Terrace Home Health

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on interview and record review, it was determined the agency failed to ensure 1 of 5 patients (Patient #6) whose records were reviewed and who had home visits observed received the home health services written in an individualized plan of care. Failing to ensure patients receive services written in an individualized plan of care placed patients at risk of deterioration and adverse health outcomes. Findings include: Patient #6 was an 80 year old female admitted to the agency on 4/12/25 with a primary diagnosis of “Encounter for change or removal of nonsurg [nonsurgical] wound dressing.” Patient #6’s other pertinent diagnoses included “Malignant neoplasm of overlapping sites of right female breast, Secondary malignant neoplasm of skin.” She received SN services. Patient #6’s medical record was reviewed. A “Plan of Care for Next Certification Period note dated 12/06/25 stated , “RN recertification of a [sic] 80 year old female on services for twice weekly wound care. Patient has been on home health services for nearly a year…..patient has two chronic wounds that are being followed by wound dr, [doctors name] who is providing orders…..SN is seeing patient twice a week for wound care to monitor for infection and to help prevent infections…Wounds have remained free of infection with SN doing twice weekly dressing changes…..During the next cert period, patient will continue to be seen twice weekly for wound care, monitoring for infection, infection prevention,…and skin breakdown prevention…..Patient continues to benefit from ongoing SN visits as she cannot change the dressings herself and her spouse is not cognitively capable of changing them. Patient is at high risk for infection with her open wound and needs nursing for wound care to help prevent infection.” Patient #6’s medical record included a SN visit note dated 12/24/25 which stated, “Patient declined visit she has appointment with podiatrist. Educated to call for any concerns. Verbalized understanding.” There was no additional visit or a documented attempt to set up an additional visit to ensure the twice a week wound dressing changes were completed as ordered in the plan of care. Patient #6’s medical record included a SN visit note dated 12/30/25 which stated, “spoke with [pt’s spouse] yesterday regarding [pt’s] appointment. [Pt] was unable to be seen on 1229 due to appointment in Boise. [Pt’s spouse] verbalized that 12/30 between 930 and 10 would work. When this nurse arrived at patient’s home, no one was home after calling [pt’s spouse] was informed that patient was at [hospital] receiving chemo infusion. Will miss visit.” There was no additional visit or a documented attempt to set up an additional visit to ensure twice a week wound dressing changes were completed as ordered in the plan of care. Patient #6’s medical record included a SN visit note dated 1/02/26 stating, “01/02/26 LPN missed visit note. Spoke with patient and her spouse last night, patient and spouse stated she had a doctors [sic] appointment today and was unable to be seen. Patient had two other visits this week that she missed. Primary nurse is working on a schedule with patient and her spouse of all her physician appointments to better plan times in the future.” There was not an additional visit or a documented attempt to set up an additional visit to ensure the twice a week wound dressing changes were completed as ordered in the plan of care. Patient #6 went 13 days without a SN visit, wound care, or dressing change from the agency. The DCS was interviewed on 1/14/26 beginning at 12:16 PM. Patient #6’s chart was reviewed in her presence. She said Patient #6 had unexpected doctors’ visits making it difficult to schedule visits. She was asked what the expectation was of missed visits. She stated she would be notified, and the doctor would be notified of the missed visit. She stated she would look at the frequency of the missed visit and if there were two missed visits she would reach out to family. She was asked if she reached out to Patient #6 and she said she did but she did not document it. There was no documented attempt to change the SN visit schedule to enable Patient #6 to receive the two times a week SN visits, as ordered, for wound care and dressing changes. The agency failed to ensure all patients received the home health services written in an individualized plan of care.”

“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, policy review, review of CDC standards, and interview, it was determined the agency failed to follow accepted standards of practice to prevent the transmission of infections and communicable diseases. This impacted 1 out of 5 patients (Patient #6) whose records were reviewed and who had home visits observed. Failing to follow accepted standards of practice to prevent the transmission of infections and communicable diseases had the potential to impact all patients receiving services at the agency by causing infections or spreading communicable diseases. Findings include: The CDC website (https://www.cdc.gov/infection-control/hcp/hand-hygiene/index.html) accessed on 1/21/26 posted a document titled, “Guideline for Hand Hygiene in Health-Care Settings.” Under the heading “Recommendations” is written, “1. Indications for handwashing and hand antisepsis…C. Decontaminate hands before having direct contact with patients….F. Decontaminate hands after contact with a patient’s intact skin (e.g., when taking a pulse or blood pressure, and lifting a patient)…. G. Decontaminate hands after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled…. H. Decontaminate hands if moving from a contaminated-body site to a clean-body site during patient care….I. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient…J. Decontaminate hands after removing gloves….2. Hand-hygiene technique A. When decontaminating hands with an alcohol-based hand rub, apply product to palm of one hand and rub hands together, covering all services of hands and fingers, until the hands are dry..” The surveyors asked for a policy or procedure on dressing changes and none was provided. Patient #6 was an 80 year old female admitted to the agency on 4/12/25 with a primary diagnosis of “Encounter for change or removal of nonsurg [nonsurgical] wound dressing.” Patient #6’s other pertinent diagnoses included “Malignant neoplasm of overlapping sites of right female breast, Secondary malignant neoplasm of skin.” She received SN services. On 1/13/26 at 11:58 AM a home visit for Patient #6 was observed. The LPN was observed completing wound care and dressing changes. Patient #6 had two wounds that were unhealed and required care and dressing change. One wound was located on her back close to her armpit and one was at the location of her right breast area. The LPN was observed cleaning both wound sites without a glove change or hand hygiene between sites. The LPN then opened clean gauze packages on a pad on the floor and dropped the now empty package back onto the surface where the clean supplies were placed. The LPN cleaned a closed wound area under Patient #6’s left breast with no hand hygiene. The LPN proceeded to pick up unopened gauze and measured the open wounds with the gauze. The LPN did not change her gloves or perform hand hygiene between cleaning the patient’s skin and wounds and wound measurement. The LPN took pictures of the patient’s wounds with her tablet and did not perform hand hygiene. The LPN then changed her gloves but did not perform hand hygiene and picked up xeroform and applied it to the open wounds. The LPN changed her gloves but did not perform hand hygiene. The LPN opened a package of ABD and put the empty package with the unopened supplies on the barrier on the floor and applied the ABD to one of the wounds. The LPN opened another package of ABD and put the empty package with the unopened supplies on the barrier on the floor and applied the ABD to the other wound. The LPN then assisted Patient #6 to apply a binder that held the bandages in place. The LPN proceeded to take Patient #6’s socks off and assess her feet and legs. The LPN did not change gloves nor perform hand hygiene between wound care and assessing other parts of Patient #6’s body with scabbed wounds. Patient #6 stated, “it has a scab now” in reference to a wound on her toe. The LPN was seen manipulating and touching the toe. The LPN did not change her gloves or perform hand hygiene and moved on to the left foot where the LPN assessed another scabbed wound on the patient’s foot. The LPN then cleaned the equipment used on the wound care dressing change and put the equipment back in her bag without a glove change or hand hygiene. The LPN entered Patient #6’s bedroom and brought clothes out to the patient. The LPN still had the same gloves on from when she performed the end of the dressing change and wound care. The LPN removed her gloves and performed hand hygiene. The LPN began typing on her tablet. Patient #6 asked the LPN if Patient #6 had something on the buttocks area of Patient #6’s depends. The LPN reached up with an ungloved hand and swiped at the buttocks area of Patient #6’s depends and assured Patient #6 there was nothing on Patient #6’s depends. The LPN did not perform hand hygiene and touched her own face and the tablet. The DCS was interviewed on 1/14/26 beginning at 10:13 AM. The DCS was asked what infection control standards the agency followed and she confirmed the agency followed CDC infection control standards. The observations during the home visit were shared with the DCS and she was asked if the observation of wound care and dressing change was the proper and expected procedure. The DCS stated, “No, absolutely not.” The facility failed to follow accepted standards of practice to prevent transmission of infections and communicable diseases.”

“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 medical record review, drug website review, and staff interview, it was determined the agency failed to ensure significant medication side effects were reported to the physician for 1 of 5 patients (Patient #8) whose records were reviewed and who had home visits observed. Failure to ensure medication side effects were reported to the physician had the potential to result in patient injury. Findings include: Patient #8 was an 80 year old male admitted to the agency 1/06/26 with a principal diagnosis of toe amputation. Additional diagnoses included type 2 diabetes and kidney failure. He received SN, PT, and OT services. Patient #8’s record included an SN visit dated 1/08/26. The note stated, “Patients daughter explained that patient has been sleep walking and eating candy at night with no recall of the event. SN encouraged them to talk with his provider as he takes ambian [sic] at night and this can be a side effect of the medication.” There was no documentation the RN reported this to the provider. It was unclear why the RN would not report this to the provider. Additionally, under homebound status, Patient #8’s medical record stated, “Patient is Homebound due to recent amputation of the fifth toe on the left foot, high fall Risk.” According to the Ambien website (https://ambien.com/about-ambien accessed 1/21/26), “AMBIEN and AMBIEN CR may cause serious side effects including complex sleep behaviors. After taking AMBIEN or AMBIEN CR you may get up out of bed while not being fully awake and do an activity that you do not know you are doing. The next morning, you may not remember that you did anything during the night. These activities may happen with AMBIEN or AMBIEN CR whether or not you drink alcohol or take other medicines that make you sleepy. Some of these complex sleep behaviors have caused serious injury and death. People taking AMBIEN and AMBIEN CR have reported … sleep-walking. Stop taking AMBIEN or AMBIEN CR and tell your doctor right away if you find out that you have done any of these activities after taking AMBIEN or AMBIEN CR.” It was unclear why the RN would not report the significant side effect of sleep walking in Patient #8 who was also at risk for falls. The DCS was interviewed on 1/14/26 beginning at 12:18 PM and Patient #8’s medical record was reviewed in her presence. When asked why the RN did not report the sleep-walking to the physician, the DCS stated she believed she did report it but did not document it. She confirmed the sleep-walking after taking Ambien should have been reported to the physician and documented. The agency failed to ensure significant medication side effects were reported to the physician.”

“Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This Element is not met as evidenced by: Based on interview, medical record review, and agency document review, it was determined the agency failed to ensure nursing services were provided under the supervision of a registered nurse. This impacted 1 out of 5 patients (Patient #6) whose records were reviewed, and home visits were observed. Failing to provide proper supervision of nursing services had the potential to impact the quality and appropriateness of services given to patients. Findings include: Patient #6 was an 80 year old female admitted to the agency on 4/12/25 with a primary diagnosis of “Encounter for change or removal of nonsurg [nonsurgical] wound dressing.” Patient #6’s other pertinent diagnoses included “Malignant neoplasm of overlapping sites of right female breast, Secondary malignant neoplasm of skin.” She received SN services. An untitled agency document was reviewed. Under a heading titled, “Details (Monitoring Approaches and Frequency)” the following was written: “All therapies will have supervisor visits scheduled at appropriate intervals (14 days for LPN…..) Under a heading titled, “Comments” the following was written: “Addressed any sup visits, found that 14 days is calculated from time of previous RN sup visit, not from time that LPN/HHA has seen the patient.” Patient #6’s medical records were reviewed. Patient #6 was documented to have had an RN/Supervisory Visit completed on 12/22/25. There was no further documented RN/Supervisory Visit at the time of the survey. The time between documented supervisory visits was greater than 14 days. The DCS was interviewed on 1/14/2026 beginning at 12:16 PM. Patient #6’s medical records were reviewed in her presence. She was asked how often she expected an RN supervisory visit to occur; she stated every 14 days. She acknowledged an RN supervisory visit had not occurred for 18 days for Patient #6. The agency failed to ensure nursing services were provided under the supervision of a registered nurse.”

“Rehab services supervised by PT, OT CFR(s): 484.75(c)(2) Rehabilitative therapy services are provided under the supervision of an occupational therapist or physical therapist that meets the requirements of §484.115(f) or (h), respectively. This Element is not met as evidenced by: Based on record review, employee HR files, and staff interviews, it was determined the agency failed to ensure all therapy services received oversight by a qualified individual. This had the potential to affect all patients receiving services from the agency. Findings include: All physical therapy services at the agency are provided by contracted individuals. The PT department is overseen by the Director of PT, a subunit of the parent company of the HHA. Idaho Code §54-2218, and Idaho Admin. Code r. 24.13.01.016: referenced 1/21/26, stated: In Idaho, physical therapist assistants (PTAs) must be supervised by a licensed physical therapist according to Idaho Code §54-18 and Idaho Administrative Code r. 24.13.01.016. The law specifies that a licensed PT is responsible for patient care provided by PTAs and defines the minimum standard of supervision, which is generally “general supervision.” Idaho law requires that supervising PTs be licensed in Idaho. Supervision by a physical therapist licensed in another state, without Idaho licensure, does not meet the legal requirements for supervision in Idaho. Even if the PT is fully licensed in another U.S. state, they cannot legally supervise PTAs in Idaho unless they also hold an active Idaho license. This state code was not followed. Examples include: 1. Staff A HR files were reviewed. Staff A was a PT. His annual competencies were reviewed and signed off by the Director of PT in Utah. 2. Staff B HR files were reviewed. Staff B was a PTA. His annual competencies were reviewed and signed off by the Director of PT in Utah. 3. Staff C HR files were reviewed. Staff C was a COTA hired on 10/20/25. There was no documentation of initial competencies at all. The Administrator was interviewed on 1/14/26, beginning at 11:00 AM. She confirmed there were no competencies documented for this COTA who began working on 11/03/25. The Director of PT was interviewed by phone on 1/13/26, beginning at 10:30 AM. He was asked how therapy staff was supervised. The Director stated he supervised therapy staff, including PT, PTA, OT, and COTA, “either virtual or in person.” The Director of PT was asked if he maintained an Idaho license of PT and he stated that he did not; that he was licensed in Utah. The agency failed to provide appropriate supervision and oversight to their contracted therapists.”