Home Health of the Ozarks

“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 policy review, home visit observation, and interview, the staff failed to follow accepted infection control standards of practice while providing care to patient’s in two of three home visit observations (Records/Patients #1 and #2). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Nursing Bag Techniques,” dated February 2018, showed in part the following: Procedure: -The bag shall not be placed on the floor; -Skin cleanser and paper towels shall be kept in an outside pocket for available access; -Prior to care, skin cleanser and paper towels shall be removed, the bag shall be opened (indicating the bag would be closed) and hands shall be cleansed; -After hand cleansing, all clean supplies and equipment needed for the visit shall be removed from the bag; -When the visit is complete, cleanse reusable supplies with alcohol, antiseptic spray/wipes and/or soap and water as appropriate; and -Hands shall be cleansed prior to returning clean equipment and supplies to the bag. Review of the provider’s undated policy titled, “Indications for Hand Hygiene,” showed in part the following: -Hand hygiene should be performed after having contact with inanimate objects in the patient’s environment; and -After removing gloves. RECORD/PATIENT #1: Observation on 04/08/2025 at 1:00 PM, showed registered nurse (RN) D had his/her nursing bag on the floor of his/her vehicle without a barrier underneath prior to the patient visit. The bag was brought into the patient’s home and placed on a barrier on the couch. The nursing bag was left open, and the patient had several dogs in the home. RN-D cleansed his/her hands and removed the pulse oximeter, thermometer, and stethoscope from the nursing bag. RN-D assessed the patient’s pulse oximetry and temperature then went to the open nursing bag, entered the nursing bag and took out one glove (left the bag of gloves open), put the glove on, entered the nursing bag and pulled out one sanitizing wipe, wiped the pulse oximeter and thermometer, laid them on a clean barrier, entered the nursing bag, pulled out the blood pressure cuff , removed the blood pressure cuff from the black bag and took the patient’s blood pressure, removed the glove from his/her hand, entered the nursing bag took out one new glove and applied it to the right hand, entered the nursing bag and took a sanitizing wipe out, wiped the blood pressure cuff and black bag off, put the blood pressure cuff back into the black blood pressure bag and put it back into the nursing bag, wiped the stethoscope off and put it into the nursing bag, put the pulse oximeter and thermometer into the nursing bag, removed the glove, and sanitized his/her hands with hand gel. Observation of the patient’s wound care during the same home visit showed; the nurse applied hand gel, applied gloves, opened a cabinet (nurse contaminated his/her gloves with this step), took out gauze and soap for wound treatment then went to the kitchen for water(faucet is an inanimate object), removed bandages from patient’s feet, then removed gloves, applied hand gel, applied new gloves and continued with wound treatment. RECORD/PATIENT #2: Observation on 04/08/2025 at 11:30 AM, the certified nursing assistant ( CNA) washed his/her hands and applied gloves prior to checking the patient’s vital signs. The CNA assembled the pulse oximeter, thermometer, and blood pressure cuff on his/her plastic notebook. The vital signs were assessed then the CNA cleaned the pulse oximeter, thermometer, and blood pressure cuff with a sanitizing wipe and put the thermometer, and pulse oximeter back on the plastic notebook, laid the blood pressure cuff in the black bag on the patient’s couch, then picked the blood pressure cuff up and moved it up to the plastic notebook with the other supplies. During an interview on 04/08/2025 at 2:30 PM, the administrator stated that (the vital sign assessment process) did not sound right. When asked if it was usual for the staff to wear gloves during vital sign assessments, the administrator stated that was not normal, they usually wore them during the bathing process. When asked about the nursing bag being on the floor, the administrator stated that the nursing bag should not be on the floor.”

“Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA’s policies and procedures. This Standard is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure professional staff followed the provider’s policies and procedures regarding discharges/transfers in one of two discharge records reviewed (Record/Patient #6). This deficient practice has the potential to affect the post-discharge care of all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Discharge and Transfer Summary,” dated February 2018, showed in part: Purpose: -To ensure a standardized process for discharging patients from the Home Health Agency (HHA); -To uphold the patient’s right to receive information about his/her care, treatment and/or services and to be involved in the decision-making process when appropriate; and -To ensure that appropriate information related to the care, treatment and/or services provided is exchanged with other service members when patients are transferred or discharged from the HHA. Policy: -Discharge/Transfer summary information shall include, but shall not be limited to: -Patient identifying information, including patient’s emergency contact; -Summary of the patient’s diagnoses as well as physical, mental, and emotional status at the time of transfer or discharge; -The date, initiation and reason for transfer or discharge; -The extent to which goals were met and any referrals made; and -Documentation of notification of all physicians issuing orders for the HHA Plan of Care, patient, patient’s legal representative (if any) and family regarding the termination of service. RECORD/ PATIENT #6: Review of the clinical record showed: -The patient was admitted to the provider on 05/09/2024; -The admission diagnoses included a pleural effusion in the right lung (a buildup of excessive fluid in the space between the lung and chest wall which may cause breathing difficulty and chest pain), hypertension (elevated blood pressure), and excessive alcohol intake/ abuse; and -The patient was discharged from the provider 07/07/2024. Review of the patient discharge summary note showed: -The patient went to the hospital with shortness of breath on 06/17/224, and was admitted to the hospital; - The patient was discharged from home health services 07/07/2024; and -The discharge summary failed to include the patient’s physical, mental, and emotional status at the time of transfer/discharge, the extent to which goals were met, and any referrals made by the provider as required by the discharge and transfer policy. During an interview on 04/08/2025 at 11:30 AM, the clinical manager stated that: -The discharge summary’s last page was missing, and could not be located; -The last page contained multiple discharge summary components, as listed in the policy; and -Due to the missing last page, patient #6’s discharge summary was incomplete.”

“Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This Standard is not met as evidenced by: Based on policy review, record review, home visit observation, and interview, the home health provider failed to ensure the aide assignment sheet included all instructions needed for the aide to provide safe care to the patient in, but not limited to, two of four aide assignment sheets reviewed (Records/Patients #2 and #3). This deficient practice has the potential to affect all the patients receiving aide services. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 02/11/2025 with a primary diagnosis of aftercare of an above the knee amputation of the right leg. The patient lived at home. Review of the patient’s Plan of Care (POC) dated 02/11/2025 to 04/11/2025 showed the following intervention: -Skilled Nurse (SN) to notify Physician for out-of-range patient vital signs which included an SpO2 level (peripheral oxygen saturation, which measures the percentage of oxygen in the blood), below 89%. -Review of the Home Health Aide (HHA) Visit dated 03/17/2025 showed the HHA (home health aide) staff documented a SpO2 reading of 82%. -Review of the HHA Visit dated 03/20/2025 showed the HHA staff documented a SpO2 reading of 87%. -Review of the HHA Visit dated 03/25/2025 showed the HHA staff documented a SpO2 reading of 88%. -Review of the HHA Visit dated 03/28/2025 showed the HHA staff documented a SpO2 reading of 88% -Review of the HHA Visit sheet showed the SN signed each HHA visit but failed to provide SpO2 parameter reference for when the HHA was to notify the SN. During an interview on 04/09/2025 at 10:30 AM, the clinical manager stated that vital sign parameters of SpO2 should be listed on the HHA visit assignment sheet as the other parameters vital signs listed on the POC. The nurse assigned to the patient should review each HHA visit for abnormal findings. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 03/18/2025 with a diagnosis of closed (surgery was not required) displaced bicondylar fracture of the right tibia (bumps at the top right and left of the shin bone are broken), and had additional diagnoses of age related osteoporosis (abnormal loss of bone density), lumbar radiculopathy (inflammation of a nerve root in the low back) , muscle weakness, and chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe). The patient lived at home with their spouse. Review of the patient’s plan of care showed the patient had a leg brace/immobilizer listed under the durable medical equipment (DME) section. Review of the Home Health Aide Assignment Sheet showed a section for “dressing care or other specific assignments” with documentation of; non-weight bearing RLE (right lower extremity). The aide assignment sheet failed to include the leg brace/immobilizer. During the home visit observation on 04/08/2025 at 11:40 AM, the aide covered the patient’s brace with a plastic bag and secured the top with tape to ensure water would not seep into the bag and get the brace wet. When asked how he/she knew what to do with the brace on the patient’s right lower extremity, he/she said that patients usually will tell him/her what to do with the brace/cast if the instructions are not on the aide assignment sheet.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on policy review, record review, home visit observation, and interview, the provider failed to ensure the patient’s plan of care (POC) was individualized with appropriate parameters and treatments in, but not limited to, two of six records reviewed (Records/Patients #1 and #2). This deficient practice has the potential to affect the care for all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Care Planning,” dated February 2018, showed in part the following: -An individualized plan of care is developed for each patient; and -The plan of care “covers” all patient care orders, and all pertinent diagnoses. RECORD/PATIENT#1: Review of the clinical record showed the patient was admitted to home health services on 07/22/2024, and was recertified on 03/13/2025 with a primary diagnosis of non-pressure chronic ulcer of other part of right foot (wounds to the toes that were not caused by pressure), and had additional diagnoses including peripheral vascular disease (PVD) (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), essential (primary) hypertension (abnormally high blood pressure that is not the result of a medical condition), and type 2 diabetes mellitus (DM) (a chronic disease that affects how the body uses sugar for energy). The patient lived at home with a spouse. Review of the POC, dated 03/19/2025 - 05/17/2025, showed in part the following: -SN-Notify MD: * “ACC (acceptable) PAIN LVL (level) 5(five)/10 (on a numeric pain scale where zero (0) equals no pain and 10 is the worst possible pain) . PAIN GOAL: 0/10.” -SN-Notify MD: Parameters: * WT (weight) gain > (greater than) 3 (three) LB (pounds) in 3 days; * Pain > 8 (eight)/10; and * FBG (fasting blood glucose) 400, RAND (random blood glucose) 400. Review of the skilled nurse visit notes dated 03/19/25, 03/21/25, 03/24/25, 03/26/25, 03/31/25, 04/02/25, 04/06/2025, and 04/08/2025 failed to include an assessment of a blood glucose measurement or measurement of an actual weight. The documentation showed the patient’s weight was “198” at every visit and was a “reported” weight. The documentation failed to include an assessment of the patient’s weight for the days prior to the skilled nurse visits to assess for weight gain per parameter order. Per interview conducted during observation on 04/08/2025 at 1:30 PM, registered nurse (RN) D stated that the patient was a diet controlled diabetic, took no medications for diabetes, and did not check his/her blood sugar levels. During an interview on 04/09/2025 at 8:45 AM, the home health administrator stated that parameter orders could vary from patient to patient and should be patient specific. The nurse should remove information that did not apply to the patient. Pain parameter orders should match patient’s expectation. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 03/18/2025 with a diagnosis of closed (surgery was not required) displaced bicondylar fracture of the right tibia (bumps at the top right and left of the shin bone are broken), and had additional diagnoses of age related osteoporosis (abnormal loss of bone density), lumbar radiculopathy (inflammation of a nerve root in the low back), muscle weakness, and chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe). The patient lived at home with their spouse. Review of the POC, dated 03/18/2025 - 05/16/2025, showed in part the following: -Under the durable medical equipment section (DME); a leg brace/immobilizer was documented; -Under the activities permitted section; non weight bearing RLE (right lower extremity) was documented; -The POC failed to contain an order related to whether the leg brace/immobilizer could be removed or should remain in place; -SN Notify MD: * “Pain intensity > (greater than) 8/10”; * “Pain acceptable pain level: 5/10, Patient pain Goal 0-5/10”; and * These were conflicting notification orders on the POC. Observation and interview on 04/08/2025 at 10:50 AM showed the patient wore a leg brace. The patient stated that the leg brace had been in place since he/she left the nursing facility and he/she was looking forward to the physician appointment next week in hopes the brace would be removed. During an interview on 04/09/2025 at 8:45 AM, the home health administrator stated that parameter orders could vary from patient to patient and should be patient specific. Pain parameter orders should match the patient’s expectation.”

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on home visit observation and interview, the home health provider failed to ensure that a written visit schedule for all personnel providing visits was given to the patient in three of three home visits conducted (Records/Patients #1, #2, and #3). This deficient practice has the potential to affect the care of all the patients served by the provider. Findings included: RECORDS/PATIENTS #1, #2, and #3: Observation on 04/08/2025 at 1:30 PM (for Patient #1), on 0408/2025 at 10:50 AM (for Patient #2) and on 04/08/2025 at 10:00 AM (for Patient #3) showed the provider’s admission folder, given to the patients at the time of admission, failed to include a written visit schedule for any personnel that provided visits. Per interview conducted during a home visit observation on 04/08/2025 at 1:20 PM, for patient #1, the registered nurse stated that the staff did not leave a schedule of visits in the patient’s home. During an interview on 04/09/2025 at 9:10 AM, the administrator stated that they did not leave a written schedule of visits with the patient as they were not aware of the requirement.”

“Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This Element is not met as evidenced by: Based on policy review, record review, and interview, the provider failed to ensure that home health aide (HHA) services were provided as ordered by the physician or allowed practitioner in two of four records that received aide services (Records/Patients #1 and #2) This deficient practice has the potential to affect all the patients that receive aide services. Findings included: Review of the provider’s policy titled, “Home Health Aide Assignments and Duties,” dated February 2018, showed in part the aide must: -Follow written patient care instructions as prepared by the registered nurse (RN); and -Report changes in the patient’s condition to a registered nurse. RECORD/PATIENT #1: Review of the home health aide assignment sheet, dated 11/13/2024, showed the aide was assigned to assess bladder elimination every visit. Review of the home health aide visit notes dated 03/20/25, 03/24/25, 03/28/25, 03/31/25, and 04/04/25 showed the aide failed to document bladder elimination assessment. RECORD/PATIENT #2: Review of the home health aide assignment sheet, dated 03/18/2025, showed in part the aide was assigned to: -Clean the bathroom every visit; -Assess bladder elimination every visit; -Vital sign parameters to report to nurse if outside listed ranges: * Systolic blood pressure (greater than) 170; * Diastolic blood pressure 90; * Pulse 120; * Respirations 24; and * Temperature 100.4. Review of the home health aide visit note, dated 03/21/2025, showed the aide failed to document cleaning the bathroom or a bladder elimination assessment. The vital sign assessments showed the temperature (90.1), and diastolic blood pressure (92) were out of range and the aide failed to notify the registered nurse (RN). The visit note was cosigned by the case managing RN, but was not dated by the RN. Review of the home health aide visit note, dated 03/25/2025, showed the aide failed to document bladder elimination assessment. The visit note was cosigned by the case managing RN, but was not dated by the RN. Review of the home health aide visit note, dated 03/28/2025, showed the aide failed to document bladder elimination assessment. The temperature (95.5) was out of range and the aide failed to notify the RN. The visit note was cosigned by the case managing RN, but was not dated by the RN. Review of the home health aide visit note, dated 04/01/2025, showed the temperature (92.4) was out of range and the aide failed to notify the RN. The visit note was cosigned by the case managing RN, but was not dated by the RN. Review of the home health aide visit note, dated 04/04/2025, showed the aide failed to document bladder elimination assessment, the temperature (91.2) was out of range and the aide failed to notify the RN. The visit note was cosigned by the case managing RN, but was not dated by the RN. During an interview on 04/09/2025 at 8:45 AM, the administrator stated that, if the vital signs are out of parameter, the aide should have notified notify the nurse, checked the box that they notified, and made a note up in the comment section. During an interview 04/09/2025 at 9:17 AM, the administrator stated that, if the aide assignment sheet has bladder elimination marked, the aide should document under elimination bladder. If no problems, they would mark no. If problems, they would mark yes and document more under comments.”