Almost Family

“Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This Element is not met as evidenced by: Based on record review and interview, the agency failed to document complaint and resolution of allegations of abuse, neglect or misappropriation in 1 of 1 allegation of misappropriation (Patient #1) in a total of 1 complaint reviewed. Findings Include: Review of facility policy titled, “Incident/Event Reporting” dated 08/01/2025 revealed, “…Procedure: Definitions: 1. Incident report: Incident reports are used to document unexpected or safety and risk related events which may occur. Incident reports are used in ongoing monitoring, evaluation and improvement activities related to patient care and safety…2. Unexpected event: …Examples of unexpected events include but are not limited to: …d. Damage, theft or loss of property belonging to a patient, visitor, employee…3. Once notified and incident reports are reviewed, the Risk Management Department will be required to make notification…Reporting Patient, Affiliate, Contractor, and Visitor Occurrences: 1. Any employee who discovers and occurrence involving a patient…is responsible for completing an incident report…and notifying his/her supervisor regarding the incident…2. All incidents should be entered into the online incident reporting system within 72 hours of the incident or from the identification of the incident…3. The Executive Director, Assistant Executive Director, or Clinical Director must assess the situation and recommend follow up action as appropriate. For significant patient occurrences, the attending physician must be notified of the occurrence in a timely manner. 4. The Executive Director or Clinical Director must also review the incident report, document additional findings and corrective action(s) taken, and perform the manager review complete function in the online reporting system no later than 30 days from the date or identification of the incident.” Review of the online complaint #3065547 revealed Complainants A, B and C alleged Caregiver G was holding Patient #1’s debit and food share cards and this was reported to the agency’s Director on 06/19/2026 via telephone. There was no evidence the phone call was documented by the agency as a complaint or incident, no investigation was completed or documented, and no actions or resolution was documented. There was no evidence the agency followed it’s policy and procedure for investigating and following up on complaints and adverse events. During an interview on 07/30/2026 at 12:33 PM Pt. #1 stated, “[Supportive Caregiver G ] helps some…she’s had them [debit cards and food share cards] for a year, I believe she went into my wallet and got them. I didn’t know she took them.” Pt. #1 stated he asked for them back and Supportive Caregiver G stated she was busy. During an interview with Director D on 07/30/2026 at 2:31 PM Director D stated she thought the report from APS was regarding another client. Director D stated there was nothing more that was completed for the investigation.”

“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 observation, record review and interview, agency staff failed to follow standard precautions regarding sharps (needle) safety in 1 of 1 home visit observation where a needle was used, out of a total of 3 home visit observations (Registered Nurse A). During an interview with Clinical Leader B and Administrator C 05/08/2024 at 12:40 PM, the above findings were reviewed. When asked what the expectation would be regarding sharps use and disposal, Clinical Leader B replied, “Bring the sharps container to the area providing care.” Administrator C replied, “If it didn’t have a guard, she shouldn’t have recapped it. It is standard practice. I don’t know why she would have done that.” Findings include: Review of policy number 8.002 “Standard Precautions” last revised 10/01/2022 revealed in part, “Staff will follow guidelines for protection from infectious disease based on Occupational Safety and Health Administration (OSHA) and Centers for Disease Control (CDC) guidelines for Standard Precautions.” Further review revealed “e. Sharps Safety. ii. Never recap used needles, or otherwise manipulate them using both hands, or use any other technique that involves directing the point of the needle toward any part of the body.” A visit was conducted at the home of Patient #3 on 5/8/2024 at 7:55 a.m. to observe Registered Nurse (RN) A provide care. After administering an insulin injection subcutaneously, RN A then attempted to recap the needle by sliding it into the cap which was on Patient #3’s chair-side table. When this was unsuccessful, RN A then placed the end of his/her finger on the top of the cap and slid the needle inside until the cap snapped into place. During an interview with Clinical Leader B on 05/08/2024 at 12:40 PM, Clinical Leader B stated, RN A, “was nervous.” During an interview with Administrator C on 05/08/2024 at 12:45 PM, Administrator C stated, that the expectation of staff was to not recap needles and to use a designated sharps container.”