Every finding on record at Vsl Vetter Home Health Care of North Platte LLC

Brookestone Home Health & Hospice is in compliance with the requirements of CFR 484.102 Condition of Participation for Home Health Agencies.

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 record review, policy and procedure review, and staff interview, the agency failed to complete a comprehensive assessment of the patient’s rehabilitative needs within 5 days after the start of care for 3 of 6 patients who had orders for Occupational Therapy included on the plan of care (Patient 1, 5, and 7). The total sample size was 8. The census was 8. Findings are: A. Review of the agency’s policy and procedure titled, 4.2 Admission Visit, Staff Assignment, revised 5/3/23, revealed, upon the completion of the initial visit, additional disciplines will provide services according to the patient’s needs, physician’s orders, and acuity, within a 5-day time frame, unless otherwise ordered by the physician. B. Review of the agency’s policy and procedure titled, 4.16 Coordination of Services-Medicare Therapy Services, revised 11/9/17, revealed: 1. Each ordered therapy service must have an initial visit by a qualified discipline to assess the patient’s function. 2. The policy and procedure did not include a time frame for when the therapy initial visit was to be completed. C. Review of Patient 1’s clinical record revealed: 1. The Home Health Certification and Plan of Care (POC) for the certification period 7/10/24 through 9/7/24, included orders for Occupational Therapy (OT) to evaluate. 2. The start of care (SOC) was 7/10/24. 3. An OT evaluation note was completed on 7/16/24 (6 days after the SOC). 4. There was no documentation in the clinical record that the patient or physician requested a delay in the OT initial visit beyond the 5 days. D. Review of Patient 5’s clinical record revealed: 1. The POC for the certification period 6/27/24 through 8/25/24, included orders for OT to evaluate and treat. 2. The SOC was 6/27/24. 3. An order dated 7/8/24 (11 days after the SOC) was received to dismiss the OT evaluation, the patient declined services. 4. There was no documentation in the clinical record that the patient or the physician requested a delay in the OT initial visit beyond the 5 days. E. Review of Patient 7’s clinical record revealed: 1. The POC for the certification period 6/21/24 through 8/19/24, included orders for an OT referral. 2. The SOC was 6/21/24. 3. An OT evaluation note was completed on 6/28/24 (7 days after the SOC). 4. There was no documentation in the clinical record that the patient or physician requested a delay in the OT initial visit beyond the 5 days. F. During an interview on 7/17/24 at 4:30 PM, the Administrator confirmed, the OT initial visit for Patient 1, 5, and 7, were not completed within 5 days of the patient’s SOC, and the clinical record did not include documentation for the delayed visit.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on record review, policy and procedure review, and staff interview, the agency failed to ensure the patient's medication profile (a real-time document used by the agency that lists the patient’s medications, including new and updated orders received between certification periods), included all medication orders as received by the agency, for 3 of 8 patient records reviewed (Patient 3, 5, and 7). The total sample size was 8. The census was 8. Findings are: A. Review of the agency’s policy and procedure titled, 4.40 Medication Regimen Review-Comprehensive, revised, 5/3/23, revealed: 1. On admission, an accurate, current, and complete list of all prescription and over the counter (OTC) medications, including name, dose, route, and frequency, taken by the patient, will be maintained on the medication profile. 2. The nurse will compare the list to those on the referral or other documents provided to the agency. 3. Medication discrepancies will be reconciled with the physician and documented in the clinical record. 4. The medication profile will include drug schedules, initial order dates, discontinued dates, and if the medication is new or changed. 5. Review of the medications will be ongoing, including the patient response and compliance with the medication regimen. 6. Changes in the medication regimen will be documented in the clinical record and communicated to the patient and/or caregiver. B. Review of Patient 3’s clinical record revealed: 1. The Patient was admitted to the agency on 6/23/24 for Skilled Nurse (SN), Physical Therapy (PT), Occupational Therapy (OT), and Home Health Aide services. 2. Patient was transferred and admitted to Great Plains Hospital 7/4/24 through 7/7/24. 3. Transition Orders and Information for the Continuation of Patient Care, from Great Plains Hospital to the agency, dated 7/7/24, included new medication orders: a. Levetiracetam, generic name for Keppra (a medication used to treat seizures), 250 milligrams (mg), 1 tablet, two times daily. Quantity 14 tablets. b. Sulfamethoxazole/Trimethoprim, generic name for Bactrim (a medication used to treat infections), 800-160 mg, 1 tablet, every 12 hours. Quantity 8 tablets. 4. The patient’s medication profile did not include the medications Keppra and Bactrim. C. Review of Patient 5’s clinical record revealed: 1. The Plan of Care (POC) for the certification period 6/27/24 through 8/25/24, included orders for Bumetanide (a medication used to treat fluid retention and high blood pressure) 2mg, 1 tablet, daily. 2. A verbal order was received on 7/12/24 to discontinue Bumetanide. 3. Bumetanide was not discontinued on the medication profile. D. Review of Patient 7’s clinical record revealed: 1. Transition Orders and Information for the Continuation of Patient Care, from Great Plains Hospital to the agency, on 6/19/24, included orders: a. Fosamax (a medication used to treat bone disease), 70 mg, 1 tablet, weekly. b. Prolia (a medication used to treat bone disease), 60mg, every 6 months. The Transition Orders failed to include the date Prolia was last administered or when the next dose was due. 2. The POC for the certification period 6/21/24 through 8/19/24, did not include orders for Fosamax and Prolia. 3. The medications, Fosamax and Prolia, were not included on the medication profile. 4. There was no documentation in the clinical record of medication reconciliation with the physician for Fosamax and Prolia. E. During an interview on 7/18/24 at 11:50 AM, the Administrator confirmed, the agency staff failed to follow the agency’s policy and procedure for updating the medication profile, when medication orders were new or changed, and failed to conduct an ongoing review of the patient’s medication regimen for Patient 3, 5, and 7.

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, observation of the provision of care, and staff interview, the agency failed to ensure 3 of 3 staff (Staff B, C, and D), observed during the provision of care for 3 of 3 patients (Patient 1, 2, and 3 respectively), performed proper hand hygiene, cleaning of equipment, bag technique, and standard precautions, according to the agency's policies and procedures. The total sample size was 8. The census was 8. Findings are: A. Review of the agency’s policy and procedure titled, 5.6 Hand Hygiene, revised 9/12/2017, revealed: 1. Hand hygiene is to occur before and after patient contact and after removing gloves. 2. The policy does not include performing hand hygiene before applying gloves. B. Review of the agency’s policy and procedure titled, 5.14 Standard Precautions, revised 5/3/23, revealed: 1. Hand Hygiene is to be done before and after all patient care. 2. Hand Hygiene is to be done after removing and disposing of gloves. 3. A plastic bag that contains dressings, is to be sealed, double bagged and placed in the patient’s trash. 4. The policy does not include performing hand hygiene before applying gloves. C. Review of the agency’s policy and procedure titled, 5.1 Bag Technique, revised 10/6/17, revealed: 1. A bag is to be utilized for supplies in the patient’s home. 2. Hands are to be washed before entering the bag. 3. A barrier is to be used to create a clean environment. D. Review of the agency’s policy and procedure titled, 5.4 Equipment, Bag Supplies, Cleaning, revised 10/6/2017, revealed: 1. Washable equipment is to be cleaned if contamination occurs during use. 2. Disposable contaminated articles are to be wrapped in a plastic bag and discarded in the patient’s home trash. E. Review of the clinical records revealed: 1. Patient 1’s Home Health Certification and Plan of Care (POC) for the certification period 7/10/24 through 9/7/24, included orders for Physical Therapy (PT) to evaluate. The PT Plan of Care included orders for PT to evaluate, then 2 times a week for 3 weeks, to increase strength, improve balance, gait training, and provide education regarding fall prevention and proper use of assistive devices. 2. Patient 2’s POC for the certification period 7/10/24 through 9/7/24, included orders for PT to evaluate, 1 time a week for 1 week, then 2 times a week for 3 weeks, to improve balance, increase strength, and provide education regarding fall prevention and proper use of assistive devices. 3. Patient 3’s POC for the certification period 6/23/24 through 8/21/24, included orders for Skilled Nurse (SN) 2 times a week, to provide wound care, monitor for falls and teach fall prevention. F. The observation and provision of care to Patient 1 on 7/16/24 at 1:00 PM, revealed Staff B failed to: 1. Utilize a bag for supplies. 2. Place iPad and oximeter on a barrier. 3. Sanitize equipment after use. 4. Sanitize hands after completing patient care and prior to leaving the patient’s home. G. The observation and provision of care to Patient 2 on 7/16/24 at 3:30 PM, revealed Staff C failed to sanitize hands on 2 occasions prior to entering the bag to obtain equipment. H. The observation and provision of care to Patient 3 on 7/17/24 at 9:00 AM, revealed Staff D failed to: 1. Sanitize hands on 3 occasions prior to entering the bag to obtain supplies and/or returning supplies into the bag. 2. Seal, double bag, and dispose of the plastic bag, that contained contaminated dressings, into the patient’s trash. 3. Sanitize hands after providing patient care prior to leaving the home. I. During an interview on 7/18/24 at 11:10 AM, the Administrator confirmed, Staff B, C, and D, failed to follow the agency’s policies and procedures for hand hygiene, standard precautions, bag technique and cleaning equipment, during the provision of care for Patient 1, 2, and 3 respectively.

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 record review, policy and procedure review, and staff interview, the agency failed to ensure a transfer summary was sent to the receiving facility for 1 of 1 patient who had a transfer (Patient 3). The total sample size was 8, the census was 8. Findings are: A. Review of the agency policy and procedure titled, 4.49 Transfer Patient, revised 5/3/23, revealed, a transfer summary will be sent to the receiving entity when a transfer is confirmed, and the agency will document that information was sent. B. Review of Patient 3’s clinical record revealed: 1. The Home Health Certification and Plan of Care revealed the patient’s start of care date was 6/23/24. 2. The patient was transferred and admitted to Great Plains Hospital on 7/4/24 through 7/7/24. 3. Physical Therapy visit scheduled on 7/5/24 was cancelled due to patient being hospitalized. 4. There was no documentation in the clinical record that a transfer summary was completed and sent to the receiving entity. C. During an interview on 7/17/24 at 4:30 PM, the Administrator confirmed, there was no documentation in the the clinical record of a transfer summary completed and sent to the receiving facility for Patient 3.