Sweetgrace Home Health Services, LLC

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based on interview, and record review, the facility failed to ensure they had a performance improvement project (PIP - a concentrated effort on a particular problem in one area of the facility or facility wide; it involves gathering information systematically to clarify issues or problems, and intervening for improvements) in progress or in development. This failure resulted in the facility to have missed opportunities for the evaluation and improvement in care or services in areas that the facility identifies as needing attention. During a concurrent interview, and record review on April 3, 2025, at 2:40 PM, with the Director of Patient Care Services Designee (DPCSD), the DPCSD stated the facility did not have a performance improvement project in progress or development. The DPCSD further stated the facility only had quality metrics which they collect data for and reviewed on a quarterly basis as a part of the facility’s “QAPI” (Quality Assurance Performance Improvement) meetings. The DPCSD further stated quality metrics discussed in QAPI every quarter included but was not limited to: outcome of general chart audits, review of infection control reports, hand hygiene compliance reports, review of complaint and grievances, medication errors, and hospitalizations. The DPCSD stated the facility did not have any currently identified issues in the quality metrics the facility was tracking, and interventions were to primarily to continue monitoring and tracking for trends. The DPCSD stated the facility did not have any projects they were working on for an area identified by the facility as needing improvement. During a review of the facility’s policy and procedure (P&P) titled, “Improving Organizational Performance,” dated November 2018, the P&P indicated, “Senior Management with Governing Body oversight will: …G. Ensure that performance improvement projects are conducted that reflect the following standards: 1. The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the organizations services and operations. 2. The organization must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects…””

“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 record review, the facility failed to ensure one Home Health Licensed Vocational Nurse 1 (HHLVN 1) followed infection control guidelines when he placed a clipboard directly on Patient 2’s dining room chair and his (HHLVN 1’s) personal glasses on the patients dining room table without the use of barriers. This failure had the potential to put the facility’s patients at risk for cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another) of infectious microorganisms. During a review of Patient 2’s face sheet (contains demographic and medical information), the face sheet indicated Patient 2 had a start of care date of December 30, 2024, with a recertification period of February 28, 2025, through April 28, 2025. Patient 2 had diagnoses which included cerebral infarction (also known as stroke – occurs when blood flow to the brain is blocked), gastrostomy status (patient has a surgical opening into the stomach, typically for feeding or medication administration via a tube [g-tube]), and muscle weakness. During a home visit observation on April 2, 2025, at 12:35 PM, with HHLVN 1, and in the presence of Patient 2, HHLVN 1 placed his clipboard and paperwork on Patient 2’s dining room chair without the use of a barrier (a device used to limit cross contamination of objects, equipment, or devices). Additionally, HHLVN 1 dropped his personal glasses on the floor of the kitchen, picked them up and placed them on the dining room table without a barrier. During an interview on April 2, 2025, at 12:45 PM, with HHLVN 1, HHLVN 1 stated he should not have placed his clipboard (with paperwork) and glasses on the barrier where his bag was, but he did not because he was focused on the patient and the tasks he was performing. During an interview on April 2, 2025, at 3:42 PM, with the Director of Patient Care Services Designee (DPCSD), the DPCSD stated staff were supposed to use a barrier for them to put their bag and belongings and/or equipment on when in the Patient’s home. The DPCSD further stated HHLVN 1 should not have placed his clipboard on Patient 2’s dining room chair and should not have placed his personal glasses on the patient’s dining room table. During a review of the facility’s policy and procedure (P&P) titled, “Bag Technique,” dated November 2018, the policy indicated, “Purpose – To describe the procedure for maintaining a clean patient care supply bag/computer bag and preventing cross-contamination. Policy – As part of the infection/exposure control plan, [name of facility] personnel will consistently implement principles to maximize efficient use of the patient care supply bag when used in caring for patients…Bag Technique…1. The bag will be placed on a clean dry surface…7. If paper towels or newspapers have been used as protective barrier for bag placement in the patient’s home, they will be discarded.” During a review of the facility’s P&P titled, “Nursing Bag Techniques,” dated June 1, 2015, the P&P indicated, “Purpose: to maintain a clean nursing bag and prevent transmission of infection to patients…Procedure: - the bag shall not be placed down on the floor at a patients home or in a patient room/care area…all the clean supplies and equipment needed for the visit shall be removed from the bag…””

“Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This Standard is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure patients clinical records are stored in a locked, waterproof file cabinet in a designated clinical record room in accordance with the facility’s policies and procedures. This failure had the potential for patients’ clinical record information loss or unauthorized use. During a concurrent observation and Interview with the Facility Administrator (ADMIN) and RN (Registered Nurse) Case Manager (CM) on April 1, 2025, at 2:31 PM, in administrator office there were five (5) cardboard boxes with more than 100 discharged patients’ medical records were sitting there. ADM’s room has a door which can be locked but had a big opening in the wall from reception side, opening of approximately 4X 4 feet wide. CM stated that we keep the discharged patients medical record in the cardboard boxes to review them and keep them in stationary/ all staff break room before sending them to offsite storage facility. CM further stated that the maximum time we keep the discharged medical record in cardboard boxes, in stationary room/ all staff break room is a week or 7 days. During an observation on April 1, 2025, at 2:45 PM, in facility’s stationary/ all staff break room, it had 2 doors on opposite side and had metal storage shelves which had stationary stored. The stationary/ staff break room also had chair, table and microwave for staff to use. The room was not locked, and all staff had access to the room at all times. During a concurrent interview and record review on April 1, 2025, at 3:40 PM, with ADMIN and CM the agency’s P&P titled “SAFEGUADING/ RETREIVAL OF CLINICAL RECORDS,” dated November 2018, indicated, “PROCEDURE: 1. All physical patients clinical records will be maintained in locked waterproof file cabinets in a designated clinical records room: C. The clinical record room will be monitored during working hours. D. If the room must be left unattended during business hours, the door will be locked. E. Only authorized personnel will have access.” The ADMIN and CM stated the Agency did not follow their P&P.”

“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 for one of seven sampled patients (Patient 2) personal health information was kept confidential when the Home Health Licensed Vocational Nurse (HHLVN 1) took a photograph of Patient 2’s abdomen and upper body using HHLVN 1’s personal cell phone. This failure resulted in Patient 2’s personal health information being put at risk by not keeping health records confidential, and using personal equipment not being monitored and secured by the agency. During a review of Patient 2’s face sheet (contains demographic and medical information), the face sheet indicated patient 2 had a start of care date of December 30, 2024, with a recertification period of February 28, 2025, through April 28, 2025. Patient 2 had diagnoses which included cerebral infarction (also known as stroke – occurs when blood flow to the brain is blocked), gastrostomy status (patient has a surgical opening into the stomach, typically for feeding or medication administration via a tube [g-tube]), and muscle weakness. During a home visit observation on April 2, 2025, at 12:35 PM, with HHLVN 1, HHLVN 1 took a photograph of Patient 2’s and upper torso where Patient 2 had a gastrostomy tube inserted into his abdomen. During an interview on April 2, 2025, at 12:50 PM, with HHLVN 1, HHLVN 1 confirmed he used his personal cell phone to take a photograph of Patient 2’s torso and abdomen. HHLVN 1 stated he used his personal phone to send pictures of Patient 2 to the facility’s main office. During an interview on April 2, 2025, at 3:51 PM, with the Director of Patient Care Services Designee (DPCSD), the DPCSD stated the facility staff were only supposed to send pictures using the facility’s encrypted electronic application called [name of software]. The DPCSD further stated facility staff should not be using their personal phones to take pictures of patients and sending them to the facility’s cellular (cell) phone via text message. During an concurrent observation and interview on April 2, 2025, at 3:55 PM, with the DPCSD, when asked how many photos HHLVN 1 has sent to the facility’s cell phone via text message from his (HHLVN 1’s) personal phone, the DPCSD showed the facility’s cell phone text message thread from HHLVN 1’s personal cell phone and more than 10 photos were observed of various patients body parts and wounds from previous home health visits he had conducted. During a review of the facility’s policy and procedure (P&P) titled, “Confidentiality of Information,” dated November 2018, the P&P indicated, “purpose – To ensure that the patient’s right to privacy is protected by following the policies and procedures regarding confidentiality and use and disclosure of protected health information (PHI) [any individually identifiable health information held or transmitted by a covered entity or its business associate.], as necessary…[name of facility] and its personnel will maintain as confidential all patient-protected health information…” During a review of the facility’s P&P titled, “Transmission Security,” dated November 2018, the policy indicated, “To ensure the confidentiality, integrity and availability of electronic protected health care information (ePHI), technical security measures to guard against unauthorized access…[name of facility] will take appropriate steps to implement security measures to protect the integrity of ePHI while it is being transmitted over electronic communications networks…Procedure…[name of facility] will use integrity controls to ensure that the value and state of its ePHI is maintained during transmission and that ePHI is protected against unauthorized alteration or destruction during transmission over electronic communication networks…3. Protected health information stored, whether intentionally or not, in a photocopier, facsimile and other devices is subject to the HIPAA Privacy and Security Rules…Encryption 1. When deemed necessary, encryption will be used to protect ePHI during transmission over electronic communications networks…””

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure a review of all medications the patient is taking was conducted (medication reconciliation) for one of three sampled patients (Patient 2), when there were discrepancies in the medications taken at home when compared to Patient 2’s medication profile (a comprehensive summary of all the medications taken by the patient) and “Plan of Care” (Patient treatment plan). This failure resulted in the facility to not have an accurate list of current medications the patient was taking in order to review all medications and identify any potential adverse effects and drug reactions, including effective drug therapy, significant side effects, drug interactions, and noncompliance with drug therapy. During a review of Patient 2’s face sheet (contains demographic and medical information), the face sheet indicated patient 2 had a start of care date of December 30, 2024, with a recertification period of February 28, 2025, through April 28, 2025. Patient 2 had diagnoses which included cerebral infarction (also known as stroke – occurs when blood flow to the brain is blocked), gastrostomy status (patient has a surgical opening into the stomach, typically for feeding or medication administration via a tube [g-tube]), and muscle weakness. During a concurrent observation, interview, and record review on April 2, 2025, at 12:35 PM, at Patient 2’s home with Home Health Licensed Vocational Nurse 1 (HHLVN 1), and in the presence of Patient 2, an observation of Patient 2’s medication bottles (which he was actively taking) were compared with his (Patient 2’s) most current medication profile,” dated February 28, 2025, and “Plan of Care” with a certification period of February 28, 2025, through April 28, 2025. Patient 2’s “Plan of Care” and “Medication Profile” indicated Patient 2 was taking amlodipine (medication used to decrease blood pressure) 5 milligram (mg – unit of measure) tablet once a day. However, when compared to Patient 2’s medication supply, there was no amlodipine observed. Patient 2 stated he had not been on amlodipine since January 18, 2025, because his blood pressure was too low. During an interview on April 2, 2025, at 12:40 PM, with HHLVN 1, HHLVN 1 stated he was aware Patient 2 was no longer taking amlodipine and that he had informed the main office staff on prior visits. During an interview on April 3, 2025, at 5:16 PM, with the Director of Patient Care Services (DPCS), the DPCS stated medications the patient is taking at home was supposed to match the medication profile for each patient. The DPCS further stated the nursing staff performing visits to the patients was supposed to inform the main office of medication changes to ensure the medication profile was accurate and updated. During a review of the facility’s policy and procedure (P&P) titled, “Medication Profile,” dated November 2018, the P&P indicated, “Purpose – To define the use of the medication profile in evaluating a patient’s medication regimen. Policy – Patients receiving medications will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications.””