St Peter’s Health Home Health and Hospice

“Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA’s governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA’s performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This Condition is not met as evidenced by: Based on interview and record review, the agency was found to not be in substantial compliance with the Condition of Participation for Quality assessment/performance improvement. Findings include: - The agency failed to identify and monitor quality specific areas, including measures derived from OASIS, for improved patient outcomes, and failed to track and trend HH specific data for improved safety of services and quality of care provided. (G644) - The agency failed to have the frequency and detail of the data collection approved by the agency’s governing body. (G644) - The agency failed to track patient adverse events and perform a root cause analysis for identification and implementation of interventions. (G654) - The agency’s governing board failed to ensure the agency program was implemented and maintained based on the specific quality measures identified for the improvement of patient outcomes specific to the agency. (G660)”

“Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This Condition is not met as evidenced by: Based on observation, interview, and record review, the agency was found to not be in substantial compliance with the Condition of Participation for Infection Prevention and Control. Findings include: - The agency failed to ensure staff utilized appropriate infection control protocols for the use of PPE during the removal of a peripherally inserted midline IV catheter. This deficient practice increased the risk of negative patient outcomes related to intravascular catheter-related infections and catheter-related bloodstream infections (See G682). - The agency failed to maintain an agency program for the surveillance, and investigation of infectious and communicable diseases that is an integral part of the agency’s QAPI program (See G684). - The agency failed to ensure infection control education, training, and competencies were provided to skilled nursing staff to ensure staff adhered to infection prevention requirements for the removal of indwelling peripherally inserted midline intravenous (IV) catheters or peripherally inserted central catheter (PICC). This deficient practice increased the risk of negative patient outcomes related to intravascular catheter-related infections and catheter-related bloodstream infections (See G686). - The agency failed to maintain an agency program for the surveillance, and investigation of infectious and communicable diseases that is an integral part of the agency’s QAPI program. (G0684).”

“Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient’s plan of care, for each patient’s medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This Condition is not met as evidenced by: Based on observation, interview, and record review, the agency was found to not be in substantial compliance with the Condition of Participation for Organization and Administration of Services. This deficient practice increased the risk of negative patient outcomes related to all patient’s utilizing peripherally inserted midline IV catheters or peripherally inserted central catheters (PICC). Findings include: - Failed to ensure skilled nursing staff utilized professional standards of care when removing a peripherally inserted midline intravenous catheter (See G984).”

“EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure all staff completed initial training on the agency’s emergency preparedness policies and procedures. Findings include: During an interview and record review on 5/6/26 at 10:30 a.m., with staff members A, O, P, and Q, staff member O noted staff member A had not completed the required Emergency Preparedness Education on the electronic education program used by the education department. Staff member P stated staff member A had transitioned into an administrative position and the training was missed in the process. Review of the agency’s Education Program Sheet and Roster, dated 12/2024, for program titled, “Infection/EP”, showed staff member A was not present for the training. Review of the agency’s policy, “Emergency Preparedness in Home Health and Hospice”, not dated, showed: - “... Training must include: Initial training in emergency preparedness policies and procedures for all employees, contractors, and volunteers that is consistent with their expected roles. ...””

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on interviews and record review, the agency failed to encode and electronically transmit each completed OASIS assessment to the CMS system within 30 days of completing the assessment for 25 (#s 14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37, and 38) of 25 sub-sampled patients. Findings include: Review of the agency’s OASIS Error Detail Report for IQIES, dated 5/1/25-5/5/26, showed the agency had 27 records submitted late, for 25 patients. During an interview on 5/5/26 at 1:12 p.m., staff member F stated many of the late submissions were due to a batching problem with the payor source name changes. Staff member F stated others were related to the agency’s EHR system and the instructions to only review the submission report once a week. During an interview on 5/6/26 at 1:30 p.m., staff member F stated the late submissions were due to a combination of billing issues, staff error and the EHR system used. Staff member F stated she was pulling submissions back from IQIES (CMS’s national electronic data repository for OASIS data assessments) to make corrections and instead should have submitted an OASIS data correction. Staff member F stated there were also issues with their EHR Medicare name changes, and the agency’s billing staff changed the home health agency’s payor source data. Staff member F stated 13 of the 27 late submissions were due to the payor name changes for patient #s 14, 15, 16, 18, 21, 22, 23, 24, 29, 30 (re-submitted twice), 31, and 32. She stated 5 of the 27 late submissions were due to HIPPS code changes for patient #s 25, 26, 27, 28, and 33. She stated 9 of the 27 late submissions were related to other staff errors for patient #s 17, 19, 20, 29, 34, 35, 36, 37, and 38. Review of the agency’s policy titled, Home Health Admission to Skilled Services, dated 1/5/26, showed: “...h. Home Health complies with mandated OASIS assessment timelines for appropriate patients.””

“Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient’s status at the time of assessment. This Standard is not met as evidenced by: Based on observation, interview, and record review, the agency failed to accurately encode a start of care OASIS assessment for pressure ulcers for 1 (#1); and failed to accurately encode a SOC OASIS for high-risk medications for 1 (#3) of 13 sampled patients. Findings include: 1. During an observation and interview on 5/6/26 at 9:00 a.m., staff member J applied a waterproof protective covering over a heel and sacral wound dressing prior to assisting the patient into the shower. Patient #1 stated both the heel, and the sacral wounds were present when he started services with the agency. Review of patient #1’s SOC OASIS and Comprehensive Assessment, dated 4/23/26, section M1306-M1342 (Skin Conditions), showed the patient had no pressure ulcers, stageable or unstageable, no statis ulcers, and no surgical wounds, noted on the OASIS at their start of care. Review of patient #1’s Encounter Notes, dated 4/23/26, showed, “[Patient #1] has residual [left] heel wound and sacral wound that were being managed by [Home Wound Company Name] in [Name of Skilled Nursing Facility] and they are continuing to follow patient for wound care at home.” The SOC OASIS did not accurately reflect the patient’s skin condition for pressure ulcers at the patient’s start of care. During an interview on 5/4/26 at 3:30 p.m., staff member A stated the OASIS should reflect the status of the patient at the time the comprehensive assessment was completed. She stated if patient #1 had pressure ulcers present during the PT initiated start of care assessment, the SOC OASIS should reflect the pressure ulcers that were noted by the PT during the SOC assessment. 2. During an interview and observation on 5/5/26 at 1:01 p.m., resident #3 stated she managed her own insulin for her diabetes. The resident’s insulin injection pens were stored in a basket on the table beside her recliner. Review of patient #3’s SOC Medication List, dated 5/1/26, showed the patient was taking the following medications with the following indication for use: - Eliquis for antiplatelet, - Novolog insulin Flexpen for diabetes, and - Lantus Solostar insulin for diabetes. Review of patient #3’s SOC OASIS dated 5/1/26, section M2001 - M2030, N0415 - N0415 (High-Risk Drug Classed medication) did not indicate the patient was taking: - I. Antiplatelet, and - J. Hypoglycemic (including insulin). The SOC OASIS did not accurately reflect the patient’s high-risk medications at the start of care. During an interview on 5/7/26 at 11:06 a.m., staff member B stated the SOC OASIS should accurately reflect any high-risk medications the patient was taking at the start of care. Staff member B stated patient #3’s medication list indicated she was taking insulin for diabetes, and Eliquis, an antiplatelet, which was not marked on the patient’s SOC OASIS for high-risk medications. Review of the facility’s policy and procedure titled, Home Health Comprehensive Assessment of Patients, with an approval date of 12/30/25, showed: “...3. Content of the Comprehensive Assessment: a. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: … c. The patient’s current health, this includes relevant past medical history, as well as, active health and medical problems… “”

“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 interview and record review, the agency failed to ensure the provider was consulted to approve the delayed start of therapy services for occupational therapy (OT) as ordered on the referred plan of care for 2 (#s 1 and 5) of 13 sampled patients. This deficient practice increased the risk of negative patient outcomes for patients in need of occupational therapy. Findings include: 1. Review of patient #1’s Referral, dated 4/22/26, showed home health services ordered for PT, OT, and aide. Review of patient #1’s SOC OASIS, dated 4/23/26, showed, “…referred to home health PT, OT and aide to address mobility, ADL, self-care, and safety needs…” Review of patient #1’s Plan of Care, dated 4/23/26, did not show ordered services for OT. During an interview and record review on 5/4/26 at 3:30 p.m., staff member A stated the provider ordered PT, OT, and aide services, for patient #1 on 4/23/26. The patient had a PT start of care on 4/23/26. She stated the ordered OT services were scheduled for 5/7/26, 14-days after the start of care. A review of the patient’s chart did not show the provider was notified to approve the late start of care for the OT services. Staff member A stated their current occupational therapist was out on medical leave. She stated they currently had an occupational therapist who was “PRN” for 2-days a week, who was currently covering for their regular occupational therapist. Staff member A stated it was because of this that the OT evaluation for patient #1 was not scheduled until 5/7/26. A review of the patient’s medical record did not show the ordering provider was notified to approve the delay in the OT services. Staff member A stated the physician ordered services should be started as soon as possible and if they were going to be delayed the provider should be notified. 2. Review of patient #5’s Referral, dated 11/14/25, showed, services ordered for PT, OT, and ST. Review of a Telephone Communication with patient #5, dated 11/14/26, showed, services referred as PT, OT, and ST, and the patient accepted all of the offered services. The telephone communication was routed to staff members S, T, and U. Review of patient #5’s PT SOC, completed on 11/17/25, showed, “…Plan: Physical Therapy to see patient… Physical Therapy interventions to include left [upper extremity range of motion]/strengthening coordinated with OT…” Review of patient #5’s Plan of Care, dated 11/17/25, did not show ordered services for OT. Review of patient #5’s Start of Care Communication Note for OT, dated 12/6/25, showed, “…Plan: OT to see patient for [one time a week] for one week, [zero times a week] for two weeks, [one time a week] for one week…” The patient did not receive the physician ordered OT services until 22-days after the patient’s start of care. During an interview and record review on 5/7/26 at 11:26 a.m., staff member B stated the provider ordered PT/OT/ST for patient #5. The patient had a PT start of care on 11/17/25. She stated the ordered OT services did not start until 12/6/25. A review of the patient’s chart did not show the provider was notified to approve the late start of care for the OT services. Staff member B stated at the time the OT services were ordered, staff member T was the only available OT. Staff member B stated the physician ordered services should be started as soon as possible and if they were going to be delayed the provider should be notified. A review of the agency’s policy and procedure titled, Care Planning, Coordination of Services and Quality of Care, with an approval date of 1/16/26, showed: “...3. a. If the agency staff misses visits or services as required by the plan of care, staff must notify the responsible physician of the missed visit if there is any potential for clinical impact upon the patient (wound care, lab draw, medication set up). The physician decides whether the patient visit may be skipped or additional interventions is required by the agency due to impact on the patient. [sic] ...c. The physician should not be approached to reduce the frequency of services based solely on the availability of staff…””

“Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA’s governing body. This Standard is not met as evidenced by: Based on interviews and record review, the agency failed to identify and monitor quality specific areas, including measures derived from OASIS, for improved patient outcomes; failed to track and trend HH specific data for improved safety of services and quality of care provided; and failed to have the frequency and detail of the data collection approved by the agency’s governing body. This deficient practice increases the risk of negative patient outcomes for all patients. Findings include: During an interview on 5/6/26 at 12:40 p.m., with staff member A, and C, staff member A stated she had not been reviewing any IQIES quality measure reports for QAPI meetings and was not aware of the areas noted as potentially avoidable events, including UTI rates, patients discharged to the community with an unhealed Stage II pressure ulcer, and the increase in number of pressure ulcers, patients with falls, and late OASIS submissions. Staff member A stated she did utilize the Press Ganey report and the HHCAHPS report but did not have the reports she used available during their QAPI meetings. She stated she only had the meeting minutes and the training documents for the all-staff monthly meetings. Staff member A stated the all-staff monthly meetings included sharing the administrative QAPI meeting minutes. Staff member A stated the agency’s current PIPs included communication between patients and clinicians, and decreasing preventable emergency room visits. Staff member A stated the agency was tracking falls and infections only to determine if the clinicians were reporting them to their supervisor, charting, and notifying the physician. Staff member A stated the agency was not investigating falls or infections beyond those criteria or developing root-cause analysis for potentially avoidable events. Staff member A stated the QAPI plan was approved by the hospital’s governing board, and the hospital’s Chief Nursing Officer was the governing board representative for the home health agency. Staff member A stated the QAPI plan was developed by the Quality Committee of the Hospital’s Operating Board and then staff member C presented the plan to the Hospital’s Operating Board for approval. Staff member A stated she did not directly report to the governing body. Staff member A stated the agency did not have an agency specific policy on QAPI. She stated the agency referred to the hospital’s QAPI plan. Review of the agency’s Home Health QAPI FY2026 Plan, not date, showed: “...Utilize quality indicator data including OASIS measures to evaluate clinical outcomes, safety, infection control, satisfaction and operations ...Agency specific HH validated data sources: iQies reports, Home Health Compare, Press Ganey HHCAHPS, Epic (EMR reports), Pepper Reports. ...” Review of the agency’s Quality-Administrative Meeting Minutes, dated 5/5/25 and 12/1/25, did not include the data from the IQIES Potentially Avoidable Event Report, Agency Patient-Related Characteristics (Case Mix) Report, or the Oasis Error detail report.”

“Track adverse patient events CFR(s): 484.65(c)(2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. This Standard is not met as evidenced by: Based on interviews and record review, the agency failed to track patient adverse events and perform a root cause analysis for identification and implementation of interventions. This deficient practice increased the risk of negative patient outcomes for all patients. Findings include: During an interview on 5/6/26 at 12:40 p.m., staff member A stated she had not been reviewing IQIES quality measure reports for QAPI meetings and was not aware of the areas noted as potentially avoidable events, including UTI rates, patients discharged to the community with an unhealed Stage II pressure ulcer, and the increase in number of pressure ulcers, patients with falls, and late OASIS submissions. Staff member A stated the agency was tracking falls and infections only to determine if the clinicians were reporting them to their supervisor, charting, and notifying the physician. Staff member A stated the agency was not investigating falls or infections beyond those criteria or developing root-cause analysis for potentially avoidable events. Review of the agency’s CMS IQIES quality measure report titled, Potentially Avoidable Event Report, dated 1/2025-2/2026, showed: - Percent of HH observed cases with outcomes for patients discharged to the community with an unhealed Stage II pressure ulcers was 1.36%, with a 0.42% adjusted prior cases with outcomes. The national average for adjusted prior cases with outcomes was 0.31%. - Percent of HH observed cases with outcomes for patients who developed urinary tract infections was 3.16%, with an adjusted prior case with outcomes of 2.71%. The national average adjusted prior cases with outcomes were 0.70%. - Percent of HH observed cases with outcomes for patients with an increase in the number of pressure ulcers was 1.36%, with an adjusted prior case with outcomes of 1.45%. The national average prior cases with outcomes were 0.32%. Review of the agency’s CMS IQIES quality measure report titled, Patient-Related Characteristics (Case Mix) Report, dated 2/2025-1/2026, showed: - Percent of HH observed cases with outcomes for patients with falls since start of care was 19.69%, with national average at 8.15%. - Percent of HH observed cases with outcomes for patients who fell and sustained major injury was 3.61%, with a national average at 0.89%. Review of the agency’s Home Health QAPI FY2026 Plan, no date, showed: “...Utilize quality indicator data including OASIS measures to evaluate clinical outcomes, safety, infection control, satisfaction and operations ...Agency specific HH validated data sources: iQies reports, Home Health Compare, Press Ganey HHCAHPS, Epic (EMR reports), Pepper Reports “... Measure, track and analyze quality indicators. Including adverse events, processes, services and operations. ...””

“Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA’s governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This Standard is not met as evidenced by: Based on interviews and record review, the agency’s governing board failed to ensure the agency program was implemented and maintained based on the specific quality measures identified for improved patient outcomes specific to the agency . Findings include: During an interview on 5/6/26 at 12:40 p.m., staff member A stated she had not been reviewing any IQIES quality measure reports for QAPI meetings and was not aware of the areas noted as potentially avoidable events, including UTI rates, patients discharged to the community with an unhealed Stage II pressure ulcer, and the increase in number of pressure ulcers, patients with falls, and late OASIS submissions. Staff member A stated she did utilize the Press Ganey report and the HHCAHPS report, but not have those reports she used during their QAPI meetings. Staff member A stated the QAPI plan was approved by the hospital’s governing board, and the hospital’s Chief Nursing Officer was the governing board representative for the home health agency. Staff member A stated the QAPI plan was developed by the Quality Committee of the Hospital’s Operating Board and then staff member C presented the plan to the Hospital’s Operating Board for approval. Staff member A stated she did not directly report to the governing body. Staff member A stated the agency did not have an agency specific policy on QAPI. She stated the agency referred to the agency’s QAPI plan. Staff member A stated the board did not direct the agency on QAPI and only approved the QAPI plan presented to them. Staff member A stated the meeting was presenting to the board member what they were looking at and there was not discussion on the plan, just an approval. Review of the agency’s Home Health QAPI FY2026 Plan, not date, showed: “...Utilize quality indicator data including OASIS measures to evaluate clinical outcomes, safety, infection control, satisfaction and operations ...Agency specific HH validated data sources: iQies reports, Home Health Compare, Press Ganey HHCAHPS, Epic (EMR reports), Pepper Reports. ... The Director reports to the governing body at a minimum of annually and more often as needed to ensure executive oversight.” Review of the agency’s Quality-Administrative Meeting Minutes, dated 5/5/25 and 12/1/25, did not include the data from the IQIES Potentially Avoidable Event Report, Agency Patient-Related Characteristics (Case Mix) Report, or the Oasis Error detail report.”

“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 ensure staff utilized appropriate infection control protocols for the use of PPE during the removal of a peripherally inserted midline IV catheter. This deficient practice increased the risk of negative patient outcomes related to intravascular catheter-related infections and catheter-related bloodstream infections and had potential to increase the risk of infections and spread of infections for all patients receiving care. Findings include: Review of patient #4’s Skilled Nurse, SOC OASIS, dated 4/27/26, showed, patient “discharged a couple days ago from the hospital for deep abscess of left hip with MSSA, [patient] reports three surgeries and now on IV antibiotics thru 5/6 with transition to oral antibiotics following… Currently he has a right midline to upper arm with Ancef infusing 24-hrs/day…” [SIC]. During an observation on 5/5/26 at 3:39 p.m., staff member M prepared to remove patient #4’s midline IV catheter, located in his right upper arm. Staff member M cleansed her hands and donned clean gloves. She clamped and removed the antibiotic line from the catheter and then left the patient’s side and completed a task in the patient’s kitchen. When staff member M returned she removed the patient’s dressing that was covering the midline insertion site. Staff member M did not change her gloves or disinfect her hands after leaving the patient’s side and performing a task in the kitchen and she did not have the patient don a mask or turn their head away from the exposed midline IV site. When staff member M removed the midline catheter from the patient’s arm, she was not wearing a mask, and she was not wearing sterile gloves. During an interview on 5/6/26 at 8:05 a.m., staff member B stated they would utilize the same protocols for the removal of a midline IV catheter as they would for the removal of a PICC line. Staff member B stated staff should wear a mask, and the patient would need to turn away from the site during the removal of the dressing and the removal of the midline IV catheter. She stated hand hygiene should occur when changing gloves, after touching a patient, or when moving between potentially contaminated or dirty care to a clean site or before performing additional care. A review of the agency’s policy and procedure titled, Hand Hygiene, with an approval date of 1/29/26, showed: - “2. Indications for Hand Hygiene Using Alcohol Based Hand Rub: - b. Hand hygiene using a hand-washing agent or alcohol-based hand rub may be used for routinely decontaminating hands in the following clinical situations: ii. Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices. iii. Before moving from work on a soiled body site to a clean body site on the same patient. iv. After contact with a patient or the patient’s immediate environment. v. After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings, even if hands are not visibly soiled. vi. After contact with inanimate objects in patient care area. vii. Prior to donning and after doffing personal protective equipment (including gloves). viii. Before accessing clean or sterile supplies and before stocking supplies. ix. After contact with infectious or non-infectious waste…” Review of the agency’s protocol for Peripherally Inserted Central Catheter Blood Sampling and Catheter Removal, reviewed from, The Visiting Nurse Associations of America, with a copyright date of 2019, utilized by the agency for midline IV catheter removal protocols, showed: - “Overview: … each time the PICC is accessed, the risk for developing a central line associated-bloodstream infection (CLABSI) increases… Healthcare workers caring for patients with PICC should be knowledgeable about and demonstrate competence using the appropriate procedures for maintaining the device and appropriate infection control measures to prevent CLABSIs…””

“Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This Standard is not met as evidenced by: Based on interviews and record review, the agency failed to maintain an agency program for the surveillance and investigation of infections and failed to ensure surveillance and investigation findings were included in the QAPI process. This deficient practice increased the risks of negative patient outcomes for all patients. Findings include: During an interview on 5/6/26 at 11:30 a.m., with staff members A, B and E, staff member A stated the infection data was collected by clinician reports to staff member B. Staff member B stated she verified that an infection was documented, reported to the physician, the category of infection was documented, and who reported the infection. Staff member B stated she categorized the infections as UTIs, wounds, respiratory, and other. Staff member B stated she did not track or trend all clinicians involved in patients’ care, or the type of organism. She stated she did not understand what qualified and quantified as a trend. Staff member A stated the data was then submitted to the hospital infection control department. Staff member E stated the data was collected, but no further work was done with the data. Staff member E stated the data was, “just collected.” Staff member B stated the information was discussed at the staff meetings but not formally discussed in the QAPI meeting unless she had a specific concern. Review of the agency’s Infection and Fall log, dated 1/2026, showed a total of 13 infections: two UTIs, three wound, two respiratory, and six other. Review of the agency’s Infection and Fall log, dated 2/2026, showed a total of 16 infections: eight UTIs, three wound, two respiratory, and three other. Review of the agency’s Infection and Fall log, dated 3/2026, showed a total of 19 infections: four UTIs, four wound, five respiratory, and six others. Review of the agency’s Infection and Fall log, dated 4/2026, showed a total of 17 infections: six UTIs, five wounds, four respiratory, and two others. This report showed ten of the infections were found at start of care. Each of the infection logs included the patient’s name, clinician who reported the infection, the category of the infection, if the physician was notified, and if the infection was charted. The infection logs did not include all clinicians involved in the patients’ care, the types of organism, if the antibiotic was effective in treating the infection, sources or causative factors of infections, tracking of patterns and trends, establishing a corrective plan (when appropriate) or monitoring the effectiveness of the corrective plan. Review of the agency’s, [Agency Name] Quality-Administrative Meeting Minutes, dated 5/5/25, did not include information related to infection control. Review of the agency’s, [Agency Name] Quality-Administrative Meeting Minutes, dated 12/1/25, did not include information related to infection control. Review of the agency’s, Home Health and Hospice Infection Control Plan, dated 12/26/24, showed: “...Plan: The plan is agency wide and includes surveillance, identification, prevention, control, and investigation of infectious and communicable diseases. [Agency name] - Home Health and Hospice follow the [Hospital name] infection prevention policy #650-0001. ...8. QAPI: a. The infection control plan is incorporated into the agency QAPI plan. ...” The Home Health and Hospice Infection Control Plan did not include information on surveillance, identification, prevention, control, and investigation of infectious diseases. Review of the [Hospital Name] Infection Prevention Plan-Policy 650-0001, dated 1/30/26, showed: “... In addition to the infection prevention plan, the IPC committee is responsible for monitoring, analyzing, and developing policies for infection control programs. ...” The Policy 650-0001 did not show a process or procedure for the surveillance or investigation of infectious diseases for the Home Health agency.”

“Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This Standard is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure infection control education, training, and competencies were provided to skilled nursing staff to ensure staff adhered to infection prevention requirements for the removal of an indwelling peripherally inserted midline intravenous (IV) catheter for 1 (# M) of 1 sampled peripheral catheter removal; and failed to ensure all staff completed agency required infection control education for 1 (# A) of 7 sampled staff files reviewed. These deficient practices increased the risk of negative patient outcomes related to intravascular catheter-related infections and catheter-related bloodstream infections and had the potential to increase the risk of infections and spread of infections for all patients receiving care. Findings include: During an interview and record review on 5/6/26 at 10:30 a.m., with staff members A, O, P, and Q, staff member O noted staff member A had not completed the required Infection Control Education on the electronic education program used by the education department. Staff member P stated staff member A had transitioned into this position and the training was missed in the process. Review of agency Education Program Sheet and Roster, dated 12/2024, for program titled, “Infection/EP”, staff member A was not present. Review of the agency, Home Health and Hospice Infection Control Plan, dated 12/26/24, showed: -“... 9. Staff Education: a. Agency wide staff education is provided annually and as needed. ...” 1. During an observation on 5/5/26 at 3:39 p.m., staff member M prepared to remove patient #4’s midline IV catheter, located in his right upper arm. Staff member M prepared a clean (non-sterile) supplies on a clean field prepared on the patient’s dining room table. Staff member M cleaned her hands and donned clean gloves. She clamped and removed the antibiotic line from the catheter and then left the patient’s side and completed a task in the patient’s kitchen. When staff member M returned she removed the patient’s dressing that was covering the midline insertion site. Staff member M did not change her gloves or wash her hands after leaving the patient’s side and performing a task in the patient’s kitchen. After removing the dressing, staff member M removed her gloves and performed hand hygiene before donning another pair of clean gloves. Staff member M then placed a piece of clean, non-sterile, folded gauze over the insertion site and pulled out the midline catheter. Staff member M was not wearing a mask, and she did not have the patient turn their head away from the site prior to removing the midline catheter. Staff member M then held the clean gauze onto the catheter removal site for approximately one minute and taped the gauze to the patient’s arm over the catheter removal site. Staff member M did not utilize a petroleum-based ointment or an occlusive dressing over the site. Patient #4 asked staff member M if he could shower, and staff member M stated he could shower, but should wait at least 10 minutes. Staff member M had not placed a water-resistant, occlusive dressing over the patient’s removal site to prevent the site from becoming contaminated or wet during the shower. During an interview on 5/6/26 at 8:05 a.m., staff member B stated they would utilize the same protocols for the removal of a midline IV catheter as a PICC line removal. Staff member B stated they provided yearly skilled nurse competencies for dressing changes and care of PICC lines but had not completed competencies for the removal or discontinuation of a PICC/Midline. Review of the agency’s education, training, and competencies provided for the management and infection control prevention of peripherally inserted central line catheter care included dressing changes and care. The competencies provided did not include the removal of midline/PICCs. Review of the agency’s protocol for Peripherally Inserted Central Catheter Blood Sampling and Catheter Removal, reviewed from, The Visiting Nurse Associations of America, with a copyright date of 2019, utilized by the agency for midline removal protocols, showed, “Overview: … each time the PICC is accessed, the risk for developing a central line associated-bloodstream infection (CLABSI) increases. Thus, accessing the catheter should be kept to a minimum to decrease the incidence of infection. The PICC should be promptly removed when an unresolved complication occurs, when infusion therapy is discontinued, or when a PICC is no longer necessary. Healthcare workers caring for patients with PICC should be knowledgeable about and demonstrate competence using the appropriate procedures for maintaining the device and appropriate infection control measures to prevent CLABSIs…””

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on interviews and record review, the agency failed to complete the initial evaluation assessment within 48 hours of receiving the referral for 1 (#8); failed to ensure the completion of the initial assessment within 48 hours of the original referral without requesting a different start of care to ensure compliance with the regulation or accommodate the convenience of the agency for 1 (#1) of 13 sampled patients. These deficient practices increased the risk of negative patient outcomes for patients not receiving care for immediate needs. Findings include: 1. Toshua’s 2. Review of patient #1’s referral, dated 4/15/26, showed a referral for SN for observation, assessment, medication and pain management for one to two times a week for one week then re-evaluate. HHA for assistance for personal care, and OT for evaluation and treatment. With a requested start date within two days. Related to disease management for Type 2 diabetes with other circulatory complication, with long-term current use of insulin, Stage 3b chronic kidney disease, primary hypertension, benign prostatic hyperplasia. Review of patient #1’s EHR, of an internal communication note between the agency and the ordering provider, dated 4/15/26, showed, “Received your referral for this patient for [Home Health] SN/OT/Aide services. At this time, we are not able to begin services until 04/24/2026. Are you willing to sign all orders pertaining to this episode of care? Do you agree with the plan to begin services on the above date? With your permission, if a more favorable SOC appointment becomes available and the patient wishes it we will perform that scheduling change, however, due to the delay in SOC opportunity, you are encouraged to seek better placement with [Names of other Home Health Agencies] if you so choose. Please let us know what your decision is within 48 hours of receipt of this message in order to meet Medicare requirements. Thank you very much for your response.” [SIC] Review of patient #1’s referral dated, 4/22/6, showed, PT, OT, and HHA for evaluation and treatment, and an aide for personal care. With a requested start of care date for within two days. Review of patient #1’s Provider Visit Note, dated 4/22/26, showed, “…The patient’s mobility is restricted, and he uses a wheelchair to get around. Given his complex medical conditions and limited mobility, it is a taxing effort for him to leave his home. He will greatly benefit from home health services to continue with adequate care given his current condition… The orders for home health have already been placed, and the patient would benefit from occupational therapy, skilled nursing, and bath aide…” Review of patient #1’s Initial Assessment, completed by PT, showed the patient’s initial visit and start of care occurred on 4/23/26. The agency failed to ensure the completion of the initial assessment within 48 hours of the original referral (received 4/15/26) without requesting a different start of care to ensure compliance with the regulation or accommodate the convenience of the agency. During an interview on 5/4/26 at 3:30 p.m., staff member A stated the expectation would be to complete the initial assessment or start of care within 24-48 hours of receiving the referral. She stated that was not always possible due to staffing. She stated if it was not possible to start care within the 24–48-hour timeframe, the referral was reviewed by a scheduler who then would contact the ordering provider to request a new start of care and offer other home health agencies as an alternative to meet the condition of participation. A review of the agency’s policy and procedure, titled Comprehensive Assessment of Patients, with an approval date of 12/30/25, showed: - “1. Initial Assessment Visit: - b. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician-ordered start of care date…” Review of referral for patient # 8, date created 4/10/26, showed patient #8 was referred by the palliative team to the home health agency on 4/10/26. Review of patient #8’s Home Health Plan of Care, dated 4/15/26, showed patient #8 was admitted to home health on 4/15/26, 5 days after the referral was received. During an interview on 5/5/26 at 2:03 p.m., staff member B stated the referral came in at 4:55 p.m. on a Friday and no one was in the office. Staff member B stated the referral was found on Monday because the home health did not work on weekends. Staff member B stated the on-call nurse did not review incoming referrals. Staff member B did not have an explanation for the two additional days before admission. Review of the agency’s policy, Home Health and Hospice Documentation Requirements and Timelines, dated 6/5/24, showed: -“1a. The initial evaluation visit are conducted by a Registered Nurse (RN), Physical Therapist (PT), Speech Language Pathologist (SLP), or Occupational Therapist (OT) within 48 hours of receiving a referral order...” [sic] Review of the agency’s policy, Home Health and Hospice-Referral Process and Patient Prioritization, dated 12/27/25, showed: -“7. Weekend Referrals: Are accepted by the on-call HSP nurses. ...””

“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 interview and record review, the agency failed to develop an individualized plan of care which included the ordered therapy services, the frequency and duration of visits, modality interventions, measurable outcomes, and goals for therapy services for 2 (#s 1 and 5); and failed to ensure the plan of care accurately reflected the patient’s current medication regimen for 1 (#1) of 13 sampled patients. This deficient practice increased the risk of negative patient outcomes for patients receiving therapy services and medication non-compliance and interactions. Findings include: A. Therapy Services on Plan of Care: 1. Review of patient #1’s Referral, dated 4/22/26, showed home health services ordered for PT, OT, and aide. Review of patient #1’s SOC OASIS, dated 4/23/26, showed, “…referred to home health PT, OT and aide to address mobility, ADL, self-care, and safety needs…” Review of patient #1’s Plan of Care, dated 4/23/26, did not included the ordered therapy services for OT, the frequency and duration of visits, modality interventions, measurable outcomes, or the goals for the ordered OT services. During record review and interview on 5/4/26 at 3:30 p.m., review of patient #1’s EHR with staff member A, did not show the patient’s plan of care was updated to reflect the OT services. Staff member A stated it was the expectation for the patient’s plan of care to include all provided services. 2. Review of patient #5’s Referral, dated 11/14/25, showed, services ordered for PT, OT, and ST. a. Review of patient #5’s PT SOC OASIS, completed on 11/17/25, showed, “…Physical Therapy interventions to include left [upper extremity range of motion]/strengthening coordinated with OT…” Review of patient #5’s ordered OT services, for the certification period dated 11/17/25 to 1/15/26, showed, OT was ordered for one visit for one week, for OT evaluation and treatment, then one visit for one week for ADL training, then one visit for one week for ADL training, discontinued on 1/2/26. b. Review of patient #5’s ordered ST services, for the certification period dated, 11/17/25 to 1/15/26, showed, ST ordered for one visit once a week for one week, for evaluation and treatment. Review of patient #5’s Plan of Cares, dated 11/17/25 to1/16/26, did not included the ordered therapy services for OT or ST, the frequency and duration of visits, modality interventions, measurable outcomes, or goals for OT or ST. During an interview and record review on 5/7/26 at 11:26 a.m., staff member B stated the provider ordered PT/OT/ST for patient #5. She stated the ordered OT services did not start until 12/6/25, and ST was for an evaluation and treatment with a date of service on 12/1/25. She stated the ST evaluation did not recommend further ST services. Staff member B stated the patient’s plan of care was not updated to reflect the OT or the ST services. Staff member B stated the current EHR did not allow for a continual update of orders or services provided. The current EHR required the plan of care to be unlocked, updated, and signed by the provider for every update to a patient’s plan of care. B. Medications on Plan of Care 1. Review of patient #1’s Remote Medication List (utilized by clinicians working remotely in patient’s homes), with a last reviewed date of 5/4/26, showed, metformin XR (Fortamet) 1,000 mg tablet and prednisolone acetate 1%(Pred Forte) ophthalmic suspension, were marked as “not taking, reported on 4/27/26.” Review of patient #1’s Plan of Care, dated 4/23/26, and last updated on 5/1/26, showed metformin XR (Fortamet) 1,000 mg tablet and prednisolone acetate 1% (Pred Forte) ophthalmic suspension, were listed as medications patient #1 was still taking. During an interview on 5/7/26 at 11:06 a.m., staff member B stated the agency clinicians utilized a remote system to review and update patient medications. The remote medication list can appear differently than what was on the patient’s plan of care (POC). Staff member B stated although the medications listed on the remote medication list “flow over” to the POC in the agency’s EHR, the POC will not reflect any medications noted on the remote medication list that are noted as “on hold” or “not taking.” She stated in order for the medications noted on the remote medication list as “on hold” or “not taking” to be removed so they do not populate on the patient’s POC, the provider must sign off the medications from the remote medication list. She stated otherwise, when the POC was printed for a patient, the clinician must hand-write on the POC any medications the patient was not currently taking. Staff member B stated the medications listed on patient #1’s remote medication list for the metformin XR (Fortamet) 1,000 mg tablet and prednisolone acetate 1% (Pred Forte) ophthalmic suspension, were marked by the ordering provider as “not taking” but were not signed off by the provider; therefore, they were not removed from the remote medication list, and they were still populating on the patient’s POC as medication the patient was taking. A review of the agency’s policy and procedure titled, Care Planning, Coordination of Services and Quality of Care, with an approval date of 1/16/26, showed: “...Policy: …Home Health can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient receives an individualized written plan of care, including revisions and additions. The plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that Home Health anticipates will occur as a result of implementing and coordinating the plan of care. ...1. Plan of Care: a. The individualized plan of care will include the following: ...iii. The types of services, supplies, and equipment required… ...x. All medications and treatments… ...iv. The frequency and duration of visits to be made… ...xiv. Patient-specific interventions (specific orders for each assessment and intervention) and education; measurable outcomes and goals identified by Home Health and the patient.””

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on interview and record review, the agency failed to notify the physician of abnormal findings during a start of care evaluation for 1 (#11) of 13 sampled patients. This deficient practice had the potential to result in a cardiovascular event for patient #11. Findings include: Review of patient #11’s, [Hospital Name] Health PALTC Progress Note, dated 3/12/26, showed patient #11’s pulse was 67 beats per minute. Review of patient #11’s, Oasis Start of Care note, dated 4/7/26, showed patient #11’s pulse was 124. The note indicated patient #11 was at a facility for pulmonary embolism, cardiomyopathy, weakness, and had a history of being at risk for a cardiovascular event. The note also indicated patient #11’s vital signs were stable. During an interview on 5/5/26 at 3:50 p.m., staff member A stated there was no physician notification documented for the tachycardia (high heart rate above 100) for patient #11. During an interview on 5/7/26 at 10:52 a.m., staff member A stated she did not know how staff would know what an abnormal vital sign reading was or when to notify the physician. Staff member A stated the agency did not have a policy or procedure, standing orders, or direction delineating what abnormal vital signs were or when to notify the physician. Staff member A stated the staff received training on blood pressure procedures but not on other vital signs. Review of the agency’s document titled, Skills Demonstration Checklist 11. Blood Pressure, dated 2020, showed: “...18. Report to nurse if blood pressure is outside parameters.” This document did not show what “outside parameters” meant. The American Heart Association website, last reviewed 8/12/24, found at Target Heart Rates Chart | American Heart Association, showed: “... a. For most adults, a resting heart rate between 60 and 100 beats per minute is normal. ...””

“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 record review, the agency failed to ensure skilled nursing staff utilized professional standards of care when removing a peripherally inserted midline intravenous (IV) catheter (a midline catheter is a flexible tube inserted into a peripheral vein in the upper arm, with the tip resting near the armpit. It provides reliable intermediate-time IV access, typically used for medication treatments such as antibiotic therapy lasting 5-30 days) for 1 (#4) of 13 sampled patients. This deficient practice increased the risk of negative patient outcomes related to all patient’s utilizing peripherally inserted midline IV catheters or peripherally inserted central catheters (PICC). Findings include: Review of patient #4’s Skilled Nurse, SOC OASIS, dated 4/27/26, showed, patient “discharged a couple days ago from the hospital for deep abscess of left hip with MSSA, [patient] reports three surgeries and now on IV antibiotics thru 5/6 with transition to oral antibiotics following… Currently he has a right midline to upper arm with Ancef infusing 24-hrs/day…” [SIC]. During an observation on 5/5/26 at 3:39 p.m., staff member M prepared to remove patient #4’s midline IV catheter, located in his right upper arm. Patient #4 was sitting in a chair at his dining room table. Staff member M prepared clean (non-sterile) supplies on a clean field on the patient’s dining room table. She set out clean gloves, clean gauze, and a piece of tape which she placed over the edge of the dining room table. Staff member M used hand sanitizer and donned clean gloves and clamped the patient’s IV catheter and disconnected the catheter from the antibiotic. Wearing the same gloves, staff member M retrieved an item from the patient’s kitchen and returned to the patient and removed the occlusive transparent dressing covering the patient’s midline insertion site. Staff member M then doffed her gloves and performed hand hygiene and donned clean gloves from the gloves placed on the clean field. Staff member M did not don sterile gloves. Staff member M then placed a piece of clean, non-sterile, folded gauze over the insertion site and pulled out the midline catheter. Staff member M was not wearing a mask, and she did not have the patient don their own mask or turn their head away from the site prior to the removal of the catheter; did not have the patient perform the Valsalva maneuver (holding his or her breath and forcefully exhaling against his or her closed mouth and nose); and she did not cleanse the site prior to removing the midline IV catheter. Staff member M then held the clean gauze onto the catheter removal site for approximately one minute and taped the gauze to the patient’s arm over the catheter removal site. Staff member M did not utilize a petroleum-based ointment or an occlusive dressing over the site. Patient #4 asked staff member M if he could shower, and staff member M stated he could shower, but should wait at least 10 minutes. Staff member M left the patient’s home before the 10 minutes were over. Staff member M did not have the patient remain in a recumbent or supine position for at least 30 minutes after the removal of the catheter and did not stay to observe for any signs of continued bleeding from the site, and or negative outcomes associated with the removal of a peripherally inserted IV catheter. The staff member did not educate the patient on ensuring the dressing did not become saturated with water or contaminated when showering. During an interview on 5/6/26 at 8:05 a.m., staff member B stated they would utilize the agency’s protocols for the removal of a PICC line when removing a peripherally inserted midline IV on a patient. She stated they completed yearly skilled nurse competencies for dressing changes and care of PICC lines but had not completed competencies for the removal or discontinuation of a PICC/Midline. Staff member B stated a sterile technique should be used for the removal of the midline catheter, the nurse should wear a mask, and the patient would need to turn away from the site. She stated the site should be cleansed prior to the removal of the catheter but stated the Valsalva maneuver may not be necessary when removing the midline. Staff member B stated the nurse should use a petroleum-based ointment and sterile gauze to ensure hemostasis (no longer bleeding from the site) was obtained and a sterile occlusive dressing which sealed all four sides of the dressing should be utilized. She stated the patient should also be instructed to remain sitting or lying for 30 minutes after the removal to ensure the site fully closes to reduce the risk of bleeding or air embolism. Review of the agency’s protocol for Peripherally Inserted Central Catheter Blood Sampling and Catheter Removal, reviewed from, The Visiting Nurse Associations of America, with a copyright date of 2019, showed: “...Overview: … each time the PICC is accessed, the risk for developing a central line associated-bloodstream infection (CLABSI) increases. Thus, accessing the catheter should be kept to a minimum to decrease the incidence of infection. The PICC should be promptly removed when an unresolved complication occurs, when infusion therapy is discontinued, or when a PICC is no longer necessary. Healthcare workers caring for patients with PICC should be knowledgeable about and demonstrate competence using the appropriate procedures for maintaining the device and appropriate infection control measures to prevent CLABSIs. Home health personnel also have an added challenge because patients coming from different organizations may use different products. The home health nurse must be familiar with or be able to access instructions for the use of many different products (e.g., different types of needleless connectors)… - Equipment: …Catheter Removal: - PPE (gloves, sterile gloves, eye protection or face mask with eye shield, if appropriate) - Suture removal kit (if sutures are present) - Gauze pads - Petroleum-based ointment or gauze - Moisture-proof absorbent pad - Sterile occlusive dressing ...Catheter Removal: 1. Perform hand hygiene and don gloves and eye protection or face mask with eye shield, if appropriate ...6. Prepare an area in a clean, convenient location, and assemble the necessary supplies. 7. Assess the catheter exit site for the presence of sutures ...11. Discontinue all IV solutions running in the catheter. Clamp catheter lumens. 12. If the catheter is sutured, open the suture removal kit and package of sterile gauze pads using aseptic technique. 13. Place a moisture-proof absorbent pad under the patient’s elbow, close to the catheter site. Rationale: An absorbent pad collects blood and body fluids associated with removal and serves as a receptacle for the contaminated catheter. 14. Place the patient in a position with the catheter site at or below the level of the heart. Rationale: Maintaining the catheter site at or below heart level minimizes the risk of venous air embolism. 15. Remove the catheter dressing and discard it in a trash can lined with a plastic bag. 16. Remove gloves, perform hand hygiene, and don sterile gloves. 17. Remove the securing device or, if sutures are present, gently cut them and pull them through the skin. Ensure that all of the sutures are removed. Retained sutures may form epithelialized tracts that may lead to infection. 18. Grasp a gauze pad with two fingers of the nondominant hand and hold it just above the catheter exit site. 19. If not contraindicated, ask the patient to perform the Valsalva maneuver by holding his or her breath and forcefully exhaling against his or her closed mouth and nose. If the Valsalva maneuver is contraindicated (e.g., patients with retinopathy, cardiac dysfunction, recent myocardial infarction, or glaucoma), ask the patient to exhale during the removal or to hold his or her breath. Rationale: A Valsalva maneuver during removal minimizes the risk for venous air embolus. The main goal is to make sure that the patient does not inhale as the catheter exits, because air can enter the exit site and follow the tract that the catheter left, creating an air embolism. 20. Using the dominant hand, gently withdraw the catheter, pulling it parallel to the skin with a constant, steady motion while using the nondominant hand to place the gauze pad gently over the site. If unable to remove the catheter, notify the practitioner. 21. As the catheter exits the site, use two fingers of the nondominant hand to apply direct pressure on the gauze pad over the insertion site. 22. If the patient was holding his or her breath, instruct him or her to breathe normally as soon as the catheter is removed. If the patient shows signs and symptoms of venous air embolus (e.g., sudden onset of respiratory distress, continued coughing, breathlessness, chest pain, rapid heart rate, wheezing, altered mental status, tachypnea, altered speech, changes in facial appearance, numbness or paralysis, hypotension, cardiac arrhythmias), immediately place him or her in the left lateral Trendelenburg position or left lateral decubitus position, initiate emergency procedures as needed, and activate emergency medical services. Rationale: A venous air embolus is a potentially life-threatening complication. The left lateral Trendelenburg position prevents air from passing into the right side of the heart and traveling into the pulmonary arterial circulation. 23. Place the catheter on the moisture-proof absorbent pad. Evaluate the condition of the catheter and compare its length to the original insertion length. Rationale: Comparing the removed catheter to the original insertion length helps confirm whether the entire catheter was removed. If insertion length and removal length do not match, lightly apply a tourniquet to the upper arm above the insertion site, place the patient on his or her left side, and notify the practitioner immediately. 24. Continue applying firm, direct pressure over the insertion site with petroleum-based ointment and sterile gauze, sealing the site until bleeding has stopped. 25. Cover the petroleum-based ointment and gauze with a transparent, semi-permeable dressing. 26. Label the dressing per the organization’s practice with the date and time of application and initial it. 27. Place the patient in a recumbent or supine position for at least 30 minutes after catheter removal…””