Every finding on record at Where the Heart Is Inc

An Emergency Preparedness survey was conducted along with a recertification survey beginning 8/7/23. This facility was found to be in compliance with all regulations reviewed related to Emergency Preparedness.

A recertification survey was initiated on 8/7/23. The facility was informed of survey findings during an exit interview on 8/10/23.

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on policy review, medical record review and interview, the facility failed to ensure Outcome Assessment Information (OASIS) data accurately reflected a patient’s status for 2 of 9 (Patients #2 and 4) active records reviewed. The findings included: 1. Review of the facility’s “COMPREHENSIVE ASSESSMENT:START OF CARE” policy revealed, “…OASIS items are incorporated into the comprehensive assessment to assess the needs of the client…” 2. Medical record review for Patient #2 revealed a Start of Care (SOC) date of 7/27/23 with diagnoses that included Burn of 1st degree of chest wall and open wound of scrotum. Review of the POC dated 7/27/23-9/24/23 revealed interventions that documented, “…Care of indwelling catheter…Change #16 foley catheter q [every] 30d [days] & [and] prn [as needed]…” Review of the SOC OASIS dated 7/27/23 revealed section M1610- Urinary Incontinence or Urinary Catheter Presence, was documented as “No incontinence or catheter”. In an interview on 8/10/23 at 12:55 PM, the facility’s Director of Nursing verified Patient #2 had an indwelling catheter upon SOC and M1610 should have been documented as the patient having a catheter. 3. Medical record review for Patient #3 revealed a SOC date of 7/19/23 with diagnoses that included Cerebral Infarction and Human Immunodeficiency Virus. Review of the POC dated 7/19/23-9/16/23 revealed interventions that documented, “…Assess/Perform/Instruct Pt/Pcg [patient/patient caregiver]: External catheter care…” Review of the SOC OASIS dated 7/19/23 revealed section M1610-Urinary Incontinence or Urinary Catheter Presence, was documented as “Patient is incontinent”. In an interview on 8/10/23 at 12:55 PM, the facility’s Director of Nursing verified Patient #3 used an external condom catheter and M1610 should have been documented as the patient having an external catheter.

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 policy review, record review and interview, the facility failed to follow the plan of care (POC) related to pain for 1 of 9 (Patient #4) active patients reviewed. The findings included: 1. Review of the facility’s “PHYSICIAN’S PLAN OF CARE/CHANGE ORDERS” policy revealed, “…The physician’s Plan of Care Home Health Certification and Plan of Treatment (CMS 485) is an individualized plan for care and treatment prepared by the client’s physician with assistance from the nurse and/or Therapist…The Agency will provide care/services consistent with the Plan of Care…” 2. Medical record review for Patient #4 revealed a Start of Care (SOC) date of 7/19/23 with diagnoses that included Cerebral Infarction and Human Immunodeficiency Virus. A POC dated 7/19/23-9/16/23 documented vital sign parameters to notify physician that included Pain Rating greater than 7 on 0-10 scale. Review of Skilled Nurse visit notes revealed on 7/19/23, 7/20/23 and 8/3/23 Patient #4 rated his pain at a 10. There was no documentation the physician was notified of the patient’s pain rating greater than 7. During an interview on 8/10/23 at 1:00 PM, the facility’s Director of Nursing verified the physician should have been notified of the pain rating greater than 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 policy review, observation and interview, the facility failed to ensure measures were utilized to prevent exposure of potential infectious bacteria for 1 of 5 (Patient #1) home visit observations. The findings included: 1. Review of the facility's "UNIVERSAL PRECAUTIONS FOR ALL HEALTH CARE WORKERS" policy revealed, "...HAND WASHING- Hands MUST be washed before and after contact with EACH client. In the absence of water, an appropriate antibacterial solution may be used…All equipment used during client care will be cleaned with alcohol or bleach prior to reuse…” 2. Observations in the home of Patient #1 on 8/8/2023 at 11:00 PM revealed Registered Nurse (RN) #1 placed her bag on a barrier on the floor. RN #1 washed her hands at the beginning of the visit, and never washed her hands or performed hand hygiene again, even after touching Patient #1’s colostomy bag and abdomen. At the conclusion of the visit, RN #1 placed the barrier that had been on the floor, into her bag. RN #1 did not clean the blood pressure cuff, stethoscope or oxygen saturation monitor that was used to assess Patient #1 during the visit. RN #1 did not perform appropriate hand hygiene, failed to clean equipment used during the visit, and comingled clean and dirty items in her work bag. During an interview on 8/10/2023 at 1:00 PM, the Director of Nursing verified RN #1 did not perform appropriate hand hygiene, did not clean equipment used on the patient, and did not separate clean and dirty items in her bag.