Every finding on record at Totality Therapy Solutions LLC

Based on the regulatory requirements and standards of 42 Code of Federal Regulations (CFR) 484.102 Emergency Preparedness (EP) Final Rule Requirement for Home Health Facilities effective 11/15/17, an EP survey was performed on 5/14/24. The facility completed a review of their EP plan on 4/20/24. No deficiencies were cited.

A recertification survey was completed on 5/22/24. Standard Level deficiencies were cited.

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 and interview, the agency failed to develop and implement policies and procedures which included infection control prevention during medication management; and failed to adhere to infection control prevention while handling medications for one (#3) of three sampled home visit patients. This deficient practice had the potential to affect all patients cared for by the agency. Findings include: During an observation on 5/22/24 at 9:37 a.m., staff member D had just finished typing information on her laptop computer. Staff member D did not sanitize her hands and don gloves after typing on her computer. Staff member D picked up a medication bottle from patient #3’s plastic bin, which held multiple medications. Staff member D poured the pills from the bottle into her bare hand, picked up the individual pills from her bare hand, then placed them into the days of the week in the pill organizer. After this first bottle of medication was dispersed, staff member D sanitized her hands and continued to fill the organizer with additional medications, again pouring the pills into her bare hand. During an observation on 5/22/24 at 9:43 a.m. staff member D individually removed whole medications from their original container, broke them into two pieces (split in half) with her fingernails, then placed them into a medication organizer. This process was completed with ungloved hands and the absence of a pill cutter. Staff member D continued until all medications were placed into the weekly medication organizer. During an interview on 5/22/24 at 10:12 a.m., staff member D stated when dispensing medication into patients’ organizers, she did not use gloves, but sanitized her hands before the process. She stated she had thumb joint issues and had a hard time “feeling” things when wearing gloves. During an interview on 5/22/24 at 10:24 a.m., staff member A and staff member B stated they did not currently have a policy and procedure which addressed infection control prevention related to the handling of medications.

Based on the regulatory requirements and standards of 42 Code of Federal Regulations (CFR) 484.22 Emergency Preparedness (EP) Final Rule Requirement for Condition of Participation for Home Health Agencies, effective 11/15/17, a recertification EP survey was performed on 5/26/2021. No deficiencies were cited. A COVID-19 Emergency Preparedness abbreviated survey was conducted on 5/26/2021 by the Montana Department of Public Health and Human Services. The facility was found to be in compliance with 42 CFR §483.73; E-0024 (b)(6).

A Recertification survey was completed on 5/26/2021. Standard level citations were cited for this survey. A COVID-19 Focused Infection Control (FIC) survey was conducted by the Montana Department of Public Health and Human Services on 5/26/2021. The facility was found to be in compliance with 42 CFR §484.70 infection control regulations and has implemented the Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19. An Emergency Preparedness (EP) survey which included a review of 42 CFR §483.73; E-0024 (b)(6), was completed on 5/26/2021. The agency was found to be in compliance with 42 CFR §483.73; E-0024 (b)(6). Facility Census: 35 Glossary CMS Centers for Medicare and Medicaid COPD Chronic Obstructive Pulmonary Disease EHR Electronic Health Record HHA Home Health Aide IDT Interdisciplinary Team LPN Licensed Practical Nurse LVN Licensed Vocational Nurse OASIS Outcome and Assessment Information Set POC Plan of Care RN Registered Nurse SN Skilled Nursing SOC Start of Care

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to accurately encode a SOC OASIS assessment for management of oral medications for 1 (#1) of 7 sampled patients. Findings include: Patient #1 had a SOC of 7/7/2020 with a primary diagnosis of COPD. Review of patient #1's OASIS SOC assessment, dated 7/7/2020 (M0090), showed, (M2020), the patient was able to independently administer her medications. Review of a Patient Communication Note, dated 7/10/2020, showed patient #1 was given medications daily by a caregiver. During an interview on 5/26/2021 at 2:03 p.m., staff member A stated the coding for management of oral medications, on patient #1's SOC OASIS, was an error. Staff member A stated patient #1 had a caregiver that administered her medications.

Standard: Initial assessment visit. CFR(s): 484.55(a) Standard: Initial assessment visit. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the timely completion of the initial assessment visit for 1 (#6) of 7 sampled patients. Findings include: Patient #6 had a SOC date of 4/6/21, with a primary diagnosis of systolic heart failure. Review of patient #6's Physician Orders dated 4/2/21, showed an order for home health for skilled nursing services two times a week. Review of patient #6's Nursing Visit Notes, showed the initial visit by the RN as completed on 4/6/21. Review of patient #6's SOC OASIS showed, SOC (M0030) on 4/6/21. Review of patient #6's EHR, did not show a phone call was made to the patient or record review completed within 48-hours of the referral to establish the patient's homebound status and any other acute care needs when an onsite visit could not be completed. During an interview on 5/25/21 at 4:04 p.m., staff member A stated it was the expectation for the initial visit to be completed within 48-hours of admitting a patient onto services. She stated she was not aware of the CMS Emergency Declaration Waiver which had waived the requirements of the initial visit, accepting a phone call and/or record review when an onsite visit cannot be made, in order to validate the patient's homebound status, and immediate care needs within 48-hours.

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the RN completed and documented onsite supervisory visits of the LPN for 1 (#6) of 7 sampled patients. Findings include: A review of the agency's policy and procedure titled, Nursing Services, with an effective date of 12/2020, showed: "1. Nursing care will be provided in accordance with the patient's plan of care, under the supervision of a registered nurse. 2. Professional nursing service will be provided by a registered nurse and include: ...Supervising LVN/LPNs and paraprofessionals providing services. 4. The LPN/LVN will be supervised by the RN as required by applicable state rules and regulations." Patient #6 had a SOC date of 4/6/21, with a primary diagnosis of systolic heart failure. Review of patient #6's POC, for certification period 4/6/21 to 6/4/21, showed SN visits were ordered for twice a week for seven weeks. A review of patient #6's Clinical Visit Notes, from 4/6/21 to 5/25/21, showed the LPN completed the SN visits for the following dates: - 4/20/21, - 4/27/21, - 5/4/21, - 5/11/21, - 5/18/21, and - 5/25/21. A review of patient #6's IDT notes, and RN visit notes, failed to show an RN conducted supervisory visits of the LPN for the dates of service. There was nothing documented in the clinical record of the oversight by the RN of the LPN. During an interview on 5/25/21 at 4:00 p.m., staff member A stated it was the expectation that an RN conduct an onsite supervisory visit of the LPN every 30-days during a patient's certification period to ensure services are being provided as ordered. Staff member A said the documentation of the supervisory visit is charted in the RN's visit note. She said they had patient #6 set up for an RN visit but the RN quit before the visit could be completed.