Ify’s Home Health Care

“Program activities CFR(s): 484.65(c) Standard: Program activities. The HHA’s performance improvement activities must-- This Standard is not met as evidenced by: Based on record review, policy and procedure review, the agency’s Plan of Correction (PoC) review, and staff interview, the agency failed to conduct and document performance improvement activities that would lead to immediate correction of deficient practices, cited during a recertification survey, exit date 1/2/24, which resulted in deficient practice being recited during a revisit survey, exit date 8/26/24, at G574 and G682. The census was 7. Findings are: A. Review of the agency’s policy and procedure titled Quality Assurance/Performance improvement B250, no date indicated, revealed: 1. The agency was to establish a performance improvement plan to continuously measure, assess, and improve the performance of clinical and other processes. 2. Results of the performance improvement plan was to be recorded quarterly. 3. The agency was to identify, address, track, and resolve problems, to ensure resolution and/or improvement. 4. Data was to be systematically collected to measure the process and outcome. B. Review of the agency’s PoC, dated 3/6/24, for the deficiency cited at G574, during a recertification survey, exit date 1/2/24, revealed: 1. The Clinical Supervisor was to audit all patient charts weekly for 60 days for any changes in medications or procedures ordered by the physician, and update changes in the chart. Thereafter, the audits were to be done quarterly. 2. The PoC completion date was to be 5/24/24. 3. Audit results were to be reviewed by the Quality Assurance Committee quarterly. 4. There was no documentation that audits were performed for any changes in medications or procedures ordered by the physician beginning 3/6/24 and after. 5. There was no documentation that the patient chart audit results were reviewed by the Quality Assurance Committee quarterly. C. Review of the agency’s PoC, dated 3/6/24, for the deficiency cited at G682, during a recertification survey, exit date 1/2/24, revealed: 1. The Clinical Supervisor (CS) was to review standard infection control use data, as submitted on competency forms, weekly. 2. The PoC completion date was 5/24/24. 3. Audit results were to be reviewed by the Quality Assurance Committee quarterly. 4. There was no documentation that standard infection control use data, as submitted on competency forms, was reviewed. 5. There was no documentation that the audit results were reviewed by the Quality Assurance Committee quarterly. D. During an interview on 8/26/24 at 10:20 AM, the Director of Nursing confirmed the agency failed to follow the agency’s policy and procedure for conducting, assessing, and documenting performance improvement activities and audit results, to correct deficient practices cited during a recertification survey, exit date 1/2/24, which resulted in deficient practice being recited during a revisit survey, exit date 8/26/24, at G574 and G682.”

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based on record review, policy and procedure review and staff interview the agency failed to conduct and document performance improvement activities and results, as identified in the Plan of Correction (PoC) for the recertification survey, exit date 1/2/24, for tags G572, G574, and G682. Findings are: A. Review of the agency’s policy and procedure titled, Quality Assurance/Performance improvement B250, no date indicated, revealed: 1. The agency was to establish a performance improvement plan to continuously measure, assess, and improve the performance of clinical and other processes. 2. Results of the performance improvement plan was to be recorded quarterly. 3. The agency was to identify, address, track, and resolve problems, to ensure resolution and/or improvement. 4. Data was to be systematically collected to measure the process and outcome. B. Review of the agency’s PoC, dated 3/6/24, for the deficiency cited at G572, during a recertification survey, exit date 1/2/24, revealed: 1. The Clinical Supervisor (CS) was to review each patient plan of care monthly. 2. The Quality Assurance Committee (QAC) was to review all therapy charts quarterly. 3. The PoC completion date was to be 5/24/24. 4. There was no documentation of the CS reviewing each patient plan of care monthly. 5. There was no documentation of the QAC reviewing all therapy charts quarterly. C. Review of the agency’s PoC, dated 3/6/24, for the deficiency cited at G574, during a recertification survey, exit date 1/2/24, revealed: 1. The Clinical Supervisor was to audit all patient charts weekly for 60 days for any changes in medications or procedures ordered by the physician, and update changes in the chart. Thereafter, the audits were to be done quarterly. 2. The PoC completion date was to be 5/24/24. 3. Audit results were to be reviewed by the Quality Assurance Committee quarterly. 4. There was no documentation that audits were performed for any changes in medications or procedures ordered by the physician beginning 3/6/24 and after. 5. There was no documentation that the patient chart audit results were reviewed by the Quality Assurance Committee quarterly. D. Review of the agency’s PoC, dated 3/6/24, for the deficiency cited at G682, during a recertification survey, exit date 1/2/24, revealed: 1. The Clinical Supervisor (CS) was to review standard infection control data, as submitted on competency forms, weekly. 2. The PoC completion date was 5/24/24. 3. Audit results were to be reviewed by the Quality Assurance Committee quarterly. 4. There was no documentation that standard infection control use data, as submitted on competency forms, was reviewed. 5. There was no documentation that the audit results were reviewed by the Quality Assurance Committee quarterly. E. During an interview on 8/26/24 at 10:20 AM, the Director of Nursing confirmed the agency failed to follow the agency’s policy and procedure for conducting, assessing, and documenting performance improvement activities and audit results, as identified in the PoC, dated 3/6/24, to correct deficiencies cited at G572, G574, and G682 during the recertification survey, exit date 1/2/24.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on record review, policy and procedure review and staff interview, the agency failed to ensure the patients medication profile (a real-time document used by the agency, as part of the plan of care, that lists the patient’s medications, including new and updated orders received between the certification periods) included all medication orders received by the agency for 2 of 5 patients records reviewed (Patient 2 and 3). The census was 7. Findings are: A. Review of the agency’s policy and procedure titled Physician Orders C-635, no date indicated, revealed: 1. Orders may be received via facsimile. 2. The nurse was to document implementation of order changes. B. Review of the agency’s policy and procedure titled Plan of Care C-580, no date indicated, revealed the plan of care was to be consistently reviewed to ensure that the client needs are met, and will be updated as necessary, but at least every 60 days. C. Review of Patient 2’s clinical record revealed: 1. The medication profile, dated 7/5/24 through 9/2/24, included Gabapentin (a medication used to treat seizures and nerve pain) 300 mg (milligrams), orally, 4 times daily. 2. An office visit note, dated 7/9/24, from CHI [(Catholic Health Initiatives)] Health Clinic Family Medicine, received via fax to the agency on 7/23/24 at 1:09 PM revealed: a. Meloxicam (a medication used to treat joint pain and stiffness), 7.5 mg, orally, once daily, was added as a new medication. b. Gabapentin order was changed to 600 mg, orally, 3 times daily. 3. The medication profile did not include the new order for the Meloxicam or the changed order for the Gabapentin. D. Review of Patient 3’s clinical record revealed: 1. An office visit note, dated 8/6/24, from Methodist Health System, received via fax to the agency on 8/13/24 at 4:51 PM, included a new order for Oxycodone (a medication used to treat moderate to severe pain), 10 mg, orally, every 4 hours PRN (as needed) for pain. 2. The medication profile, dated 7/3/24 through 8/31/24, did not include the new order for the Oxycodone. E. During an interview on 8/22/24 at 12:30 PM, the Director of Nursing confirmed the agency failed to follow the agency’s policy and procedure for keeping the medication profile updated when medication orders were new or changed for Patient 2 and 3.”

“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 record review, policy and procedure review, and staff interview, the agency failed to ensure Physical Therapy (PT) and / or Occupational Therapy (OT) completed therapy visits as ordered on the Plan of Care, for 2 of 3 records reviewed, who received therapy services (Patients 6 and 7). The total sample size was 7. The census was 5. Findings are: A. Review of the Agency’s policy and procedure titled, Clinical Documentation, Policy number C-680, no date indicated, revealed: 1. When ordered services were not provided, the reason for the missed visits were to be documented and reported to the physician. 2. Modifications to the plan of care were to be documented in the clinical record. 3. Additional information pertinent to patient care was to be documented on a progress note or flow sheet. B. Review of the Agency’s policy and procedure titled, Plan of Care, Policy number C-580, no date indicated, revealed, the physician was to be notified of any changes or alterations to the Plan of Care by obtaining a verbal or telephone order. C. Review of Patient 6’s clinical record revealed: 1. The Patient’s Home Health Certification and Plan of Care (POC) for the certification period of 6/27/23 through 8/25/23, included orders for Occupational Therapy (OT), 1 to 2 times per week for 3 weeks, for evaluation and wheelchair management. 2. There was no documentation the clinical record of OT visits conducted the week of 7/3/23 through 7/9/23. 3. There was no documentation in the clinical record that the physician was notified of the missed OT visits the week of 7/3/23 through 7/9/23. 4. There was no documentation in the clinical record for the reason for the missed OT visits for the week of 7/3/23 through 7/9/23. 5. There were OT visit notes for 7/26/23 and 8/16/23. 6. There were no orders in the clinical record for the OT visits performed on 7/26/23 and 8/16/23. D. Review of Patient 7’s clinical record revealed: 1. The POC for the certification period of 7/19/23 through 9/16/23, included orders for Physical Therapy (PT), 1 to 3 times per week for 9 weeks, to assist with and teach home exercises to promote strength and mobility. 2. There was no documentation in the clinical record that PT visits were conducted the weeks of 8/21/23 through 8/27/23, and 8/28/23 through 9/3/23. 3. There was no documentation in the clinical record that the physician was notified of the missed PT visits for the weeks of 8/21/23 through 8/27/23, and 8/28/23 through 9/3/23. 4. There was no documentation in the clinical record as to the reason for the missed PT visits for the weeks of 8/21/23 through 8/27/23 and 8/28/23 through 9/3/23. E. During an interview on 1/2/24 at 12:00 PM, the Director of Nursing (DON) confirmed: 1. Patient 6 ’s clinical record did not include documentation of the reason for the missed OT visits for the week of 7/3/23 through 7/9/23 and did not include documentation to indicate the physician was notified of OT missed visits. 2. There were OT visits documented on Patient 6’s clinical record on 7/26/23 and 8/16/23 without orders on the POC for these visits. 3. Patient 7’s clinical record did not include documentation of the reason for the missed PT visits for the weeks of 8/21/23 through 8/27/23, and 8/28/23 through 9/3/23, and did not include documentation to indicate the physician was notified of the PT missed visits. 4. The staff did not follow the agency’s policy and procedures for documenting the reason for the missed visits, updating the physician of the missed visits, and alterations to the POC by obtaining a verbal or telephone order.”

“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 record review, policy and procedure review, the observation of the provisions of care, and staff interview, the agency failed to ensure 2 of 2 staff (Staff B and C) observed during the provisions of care to 3 of 3 patients (Patients 1, 2, and 3), performed proper hand hygiene, cleaning of equipment, and/or bag technique. The total sample size was 7. The census was 5. Findings are: A. Review of the agency’s policy and procedure, titled, Hand Washing, Policy number N-130, effective date August 2002, revealed: 1. Handwashing was to be performed, before contact with patients susceptible to infection, after caring for a patient, after handling contaminated equipment and between different patients. 2. The policy and procedure did not include instructions to perform hand washing when entering and leaving the patients home, and steps to use a paper towel to turn off the water faucet. B. Review of the agency policy and procedure, titled, Nursing Bag, Policy number N-120, effective date August 2002, revealed: 1. The purpose of the nursing bag is to carry supplies used for patient care. 2. The nursing bag is to be placed on a clean, dry surface. 3. Hands are to be sanitized prior to entering the nursing bag. 4. When washing hands at the sink with soap and water, the water faucet is to be turned off using a paper towel. 5. The inside of the nursing bag and its contents are considered clean, and staff are to clean all items removed from the nursing bag before returning items to the bag. 6. The policy and procedure did not include the agency approved equipment cleaning product to be used. C. Review of the clinical records revealed: 1. Patient 1’s Home Health Certification and Plan of Care (POC) for the certification period of 9/25/23 through 11/23/23 and 11/24/23 through 1/22/24, included orders for Skilled Nurse (SN), 1 to 7 times per week, to administer a medication, monitor and educate. D. Patient 2’s POC for the certification period of 12/14/23 through 2/11/24, included orders for Physical Therapy (PT),1 to 3 times per week, to assist with and teach home exercises to promote strength and mobility. E. Patient 3’s POC for the certification period of 10/11/23 through 12/9/23, and 12/10/23 through 2/7/24, included orders for SN, 1 to 7 times per week, to assist patient with bowel regime. F. The observation of the provisions of care to Patient 1, on 12/27/23 at 2:00 PM, revealed Staff B failed to: 1, Carry supplies used for patient care in a nursing bag. 2. Clean the stethoscope after use for patient care and prior to placing the stethoscope back around neck. G. The observation of provisions of care to Patient 2, on 12/27/23 at 3:00 PM, revealed Staff C failed to: 1. Sanitize hands prior to entering the nursing bag to obtain supplies for patient use, and prior to returning the supplies back into the nursing bag after use. 2. Use a product containing a disinfectant component to clean the blood pressure equipment and gait belt, prior to returning to the nursing bag after use with the patient. 3. Clean the personal cell phone that was retrieved from Staff C’s pant pocket after use on 2 occasions during care. 4. Dispose of barrier pad, used for a barrier between the floor and the nursing bag, into the trash at the end of the visit. The dirty barrier pad was folded and placed into the nursing bag. 5. Sanitize hands after providing patient services and prior to leaving home. H. The observation of provisions of care to Patient 3, on 12/28/23 at 9:00 AM, revealed Staff B failed to use a paper towel to turn off the water faucet after washing hands at the sink on 3 separate occasions. I. During an interview, on 12/27/23 at 3:30 PM, Staff C confirmed the wipes used to clean the equipment prior to returning items to the nursing bag were baby wipes with no disinfectant component. J. During an interview, on 12/28/23 at 11:00 AM, the Director of Nursing (DON) confirmed that Staff B and C, failed to follow the agency’s policy and procedures for hand hygiene, cleaning of equipment and/or bag technique during the provisions of care to Patients 1, 2, and 3.”

“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 record review, policy and procedure review, the observation of the provisions of care, and staff and patient interview, the agency failed to include orders for patient specific treatments on the Plan of Care for 3 of 7 patient records reviewed (Patient 2, 3, and 5). The census was 5. Findings are: A. Review of the agency’s policy and procedure titled, Plan of Care, Policy number C-580, no date indicated, revealed: 1. The Plan of Care was to include orders for medications, and specific treatments or procedures, to provide guidelines for staff to develop an individual Plan of Care to meet the specific needs of the patient. 2. PRN (as needed) orders are to have a description of the patient’s needs, that would warrant the reason for a PRN order to be implemented. B. The review of Patient 2’s clinical record revealed: 1. The Home Health Certification and Plan of Care (POC) for the certification period of 12/14/23 through 2/11/24 did not include an order for oxygen. C. Review of Patient 3’s clinical record revealed: 1. The (POC) for the certification period 10/11/23 through 12/9/23, and 12/10/23 through 2/7/24, included orders for the Skilled Nurse (SN), to administer a laxative PRN, and to change the patient’s suprapubic urine catheter (a urinary catheter inserted into the bladder through a small incision in the abdomen, to drain urine), every month. 2. The POC did not include the reason for the PRN laxative administration. 3. The POC did not include the urinary catheter size to be used. D. Review of Patient 5’s clinical record revealed: 1. The POC for the certification period 9/4/23 through 11/2/23, and 11/3/23 through 1/1/24, included orders for the SN to change the patient’s suprapubic urinary catheter monthly and PRN. 2. The POC did not include the reason for the PRN urinary catheter change. 3. The POC did not include the urinary catheter size to be used. 4. SN notes dated 9/5/23 and 10/31/23, the SN documented the patient uses oxygen at bedtime. 5. The POC did not include an order for oxygen. E. The observation for provisions of care on 1/27/23 at 3:00 PM, Patient 2 was observed wearing oxygen during the visit. F. During an interview on 12/27/23 at 3:50 PM, Patient 2 confirmed oxygen was a new treatment. G. During an interview on 1/2/24 at 3:30 PM, the Director of Nursing (DON) confirmed: 1. Patient 2’s POC did not include orders for oxygen. 2. The POC for Patient 3 did not include for the reason for the PRN laxative administration and the size of the urinary catheter to be used. 3. The POC for Patient 5 did not include the reason for the PRN urinary catheter change, size of the urinary catheter to be used, and oxygen orders. 4. Staff did not follow the agency’s policy and procedures for including all orders on the POC.”