Around the Clock Home Care

“Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This Standard is not met as evidenced by: Based on observation, interview, and record review, the agency failed to provide education to one of seven sampled patients (Patient 1) regarding environmental factors regarding infection prevention according to the plan of care. This failure had the potential to result in Patient 1 having worsening wound and/or developing wound infections. Findings: During an observation on 7/7/25 at 10:45 a.m. in Patient 1’s home, Patient 1 was sitting on her bed. Patient 1 had wound dressing on her bottom and abdominal area. There was a detached wound VAC (vacuum assisted closure, negative pressure wound therapy used to help wounds heal. It works by applying gentle suction to the wound through a special dressing, which helps to remove excess fluid, reduce swelling, and promote the growth of new tissue) on the bed. There were clutters everywhere, folded clothes, books, shelves filled with things, bed was filled with folded clothes and miscellaneous things. The walkways were very narrow filled with various things on the sides, the floors had debris and stains. The Licensed Vocational Nurse (LVN) 1 performed the home visit to Patient 1 but did not educate Patient 1 regarding environmental safety and cleanliness. During a review of Patient 1’s “Orders and Treatments (OT)” dated 5/15/25, the OT indicated, “SN [Skilled Nurse] to instruct on maintaining a safe/sanitary home environment to ensure optimal health and healing.” During an interview on 7/8/25 at 12:47 p.m. with LVN 1, LVN 1 stated she did not educate Patient 1 on maintaining a safe and sanitary home environment. LVN 1 stated, “I have not seen any progress [on maintaining safe and sanitary environment]. I did not tell her yesterday [7/7/25].” During a review of the agency’s policy and procedure (P&P) on “Education-Patient/Family” dated 11/2018, the P&P indicated, “Educate of patient/family may include, but is not limited to medications, safety, infection control, treatments and procedures and discharge planning. Continue to reinforce the new information or skills to reinstruct the patient/family as needed.””

“Social Worker CFR(s): 484.115(m) Standard: Social worker. A person who has a master’s or doctoral degree from a school of social work accredited by the Council on Social Work Education, and has 1 year of social work experience in a health care setting. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to follow its policy and procedure (P&P) on “Competency Program” and “Performance Evaluation” for one of one sampled Social Worker (SW 1) when annual competencies and performance evaluations were not completed annually. This failure had the potential for compromised care to patients. Findings: During a concurrent interview and record review on 7/8/25 at 2:58 p.m. with Vice President of Operations (VPO), SW 1’s employee file was reviewed. SW 1’s “Initial competency assessment skills checklist - Medical Social worker” dated 6/19/20 was reviewed. VPO stated, SW 1 date of hire was 6/19/20, and SW 1’s had an initial competency but no annual competency since 2020. VPO stated there were no performance evaluations in SW 1’s employee file. VPO stated SW 1 should have had an annual competency and performance evaluation annually, and this had not been completed. During a review of the agency’s P&P titled “Competency Program” revised November 2024, the P&P indicated, “Purpose: To ensure that the competence of clinical organization personnel is assessed, maintained, and improved on a continuing bases. Procedure: The organization will establish and annually re-evaluate its job specific “Competency Based Orientation Checklist” which reflects duties commonly required in the performance of patient contact positions. 2. The organization will establish and annually evaluate a group of specific “Competency Based Orientation Checklist” which reflects duties commonly required in the performance of patient contact positions.” During a review of the agency’s P&P titled “Performance Evaluations” revised November 2024, the P&P indicated, “Purpose To provide consistent and regular performance evaluations to promote improvement. Procedure: 1. Performance evaluations will be completed (and dated) on all personnel as follows: A. During the probationary period. B. Annually, based on personnel’s annual evaluation date.””

“Protect patient during investigation CFR(s): 484.50(e)(1)(iii) (iii) Take action to prevent further potential violations, including retaliation, while the complaint is being investigated. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure its policies and procedures on abuse prevention and patient complaints indicated the requirement to suspend staff accused of abuse while the complaint is being investigated. This failure had the potential to place patients at risk for retaliation and further abuse. Findings: During a concurrent interview and record review on 7/9/25 at 9 a.m. with Administrator, the agency’s policies and procedures (P&Ps) titled “Abuse/Neglect Assessment and Reporting” dated November 2018 and “Complaint and Grievance Process – Customer” dated November 2018 were reviewed. Administrator stated the above policies were the agency’s P&Ps on abuse prevention and patient complaints. The P&Ps did not indicate staff accused of patient abuse will be suspended pending the investigation of the abuse allegation. Administrator stated suspending staff accused of abuse while the allegations are being investigated is important to protect patients from abuse and should be included in the P&Ps.”