Grace 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 record review and interview, the agency failed to ensure the SN followed the patient’s written individualized POC (plan of care) as evidenced by, the SN failing to monitor blood sugar results for 2 (#10, #15) patients, and failing to obtain weights for 2 (#10, #14) patients. The sample size was 17 patients. 3. Review of the Patient #14’s electronic clinical record revealed the start of care date was 06/04/2026.The patient’s diagnoses included unspecified atrial fibrillation, hypertensive heart and chronic kidney disease, chronic systolic congestive heart failure, and end stage renal disease with dependence on renal dialysis. The certification period reviewed was 06/04/2026 to 08/02/2026. Review of the Patient’s POC (Plan of Care) for certification period 06/04/2026 to 08/02/2026 revealed an order for “Skilled Nurse visits 1wk1, 2wk1, 1wk7 (1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 7 weeks).” Further review of the patient’s POC revealed an order and intervention for “Skilled nurse to assess vital signs and all body systems and report out of parameter findings to RN (Registered Nurse) and MD (Medical Doctor)... Notify physician for ...weight greater than 134 lbs. (pounds) or less than 124 lbs.” Review of the patient’s SN (Skilled Nurse) visit notes dated 07/02/2026 and 07/07/2026 revealed that there was no evidence the patient’s weight was obtained and/ or recorded. On 09/02/2026 at 8:48 a.m., an interview was conducted with S2DON. S2DON reviewed Patient #14’s electronic clinical record and confirmed that there was no evidence the patient’s weight was obtained on 07/02/2026, and 07/07/2026. She stated that due to Patient #14’s diagnosis, her weights should have been documented. Findings: 1. Patient #10. Review of the patient’s electronic clinical record revealed the start of care date was 03/18/2026. The patient’s diagnoses included chronic kidney disease and diabetes. The certification period reviewed was 03/18/2026 to 05/16/2026. Review of Patient #10’s POC for certification period 03/18/2026 to 05/16/2026 revealed the following orders: SN 1w9 (skilled nurse visit one time a week for nine weeks). Further review of the POC revealed, “skilled nurse to perform blood sugar via finger stick every visit.” Further review of the POC revealed, “Notify physician of weight greater than 124 pounds or less than 114 pounds.” Review of Patient #10’s SN visit notes dated 03/18/2026, 03/31/2026, 04/09/2026, and 04/23/2026 revealed no evidence the SN obtained or recorded the patient’s blood sugar results. Review of Patient #10’s SN visit note dated 04/23/2026 revealed no evidence the SN obtained the patient’s weight. On 09/02/2026 at 1:30 p.m., an interview and review of the patient’s electronic clinical records was conducted with S2DON. She verified there was no evidence the SN obtained or recorded the patient’s blood sugar results for SN visits made on 03/18/2026, 03/31/2026, 04/09/2026, and 04/23/2026. S2DON also verified there was no evidence the patient’s weight was obtained for the SN visit made on 04/23/2026. She confirmed that the blood sugar results and weight should have been obtained and recorded. 2. Patient #15. Review of the patient’s electronic clinical record revealed the start of care date was 03/25/2026. The patient’s diagnoses included chronic obstructive pulmonary disease and diabetes. The certification period reviewed was 03/25/2026 to 05/23/2026. Review of Patient #15’s POC for certification period 03/25/2026 to 05/23/2026 revealed the following orders: SN 1w9 (skilled nurse visit one time a week for nine weeks). Further review of the POC revealed the following orders: “Notify physician of fasting blood sugar greater than 250 or less than 70. Random blood sugar greater than 300 or less than 70.” Review of Patient #15’s SN visit note dated 03/31/2026 revealed there was no evidence the SN obtained or recorded the patient’s blood sugar result. On 09/02/2026 at 1:30 p.m., an interview was conducted with S2DON. S2DON reviewed the above mentioned SN visit note for Patient #15 and confirmed there was no evidence the skilled nurses obtained or recorded the patient’s blood sugar result and stated that it should have been done.”

“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 agency failed to follow accepted standard precautions to prevent the transmission of infections and communicable diseases by the SN (Skilled Nurse) failing to remove gloves and perform hand hygiene during wound care for 1 (Patient #2) out of 17 sampled patients. Findings: A review of the facility’s policy titled “Infection Control Program” with a last reviewed date of 11/01/2025 revealed in part…Procedure…C. Prevention and Control Activities 1. The Agency will follow accepted standards of practice, including the use of standard precautions and as needed, transmission-based precautions with standard precautions, to prevent the transmission of infections and communicable disease…3. Other policies to be followed by staff to prevent, control, and improve infection include but are not limited to: Hand Hygiene… Review of Patient #2’s electronic clinical record revealed the start of care date was 04/23/2026. The patient’s diagnoses included, but were not limited to, pressure ulcer of right buttock, personal history of diseases of the skin, diabetes mellitus, and morbid obesity. The certification period reviewed was from 08/21/2026 to 10/19/2026. Review of the Patient #2’s POC (Plan of Care) revealed the following order: SN 1w1, 3w8 effective 08/21/2026 (skilled nurse visit one time a week for one week, three visits a week for eight weeks, effective 08/21/2026). Further review of the patient’s POC revealed the following orders: Wound care three times weekly by SN each visit, SN to perform wound care to: Right buttocks, Wound Type: Pressure Ulcer Stage 2, Treatment to be performed: Clean with wound cleanser, apply barrier cream, cover with bordered foam, Frequency of treatment to be performed: MWF (Monday, Wednesday, Friday) and prn (as needed) soiling; Treatment to be performed by: SN during each visit; Wound care to left breast, traumatic ulceration-wash with wound cleanser, pat dry, apply calcium alginate to wound bed and cover with border foam dressing. On 08/31/2026 at 2:08 p.m., during a scheduled home visit, an observation was conducted of S3SN as she provided wound care to Patient #2’s right buttocks. S3SN cleaned the patient’s wound. With the same gloves, S3SN retrieved barrier cream, applied it to the patient’s wound, and then covered the wound with a clean dressing. S3SN did not change gloves or sanitize hands after cleaning Patient #2’s wound nor prior to applying the barrier cream and clean dressing. Observation was continued of S3SN as she provided wound care to Patient #2’s left breast. S3SN cleaned the patient’s wound. With the same gloves, S3SN retrieved calcium alginate, applied it to the patient’s wound, and then covered the wound with a clean dressing. S3SN did not change gloves or sanitize hands after cleaning Patient #2’s wound nor prior to applying the calcium alginate and clean dressing. On 08/31/2026 at 3:00 p.m., an interview was conducted with S3SN. S3SN confirmed she should have changed gloves and sanitized her hands after cleaning Patient #2’s wound to right buttocks and prior to applying barrier cream and the clean dressing and did not. S3SN also confirmed she should have changed gloves and sanitized hands after cleaning Patient #2’s wound to her left breast and prior to applying calcium alginate and the clean dressing and did not.”