Mountain Home Health Services

“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 agency policy, direct observation, and staff interviews the Registered Nurse failed to practice proper hand hygiene/correct bag technique for 1 of 3 patients who received a joint visit to observe wound care [# 6 ]. The findings included: The policy, Hand Hygiene Policy and Compliance Program [7/2021], was received by RN # 2 on 9/15/25 at approximately 3:24 pm. The policy stated, “Hand hygiene will be done by all employees to reduce the transfer of microbes to patients...The agency will follow the Centers for Disease Control and Preventions [CDC] guidelines for hand hygiene...After removing gloves...Moving from contaminated patient body site to clean site during patient care, After contact with inanimate objects or medical equipment close to the patient...Use of gloves...Change or remove gloves if moving from contaminated to clean patient site or the environment...” The policy, Home Care Bag Technique [4/2024], was received by RN # 2 on 9/15/25 at approximately 3:24 pm. The policy stated, “...The home care bag is placed on a clean, dry surface and a barrier placed between the bag and the surface... Patient # 6 had a Start of Care date of 8/19/22 with an admitting diagnosis of burn of second degree of left foot and pressure ulcer of left buttock, stage 3 [full thickness skin loss that extends into the subcutaneous tissue, but does not involve muscle, tendon or bone]. Review of the Plan of Care [POC] for the certification period 8/3/25-10/1/25 included orders for SN [skilled nursing] 2 times a week for 8 weeks and “SN to perform and teach pt/cg to perform following wound care...to left medial gluteal fold cleanse wound and peri wound with normal saline and pat dry...apply thin layer of triad to periwound area. Apply lightly moistened collagen to wound bed, cover with mepilex border...” On 9/15/25 at approximately 11:30 am a joint visit was made with RN # 1 to observe wound care. Upon arrival, the RN placed her nursing bag and documentation device on the floor of the patient’s bedroom without placing a barrier under the items. The RN then removed a barrier from bag and placed nursing bag on the barrier on the floor. The RN proceeded to perform wound care to the gluteal fold. The RN sanitized her hands and donned gloves and proceeded to clean the wound with wound cleanser. She then reached back into the patient’s box of clean supplies and removed 4x4’s from a large pack with the soiled gloves on. She continued with wound care. After completing the wound care to the gluteal fold, the RN proceeded to reach back into the box of supplies to remove items for the patient’s foot while still wearing the soiled gloves. During an interview on 9/16/25 at approximately 3 pm with the agency director and RN # 2 both confirmed the RN failed to follow proper glove/hand hygiene while doing the dressing change and failed to use proper bag technique during the visit.”

“Property and person treated with respect CFR(s): 484.50(c)(1) Have his or her property and person treated with respect; This Element is not met as evidenced by: Based on agency policy, direct observation, and staff interviews the Registered Nurse failed to provide privacy for the patient during wound care for 1 of 3 patients who received a joint visit [#10]. The findings included: The policy, Patient Bill of Rights and Responsibilities [2/22], was provided by RN # 2 on 9/16/25 at approximately 3:30 pm. The policy stated, “ ...Have his/her property and person treated with respect...” Patient # 10 had a Start of Care date of 2/14/25 with an admitting diagnosis of pressure ulcer of left buttock, stage 2 [partial thickness skin injury that involves damage to the top layer of skin]. Review of the Plan of Care for the certification period 8/13/25-10/11/25 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 8 weeks and “Skilled nurse to perform pressure ulcer care to buttocks weekly. Cleanse with wound cleanser and pat dry ...cover with duoderm.” On 9/16/25 at approximately 9:30 am a joint visit was made with RN # 3 to observe wound care. Patient # 10 lived in an apartment complex. Upon arrival at the patient’s home and throughout the visit the front door remained open. Several people were noted to be passing by the front door. As the patient prepared to receive wound care, she stood up at a small table in the living area and RN # 3 started to assist the patient to remove her outside garment. The front door remained open. The surveyor stopped the visit and closed the front door. After the front door was closed the RN continued with wound care. During an interview with the agency director and RN # 2 on 9/16/25 at approximately 3 pm they confirmed the front door should have been closed prior to beginning the wound care.”

“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: Base on agency policy, direct observation, clinical review, and interviews with staff and patients/caregivers, the Plan of Care [POC] failed to include all the current/correct medications the patient was taking for 4 of 5 patients who received a home visits [#6,7,8, and 10]. The findings included: The policy, Medication Reconciliation [2/2021] was provided by the agency administrator on 9/17/25 at approximately 9:30 am. The policy stated, “...Medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication. The patient’s medication list in the home will also be updated...” 1. Patient # 6 had a Start of Care date of 8/19/22 with admitting diagnoses of burn of second degree of left foot and pressure ulcer of left buttock, stage 3 [full thickness skin loss that extends into the subcutaneous tissue, but does not involve muscle, tendon or bone]. Review of the Plan of Care [POC] for the certification period 8/3/25-10/1/25 included orders for SN [skilled nursing] 2 times a week for 8 weeks and “Skilled nurse to review medication profile and reconcile medications as needed...” On 9/15/25 at approximately 11:30 am a joint visit was made with RN # 1 to observe wound care. During the visit a medication review was completed using a medication profile provided by the agency. The following discrepancy was noted: The medication profile listed Minocycline [antibiotic] 100 mg. Take 1 tablet twice daily. During an interview with the patient, he reported the physician had discontinued the medication “earlier in the month.” During an interview on 9/16/25 at approximately 3 pm with the agency director and RN # 2 both confirmed the POC did not include all current/correct medications the patient was taking. 2. Patient # 7 had a Start of Care date of 8/25/25 with an admitting diagnosis of type 2 diabetes mellitus with other circulatory complications. Review of the Plan of Care [POC] for the certification period 8/25/25-10/23/25 included orders for PT [Physical therapy] 1 time a week for 1 week then 2 times a week for 8 weeks and “Clinician to perform drug regimen review/assessment...” On 9/16/25 at approximately 10 am a joint visit was made with PT # 9. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: Famotidine [reflux] 40 mg daily was on the medication profile. During an interview with the patient he reported, “If it’s not on my list of medications in my wallet, I don’t take it.” [Review of the medication list provided by the patient did not include Famotidine]. During an interview on 9/16/25 at approximately 3 pm with the agency director and RN # 2 both confirmed the POC did not include all current/correct medications the patient was taking. 3. Patient # 8 had a Start of Care date of 5/5/25 with an admitting diagnosis of chronic venous hypotension [increase in pressure in the veins of the lower body] with ulcer of bilateral lower extremity. Review of the Plan of Care [POC] for the certification period 9/2/25-10/31/25 included orders for PT [physical therapy] 2 times a week for 9 weeks. On 9/16/25 at approximately 12 noon a joint visit was made with PTA # 6. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: The medication profile listed Hydralazine [blood pressure] 25 mg three times a day. During an interview with the patient, he reported the medication [Hydralazine] was not reordered when he was discharged from the hospital. During an interview with the administrator and RN # 2 on 9/16/25 at approximately 3 pm, they confirmed the POC did not include all/correct medications the patient was taking. 4. Patient # 10 had a Start of Care date of 2/14/25 with an admitting diagnosis of pressure ulcer of left buttock, stage 2 [partial thickness skin injury that involves damage to the top layer of skin]. Review of the Plan of Care for the certification period 8/13/25-10/11/25 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 8 weeks and “Skilled Nurse to review medication profile and reconcile medications as needed...” On 9/16/25 at approximately 9:30 am a joint visit was made with RN # 3. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: The medication profile listed Lasix [fluid medication] 40 mg daily. During an interview with the patient she stated, “The doctor stopped that and put me back on Bumex [fluid medication].” Review of the medication profiled revealed the patient started on Bumex 1 mg daily on 7/22/25. The medication profile listed Oxybutynin [bladder spasms] 5 mg daily. During the interview with the patient, the patient stated, “I don’t take that anymore.” Novolog [diabetes] insulin was not on the medication profile. The patient presented a bottle of Novolog and reported she takes 40 units with meals. Tylenol [over the counter pain relief] was not on the medication profile. The patient stated, “I take 500 mg. I take 2 in the morning and 2 at bedtime.” During an interview on 9/16/25 at approximately 3 pm with the agency director and RN # 2 both confirmed the POC did not include all current/correct medications the patient was taking.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on agency policy, clinical record review and staff interviews the agency failed to follow the physician’s order on the Plan of Care [POC] related to reporting vital signs outside of the given parameters for 3 of 19 records reviewed [#10, 2, 13, and 16]; and failed to follow the physician’s order for foley catheter size for 1 of 2 charts reviewed with a foley catheter [#16]. The findings included: The policy, Coordination of Patient Care [4/2024], was provided by the agency director on 9/17/25 at approximately 9:30 am. The policy stated, “...The agency must assure communication with all physicians/practitioners involved in the plan of care...” 1. Patient # 10 had a Start of Care date of 2/14/25 with an admitting diagnosis of pressure ulcer of left buttock, stage 2 [partial thickness skin injury that involves damage to the top layer of skin]. Review of the Plan of Care [POC] for the certification period 8/13/25-10/11/25 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 8 weeks and “Vitals Physician Alert Range...Pain greater than 7...” Review of the clinical record revealed LPN # 5 conducted routine visits on 8/18/25, 9/1/25, 9/4/25, 9/8/25, and 9/11/25. LPN # 5 documented a pain level of 8. There is no evidence the physician was notified of the patient’s pain level being outside the given parameters. During an interview with the agency director and RN # 2 on 9/17/25 at approximately 9:30 am, it was confirmed the LPN failed to notify the physician of the pain level in accordance with the POC. 2. Patient # 2 had a Start of Care date of 3/18/25 with an admitting diagnosis of chronic hepatic failure without coma. Review of the Plan of Care [POC] for the certification period 3/18/25-5/16/25 included orders for 1 time a week for 4 weeks and “Vitals Physician Alert Range...fasting blood sugar less than 65 or greater than 225...random blood sugar less than 65 or greater than 300...” Review of the clinical record revealed RN # 3 conducted a routine visit on 4/22/25 and documented a blood sugar of 381. There was no evidence the RN notified the physician of the blood sugar being outside the given parameter. During an interview with the administrator on 9/17/25 at approximately 11 am, the administrator confirmed the physician was not notified of the blood sugar in accordance with the POC. 3. Patient # 13 had a Start of Care date of 5/1/525 with an admitting diagnosis of hemiplegia and hemiparesis [paralyzed and weakness on one side of the body] following cerebral infarction [stroke]. Review of the Plan of Care [POC] for the certification period 5/1/25-6/29/25 revealed orders for ST [speech therapy] 1 time a week for 1 week; home health aide 1 time a week for 8 weeks and “Vitals Physician Alert Range...blood pressure systolic [bottom number] less than 104 or greater than 190...diastolic [top number] less than 50 or greater than 100...” Review of the clinical record revealed ST # 7 conducted an evaluation visit on 5/15/25 and documented a blood pressure reading of 150/107. Further review of the clinical record revealed the home health aide documented a blood pressure reading of 148/102 on 6/17/25. There was no evidence the physician was notified of either blood pressure reading. During an interview with the agency administrator on 9/17/25 at approximately 11 am, it was confirmed the physician was not notified of the blood pressure readings in accordance with the POC. 4. Patient # 16 had a Start of Care date of 5/31/24 with an admitting diagnosis of encounter for fitting and adjustment of urinary device. Review of the Plan of Care [POC] for the certification period 7/25/25-9/22/25 revealed orders for SN [skilled nursing] 1 time a month for 2 months and “Skilled nurse for insertion of foley catheter size 16 french, 10 cc balloon...Change monthly [due on or around the 23rd of the month] ...Review of the clinical record revealed RN # 4 changed the foley catheter on 8/25/25 and placed the old foley catheter with an 18 french catheter with a 10 cc balloon. During an interview with the administrator on 9/17/25 at approximately 11 am, the administrator confirmed the RN failed to follow the physician’s order related to the size of the foley catheter.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on agency policy, clinical record review and staff interviews the Registered Nurse failed to document a wound assessment with each nursing visit when wound care was preformed for 5 of 6 patients with a wound [#6, 8, 10, 11, and 12]; and the Registered Nurse copied and pasted nursing notes for 1 of 19 charts reviewed [#9]. The findings included: The policy, Wound Care [no date], was provided by the RN # 3 on 9/16/25 at approximately 3:35 pm. The policy stated, “...The nurse should assess the wound for symptoms of inflammation or infection on each visit.... 1. Patient # 6 had a Start of Care date of 8/19/22 with an admitting diagnosis of burn of second degree of left foot and pressure ulcer of left buttock, stage 3 [full thickness skin loss that extends into the subcutaneous tissue, but does not involve muscle, tendon or bone]. Review of the Plan of Care [POC] for the certification period 8/3/25-10/1/25 included orders for SN [skilled nursing] 2 times a week for 8 weeks and “SN to perform and teach pt/cg to perform following wound care...to left medial gluteal fold cleanse wound and peri wound with normal saline and pat dry...apply thin layer of triad to periwound area. Apply lightly moistened collagen to wound bed, cover with mepilex border...” Review of the clinical record revealed the patient received 15 SN visits from 8/4/25-9/15/25. Further review of the clinical record revealed no documented wound assessment for 6 of the 15 SN visits. During an interview with the agency administrator on 9/17/25 at approximately 11 am, the administrator stated, “They should document a wound assessment with every visit that wound care is completed.” 2. Patient # 8 had a Start of Care date of 5/5/25 with an admitting diagnosis of chronic venous hypotension [ increase in pressure in the veins of the lower body] with ulcer of bilateral lower extremity. Review of the Plan of Care [POC] for the certification period 9/2/25-10/31/25 included orders for SN [skilled nursing] 3 time a week for 9 weeks and “Wound care to left proximal lateral lower leg...cleanse wound and periwound with normal saline or wound cleanser...apply prisma collagen in wound bed...apply gauze...apply tubigrip ...cleanse wound to left upper leg with saline or wound cleanser...apply prisma collagen in wound bed... apply tubigrip...lower right extremity...cleanse wound...apply thin layer of triad...apply prisma collagen...apply tubigrip...” Review of the clinical record revealed the patient received 4 SN visits from 9/2/25-9/12/25. Further review revealed no documented wound assessment for 2 of the 4 SN visits. During an interview with the agency administrator on 9/17/25 at approximately 11 am, the administrator stated, “They should document a wound assessment with every visit that wound care is completed.” 3. Patient # 10 had a Start of Care date of 2/14/25 with an admitting diagnosis of pressure ulcer of left buttock, stage 2 [partial thickness skin injury that involves damage to the top layer of skin]. Review of the Plan of Care for the certification period 8/13/25-10/11/25 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 8 weeks and “Skilled nurse to perform pressure ulcer care to buttocks weekly. Cleanse with wound cleanser and pat dry ...cover with duoderm.” Review of the clinical record revealed the patient received 14 SN visits from 8/4/25-9/10/25. Review of the SN documentation revealed no documented wound assessments for 8 of the 14 visits. During an interview with the agency administrator on 9/17/25 at approximately 11 am, the administrator stated, “They should document a wound assessment with every visit that wound care is completed.” 4. Patient # 11 had a Start of Care date of 8/29/25 with an admitting diagnosis of encounter for surgical aftercare following surgery on the digestive system. Review of the Plan of Care for the certification period 8/29/25-10/27/25 revealed orders for SN [skilled nursing] 1 time a week for 6 weeks and “Skilled nurse to perform/teach wound care to incision/suture site located mid abdomen and left knee...” Review of the clinical record revealed no wound assessments with the visit on 9/4/25. During an interview with the agency administrator on 9/17/25 at approximately 11 am, the administrator stated, “They should document a wound assessment with every visit that wound care is completed.” 5. Patient # 12 had a Start of Care date of 8/16/25 with an admitting diagnosis of open bite, right lower leg. Review of the Plan of Care for the certification period 8/16/25-10/14/25 included orders for SN [skilled nursing] 1time a week for 1 week, 2 times a week for 7 weeks, 1 time a week for 1 week and “Skilled nurse to perform/teach wound care to right posterior leg as follow: ...cleanse with wound cleanser or normal saline...apply triad paste...apply iodosorb...cover with aquacel ag...” Review of the clinical record revealed the patient received 7 SN visits from 8/16/25 – 9/12/25. Further review of the clinical record revealed no documented wound assessments for 5 of the 7 visits. During an interview with the agency administrator on 9/17/25 at approximately 11 am, the administrator stated, “They should document a wound assessment with every visit that wound care is completed.” 6. Patient # 9 had a Start of Care date of 8/26/25 with an admitting diagnosis of displaced tri-malleolar [ankle area] fracture of right lower leg. Review of the Plan of Care for the certification period 8/26-25-10/24/25 included orders for SN [skilled nursing] beginning 9/7/25 1 time a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 1 week. Review of the clinical record revealed RN # 1 completed the SOC assessment on 8/26/25. Further review of the clinical record revealed RN # 10 conducted routine visits on 8/29/25 and 9/2/25. Review of the documentation for 8/29/25 and 9/2/25 revealed the same visit notes as RN # 1 had documented at the time of admission. During an interview with the administrator on 9/17/25 at approximately 10 am, the administrator stated, “She copied and pasted the admission note to her visit notes on 8/29/25 and 9/2/25.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on clinical record review and staff interviews the agency failed to provide aide supervisory visits at least every 14 days for 2 of 3 patients who received aide services [#13 and 17]. The findings included: 1. Patient # 13 had a Start of Care date of 5/1/525 with an admitting diagnosis of hemiplegia and hemiparesis [paralyzed and weakness on one side of the body] following cerebral infarction [stroke]. Review of the Plan of Care [POC] for the certification period 5/1/25-6/29/25 revealed orders for SN [skilled nursing] 1 time a week for 4 weeks; home health aide 1 time a week for 8 weeks; PT [physical therapy] 1 time a week for 8 weeks. Review of the clinical record revealed the patient received weekly home health aide visits beginning 5/6/25. Further review of the clinical record revealed no home health aide supervisory visit was conducted until 6/17/25. During an interview with the administrator on 6/17/25, the administrator stated, “Clinicians are supposed to do aide supervisory visits each visit to prevent missing one. They know they must be done within 14 days.” 2. Patient # 17 had a Start of Care date of 11/23/22 with an admitting diagnosis of encounter for fitting and adjustment of urinary device. Review of the Plan of Care for the certification period 7/10/25-9/7/25 revealed orders for SN [skilled nursing] 1 time a week for 8 weeks starting 7/13/25 and home health aide 1 time a week for 8 weeks beginning 7/13/25. Further review of the clinical record revealed the patient received weekly aide visits. No aide supervisory visits were completed until 8/4/25. There was a second aide supervisory visit conducted 8/18/25. There was no evidence of another aide supervisory visit from 8/18/25-9/5/25. During an interview with the administrator on 6/17/25, the administrator stated, “Clinicians are supposed to do aide supervisory visits each visit to prevent missing one. They know they must be done within 14 days.””