Every finding on record at Valley Medical Systems, Inc.

The following reflects the findings of the Department of Public Health-Licensing & Certification during a recertification survey.Representing the Department of Public Health: Health Facilities Evaluator Nurse 40030 RN, Health Facilities Evaluator Nurse.Sample Patients with Home Visits: 7Sample Patients without Home Visits: 10Total sampled patients: 17The agency was found to be in substantial compliance with the Conditions of Participation

Make efforts to resolve the problem(s) CFR(s): 484.50(d)(5)(ii) (ii) Make efforts to resolve the problem(s) presented by the patient's behavior, the behavior of other persons in the patient's home, or situation; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to address causes for discharge for two of five sampled patients (Patient 16 and 17) when the agency did not make efforts to resolve problems presented by the patients’ behaviors. These failures resulted in Patients 16 and 17's rights not to be upheld and being discharged from home health (HH) without cause. 1. During a review of Patient 16’s “SN (Skilled Nursing) Discharge Summary” (DS), dated 11/5/21, the DS indicated, “… Reason for D/C: (discharge) Noncompliant …” During a review of Patient 16’s “Physician Order” (PO), dated 11/5/21, the PO indicated, “… Discharge patient from all [agency name] services for non-compliance …” During an interview on 5/12/22, at 8:46 a.m., with Registered Nurse (RN) 1, RN 1 stated, Patient 16 had been noncompliant with HH visits throughout her admission. RN 1 stated, there were times when Patient 16 did not answer the phone for visits. RN 1 stated, Patient 16 was not available all the time for nursing visits. RN 1 stated, Patient 16 was going to be admitted on 11/5/21 after being away from the agency for a few months. RN 1 stated, Patient 16 was not available for any visits after the start of care (SOC) visit. RN 1 stated, he placed a physician order to discharge Patient 16 from the agency. RN 1 stated, there was no documentation about resolving issues of noncompliance with Patient 16. RN 1 stated, the clinicians (RNs and Physical therapists) who were able to visit Patient 16 could have addressed the issues of compliance with visit schedule. RN 1 stated, the physician was not informed of noncompliance with HH visits before being discharged. RN 1 stated, there should have been an effort to attempt to resolve any issues with Patient 16 regarding compliance with HH visits before discharge. During review of Patient 16’s clinical record, there was no documentation of attempts to resolve problems with noncompliance of home visit, nor informing the physician of noncompliance throughout Patient 16’s admission. 2. During a review of Patient 17’s “Discharge (DC)," dated 11/10/21, the DC indicated, “… Discharge from [agency name] services for non-compliance …” During a review of Patient 17’s “PO,” dated 11/10/11, the PO indicated, “… Discharge patient from all [agency name] services due to non-compliance …” During an interview on 5/12/22, at 8:46 a.m., with RN 1, RN 1 stated, Patient 17 had been noncompliant with home visits during her admission to HH. RN 1 stated, the agency decided to discharge her from the services because the agency could not get a hold of her for scheduling home visits. RN 1 stated, there was no documentation about resolving issues of noncompliance with Patient 17. RN 1 stated, the clinicians who were able to visit Patient 16 could have addressed the issues of compliance with visit schedule. RN 1 stated, the physician was not informed of noncompliance with HH visits before being discharged. RN 1 stated, there should have been an effort to attempt to resolve issues with Patient 17 regarding compliance with HH visits before discharge. During a review of Patient 17’s clinical record, there was no documentation of attempting to resolve problems with noncompliance of HH visit, nor informing the physician of noncompliance throughout Patient 16’s admission. During an interview on 5/12/22, at 10:20 a.m., with the Director of Patient Care Services (DPCS), DPCS stated, the process for addressing patient noncompliance with care and HH visits was to educate patients about continuing to be compliant with care. DCPS stated, it was the right of patients to refuse care. DCPS stated, clinicians needed to attempt to resolve issues with patients before discharging all HH services. DPCS stated, Patients 16 and 17 were not being compliant with home visits throughout their admission to HH. DPCS stated, the clinicians should have attempted to resolve problems with the patients during visits. DPCS stated, the clinicians should have documented all attempts to try and resolve issues with patient noncompliance before discharging from HH services. During a review of the agency’s policy and procedure (P&P) titled “Patient Discharge Process,” undated, the P&P indicated, “… Purpose … To assure collaboration with the physician, patient, family and other disciplines in planning for discharge from [agency name] … 3. The physician will be involved in the discharge plan and specific ongoing care needs will be identified and addressed as part of the plan. 4. The impending discharge will be reviewed with other members of the home care team to assure coordination and continuity with the patient and family/caregivers … 9. To avoid charges of “abandonment” at the time of discharge [agency name] documentation will include the following: a. Evidence that the decision was not made unilaterally. The patient, family and physician participated in the decision to discharge patient from [agency name] … Discharge Criteria: 1. Criteria for discharge may include, but are not limited to the following: … c. Patient is non-compliant with the established plan of care. [agency name] will do the following before it discharges a patient for cause: Advise the patient/representative, and the patient’s physician who will be responsible for providing care and services to the patient after discharge from [agency name] (if any) that a discharge for cause is being considered. Make efforts to resolve the problem(s) presented by the patient’s behavior, the behavior of other persons in the patient’s home, or situation … Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records …”

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 interview and record review, the agency failed to ensure a Registered Nurse (RN) performed an initial assessment within 48 hours of start of care (SOC - initial visit wherein a clinical assessment was done to identify the needs of the patient that will be addressed by a home health agency) for one of 17 sampled patients (Patient 17) when Physical Therapist (PT) 1 initiated the start of care visit 5 days prior to RN visit. This failure resulted in Patient 17 not being assessed and her needs not identified timely by the RN. During a review of Patient 17’s hospital clinical record titled “Home Health Packet,” dated 7/14/21, the Home Health Packet indicated, “… Home Health Services needed: Patient (17) will need PT (Physical Therapist), OT (Occupational Therapist), MSW (Medical Social Worker), RN (Registered Nurse) for medication education and compliance …” During a review of Patient 17’s “SOC”, dated 7/17/21, indicated, “… PT (1) SOC completed …” During a review of Patient 17’s “SN (Skilled Nursing) Evaluation Visit”, dated 7/22/21, indicated, “… Electronically Signed by: RN (1) …” During an interview on 5/12/22, at 8:46 a.m., with RN 1, RN 1 stated, he did not know what clinician needed to do during an initial start of care (SOC) visit for patients. RN 1 stated, he assumed an RN would need to perform an SOC visit if the patient required nursing services. During a concurrent interview and record review on 5/12/22, at 10:10 a.m., with the Director of Patient Care Services (DPCS), DPCS reviewed Patient 17’s “Home Health Packet,” dated 7/14/21, the “SOC,” dated 7/17/21 and the “SN Evaluation Visit,” dated 7/22/21. DPCS stated, Patient 17’s initial referral order was to include nursing services for medication management and education. DPCS stated, the initial SOC visit was performed by PT 1 on 7/17/21. DPCS stated, an SN visit was done by RN 1 on 7/22/21. DPCS stated, when nursing services were ordered for a patient during the referral process, the RN needed to perform the initial SOC visit. DPCS stated, a RN needed to do the SOC visit for Patient 17 on 7/17/21. DPCS stated, RN 1 needed to do the initial SOC to assess Patient 17’s care needs to ensure an appropriate comprehensive assessment was done for the patient. PT 1 was not available for interview. During a review of the agency’s policy and procedure (P&P) titled, “Comprehensive Patient Assessment,” undated, indicated, “… To determine the appropriate care, treatment and services to meet patient initial needs … SPECIAL INSTRUCTIONS 1. The Comprehensive Assessment will be completed by a Registered Nurse. The Comprehensive Assessment may be completed by a Physical Therapist or Speech Language Pathologist when those therapy services are the only service ordered by the physician. 2. The Comprehensive Assessment will include a review of all medications the patient is using. This assessment will identify potential adverse effects and drug reactions, including ineffective therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with therapy …”

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to complete a comprehensive assessment for one of 17 sampled patients (Patient 11) when the agency's Physical Therapy (PT) service did not perform an initial comprehensive assessment within 5 days of the start of care (SOC- initial visit in where a clinical assessment is done to identify the needs of the patient that will be addressed by a home health agency) date. This failure resulted in PT services not started in a timely manner and placed Patient 11 at a risk for his care needs not met. During a review of Patient 11’s “SOC”, dated 2/8/22, the “SOC” indicated, “… Signed Electronically by [Registered Nurse (RN) 2] … PT Frequency: Eval (evaluation) …” During a review of Patient 11’s “Physician Order (PO),” dated 2/22/22, the PO indicated, “… Physical Therapy 2wk6 (two visits for six weeks) Effective from 2/22/22 …” During a review of Patient 11’s “PT Evaluation”, dated 2/22/22, the PT Evaluation indicated, “… Electronically Signed by [PT 2] …” During an interview on 5/11/22, at 10:08 a.m., with Registered Nurse (RN) 2, RN 2 stated, she had done the initial SOC visit on Patient 11 and identified the need for PT for Patient 11. RN 2 stated, she had requested for a PT evaluation for Patient 11 on 2/8/22. During an interview on 5/11/22, at 11:10 a.m., with PT 2, PT 2 stated, he had placed an order for PT evaluation for Patient 11. PT 2 stated, he did not remember the timeframes for doing a PT evaluation on patients from the SOC visit. PT 2 stated, the agency called him for evaluations on patients and he performed the evaluations when he had the time. PT 2 stated, he was not able to get a hold of Patient 11 on the phone to schedule an evaluation visit. PT 2 stated, he did not remember making a documentation regarding Patient 11’s availability. During a concurrent interview and record review on 5/12/22, at 10 a.m., with the Director of Patient Care Services (DPCS), Patient 11’s “SOC”, dated 2/8/22; “PO,” dated 2/22/22; and “PT Evaluation”, dated 2/22/22 were reviewed. DPCS stated, the SOC visit for Patient 11 was on 2/8/22. DPCS stated, RN 2 identified the need for Patient 11 to get a PT evaluation. DPCS stated, PT 2 did the evaluation on 2/22/22. DPCS stated, PT 2 needed to have done the PT evaluation within five days from the SOC date. DPCS stated, PT 2 should have documented a note indicating the reason for the delay to complete the PT evaluation for Patient 11. DPCS stated, there was no documentation of Pt 2’s encounter with Patient 11 requesting a later date. DPCS stated, it was important for PT 2 to do an evaluation within five days of the SOC to immediately address Patient 11’s initial care needs. During a review of the agency’s policy and procedure (P&P) titled, “Comprehensive Patient Assessment”, undated, indicated, “… A thorough, well organized, comprehensive and accurate assessment, consistent with the patients immediate needs will be completed for all patients in a timely manner, but no later than five calendar days after start of care … PURPOSE To determine the appropriate care, treatment and services to meet patient initial needs and his/her changing needs … To identify patients medical, nursing, rehabilitative, social and discharge planning needs …”

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 observation, interview and record review, the agency failed to review all medications and update the medication profile with the current medications for three of seven sampled patients with home visits (Patients 1, 2 and 4) when: 1. Patient 1 had three medications (Atenolol-used to treat high blood pressure and chest pain; Pantoprazole-use to treat high levels of stomach acid; Magnesium oxide-used treat a mineral supplement the body needs to relieve a sour stomach caused by too much acid the stomach) he took at home that were not in his active medication profile. 2. Patient 2 had one topical medication [brand name - used to form a barrier on the skin to protect it from irritants] that was not on the Patient 2’s medication profile. 3. Patient 4 had one medication (atorvastatin-used to treat high fat content levels in the blood) that had a different dose on the medication list, and four different vitamins with no indication. These failures placed Patients 1, 2 and 4 at potential risks for ineffective drug therapy, adverse effects, drug reactions and unnecessary medications. 1. During a concurrent observation and interview on 5/3/22, at 11 a.m., with Caregiver (CG) 1, in Patient 1’s home, a review of the patient’s medications was done. There were three medication bubble packs, one labeled “Atenolol 25 mg (milligrams- unit of measure) take 1 tablet by mouth once daily” dated 4/14/22, a second labeled “Pantoprazole 20 mg take 1 tablet by mouth once daily before breakfast” dated 4/28/22 and a third labeled “Magnesium Oxide 400 mg tabs take 1 tablet by mouth once daily before breakfast” dated 4/18/22. During a review of Patient 1’s “Medication Profile” (MP), dated 3/19/22-5/17/22, the MP indicated, “Active Medications”, there was no indication for Atenolol, Pantoprazole, or Magnesium Oxide medications. 2. During a concurrent observation and interview on 5/3/22, at 2:23 p.m., with CG 2, in Patient 2’s home, a review of the patient’s medications was done. There was an undated medication tube labeled [brand name]. CG 2 stated Patient 2 had been receiving the topical medication as needed for skin irritations. During a review of Patient 2’s “MP”, dated 3/20/22-5/18/22, the MP indicated, “Active Medications”, there was no indication of [brand name] topical ointment. 3. During an observation and interview on 5/4/22, at 11:48 a.m., with Patient 4, in Patient 4’s home, a review of the patient’s medications was done. There was medication bottle labeled “Atorvastatin 80 mg tablet take 1 tablet by mouth once daily”. There were four medication bottles containing vitamins. One bottle was labeled Calcium (mineral supplement to maintain bone density) 600 mg per tablet. A second bottle was labeled Vitamin C (mineral supplement to maintain collagen in the bones) 500 mg. A third bottle was labeled Vitamin D3 supplement (mineral supplement use for absorption of other essential minerals in the body) 50 mcg (micrograms). A fourth bottle labeled Zinc (mineral supplement used to help the immune system and metabolism function) 50 mg. Patient 4 stated he had been taking the vitamins since before being admitted to the home health agency. During a review of Patient 4’s “MP”, dated 3/30/22-5/28/22, the MP indicated, “… Atorvastatin 20 mg Oral Tablet 2 tables daily PO (by mouth) …” There was no indication of Calcium, Vitamin C, Vitamin D3 or Zinc in Patient 4’s MP. During an interview an interview on 5/10/22, at 9:30 a.m., with the Director of Patient Care Services (DPCS), DPCS stated, all clinicians needed to ensure medication reconciliation (the process of comparing patient’s medication orders to the medications that the patient had been taking) were done to ensure all medications for each patient was updated. DPCS stated, the clinicians needed to interview patients thoroughly to ensure complete tracking of new medications on admission being taken at home. DPCS stated, the clinicians needed to review the medications on every visit to ensure changes done by the physicians are updated timely. DPCS stated, vitamins and topical medications needed to be on the patient’s MP. DPCS stated, it was important for the patients’ medications to be updated to ensure safety from possible medication interactions or side effects. During a review of the agency’s policy and procedure (P&P) titled, “Medication Reconciliation,” undated, the P&P indicated, “POLICY [name of agency] will reconcile all medications taken by the client prior to admission to home care with those ordered at the time of admission and before and inpatient admission stay. PURPOSE To prevent potential medication errors and to assure clients are receiving all prescribed and necessary medications … Medications: includes all over the counter, prescription, regularly taken PRN (as needed) medications, herbals (made from herbs) and nutraceuticals (any substance that is food or a part of food that has medical or health benefits) that the client takes … SPECIAL INSTRUCTIONS 1. At the time of admission to the home care [Agency Name], the admitting professional will document a complete list of medications taken by the client prior to admission. This will include all over the counter, prescribed, and PRN medications. Documentation of these medications will be listed on the Medication profile and include name, dose, route of administration, frequency. 2. The information will be obtained from the client if possible. If the client is unable to communicate this information, it may be obtained from family members, medication bottle labels, patient’s pharmacy, patient’s physician or from an inpatient facility if recently discharged. 3. The admission professional will review this medication list with the physician, and confirm those medications that are to be continued or discontinued. The doses will be confirmed with the physician and changes will be noted in the record and on the Physician Plan of Care …” During a review of the undated policy and procedure (P&P) titled, “Comprehensive Patient Assessment”, indicated, “… Special Instructions … 2. The Comprehensive Assessment will include a review of all medications the patient is using. This assessment will identify potential adverse effects and drug reactions, including ineffective therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with therapy …”

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 observation, interview, and record review the agency failed to ensure the plan of care (POC) contained the care needs for two of seven sampled patients with home visits (Patient 2 and 7) when: 1. Patient 2 did not have a care plan for oxygen use for the period of 3/20/22 to 5/18/22. 2. Patient 7 did not have a care plan for oxygen use for the period of 4/11/22 to 6/9/22. These failures placed Patient 2 and 7 and a potential risk to have their oxygen care needs not met. 1. During an observation on 5/3/22, at 1:20 p.m., in Patient 2’s home, Patient 2 was on continuous oxygen at 2L/minute (2 liters per minute [LPM] - measurement of oxygen flow). During an interview on 5/3/22, at 2:10 p.m., with Registered Nurse (RN) 3, RN 3 stated, Patient 2 had been on continuous oxygen since the start of care (SOC-initial visit in where a clinical assessment is done to identify the needs of the patient that will be addressed by a home health agency). RN 3 stated, Patient 3’s oxygen use should be care planned in his POC. During a review of Patient 2’s “SOC”, dated 1/19/22, the SOC indicated, “… Respiratory Status … Oxygen use, continuous LPM 2 via nasal cannula …” During a review of Patient 2’s “Home Health Certification and Plan of Care”, dated 3/20/22 to 5/18/22, the POC indicated no care plan for oxygen use. 2. During an observation on 5/5/22, at 2:58 p.m., in Patient 7’s home, Patient 7 was on continuous oxygen at 2L/minute. During an interview on 5/5/22, at 3:35 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, Patient 7 was on continuous oxygen since SOC. LVN 1 stated, Patient 7 should have a POC for oxygen use to determine the interventions needed to maintain adequate respiration. LVN 1 stated, Patient 7’s primary diagnosis for home health services was Chronic Obstructive Pulmonary Disease (COPD-condition involving constriction of the airways and difficulty or discomfort in breathing). LVN 1 stated, Patient 7 could get hypoxic (absence of enough oxygen in the tissues to sustain bodily function) if oxygen use was not monitored and care planned and could lead to harm for Patient 7. During a review of Patient 7’s “POC”, dated 4/11/22 to 6/9/22, there was no care plan for oxygen use. During a concurrent interview and record review on 5/10/22, at 9:30 a.m., with the Director of Patient Care Services (DPCS), Patient 2’s POC dated 3/20/22 to 5/18/22 and Patient 7’s POC dated 4/11/22 to 6/9/22 were reviewed. DPCS stated, the patients’ POC was developed based on the patients’ diagnosis to home health. DPCS stated if patients had oxygen in the home, the POC should contain interventions regarding safety of oxygen, oxygen use, and education. DPCS stated, Patients 2 and 7 should have had a care plan to address oxygen use in the POC since both patients were using oxygen in the home. During a review of the agency’s policy and procedure (P&P) titled, “Plan of Care,” undated, indicated, “… The Plan of Care is based on a comprehensive assessment and information provided by the patient/family and health team members. Planning for care is a dynamic process that addresses the care, treatment and services to be provided … SPECIAL INSTRUCTIONS … 2. The Plan of Care shall be completed in full to include: a. Care and services necessary to meet the patient‐specific needs as identified in the comprehensive assessment … l. Medications, treatments, and procedures … n. Any safety measures required to protect against injury to the patient … p. Instructions to patient and family …”

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the agency failed to revise the plan of care (POC) to reflect the most current information from the patient’s comprehensive assessment for one of 17 sampled patients (Patient 6) when Patient 6 did not have a glucometer to support her care plan interventions for diabetes (condition with too much sugar in the blood) management. This failure resulted in Patient 6 not able to appropriately manage her diabetes at home which could potentially lead to harm. During a concurrent observation, and interview on 5/5/22, at 12:38 p.m., in Patient 6’s home, there was no glucometer in Patient 6’s home. Patient 6 stated, she did not have a glucometer (device used to measure the amount of sugar in the blood). Patient 6 stated, her blood sugar was controlled with a medication. During a concurrent interview and record review on 5/10/22, at 11:28 a.m., with Registered Nurse (RN) 2, Patient 6’s “Home Health Certification and Plan of Care” (POC), dated 5/1/22-6/29/22 was reviewed. The POC indicated, “… SN (Skilled Nurse) may provide a cup of milk, 6 ounces of soda (1/2 can), ½ cup of orange juice, quick-acting glucose (sugar) product i.e.: 3 or 4 glucose tablets or 1 tube of glucose gel if blood sugar level is between [60-80] mg/dl (milligram per deciliter). Wait 10 to 15 minutes, Re-check blood glucose level. Repeat quick-acting glucose product if blood glucose level is less than [80] mg/dl and contact physician. If greater than [80] mg/dl, administer insulin …” RN 2 stated, Patient 6 did not have the ability to check her blood sugar levels with a glucometer. RN 2 stated, Patient 6’s diabetes was being managed with an antidiabetic (used to treat diabetes by altering sugar level in the blood) medication along with the laboratory test (diagnostic test that measures the average blood sugar levels) over the past three months. RN 2 stated, the interventions in Patient 6’s POC should have been revised to ensure Patient 6 had the ability to check her blood sugar levels. RN 2 stated the POC should have had interventions that included teachings about diabetes management. During a concurrent interview and record review, on 5/10/22, at 11:40 a.m., with the Director of Patient Care Services (DPCS), DPCS stated, Patient 6 did not have a glucometer in the home to check her blood sugar levels. DPCS stated, the POC should have been revised to reflect the appropriate interventions to manage Patient 6’s diabetes. During a review of the agency’s policy and procedure (P&P) titled “Plan of Care,” undated, indicated, “… The Plan of Care is based on a comprehensive assessment and information provided by the patient/family and health team members. Planning for care is a dynamic process that addresses the care, treatment and services to be provided … 2. Plan will be modified and added to only with approval of attending physician … SPECIAL INSTRUCTIONS … 2. The Plan of Care shall be completed in full to include: a. Care and services necessary to meet the patient‐specific needs as identified in the comprehensive assessment … 9. Professional staff shall promptly alert the physician to any changes that suggest a need to alter the Plan of Care …”

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, interview, and record review, the agency failed to follow standard precautions to prevent the transmission of infections for three of seven sampled patients with home visits (Patients 1, 3 and 5) when: 1. Physical Therapist (PT) 3 did not use a barrier between herself and Patient 1’s walker. 2. Licensed Vocational Nurse (LVN) 2 did not perform appropriate hand hygiene during a home visit with Patient 3. 3. LVN 3 did not perform hand hygiene in between glove use during a home visit with Patient 5. These failures placed Patients 1, 3 and 5 at a risk of acquiring infections from other patients. 1. During an observation on 5/3/22, at 10:14 a.m., in Patient 1’s home, PT 3 sat on Patient 1’s walker. PT 3 did not place a barrier on Patient 1’s walker before sitting nor disinfected the walker before or after the home visit. During an interview on 5/3/22, at 10:30 a.m., with PT 3, PT 3 stated, she sat on Patient 1’s walker without disinfecting the seat or placing a barrier in between the walker seat and herself. PT 3 stated, she should have placed a barrier on the walker to prevent any cross-contamination (process by which bacteria are unintentionally transferred from one substance or object to another, with harmful effect) from patients’ homes. 2. During an observation on 5/4/22, at 8 a.m., in Patient 3’s home, LVN 2 placed gloves on and proceeded to take Patient 3’s vital signs (clinical measurements such as temperature, blood pressure, heart rate and respiration rate that indicated the state of a patient’s essential body functions). LVN 2 then wrote down measurements, placed her notebook down and used hand sanitizer over her gloves. LVN 2 proceeded to perform patient care on Patient 3. During an interview on 5/4/22, at 8:32 a.m., with LVN 2, LVN 2 stated, using hand sanitizer over gloves was not the proper way of performing hand hygiene. LVN 2 stated, she was supposed to remove her gloves before performing hand hygiene with sanitizer. LVN 2 stated, not properly sanitizing her hands increased the risk of cross-contamination that could affect other patients and cause them to be ill. 3. During an observation on 5/5/22, at 8:20 a.m., in Patient 5’s home, LVN 3 performed wound care on Patient 5. LVN 3 removed her gloves and donned new gloves without performing hand hygiene with hand sanitizer. During an interview on 5/5/22, at 8:58 a.m., with LVN 3, LVN 3 stated, she needed to perform hand hygiene, directly on hands, in between glove use to prevent cross-contamination from patient to patient. LVN 3 stated, she should have performed hand hygiene after removal of her first set of gloves, before applying new gloves. During an interview on 5/10/22, at 9:30 a.m., with the Director of Patient Care Services (DPCS), DPCS stated, her expectation was for all clinicians (LVNs and PTs) to have proper infection control practices in patients’ homes. DPCS stated, clinicians should avoid cross-contamination by using barriers for placing equipment. DPCS stated, PT 3 should have placed a barrier on the surface if she was going to sit down in Patient 1’s home. DPCS stated, PT 3 should not have sat down on Patient 1’s walker without performing disinfection or used a barrier in the home. DPCS stated, proper hand hygiene was important such as sanitizing hands before and after glove use and discarding gloves before sanitizing hands. DPCS stated, LVN 2 should have discarded gloves before sanitizing hands and not sanitized over gloves. DPCS stated LVN 3 should have performed hand hygiene in between glove use. During a review of the agency’s policy and procedure (P&P) titled, “Infection Control Plan,” undated, indicated, “… Hand Hygiene … 3. Hand decontamination using an alcohol-based hand rub should be performed … C. After contact with a patient’s intact skin (when taking a pulse, blood pressure or lifting a patient) … F. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient … G. After removing gloves … PERSONAL PROTECTIVE EQUIPMENT … 1. Gloves … C. Gloves are to be changed. 1. Between tasks and procedures on the same patient … D. Gloves should never be washed or disinfected for reuse…” During a review of the agency’s P&P titled, “Nursing Bag,” dated August 2002, indicated, “… Purpose … To carry adequate supplies for home care clients … To maintain supplies in clean environment … Equipment/Supplies … Keep paper towels … in the outside pocket of the bag …”

Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This STANDARD is not met as evidenced by: Based on observation, interview, and record review the agency failed to ensure responsibilities of a skilled professional, when Licensed Vocational Nurse (LVN) 2 did not recognize abnormal body temperature (lower than normal) immediately for one of seven sampled patients with home visits (Patient 3). This failure placed Patient 3 at a potential risk of his abnormal body temperature not to be properly assessed and treated which could lead to harm. During an observation on 5/4/22, at 7:50 a.m., in Patient 3’s home, LVN 2 took Patient 3’s temperature which read 96 degrees Fahrenheit (°F -scale used to measure body temperature). LVN 2 recorded Patient 3’s temperature on her notepad. During an interview on 5/4/22, at 8:32 a.m., with LVN 2, LVN 2 stated, she documented Patient 3’s temperature as 96°F. LVN 2 stated, 96°F was a low reading for a body temperature. LVN 2 stated, if a patient’s body temperature was too low, she should have rechecked the temperature or call the physician about the abnormal reading. LVN 2 stated, Patient 3 did not feel cold. LVN 2 stated, she should have rechecked Patient 3’s temperature. LVN 2 stated it was important to get appropriate temperature readings for patients to properly assess of any abnormal findings. During a review of Patient 3’s “LVN Visit Note”, dated 5/4/22, the LVN Visit Note indicated, Patient 3’s Temperature as 96°F. During an interview on 5/10/22, at 9:30 a.m., with the Director of Patient Care Services (DPCS), DPCS stated, it was the expectation for all clinicians (LVNs, PTS, RNs) to identify what abnormal temperature readings were. DPCS stated, if a clinician believed a temperature reading was out of range, she would expect the clinician to retake the temperature reading to ensure it was accurate. DPCS stated, normal body temperature for a patient who was not experiencing symptoms of high or low body temperature should have been approximately between 97.6 to 99.1 °F. DPCS stated, Patient 3’s temperature reading of 96 °F would have been too low and LVN 2 should have retaken Patient 3’s temperature. During a review of the agency’s policy and procedure (P&P) titled, “Licensed Vocational Nurse,” undated, indicated, “… Essential Functions/Areas of Accountability … 1. Provides professional nursing care as defined in the nurse practice act and under the direction of a Registered Nurse … Scope of clinical practice includes personal care services, monitoring and reporting findings … and nursing services within professional scope of practice …” During a review of a professional reference from https://www.nursingtimes.net/clinical-archive/assessment-skills/measuring-body-temperature-using-a-tympanic-thermometer-2-14-09-2020/ titled “Measuring body temperature using a tympanic thermometer,” dated September 2020, indicated, “… Nurses need to know how to measure body temperature accurately and reliably, as inaccurate results may influence diagnosis and treatment, lead to a failure to identify patient deterioration and compromise patient safety. It is, therefore, important that nurses understand the significance of abnormal temperature readings and, when delegating this task to unregistered staff, ensure they are competent and know when to report concerns … Normal body temperature: 36.1-37.5 °C (Celsius-unit of temperature - 96.98-99.5 °F ) …”