Wel-Home Health of Red Oak

“Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide’s performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This Standard is not met as evidenced by: Based on personnel file review, agency policy review and clinical record review, the agency failed to ensure 3 of 3 sampled home health aides (Staff E, F and G), demonstrated completion of all of the assigned extra skills while observed by a registered nurse to determine competency in each task prior to being allowed to care for agency patients independently for 2 patients (Patient #1 and #4). Failure to ensure that home health aides demonstrated completion of all of the assigned extra skills while observed by a registered nurse (RN) to determine competency in each task prior to being allowed to care for agency patients independently, increased the potential risk of harm to the patient. Findings include: According to the undated agency policy, titled Home Health Aide Assignments, the initial assessment for need shall be determined by the home health coordinator or designated Registered Nurse (RN). Factors to be considered shall include, but not be limited to experience and competency of the home health aide. 1.Patient #1 had a start of care date of 11/7/24. Clinical record review revealed the following: a. The Plans of Care, dated 11/7/24 to 1/5/25 and 1/6/25 to 3/6/25, identified the patient had the diagnosis of urinary device and included physician orders for skilled nursing and home health aide services. The POC included orders for the medication Eliquis (blood thinner). b. The home health aide care plan, dated 1/3/25, directed the aide to perform the task of skin care, nail care, assist with dressing every visit, bed bath-partial/complete, per patient request every visit, denture care every visit, hair care -brush every visit, nail care every visit, oral care every visit, shampoo in sink per patient request every visit, skin care every visit, check pressure areas every visit, assist shower every visit, shampoo every visit, deodorant every visit, catheter care. c. The task of bleeding precautions require extra skills competency testing prior to assigning the aide to perform the tasks as an extension of nursing services. d. The home care aide nates, dated 12/3, 12/6, 12/10, 12/13, 12/17, 12/20, 12/24, 12/27, 12/31/24 and 1/3, 1/7, 1/10, 1/24, 1/17, 1/21, 1/28 and 1/31/25, included documentation the aide assigned and performed the task of bleeding precautions. The clinical record documented Staff E and Staff F, Home Health Aide, provided care to Patient #1. Personnel file review revealed the following: e. Staff E, Home Health Aide, had a hire date of 6/15/17. Staff E had never been competency tested to perform the task of bleeding precautions. f. Staff F, Home Health Aide, had a hire dated of 1/30/20. Staff F had never been competency tested to perform the task of bleeding precautions. 2. Patient #4 had a start of care date of 1/23/25. Clinical record review revealed the following: a. The POC, dated 1/23/25 to 3/23/25, identified the patient had a diagnosis of pneumonia and included physician orders for skilled nursing and home health aide services. The POC also included the order for the medication Eliquis. b. The home health aide care plan, dated 1/s3/25, directed the aide to perform the task of bleeding precautions. c. The task of bleeding precautions require extra skills competency testing prior to assigning the aide to perform the tasks as an extension of nursing services. d. The home care aide nates, dated 1/29/25, included documentation the aide assigned and performed the task of bleeding precautions. The clinical record documented Staff G, Home Health Aide, provided care to Patient #4. Personnel file review revealed the following: e. Staff G, Home Health Aide, had a hire date of 5/10/22. Staff G had never been competency tested to perform the task of bleeding precautions. The above findings reviewed with the Administrator.”

“Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This Standard is not met as evidenced by: Based on clinical record review, agency policy review, and agency staff interview, the agency failed to provide individualized and specific written patient care instructions from a registered nurse (RN) to agency home health aides for 2 of 2 sampled patients receiving home health aide services (Patients #1 and #4). Failure to ensure agency registered nurses provided patient specific written instructions directing the care provided by the agency’s home health aides for each patient increased the risk agency patients would receive inappropriate or inconsistent home health aide services. Findings include: According to the undated agency policy, titled Home Health Aide Assignments, the initial assessment for need shall be determined by the home health coordinator or designated Registered Nurse (RN) and developed through the Plan of Care construction. 1. Patient #1 had a start of date of 11/7/24. Clinical record review revealed: a. The Plan of care (POC), dated 1/6/25 to 3/6/25, identified the patient had a diagnosis of encounter for urinary device and included orders for skilled nursing and home health aide services. The POC also included physician orders for the medication Eliquis (blood thinner). b. The home health aide care plan, dated 1/3/25, included the task of nail care assigned to the aide. c. Review of the home health aide notes, dated 1/3, 1/7, 1/10, 1/14, 1/17, 1/21, 1/28, 1/31 and 2/4/25, included documentation aide services provided nail care to the patient. 2. Patient #4 had a start of date of 1/23/25. Clinical record review revealed: a. The POC, dated 1/23/25 to 3/23/25, identified the patient had a diagnosis of encounter for pneumonia and included orders for skilled nursing and home health aide services. The POC also included physician orders for the medication Eliquis (blood thinner). b. The home health aide care plan, dated 1/23/25, included the task of nail care assigned to the aide. c. Review of the home health aide notes, dated 1/27/25, included documentation aide services provided nail care to the patient. The agency failed to provide written individual patient instruction for nail care. The above findings reviewed with the Administrator.”

“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 observations, patient interviews, staff interview, clinical record reviews and agency policy review, the agency failed to complete an accurate drug regimen review with each comprehensive assessment for 3 of 3 sampled patients with home observation visits (Patients #1, #2 and #3). Failure to ensure medications reviewed at the time of each drug regimen review are current and accurate placed the patients at risk for increased potential unidentified medication interactions, side effects and duplication of medications. Findings include: According to the agency policy titled Drug Regimen Review, dated December 2020, the patient’s clinical record should reflect all medications, including times of administration and route, that the patient is taking both prescription and non-prescription, The documentation in the clinical record should confirm that the agency nurse considered each medication the patient is currently taking for possible side effects and the list, in its entirety, for possible drug interactions. During an interview on 2/4/25 at 8:28 AM the Administrator stated the drug regimen review (DRR) process is completed by the Registered Nurse (RN) on admission, recertification and discharge. 1.Patient #1 had a start of care date of 11/7/24. Clinical record review revealed the following: a. The Plan of Care (POC), dated 1/6/25 to 3/6/25, identified the patient had a diagnosis of Encounter for urinary device and included physician orders for medication and skilled nursing services. Medications included the following bowel medications for constipation: Dulcolax 10 mg rectal suppository, every 24 hours as needed, Milk of Magnesia 400 mg/5ml oral every 24 hours as needed, Miralax 17 gram/dose oral every 24 hours as needed and senna plus 8.6 mg-50 mg tablet every 12 hours as needed. b. The recertification comprehensive assessment, dated 1/3/24, completed by Staff D, RN, included documentation a DRR was completed and no discrepancies identified. c. During a home observation visit on 1/23/25 at 9:00 AM with Staff B, LPN, set up the patient’s medications. During the same home observation visit the patient stated he/she did not have any of the laxative medications in the home and had not needed laxatives for several years. The DRR failed to include an accurate review of all medications taken by the patient. 2. Patient #2 had a start of care date of 9/27/22. Clinical record review revealed the following: a. The POC, dated 1/14/25 to 3/14/25, identified the patient had a diagnosis of Encounter for anxiety and included physician orders for medication and skilled nursing services. b. The recertification comprehensive assessment, dated 1/9/24, completed by the Administrator, included documentation a DRR was completed and no discrepancies identified. c. During a home observation visit on 1/23/25 at 9:15 AM with Staff C, LPN, set up the patient’s medications. During the same home observation visit the patient stated he/she had the following medicated ointments in the home for pain: Biofreeze and Salonpas. The DRR failed to include an accurate review of all medications taken by the patient. 3. Patient #3 had a start of care date of 1/18/22. Clinical record review revealed the following: a. The POC, dated 1/2/25 to 3/2/25, identified the patient had a diagnosis of Encounter for vascular device and included physician orders for medication and skilled nursing services. b. The group home medication list, dated 2/4/25 to 2/5/25, included the medication cetirizine (allergy medication) 1 mg/1ml give 1 mg as needed. The agency medications list failed to include the medication. c. The undated agency medication list included the following medications: Diazepam 7.5 mg-10 mg give 10 mg rectal as needed for seizure lasting 5 minutes, Acetaminophen 325 mg give 2 tablets every 6 ours as needed for pain/fever and Ibuprophen 200 mg every 8 hours as needed for pain./fever. The medications not included on the group home medication list. The DRR failed to include an accurate review of all medications taken by the patient.”

“HH aide supervision elements CFR(s): 484.80(h)(4)(i-vi) Home health aide supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to, the following elements: (i) Following the patient’s plan of care for completion of tasks assigned to a home health aide by the registered nurse or other appropriate skilled professional; (ii) Maintaining an open communication process with the patient, representative (if any), caregivers, and family; (iii) Demonstrating competency with assigned tasks; (iv) Complying with infection prevention and control policies and procedures; (v) Reporting changes in the patient’s condition; and (vi) Honoring patient rights. This Element is not met as evidenced by: Based on clinical record review, agency policy review and staff interview, the agency failed to ensure registered nurses supervising home health aides maintained documentation of a review of all required supervisory elements including following the patient plan of care, maintaining open communication with patient/caregiver, demonstrating competency of all assigned tasks, complying with infection prevention and control policies, reporting changes in the patient condition and honoring patient rights for 1 of 1 sampled patients receiving home health aide services requiring home health aide supervision (Patient #1). A total of 21 patients received home health aide services and the agency employed 4 home health aides at the time of the survey. Failure to ensure the supervision of home health aides by registered nurses maintained documentation of a review of all required supervisory elements increased the risk of agency staff not meeting the patients’ personal care needs. The agency’s policy, titled Home Health Aide Supervision, revised February 2022, home health aide supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to, the following elements: following the patient’s plan of care, Maintaining an open communication process with the patient, representative or caregiver and family, demonstrating competency with assigned tasks, complying with infection prevention and control policies and procedures, reporting changes in the patient’s condition and honoring patient rights. 1. Patient #1 had a start of care date of 11/7/24. Clinical record review revealed the following: a. The Plans of Care, 11/7/24 to 1/5/25 and 1/6/25 to 3/6/25, included orders for skilled nursing and home health aide services. b. Skilled nursing visit notes, dated 12/6, 12/20, 12/27/24, 1/3, 1/17 and 1/31/25, included documentation home health aide supervision was completed and the aide followed the care plan. The notes lacked documentation the nurse assessed the aide’s ability to meet the following required supervisory elements: maintaining open communication with patient/caregiver, demonstrating competency of all assigned tasks, reporting changes in the patient condition and honoring patient rights. The agency failed to supervise the home health aide on all of the required supervisory elements. The above findings were reviewed with the Administrator.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on clinical record review, agency policy review, and agency staff interview, the agency failed to complete provide wound assessments on a weekly basis per agency policy for 1 of 1 sampled patients with wounds (Patient #5). Failure to accurately and thoroughly complete wound assessments put patients at an increased risk of unidentified condition changes. Findings include: According to the agency policy titled Wound Care in the Home Care Setting, dated December 2020, pressure ulcers and other wounds will be measured at least weekly (every 7 days). During an interview on 2/4/25 at 8:28 AM the Administrator stated wound measurements expected to include length, width and depth weekly and are documented on the wound visit sheet. 1.Patient #5 had a Start of Care date of 12/29/22. Clinical record review revealed the following: a. The Plan of Care, dated 12/18/24 to 2/15/25, identified the patient had a diagnosis of infection following surgical procedure. The POC included orders for skilled nursing services weekly. b. The skilled nurse note, dated 12/8/24, Staff R, Registered Nurse (RN) included documentation of a wound to the anterior left subclavian due to trauma. The measurements included 2 centimeters (cm) length, by 1 cm width by 0.01 cm depth. c. The skilled nurse visit notes, dated 12/6/24, Staff , Licensed Practical Nurse (LPN) identified a wound of the right medial leg but failed to include documentation of measurements of the wound. d. The skilled nurse visit note, dated 12/10/24, Staff B, LPN identified a wound of the right medial leg and right heel, but failed to include documentation of measurements of the wounds. e. The skilled nurse visit notes, dated 12/18/24, Staff D, RN identified a wound of the right medial leg but failed to include documentation of measurements of the wound. The agency nurse failed to obtain complete wound assessment and measurements weekly per agency policy. The above findings reviewed with the Administrator.”