Elevate Home Health Group

“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 provider failed to follow appropriate infection control practices to prevent cross contamination during wound care for 1 of 1 patient reviewed for wound care of a total sample of 7 patients, (#2). Patient #2 was admitted for home care services on 2/26/24 with diagnoses included encounter for orthopedic aftercare, presence of right artificial hip joint, diabetes mellitus type 2, muscle weakness, unilateral primary osteoarthritis right hip, abnormality of gait and mobility. The start of care assessment completed the Director of Nursing (DON) on 2/26/24 that showed patient #2 had an observable surgical wound. Review of the Home Health Certification and Plan of Care for period 2/26/24 to 4/25/24 revealed an order for nursing wound care that read, “SN [Skilled Nurse] to perform wound care to right hip, cleanse with normal saline, pat dry, soak gauze and ring it out, apply gauze over incision site, cover with 2 cm [centimeter] x 2 cm island dressing daily. SN to educate wife/patient how to perform wound care in absence of home health care or surgeon”. On 3/5/24 from 12:15 to 1 PM, RN G was observed doing home visit and providing wound care to patient #2’s right hip/groin region. RN G set up her supplies for wound care on paper barrier she placed on the kitchen table. The supplies included wound cleanser, non-sterile gauze, and border dressing. RN G utilized hand sanitizer bottle noted in her shoulder bag prior to donning gloves. Patient #2 was able to stand and pull his under pants to the side and the nurse removed soiled dressing from his right hip/groin region. The surgical wound opening was approximately 1cm by 1 cm with approximately 20% slough (dead tissue) noted at base of wound bed. The soiled old dressing was noted with a small amount of pinkish/yellow colored drainage. RN G placed the soiled dressing in her dirty gloves which she threw in waste basket RN G then without performing hand hygiene she donned new clean gloves and proceeded to clean wound with wound cleanser and apply border dressing to patient #2’s surgical site. A follow up interview was conducted with RN G outside of patient #2’s home regarding concerns that she did not follow the physician orders for wound care or demonstrate appropriate infection control practice regarding hand hygiene during wound care. RN G validated that she did not follow physician order or perform hand hygiene once she removed soiled wound dressing and dirty gloves. RN G said she had only been doing home health for 9 to 10 months and she did not check the physician order prior to providing the wound care today. RN G said she did not know that she needed to perform hand hygiene post removal of soiled dressing/dirty gloves and prior to application of new clean dressing. On 3/6/24 at 3:53 PM, the DON said that when the nurses do wound care they should use hand sanitizer after they pull off dirty/soiled dressing and prior to putting on clean gloves and dressing. The Home Health Agency policy Hand Hygiene policy and procedure revised April 2020 read, “Purpose to prevent cross-contamination and home care acquired infections. Personnel providing care in home setting will regularly wash their hands…When hands are visible dirty, contaminated with proteinaceous material, or are visibly soiled with blood or other body fluids, they should be washed with either a non-antimicrobial or antimicrobial soap and water. When hands are not visible soiled, they should be washed using an alcohol-based hand rub for routinely decontaminating hands. An alternative to use of an alcohol-based hand rub is to wash hands with an antimicrobial soap and water…After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings, if hands are not visibly contaminated…. After removing gloves…””

“Contents of clinical record CFR(s): 484.110(a) Standard: Contents of clinical record. The record must include: This Standard is not met as evidenced by: Based on observation, interview, and record review, the provider failed to maintain complete and accurate records according to accepted professional standards and practices regarding clear/concise wound care orders for 1of 1 patient reviewed for wound care of a total sample of 7 patients, (#2). During a wound care observation with Registered Nurse (RN) G at patient #2’s home there were not any written instructions in the home care folder for the caregiver on how to provide wound care to his open wound surgical site right hip/groin area. When asked to provide the instructions the RN could only show on her tablet the following which read, “SN to cleanse with normal saline, pat dry, soak gauze and ring it out, cover incision with gauze and cover with island border dressing”. It was difficult to view the instructions on the RN’s small tablet and she did not show the actual order date either. RN G said they never keep written instructions for caregivers in the patients’ home folders. Patient #2 was admitted for home care services on 2/26/24 and was at a skilled nurse facility prior. His diagnoses included encounter for orthopedic aftercare, presence of right artificial hip joint, diabetes mellitus type 2, muscle weakness, unilateral primary osteoarthritis right hip, abnormality of gait and mobility. Review of patient #2’s medical record revealed plan 1/17/24 by the orthopedic physician assistant (PA) which read, “Plan…Continue daily wet-to-dry dressing change to proximal portion of incision….” Wet-to-dry gauze dressings are often used with open wounds. They help clean the wound and remove dead tissue… (retrieved on 3/30/24 from https://healthonline.washington.edu). The start of care assessment dated 2/26/24 for patient #2 completed by Director of Nursing (DON) read, “Patient has small incision n the right hip that is slow healing SN [Skilled Nurse] to cleanse with normal saline, pat dry, soak gauze and ring it out, cover incision with gauze and cover with island border dressing….” Review of the Home Health Certification and Plan of Care for period 2/26/24 to 4/25/24 revealed an order for nursing wound care that read, “SN [Skilled Nurse] to perform wound care to right hip, cleanse with normal saline, pat dry, soak gauze and ring it out, apply gauze over incision site, cover with 2 cm [centimeter] x 2 cm island dressing daily. SN to educate wife/patient how to perform wound care in absence of home health care or surgeon”. An update to the Plan of Care (POC) documented by the Chief of Operation Officer (COO) also dated 2/26/24 read, “Wound care to right hip as follows: cleanse with wound cleanser or normal saline, pat dry, soak gauze and ring it out, apply gauze over incision site, cover with 2 cm x 2 cm island dressing daily. SN to educate wife/patient how to perform wound care in absences of home health care or surgeon…” On 3/6/24 at 3:53 PM, an interview and concurrent record review was conducted with the DON. The DON could not explain why the medical record for patient #1 contained 3 different orders for wound care dated 2/26/24 or why the orders were not clear and concise and conflicted with the order orders from the orthopedic surgeon’s office for a wet to dry dressing t anterior hip proximal portion of incision. The wound care orders were not clarified by the HHA regarding what type of solution would be used for a wet to dry dressing or what type of solution to soak the gauze with prior to ringing it out. On 3/7/24 at 12:01 PM, the COO verified that she was an RN and had written one of the wound care orders dated 2/26/24 for patient #2. She said, the nurses should follow standard of practice by checking a physician order prior to doing wound care, getting order clarified if needed by the physician and that orders should be clear and concise. The COO acknowledged the wound care order for patient #2 were not clear or concise because they were not specific regarding what the gauze should be soaked with or that the moistened gauze was to be applied to the actual wound bed. Review of the Home Health Agency’s (HHA) policy and procedure dated April 2020 for Verification of Physician Orders read, “ Purpose: To ensure that accurate physician [or other authorized licensed independent practitioner] orders are obtained in accordance with applicable law and regulation….An order or prescription will be verified when there is a question or discrepancy in the order/ prescription ….The order or prescription reviewed may be the original order, a facsimile copy if permitted by law, or the direct transcription of a verbal order…””

“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 interviews and record review, the Home Health Agency (HHA) failed to provide the services of a Social Worker to 1 of a sample of 7 patients who were recently discharged from an acute care hospital and in need of post hospital services (#2) Patient #2 was a 68-year-old male admitted to the Home Health Agency with a Start of Care date of 2/26/24. His diagnosis included Presence of right artificial hip joint, Type 2 Diabetes Mellitus, Muscle weakness, other abnormalities of gait, and weakness. The Plan of Care documented he received services by the RN, Physical Therapy. In an interview with the patient in his home on 3/5/24 at 12:20 PM, he related he was discharged from the hospital about 2 weeks ago and was supposed to have a walker and bedside commode (BSC) at home however had not received them yet. He stated he is still waiting for his BSC and walker to be delivered. He related he has to use the regular toilette in his home which causes him a lot of pain. He said he called his insurance company and they said they buy the equipment once every 5 years only, so he got a loaner walker form someone in HHA until he could get one. He related he had to make numerous calls to the insurance companies, equipment companies, and the Veterans Administration to try to get any information about the equipment and coverage. He related it had been very difficult for him and he still did not have the equipment. He related he could have used some help from someone, but no one talked to him about a social worker to help. In an interview with the HHA RN at 1:05 PM, who was in the home for the home visit, she stated she had called the HHA intake coordinator to try to help. She stated the HHA did not have a social worker and related a lot of these issues could be addressed by social services and he should not have to do all of this work. In an interview with the Director of Nurses regarding a HHA social worker, on 3/6/24 at 11:45 AM, she replied there was not a social worker available for the patient. She related the HHA had tried to hire or find one but has not been able at this time.”

“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 record review and interview, the provider failed to ensure accurate review of all medications as part of comprehensive assessment and admission to home health agency for 1 of 7 patients reviewed for home health care and services, (#6). Patient #6 an 81-year-old female was admitted to the Home Health Agency (HHA) on 2/24/24 with diagnoses including hypertension, glaucoma, arthritis, diabetes mellites type 2, myocardial infarction, emphysema, hypothyroidism, depression, and anxiety. The HHA Registered Nurse (RN) start of care assessment dated 2/24/24 showed the patient has impaired vision can only see large print, she is wheelchair bound, dependent on spouse for all her activities of daily living, very hard of hearing, can feed self however needs meal set up and is able to take medications correctly if given reminders by another person regarding correct times. The medication schedule left in the home by the RN on 2/24/24 was missing dosage and frequency on some of the medications and did not include drug classification, route, side effects, discontinue date or patient/caregiver understanding on any of the medications as follows: · Metformin 500 mg (milligrams) did not include frequency or times to be taken. · Aspirin 81 mg did not include time to be taken. · Doxycycline 100 mg twice a day for 4 days did not included times to be taken. · Duloxetine 60 mg daily did not include time of day to be taken. · Avapro 150 mg daily did not include time of day to be taken. · Levothyroxine 88 mcg (micrograms) daily did not include time of day to be taken. · Lumigan eye drops bedtime did not include dosage, which eyes, or time of day to be taken. · Methylprednisolone 4 mg had no instructions for frequency or times to be taken. · Bystolic 10 mg daily did not include time of day to be taken. · Lasix 40 mg daily did not include time of day to be taken. · Xanax 0.5 mg as needed did not include how often it could be used. · Symbicort did not include a dosage or how often to be used. On 3/7/24 the HHA Director of Nursing (DON) verified the medication schedule that was left in the home folder for patient #6 by Registered Nurse (RN) G was lacking times, drug classification, side effects and patient or caregiver understanding of the medication for all medications. The DON explained that the medications are prepopulated from prior orders/admission onto the Home Health Certification and Plan of Care form. The DON added, she would need to follow up with nurses to make sure they are giving the patient/caregivers accurate medications schedules on admission and all subsequent visits to ensure patients take medications safely. On 3/7/24 at 1:25 PM the Chief Operations Officer (COO) verified she is also an RN. The COO said that the admission nurse did not give the patient #6 and caregiver an adequate list of home medications. The COO explained that when the nurse goes out to do an admission the medications from the prior admission pre-populates over to the current plan of care and based on the prior medications the only change was her diabetic medication metformin. The COO said, the current Home Health Certification and Plan of Care for certification period 2/24/24 to 4/23/34 versus the Medication Schedule that was left in home for patient #6 on 2/24/24 by the RN was not accurate set of instructions. The COO added the nurse should have included how often, times, side effects, and patient/caregivers’ level of understanding for all medications. The COO said she was disappointed to find out nurses were not providing patients/caregivers with an accurate list of medications in the home because it is used for teaching as well as taken by them to their medical appointments. Review of the HHA policy and procedure for Medication Profile revised April 2019 read, “Medication profiles will be updated for each change to reflect current medications, new, and or discontinued medications. Upon admission to the organization, the admitting clinician will initiate a medication profile to document the current medication regimen….The review will be performed by qualified personnel and will identify drug/food interactions, potential adverse effects and drug reactions…to ensure the patient and family/caregiver as well as other clinicians understand the medication regimen….The medication profiles included, but not limited to: all current medications, date prescribed, name of medication, dose, frequency, drug classification, date discontinued, and drug and /or food allergies. Using the medication profile to teach purpose of medications, dosages, routes, administration times, side effects and contraindications. …””

“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 provider failed to follow physician’s orders for 1 of 1 patient reviewed for wound care of a total sample of 7 patients, (#2). Patient #2 was admitted for home care services on 2/26/24 and was at a skilled nurse facility prior. His diagnoses included encounter for orthopedic aftercare, presence of right artificial hip joint, diabetes mellitus type 2, muscle weakness, osteoarthritis right hip, abnormality of gait and mobility. The start of care assessment completed by Registered Nurse (RN) on 2/26/24 revealed that patient #2 has an observable surgical wound. Review of the Home Health Certification and Plan of Care for period 2/26/24 to 4/25/24 revealed an order for nursing wound care read, “SN [Skilled Nurse] to perform wound care to right hip, cleanse with normal saline, pat dry, soak gauze and ring it out, apply gauze over incision site, cover with 2 cm [centimeter] x 2 cm island dressing daily. SN to educate wife/patient how to perform wound care in absence of home health care or surgeon”. On 3/5/24 12:15 PM, RN G was observed providing wound care during a home visit to patient #2’s right hip/groin region. RN G set up her supplies for wound care on paper barrier she had placed on the kitchen table which included wound cleanser, non-sterile gauze, and border dressing. RN G had bottle of hand sanitizer noted in her shoulder bag that she utilized prior to donning nonsterile gloves. Patient #2 was able to stand and pull his under pants to the side and the nurse removed soiled dressing from right hip/groin region. The surgical wound was approximately 1cm by 1 cm open area with approximately 20% slough (dead tissue) noted at wound base and small amount of pinkish/yellow colored drainage noted on the old dressing. The nurse then used wound cleanser moistened gauze to clean the wound bed and applied a dry dressing which was boarder gauze to the surgical site wound. The patient indicated that was not how his wife was doing the care. RN G could not show any instructions in the home health care home folder regarding wound care orders and said that they never keep instructions for caregivers in the patients’ home folders. RN G showed on her computer tablet an order that read, “SN to cleanse with normal saline, pat dry, soak gauze and ring it out, cover incision with gauze and cover with island border dressing”. On 3/5/24 at 1 PM, a follow up interview post wound care was conducted with RN G outside of patient #2’s home. RN G said she did not follow the physician orders because she got a verbal ok from her Director of Nursing (DON) last week that she could use the wound cleanser instead of the saline. RN G confirmed she and the DON did not update the current plan of care or orders since last week to reflect use of saline or wound cleanser. RN G was asked as to why there was no plan of care in home folder regarding wound care instructions and stated, “she has not ever seen one prior in any of the patient home folders”. On 3/6/24 at 3:53 PM an interview and concurrent record review were conducted with the DON. The DON acknowledged that RN G did not follow the physician orders for wound care when observed by surveyor on 3/5/24. The DON said the nurses are supposed to check the physician orders for wound care the night prior to home visit to ensure they are aware of current wound orders and call the physician to clarify if not clear. The DON said that it was ok for RN G to cleanse with wound with either wound cleanser or normal saline, but she should have soaked gauze, applied moistened gauze over incision site prior to covering with border/island dressing. The DON acknowledged the wound care orders were not clear and concise because they did not specify what to soak gauze with prior to ringing it out, nor did the order reflect the original intent by the orthopedic surgeon for a wet to dry dressing. The DON added that she needed to go out more frequently with nurses to ensure they were providing wound care as ordered and performing proper hand hygiene as well. Review of the HHA policy and procedure for Provision of Care and Record Management dated April 2020 read, “Orders are review for appropriateness and accuracy before care, treatment and services are provide….””