Safety Care Inc.

“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 observation, interview and document review, the agency failed to ensure visits were conducted as required in the plan of care and document the potential clinical impact of the missed service for 1 of 5 patients (P7) active records reviewed. Findings Include: P7’s plan of care (POC) for certification period 5/19/25 to 7/17/25, identified a start of care (SOC) date of 5/19/25. Principle diagnosis identified essential hypertension (high blood pressure). Services were ordered for skilled nurse (SN) visits once a week for sixty days. SN visits to manage medications, monitor disease process, and vital sign checks. Skilled observation for evaluation of cardiopulmonary status, teach disease process, teach diet, and teach home safety/fall prevention. P7’s POC for certification period 7/18/25 to 9/15/25, included principle diagnosis essential hypertension (high blood pressure). Services were ordered for skilled nurse visits once a week for sixty days. SN visits to manage medications, monitor disease process, and vital sign checks. Skilled observation for evaluation of cardiopulmonary status, teach disease process, teach diet, and teach home safety/fall prevention. Review of P7’s SN visits completed during the recertification period 5/19/25 to 7/17/25, identified there were missed SN visits on 5/23/25, 6/4/25, 6/11/25, 6/25/25, and 7/2/25. Review of P7’s SN visits completed during the recertification period 7/18/25 to 9/15/25, identified there were missed SN visits on 7/23/25, 7/30/25, and 8/6/25. P7’s medical record lacked documentation of education provided for potential clinical impacts for P7’s missed visits. During an interview on 8/19/25 at 3:45 p.m., director of nursing (DON) verified P7’s missed visits, and confirmed the potential clinical impact of the missed visits was not documented, but indicated their usual process was to discuss the potential clinical impacts with their patients for missed visits. The agency’s policy titled Missed Visits, revised 2025, identified in the event a client could not be seen for any reason, a missed visit notification would be sent to the attending physician. The clinician could try to reschedule for the following week. Nurse to use professional judgement on the risks of not seeing their client for that week. The client should be notified of the potential risks and clinical impact if they missed their scheduled visits, and the nurse could document that in their missed visit notification.”

“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 document review, the agency failed to follow accepted standards of practice related to cleaning of reusable patient use equipment to prevent transmission of infections and communicable disease for 2 of 3 patients (P4, P5) observed during a home visit. Findings include: P4’s plan of care (POC) for certification period 7/24/25 to 9/21/25, included diagnoses of hypertension (elevated blood pressure) and type 2 diabetes. The POC indicated weekly skilled nurse visits (SNV) for 60 days for medication management and blood pressure (BP) and glucose reporting to primary physician. P5’s plan of care (POC) for certification period 7/16/25 to 9/13/25, included diagnoses of Alzheimer’s disease. The POC also indicated weekly skilled nurse visits (SNV) for lung sounds and gastrostomy tube monitoring. During a home visit on 8/19/25 at 11:05 a.m., registered nurse (RN)-A was observed to perform hand hygiene and removed an automatic BP monitoring cuff and oximeter (device used to check oxygen level in blood as well as pulse) from her bag. RN-A did not disinfect the equipment. RN-A placed the blood pressure cuff on R4’s right arm to assess R4’s blood pressure and the oximeter on a finger of R4’s left hand to assess R4’s oxygen level and pulse. RN-A then gathered the BP cuff and the oximeter and placed them into her bag without disinfecting them. During a home visit on 8/19/25 at 11:45 a.m., RN-A was observed to perform hand hygiene and removed an automatic BP monitoring cuff, oximeter and stethoscope from her bag without using anything to disinfect the equipment. RN-A placed the blood pressure cuff on R5’s right arm to assess R5’s blood pressure and the oximeter on a finger of R5’s left hand to assess R5’s oxygen level and pulse. RN-A placed the drum of the stethoscope on R5’s back to assess R5’s lungs. RN-A then gathered the BP cuff, oximeter and stethoscope and placed them into her bag without disinfecting them. During an interview on 8/19/25 at 12:20 p.m., RN- A verified she had not disinfected the reusable medical equipment prior to placing it back into her bag. RN-A stated her usual practice was to wipe the shared medical equipment using an alcohol wipe in her car prior to each home visit. RN-A stated she was unsure if an alcohol wipe was an appropriate disinfectant to use on shared medical equipment to prevent the transmission of infections. During an interview on 8/19/25 at 1:35 director of nursing (DON) stated staff should be cleaning and disinfecting reusable medical equipment with a medical-grade disinfection wipe, after patient use, such as a Sani- wipe prior to putting equipment back into their bag to prevent the transmission of infections. Review of an agency policy titled Disinfecting Medical Equipment revised 2025, identified it was crucial to follow infection control guidelines to safeguard clients and healthcare workers against potential harm caused by improper disinfecting of medical equipment. Identified disinfectants must be EPA-registered Alcohol alone is not an acceptable disinfectant. Further identified shared equipment used by multiple patients, such as blood pressure cuffs and stethoscopes need to be disinfected between each patient encounter.”

“In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This Element is not met as evidenced by: Based on observation, interview and document review, the agency failed to comprehensively assess, attempt alternatives and ensure dimensions were assessed for potential entrapment risks for 1 of 1 patients (P5) reviewed who had side rails. Findings Include: P5’s plan of care (POC) with certification period 7/16/25 to 9/13/25, identified a start of care (SOC) date of 1/23/24. Principle Diagnoses identified Alzheimer’s disease. POC identified hospital bed at bedtime with both side rails up to prevent falls. Caregiver stated that P5 had not fallen. No falls reported past recert period. P5’s Bed Safety Rail Assessment Tool dated 5/13/21, identified P5 had a hospital bed, and recommended full side rails to both sides of bed. Alternatives considered to bed safety rails, was blank, as well as the assessment of bed and environment. Is client at risk of becoming entrapped if safety rails were used, was marked no. Bed rails and bumpers recommended, both were marked yes. P5’s Bed Safety Rail Assessment Tool lacked a comprehensive assessment to include appropriate alternatives prior to the use of bed rails, and measurements of entrapment zones to ensure P5 was not at risk of entrapment. During a home visit observation on 8/19/25 at 11:45 a.m., P5 was sitting on sofa in living room. In front of P5 was a hospital bed with full bed rails, one side the rail was raised up and the side nearest P5 was in the low position. During interview on 8/19/25 at 11:52 a.m., registered nurse (RN)-A stated she had not completed a bed rail assessment for P5. RN-A indicated P5 had the bed with rails before the agency worked with P5, which had been for years. During interview on 8/19/25 at 2:44 p.m., director of nursing (DON) indicated P5 had bed rails to prevent falls. DON stated a bed rail assessment had been completed when P5 began services with the agency. DON confirmed the agency did not complete entrapment zone measurements to determine entrapment risks. At 3:35 p.m., DON confirmed areas of P5’s bed rail assessment were not completed, including alternatives tried prior to bed rail use. DON stated his expectation would be that all areas of P5’s assessment would be completed. DON indicated if measurements were not taken, the risk for entrapment could not be determined. The agency policy titled Bed Rail Assessment, revised 2025, identified bed rail assessments were vital for ensuring patient safety and preventing entrapment or injury. Procedure included to explore alternative strategies to address patient’s needs before resorting to bed rails. If bed rails were deemed necessary, ensure properly installed, compatible with bed and mattress, and used according to manufacturer recommendations. Pay close attention to potential entrapment zones between the mattress and rail, and within the rail structure itself.”