Every finding on record at West Winds Health Services

A recertification survey for compliance with 42 CFR Part 484, Subpart G, Subsection 484.102 Emergency Preparedness Requirements for Home Health Agencies, was conducted from 1/20/26 through 1/21/26. West Winds Health Services, Inc was found in compliance.

A recertification health survey for compliance with 42 CFR Part 484, Subparts B-C, requirements for Home Health Agencies, was conducted from 1/20/26 through 1/21/26. West Winds Health Services, Inc was found not in compliance with the following requirements: G762 and G1022.

Minimum hours of training CFR(s): 484.80(b)(2) A minimum of 16 hours of classroom training must precede a minimum of l6 hours of supervised practical training as part of the 75 hours. This ELEMENT is not met as evidenced by: Based on record review, interview, and policy review the provider failed to ensure a structured home health training program, which included 16 hours of classroom training, was completed for two of two (E and F) newly employed home health aides prior to in-home training. Findings included: Review of home health aide E’s personnel file revealed that she was hired on 5/1/24. There was no documentation that she completed the classroom training. She had home health aide evaluation forms completed on 6/26/24 and 5/20/25 for the in-home training.Review of home health aide F’s personnel file revealed that she was hired on 8/25/25. There was no documentation that she completed the classroom training. She did not have any home health aide evaluation forms completed for the in-home training.Interview on 1/21/26 with registered nurse (RN)/owner A revealed that before the home health aides would leave for the in-home training she would spend approximately an hour with each home health aide reviewing infection control, vital sign parameters (measurements of body's basic functions, such as temperature, blood pressure, pulse, and respiration rate), required home health aides paperwork, proper use of gait belts, and situations that must be report to nursing staff. Following this review, home health aides were required to watch a video addressing elder abuse and neglect and reporting requirements. RN/owner A stated the home health aides completed a minimum of 40 hours and up to 120 hours in-home training under the supervision of the nurse. She indicated that not all nurses completed a written home health aide form; instead, most nurses provide real-time feedback to the home health aides during the in-home training. Review of the provider’s March 2018 Home Health Aide Services and Training Program policy revealed: Policy: “All Home Health Aides employed or contracted by the Agency will satisfactorily complete a home health aide training program and competency evaluation program prior to performing patient care. Home Health Aides are selected on the basis of such factors as sympathetic attitude toward the care of the sick, ability to write, read and carry out directions, and maturity and ability to deal effectively with the demands of the job.” Procedure: “4. A minimum of 16 hours of classroom training must precede a minimum of 16 hours of supervised practical training as part of the 75 hours.” “7. The Agency must maintain documentation that demonstrates the requirements of this standard have been met.”

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 a record review, and interview, the provider failed to notify the physician within five business days following discharge for two of two patients (4 and 5) who discharged from the home health agency (HHA). Findings included: Review of patient 4’s medical record revealed he was admitted on 6/4/25. His admitting diagnoses included type 2 diabetes, heart failure, non-pressure chronic ulcer(skin tissue breakdown), end stage renal disease (chronic kidney disease), and hypertension (high blood pressure). Patient was discharged from the HHA on 9/3/25 with goals met. The discharge summary report was signed by registered nurse (RN) C on 9/8/25 and “Faxed 9/9/25” was written on the discharg summary. 2. Review of patient 5’s medical record revealed she was admitted on 8/28/25. Her admitting diagnoses included hypertensive heart and chronic kidney disease without heart failure, chronic kidney disease, anxiety disorder, major depressive disorder and rheumatoid arthritis (autoimmune disease that attacks the joint lining causing painful, swollen, warm joints). Patient was discharged from the HHA on 11/25/25 with goals met. The discharge summary report was signed by RN D on 12/8/25 and “Faxed 12/9/25” was written on the discharged summary. 3. Interview on 1/20/26 at 4:53 p.m. with office manager B revealed she was not aware that the discharge summary was required to be sent to the physician within five business days of the patient's discharge date. She stated that she was responsible for sending the discharge summary to the physician once the clinician had completed it. 4. Interview on 1/21/26 at 8:29 a.m. with RN/owner A revealed she was aware the discharge summary must be sent to the physician within five business days following a patient’s discharged from the HHA. RN/owner A reported that during a staff meeting in March 2024, she reviewed the required, “Discharge Summary sent within 5 days” and RN D attended that staff meeting. RN C had not yet begun employment with the HHA at that time that meeting was held.. RN/owner A stated that she reviewed the five-day discharge summary requirement with RN C upon RN C’s hire. RN/owner A confirmed that the agency did not have a written policy addressing completion of the discharge summary and notification of the physician within five business days.

A recertification survey for compliance with 42 CFR Part 484, Subpart G, Subsection 484.102 Emergency Preparedness Requirements for Home Health Agencies, was conducted from 11/21/22 through 11/22/22. West Winds Health Services, Inc was found not in compliance with the following requirement: E0001.

Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: Based on policy review and interview, the provider failed to develop and implement a comprehensive emergency preparedness program based on an all-hazards community-based risk approach that had the potential to affect all patients. Findings include: 1. Interview on 11/21/22 at 12:30 p.m. and on 11/22/22 at 8:40 a.m. with owner/registered nurse A and office manager B regarding the emergency preparedness program revealed: *They had not written a formal emergency plan to follow in the event of an emergency. *They had not been aware of what was required to be included in an emergency preparedness program. *They had not: -Documented a community-based risk assessment that included strategies to address an emergency event. -Documented the collaboration with the local, regional, or state emergency managers to implement emergency procedures within the community setting. -Identified a specific procedure informing staff how to or who to contact in the event a patient required evacuation from their home. -Developed a complete communication plan. -Documented their participation in a full-scale community-based exercise, facility-based functional exercise, mock disaster drill, table-top exercise, or other emergency preparedness training. -Documented their activation or response to actual emergencies that occurred such as the 2020 coronavirus pandemic or winter storm events. *They had not implemented a comprehensive emergency preparedness program that met the requirements indicated in the regulations.

A recertification survey for compliance with 42 CFR Part 484, Subparts B-C, requirements for home health services, was conducted from 11/21/22 through 11/22/22. West Winds Health Services, Inc. was found not in compliance with the following requirements: G682 and G798. West Winds Health Services, Inc. vaccination program was reviewed for compliance with the Centers for Medicare and Medicaid (CMS) Quality, Safety and Oversight (QSO) memorandum QSO-23-02-ALL, dated October 26,2022 from 11/21/22 through 11/22/22. West Winds Health Services, Inc. was found in compliance.

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 provider failed to ensure infection prevention and control practices had been maintained for: *One of one observed suprapubic catheter change by owner/registered nurse (RN) A for patient (1). *Two of two observed dressing changes by owner/RN A for two of two patients (1 and 2). Findings include: 1. Observation on 11/21/22 between 2:30 p.m. and 4:00 p.m. of owner/RN A completing a home visit with patient 1 for a suprapubic catheter and wound vacuum (vac) assisted closure dressing changes revealed: *She washed her hands with soap and water at the patient’s kitchen sink and dried her hands with paper towels that she brought with her, upon entrance into the patient’s home. *The patient was lying in bed. *She put on gloves, gathered supplies, removed the patient’s indwelling suprapubic catheter, and disposed of it and her used gloves in a plastic bag on the floor next to the patient’s bed. *Without performing hand hygiene, she put on sterile gloves and placed the new catheter into the suprapubic site of the patient. *She removed and disposed of her gloves into the plastic bag on the floor next to the patient’s bed, and without performing hand hygiene put on new gloves, gathered supplies, removed the wound vac dressing from the patient’s coccyx area, and disposed of it and her used gloves into the plastic bag on the floor next to the patient’s bed. *Without performing hand hygiene, she put on new gloves, gathered wound vac supplies, and completed the wound vac dressing change. *She removed and disposed of her gloves into the plastic bag on the floor next to the patient’s bed, and without performing hand hygiene put on new gloves, obtained socks from a pile of clothing on the floor, applied lotion to the patient’s lower extremities, applied the patient’s socks, and disposed of her used gloves into the plastic bag on the floor next to the patient’s bed. *Without performing hand hygiene, she put on new gloves, completed vital signs, an assessment, and charting. *Prior to exiting the patient’s home, she disposed of the plastic bag and washed her hands with soap and water at the patient’s kitchen sink and dried her hands with paper towels. 2. Observation on 11/21/22 between 4:30 p.m. and 5:15 p.m. of owner/RN A completing a home visit with resident 2 for a wound dressing change revealed: *She washed her hands with soap and water at the patient’s kitchen sink and dried her hands with paper towels that she brought with her, upon entrance into the patient’s home. *The patient was sitting in her wheelchair. *She put on gloves, gathered supplies, placed a disposable chucks pad on the floor at the patient’s feet, sat on the floor at the feet of the patient, removed the patient’s dressing from her right foot, and disposed of it and her used gloves. *Without performing hand hygiene, she put on new gloves, gathered additional supplies, completed the wound dressing change to the right foot, removed her used gloves, and placed them on the chucks pad. *Without performing hand hygiene, she put on new gloves, completed vital signs, an assessment, a phone call to the physician’s office reporting the right foot wound status, and charting. *Prior to exiting the patient’s home, she disposed of the chucks pad and used gloves, washed her hands with soap and water at the patient’s kitchen sink, and dried her hands with paper towels. 3. Interview on 11/22/22 at 10:30 a.m. with owner/RN A regarding the observations above revealed she: *Questioned if hand hygiene was required between glove changes if she removed her gloves by turning them inside out as she removed them. *Purchased hand sanitizer for staff to use during patient care. *Had hand sanitizer and stored it in the middle console of her vehicle. *Had not completed hand hygiene between glove changes at the home visits with resident 1 where she completed a suprapubic catheter and wound vac dressing change, and resident 2 where she completed a wound dressing change. 4. Review of the provider's March 2018 Hand Hygiene Policy and Compliance Program revealed: *”Procedure -1. Indications for staff performing hand hygiene are:” --"Before and after each procedure.” -“2. All employees are responsible for implementing hand hygiene procedures in an ongoing attempt to prevent and/or contain infectious processes and communicable diseases.” -“7. The Agency will follow the Centers for Disease Control and Prevention (CDC) guidelines for hand hygiene: -- CDC Hand Hygiene Guidelines ---I. Indications for handwashing and hand antisepsis” ----“After removing gloves.” ----“Before handling invasive device for insertion.”

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on record review, interview, and policy review, the provider failed to provide home health aides (HHA) with written patient care instructions for two of three sampled patients (2 and 3) who received HHA services. Findings include: 1. Review of patient 2's medical record revealed: *Her start of care date was 7/1/21. *HHA was ordered and started on 8/7/21. *There had not been written instructions completed for the HHA to follow when providing services to patient 2. 2. Review of patient 3's medical record revealed: *Her start of care date was 1/8/22. *HHA was ordered and started on 3/3/22. *There had not been written instructions completed for the HHA to follow when providing services to patient 3. 3. Interview on 11/22/22 at 8:20 a.m. with owner/registered nurse A revealed: *The HHAs had been given verbal instructions over the phone. -The verbal instructions had not been documented in patient 2 or 3's medical records. *The written instructions should have been completed for the HHA to follow prior to providing services to the patients. 4. Review of the provider's June 1999 Home Health Aide policy revealed: "All Home Health Aide services are provided under specific instructions. The Aide Care Plan is implemented at the initial visit with RN, Aide, and Client [patient]. The Aide Care Plan is copied, the original in the chart and the copy for the Aide to use as a reference."