Healthkeeperz Inc.

“L0514 Based on agency policy, clinical record review, and staff interviews, the agency failed to accept a patients right to refused care or treatment for 1 of 1 patient refusing care. (patient #6) Findings included: A policy Client Bill of Rights (revised 10/06/2021) received on 03/18/2025 at 5:41 PM from the agency director stated, “;All company staff and contract personnel shall be knowledgeable of the clients rights and responsibilities, the policies and procedures pertaining to these rights, and shall assume responsibility for their implementation... Participate in, be informed about, and consent or refuse care in advance or during treatment...” Patient #6 was admitted on 02/05/2025 with a diagnosis of age-related physical disability. The plan of care for 02/05/2025-05/05/2025 included orders for medical social work (MSW) visits 2 times a month for 2 months, 3 times a month for 1 month, and 5 PRN (as needed). The patient is a resident of a facility. During the MSW visit on 02/18/2025 MSW #6 documented, “;Social worker emphasized to continuously try to feed the patient and not just accepted his refusal.” A home visit at the facility was conducted on 03/18/2025 at approximately 10:45 AM with RN #3. Patient #6 was alert and able to make their needs known and stated that they did not like the food at the facility. An interview conducted on 03/18/2025 at 3:20 PM with MSW #6 revealed that MSW #6 was aware of the patients right to refuse.”

“Based on agency policy, clinical record review, and staff interviews, the agency failed to include a complete medication list in the plan of care for 2 of 2 patients with registered nurse home visits. (patients #3 and 6) Findings included: A policy, Medication Review and Reconciliation (revised 08/18/2021) received on 03/17/2025 at 4:29 PM from the agency director stated, “;A thorough medication review will be conducted on all Home Health and Hospice clients during admission and with each visit thereafter.” Patient #3 was admitted on 06/13/2024 with a diagnosis of age-related disability. Patient #3 was a facility resident. The plan of care for 02/08/2025-04/08/2025 included orders for skilled nurse visits 2 times a week for 8 weeks, 1 time a week for 1 week, and 5 PRN (as needed). A home visit was conducted on 03/17/2025 at approximately 2:05 PM with registered nurse (RN) #2. A comprehensive review of the medications found the hospice medical record included orders for “;lorazepam [anxiety medication] 2MG/ML oral concentrate 0.25mL oral every 4 hours/PRN” and “;Trazadone [antidepressant] 50 MG 1 tablet oral at bedtime.” A review of the facility medication orders revealed that there were no orders for lorazepam or Trazadone. Further review of the facility medication orders found orders for “;POT CLORIDE TAB 20MEQ by MOUNTH everyday [potassium chloride tablets 20 milliequivalent], VESICARE [bladder control] 5mg take one tablet by mouth every day, OLANZAPINE [antipsychotic] take 1 tablet by mouth every 6 hours, and clonidine [increases blood pressure] 0.1 mg tabs take 1 tablet by mouth once a day as needed.” Further review of the hospice clinical record revealed that potassium chloride, Vesicare, olanzapine and clonidine were not included in the plan of care. 2. Patient #6 was admitted on 02/05/2025 with a diagnosis of age-related physical disability. The plan of care for 02/05/2025-05/05/2025 included orders for skilled nurse visits 3 times a week for 13 weeks, 1 time a week for 1 week, and 5 PRN. Patient #6 was a facility resident. A home visit was conducted on 03/18/2025 at approximately 10:45 AM with RN #3. A comprehensive review of the medications found the hospice medical record included orders for “;lorazepam [anxiety medication] 0.5mg tablet 1 tablet every oral every 4 hours/PRN” A review of the facility medication orders revealed that there were no orders for lorazepam. Further review of the facility medication orders found orders for “;Sertraline HCL [antidepressant] tablet 25mg give 1 tablet by mouth one time a day” and “;Gabapentin [treats nerve pain] 300 MG give 1 capsule by mouth 3 times a day.” Further review of the hospice clinical record revealed that Sertraline and Gabapentin were not included in the plan of care. During an interview conducted on 03/17/2025 at 2:56 PM RN #2 stated, “;I try do it [medication review] every couple months.” During an interview conducted on 03/18/2025 at 10:55 AM the agency director stated, “;Each visit [nurse] should have a medication reconciliation.””

“Based on agency policy, observation, and staff interviews, the agency failed to take precautions to prevent the spread of infection for 2 of 2 patients with registered nurse observation visits conducted. (patients #3 and 6) Findings included: A policy, Nursing Bag Technique (revised 0/26/2021) received on 03/17/2025 at 4:32 PM from the agency director stated, “;Prepare a receptacle for disposal of used supplies... Close the bag and leave it closed during the visit.” A policy, Standard Infection Control Procedures for Home Care (not dated) received on 03/18/2025 at 5:40 PM from the agency director stated, “;Donning/Doffing PPE [putting on and taking off personal protective equipment] stated, “;Discard gloves in waste container.” Patient #3 was admitted on 06/13/2024 with a diagnosis of age-related disability. Patient #3 was a facility resident. The plan of care for 02/08/2025-04/08/2025 included orders for skilled nurse visits 2 times a week for 8 weeks, 1 time a week for 1 week, and 5 PRN (as needed). A home visit at the facility was conducted on 03/17/2025 at approximately 2:05 PM with registered nurse (RN) #2. RN#2 performed hand hygiene and removed items from the clinical bag. The clinical bag remained open for the entire visit. An interview conducted on 03/18/2025 at 4:06 PM with RN #2 revealed that the clinical bag is not normally left open while providing care. During an interview on 03/18/2025 at 4:08 PM the agency director stated, “;We [all staff] should keep the bag closed during the visit.” 2. Patient #6 was admitted on 02/05/2025 with a diagnosis of age-related physical disability. The plan of care for 02/05/2025-05/05/2025 included orders for skilled nurse visits 3 times a week for 13 weeks, 1 time a week for 1 week with 5 PRN. Patient #6 was a facility resident. A home visit was conducted at the facility on 03/18/2025 at approximately 10:45 AM with RN #3. RN #3 donned clean gloves, performed a skin assessment of patient #6s sacrum (lower back near) and buttocks, removed the contaminated gloves and placed them into the RNs pocket. An interview conducted on 03/18/2025 at 3:22 PM with RN #3 revealed that the contaminated gloves were placed into a pocket because the trash can did not have a liner in it. An interview on 03/18/2025 at 3:27 PM with the agency director revealed that soiled gloves should not be placed in the clinicians pocket.”

“Based on clinical record review and staff interviews, the agency failed to provide spiritual counseling for 2 of 12 patients. (patients #1 and #6) Findings included: Patient #1 was admitted on 05/15/2024 with a diagnosis of chronic obstructive pulmonary disease (lung disease). The plan of care for 05/15/2024-07/13/2024 included orders for skilled nurse visits 2 times a week for 9 weeks with 5 PRN (as needed) and medical social work visits 2 times a month for 2 months, 1 time a month for 1 month with 5 PRN. Clinical record review revealed that a chaplain [spiritual] assessment was not conducted. Further review revealed that there was no documentation of the patient refusing chaplain visits. 2. Patient #6 was admitted on 02/05/2025 with a diagnosis of age-related physical disability. The plan of care for 02/05/2025-05/05/2025 included orders for skilled nurse visits 3 times a week for 13 weeks, 1 time a week for 1 week with 5 PRN and medical social work visits 2 times a month for 2 months, 1 time a month for 1 month with 5 PRN. Clinical record review revealed that a chaplain [spiritual] assessment was not conducted. Further review revealed that there was no documentation of the patient refusing chaplain visits. An interview conducted on 03/18/2025 at approximately 4:30 PM with the chaplain revealed that initial chaplain [spiritual] assessments are conducted as assigned by the scheduler. An interview with the agency director on 03/17/2025 at approximately 1:15 PM revealed that if a patient refuses it should be documented in the clinical record.”