Every finding on record at Wellspring Home Health Center, LLC

This survey was for a complaint investigation survey #70601. Provider #: 02-7036 Visit dates: 5/18 - 20/22 Conditions of Participation: 0510 - Comprehensive Assessment of Patients, 0560 - Discharge Planning, 0570 - Care planning, Coordination, Quality of care 11 Records were reviewed, including 3 closed records. 3 home visits were conducted. 2 home visits were conducted to observe skilled nursing and 1 visit was conducted to observe a home health aide. State of Alaska - DHSS/HCS Health Facilities Licensing & Certification 4601 Business Park Blvd, Bldg K Anchorage, AK 99503

Have a confidential clinical record CFR(s): 484.50(c)(6) Have a confidential clinical record. Access to or release of patient information and clinical records is permitted in accordance with 45 CFR parts 160 and 164. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review the facility failed to ensure privacy of protected health care information of one patient (#11). Specifically, medication information for 1 Patient was entered incorrectly and then shared with Patient #8. This failed practice denied one patient (#11), out of eleven sampled patients, the right to privacy. Findings: Observation during a home visit with Patient #8 on 5/19/22 at 1:15 PM revealed physical therapy had provided a copy of Patient #8’s “Home Health Certification and Plan of Care” for the certification period for 4/08-06/22. The copy was located on the Patient's dining room table. Record review of the “Home Health Certification and Plan of Care,” for certification period 4/08/22-6/06/22, revealed “21. Orders for Discipline and Treatments (Specify Amount/ Frequency/ Duration) ... Respiratory: Oxygen at 2 liters per 1 minute Pulse Oximetry: Every Visit pulse Pulse Oximetry: PRN dyspnea [shortness of breath] Teach Oxygen Use / Precautions." Observation during the home visit on 5/29/22 revealed Patient #8 did not use oxygen. 22. “Goals/ Rehabilitation Potential/ Discharge Plans/Referral Plans/ Other Notes” See above Collaborated with patient on Plan of Care PT goals: continued...” “If [Patient #11] should need emergent care [he/she] wishes to be only sent to JBER [Joint Base Elmendorf Richardson]. Orders may be received from the following providers…. Orders may be received from any VA [Veterans Administration] provider.” The Certification and Plan of Care had been signed off by Patient #8’s primary care provider [PCP] and a physical therapist. During an interview on 5/19/22 at 4:30 PM, when asked about Patient #11’s information and name being on Patient #8’s Plan of Care, the Clinical Manager stated she was not sure how that happened as Patient #11 was not getting physical therapy services. The Clinical Manager stated she would contact their information technology company." Review of the “Patient Information Handbook,” “Notice of Use of Private Health Care Information,” dated 9/01/13, revealed “Your Health Care Information is Private” “1. We must keep your health care information from others who do not need it.”

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview the facility failed to ensure one resident’s (#11) care plan was followed for one patient (#11), out of eleven sampled patients. Specifically, the patient’s Mediset [medication container that organizes medications by days and times the medications need to be taken] was not filled as scheduled. This failed practice placed the patient at risk for not receiving medications as ordered. Findings: Record review on 5/19-20/22 revealed Patient #11 was admitted to the agency on 12/09/21. Review of the most recent Certification and Care Plan, for the certification period 4/08-6/06/22, revealed the Patient had diagnoses that included chronic obstructive pulmonary disease (lung diseases that block air flow and make it difficult to breath), diabetes, and post-traumatic stress disorder. The Patient was oriented but forgetful, used oxygen and was at risk for falling. Further review revealed nursing staff were to come in and review vital signs, as well as review and provide teaching about medications and compliance, blood glucoses, diabetic care, oxygen use, and “Set up Meds Every 1 weeks." Record review of a nursing note, dated 4/13/22, revealed “The Patient has been compliant with [his/her] Mediset use. Medisets filled x 2 weeks + patient will order necessary refills.” “The patient is much more relaxed since moving out of her ALF + living alone + reports [he/she] feels a lot happier." Review of a nursing note, dated 4/27/22, revealed a missed visit “Multiple attempts to call Patient. Left VM [voice mail]. Patient called back this evening, nurse unable to go for visit at that time." No further visits were scheduled for that week. Review of a nursing note, dated 5/06/22 revealed “Med set was filled, and all medications were accounted for." During an interview on 5/19/22 at 4:15 PM, the Clinical Manager was asked how the Patient’s Mediset were set up for the 2 weeks between 4/27/22 and 5/06/22, as no further visits had been provided. The CM stated she would have to look into the event. No further information was provided at time of exit on 5/20/22 at 7:00 PM.

Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient's discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner's issuing orders for the HHA plan of care, and the patient's 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). This ELEMENT is not met as evidenced by: Based on record review and interview the facility discharged a patient from services prior to notification to the patient’s primary care practitioner (PCP). This failed practice placed one patient (#4) at risk for not receiving necessary services from the home health agency. Findings: Record review on 5/19/22 revealed Patient #4 had diagnoses that included cellulitis of the right and left lower legs, chronic pressure ulcers of the right and left foot, and lymphedema (tissue swelling caused by an accumulation of fluid in the lower legs.) Review of a physician order, dated 5/5/21, revealed Patient #4 was referred to the Home Health Agency (HHA). Review of a Physician’s Order, dated 2/25/22, for Patient #4 revealed “OK to recert patient for cert period starting 3/02/22 for SN [skilled nursing] and the application of Unna boots [compression wrap to the legs applied by a health care provider] + 3 prn [as needed] wound care intervention or recert needs." Review of a fax communication dated 4/22/22, from an outpatient wound care clinic revealed, “Patient discharged from WCC [wound care clinic]." A nurse had signed the discharge instructions. Review of a "Communication Note," dated 4/27/22, revealed “Spoke with wound center [nurse name] in regard to Patient’s new health status change with BLE [bilateral lower extremities]. Patient was discharged from services due to being healed and was informed [he/she] did not need Unna boots anymore per [nurse name]. Patient can be seen again if [he/she] is willing to come back in for services, but at this time, they are not able to give new wound orders for [his/her] BLE edema [tissue swelling] and weeping [draining through skin]. Patient is to follow up with PCP [primary care provider.]" Review of a "Communication Note," dated 4/28/22, revealed “Nurse contacted [name] Manager Nurse/Supervisor again today to see that patient got seen by skilled nurse for [his/her] edema/weeping to BLE. [nurse name] stated that Patient is being discharged because Patient was discharged from wound center and that [he/she] does not have a PCP to write orders for [him/her]. This nurse asked [his/her] if they had informed Patient [he/she] was being discharged; Supervisor stated, ‘I don't know.’ Nurse informed Supervisor that someone needed to contact Patient because [he/she] is Medicare and needed a NOMAC [Notice of Medicare Non-Coverage] and needed notified." Nurse had made it known to Supervisor that the Patient needed to be seen due to possible deterioration in health. Nurse volunteered to contact patient to see how [he/she] was doing via phone." Patientcontact. Nurse called patient to check on [his/her] edema; Patient stated no one from Wellspring has contacted [him/her], but this nurse to check on [his/her] status. Patient states [he/she] seen [his/her] PCP today and that PCP was not happy with the way [his/her] legs looked and wanted [him/her] to go to the ER [emergency room] for Cellulitis to BLE; Patient opted out of ER and wanted to be treated at home. Patient was put on Keflex [antibiotic] [he/she] believes is the medication for Cellulitis and is to be seen twice a week for Unna boots." A Communication Note dated 4/29/22 revealed “Orders were received from ‘Wound Clinic’ on 4/22/22 discharging Patient, Pt. was to use compression wraps as of 4/29 agency has not received any orders to continue treatment. Patient requesting to transfer to another agency. Patient discharge per wound clinic and patient request." Review of a discharge assessment, conducted on 4/29/22 by a registered nurse, revealed documentation of a physical assessment. Under Indicate Reason for Discharge the nurse had marked the boxes “Patient refused further care” and “Agency/Organization decision (explain).” “Patient no longer had PCP, when told we could no longer service [him/her] without orders, [he/she] did not want us to see [him/her] any longer. Under the box marked “Other” “No PCP” had been entered. “Discharge Instructions (specify future follow up, referrals, etc.) The patient did not allow us to do a discharge visit…Patient/ caregiver were notified beforehand of pending discharge.” The discharge assessment was dated for 4/29/22 and signed by the RN on 5/16/22. Review of “Physician Orders,” dated 4/29/22, for Patient #4 revealed “Reasons: Orders were received from the wound clinic on 4/22/22 discharging Patient, Pt to use compression wraps, as of 4/29/2 had not received orders to continue treatment, pt. requesting transfer to another agency. Patient discharged per wound clinic and patient request.” “Physician Orders: Agency Discharge effective 4/29/22.”. Review of the document revealed it was faxed to the provider on 5/15/22 was signed by the Patient’s PCP on 5/17/22, 20 days after the Patient’s discharge. During an interview with the Clinical Manager on 5/19/22 at 6:00 PM, when asked how the Patient had been admitted to the HHA by a PCP but then did not have a PCP until after his/her discharge, The Clinical Manger stated she had called the Patient after the event with the wound care clinic, however the Patient had been angry, and had determined [he/she] no longer wanted to receive services from their agency. The Clinical Manager verified the Patient had a primary PCP but Patient #4 was then followed by a PCP extender. She stated there had been confusion regarding the orders from the wound care clinic, as the Patient had initially just wanted a break from the Unna boots, not stopping completely necessary treatment. Review of the "Facility Discharge /Transfer Policy,” undated, revealed the “1) Reason for Discharge?” and “2) Discharge for Cause” revealed not having a PCP as a cause for discharge.

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on record review and interview, the facility failed to ensure nursing services were provided under the supervision of a registered nurse. Specifically, the facility failed to provide supervisory visits to monitor, and evaluate Licensed Practical Nurse (LPN) performance in the provision of nursing services and care to three residents (#s 1, 4 and 7) out of eleven sampled residents. This failed practice had the potential to affect all residents that required skilled nursing care and placed residents at risk for ineffective nursing services. Findings: Resident # 1 Record review on 5/18-20/22 of the medical record, revealed Resident #1’s start of care was 3/1/22 with diagnoses that included chronic obstructive pulmonary disease. Review of the calendar from 3/1/22 to 4/29/22 revealed the skilled nurse (SN [Licensed Practical Nurse or Registered Nurse]) visited the Resident on 3/7/22, 3/14/22, 3/21/22, 3/28/22, 4/4/22, 4/11/22, 4/18/22, and 4/25/22. Further review of the medical record revealed no Licensed Practical Nurse (LPN) supervisory visit notes on 4/5/22 and 4/27/22 for an LPN who provided care to Resident #1. Patient #4 Record review on 5/19-20/22 of the medical record, revealed Resident #4’s start of care was 5/04/21 with diagnoses that included lymphedema (swelling caused by lymphatic system blockage), cellulitis (bacterial skin infection), and non-pressure chronic ulcers to the right and left feet. Review of the calendar dated 3/1/22 to 4/29/22 revealed the skilled nurse [Licensed Practical Nurse had visited the Resident on 3/7/22, 3/14/22, 3/21/22, 3/28/22, 4/4/22, 4/06/22, 4/11/22, 4/18/22, and 4/25/22. Further review of the medical record revealed a visit conducted by a registered nurse on 3/02/22 revealed the “Supervisory Visit” was marked “Yes” and “Staff” were “Not Present”. The next scheduled supervisory visit was to be 3/25/22. Under the section “Is Patient/Family Satisfied with Care?” “Yes” was marked and “Yes, yes [he/she] always does a good job.” The visit did not identify the discipline supervised. Further review of the medical record revealed no supervisory visit notes of skilled nursing services provided by an LPN from 3/07-4/25/22 who provided care to Resident #4 prior the Patient’s discharge. During an interview on 5/20/22 at 6:00 PM, the Clinical Manager stated she was unable to find further supervisory visits. Resident # 7 Record review on 5/18-20/22 of the medical record, revealed Resident #7’s start of care was 3/11/22 with diagnoses that included bilateral primary osteoarthritis of the hip. Review of the calendar from 3/11/22 to 5/19/22 revealed the SN visited the Resident on 3/16/22, 3/21/22, 3/28/22, 3/30/22, 4/4/22, 4/11/22, 4/25/22, 5/6/22 and 5/13/22. Further review of the medical record revealed no Licensed Practical Nurse (LPN) supervisory visit notes on 4/7/22, 4/19/22, 4/27/22, and 5/5/22 for an LPN who provided care to Patient #7. During an interview on 5/20/22 at 4:15 PM, the Director of Nursing (DON) stated the frequency of the supervisory visit was every 14 days. During an interview on 5/20/22 at 5:54 PM, the DON stated there were no supervisory notes for LPN and who visited Resident #s 1 and 7. Review of the Licensed Practical Nurse Job Duties, undated, revealed the LPN “Provides skilled nursing care under the direct supervision of the Registered Nurse." Review on 5/20/22 at 6:00 PM of the Registered Nurse (RN) job description revealed the RNs responsibilities included “…evaluates the effectiveness of nursing service to the patient and family on an ongoing basis…supervising…caregivers regarding the nursing care needs and related problems of the patient at home…provides guidance and supervision to the LPN (Licensed Practical Nurse) …as per agency policy…submits clinical notes within 24 hours and at end of…shift…”

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on record review and interview, the facility failed to ensure a registered nurse or appropriate skilled professional provided supervision of home health aides. Specifically, the facility failed to provide supervisory visits to monitor, and evaluate the home health aide who provided care to one patient (#7) out of eleven sampled patients. This failed practice had the potential to affect all patients that required home health aide care and placed patients at risks of poor quality of home health care and poor quality of life. Findings: Patient #7 Record review on 5/18-20/22 of the medical record, revealed Patient #7’s start of care was 3/11/22. The Patient had diagnoses that included bilateral primary osteoarthritis of the hip. Review of the calendar from 3/11/22 to 5/19/22 revealed Certified Home Health Aide (CHHA) visited the Patient on 3/16/22, 3/21/22, 3/24/22, 3/28/22, 3/31/22, 4/4/22, 4/25/22, 4/28/22, 5/2/22, 5/5/22, 5/9/22, and 5/16/22. Further review of the medical record revealed no Home Health aide supervisory visit notes on 3/29/22, 4/7/22, 4/20/22 and 5/5/22 for a CHHA who provided care to Patient #7. During an interview on 5/20/22 at 4:15 PM, the Director of Nursing (DON) stated the frequency of the supervisory visit was every 14 days. During an interview on 5/20/22 at 5:54 PM, the DON stated there were no supervisory notes for CHHA provided care to Patient #7. Review on 5/20/22 at 6:00 PM of the Registered Nurse (RN) job description revealed the RNs responsibilities included “…supervising…caregivers regarding the nursing care needs and related problems of the patient at home…supervises the care given by the HHA/ Certified Nurse Aide (CNA) …as per agency policy…submits clinical notes within 24 hours and at end of…shift…”