Every finding on record at We Care Home Health Services

This Statement of Deficiencies was generated as a result of an Emergency Preparedness survey conducted at your agency from September 22, 2022 through September 27, 2022, in accordance with 42 Code of Federal Regulations (CFR) and the State Operations Manual (SOM), Appendix Z- Emergency Preparedness for All Provider and Certified Supplier Types. The findings and conclusions of any investigation by the Division of Public and Behavioral Health shall not be construed as prohibiting any criminal or civil investigations, actions or other claims for relief that may be available to any party under applicable federal, state, or local laws. The following deficiencies were identified:

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on interview and document review, the facility failed to have all their staff trained and participate in the emergency preparedness training and testing program. Findings include: The facility sign-in sheet for employees participating in the emergency preparedness training and testing program for 07/09/2021, had 14 employee who participated and completed the training. The facility sign-in sheet for employees participating in the emergency preparedness training and testing program for May 2022, had seven employees who participated and completed the training. The employee roster had 28 staff employed for the agency. On 09/27/2022 in the afternoon, the Administrator indicated it was difficult for all the staff to gather and complete the emergency preparedness training and testing program for 2021 and 2022 and not all the staff were trained.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on interview and document review, the facility failed to have all their staff trained and participate in the emergency preparedness training and testing program. Findings include: The facility sign-in sheet for employees participating in the emergency preparedness training and testing program for 07/09/2021, had 14 employee who participated and completed the training. The facility sign-in sheet for employees participating in the emergency preparedness training and testing program for May 2022, had seven employees who participated and completed the training. The employee roster had 28 staff employed for the agency. On 09/27/2022 in the afternoon, the Administrator indicated it was difficult for all the staff to gather and complete the emergency preparedness training and testing program for 2021 and 2022 and not all the staff were trained.

This Statement of Deficiencies was generated as a result a Medicare Recertification Survey conducted at your agency from September 22, 2022 through September 27, 2022, in accordance with 42 CFR (Code of Federal Regulations) Part 484-Home Health Services. The active census on the first day of the survey was 48 patients. Seven clinical records were reviewed. Three home visits were conducted. The findings and conclusions by the Division of Public and Behavioral Health shall not be construed as prohibiting any criminal or civil investigations, actions or claims for relief that may be available to any party under applicable federal, state or local laws. The following regulatory deficiencies were identified:

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on state tabulations for OASIS assessment submissions, the agency failed to maintain a minimum compliance rate of less than 10% late submissions. Findings include: According to the state OASIS Education Coordinator, the agency failed to maintain a minimum compliance rate of less than 10% late OASIS transmissions submitted per quarter for the last year. Specifically, late submission rates varied between 21% and 46% for the past year. These were the agency's highest late submission rates dating back 3 and half years. On 9/27/2022 in the afternoon, the Director of Patient Care Services and Administrator confirmed the findings, indicating nurses were late in completing and submitting the assessments.

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 record review and interview, the agency failed to ensure all medications were included on the medication profile for 2 of 7 patients (Patient #2 and #3). Findings include: Patient #2 On 2/25/2022, the agency admitted Patient #2 with heart disease and hypertension. On 2/25/2022, the plan of care documented the patient had another pertinent diagnosis of dependence on supplemental oxygen. The plan of care and the medication profile both lacked documented evidence oxygen was identified and listed as a medication. On 9/27/2022 in the afternoon, the Director of Patient Care Services and Administrator confirmed the finding. Patient #3 On 7/6/2022, the agency admitted Patient #3 with right side hemiplegia. On 9/23/2022 at 3:00 PM, a home visit was conducted with a physical therapist. Shortly after the visit concluded, Patient #3's daughter arrived, and a medication profile review was conducted. The medication profile provided for the visit was dated 7/6/2022. The following anomalies were identified as not being listed on the provided profile: On 7/27/2022, prescriptions were filled for Enulose, Gabapentin 100 milligrams three times daily and Megestrol daily. Farxiga 5 milligrams daily was identified. On 7/27/2022, Hydrochlorothiazide was modified to 12.5 milligrams. Symbicort daily was identified also. On 9/27/2022 in the afternoon, the Director of Patient Care Services and Administrator confirmed the findings.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure skilled nursing visits were conducted as ordered by a physician for 1 of 7 patients (Patient #1). Findings include: Patient #1 On 6/2/2022, the agency admitted Patient #1 with surgical aftercare. On 6/15/2022, the agency transferred Patient #1 to acute care with pneumonia. On 6/25/2022, the agency resumed Patient #1's care, and a physician ordered skilled nursing visits twice weekly for the week of 7/3/22 through 7/9/2022. Patient #1's clinical record lacked documented evidence the agency conducted skilled nursing visits or otherwise discontinued/modified the frequency or documented missed visits. On 9/27/2022 at 2:10 PM, the Director of Patient Care Services and Administrator confirmed the findings.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure physical therapy visits were conducted only as ordered for 1 of 7 patients (Patient #1). Findings include: Patient #1 On 6/2/2022, the agency admitted Patient #1 with surgical aftercare. On 6/15/2022, the agency transferred Patient #1 to acute care with pneumonia. On 6/25/2022, the agency resumed Patient #1's care, and a physician ordered a physical therapy evaluation. On 7/5/2022 and 7/7/2022, the agency conducted and documented physical therapy skilled visits. The clinical record lacked documented evidence the physical therapist or agency obtained a skilled visit frequency for the physical therapy visits. On 9/27/2022 at 2:10 PM, the Director of Patient Care Services and Administrator confirmed the findings.

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 policy review, the agency failed to ensure a Registered Nurse (RN) used proper treatment bag technique for 1 of 7 patients (Patient #5) and a RN was using a penlet for blood glucose testing for each patient who needed glucose monitoring. Findings include: Patient #5 On 9/28/2021, the agency admitted Patient #5 with iron deficiency anemia. On 7/25/2022, the agency recertified Patient #5 with iron deficiency anemia. On 7/25/2022, the plan of care documented a physician ordered weekly skilled nursing visits. On 9/23/2022 at 8:45 AM, a home visit was conducted with a registered nurse. During the home visit, the registered nurse used an infection control barrier for implements removed from the work bag, but the nurse failed to use an infection control barrier for the work bag itself. On 9/23/2022 after the above visit, the Registered Nurse confirmed the work bag was not placed on a clean surface barrier. Directive #2 of the Nursing Bag Technique revealed upon entering the home, place the bag on a clean surface. On 09/23/2022 in the morning, the Director of Patient Care Services (DPCS) indicated there was one Registered Nurse (RN) using their own glucose monitor to obtain glucose levels on patients. On 09/23/2022 in the afternoon, the RN was contacted by phone and the RN indicated using a penlet, cleaning and changing the lancet for each patient. The RN indicated using the penlet for two patients several months ago and has not had to take another patient blood sugar level. On 09/23/2022 in the morning, the Administrator confirmed the RN should not be using their own glucose monitor and not to use a penlet from one patient to another even when sanitizing and changing the lancet was done.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure OASIS assessments were authenticated for 4 of 7 patients (Patient #1, #2, #3 and #5). Findings include: Patient #1 On 6/2/2022, the agency admitted Patient #1 with surgical aftercare. On 6/2/2022, a clinician conducted and documented a start of care OASIS assessment. The agency failed to ensure a clinician authenticated the assessment. On 6/15/2022, a registered nurse conducted and documented a transfer OASIS assessment. The agency failed to ensure the registered nurse authenticated the assessment. Patient #2 On 2/25/2022, the agency admitted Patient #2 with heart disease and hypertension. On 2/25/2022, the agency conducted and documented a start of care OASIS assessment. The agency failed to ensure a clinician authenticated the assessment. Patient #3 On 7/6/2022, the agency admitted Patient #3 with right-side hemiplegia. On 7/6/2022, a registered nurse conducted and documented a start of care OASIS assessment. The agency failed to ensure the registered nurse authenticated the assessment. On 9/3/2022, a registered nurse conducted and documented an OASIS recertification assessment. The agency failed to ensure the registered nurse authenticated the assessment. Patient #5 On 9/28/2021, the agency admitted Patient #5 with iron deficiency anemia. On 7/20/2022, a registered nurse conducted and documented an OASIS recertification assessment. On 7/25/2022, the agency recertified Patient #5 with iron deficiency anemia. The agency failed to ensure the nurse authenticated the assessment. On 9/27/2022 at 2:10 PM, the Director of Patient Care Services and Administrator confirmed the findings.

Social Worker CFR(s): 484.115(m) Standard: Social worker. A person who has a master's or doctoral degree from a school of social work accredited by the Council on Social Work Education, and has 1 year of social work experience in a health care setting. This STANDARD is not met as evidenced by: Based on interview, record review and document review, the facility failed to confirm if their social worker was qualified for their position for 1 of 1 Social Worker (Social Worker 1). The agency' s Medical Social Worker Job Description form dated October 2017 documented the social worker qualifications were to have a master’s degree from a school accredited or approved by the council on Social Work Education or has a baccalaureate in social work, psychology, sociology or other field related to social work. The State of Nevada Board of Examiners for Social Workers revealed Social Worker 1 was a Licensed Certified Social Worker. There was no verified documented evidence Social Worker 1 was a master’s degree holder from a school accredited or approved by the council on Social Work Education. On 09/27/2022 in the morning, the Director of Patient Care Services and the Administrator indicated they were not aware of the latest Federal requirements which required the social worker to have a master's or doctoral degree from a school of social work accredited by the Council on Social Work Education and has one year of social work experience in a health care setting. They confirmed their policy did not follow the Federal regulations. On 09/27/2022, in the afternoon, the Administrator indicated the agency did not verify if their social worker had a master’s degree from a school accredited or approved by the council on Social Work Education.