Tufts Medicine Care 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, policy review, and interview, the agency staff failed to ensure infection control guidelines were maintained during the home visit observations when disinfecting medical equipment for 2 patients (#12 and #16), out of a total sample of 7 patient home visits. Findings include: Review of the agency policy, titled Management of Organization Issued Medical Equipment, Supplies and Sterile Product use, last reviewed 9/2025, included the following: *Follow Standard Precautions when cleaning contaminated equipment. *Reusable equipment will be cleaned and disinfected between patients regardless of visible contamination, in accordance with CMS and manufacturer guidelines. 1. For Patient #12, the Occupational Therapist (OT) failed to follow accepted standards of practice when disinfecting medical equipment after use on the patient. Patient #12 was admitted to the agency in January 2026 with a diagnosis of right artificial joint replacement surgery. On 1/28/26 at 3:00 P.M., a home visit was conducted with OT #1. OT #1 prepared her clean field in the living room by placing a clean drape on top of the chair ottoman and then setting her medical equipment, that included a blood pressure (BP) cuff, a thermometer, an oximeter (checks oxygen saturation), and a stethoscope, on the clean drape. OT #1 proceeded to perform hand hygiene and then used the medical equipment to check Patient #12’s vital signs. After checking the patient’s vital signs, the OT placed her medical equipment (now considered dirty) back onto the clean drape, contaminating the drape. OT #1 performed hand hygiene and then continued with her assessment of the patient. After completing her assessment of the patient, OT #1 cleaned the medical equipment, using a sanitizer wipe. After cleaning each piece of medical equipment, she placed the clean medical equipment back onto the now contaminated drape, re-contaminating the medical equipment. 2. For Patient #16, the Physical Therapist (PT) failed to follow accepted standards of practice when disinfecting medical equipment after use on the patient. Patient #16 was admitted to the agency in August 2025 with a diagnosis of iron deficiency anemia due to blood loss. On 1/29/26 at 9:00 A.M., a home visit was conducted with PT #1. PT #1 prepared her clean field on the kitchen counter by placing a clean drape down and then setting her medical equipment, that included a BP cuff, a thermometer, an Oximeter, and a stethoscope on the clean drape. She then proceeded to perform hand hygiene and started her assessment of the patient. PT #1 used her medical equipment to perform vital signs on Patient #16. After completing the vital signs, PT #1 put her medical equipment (now considered dirty) back onto the clean drape, contaminating the drape. PT #1 performed hand hygiene and then proceeded to complete her exercise routine with Patient #16. After completion of the exercise routine, PT #1, while talking to the patient, began to clean her medical equipment using a sanitizer wipe. After cleaning each piece of medical equipment, she placed the medical equipment back onto the contaminated drape, re-contaminating the medical equipment. During an interview on 1/29/26 at 10:00 A.M., the PT said she was unaware that she did that, but that she would review that. During an interview on 1/29/26 at 11:30 A.M., the Clinical Director said the medical equipment should be cleaned after use and then placed back into the staff members clean work bag. She said the medical equipment should not be put back on the drape if the drape was contaminated.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on record review and staff interview, the agency failed to ensure staff provided care and services ordered by the physician as indicated in the plan of care for 1 patient (#1), out of a total sample of 17 patients. Findings include: Review of the agency policy, titled Physician Orders/Plan of Care, revised 7/2025, included the following: *Plan of Care: upon completion of the comprehensive assessment a patient specific POC (plan of care) is established by the clinician under the supervision of the clinical manager. The POC includes treatment interventions, goals, frequency and duration of disciplines involved with care. The POC is approved by the ordering physician and is periodically reviewed by the same physician to ensure an appropriate plan is in place based on a patient’s individual needs. Review of the agency policy, titled Missed Visits, dated 3/2025, included the following. *When a physician ordered service is not provided within the approved visit range, documentation is to be placed in the patient’s medical record and the physician notified as to why the visit was missed. For Patient #1, the agency failed to ensure that a Physical Therapy (PT) evaluation was provided as ordered in the Plan of Care. Review of the physician ordered plan of care, dated 12/5/25 through 2/2/26, indicated the following: *Physical Therapy (PT) 1 visit every 2 weeks for 2 weeks (PT eval) (12/5/25 to 12/13/25) Review of the medical record indicated no documented evidence that a PT evaluation was completed between 12/5/25 and 12/13/25. During an interview on 1/29/26 at 3:00 P.M., the Clinical Manager said the admitting nurse recommended a PT evaluation and an order was put in for the patient to be evaluated. She said that multiple nurses who saw the patient said he/she did not need PT services. The Clinical Manager said staff failed to document in the medical record that the patient did not require PT services and failed to discontinue the order for the evaluation.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on record review and interview, the Home Health Agency failed to ensure that a Registered Nurse (RN) supervised the Home Health Aide at least every 14 days for 1 of 2 sampled patients (#6) receiving these services in a total sample of 17 patients. Findings include: Review of the agency’s policy titled “Supervision of Home Health Aide”, reviewed date of July 2015, indicated the following: *Patients receiving skilled care will receive a home health aide on-site supervisory visit (in the patient’s home) no less than every 14 days. The supervisory visit may be direct (with home health aide present) or indirect (with home health aide absent) for the purpose of re-assessing the home health plan of care and services. Patient #4 was admitted to the agency in November 2025 with a diagnosis of gastrointestinal hemorrhage, requiring skilled care. Review of the physician’s ordered Home Health Plan of Care and Certification, dated 11/19/25-1/17/26, indicated the following: *Skilled Nursing Visit (SNV) 1 times a week for 9 weeks. *HHA visit (HHAV) 1 times a week for 9 weeks. Review of the clinical record indicated that during certification period 11/19/25-1/17/26, HHA services were provided once a week. Further review of the clinical record indicated the only documented HHA supervisory visit by the RN was completed on 11/28/25, 12/15/25, and 1/2/26, not every 14 days as required. During an interview on 1/30/26 at 10:30 A.M., the Clinical Director reviewed the medical record and said that HHA supervisory visit was not completed every 14 days as required.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on interview and document review, the Home Health Agency (HHA) failed to ensure that a discharge summary was sent to the primary care practitioner or other health care professional who would be responsible for providing care and services to the patient after discharge from the HHA within five (5) business days after discharge, for 1 of 5 applicable discharged patients (#7), out of a total sample of 17 patients. Findings include: Review of the HHA policy, titled, Discharge of the Home Care Record, last reviewed 7/2025, included the following: It is the responsibility of the primary clinician to complete and submit discharge paperwork within 2 working days or 48 hours of discharge of an active patient. The patient and the physician will be notified upon each discipline’s discharge and when the patient is discharged from the organization. A copy of the “Discharge Summary” will be sent to the physician upon completion. The clinical department notifies Medical Records Department when a summary needs to be sent (via EPIC work queue). The Medical Records clerk will fax all summaries to the physician’s offices. Patient #7 was admitted to the HHA in December 2025 with a diagnosis of bilateral primary osteoarthritis of the knees. Review of the medical record indicated that Patient #7 was discharged from the HHA on 1/7/26. Review of the medical record failed to indicate that a Discharge Summary had been sent to the physician who would be caring for Patient #7. During an interview on 1/29/26 at 3:20 P.M., the Clinical Director said that a Discharge Summary should have been sent to the physician and it was a human error that it was not sent.”