Every finding on record at Valley County Hospital

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

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on record review, policy and procedure review, and staff interview the agency failed to ensure staff followed their policy and procedure for physician orders when a verbal order was received for 1 of 7 patient records reviewed (Patient 4). The census was 48. Finding are: A. Review of the agency policy and procedure titled, Physician Orders/Plan of Care, revised 6/3/16 revealed: 1. Once a physician's order (verbal order) was received, the receiving staff was to complete a Physician's Telephone order form stating the order, the date, the patient's name, the physician’s name, and was to be signed by the ordering physician. 2. The Physician's Telephone order form was to be mailed or routed to the ordering physician for signature and upon return placed in the patient's clinical record. B. Review of the Patient 4's clinical record revealed: 1. A Home Health Certification and Plan of Care (POC) for the certification period of 9/6/23 through 11/4/23. The POC included orders for Skilled Nurse (SN) 3 times per week to complete wound care to the patient's left lower leg stump and to wounds on right lower extremity, foot, and toes. 2. A SN Routine LPN Visit note dated 10/18/23. The LPN (Licensed Practical Nurse) documented that [gender] received an order for TheraHoney sheet (a dressing made of medical grade honey) cut in pieces and applied to open areas on foot, toes and to bottom side of toes, with OptiLock dressing (a non-adherent dressing) applied over the Therahoney. 3. There was no Physician's Telephone order form completed by the LPN receiving the wound care orders as noted in the SN Routine LPN Visit note dated 10/18/23. C. During an interview on 11/2/23 at 9:25 AM, the Director/Clinical Manager confirmed the LPN failed to follow the agency policy and procedure to complete a Physician’s Telephone order for when a verbal order was received from Patient 4's physician.

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 record review, policy and procedure review, and staff interview, the agency failed to ensure staff promptly notify the patient's physician when a change in wound status occurred for 1 of 3 patient records reviewed (Patient 4), who received wound care, and the agency failed to have a policy and procedure for updating the patient's physician of a change in the patient's condition or needs. The total patient sample size was 7, the census was 48. Findings are: A. Review of the agency policies and procedures revealed the agency did not have a policy or procedure for promptly notifying the patient’s physician of a change in the patient's condition or needs. B. Review of Patient 4’s clinical record revealed: 1. A Home Health Certification and Plan of Care (POC) for the certification period of 9/6/23 through 11/4/23. The POC included orders for Skilled Nurse (SN) 3 times per week to complete wound care to the patient's left lower leg stump and to wounds on the right lower extremity, foot, and toes. 2. A SN Routine LPN Visit note dated 10/16/23. The LPN (Licensed Practical Nurse) documented the patient was instructed to make an appointment with [gender] physician as soon as possible due to changes of the left stump wound identified during the assessment. 3. There was no documentation in the clinical record that the patient’s physician was notified of the changes identified during the wound assessment on 10/16/23 until 10/25/23 when a document titled Physician Communication was sent to the patient’s physician (9 days after the patient was informed of the wound changes). C. During an interview on 11/2/23 at 9:25 AM, the Director/Clinical Manager confirmed the nurse failed to promptly notify the patient’s physician of changes in Patient 4’s wound status when those changes were identified by the nurse. The Director/Clinical Manager also confirmed the agency did not have a policy and procedure for physician notification when a change in the patient's condition or needs occurs.

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 record review, policy and procedure review, the observation of the provision of cares, and staff interview, 2 of 3 agency staff observed during the provision of cares (Staff B and D) to Patient 1 and 3 respectively failed to follow the agency policy for proper bag technique. The total patient sample size was 7, the census was 48. Findings are: A. Review of the agency policy and procedure titled Nursing Bag Technique for Infection Control, revised 5/8/17, revealed: 1. Staff were to perform hand hygiene before entering the nursing bag. 2. Staff were not to re-enter the nursing bag after contact with the patient until hand hygiene was performed. 3. Staff were not to enter the nursing bag with gloved hands; gloves were to be removed and hand hygiene performed prior to re-entering the nursing bag. 4. Staff were to keep the bag closed when pets, children, or visible infestations of pests are present. B. Review of Patient 1’s clinical record revealed The Home Health Certification and Plan of Care for the certification period of 9/25/23 through 11/23/23 included orders for Skilled Nurse (SN) 2 times a week for one week, then 1 time a week for 8 weeks, and 2 as needed visits for observation and assessment. C. Review of Patient 3’s clinical record revealed an order for physical therapy 1 time per week for 1 week, then 2 times per week for 3 weeks, then 1 time per week for 2 weeks. D. During the observation of the provision of cares by Staff B to Patient 1, Staff B failed to: 1. Sanitize hands after taking the patient’s vital signs and before re-entering the nurse bag to remove a laptop. 2. Sanitize hands after completing patient visit and prior to entering the nurse bag to remove additional gloves and disinfectant wipes to clean equipment. E. During the observation of the provision of cares by Staff D to Patient 3, Staff D failed to: 1. Close the nurse supply bag after items needed for the visit were removed. 2. Ensure the contents of the nurse supply bag remained clean when Staff D placed the laptop, used for documentation throughout the visit, directly on top of the nurse bag opening. F. During an interview on 11/2/23 at 9:25 AM, the Director/Clinical Manager confirmed Staff B and Staff D failed to follow the agency’s policy and procedure for proper bag technique during the provision of cares to Patient 1 and Patient 3 respectively.