Providence Home Health

“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 observations, interview, and policy review, the Home Health Agency (HHA) Skilled Nurses (SN) #1 and #2 failed to follow standard precautions and HHA policy regarding hand hygiene to prevent the spread of infection and communicable disease. Findings included: Observation on 04/08/2024 at 1:55 PM for Patient #1 showed Skilled Nurse (SN) #1 with long, artificial fingernails performing wound care. Observation on 04/09/2024 at 9:05 AM for Patient #3, showed SN #2 with long, artificial nails performing wound care. Record review of the HHA’s policy titled “Hand Hygiene”, date 03/20/2020, showed that staff should keep fingernails no more than 1/4 inch past the tip of the finger and not allowed to wear artificial nails. During an interview on 04/09/2024 at 11:30 AM, Administrator stated that this was not conforming with HHA policy.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on observation, record review, and interview, the Home Health Agency (HHA) failed to ensure complete and accurate wound care orders for 1 out of 10 patients (Patient #3). Findings included: Observation on 04/09/2024 at 9:05 AM showed Skilled Nurse (SN) #2 performing wound care to an old graft site on the right upper thigh for Patient #3 ; cleaning the site with wound cleanser, applying Silvadene cream and leaving it open to air. Review of Patient #3’s record on 04/09/2024 at 11:21 AM showed physician orders for wound care to the graft site dated 03/20/2024 which stated “cleanse with wound cleanser, apply Silvadene cream using clean technique”. The wound care order does not state to leave the wound open to air. During an interview on 04/10/2024 at 10:20 AM, Administrator stated that order should have stated to cover wound or leave open to air.”

“Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This Element is not met as evidenced by: Based on observation, interview, and record reviews, the Home Health Agency (HHA) failed to ensure staff were following visit schedules and wound care ordered by the physician for 6 out of 10 patients (Patients #1, #3, #4, #5, #6 and #9). Patient #4’s (P4’s) record was reviewed on 4/9/24 at 9:00 AM. P4 was admitted to the HHA on 12/27/2023 with a diagnosis of a fractured pelvis. The Home Health Certification and Plan of Care for the period 2/25/24 to 4/24/24 indicated a Physical Therapist (PT) was supposed to visit P4 “1W1” (one time a week for one week), “2WK1, 1WK3...” beginning 2/25/24. There was no documented evidence a PT visited P4 the week of 3/17/24. In an interview with the Business Office Manager (BOM) on 4/10/24 at 9:40 AM, he/she reviewed P4’s record and confirmed the findings. Findings included Observation on 04/08/2024 at 1:55 PM for Patient #1 showed Skilled Nurse (SN) #1 performing wound care to sacral wound cleaned with wound cleanser, pat dry with gauze, pack with Aquacel ribbon, cover with foam and secure with transparent negative pressure therapy drape. Review of Patient #1’s record on 04/08/2024 at 11:43 AM showed current physician wound care orders “Clean sacral wound with wound cleanser pat dry apply aquacel AG ribbon, cover with foam border and secure change 3 X week”. SN #1 did not use foam border dressing and there are no orders for specific treatment to secure. During an interview on 04/10/2024 at 10:12 AM, Administrator stated that the wound care was not following the physician orders. Review of Patient #3’s record on 04/09/2024 at 11:21 AM showed physician orders dated 03/19/2024 stating that “SN effective 03/10/2024 3 week 1”. There is only 1 SN visit documented during that week on 03/12/2024. During an interview on 04/10/2024 at 10:20 AM, Administrator stated that no other documentation in the chart for that week and verified the finding. Review of Patient #5’s record on 04/09/2024 at 12:25 PM showed SN visit schedule for episode beginning 02/20/2024, 1 visit for 1 week, 2 visits for 1 week, 1 visit for 1 week, 1 visit every 2 weeks for 4 weeks. There are SN visits documented on 02/20/2024, 03/04/2024, 03/18/2024 and 04/03/2024. This is every other week. During an interview on 04/10/2024 at 10:49 AM, Administrator stated that this was a computer system error. Review of Patient #6’s record on 04/09/2024 at 1:33 PM showed SN visit schedule beginning 03/31/2024 2 visits per week for 4 weeks, 1 visit per week for 4 weeks. There are SN visits documented on 04/05/2024 and 04/08/2024 with no second visit documented for those weeks. During an interview on 04/10/2024 at 10:55 AM, Administrator stated that no documentation in the chart for missed visits those weeks and verified the finding. Review of Patient #9’s record on 04/09/2024 at 1:03 PM showed Physical Therapy (PT) visit schedule starting 10/24/2023, 1 visit per week for 4 weeks, 1 visit every other week for 2 weeks, 1 visit per week for 3 weeks. There is a documented PT visit on 12/06/2023 which does not follow every other week schedule. During an interview on 04/10/2024 at 10:35 AM, Administrator stated that this was a confusing schedule and verified the finding.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observations, record reviews, and interviews, the Home Health Agency (HHA) failed to ensure patient medication lists were accurate and included all of the medications, supplements, and herbal remedies the patients had been taking for two of four patients reviewed for medications during home visits (Patients #2 and Patient #4). The findings include: A home visit to Patient #2 (P2) was made with Physical Therapy Assistant (PTA) 1 on 4/8/24 at 1:00 PM, There were discrepancies between the HHA medication list and the medications P2 is taking. P2 stated she is taking Ferrous Sulfate 325 mg one tablet twice a day. The bottle has a fill date of 2/26/24. Ferrous Sulfate is not on P2’s HHA medication list. P2 stated she is taking Losartan 25 mg one tablet a day. The fill date on the bottle is 2/26/24. Losartan is not on P2’s HHA medication list. P2 states she is taking these medications “every day.” During a concurrent interview with PTA 2, he/she confirmed the findings. A home visit to Patient #4 (P4) was made with Physcal Therapist (PT) 2 on 4/9/24 at 10:36 AM. There were discrepancies between the HHA medication list and the medications, supplements and herbal remedies P4 is taking. P4 states she/he is taking Duloxetine 30 mg on days she feels depressed. Duloxetine is not on P4’s medication list and the fill date on the bottle is 6/17/21. (P4 confirmed she/he is also taking the Lexapro, another antidepressant, as indicated on the medication list.) Simethicone 80 mg was in the home and P4 confirmed taking is as needed. Ginseng 500 mg and vitamin C 500 mg were in the home and P4 confirmed taking them. Arthritis Hot Cream and Sikura menthol ointment were in the home and P4 stated she used them every day, multiple times a day, to her knees and buttocks and other areas of arthritis pain. During a concurrent interview with PT 2, he/she confirmed the findings.”

“Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This Element is not met as evidenced by: Based on record review and interview, the Home Health Agency (HHA) failed to ensure a comprehensive assessment for re-certification had been completed within the last 5 days of the end of the episode of care for Patient #3, 1 of 10 patients reviewed. Findings included Review of Patient #3’s record on 04/09/2024 at 11:21 AM showed end of episode 1 on 03/16/2024. Patient #3’s recertification was documented as completed on 03/20/2024. This is 4 days into the second episode. During an interview on 04/10/2024 at 10:20 AM, Administrator stated that there were scheduling issues with the Registered Nurse (RN) and there are orders in the chart for a late recertification due to staff emergency.”

“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 and interview, the Home Health Agency (HHA) failed to provide an accurate and complete comprehensive assessment for 2 out of 10 patients (Patients #5 and #7) to include information related to gender or allergies. Findings included: Review of Patient #5’s record on 04/09/2024 at 12:25 PM showed the patient had allergies to adhesive and Betadine. Patient #5 had physician orders to change his/her supra-pubic catheter every two weeks. Skilled Nurse (SN) documentation on 02/20/2024, 03/04/2024, 03/18/2024 and 04/03/2024 showed the SN had cleaned the patient’s perineal area with Betadine at each catheter change. During an interview on 04/10/2024 at 10:49 AM, the Administrator stated this was an error because the physician’s history and physical does not state an allergy to Betadine. Review of Patient #7’s record on 04/09/2024 at 1:56 PM showed a Start of Care on 10/12/2023. Review of Form 485 revealed for Episodes of Care dated 10/12/2023 and 02/08/2024; that Patient #7 was female. Patient #7 is a male. During an interview on 04/10/2024 at 10:30 AM, the Administrator stated this is an overlooked error and verified the finding.”

“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 record review and interview, the Home Health Agency (HHA) failed to obtain physician orders for Skilled Nurse (SN) visits for 1 of 10 patients (Patient #3). Findings included: Review of Patient #3’s record on 04/09/2024 at 11:21 AM showed a SN visit on 03/20/2024 for re-certification. There was no documentation of physician orders for this visit. During an interview on 04/10/2024 at 10:20 AM, the Administrator stated that there were issues with the computer system and staffing.”