Cherokee Home Health

“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, agency policy and procedure, and interview with staff it was determined the agency failed to ensure the staff followed the infection prevention and control policy during home visits. This affected one of five home visits (HV) to include HV # 2, and had to potential to affect all patients served by this agency. Findings include: Policy: Infection Control and Prevention Policy and Procedure. Policy number: 8.005 Revision date: 3/1/25 Purpose: To prevent the spread of disease and infection between and among patients and staff. To provide the minimum level of precautions used for all patients receiving care, regardless of their diagnosis or presumed infection status. Policy: Staff will follow guidelines for protection from infectious disease based on an Occupational Safety and Health Administration (OSHA) and Centers for Disease Control (CDC) guidelines for Standard Precautions... Procedure: ...4.Standard Precautions include: a. Hand Hygiene i. Perform hand hygiene after touching blood, bodily fluids, secretions, excretions, and contaminated objects, whether or not gloves are worn... ...d. Patient - Care Equipment. ...ii. Ensure that reusable equipment is not used for the care of another person until it has been cleaned appropriately... 1. An observation was performed on 7/29/25 at 12:53 PM, with Employee Identifier (EI) # 3, Licensed Physical Therapist Assistant (LPTA) at HV # 2’s home. During the home visit the floor had animal urine and feces noted. EI # 3 touched a contaminated shoe with his/her bare hand, then touched clean patient care equipment without cleaning hands prior. EI # 3 failed to re-clean equipment prior to placing them in the clean bag. An interview was performed on 7/31/25 at 9:20 AM with EI # 1, Patient Care Manager, who confirmed the staff failed to follow the agency’s Infection Control and Prevention policy.”

“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 Medical Record (MR) review, agency policy and procedure, interviews with staff it was determined the agency failed to ensure all ordered disciplines evaluated the patient within five days after the Start of Care (SOC). This affected two of five patients with Occupational Therapy (OT), including MR # 2, MR # 8, and had the potential to affect all patients serviced by OT at this agency. Findings Include: Policy: Patient Assessment, Initial and Reassessment. Policy Number: 2.1.002 Revised date: 09/01/24 Purpose: To describe the process of patient assessments. Policy: ... d. Physical Therapist, Speech Therapist, Occupational Therapist, Medical Social Worker, and Dietician may make initial evaluations of the patient status to determine the need for specific therapies. This initial discipline specific evaluation will occur within the 5 days from the Start of Care date or sooner if medically necessary... 1. MR # 2 was admitted to the agency on 6/27/25 with a primary diagnosis of Secondary Malignant Neoplasm of Brain. A review of the Plan of Care (POC) dated 6/27/25 revealed an ordered frequency for OT one time a week for one week effective week of 6/29/25. A review of the OT Missed visit notification dated 7/4/25 revealed the OT attempted evaluation on day seven after the SOC. A review of the OT evaluation visit note report dated 7/14/25 revealed the patient was evaluated 17 days after the SOC. An interview was conducted on 7/31/25 at 9:24 AM with Employee Identifier (EI) # 1, Patient Care Manager, who confirmed the patient was not evaluated per the agency policy. 2. MR # 8 was admitted to the agency on 3/8/25 with a primary diagnosis of Chronic Obstructive Pulmonary Disease with Acute Exacerbation. A review of the POC dated 3/8/25 revealed an ordered frequency for OT of one time a week for one week effective week of 3/9/25. A review of the OT evaluation visit note report dated 3/14/25 revealed the patient was evaluated six days after the SOC. An interview was conducted on 7/31/25 at 9:38 AM with EI # 1, who confirmed the patient was not evaluated per the agency policy.”

“Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This Element is not met as evidenced by: Based on Medical Record (MR) review, agency policy and procedure, and staff interview it was determined the agency failed to ensure that staff notified the physician regarding changes in the patient’s condition. This affected MR # 8, one of 13 MRs reviewed and had the potential to affect all patients served by this agency. Findings include: Policy: Coordination of Care from Admit Through Discharge. Policy Number: 2.1.017 Revision date: 9/1/24 Purpose: To establish processes and criteria so that the coordination of patient care will be optimal from admit through discharge. Policy: The agency provides care and services within an integrated continuum of care system. This is accomplished by: Identifying patient needs through assessment and communication with other health care providers... ...4. Coordination of care with physician/authorized practitioner: At admission, throughout care, and at discharge, coordination of services is promoted through routine communications with the patient’s physician: a. When changes occur in the patient’s condition or response to treatment... MR # 8 was admitted to the agency on 3/8/25 with a primary diagnosis of Chronic Obstructive Pulmonary Disease with Acute Exacerbation A review of the Plan of Care dated 3/8/25 revealed an order for Nursing one time a week for nine weeks and two as needed visits for respiratory and cardiac complications. A review of the Visit Note Report dated 3/18/25 revealed the nurse documented the patient had abnormal lung sounds. The visit note contained no documentation the physician was notified of the abnormal lung sounds. A review of the Visit Note Report dated 4/8/25 revealed the nurse documented the patient had a large new area of bruising. The visit note contained no documentation the physician was notified of the bruising. A review of the Visit Note Report dated 4/22/25 revealed the nurse documented the physician was called and a message was left regarding the patient had not been taking two medications since discharge from the hospital because the caregiver wanted to wait until the Primary Care Physician (PCP) was called to confirm, and the patient had a 10 pound weight gain in three days. The patient care manager (PCM) documented faxed on 4/23/25. No documentation was found in the MR of any follow up on the fax and or the call made. An interview was conducted on 7/31/25 at 9:38 AM with Employee Identifier # 3, PCM, who confirmed the staff did not notify the physician of changes in the patient’s condition per the agency policy.”