Common Spirit Health at Home

“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, record review, and interview, the agency failed to follow adequate infection control practices, including hand hygiene during 2 of 4 home visits. (Patient # 6, 11) Findings include: 1. According to the “Hand Hygiene” policy (33.900, revised 11/14/2025), hand hygiene is performed before and after direct patient contact, after contact with wound dressings, and after removing gloves. The use of gloves does not eliminate the need to perform hand hygiene. Gloves should be changed between tasks and procedures on the same patient to prevent cross-contamination. 2. During a home visit on 02/19/2026 at 8:30 AM with Patient #6, RN 1 applied clean gloves and proceeded to remove Patient # 6’s wound dressing per the POC. RN 1 continued with the wound care treatment as ordered but failed to change gloves between tasks and perform hand hygiene after removing gloves. 3. During a home visit on 02/23/2026 at 2:50 PM with Patient #11, RN 2 applied clean gloves and proceeded to remove Patient # 11’s wound dressings per the POC. RN 2 continued with the wound care but failed to change gloves between tasks and perform hand hygiene after removing gloves. 4. During an interview on 02/19/2026 at 9:10 AM, RN 1 indicated that hand hygiene should be done anytime gloves are removed, between tasks, after touching anything of the patient’s. Gloves should be worn during dressing changes and should be changed between tasks or when soiled. 5. During an interview on 02/23/2026 at 4:00 PM, RN 2 indicated that gloves should be changed anytime after touching something soiled, when gloves are visibly soiled, and between tasks. RN 2 also indicated that hand hygiene should be done after touching the patient or patient belongings and after removing gloves, before putting on clean gloves. 410 IAC 17-12-1(m)”

“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, record review, and interview, the agency failed to follow physician orders related to wound care for 1 of 4 wound care observations completed. (Patient #11) Findings Include: 1. According to the “Verbal and Written Orders” policy (85.03, revised 03/02/2025), all orders for patient care, including medications and treatments, will be entered in the Patient Medical Record. The orders for treatment will include the type of treatment, frequency of treatment, and specific requirements of treatment. 2. A record review on 02/23/2026 for Patient #11, SOC 02/09/2026, indicated skilled nursing to cleanse bilateral lower extremities with soap and water and apply UNNABoot every Monday, Wednesday, and Friday. 3. During a home visit with Patient #11 on 02/23/2026 at 2:50 PM, SOC 02/09/2026, RN 2 was observed initiating the patient’s treatment per the POC. RN 2 applied Xeroform to bilateral lower extremities and wrapped the extremities with a gauze bandage. RN 2 failed to apply the dressings ordered on the POC. 3. During an interview on 02/23/2026 at 3:30 PM, RN 2 indicated that Patient #11 had seen the physician the previous Wednesday and received new orders. RN 2 did not have a copy of the new orders and indicated that the patient’s sister had the new orders. RN 2 indicated that she received a call from the patient’s sister on Friday stating that the orders had changed and had told her what they were. RN 2 indicated that she would be calling the physician that day to change the order back to the original. 410 IAC17-13-1(a)”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on record review and interview, the agency failed to complete an initial assessment within 48 hours of a referral for 2 of 5 therapy patient record reviews. (Patient #2, #4) Findings include: 1. A 07/01/2023 revised policy titled “Admission for Care and Services” indicated that if the patient is accepted, the initial assessment will be completed within 48 hours of the referral. 2. A review of Patient #2’s record included an unsigned referral dated 01/29/2024, a start of care (SOC) date 02/01/2024, and the initial assessment date of 02/01/2024; the agency failed to complete the initial assessment within 48 hours of the referral. 3. A review of Patient #4’s record included an unsigned referral dated 05/14/2024, a start of care (SOC) date 05/17/2024, and the initial assessment date of 05/17/2024; the agency failed to complete the initial assessment within 48 hours of the referral. 4. During the entrance conference on 05/21/2024 at 11:15 AM, the Director of Nursing indicated that the agency admission visits are done within 48 hours of referral. 5. During an interview on 05/22/2024 at 10:56 AM, Registered Nurse (RN) 2 indicated the agency tries to complete the start of cares within 24 to 48 hours of receiving referrals. If not completed within 48 hours, a new order from the physician would be obtained and scanned into the patient’s chart. 410 IAC 17-14-1(a)(1)(A)”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on record review and interviews, the agency failed to properly obtain and/or document a verbal or written POC order from the primary physician before providing services and treatments to patients for 5 of 6 patient record reviews. (Patient #1, #2, #3, #4, #5) Findings include: 1. A policy titled “Plan of Care and Physician and Allowed Practitioner Orders” indicated that a signature and date on the POC indicates the verbal order was obtained for the first 60-day episode. The policy indicated that there must be a written verification by the clinician of a verbal order by the physician. A verbal order is sufficient to implement the POC until a signed POC is returned. All care and services provided are according to current physician or allowed practitioner orders. 2. The record review for Patient #1, certification period 02/02/2024 to 04/01/2024, revealed patient care was provided to Patient #1 without a verbal order or physician-signed order for the following days: 02/02/2024, 02/05/2024, and 02/07/2024. During an interview on 05/21/2024 at 4:00 PM, the Director of Nursing could not provide documentation of who the Registered Nurse (RN) or Physical Therapist (PT) spoke with or details related to what would be provided on Patient #1’s plan of care until the physician’s signature was obtained on the plan of care. 3. The record review for Patient #2 revealed that patient care was provided to Patient #2 without a verbal or physician-signed order on 02/12/2024. 4. The record review for Patient #3 revealed that patient care was provided to Patient #3 without a verbal or physician-signed order on 04/01/2024, 04/03/2024, 04/09/2024, and 04/18/2024. During an interview on 05/22/2024 at 8:50 AM, the Manager of Clinical Services indicated that the physician had not signed the POC while the patient was receiving services. She indicated that staff provide a verbal report of the POC to the physician upon admission, which would be documented in the care coordination note or on the POC. She could not locate documentation of the verbal report provided to the physician. 5. The record review for Patient #4 revealed patient care was provided to Patient #4 without a verbal order or physician-signed order on 05/20/2024, 5/21/2024 During an interview on 05/22/2024 at 8:50 AM, the Manager of Clinical Services indicated the POC had not been signed for services being provided and could not locate documentation of the verbal report provided to the physician. 6. The record review for Patient #5 revealed that patient care was provided to Patient #2 without a verbal or physician-signed order on 05/02/2024, 05/06/2024, 05/07/2024, 05/08/2024, 05/09/2024, 05/13/2024, 05/15/2024, 05/16/2024, 05/20/2024, and 05/21/2024. 7. The POC failed to identify who specifically provided the verbal order for the start of care and who specifically received the verbal order. 8. During an interview on 05/22/2024 at 10:03 AM, the Director of Nursing (DON) stated that staff would contact the physician to report the services the agency would provide and the frequency of those services. She referred to the top of the POC, where a date and time had been marked as a verbal order, and stated that this verbal order applied to the entire POC. The DON indicated she has read the regulations and reviewed the state newsletter from December 2023 concerning Physician Coordination of Patient Plans of Care. The DON believes that neither requires her to document the discussion with the physician and considers the date and time under the verbal order on the POC to be sufficient. 410 IAC 17-14-1(a)(H)”