Colorado VNA LLC

“Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This Standard is not met as evidenced by: Based on the interview and record review, the HHA failed to send all necessary medical information about the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences to the receiving facility or health care practitioner, which hindered the safe and effective transition of care for 7 patients. (Patients #1-7) Findings include: AGENCY POLICY According to the policy, “Transfer/Discharge,” dated 12/5/22 (in part): “When CVNA is planning to transfer a patient to another organization, contact the receiving organization and confirm that the organization agrees to accept the patient. Provide the following information regarding the patient: A. Summary of care or services B. If appropriate, copies of orders, clinical information, discharge summary” 1. The clinical record for Patient #1 was reviewed on 3/26/25. Plan of care orders for the certification period dated 12/11/24 to 2/8/25 revealed a start of care date of 12/11/24; diagnoses included type two diabetes, chronic wounds, major depression, and chronic kidney disease. Plan of care orders included skilled nursing (SN) services twice a week for 60 days for wound care, diabetic management, education, and occupational therapy once a week to establish a plan of care. Records showed that on 12/16/24, the agency provided Patient #1 with a verbal 14-day discharge notice and contacted a receiving home health agency for the patient due to the closure of an area of the state the agency was operating where Patient #1 resided. Records revealed that on 12/31/24, the agency documented care coordination had been completed with a physician, patient, and the receiving agency. No record evidence was present at the time of the survey to suggest that the receiving agency was provided the necessary medical information about the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences. 2. Similar findings for Patients #2, #3, #4, #5, #6, and #7 were found that the transferring agency failed to have record evidence the receiving agency was provided the necessary medical information about the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences. During an interview with the agency leadership team on 3/27/25, at 4:30 p.m., the leadership team (Employees #1, #2, #3, and #4) were asked to provide documentation showing where the agency supplied the necessary patient information to the receiving agency for all discharged patients. In response, they stated the health information management team faxed the information for the agency, but it was not documented in the record. They went on to say they would start to document in the record, the faxed patient information to the receiving agency.”

“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 agency failed to ensure home health aide (HHA) staff followed accepted standard infection control practices to prevent the transmission of infections and communicable diseases for 1 of 1 patients observed receiving perineal care during a HHA home visit (Patient #1). Findings include: 1. The clinical record for Patient #1 was reviewed on 11/6/23. The Plan of Care for the certification period dated 9/1/23 to 10/30/23 revealed a start of care date of 1/4/23; diagnoses included neuromuscular dysfunction of the bladder, presence of a urinary device, incomplete quadriplegia, type two diabetes, chronic venous insufficiency, chronic obstructive pulmonary disease, hypertension, chronic respiratory failure, migraines, depression, anxiety, hyperlipidemia, hypothyroidism, obstructive sleep apnea, and obesity. Plan of Care orders included skilled nurse (SN) visits one time a week for eight weeks and one as needed (PRN) visit for observation and assessment, suprapubic catheter changes once a month, once weekly injection of Trulicity (an injectable prescription medicine to improve blood sugar), supervision of the HHA, and education regarding gastrointestinal status, fall risk/prevention, diabetic care and nutrition; and HHA visits one time a week for one week, four times a week for eight weeks, and one time a week for one week for assistance with personal care and activities of daily living (ADLs). a) Observations showed HHA #4 failed to utilize appropriate infection control procedures during the provision of perineal care for Patient #1. A home visit was conducted on 11/7/23 at 10:27 a.m. for Patient #1. The surveyor and Nurse Case Manager #9 observed HHA #4 providing perineal care to Patient #1. Upon entering Patient #1’s home, HHA #4 placed a blue Chux (a disposable pad) on a table and placed her work bag on the blue Chux. HHA #4 was observed to sanitize her hands and don gloves. HHA #4 assisted Patient #1 to the bathroom to empty her urine bag. After returning, HHA #4 was observed to doff the gloves, sanitize her hands and don a new pair of gloves. HHA #4 brought a basin of water to the table by Patient #1’s bedside. HHA #4 assisted Patient #1 to transfer from her wheelchair to her bed. HHA #4 removed Patient #1’s soiled depend and tossed the depend in the trash can. Without changing her contaminated gloves, HHA #4 continued to wipe Patient #1, cleaning her skin including her perineal area with the same set of gloves. Patient #1 was having diarrhea. HHA #1 was observed to doff her gloves, sanitize her hands and don a new pair of gloves and then HHA #4 continued to clean diarrhea from Patient #1’s perineal area. Without changing her gloves or sanitizing her hands, HHA #4 was observed to apply Calmoseptine (a barrier cream) to Patient #1’s perineal area and to don a new depends on Patient #1. During an interview on 11/7/23 at 11:25 a.m., Nurse Case Manager #9 acknowledged she observed HHA #4 failed to follow infection control protocols several times during the care HHA #4 provided to Patient #1. During an interview on 11/7/23 at 4:46 p.m., HHA #4 acknowledged she failed to change her gloves and sanitize her hands after removing Patient #1’s soiled depends and after she completed cleaning Patient #1’s perineal area prior to applying the Calmoseptine cream. HHA #4 stated she was aware of infection control protocols and the importance of them and would not forget to follow infection control protocols in the future.”