Johnson County Healthcare Center Home Health Agency

“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, staff interview, and policy and procedure review, the agency failed to ensure infection prevention guidelines for wound care were followed during 2 of 3 client home visits (#2, #3). The findings were: 1. Observation during the home visit for client #2 on 3/25/26 at 9 AM showed RN #1 failed to do hand hygiene prior to donning gloves. She placed the barrier under the client’s legs, then pulled supplies out of her bag. She cleaned the right 2nd toe, then got a dressing out of a storage bag. She cleaned the right shin and left shin. She then went through three different supply bags (still wearing the same gloves) looking for different supplies. She pulled a pair of scissors from her work bag, cut optifoam dressing, then placed the dressing on the 2nd right toe. At this point she doffed her gloves and performed hand hygiene. 2. Observation during the home visit for client #3 on 3/24/26 at 11 AM with RN #1 showed the nurse failed to do hand hygiene prior to donning gloves. She placed a barrier down under the client left leg and donned gloves. She pulled her scissors out of her work bag and cut off the old dressing. The wound had sutures and staples still in place from a great toe amputation. The nurse searched through a supply bag for supplies. She went out to her truck and came in and doffed gloves and performed hand hygiene. She did multiple other tasks such as taking vitals, taking photographs, documenting on her laptop. She then donned gloves, cleaned the wound, opened dressing packets and cut dressings. She placed the new dressing over the wound and dressed the wound. At that point she doffed her gloves. 3. Interview with RN #1 on 3/25/26 at 10:20 AM revealed that it was her normal routine when doing wound care. 4. Interview with the administrator on 3/25/26 at 4:05 PM revealed it was the expectation for staff to perform “hand hygiene, don gloves, do the dirty, then doff gloves. The staff would then perform hand hygiene don new gloves, and dress the wound, doff gloves, and perform hand hygiene. 5. Review of the policy “Wound Assessment & Documentation” hand delivered on 3/26/26 at 9 AM by the administrator showed “…6. Infection Control Principles Perform hand hygiene before and after wound care…” 6. Review of the policy “Hand Hygiene” hand delivered on 3/26/26 at 9 AM by the administrator showed “…Procedures Hand Hygiene Indications…When moving from a dirty procedure to a clean procedure…Before donning any personal protective equipment (PPE) and after doffing any PPE…Before and after contact with non-intact skin…Glove Use…Remove gloves and perform hand hygiene at the appropriate indication (e.g., after exposure to body fluids and before a clean procedure) …””

“HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator’s name, business address, and business phone number in order to receive complaints. This Element is not met as evidenced by: Based on observation, review of the patient handbook, and staff interview the agency failed to ensure the correct business address was provided for clients to contact the administrator. The findings were: 1. Observation on 3/23/26 at 1:40 PM revealed the building of the Home Health Agency failed to show it was the location of the Home Health Agency and the administrator. There was no signage showing the agency name, nor the hours of business. 2. Review of the “Home Health Patient & Family Handbook” showed the address of the hospital and not the location of the Home Health Agency and the Home Health Agency administrator. 2. Interview with the administrator on 3/23/26 at 2:25 PM confirmed the building was not identified as the Home Health Agency, and was not the location given to the clients to contact the administrator.”

“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 client medical record review, staff interview, and policy review the agency failed to ensure the initial assessment visit was held either within 48 hours of referral, or on the physician or allowed practitioner ordered start of care date for 2 of 7 clients (#3, #6). The findings were: 2. Review of client # 6 medical records showed the physician ordered SOC on 2/26/26. The agency’s initial assessment was completed on 3/2/26, which showed the SOC was 4 days after the ordered date. Further review showed there was no order by the physician for the delay of services. a. Interview with the administrator on 3/25/26 at 11:40 AM confirmed the delay of care. 1. Review of client #3 medical records showed the physician ordered the Start of Care (SOC) on 3/12/26. The agency initial assessment was done on 3/17/26 showing the SOC was 5 days after the ordered date. Further, review showed there was no order by the physician for the delay of services. 2. Client # 6 (Christine) 3. Interview with the administrator on 3/24/26 at 2 PM revealed the agency did not get the physician order for the delay of services. He stated the agency did delay the SOC. 4. Review of policy “Acceptance of Patients HH/Hospice” hand delivered by the administrator on 3/25/26 at 12:20 PM showed “...Responsibilities...Registered Nurse and/or Qualified Therapist (home Health) Perform the initial assessment to determine home health eligibility, service needs, and whether the agency can meet the patient’s needs in the home environment.” The policy failed to include the need for the assessment to be within 48 hours, or the need for the physician order for the delay in SOC.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on medical record review and staff interview the agency failed to ensure supervisory visits were provided in no less then every 14 days for 2 of 7 clients reviewed (#1, #7). The findings were: 1.Review of client #1’s plan of care for the certification period of 2/7/26 through 4/7/26 showed the skilled nursing frequency was once every 60 days, and the CNA frequency was 3 times a week. Further review showed no supervisory visits had been completed between 2/7/26 through 3/11/26 ( 32 days).Interview with the administrator on 3/24/26 at 2:45 PM revealed supervision visits were not being conducted every 14 days on clients with veteran benefits. 4. Review of the policy titled “Home Health / Hospice Aid Training, Assignment, Supervision and Documentation Guidelines” n.d. hand delivered on 3/24/26 at 3:20 PM by the administrator showed “…5. Aids are Supervised by an RN or other qualified professional in accordance with federal hospice and home health conditions of participation, Wyoming requirements, and applicable payer expectations…” 1. Review of client #1’s plan of care for the certification period of 2/7/26 through 4/7/26 showed the skilled nursing frequency was once every 60 days, and the CNA frequency was 3 times a week. Further review showed no supervisory visits had been completed between 2/7/26 through 3/11/26 (32 days).Interview with the administrator on 3/24/26 at 2:45 PM revealed supervision visits were not being conducted every 14 days on clients with veteran benefits. 2. Review of client #7 plan of care for the certification period from 1/24/26 through 3/24/26 showed the skilled nurse frequency was 1 time a week, and the CNA frequency was 2 times a week. Further review showed the CNA went 34 days without a supervisory visit (1/25/26 - 2/25/26). Then went 19 days without a supervisory visit (2/25/26 - 3/13/26). 3. Interview with the administrator on 3/25/26 at 4:05 PM revealed the supervisory visits on the 2 clients were not done every 14 days, and confirmed they were missed. 4. Review of the policy titled “Home Health / Hospice Aid Training, Assignment, Supervision and Documentation Guidelines” n.d. hand delivered on 3/24/26 at 3:20 PM by the administrator showed “…5. Aids are Supervised by an RN or other qualified professional in accordance with federal hospice and home health conditions of participation, Wyoming requirements, and applicable payer expectations…””