Haven Healthcare

“Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This Standard is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to ensure a copy of the current plan of care (POC- information identified based upon the patient identified needs and development of appropriate interventions) was provided to one of 5 sampled patients (Patient 3). This deficient practice had the potential for lack of coordination of the plan of care with Patient 3 and other clinicians involved in the patient care and treatment. Findings: During a review of Patient 3’s Patient Information indicated a start of care (SOC) on 1/22/2024, with diagnoses including pressure ulcer of other site, stage 2 (an open wound that only affect the upper layer of your skin), laceration without foreign body, right knee, and type 2 diabetes mellitus (a condition that results in too much sugar circulating in the bloodstream). During a review of Patient 3’s Home Health Certification and Plan of Care for the certification period starting from 1/22/2024 to 3/21/2024, included an order for the skilled nurse (SN) frequency of visits of twice a week for four weeks and then once a week for 4 weeks, for wound care right below the knee amputation (RBKA, amputation that involves removing the foot, ankle joint, distal tibia, fibula, and corresponding soft tissue structures), to instruct on all aspects of diabetic management, and to assess blood sugar via finger stick (a minimally invasive procedure using a lancet to draw a drop or two of capillary blood from a finger) every visit prior to insulin (used to treat high blood sugar) administration. During a joint home visit observation to Patient 3’s residence on 3/23/2024 at 2:15 p.m., with a licensed vocational nurse (LVN 3). Patient 3 was observed sitting in the sofa, awake, alert, and oriented x3 (to person, place, and time), accompanied by a family member (FM 1). During a review of Patient 3’s home health agency folder located inside the patient’s house showed there was no copy of the current Home Health Certification and Plan of Care (document used to establish the patient’s treatment plan for the initial certification period and any continued sixty-day recertification’ periods). During an interview with Family Member 1 (FM 1), on 3/23/2024 at 2:45 p.m., FM 1 stated she has not seen a copy of Patient 3’s Plan of Care in the agency’s folder and would like to have a copy to know Patient 3’s current treatment and care. During an interview, on 3/24/2024, at 1:05 p.m. with the Chief Nursing Officer (CNO), CNO stated and agreed patients should have a current copy of their POC at home. During a review of the agency’s undated policy and procedure titled, “The Process of Patient Management (Plan of Treatment/Plan of Care)”, indicated a plan of care shall be developed and documented within 24 hours of the start of care. Patient and family/caregivers will be included in the care planning process. The plan of care will include, among others, all pertinent diagnoses, medications, equipment and supplies needed, safety precautions, and interventions and goals for each discipline.”

“Patient rights CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient’s rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This Condition is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to ensure the Condition of Participation (conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions] program) regarding Patient Rights was met as follows: 1. The HHA failed to ensure one of seven sampled patients (Patient 1) had the right to be free and protected from physical abuse (the willful infliction of injury with resulting physical harm) and sexual abuse (non-consensual sexual contact of any type) for one out of seven sample patients (Patient 1). (Refer to G430) 2. The HHA failed to report an alleged physical and sexual abuse to the Department for one of seven sampled patients (Patient 1). (Refer G488) The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated (written law) compliance with Federal Regulations for Patient Rights to ensure highest quality health care is provided to patients assessed to receive home health services.”

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on observations, interviews and record reviews, the Home Health Agency (HHA) failed to ensure the Condition of Participation for Care Planning, coordination, quality of care was met as follows; The HHA failed to ensure a plan of care was formulated and physician’s treatment order was obtained for one of 7 patients’ (Patient 2) nephrostomy (a small tube to drain urine from kidney) site. This deficient practice had the potential to cause infection on the nephrostomy site. ( Refer to G572) The SN (skilled nurse) failed to provide indwelling catheter (tube that drains urine from the bladder to a bag) care as per physician’s order for one of seven sampled patients (Patient 5). (Refer to G580) The visiting nurse failed to notify the attending physician for one out of seven sampled patients (Patient 5), who had sediments (solid materials) present in the urine. This deficient practice placed the patient who had an indwelling catheter (tube that drains urine from the bladder into a drainage bag) at a high risk to have urinary tract infection. (Refer to G590) The HHA failed to ensure proper coordination of services and care planning for 1 of 7 sampled residents. (Patient 2). (Refer to G600) The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated (written law) compliance with Federal Regulations for Care planning, coordination, quality of care, to ensure highest quality health care is provided to patients assessed to receive home health services.”

“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 observation, interview and record review, the home health agency (HHA) failed to ensure a plan of care was formulated, and physician’s treatment order was obtained for one of 7 patients’ (Patient 2) who had a nephrostomy (a small tube to drain urine from kidney) site. This deficient practice had the potential to cause infection on the nephrostomy site. A review of the home health agency’s (HHA’s) document titled “ Patient Information” indicated that Patient 2 had a start of care (SOC) of 12/26/2023 with diagnosis including diabetes (abnormal blood sugar levels) and essential hypertension (high blood pressure). A review of the HHA’s document titled “ Home Health Certification and Plan of Care” for certification period of 12/26/2023 to 2/23/2024, indicated Skilled Nursing (SN) visits twice a week for one week and once a week for eight weeks for nephrostomy (a small tube to drain urine from kidney) drain, dressing change/gastrointestinal (stomach and intestine) assessment/cancer disease process, physical therapy (PT, exercises of the lower body twice a week for three weeks for gait, safety, assess/strengthening/four wheel walker ordering, occupational therapy (OT, exercises of the upper body) twice a week for 2 weeks for upper arm assess/teach. Patient 2 had a port-a-cath (a catheter inserted through a vein used to receive frequent doses of chemotherapy medications). SN to notify the physician of temperature greater than (>) 103 or less than ( 100 or 30 or 170 or 100 or 300 or 300 or l<70. SN to perform nephrostomy care on right side weekly and as needed by family. SN to instruct patient or caregiver on signs/symptoms of urinary tract infection (UTI, infection in the urine) to report to physician. SN may obtain urinalysis and urine culture & sensitivity (C&S) test (urine test) as needed for signs/symptoms of UTI, flush nephrostomy site with 10 milliliter (ml, unit of measurement) of normal saline(NS, a solution) weekly or as needed (PRN) when clogged or excessive sediment (accumulation of particles) in the urine collection bag. A joint home visit was conducted on 2/2/2024 at 1:40 p.m., with Registered Nurse 1 (RN1) at Patient 2’s residence. Patient 2 answered the door. Patient 2 was verbally responsive, alert and oriented to name, place, person and time. Patient 2 had a nephrostomy tube attached to her right side draining yellow colored urine attached to a leg bag. Patient 2 led the staff to the living room. During a concurrent observation and interview on 2/2/2024 at 1:4 p.m., with RN1 at the home visit, RN 1 cleansed the nephrostomy site using a port dressing change kit (a kit that contained all the necessary items, such as gloves, sterile gauze, dressings, and the antiseptic solution Chloraprep, to perform the dressing change in a safe and efficient manner). RN 1 stated that it has chloraprep (a sterile antiseptic solution containing a combination of two percent (2%) Chlorhexidine gluconate in 70% isopropyl alcohol, which is effective for both rapid and persistent reduction of bacterial load across various body regions for a broad spectrum of organisms) used to disinfect the nephrostomy site. RN 1 stated that she did not write order for Patient 1’s nephrostomy site. RN 1 stated she always use chloraprep for Patient 2’s nephrostomy site. During an interview with the RN Supervisor (RNS) on 2/6/2024 at 3:00 p.m., RNS stated during the visiting nurse’s assessment of Patient 2’s medications, Patient 2’s equipment and other treatments should have been clarified with the doctor and should have been included in the plan of care. A review of the HHA’s undated policy and procedure (P&P) titled, “ Comprehensive Assessments of Patients,” indicated it is the HHA’s policy to provide a patient-specific comprehensive assessment that accurately reflects the patient’s current health status and includes information that may be used to demonstrate the patient’s progress toward achievement of desired outcomes. A review of the HHA’s undated P&P titled, “ Physicians Orders,” indicated no medication or treatment shall be given except on the signed order of a person lawfully authorized to give such order.”

“Coordination of Care CFR(s): 484.60(d) Standard: Coordination of care. The HHA must: This Standard is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to coordinate care and services for 1 of 7 sampled residents. (Patient 2) This deficient practice had the potential in the delay of required necessary services included in the plan of care. A review of the home health agency’s (HHA’s) document titled “ Patient Information” indicated that Patient 2 had a start of care (SOC) of 12/26/2023 with a medical diagnosis of Type 2 Diabetes (A long-term condition in which the body has trouble controlling blood sugar and using it for energy) and essential hypertension (occurs when you have abnormally high blood pressure that is not the result of a medical condition). A review of the HHA’s document titled “ Home Health Certification and Plan of Care” for the certification period of 12/26/2023 to 2/23/2024, indicated Skilled Nursing (SN) visits twice a week for one week and once a week for eight weeks for Nephrostomy(a small tube that helps drain pee from your kidney) drain, dressing change/Gastrointestinal assessment/cancer disease process,. Physical Therapy (PT) for twice a week for three weeks for gait safety assess/strengthening/four wheel walker ordering,. Occupational Therapy (OT): twice a week for 2 weeks for upper arm assess/teach. Patient has a porta Cath ( a small piece of medical equipment that sits under the skin with a long tube inserted through a vein used to receive frequent doses of chemotherapy medications). SN to notify the physician of Temperature greater than(>) 103 or less than() 100 or less than() 30 or less than() 170 or less than()100 or less than() 300 or less than() 300 or less than(<) 70. SN to perform nephrostomy care on Right side 1) cleanse with Normal saline (NS) , 2) pat dry, 3) Apply Split gauze, 4) Secure with Tape. Frequency: weekly by SN and as needed by family. SN to instruct the on signs/symptoms of UTI(urinary tract infection) to report to MD/SN. SN may obtain urinalysis and urine culture & sensitivity (C&S) test as needed for signs/symptoms of UTI to include pain, foul odor, cloudy or blood-tinged urine and fever. Flush Nephrostomy site with 10ml (milliliter- unit of measurement) NS weekly or PRN clogged or excessive sediment. A joint home visit conducted on 2/2/2024 at 1:40 p.m., with Registered Nurse 1(RN1) at Patient 2’s residence. Patient 2 answered the door. Verbally responsive, alert and oriented to name, place, person and time. Ambulate with or with any assistance. Patient 2 Observed to have a nephrostomy tube attached to her right kidney draining yellow colored urine attached to a leg bag. Patient 2 led the staff to the living room. During an interview with Patient 2 on 2/2/2024 at 1:40 p.m., Patient 2 stated that she was diabetic and is taking long term oral hypoglycemic medication (medications to control blood sugar) Metformin 500 milligrams by mouth twice daily with meals. When asked what was her blood sugar, she stated “ I do not know because I do not have a glucometer(a machine use to test for blood sugar level). I used to have it but my old machine failed and my doctor did not issue me a new one.” During a review of the HHA’s document titled “Home health Certification and Plan of Care” for the certification period of 12/26/2023 to 2/24/2024, indicated on the DME(durable medical equipment) and Supplies listed dressing supplies and glucometer. During an interview with Registered Nurse 1 (RN1) on 2/2/2024 at 2:00p.m., RN1 stated she does not know why the patient did not have any glucometer at home and stated she will ask the agency to issue her one so the patient can monitor her blood sugar per plan of care. During a concurrent interview and record review with the Registered nurse supervisor (RNS) on 2/6/2024 at 3:00 p.m., RNS stated that during the initial assessment, the nurse will verify the patient’s, medications, equipment and other treatments should be clarified with the patients doctor and should be included in the plan of care. A review of the HHA’s policy titled “Comprehensive Assessment of Patients” indicated The physician will be notified promptly each time that there is a change in condition, change in the Plan of Care and revision of the Comprehensive Assessment. The data collected at the time of Assessment of all patients will include but not be limited to the following: 10.12 Medications and 10.13 Equipment.”

“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 and interview, the home health agency (HHA) failed to implement the accepted standards of infection control practice when the Registered Nurse did not follow proper nursing bag technique for 1 out of 7 sampled patients (Patient 2). This failure had the potential to expose Patient 2 to serious infections that could impact a major health risk to the patient’s already immunocompromised (weak immune system) health status. A review of the home health agency’s (HHA’s) document titled “ Patient Information” indicated that Patient 2 had a start of care (SOC) of 12/26/2023 with a medical diagnosis of Type 2 Diabetes (A long-term condition in which the body has trouble controlling blood sugar and using it for energy) and essential hypertension (occurs when you have abnormally high blood pressure that is not the result of a medical condition). A review of the HHA’s document titled “ Home Health Certification and Plan of Care” for the certification period of 12/26/2023 to 2/23/2024, indicated Skilled Nursing (SN) visits twice a week for one week and once a week for eight weeks for Nephrostomy(a small tube that helps drain pee from your kidney) drain, dressing change/Gastrointestinal assessment/cancer disease process,. Physical Therapy (PT) for twice a week for three weeks for gait safety assess/strengthening/four wheel walker ordering,. Occupational Therapy (OT): twice a week for 2 weeks for upper arm assess/teach. Patient has a porta Cath ( a small piece of medical equipment that sits under the skin with a long tube inserted through a vein used to receive frequent doses of chemotherapy medications). SN to notify the physician of Temperature greater than(>) 103 or less than() 100 or less than() 30 or less than() 170 or less than()100 or less than() 300 or less than() 300 or less than(<) 70. SN to perform nephrostomy care on Right side 1) cleanse with Normal saline (NS) , 2) pat dry, 3) Apply Split gauze, 4) Secure with Tape. Frequency: weekly by SN and as needed by family. SN to instruct the on signs/symptoms of UTI(urinary tract infection) to report to MD/SN. SN may obtain urinalysis and urine culture & sensitivity (C&S) test as needed for signs/symptoms of UTI to include pain, foul odor, cloudy or blood-tinged urine and fever. Flush Nephrostomy site with 10ml (milliliter- unit of measurement) NS weekly or PRN clogged or excessive sediment. A joint home visit conducted on 2/2/2024 at 1:40 p.m., with Registered Nurse 1(RN1) at Patient 2’s residence. Patient 2 answered the door. Verbally responsive, alert and oriented to name, place, person and time. Ambulate with or with any assistance. Patient 2 observed to have a nephrostomy tube attached to her right kidney draining yellow colored urine attached to a leg bag. Patient 2 led the staff to the living room. On concurrent observation of RN 1 during the home visit, RN 1 placed her nursing bag on the floor without placing any protective barrier. During an interview with RN 1 after the home visit on 2/2/2024 at 2:30 p.m., RN 1 stated that she noticed there was a coffee table where she can placed her nursing bag. RN 1 agreed that standard nursing practice for infection control, “anything placed below the waist is considered dirty”. During an interview with the Registered Nurse Supervisor (RNS) on 2/6/2024 at 3:00 p.m., RNS stated that the nurse should have followed the agency’s bag technique to prevent the cause and spread of infection during their home visit. A review of the HHA’s policy titled “Nursing Bag and Supplies” dated 2/1/2014 indicated Haven HealthCare field nurses can choose to have a nursing bag in which she will carry supplies. The bag shall be a bag that can be cleaned weekly with bleach or alcohol; or a washable bag that will be washed in the home laundry as needed or at least weekly. The nurse shall carry barriers to use in the home on which to set the bag. The barriers can be newspapers, brown wrapping paper sheets, etc.”

“Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This Element is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA) failed to ensure one of seven sampled patients (Patient 1) had the right to be free from physical abuse (the willful infliction of injury with resulting physical harm) and sexual abuse (non-consensual sexual contact of any type) by failing to: 1. Ensure Patient 1 who had a diagnosis of dementia (a loss of memory and other mental abilities severe enough to interfere with daily life) and was bedbound (is someone who has become very weak and is no longer able to move easily, instead, they are confined to their bed), did not have a spouse or a partner, was free and protected from alleged physical abuse and alleged sexual abuse. As a result: a. On 11/6/2023, during a home visit, Registered Nurse (RN 1) found Patient 1 with suspicious skin wounds (an injury that breaks the skin) to her legs, abdomen, and left arm. RN 1 notified the HHA of the alleged physical abuse. The HHA did not investigate the alleged physical abuse, did not report to the Department, and to the local police, and did not protect Patient 1. b. On 1/22/2024 Patient 1 was transferred via ambulance to the General Acute Care Hospital 1 (GACH 1) for altered mental status (a change in mental function). Patient 1’s GACH 1 History and Physical Exam form dated 1/22/2024, timed 9:12 pm, indicated Patient 1’s urinalysis test (UA, test of the urine) was contaminated due to having sperm (fluid that is produced from the male reproductive tract) present in the urine. On 2/2/2024, at 5:15 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the provider’s non-compliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm impairment, or death to a patient) in the presence of the agency’s Administrator and the Registered Nurse Supervisor related to the home health agency’s failure to ensure Patient 1 had the right to be free and protected from physical and sexual abuse. On 2/2/2024, at 9:13 p.m., the home health agency sent the IJ Removal Plan (the facility’s plan of action to correct the deficient practices) by email. The survey team reviewed the IJ Removal Plan and notified the RN Supervisor, the IJ Removal Plan was not accepted on 2/3/2024, at 8:15 a.m. On 2/3/2024, at 3:25 p.m., the home health agency sent the revised IJ Removal Plan by email. The survey team reviewed the IJ Removal Plan. The survey team notified the RN Supervisor by email, the IJ Removal Plan was not accepted on 2/3/2024 at 7 p.m. On 2/3/2024, at 6:52 p.m., the agency sent a revised IJ Removal Plan by email. The survey team notified the RN Supervisor by email, the IJ Removal Plan was not accepted on 2/4/2024, at 9/21/2024. On 2/4/2024, at 4:56 p.m., the agency sent a revised IJ Removal Plan by email. The survey team notified the RN Supervisor by email, the IJ Removal Plan was not accepted on 2/5/2024, at 12 p.m. The survey team notified the RN Supervisor. On 2/5/2024, at 3 p.m., the survey team completed the survey tasks, and exited with the IJ situation not removed. On 2/12/2024 at 5:10 p.m. the district office received the agency’s revised IJ Removal Plan by email. On 2/13/2024, the survey team reviewed the IJ Removal Plan and was not acceptable and the agency was informed on 2/13/2024, and at 11:07 a.m. on 2/13/2024, an unacceptable Plan of Correction (POC) letter was sent to the agency by email. On 2/13/20234 at 4:50 p.m. the agency sent a revised IJ Removal Plan by email. On 2/14/2024, at 3:00 p.m., the survey team reviewed the agency’s revised IJ Removal Plan and was acceptable. On 2/15/2024, at 2:25 p.m. the survey team conducted an onsite IJ Removal Plan implementation at the agency based on observation, interview and record review, in the presence of administrator, chief nursing officer, and RN Supervisor, and the IJ was removed. The agency’s acceptable IJ Removal Plan included the following: The agency’s priority was to have Patient 1 removed from her home as soon as possible. Agency’s RN reassessed Patient 1 on 2/3/2024. The agency transferred Patient 1 to General Acute Care Hospital (GACH) 1 and contacted specific department involved (Adult Protective Services (APS), Police Department, and Department of Public Health) on 2/3/2024. The patient was sent back home on 2/4/2024 at 1:40 a.m. The agency contacted GACH 1 and talked with the hospital’s social worker. The police department contacted the agency and was provided the case number. On 2/5/2024, all field staff was informed the patient has been discharged to home and instructed to educate caregiver and family and keeping the patient safe and free of abuse. A memo sent to all field staff informed them they are required to assess each patient on each visit to determine if there is any suspicion of abuse of neglect. Field staff will be required to document the findings in goals and interventions. RN Supervisor received a one on one counseling on 2/2/2024 on proper notification of administration and leadership with these types of allegations. HR Director completed counseling action plan for RN Supervisor, Chief Nurse Officer and Administrator on 2/4/2024. On 2/5/2024, the agency contacted the physician and was informed that the patient was back home. On 2/6/2024, case conference held and staff are to be report for any signs of abuse for Patient 1, and the agency continued daily visit of Patient 1. On 2/7/2024, during the RN visit, the patient was noted of change in mental status, the physician was notified and patient was transferred to GACH 1 by 911 (medical telephone emergency). The physician requested patient not to return home due to safety concern and chief nurse office notified GACH 1’s social worker. On 2/8/2204, the patient was admitted to the acute hospital and will not be placed at home due to patient safety. The agency informed the physician the patient was no longer on agency’s services due to the hospital admission. The agency provided Emergency Mandatory educated conducted on 2/5/2024. Re-education conducted during mandatory staff meeting on 2/7/2024 on Abuse and how to file an APS report. The presenter was from QPIPlus held on 2/7/2024 and to be conducted quarterly and competency tests are required. A memo sent to all field staff on 2/3/2024 informing them they are required to assess each patient on each visit to determine if there is any suspicion of abuse or neglect. All patients screened via visits or via phone for safety/abuse that began on 2/3/2024 with call log. Field staff to receive a phone call daily by 4 p.m. for next week from the Administrator to ensure field staff are assessing the patients for abuse and neglect. Audits were done on 2/5/2024 to 2/12/2024. On 2/9/2024, education on the updated Abuse program, competency test completed and sign-in sheet indicating new policy reviewed and understood. Agency conducted Supervisory visits,15% of census that started 2/3/2024. On 2/13/2024, all active patients have had on-site direct observation and assessment for any signs and symptoms of abuse and neglect. These assessments have systematically been reported to the clinical supervisor. The patient is still in the acute hospital and waiting for placement into a skilled nursing facility. The QAPI committee met and discussed all corrective actions, root cause analysis identified, policy and procedures was updated for seven step abuse and neglect identification, preventions, and reporting protocol. Findings: During a review of Patient 1’s Patient Information (admission record), the Patient Information indicated the HHA admitted Patient 1 on 1/6/2022 with diagnoses including dementia and depression (a mood disorder marked by varying degrees of sadness). During a review of Patient 1’s Patient Communication note dated 11/6/2023, the Patient Communication note indicated Patient 1 had new suspicious skin wounds to Patient 1’s legs, abdomen, and left arm. The Patient Communication note indicated when RN 1 was there, the “grandson (unidentified) was very verbally abusive to the patient, saying I don’t care and I am sick of you.” The Patient Communication note indicated “These are not normal scratch marks. The patient is unable to reach down that far to scratch her knees and calf. Filing report to APS (Adult Protective Services)”. During a review of Patient 1’s Skilled Nursing Visit dated 11/6/2023, indicated Patient 1’s “Grandsons behavior is inappropriate and abusive.” During a review of Patient 1’s Plan of Care (POC, the process of identifying a patient’s needs to ensure collaboration among nurses, patients, and other healthcare providers) for certification period 12/27/2023 to 2/24/2024, the POC indicated an order for the Skilled Nurse (SN) to provide SN to visit twice a week for nine weeks. During a review of Patient 1’s GACH 1 Urinalysis test result with a collected date of 1/22/2024, at 4:42 pm, indicated there was sperm present in Patient 1’s urine. During a review of Patient 1’s GACH 1 Toxicology report (detection of poisons) with a collected date of 1/22/2024, at 4:42 pm, indicated Patient 1 tested positive for ethanol (alcohol) and amphetamines (drugs). During a review of Patient 1’s Police report created on 1/31/2024, at 11:30 a.m., indicated Patient 1 was bedridden with dementia and unable to consent to anything. During a review of Patient 1’s undated Unusual Occurrence (events or situations that do not happen daily) Form, the Unusual Occurrence Form indicated Patient 1 had a past medical history of dementia and being bedbound. The Unusual Occurrence Form indicated Patient 1 did not have a spouse or a partner in the home. The Unusual Occurrence Form Patient 1 was hospitalized on 1/22/2024 for altered mental status and was found with UTI in a specimen that was contaminated with sperm. The Unusual Occurrence Form indicated Patient 1’s toxicology (detection of poisons) report demonstrated Patient 1 had ethanol and amphetamines. The Unusual Occurrence Form indicated “visiting nurses (unidentified) concurred that there is a possibility that the patient is being abused and the results were cause for alarm.” During a concurrent home visit observation and interview on 2/2/2024, at 1:30 p.m., inside Patient 1’s residence with RN 1, Patient 1 was lying in a hospital bed. Patient 1’s home was unkept and cluttered. Patient 1 was alert and oriented to place and time. Patient 1’s legs and abdomen were covered with s was bed bound and was unable to move her lower legs. During an interview on 2/2/2024, at 2:30 p.m., with RN 1, RN 1 stated on one of her visits on 11/6/2023, Patient 1 had “acid burns (skin wounds) under her left breast fold all the way down her lower legs.” RN 1 stated she reported the incident to APS and to the HHA. During an interview on 2/2/2024, at 4:30 p.m., with the RN Supervisor, the RN supervisor stated GACH 1 faxed a copy of the Patient 1’s discharged report to the HHA on 1/29/2024. The RN Supervisor stated upon seeing Patient 1’s UA result indicating there was a sperm presence in Patient 1’s urine, the HHA red flagged the result and considered as a possible sexual abuse incident. The RN Supervisor stated she sent a nurse (unidentified) to Patient 1’s home for evaluation and reported the incident to APS the same day. The RN Supervisor stated she notified the police and the Department on 1/31/2024. During an interview on 2/2/2024, at 4:50 p.m., with the Chief Nursing Officer (CNO), the CNO stated the HHA did not know what else to do to prevent and protect Patient 1 from being abused. The CNO the HHA did not report the alleged physical abuse on 11/6/2023 to the Department. During a review of the agency’s policy and procedure titled, “Safety-Patient Abuse, Neglect and Exploitation,” dated 2/1/2024, indicated all patients have the right to be free from abuse or neglect as well as the fear of being abused or neglected. Allegations or information indicating abuse or neglect may have occurred will be thoroughly and promptly investigated with follow up action taken. Should the investigation conclude that abuse or neglect has occurred, the physician and Department of Public Health will be notified.”

“Immediate reporting of abuse by all staff CFR(s): 484.50(e)(2) Any HHA staff (whether employed directly or under arrangements) in the normal course of providing services to patients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of patient property, must report these findings immediately to the HHA and other appropriate authorities in accordance with state law. This Element is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to report allegations of physical abuse (the willful infliction of injury with resulting physical harm) and sexual abuse (non-consensual sexual contact of any type) immediately (without delay; at once) to the Department for one of seven sampled patients (Patient 1). This deficient practice resulted in the delay of investigation by the Department and had the potential for Patient 1 to experience further abuse. Findings: During a review of Patient 1’s Patient Information (admission record), the Patient Information indicated the HHA admitted Patient 1 on 1/6/2022 with diagnoses including dementia (a loss of memory and other mental abilities severe enough to interfere with daily life) and depression (a mood disorder marked by varying degrees of sadness). During a review of Patient 1’s Patient Communication note dated 11/6/2023, the Patient Communication note indicated Patient 1 had new suspicious skin wounds (an injury that breaks the skin) to Patient 1’s legs, abdomen, and left arm. The Patient Communication note indicated when Registered Nurse 1 (RN 1) was there, the “grandson (unidentified) was very verbally abusive to the patient, saying I don’t care and I am sick of you.” The Patient Communication note indicated “These are not normal scratch marks. The patient is unable to reach down that far to scratch her knees and calf. Filing report to APS (Adult Protective Services)”. During a review of Patient 1’s Skilled Nursing Visit dated 11/6/2023, indicated Patient 1’s “Grandsons behavior is inappropriate and abusive.” During a review of Patient 1’s Plan of Care (POC, the process of identifying a patient’s needs to ensure collaboration among nurses, patients, and other healthcare providers) for certification period 12/27/2023 to 2/24/2024, the POC indicated an order for the Skilled Nurse (SN) to provide SN to visit twice a week for nine weeks. During a review of Patient 1’s General Acute Care Hospital 1 (GACH 1) Urinalysis test (UA, test of the urine) result with a collected date of 1/22/2024, at 4:42 pm, indicated there was sperm (fluid that is produced from the male reproductive tract) present in Patient 1’s urine. During a review of Patient 1’s GACH 1 Toxicology report (detection of poisons) with a collected date of 1/22/2024, at 4:42 pm, indicated Patient 1 tested positive for ethanol (alcohol) and amphetamines (drugs). During a review of Patient 1’s Police report created on 1/31/2024, at 11:30 a.m., indicated Patient 1 was bedridden with dementia and unable to consent to anything. During a review of Patient 1’s undated Unusual Occurrence (events or situations that do not happen daily) Form, the Unusual Occurrence Form indicated Patient 1 had a past medical history of dementia and being bedbound. The Unusual Occurrence Form indicated Patient 1 did not have a spouse or a partner in the home. The Unusual Occurrence Form Patient 1 was hospitalized on 1/22/2024 for altered mental status and was found with UTI in a specimen that was contaminated with sperm. The Unusual Occurrence Form indicated Patient 1’s toxicology report demonstrated Patient 1 had ethanol and amphetamines. The Unusual Occurrence Form indicated “visiting nurses (unidentified) concurred that there is a possibility that the patient is being abused and the results were cause for alarm.” During a concurrent home visit observation and interview on 2/2/2024, at 1:30 p.m., inside Patient 1’s residence with Registered Nurse 1 (RN 1), Patient 1 was lying in a hospital bed. Patient 1’s home was unkept and cluttered. Patient 1 was alert and oriented to place and time. Patient 1’s legs and abdomen were covered with s was bed bound and was unable to move her lower legs. During an interview on 2/2/2024, at 2:30 p.m., with RN 1, RN 1 stated on one of her visits on 11/6/2023, Patient 1 had “acid burns (skin wounds) under her left breast fold all the way down her lower legs.” RN 1 stated she reported the incident to APS and to the HHA. During an interview on 2/2/2024, at 4:30 p.m., with the RN Supervisor, the RN supervisor stated GACH 1 faxed a copy of the Patient 1’s discharged report to the HHA on 1/29/2024. The RN Supervisor stated upon seeing Patient 1’s UA result indicating there was a sperm presence in Patient 1’s urine, the HHA red flagged the result and considered as a possible sexual abuse incident. The RN Supervisor stated she sent a nurse (unidentified) to Patient 1’s home for evaluation and reported the incident to APS the same day. The RN Supervisor stated she notified the police and the Department on 1/31/2024. During an interview on 2/2/2024, at 4:50 p.m., with the Chief Nursing Officer (CNO), the CNO stated the HHA did not know what else to do to prevent and protect Patient 1 from being abused. The CNO the HHA did not report the alleged physical abuse on 11/6/2023 to the Department. During a review of the agency’s policy and procedure titled, “Safety-Patient Abuse, Neglect and Exploitation,” dated 2/1/2024, indicated all patients have the right to be free from abuse or neglect as well as the fear of being abused or neglected. Allegations or information indicating abuse or neglect may have occurred will be thoroughly and promptly investigated with follow up action taken. Should the investigation conclude that abuse or neglect has occurred, the physician and Department of Public Health will be notified.”

“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 observation, interview and record review, the SN (skilled nurse) failed to provide indwelling catheter (tube that drains urine from the bladder to a drain bag) care as per physician’s order for one of seven sampled patients (Patient 5). This deficient practice had the potential to cause Patient 5 urinary tract infection (urine infection caused by bacteria). During a review of Patient 5’s Face sheet indicated a start of care (SOC) date of 3/11/23, with a diagnosis that includes retention of urine. During a review of Patient 5’s Home Health Certification and Plan of Care (POC) for certification period from 1/5/24 to 3/4/24, included an order for the skilled nurse (SN) visit once a week for 9 weeks for indwelling catheter (tube that drains urine from the bladder to a bag) assessment and UTI surveillance (observation). One of the SN intervention was to irrigate indwelling catheter with 100- 250 cc of sterile normal saline (solution) as needed for blockage, sediments (solid materials) and leakage. On 2/3/24, at 1 p.m., a home visit was conducted at Patient 5’s residence. Patient 5 was observed lying in bed asleep. The patient had an indwelling catheter with yellow, clear urine draining in bag. During a review of Patient 5’s Skilled Nursing Visit notes dated 1/8/24 and 1/28/24, the skilled nursing visit notes indicated Patient 5’s urine had sediments present in the drainage bag. However, there was no documented evidence the visiting nurse irrigated the indwelling catheter per order as needed for sediments. On 2/5/24, at 1 p.m., during an interview with Registered Nurse (RN) Supervisor, the RN Supervisor stated if the patient’s urine was found with sediments by the visiting nurse, the visiting nurse was expected to irrigate the indwelling catheter with normal saline as ordered by the physician.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on observation, interview, and record review, the visiting nurse failed to notify the attending physician for one out of seven sampled patients (Patient 5), who had sediments (solid materials) present in the urine. This deficient practice had the potential for a delayed treatment, and placed the patient at for urinary tract infection. During a review of Patient 5’s Face sheet indicated a start of care (SOC) date of 3/11/23, with a diagnosis that includes retention of urine. During a review of Patient 5’s Home Health Certification and Plan of Care (POC) for certification period from 1/5/24 to 3/4/24, included an order for the skilled nurse (SN) visit once a week for 9 weeks for indwelling catheter (tube that drains urine from the bladder to a bag) assessment and UTI surveillance (observation). One of the SN intervention was to irrigate indwelling catheter with 100- 250 cc of sterile normal saline (solution) as needed for blockage, sediments (solid materials) and leakage. On 2/3/24, at 1 p.m., a home visit was conducted at Patient 5’s residence. Patient 5 was observed lying in bed asleep. The patient had an indwelling catheter with yellow, clear urine draining in bag. During a review of Patient 5’s Skilled Nursing Visit notes dated 1/8/24 and 1/28/24, the skilled nursing visit notes indicated Patient 5’s urine had sediments present in the drainage bag. However, there was no documented evidence the visiting nurse irrigated the indwelling catheter per order as needed for sediments. On 2/5/24, at 1 p.m., during an interview with Registered Nurse (RN) Supervisor, the RN Supervisor stated if the patient’s urine was found with sediments by the visiting nurse, the visiting nurse was expected to irrigate the indwelling catheter with normal saline as ordered by the physician. During a review of the home health agency’s undated policy and procedure (P&P) titled, “Plan of Care”, the P&P indicated it is the staff member’s responsibility to report any condition or problems to the physician. .”