed) skilled nurse visits for disease-related complications. C. Review of Patient 1’s clinical record, revealed documentation dated 7/12/22 by the patient’s Registered Nurse Case Manager (RNCM)-F, confirming the RNCM called the patient at 5:22 PM on 7/12/22 for follow up of the patient’s condition, following the patient having an outpatient hospital procedure on 7/11/22 for kidney stone laser blasting and stent placement. The patient informed RNCM-F there had been some blood in their urine, which resolved by drinking fluids and the patient was taking medications as ordered for pain. The RNCM-F documented the patient was informed to call the agency if any concerns developed and the next scheduled routine visit was to occur in approximately 1 week. There was no documentation of contact by the agency with the patient on 7/13 or 7/14/22. D. Documentation dated 7/15/22 at 11:53 AM revealed Patient 1's caregiver, from the private duty agency, had called the Home Health Agency (HHA) and informed them the patient had blood in [gender] urine and requested the HHA nurse call the client. E. Documentation dated 7/15/22 at 11:54 AM revealed the agency received a phone call from Patient 1’s caregiver, from the private duty agency, informing the HHA the patient was clammy, and overall, just not [gender]self. The caregiver informed the HHA the patient’s temperature could not be taken due to a nonfunctioning thermometer and the patient had blood in [gender] catheter. The patient’s caregiver requested a PRN visit from the HHA skilled nurse to assess the patient and the situation. F. Documentation of an email from the HHA administrative assistant dated 7/15/22 at 12:07 PM revealed Patient 1’s caregiver, from the private duty agency, had called the agency again to inform the HHA staff on how to gain access to the patient’s home. The email revealed the caregiver informed the HHA the caregiver would not be at the patient’s home between 2:00 PM and 5:00 PM. G. Documentation of an email dated 7/15/22 at 2:19 PM from scheduling coordinator-I, revealed RN-J was asked to call the patient to determine if the patient needed a skilled nurse visit on 7/15 or 7/16/22. Another email dated 7/15/22 at 3:57 PM revealed RN-J was made aware the patient’s caregiver would not be in the patient’s home between 2:00 and 5:00 PM. H. Review of Patient 1’s clinical record revealed documentation by RN-J that the patient was called by RN-J at 2:32 PM and at 3:33 PM and the patient did not answer the phone. RN-J documented a voicemail was left informing the patient RN-J had called to contact the patient and requested the patient return the call. I. Documentation by the on-call HHA RN-E dated 7/15/22 at 5:42 PM revealed the RN-E received a call from the HHA answering service, from Patient 1’s private duty agency caregiver, asking when the HHA- RN was coming to see the patient. The same documentation revealed the HHA RN-E and the private duty caregiver discussed the patient's symptoms and triaged the patient over the phone and due to the patient’s symptoms, the patient was transferred to the hospital. J. Review of an email from Scheduling coordinator-K sent to Patient 1’s Case Manager, RN-F, dated 7/16/22 at 2:36 PM, revealed the patient was an inpatient at an acute care hospital due to sepsis. K. Interview with the HHA, RN Program Coordinator on 7/21/22 at 10:00 AM confirmed the HHA did not conduct a PRN skilled nursing visit to assess Patient 1’s condition on 7/15/22, as ordered by the patient’s physician, after the HHA being informed of the patient’s change in condition by the patient's caregiver, as requested by the patient’s caregiver, and as outlined in the agency policy and procedure.

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, review of policy and procedure and staff interview, the agency failed to ensure a skilled nurse visit for assessment of the patient was conducted for 1 of 3 patients reviewed (Patient 1), as ordered by the patient’s physician and as requested by the patient's caregiver following the patient's change in condition. Agency census was 343 and sample size was 3. This practice provided the opportunity for skilled nurse visits not to be provided as deemed necessary by the patient's attending physician and resulting in patient's potential decline in condition. Findings are: A. Review of the Home Health Agency (HHA) policy and procedure, titled Care Planning Process, with a review date of 1/14/22, revealed the plan of care will be based on the physician’s orders and will encompass the equipment, supplies and the services required to meet the patient’s needs. The plan of care will be revised as frequently as deemed necessary by the clinicians in collaboration with the patient/caregiver based on the ongoing assessments and responses to treatments of the patient. B. Review of Patient 1’s clinical record and Home Health Certification and Plan of Care for the certification period of 6/9/22 to 8/7/22 revealed the patient had diagnoses of encounter for attention to cystostomy, urinary tract infection, type 2 diabetes mellitus with chronic kidney disease and long term and current use of insulin, and physician orders for a skilled nurse visit 1 time every 2 weeks and 3 PRN (as needed) skilled nurse visits for disease-related complications. C. Documentation dated 7/15/22 at 11:54 AM revealed the agency received a phone call from Patient 1’s private duty agency caregiver, informing the Home Health Agency (HHA) the patient was clammy, and overall, just not [gender]self. The caregiver informed the HHA the patient’s temperature could not be taken due to a nonfunctioning thermometer and the patient had blood in catheter. The patient’s caregiver requested a PRN visit from the HHA skilled nurse to assess the patient and the situation. D. Review of Patient 1’s clinical record revealed documentation Registered Nurse (RN)-J called the patient at 2:32 PM and at 3:33 PM and the patient did not answer the phone. Documentation revealed RN-J left a voicemail both times informing the patient the HHA RN was attempting to call to talk to the patient and to please return the phone call. There was no documentation the HHA and/or RN-J made further attempts to contact the patient. E. Documentation by the on-call HHA RN-E dated 7/15/22 at 5:42 PM revealed RN-E received a call from the HHA answering service, from Patient 1’s private duty agency caregiver, asking when the HHA RN was coming to see the patient. The same documentation revealed HHA RN-E and the patient's caregiver triaged the patient’s symptoms over the phone and due to the patient’s symptoms, the ambulance was called and the patient was transferred to the hospital. F. Interview with the HHA, RN Program Coordinator (PC) on 7/21/22 at 10:00 AM confirmed Patient 1 had a physician order for PRN (as needed) skilled nurse visits for disease related complications, 3 times during the certification period of 6/9/22 to 8/7/22. During the same interview the RN-PC confirmed the HHA did not conduct a PRN skilled nursing visit for Patient 1 on 7/15/22, following the HHA being informed of the patient’s change in condition, or in response to the patient caregiver's request for a PRN visit from the HHA skilled nurse to assess the patient and the situation, or as outlined in the agency policy and procedure, or as ordered by the patient’s physician.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Findings are: G960: Based on review of clinical records, review of policy and procedures and staff interview, the agency failed to ensure Home Health Agency (HHA) staff were assigned and completed PRN (as needed) skilled nurse visits as ordered by the physician for 1 of 3 patients reviewed (Patient 1). Agency census was 343 and sample size was 3. G966: Based on review of clinical records, review of policy and procedure and staff interview, the agency failed to ensure the needs of 1 of 3 patients reviewed (Patient 1) were consistently assessed when a potential change of condition was identified. Agency census was 343 and sample size was 3. G968: Based on review clinical records, review of policy and procedure and staff interview, the agency failed to ensure the plan of care for 1 of 3 patients (Patient 1) was implemented when PRN (as needed) skilled nursing visits were not conducted as ordered by the physician and as outlined in the patient’s plan of care. Agency census was 343 and sample size was 3. The above failed practices of not scheduling or ensuring PRN visits were conducted, as ordered by the patient’s physician to assess the needs of patients experiencing a change in condition, provided the opportunity for potential harm for all 343 patients receiving services from the agency.

Make patient and personnel assignments, CFR(s): 484.105(c)(1) Making patient and personnel assignments, This ELEMENT is not met as evidenced by: Based on review of clinical records, review of policy and procedures and staff interview, the agency failed to ensure Home Health Agency (HHA) staff were assigned and completed PRN (as needed) skilled nurse visits as ordered by the physician for 1 of 3 patients reviewed (Patient 1). Agency census was 343 and sample size was 3. Findings are: A. Review of policy and procedure, titled Care/Service Coordination with a revision date of 11/23/21, revealed timely and ongoing communications is the responsibility of each team member of the interdisciplinary group and will be appropriate to the needs and abilities of the patient and relevant to the care/service provided. Care coordination will include integration of services to ensure identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. B. Review of Patient 1’s clinical record and Home Health Certification and Plan of Care for the certification period of 6/9/22 to 8/7/22 revealed the patient had diagnoses of encounter for attention to cystostomy, urinary tract infection, type 2 diabetes mellitus with chronic kidney disease and long term and current use of insulin, and physician orders for a skilled nurse visit 1 time every 2 weeks and 3 PRN (as needed) skilled nurse visits for disease related complications. C. Review of Patient 1’s clinical record, revealed documentation dated 7/12/22 by the patient’s Case Manager, Registered Nurse (RN)-F, of the RN call to the patient at 5:22 PM on 7/12/22 for follow up of the patient’s condition, following an outpatient hospital procedure on 7/11/22 for kidney stone laser blasting and stent placement. RN-F documented a conversation with the patient and the patient informed RN-F there had been some blood in [gender] urine, which resolved by drinking fluids. The RN documented the patient was informed to call the agency if any concerns developed and of the patient's next scheduled skilled nurse visit in approximately 1 week. D. Documentation dated 7/15/22 at 11:53 AM revealed Patient 1’s caregiver, from the private duty agency, had called the HHA and informed them the patient had blood in [gender] urine and requested the HHA nurse call the client. E. Documentation dated 7/15/22 at 11:54 AM revealed the agency received a phone call from Patient 1’s caregiver, from the private duty agency, informing the Home Health Agency (HHA) the patient was clammy, and overall, just not [gender]self. The caregiver informed the HHA the patient’s temperature could not be taken due to a nonfunctioning thermometer and the patient had blood in [gender] catheter. The patient’s caregiver requested a PRN visit from the HHA skilled nurse to assess the patient and the situation. F. Documentation through an email from the HHA administrative assistant, dated 7/15/22 at 12:07 PM, revealed Patient 1’s caregiver, from the private duty agency, had called the agency again to inform the HHA staff on how to gain access to the patient’s home. The email revealed the caregiver informed the HHA the caregiver would not be at the patient’s home between 2:00 PM and 5:00 PM. G. There was no documentation in Patient 1’s clinical record to indicate the agency assigned a skilled nurse to conduct a PRN visit for assessment of the patient following notification of the patient’s decline in condition until 2:19 PM (2 hours and 22 minutes later) on 7/15/22, when the scheduling coordinator sent an email to RN-J asking the RN to call the patient to determine the need for a PRN visit. H. During interview with the HHA RN Program Coordinator (PC) on 7/21/22 at 10:00 AM, the RNPC and the agency Administrator, confirmed Patient 1’s Case Manager was not working on 7/15/22 and confirmed when PRN visits were requested by patients, the request was sent to the scheduling coordinators for assignment. The Administrator and the RNPC confirmed there were no staff specifically assigned to conduct PRN visits. During the same interview the RNPC and the Administrator confirmed the agency did not have a system in place to assign staff for the provision of PRN visits. I. This practice provided the opportunity for PRN visits to not be conducted as needed for disease related conditions for patients with the potential for patient harm. This practice had the potential to affect all 343 patients.

Assure patient needs are continually assessed CFR(s): 484.105(c)(4) Assuring that patient needs are continually assessed, and This ELEMENT is not met as evidenced by: Based on review of clinical records, policy and procedure, the agency failed to ensure the needs of 1 of 3 patients reviewed (Patient 1) were consistently assessed when a potential change of condition was identified. Agency census was 343 and sample size was 3. Findings are: A. Review of agency policy and procedure, titled Reassessment/Recertification with a revision date of 10/10/21, revealed each patient was to be reassessed, using a comprehensive OASIS (The Outcome and Assessment Information Set, which is a comprehensive assessment tool that was developed for the purpose of gathering data on home health care patients) for review and revision of the plan of care when there is a significant change in the patient’s condition. B. Review of Patient 1’s clinical record and Home Health Certification and Plan of Care for the certification period of 6/9/22 to 8/7/22 revealed the patient had diagnoses of encounter for attention to cystostomy, urinary tract infection, type 2 diabetes mellitus with chronic kidney disease and long term and current use of insulin, and physician orders for a skilled nurse visit 1 time every 2 weeks and 3 PRN (as needed) skilled nurse visits for disease related complications. C. Documentation dated 7/15/22 at 11:53 AM revealed the caregiver from Patient 1’s private duty agency had called the HHA and informed them the patient had blood in [gender] urine and the caregiver requested the HHA nurse call the client. D. Documentation dated 7/15/22 at 11:54 AM revealed the agency received a phone call from Patient 1’s caregiver and the Home Health Agency (HHA) was informed the patient was clammy, and overall, just not [gender]self. The caregiver informed the HHA the patient’s temperature could not be taken due to a nonfunctioning thermometer and the patient had blood in catheter. The patient’s caregiver requested a PRN visit, for the patient, by the HHA skilled nurse, to assess the patient and the situation. E. Review of Patient 1’s clinical record revealed a PRN visit, as ordered by the patient’s physician for disease related complications and to assess the needs of the patient, was not conducted by the agency and the patient was transferred to the hospital on 7/15/22. F. This practice of not providing PRN visits, as ordered by the patient’s physician to assess the needs of patients experiencing a change in condition, provided the opportunity for potential harm for all 343 patients receiving services from the agency.

Assure implementation of plan of care CFR(s): 484.105(c)(5) Assuring the development, implementation, and updates of the individualized plan of care. This ELEMENT is not met as evidenced by: Based on review clinical records, review of policy and procedure and staff interview, the agency failed to ensure the plan of care for 1 of 3 patients (Patient 1) was implemented when PRN (as needed) skilled nursing visits were not conducted as ordered by the physician and as outlined in the patient’s plan of care. Agency census was 343 and sample size was 3. Findings are: A. Review of the policy and procedure titled Care Planning Process, with a revision date of 1/14/22, revealed the Plan of Care was to be individualized and was to be a patient specific clinical plan, which included orders for patient specific home health service needs, identified in the comprehensive assessment, and the responsible discipline(s), treatments, and procedures, including amount, frequency, and duration. The care planning decisions were to be based upon the physician’s orders and were to encompass the equipment supplies and services required to meet the patients needs. B. Review of Patient 1’s clinical record and Home Health Certification and Plan of Care for the certification period of 6/9/22 to 8/7/22 revealed the patient had diagnoses of encounter for attention to cystostomy, urinary tract infection, type 2 diabetes mellitus with chronic kidney disease and long term and current use of insulin, and physician orders for a skilled nurse visit 1 time every 2 weeks and 3 PRN (as needed) skilled nurse visits for disease related complications. C. Documentation by the on-call Home Helath Agency (HHA) Registered Nurse (RN)-E dated 7/15/22 at 5:42 PM revealed RN-E received a call from the HHA answering service, from Patient 1’s private duty agency caregiver, asking when the HHA-RN was coming to see the patient. The same documentation revealed the HHA RN-E, and the caregiver triaged the patient’s symptoms over the phone and due to the patient’s symptoms, the patient was transferred to the hospital via ambulance. D. Review of Patient 1’s clinical record revealed a PRN (as needed) visit, as ordered by the patient’s physician for disease related complications, was not conducted by the agency following notification of the patient's change in condition by the patient's caregiver and following the request of a PRN visit by the patient's caregiver. E. This practice of not providing PRN visits as ordered by the patient’s physician to assess the needs of patients experiencing a change in condition provided the opportunity for potential harm for all 343 patients receiving services from the agency.

Tabitha Home Health Care is in compliance with the requirements of 42 CFR 484.102 Condition of Participation for Home Health Agencies.

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 policy and procedure review, the observation of the provision of cares, and staff interview, 3 of 7 agency staff observed during the provision of cares (Staff -D, E, and F) failed to follow the agency policies and procedures for hand hygiene, glove use, and/or proper bag technique while providing cares to Patient-1, 2, and 3 respectively. The census was 367. A. Review of the agency policy and procedure titled, Hand Hygiene, last updated 7/28/21, revealed the agency staff were to complete hand hygiene using an alcohol based hand rub: 1. Before having direct contact with patients. 2. Before donning sterile gloves. 3. After contact with a patient's intact skin (when taking a pulse, blood pressure, or lifting a patient). 4. After contact with body fluids. 5. When moving from a contaminated body site to a clean body site. 6. After contact with inanimate objects in the immediate vicinity of the patient. 7. After removing gloves. B. Review of the agency policy and procedure titled, Bag Technique, last reviewed 7/28/21, revealed: 1. Hand hygiene was to always be completed prior to entering the nurse bag. 2. All supplies necessary for the visit were to be removed after washing hands. 3. Hands were to be decontaminated prior to returning clean equipment to the nurse bag. C. Review of the agency policy and procedure titled, Personal Protective Equipment, last reviewed 7/28/21 revealed: 1. Gloves were to be removed after contact with each person, fluid item, surface, or if torn or punctured. 2. Hands must be decontaminated immediately, or as soon as feasible, after removal of gloves. D. During observation of the provision of cares to Patient-1 on 11/23/21 at 9:00 AM, Home Health Aide (HHA)-D, the HHA failed to: 1. Remove gloves and sanitize hands when moving from a contaminated body part (peri-area) to clean body part (washing hair). 2. Remove gloves and sanitize hands after assisting with bathing and prior to assisting patient to dry cleaned body. 3. Remove gloves and sanitize hands after assisting the patient with bathing tasks, including providing peri-cares to the patient, and prior to opening multiple dresser drawers in the patients bedroom. E. During the observation of the provision of cares to Patient -2 on 11/23/21 at 11:30 AM, HHA- E failed to: 1. Remove gloves and sanitize hands after assisting patient to dry [gender] body after bathing, and prior to entering patient's bedroom and opening dresser drawers to obtain clothing for patient and prior to opening drawers in a living room table to obtain scissors for use (to cut tag from clothing). F. During the observation of the provision of cares to Patient-3 on 11/23/21 at 2:40 PM, Physical Therapist- F failed to: 1. Sanitize hands after performing a temperature check and prior to obtaining blood pressure cuff from nurse bag. 2. Sanitize hands after taking a blood pressure and prior to obtaining an oximeter (an electronic device that measures the circulating oxygen in the blood) from the nurse bag. G. During an interview on 12/2/21 at 12:50 PM the Administrator confirmed Staff- D, E, and F did not follow the agency policy and procedures for hand hygiene, glove use, and/or proper bag technique when providing cares to Patient-1, 2, and 3 respectively.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on record review, policy and procedure review, and staff interview, the agency failed to ensure the Registered Nurse (RN) followed the agency policy and procedure to develop a Home Health Aide (HHA) plan of care that was individualized to the patient specific needs for 4 of 8 patients reviewed who received HHA services (Patient- 1, 2, 8, and 12). The census was 367. Findings are: A. Review of the agency policy and procedure titled, Home Health Aide Plan of Care, last reviewed 8/7/21, revealed the patient's RN Case Manager was to develop the written HHA plan of care consistent with the comprehensive assessment, physician orders, and was to be individualized to the specific patient needs. B. Review of Patient-1's clinical record revealed: 1. The Home Health Certification and Plan of Care for the certification period of 11/17/21 through 1/15/22 included orders for HHA services 1 time per week for 1 week, then 2 times a week for 1 week for assistance with personal care, hygiene, activities of daily living, and bathing. The plan of care also indicated the patient needs assistance with safely bathing. 2. The written Aide Care Plan Report (HHA Plan of Care) only instructed the HHA to provide all activities of daily living tasks listed, including bathing, on an as needed basis. C. Review of Patient-2's clinical record revealed: 1. The Home Health Certification and Plan of Care for the certification period of 11/14/21 through 1/12/22, included orders for HHA services 1 time per week for 1 week, then 2 times per week for 2 weeks. The patients primary diagnoses was listed as a fracture of an unspecified part of the neck of the femur (a hip fracture) with routine healing. 2. The form Tabitha Nursing and Rehabilitation Center Medication Review Report (used for interagency transfer information) included instructions for activity as tolerated with restrictions: Anterior hip precautions. Ambulate with assistance, do not bend forward greater than 90 degrees. 3. The Aide Care Plan Report did not include instruction to the HHA for the anterior hip precautions listed in C2 above. D. Review of Patient- 8's clinical record reviewed: 1. The Home Health Certification and Plan of Care for the certification period of 11/10/21 through 1/8/22, included orders for HHA services 2 time per week for 3 week, for assistance with personal care, hygiene, activities of daily living. The Patient has a listed diagnosis of encounter for change or removal of surgical wound dressing, encounter for surgical aftercare following surgery on the circulatory system. It also revealed the patient had an incision site located to area under left breast. 2. The patient's discharge instructions include incision care orders including: safe to wash incision with antibacterial soap and warm water, avoid vigorous scrubbing, do not apply lotions, creams, oils, or powders on the incision. Patient also instructed to report tenderness to incision, increased redness or swelling to incision, any drainage, or any fever greater than 101. 3. The Aide Plan of Care Report did not include any of the instructions to the HHA for any incision care instructions or for reporting any of the listed signs or symptoms as listed in D2 above, to the nurse. E. Review of Patient 12's clinical record revealed: 1. The Home Health Certification and Plan of Care for the certification period of 11/11/21 through 1/9/22, included orders for HHA 2 times a week for 3 weeks, then 1 time a week for 1 week. The patient diagnosis was listed as displaced intertrochanteric fracture of the right femur (hip fracture), with routine healing and indicated the patient was to be partial weight bearing (not able to bear full weight on the affected hip). 2. The Aide Plan of Care Report did not include instructions to the HHA regarding the weight bearing status for the patient. F. During an interview on 11/23/21 between 11:30 AM and 12:30 PM, the HHA confirmed there were no directions on the Aide Plan of Care Report to monitor or instruct the patient to maintain hip precautions as listed in C2 above. G. During an interview on 12/2/21 at 12:50 PM, the Administrator confirmed the Aide Plan of Care Report for Patient-1, 2, 8, and 12 developed by the registered nurse did not include patient specific interventions or instructions for the agency HHA's to follow while providing cares to the agency patients.