Beth Israel Lahey 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, interview and policy review, the agency failed to ensure that 1 staff member (Registered Nurse [RN] #1) adhered to infection control standards to reduce the risk for spread of infections, related to glove use during a dressing change and failed to disinfect medical equipment between patient use for 1 of 1 applicable patients (#15), during 1 of 7 home visits. Findings include: A. For Patient #15, the agency failed to ensure that RN #1 changed her gloves after removing an old dressing and between tasks and procedures on the same patient. Review of the agency policy, titled, Standard Precautions, reviewed 11/5/24, included the following: *Gloves are to be changed between tasks and procedures on the same patient. *Gloves are to be changed after removing an old dressing. Patient #15 was admitted to the agency in November 2025 with a diagnosis of encounter for attention to other artificial openings of the urinary tract. On 2/12/26 at 9:10 A.M., the surveyor observed RN #1 conduct a home visit for Patient #15, including dressing changes to both a left and a right nephrostomy tube (artificial openings of the urinary tract). RN #1 performed hand hygiene and donned gloves. She removed the dressing covering the left nephrostomy tube and without changing her gloves proceeded to cleanse the area and place a new dressing. With the same gloves she proceeded to remove the dressing from the right nephrostomy tube, cleanse the area and place a new dressing. At this point she removed her gloves and performed hand hygiene. During an interview on 2/12/26 at 10:05 A.M., RN #1 said that she should have change her gloves more often during the dressing changes to the left and right nephrostomy tubes. B. For Patient #15, the agency failed to ensure that RN #1 followed accepted standards of practice when disinfecting medical equipment after use between patients. Review of the agency policy, titled, Infection Control - Bag Technique, copyright 2014, included the following: *The purpose of bag technique is to reduce the risk of cross-infection between patients via the clinician bag and the supplies it contains. *Bag technique requires keeping the inside of the bag and all its contents “clean”. *Disinfect reusable items before returning them to the bag as necessary. Patient #15 was admitted to the agency in November 2025 with a diagnosis of encounter for attention to other artificial openings of the urinary tract. On 2/12/26 at 9:10 A.M., the surveyor observed RN #1 conduct a home visit for Patient #15, including taking vital signs. RN #1 prepared her clean field by placing a clean drape on top a table and placed her medical equipment, that included a blood pressure (BP) cuff, a thermometer, an oximeter (checks oxygen saturation), and a stethoscope, on the clean drape. RN #1 proceeded to perform hand hygiene and then used the medical equipment to check Patient #15’s vital signs. After checking the patient’s vital signs, RN #1 placed her medical equipment (now considered dirty) back onto the clean drape, contaminating the drape. RN #1 performed hand hygiene and then continued with her assessment of the patient. After completing her assessment of the patient, RN #1 disinfected the medical equipment. After cleaning each piece of medical equipment, she placed the clean medical equipment back onto the now contaminated drape, re-contaminating the medical equipment. During an interview on 2/12/26 at 10:05 A.M., RN #1 said she tries to keep clean and dirty items separate. She said she should have had a clean field to place the medical equipment on so it could dry before placing the items back in her bag.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on record review, policy review and interview, the agency failed to ensure clinical documentation was complete and appropriately authenticated and dated in accordance with currently accepted standards of practice for 4 patients (#6, #9, #15 and #1), out of a total sample of 17 patients. Findings include: 4. Patient #1 was admitted to the agency in December 2025 with a diagnosis of Cerebellar artery embolic stroke. Review of the Physician ordered POC for certification period 12/4/25 through 2/1/26 indicated the following: Skilled Nurse (SN) visits 1 time a week for 9 weeks, with 2 as needed (PRN) visits for exacerbation. Review of the clinical record indicated the following SN visit was not dated/signed on the day services were rendered: *1/8/26 SN visit, note completed on 1/12/26. During an interview on 2/12/26 at 2:30 P.M. the Executive Director of Quality Compliance said that the visit note was not signed timely. Review of the agency policy, titled, Entries into the Clinical Record, revised, 10/29/24, included the following: *Entries into the clinical record will be made on the day care is provided to the patient. All documentation will be uploaded at the end of the workday. 1.Patient #6 was admitted to the agency in August 2025 with a diagnosis of Aftercare following joint replacement surgery and presence of right artificial shoulder joint. Review of the Physician ordered Plan of Care (POC) for certification period 8/17/25 to 10/15/25 indicated the following: Skilled Nurse (SN) visits 1-2 times a week for 9 weeks, with 1-3 as needed (PRN) visits for any change in condition. Review of the clinical record indicated the following SN visits were not dated/signed on the day services were rendered: *8/20/25 SN visit, note completed on 8/27/25. *8/27/25 SN visit, note completed on 8/30/25. During an interview on 2/12/26 at 11:15 A.M., the Clinical Education Manager said that the notes were not signed timely. 2. Patient #9 was admitted to the agency in August 2025 with a diagnosis of Iron deficiency anemia secondary to blood loss (chronic). Review of the Physician ordered POC for certification period 8/7/25 to 10/5/25 indicated the following: Skilled Nurse (SN) visits 1-2 times a week for 8 weeks, with 1-3 as needed (PRN) visits for change in condition. Review of the clinical record indicated the following SN visits were not dated/signed on the day services were rendered: *8/14/25 SN visit, note completed 8/18/25. *8/29/25 SN visit, note completed 9/18/25. *9/4/25 SN visit, note completed 9/8/25. *9/25/25 SN visit, note completed 10/6/25. During an interview on 2/12/26 at 11:40 A.M., the Clinical Education Manager said that the notes were not signed timely. 3. Patient #15 was admitted to the agency in November 2025 with a diagnosis of Encounter for attention to other artificial openings of urinary tract. Review of the Physician ordered POC for certification period 11/25/25 to 1/23/26 indicated the following: Skilled Nurse (SN) visits 1-2 times a week for 9 weeks, with 1-3 as needed visits for change in status. Review of the Physician ordered POC for certification period 1/24/26 to 3/24/26 indicated the following: SN visit 1 time a week for 10 weeks, with 1-3 visits as needed for change in status. Review of the clinical record indicated the following SN visits were not dated/signed on the day services were rendered: *1/7/26 SN visit, note completed 1/12/26. *1/14/26 SN visit, note completed 1/19/26. *1/21/26 SN visit, note completed 1/23/26. *1/28/26 SN visit, note completed 1/31/26. During an interview on 2/12/26 at 10:45 A.M.., the Clinical Education Manager said that the notes were not signed timely.”

“Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This Element is not met as evidenced by: Based on record review, policy review, and interview, the agency failed to ensure the Notice of Medicare Non-Coverage (NOMNC-an official Centers for Medicare and Medicaid Services (CMS) form that informs beneficiaries when their Medicare-covered skilled services, home health or outpatient rehabilitation services are ending and explains the right to appeal the decision) was provided prior to discharge for 1 of 5 applicalbe patients (#10), out of a total sample of 17 patients. Findings include: Review of the agency’s policy entitled Discharge Criteria and Process, with revised date of 10/21/24, indicated the following: *For Medicare and Medicare HMO patients, the organization will issue a Notice of Medicare Non-Coverage at least 48 hours. Patient #10 was admitted to the agency in January 2026 with a diagnosis of hypertension and chronic kidney disease with heart failure and required home care services. Review of the physician order Home Health Plan of Care for certification period 1/3/26 through 3/3/26, indicated the following services: -Physical Therapy services (PT): 1 to 2 times a week for 9 weeks. Review of the clinical record indicated that Patient #10’s goals were met and was discharged from the agency on 1/21/26. Further review of the clinical record indicated the NOMNC notice was provided and signed by the patient on 1/21/26, not 2 days prior to discharge as required. During an interview on 2/11/26 at 2:30 P.M., the Executive Director of Quality Compliance and Education reviewed the clinical record for Patient #10 and said the NOMNC was not provided timely as required.”