Every finding on record at Traditions Health Care of Springfield, LLC

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 12/19/2023. During the survey it was determined the home health provider is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Providers.

A partial extended survey for Medicare recertification for the home health provider was completed on 12/19/2023. The provider had 137 current patients.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on policy review, record review, home visit observation, and interview, the provider failed to ensure a complete and accurate list of all the medications that the patient was currently using in, but not limited to, two of three home visit observations (Records/Patients #2 and #3). This deficient practice has the potential to affect the home health provider’s ability to ensure safe and effective use of medications for all patients served by the provider. Review of the home health provider’s policy, titled “Medication List and Monitoring” latest revision dated 02/2023, showed in part the following: -To outline a process for ongoing medication monitoring; - The agency will maintain a current accurate list of all prescription, over the counter (OTC) and sample medications, herbals, and home remedies taken by the patient; - An agency Registered Nurse (RN) will be responsible for coordinating the efforts of monitoring the medication regimen by compiling assessment data through a collaborative effort of all agency staff involved in the patient’s / client’s care; - Medication monitoring will include appropriate data / information to develop an accurate patient / client medication history and a current complete medication profile. This data will be available to all agency staff involved in the patient’s / client’s care; - Professional clinical staff will update the medication list with any change in the medication regimen; and - Verification that medications listed have been reviewed to identify any potential adverse effects, and drug reactions including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and non-compliance with drug therapy. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to the home health provider on 10/21/2023 for care of a pressure sore on the right great toe, and medication management. The patient lived at home. The patient received skilled nursing services. Observation on 12/18/2023 at 4:55 PM, during the patient’s home visit, showed the medications were reconciled by RN-B using a current medication profile supplied by the home health provider, and interview with the cognitive patient. This reconciliation showed the following discrepancies: - Furosemide (diuretic- a class of medicine that help reduce fluid buildup in the body) 80 milligram (mg) tablet, to be taken by mouth daily; and - Hydrochlorothiazide (diuretic- a class of medicine that help reduce fluid buildup in the body) 12.5 mg tablet, to be taken by mouth daily. The medications / empty bottle for the medications were not present and could not be located during the home visit medication reconciliation. During an interview on 12/18/2023 at 5:00 PM, RN - B stated his/her medication list showed the patient should be currently taking both Furosemide 80 milligram (mg) tablet by mouth daily, and Hydrochlorothiazide 12.5 mg by mouth daily. During an interview on 12/18/2023 at 5:05 PM, the cognitive patient did not provide an answer when asked if he/she took the two medications or the whereabouts of the containers for both medications. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to the home health provider on 06/22/2023 after a hospital stay for coronary angioplasty (surgical procedure to open narrowed blood vessels to the heart), and chronic kidney disease with heart failure. The patient lived at home. The patient received skilled nursing services from the home health provider. Observation on 12/19/2023 at 9:10 AM, during the patient’s home visit, showed the medications were reconciled by RN-A using a current medication profile, supplied by the home health provider and interview with the patient. This reconciliation showed the following discrepancies: - Juice Plus Omega Capsule (a dietary supplement) - Four Tablets to be taken by mouth daily. The medication failed to be on the provider’s list; - Juice Plus Vegetable Blend Capsule (dietary supplement) - Three Tablets to be taken by mouth daily. The medication failed to be on the provider’s list; and - Juice Plus Berry Blend Capsule (dietary supplement) - Four Tablets to be taken by mouth daily. The medication failed to be on the provider’s list. During an interview on 12/19/ 2023 at 9:30 AM, the cognitive patient stated that he/she had taken the Juice Plus supplements for over a year. During an interview on 12/20/2023 at 4:00 PM, the administrator stated the following: - Staff are responsible for following the medication management policy, and asking the patient about medication changes each visit; - Staff are responsible to reconcile all medications including over the counter, and supplements with the patient; - Staff are to pull the medications bottles and compare to the medication list; and - Staff are to call the physician and get a correction with any discrepancies.

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 policy revies, record review, and interview, the provider failed to ensure the plan of care contained pertinent diagnoses and interventions to address the needs of the patient as identified in the initial comprehensive assessment in one of five records reviewed (Record/Patient #4). This deficient practice has the potential to affect the accurate care planning for all of the provider's patients. Findings included: Review of the home health provider’s policy, titled “Plan of Care” latest revision dated 03/17/2023, showed, in part: - The agency will use data/information gathered during patient/client assessments in the care planning process which involves the identification of patient/client goals, actions or interventions that will resolve or alleviate the patient’s/client’s problems and/or needs; - All pertinent diagnoses; and - The plan of care must include all medications and treatments. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 11/22/2023 with a primary diagnosis of an open wound to the left lower leg. The patient resided in their own home with the assistance of family and friends. Review of the physical therapy start of care visit dated 11/22/2023, showed documentation that the family was cleansing a wound on the patient’s toe with betadine solution and covering the wound with a tape bandage two times per day. The documentation failed to show a wound on the patient's left leg. The nursing evaluation dated 11/25/2023 failed to contain documentation of a wound on the patient’s left lower leg. Review of the plan of care dated 11/22/2023 to 01/20/2024 showed that: - The primary diagnosis for home health services was an open wound to the left lower leg; and - Contained orders for wound care supplies including wound cleanser, skin prep (pads), and bandages. The plan of care failed to: - Contain interventions for care of the wound on the left lower leg related to the primary diagnosis for care; and - Contain interventions for the wound on the patient’s right toe as identified in the comprehensive start of care assessment. During an interview on 12/19/2023 at 2:11 PM, the administrator stated that: - The plan of care dated 11/22/2023 failed to contain interventions for the care of the wound on the patient’s right toe; - The patient did not have a wound on the left lower extremity at the start of care evaluation visits; and - The primary diagnosis for the plan of care dated 11/22/2023 was incorrect.

The Emergency Preparedness regulations were reviewed as part of the Medicare certification survey completed on 05/05/2021. During the survey it was determined Healthback Home Health of Springfield is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Agencies.

A partial extended survey for Medicare certification for Healthback Home Health of Springfield was completed on 05/05/2021. The agency had 199 current patients. A COVID-19 Focused Infection Control Survey was completed in conjunction with the survey and no deficiencies were identified related to the Focused Infection Control Survey.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review and interview, the agency failed to complete the initial assessment of the patient within 48 hours of the referral to home care, or 48 hours after the patient's return home, or on the physician ordered start of care date in one (Patient/Record #2) of five records reviewed. This deficient practice has the potential to affect the immediate needs of all the agency's patients. Findings included: Review of the agency's policy, "Initial Assessment/Plan of Care," with a revised date of 12/27/17 showed that the plan of care will be developed following completion of the initial assessment and sent to the physician for signature. An initial assessment visit, is held either within 48 hours of the referral or within 48 hours of the client's return home, or on the physician-ordered state of care date, and is completed to determine eligibility for the Medicare home health benefit, including homebound status. RECORD/PATIENT #2: Review of the clinical record showed: - The agency's client referral form dated 03/30/2021 showed a referral date of 03/31/2021; - The admission nursing assessment was dated 04/06/2021 and - The agency did not start the patient's care until 04/06/2021 (six days after the physician's referral). During an interview on 05/04/2021 at 4:10 PM, the Administrator stated that the start of care should be within 48 hours of the patient's referral.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on policy review, home visit observation, record review, and interview, the agency failed to maintain a complete/accurate medication profile in three (Records/Patients #1, #2 and #5) of five records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Medication Review Process," dated 2018, showed: - The patient's home meds are to be reconciled with the physicians and/or hospital discharge documentation to ensure patient safety and physician oversight of all medications; - Any discrepancies shall be reported to physician for guidance; - Registered Nurse (RN) case manager will review all medications found in patient's home; and - Reconcile medications at each visit, and add profile by writing an order, and adding to medication profile RECORD/PATIENT #1: Review of the patient record showed: - Patient recently discharged from the hospital due to a compression fracture (wedged break) of his/her lower back; - Patient care giver (cg) lives with him/her and assists with his/her care; and - Plan of Care (POC)/start of care (SOC) dated 03/22/2021. During a home visit observation on 05/03/2021 beginning at 2:30 PM, the nurse reviewed the patient's medications. The following discrepancies were found: -The medication profile showed an order for calcitonin (Salmon - treatment for bone weakness) 200 units nasal spray, one spray daily. The caregiver said the doctor took him/her off this medication when he/she came home on 03/21/2021; - The medication profile showed an order for fesoterodine (treat overactive bladder, frequent urination) extended release 4 milligram (mg) at bedtime. The cg stated not taking since return home; - The medication profile showed an order for Mecobalamin (Vitamin B 12) 1,000 microgram sublingual (under the tongue) one tablet every morning. Cg stated has not taken since return home; - The medication profile showed pantoprazole (treat damage from heartburn) 40 mg one tablet daily. Cg stated that the patient does not take this medication. Cg stated that the patient takes omeprazole in the morning and at night since 2013; and - The medication profile showed Vitamin D3, 50 microgram capsule, one capsule twice a day. Cg stated that the patient has not taken since return home. During an interview on 05/04/2021 at 4:30 PM, with the administrator, the administrator acknowledged the findings, and no further information was provided. RECORD/PATIENT #2: Review of the patient record showed that the patient was admitted to home health agency (HHA) for treatment of an ulcer (open sore) on his/her right foot on 04/06/2021. Medication review with the physician referral medications and the agency medication list showed aspirin (treat pain, swelling) 325 mg three times a day on the agency medication list. The referral medication list from the physician office showed aspirin 325 mg one time a day. During an interview on 05/05/2021 at 11:20 AM, the administrator concurred with the findings. The administrator contacted the physician immediately for clarification and the physician ordered aspirin 325 mg one time a day. RECORD/PATIENT #5; Review of the patient's record showed patient admitted 04/11/2021 for type 1 diabetes mellitus (disorder in which the body cannot make use of sugars and starches in a normal way. A key element in the proper use of sugar and starches is the hormone Insulin, which is secreted by special cells in an area of the pancreas. Diabetes results from either a lack of insulin or an inability of the body to use the insulin properly) with foot ulcer. During a home visit observation and review with the patient of his/her home medications. on 05/04/2021 beginning at 1:15 PM, the following medication discrepancies were found: - Agency medication list showed Lantus U-100 Insulin subcutaneous (under the skin) - five - eight units (measure of dose) daily. Patient stated that has changed, I am taking eight units. - Agency medication list showed Novolin N Flexpen 100 units/MI subcutaneous - five unit - three times a day. Patient stated taking six units three times a day per sliding scale. Agency medication list failed to document a sliding scale order. During an interview on 05/04/2021 at 5:30 PM, the administrator concurred with the findings, no further information was provided.

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 policy review, record review, home visit observation, and interview, the agency failed to ensure a complete/accurate plan of care (POC) that included all required information was completed in, but not limited to, one (Record/Patient #2) of five records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Initial Assessment/Plan of Care," dated 12/27/17, showed: - The POC will be developed following completion of the initial assessment and sent to the physician for signature. An initial assessment visit is completed to determine the immediate care and support needs of the client. The POC will delineate specific services and assessments to be delivered based on the evaluation and will include amount, frequency, duration, and expected outcomes for the patient. Personnel will promptly alert the physician to any changes in the patient's condition or needs that suggest outcomes are not being achieved and/or that the POC should be altered. The initial POC includes but is not limited to: caregiver needs, patient specific interventions and education, measurable outcomes and goals identified by the agency and the patient, mental status/psychosocial/cognitive status, Review of the agency policy titled, "Client/Family Education," revised date 12/27/17, showed that each patient, and his or her caregiver where applicable receives ongoing education and training provided by the agency, as appropriate, regarding the care and services identified in the POC. The agency must provide training, as necessary, to ensure a timely discharge. RECORD/PATIENT #2: Review of the clinical record showed that the patient was admitted to service on 04/06/2021 with diagnoses of chronic ulcer (open wound) to right foot, Chronic diastolic (Congestive) heart failure (CHF)- (when the heart doesn't pump blood as well as it should). The plan of care (POC) for the current certification period, beginning 04/06/2021, failed to include interventions for the assessment and management of CHF. The POC failed to include importance of patient weights daily. During an interview on 05/04/2021 at 4:20 PM, the administrator stated that he/she would expect the POC to contain interventions to address the management of CHF, e.g. education related to weight assessment, medication instructions etc.

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 clinical record review, home visit observation, and interview, the agency failed to ensure staff promptly notified the physician for a change of condition in four (Records/Patients #1, #2, #3 and #4) of five records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Medical Supervision," revised date 12/27/17, showed the physician will be contacted when there is any change in client condition. RECORD/PATIENT #1 Review of the clinical record showed the patient was admitted to Home Health (HH) on 03/22/2021 with a primary diagnosis of wedge compression fracture (break) of lower back. Registered nurse (RN) documentation on 03/31/2021 showed a severe interaction between patient's medication Potassium Chloride ER (hormone) 20 milliequivalent and Toviaz (treat frequent urination) four milligrams (mg). Record failed to show notification to the physician related to this severe interaction. During an interview with the administrator on 05/04/2021 at 1:40 PM, the administrator stated that he/she could not find where the doctor was notified. Administrator stated that he/she would expect physician notification of severe drug interactions. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to HH on 04/06/2021 with a primary diagnosis of a non-pressure ulcer (open wound) on right foot and area on left foot. RN documentation showed the left foot measurements from 04/06 - 04/22/2021 ranging from 0.3 X 0.3 X 0.1 to 0.5 X 0.5 X 0.1. Documentation on 04/30/2021 showed increase in measurement to 1.1 X 1.0 X 0.2. The clinical record failed to include documentation that the RN reported the increased wound size to the physician. The findings were reviewed with the administrator on 05/04/2021 at 4:25 PM. The administrator stated that he/she would expect the RN to notify the physician of the increase in the wound size. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to HH on 03/19/2021 with diagnoses of Parkinson's disease (chronic disorder of the nervous system characterized by tremors, slow movements, and generalized body stiffness), dizziness and giddiness, and major depressive disorder. During a home visit observation 05/04/2021 beginning at 11:15 AM, the patient stated during medication review, that he/she did not take all of her medications, he/she stated that he/she did not like to take them. Two of the medications that he/she stated that he/she did not always take were his/her pain medication and his/her medication for anxiety/depression. Review of the patient's record showed that he/she always described his/her pain at six or above. The agency pain scale identified "six" as severe pain. Physical therapy (PT) note on 03/22/2021 showed patient rated pain at an eight (eight on agency scale reflects horrible pain). Visit note failed to show physician notification. PT note on 04/13/2021 showed that the patient stated, "no fall since Sunday (04/11)." The record failed to include notification to physician and/or supervisory nurse. PT note on 04/29/2021 showed that the patient said that he/she had been having diarrhea (loose stools) for two days. The record failed to include physician notification of diarrhea. Review of the patient's record showed documentation of patient neurological findings as dizzy, giddy, and at times confused. During home health visit patient on 05/04/2021, became anxious when occupational therapist attempted to place a safety belt around the patient's waist for ambulation safety. No physician notification of patient's neurological complaints, and/or noncompliance with depression/anxiety medication. The findings were reviewed with the administrator on 05/04/2021 at 4:45 PM. No further documentation provided. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted for HH on 04/06/2021 with a primary diagnosis of a non-pressure ulcer on right foot. Review of the plan of care (POC) dated 04/06/2021 showed the RN to provide/educate on non pressure ulcer care to medial left great toe. Review of the RN documentation showed wound measurements from 04/06 - 04/30 ranging from 0.3 X 0.3 X 0.1 to 0.7 X 0.7 X 0.1. Documentation on 04/30/2021 showed wound measurement 1.1 X 1 X 0.2. The clinical record failed to contain documentation that the RN reported the increased wound size to the physician. The findings were reviewed with the administrator on 05/04/2021 at 11:10 AM. The administrator stated that the RN should have notified the physician of the increase in the wound size.

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on policy review, home visit observation, record review, and interview, the agency failed to ensure staff provided patient's ongoing education and training in, but not limited to, two (Records/Patients #2 and #3) of five records reviewed. This deficient practice has the potential to affect all patients served by the home health agency. Findings included: Review of the agency policy titled, "Client/Family Education," revised date 12/27/17, showed that each patient, and his or her caregiver where applicable receives ongoing education and training provided by the agency, as appropriate, regarding the care and services identified in the plan of care (POC). The agency must provide training, as necessary, to ensure a timely discharge. Review of the agency policy titled, "Initial Assessment/Plan of Care," revised 12/27/17, showed the following: - Each patient must receive an individualized plan of care, including any revisions or additions; - The individualized plan of care must also specify the patient and caregiver education and training; and - The individualized POC must provide patient and caregiver training to facilitate timely discharge. RECORD/PATIENT #2: Review of the POC dated 04/06/2021 showed the following: - A diagnosis of non-pressure chronic ulcer (open wound) on the right foot; and - Skilled nurse (SN) to provide/educate on non-pressure ulcer care to medial left great toe; - SN to cleanse with saline, pat dry with 4 X 4, apply skin prep to peri wound skin and allow to dry thoroughly, apply medihoney, cover with gauze and secure with tape. Change every three days and as needed; and - Caregiver (cg) to perform wound care in absence of skilled nurse. Review of SN visit notes failed to show cg performance of wound care. SN documented that cg was able to verbalize ability to change dressing in SN absence, no observation of cg performance of wound care. During interview with the administrator on 05/05/2021, the administrator concurred that the SN should observe cg performance of wound care. RECORD/PATIENT #3: Review of the clinical record showed that the patient was admitted to service on 03/19/2021 with a diagnoses of Parkinson's disease (chronic disorder of the nervous system characterized by tremors, slow movements, and generalized body stiffness), dizziness and giddiness, and major depressive disorder. Review of the medication profile showed the patient on escitalopram 20 milligrams (mg) daily for "mood". [Drug reference showed escitalopram is in class of antidepressants, and is also used to treat generalized anxiety disorder] POC showed SN to provide instructions/reinforcement to recognize signs and symptoms of depression and measures to reduce risk of depression. During home visit observation on 05/04/2021, beginning at 11:15 AM, patient received occupational therapy (OT) exercises. Patient became anxious and shaking physically when OT attempted to place a belt around his/her waist for walking exercise. OT was not able to apply the belt for safety during the exercise. During the home visit observation patient stated that he/she did not take all the medication on his/her medication profile. Patient stated that he/she did not take escitalopram routinely. Patient was unable to verbalize what the medication was prescribed for. Record review failed to show documentation of patient education regarding recognition of signs and symptoms of depression and measures to reduce risk of depression. Seven of seven SN visits showed no SN documentation of education related to depression and/or control of depression. POC goal stated Patient/Caregiver will verbalize understanding of effect and compliance of antidepressants to control signs/symptoms of depression. Documentation stated "additional time required to meet intervention/goal". During an interview on 05/04/2021 at 4:50 PM, the administrator acknowledged the findings, no further information provided.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on home visit observation, and interview, the agency failed to ensure the name and contact information of the home health agency clinical manager was listed in the admission packet of information left in patient homes in three (Records/Patients #1, #3, and #5) of three home visits. This deficient practice has the potential to affect all patients served by the agency. Findings included: RECORDS/PATIENTS #1, #3 and #5: Home visit observations on 05/03/2021 through 05/04/2021 showed the admission packet of information left in the patients home did not include the name and contact information of the home health agency clinical manager. During an interview on 05/05/2021 at 3:45 PM, the Administrator concurred with the findings. He/she stated that at this time he/she was also performing the clinical manager's duties.

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 review, record review, observation, and interview, the agency failed to ensure staff followed infection control standards of practice in two (Records/Patients #3 and #5) of three home visit observations. This deficient practice has the potential to affect the health and safety of all patients served by the agency. Findings included: Review of the agency's policy titled, "Hand Washing overview," showed: Hands should be washed: - After contact with the patient's intact or non-intact skin; - Before entering the supply bag, other than retrieving hand washing supplies; and - After contact with inanimate objects in the immediate vicinity of the patient. Review of the agency's policy titled, "Infection Prevention and Control For All Wound Types," dated 2017 showed, maintain a clean environment by preparing a clean field, using clean gloves and sterile instruments, and preventing direct contamination of materials and supplies. Review of the agency's policy titled, "Clinical Bag Procedure," revised date 11/2018 showed that the clinical bag will not have a "dirty" area. All equipment will be cleansed before and after use prior to replacing into bag. RECORD/PATIENT #3: Review of the patient's plan of care (POC) dated 03/19/2021 showed an order for occupation therapy (OT) to evaluate the patient. Physician order dated 03/26/21 directed OT to provide exercises designed to restore functional strength and range of motion (ROM). OT to establish/upgrade home exercise program to improve functional level. OT to provide muscle re-education designed to restore function lost due to disease or surgical intervention and OT to provide training/treatments to improve fine motor skills. During home visit observation on 05/04/2021, at 11:00 AM, OT provided home exercises. OT directed patient #3 to place wooden clothes pins on a strap hanging from the patient's door. OT had patient #3 remove the clothes pins and place in a plastic bag. OT cleaned the clothes pins with an alcohol wipe. OT then placed the plastic bag that held the clothes pins used by the patient in his/her equipment bag. After patient's exercise completion, OT folded patient's walker and placed next to patient's door. Rubber stopper from the walker fell off the walker leg. OT picked up the rubber stopper from the floor. OT replaced the stopper on the patient's walker. OT failed to perform hand hygiene after contact with the rubber stopper. OT went on to touching his/her equipment bag etc. During an interview with the OT after placement of the soiled plastic bag in his/her equipment bag, OT removed the used plastic bag and threw it in the patient's trash container. During an interview with the Administrator on 05/04/2021 at 3:40 PM, the Administrator stated that the OT should have left the clothes pins in the home. The Administrator stated that the clothes pins could not be cleaned. RECORD/PATIENT #5: Review of the patient's POC dated 04/11/2021, showed an order for the registered nurse (RN) to provide wound care to fourth toe using aseptic technique. During the home visit observation of wound care, the RN was observed performing wound care over his/her cleaned vital sign equipment. Patient #5 placed his/her foot on the chair arm rest directly above the RN's equipment. RN proceeded to remove soiled dressing and perform patient's wound care. RN failed to move his/her equipment from wound care site and failed to cleanse the equipment prior to placing it in his/her equipment bag. The RN dropped his/her can of disinfectant wipes, with one of the wipes falling out of the container. The RN picked up the disinfectant wipes container, failed to clean the container and placed the wipe that fell to the floor into the container for later use and placed the container back into his/her equipment bag. During an interview with the Administrator 05/04/2021 at 4:00 PM, the administrator concurred that the RN should have moved her vital sign equipment prior to wound care and that the wipe container should not have been replaced into his/her bag without disinfection.

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on review of the Missouri Home Health Aide Competency Evaluation, employee file review, and interview, the agency failed to ensure the registered nurse (RN) documented specific comments regarding the tasks observed and the aides performance as required in one (Employee #1) of one home health aide employee file reviewed and failed to ensure all the required tasks had been completed before providing care independently in one (Employee #1) of one home health aide employee file reviewed. This deficient practice has the potential to affect all patients who receive home health aide services. Findings included: Review of the Missouri Home Health Aide/Hospice Aide Competency exam instructs the agency to have the qualified RN observe the aide performing all tasks listed while providing care to a patient. The RN must document specific comments regarding the tasks and the aide's performance, identifying the patient by initials, enter the date the aide satisfactorily completed the task, and sign each task observed. The aide must complete all of the tasks to pass the basic skills test. An aide is not qualified and cannot provide care independently unless all tasks have been satisfactorily completed. Employee #1: Review of the employee file showed: - The basic skills test failed to include specific comments regarding the tasks observed and the aides performance for all the tasks observed; and the following techniques required by regulation were marked not applicable (N/A) - safe transfer technique, bed bath, elimination/incontinent care, and active/passive range of motion. - No optional skills allowed by state law were observed. Optional skills e.g. dressing change ostomy/urinary pouch etc. were marked N/A. During an interview on 05/05/2021 at 3:45 PM the Administrator concurred with the findings.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to provide/send a completed transfer summary within two business days of becoming aware of an unplanned transfer in one (Record/Patient #7) of two closed records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: RECORD/PATIENT #7: Review of the agency's transfer policy with a revised date of 12/27/17 showed: - A transfer summary will be forwarded to the receiving service entity; - A completed transfer summary (Episode Summary) will need to be sent within 2 business days of a planned transfer, if the client's care will be immediately continued in a health care facility; and - Is sent within 2 business days of becoming aware of an unplanned transfer, if the client is still receiving care in a health care facility at the time when HealthBack becomes aware of the transfer. Review of the plan of care dated 02/25/2021 through 04/25/2021 showed diagnoses included but not limited to: - Inflammatory (localized reaction of the body) disorders of scrotum (skin surrounding male sex organs); - Ischemic cardiomyopathy (disorders of the heart muscle); and - Other cardiac (heart) conditions. Review of a physician order showed the patient was admitted to the hospital on 04/15/2021 for pacemaker (an artificial device that gives out electrical discharges to stimulate regular contractions of the heart muscle) problems. The hospital admission/transfer was unscheduled. Review of the medical record failed to show that a transfer summary was sent, within two business days of the unplanned transfer, to the hospital. Review of an episode summary showed the summary was sent to the physician on 04/23/2021. The agency was unable to find documentation of a transfer/episode summary sent to the hospital. During an interview on 05/05/2021, the administrator stated that no transfer summary was sent to the physician or hospital within two days of the unplanned transfer on 04/15/2021.