Well Care Home Health of the Southern Triangle, Inc.

“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 clinical record review, and staff interviews, the agency failed to complete the registered nurse initial assessment within 48 hours of receiving the referral for 1 of 4 patients. (patient #1) Findings included: The referral received by the agency on 04/04/2025 at 11:37 AM for patient #1 included orders for skilled nursing, home health aide services, and physical therapy. A review of the clinical record revealed that the first documented attempt to contact the patient/care giver to arrange for the start of care was made on 04/07/2025. An interview conducted on 05/12/2025 with the agency director confirmed that there was no documentation of an attempt to complete the admission until 04/07/2025 and the expectation is to complete the start of care within 48 hours of receiving a referral.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews, the agency failed to document a discharge summary for 1 of 2 discharged records reviewed. (patient #2) Findings included: A policy, Discharge Policy (approval 12/20/2024) received on 05/12/2025 at 12:41 PM from the agency director stated, “The discharge record will be organized according to the organization policy regarding clinical record contents. Documentation will be reviewed by the Clinical Supervisor or designee and completed within 30 days of the discharge; at which time it will be removed from the active files.” A policy, Clinical Records (revised 02/2022) received on 05/12/2025 at 12:14 PM from the agency director stated, “Discharge paperwork will be completed and incorporated into the electronic clinical record within two (2) days of discharge unless otherwise specified in contractual arrangements.” Patient #2 was admitted on 11/25/2024 with a diagnosis of pulmonary embolism (condition in which arteries in the lungs become blocked). The plan of care for 11/25/2024-01/23/2025 included orders for skilled nurse visits 1 time a week for 1-week, physical therapy visits 1 time a week for 7 weeks, 1 every 2 other week for 2 weeks, and on 12/26/2024 an order for “physical therapy 1 time a week for 3 weeks then discharge.” A review of the clinical record revealed no documentation related to discharge or a discharge summary. An interview conducted on 05/12/2025 with the agency director revealed that there was no documentation related to discharge and the expectation is for a discharge summary to be completed.”

“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, complaint log review, and staff interviews the agency failed to follow accepted standards of practice when disposing of a contaminated needle. (patient #1) Findings included: A policy, Labs and Specimens-Blood: Venipuncture (no revision/review date) was received on 04/15/2024 at 3:05 P.M. from the Performance Improvement Coordinator. The policy stated, “Ensure sharps container is open and nearby.” Patient #1 was admitted on 11/01/2023 with a diagnosis of acute cystitis without hematuria (inflammation of the bladder without blood in the urine). The plan of care for 11/01/2023-12/30/2023 included orders for skilled nurse (SN) visits 2 times a week for 2 weeks, 1 time a week for 5 weeks, and 3 every 2 weeks for 2 weeks. The SN visit of 11/03/2023 LPN #2 stated, “Patient tolerates lab draw…” For the communication note of 11/06/2023 LPN #2 stated, “I placed my gloves and needled [sic] inside gloves on the side of the trash can.” A review of the complaint log was conducted. On 11/06/2023 the complaint log included a statement from LPN #2, “When she [LPN #2] went back inside and completed the blood draw she [LPN#2] realized that she has left the sharps container (in her jacket) in the car… she [LPN #2] laid the sharp [contaminated needle], on a glove, on the side of the trash can…” An interview was conducted on 04/15/2024 at 3:50 P.M. with LPN #2. LPN #2 stated, “Normally my frequent flyers for blood draws have their own sharps containers, the daughter was in my face throughout the visit. Normally I discard the needle in the sharp’s container, dispose of my gloves and them wash my hands.” An interview was conducted on 04/15/2024 at approximately 3:35 P.M. with the agency director. The agency director stated the expectation is “to make sure they take their sharps container in and dispose of sharps while they are in the home.””