Ann’s Choice Visiting Nurse 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 a review of clinical records (CR), home health agency (HHA) policies, clinical home visit observations (OBS), and an interview with the agency Administrator and the Clinical Manager, the agency failed to follow its policy pertaining to infection control for one (1) of three (3) home visits observations. (OBS#1) Findings include: The “Hand Hygiene- Standard Operating Procedure” policy reviewed on April 22, 2025, at approximately 3:55 pm states in part, “Purpose and scope: To prevent the spread of potentially infectious organisms to residents/patients, staff and visitors. This SOP is applicable to all departments within Erickson Senior Living, LLC. Procedure: 1. When to perform some form of hand hygiene (at minimum): ...Immediately before, between, and after physical contact with a resident/patient...” OBS#1 An on-site observation home visit was conducted on April 22, 2025, at approximately 11:00 AM at the home of CR#1. The Speech Therapist (ST) was observed attempting to perform vital signs on the patient by placing the pulse oximeter on CR #1’s finger without performing hand hygiene, before contact with the patient. The ST touched the laptop to record the results, touching the keypad. The ST then picked up the blood pressure cuff from the barrier and went over to place the cuff on CR #1. The ST removed the device and placed it back on the barrier without performing hand hygiene during this entire process. An interview with the agency Administrator and the Clinical Manager conducted on April 22, 2025, at approximately 4:15 pm, confirmed the above findings.”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based upon review of agency policy, clinical records (CR) and interview with the agency Administrator and the Clinical Manager, the agency failed to ensure that physician orders were signed by the professional receiving the order, in accordance with agency policy, for five (5) of seven (7) CR reviewed (CR #1, 3, 4, 5, and 6), and by the attending physician for one (1) of seven (7) CR reviewed. (CR #5) Findings include: Review of agency policy titled “SOP (Standard Operating Procedure)-RAP (Request for Anticipated Payment)/Final Timelines” on April 22, 2025, at approximately 3:15 P.M. states, “ Procedure: RAP – Start of Care/BP1 (BP1 abbreviation not clarified), Day Six: CM Updates/Completes/Prints 485... Day Seven: OC (Office Coordinator) mails 485 to physician and marks “sent” in Doc (document) tracker.” Review of agency policy titled “Physician Orders” on April 22, 2025, at approximately 3:15 P.M. states, “ Procedure: 4. Orders will be documented on a form provided by the Home Health Agency, dated, timed, and signed by the professional receiving the order... 8. Signed orders will be in the clinical record within 30 days of initiation of care or interim order, unless otherwise specified by applicable state law and regulation.” Review of CR on April 21, 2025, from approximately 1:30 P.M. to 3:30 P.M. and April 22, 2025, from approximately 9:00 A.M. to 11:30 A.M. and 1:30 P.M. to 3:30 P.M. revealed the following: CR #1, start of care April 1, 2025, contained a Home Care Certification and Plan of Care for the certification period April 1, 2025, through May 30, 2025, was not signed by the professional receiving the order. CR #3, start of care April 15, 2025, contained a Home Care Certification and Plan of Care for the certification period April 15, 2025, through June 13, 2025, was not signed by the professional receiving the order. CR #4, start of care April 11, 2025, contained a Home Care Certification and Plan of Care for the certification period April 11, 2025, through June 9, 2025, was not signed by the professional receiving the order. CR #5, start of care March 23, 2025, contained a Home Care Certification and Plan of Care for the certification period March 23, 2025, through May 21, 2025, was not signed by the professional receiving the order, and was not signed by the physician as of the exit date of the survey, April 22, 2025, which was day 30 when the Home Care Certification and Plan of Care was due back signed by the physician. CR #6, start of care December 3, 2024, contained a Home Care Certification and Plan of Care for the certification period December 3, 2024, through January 27, 2025, was signed by the professional receiving the order on December 23, 2025, twenty-one (21) days after the start of care. The Home Care Certification and Plan of Care was not signed prior to the seventh day after start of care when it was required to be sent to the physician for signature. An interview with the agency Administrator and the Clinical Manager on April 22, 2025, at approximately 4:15 P.M. confirmed the above findings.”