Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 017025 (X3) Date Survey Completed 05/12/2022
Name of Provider or Supplier Saad Enterprises, Inc. Street Address, City, State 1515 University Blvd, South, Mobile, AL
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
E0000 Based on the recertification survey conducted on 5/12/22, Saad Healthcare was found to be in substantial compliance with the standards for Emergency Preparedness.
G0000 A recertification survey was conducted from 5/10/22 to 5/12/22 at Saad Healthcare and standard level deficiencies were cited.
G0444 State toll free HH telephone hotline
CFR(s): 484.50(c)(9)

Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs.


This ELEMENT is not met as evidenced by:
Based on review of Medical Records (MR), review of the Home Folder Packet, observations from Home Visits (HV), and interviews, it was determined the agency failed to ensure all patients were provided information for the State Hotline Number and grievance process.




This deficient practice affected 6 of 7 HV including HV # 1, HV # 2, HV # 3, HV # 4, HV # 5, HV # 7, and had the potential to affect all patients admitted to this agency.




Findings include:




Agency Policy: Home Folder




Provided to the surveyors on 5/12/22




Date: No date or number on policy




...The patient's home folder should contain the following:




1. Copies of the forms that are signed in the Electronic Medical Record:




a. Patient Bill of Rights - with attention to the Hotline number...




Agency patient form: Saad Healthcare Services.




Patient Disclosure and Notice; Patient's Consent; Patient's Bill of Rights and Responsibilities




Provided to the surveyors on 5/12/22




... C. Patient Bill of Rights (Saad Healthcare agrees to do the following in the performance of the healthcare services): Each person receiving care from Saad Healthcare shall have the right:




...12. To be informed of the State toll free Bureau of Licensure and Certification Hot Line...




















1. A copy of a current admission pack to be provided to patients on admission was provided to the surveyors on 5/10/22 at approximately 10:00 AM.




Review of the new admission pack revealed no statement of the State Hotline Number.




2. In home visits conducted on 5/10/22 and 5/11/22 on HV # 1, HV # 2, HV # 3, HV # 4, HV # 5, and HV # 7 revealed no documentation of the State Hotline Number in either of the patient's home health folders.




In an interview conducted on 5/12/22 at 11:10 AM, Employee Identifier (EI) # 8, Registered Nurse Supervisor, confirmed not all patients had the State Hotline Number in the home. EI # 8 stated the signature sheet with the State Hotline Number had been left out of the new admission packs.

























G0536 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 review of medical records (MR), facility policy, and interviews, it was determined the agency failed to ensure medication profiles were updated for all patients.




This affected 2 of 7 Home Visits (HV) conducted, and did affect HV # 1, HV # 6, and had the potential to affect all patients served by the agency.




Findings include:




Facility Policy: Medication Profile Process




Policy number: None listed




Date revised: 01/21




...Section 2: Policy




2.1 A Plan of Care with Medication Profile will be completed on every patient upon admission to the agency and verified with physician for accuracy. All disciplines with the exception to Home Health Aides will reconcile medications every visit and as needed for medication changes and updates...











2. HV # 6 was admitted to the agency on 3/10/22 with diagnoses including Essential (Primary) Hypertension and Acute Embolism and Thrombosis Unspecified Deep Veins of Unspecified Lower Extremity.




A HV was conducted on 5/11/22 at 9:40 AM to observe the SN (Skilled Nurse) provide care. During the visit, EI # 3, RN reviewed the medications with the patient, caregiver and surveyor and the following discrepancies were found:




Amlodipine 10 mg tablet daily listed on the CMR printed for the surveyor on 5/10/22 at 1:46 PM and per HV # 6 and the caregiver, was discontinued between July of 2021 and January of 2022 by "the Cancer doctor."




Lipitor 40 mg tablet daily at bedtime was listed on the CMR, but per HV # 6 and the caregiver, was discontinued March 21, 2022.




Magnesium Oxide 500 mg, one tablet twice daily found in the home and not on the CMR. The date on the bottle revealed October 20, 2021 and per HV # 6 and the caregiver, the medication was restarted about one month ago.




An interview conducted on 5/12/22 at 12:50 PM with EI # 9, Clinical Educator confirmed the medication profile was not updated per policy.







1. HV # 1 was admitted to the agency on 4/20/22 with diagnoses including Spinal Stenosis Lumbar Region without Neurogenic Claudication, and Muscle Spasm of Calf.




Review of the Home Health Certification and Plan of Care, dated 4/20/22 to 6/18/22, revealed orders for PT (Physical Therapy) 1WK (Week) 1, 2 WK 4, and OT (Occupational Therapy) effective 5/1/22, 2 WK 4.




A HV was conducted on 5/10/22 at 2:15 PM to observe care provided by EI # 5, Occupational Therapist. During the HV, the surveyor compared the current Client Medication Report (CMR), printed on 5/10/22 at 11:54 AM, with the medications in the home. The following discrepancy was observed:




Baclofen 10 mg (milligrams) tablet, 1 tablet, 3 times daily was listed on the CMR. The caregiver stated HV # 1 could not tolerate that dose, and the doctor's office had instructed to give 1/2 tablet, two times a day, on 5/1/22.




An interview was conducted on 5/12/22 at 12:54 PM with EI # 8, RN (Registered Nurse), Supervisor, who confirmed staff failed to update the medication profile.
G0578 Conformance with physician orders
CFR(s): 484.60(b)

Standard: Conformance with physician or allowed practitioner orders.


This STANDARD is not met as evidenced by:
Based on review of Medical Records (MR), Agency Policy and Procedure, and interviews, it was determined the agency failed to ensure the visit frequency was followed in 1 of 12 active records reviewed including MR # 6 and had the potential to affect all patients admitted to this agency.




Findings include:




Agency Policy: Missed/... Visits




Last Review and Revision: 02/2020




...Procedure:




4.1 If any discipline arrives at the home of a patient and cannot gain entry to the home, the following steps will be followed:




A. Attempt to reach the patient by telephone.




B. If this is not successful, contact the caregiver or contact person...




D. If all attempts to locate a patient are unsuccessful, the visit status will be changed to Rescheduled in the Electronic Medical Record and sent to the back office where the Scheduling Coordinator will be notified...








1. MR # 6 was admitted to the agency on 4/16/22 with diagnoses including Fistula of Intestine and Other Symptoms and Signs Concerning Food and Fluid Intake.






Review of the Home Health Certification and Plan of Care dated 4/16/22 revealed orders for Skilled Nurse (SN) 1 x a week x 9 weeks.






Review of the Client Coordination Note Reports (CCNR) dated 4/22/22 revealed documentation of a missed visit for 4/21/22.






Review of the CCNR dated 5/2/22 revealed documentation of a missed visit for 4/29/22.






There were no SN visit notes provided for the weeks of 4/17/22 and 4/24/22 and no other attempts documented to reschedule the visits.






Review of the CCNR dated 5/9/22 for the visit on 5/5/22 revealed “…Patient has non healing surgical wound to abdomen. Wound Vac (Vacuum) dressing in place…Patient reports noticing purulent drainage oozing from underneath Vac tape this am…Copious amounts of purulence under drape…”






There was no SN Visit Note Report provided for the 5/5/22 visit.






In an interview conducted on 5/12/22 at 1:10 PM, Employee Identifier (EI) # 10, Registered Nurse (RN), Supervisor, confirmed no other visits had been completed since admission on 4/16/22. EI # 10 stated MR # 6 was admitted to the hospital on 5/10/22 and was scheduled for a debridement of the wound.
G0580 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 review of agency policies and procedures, medical record (MR) reviews and staff interviews, it was determined the agency failed to ensure physician's orders were obtained prior to providing wound care.




This deficient practice affected 1 of 6 MR's reviewed with wounds and 1 of 3 MR's reviewed with PICC (Peripherally Inserted Central Catheter) including Home Visit (HV) # 6, MR # 6, and had the potential to affect all patients served by the agency.




Findings include:




Agency Policy:




Wound Care




Revised Date 4/18




2.5 Wound care protocols are by physician orders.




Agency Policy:




Physician Notification and Physician Orders




Date Revised: 3/18




Purpose / Objective




1.1 To ensure that the physician is notified of all changes in patient status and that all changes to the Plan of Care are addressed in a Physician Change Order and/or Coordination Note.




Procedure:




4.2 Reasons to obtain a New Order, or provider physician notification, will include but are not limited to the following:




c. New or Changed Wound Care Protocols.


2. MR # 6 was admitted to the agency on 4/16/22 with diagnoses including Fistula of Intestine and Other Symptoms and Signs Concerning Food and Fluid Intake.





Review of the HHC and POC dated 4/16/22 revealed no orders for the care and flushing of the PICC line.




Review of the VNR dated 4/16/22 revealed the nurse documented the PICC line "flushes easily". There was no documentation of what the PICC line was flushed with.




In an interview conducted on 5/12/22 at 1:10 PM, EI # 10, Registered Nurse, Supervisor, confirmed there was no order on 4/16/22, the day of admission, to flush the PICC line.















1. HV # 6 was admitted to the agency on 3/10/22 with diagnoses including Essential (Primary) Hypertension and Acute Embolism and Thrombosis of Unspecified Deep Veins of Unspecified Lower Extremity.




Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 3/10/22 to 5/8/22 revealed Skilled Nurse (SN) to observe and assess integumentary status to identify changes and intervene to minimize complications....SN to report significant changes in status to physician for early intervention.




Review of the Visit Note Report (VNR) by the SN dated 3/16/22 revealed, "New wound assessed to left calf. Wound care orders implemented....Image obtained....Instructed on materials used in wound care." There was no documentation the physician was contacted to inform him/her of the new wound and obtain wound orders for care and no documentation of what wound care and supplies were used in the care of the wound.




Review of the VNR by the SN dated 3/22/22 revealed, "Wound care completed to Left Calf using Clean technique and sterile supplies per MD orders". There was no documentation of physician orders for the wound care provided.




An interview conducted on 5/12/22 at 12:50 PM with Employee Identifier (EI) # 9, Clinical Educator confirmed the SN provided wound care on 3/16/22 and 3/22/22 without documented physician's orders.
G0682 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, facility policies and procedures, CDC (Centers for Disease Control and Prevention) Hand Hygiene Recommendations, and interviews, it was determined the facility failed to ensure staff:




1) Removed contaminated gloves and performed hand hygiene prior to cleaning non-disposable equipment.




2) Performed hand hygiene when performing wound care per agency policy.




This affected 3 of 7 Home Visits (HV) conducted, and did affect HV # 3, HV # 1, and HV # 5, and had the potential to affect all patients served by the agency.




Findings include:




Facility Policy: Hand Washing Indications




Policy number: 11160.20




Date revised: 01/22




Section 1: Purpose/ Objective




1.1 To prevent nosocomial infections.




...Section 2: Policy




2.1 All employees will follow CDC Hand Washing Recommendations...




Section 4: Procedure




...4.3. Employees should always sanitize their hands BEFORE and AFTER touching wounds.




4.4. Employees should sanitize theirs hands BEFORE and AFTER situations during which microbial contamination of hands is likely to occur, especially those involving contact with mucous membranes, blood or bodily fluids, secretions, or excretions.




Source: CDC Website




Topic: Hand Hygiene Recommendations Guidance for Healthcare Providers about Hand Hygiene and COVID-19




Updated: May 17, 2020



Hand Hygiene Guidance




The Core Infection Prevention and Control Practices for Safe Care Delivery in All Healthcare Settings recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) include the following strong recommendations for hand hygiene in healthcare settings.






Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications:






Immediately before touching a patient




Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices




Before moving from work on a soiled body site to a clean body site on the same patient




After touching a patient or the patient’s immediate environment




After contact with blood, body fluids, or contaminated surfaces




Immediately after glove removal


3. HV # 5 was admitted to the agency on 3/25/22 with diagnoses including Encounter for Surgical Aftercare Following Surgery of the Digestive System, Perforation of Intestine, and Peritoneal Abscess.




A HV was conducted on 5/10/22 3:05 PM to observe wound care provided by EI # 7, RN.




EI # 7 performed hand hygiene, donned gloves then removed the soiled surgical dressing from the abdomen. EI # 7 then applied wound cleanser to a clean 4 x 4 and cleaned the open wound site. EI # 7 then removed gloves and performed hand hygiene.




EI # 7 failed to remove gloves and perform hand hygiene after removing the soiled dressing.




In an interview conducted on 5/12/22 at 1:15 PM, EI # 8 confirmed the staff failed to follow agency policy for hand hygiene when performing wound care.













1. HV # 3 was admitted to the agency on 12/28/21 with diagnoses including Encounter for Attention to Gastrostomy, and Dysphagia Following Cerebral Infarction.




A HV was conducted on 5/10/22 at 12:30 PM to observe care provided by Employee Identifier (EI) # 6, HHA (Home Health Aide).




EI # 6 performed hand hygiene, donned gloves and checked HV # 3's blood pressure. Using the same gloves, EI # 6 cleaned the blood pressure cuff and stethoscope. Continuing with the same gloves, EI # 6 checked HV # 3's oxygen (O2) saturation, then cleaned the O2 monitor while wearing the same gloves. EI # 6 failed to remove contaminated gloves and perform hand hygiene prior to cleaning equipment used on HV # 3.




An interview was conducted on 5/12/22 at 11:41 AM with EI # 8, RN (Registered Nurse), Supervisor, who confirmed staff failed to remove gloves and perform hand hygiene prior to cleaning equipment.




2. HV # 1 was admitted to the agency on 4/20/22 with diagnoses including Spinal Stenosis Lumbar Region without Neurogenic Claudication, and Muscle Spasm of Calf.




A HV was conducted on 5/10/22 at 2:15 PM to observe care provided by EI # 5, Occupational Therapist.




EI # 5 performed hand hygiene, donned gloves, and checked HV # 1's blood pressure and pulse. Wearing the same gloves, EI # 5 cleaned the stethoscope and blood pressure cuff. EI # 5 failed to remove contaminated gloves and perform hand hygiene prior to cleaning equipment used on HV # 1.




An interview was conducted on 5/12/22 at 12:24 PM with EI # 8, who confirmed staff failed to remove gloves and perform hand hygiene prior to cleaning equipment.
G0706 Interdisciplinary assessment of the patient
CFR(s): 484.75(b)(1)

Ongoing interdisciplinary assessment of the patient;


This ELEMENT is not met as evidenced by:
Based on review of medical records (MR), agency policy, and interviews, it was determined the agency failed to ensure wounds were assessed and measured weekly per policy.




This deficient practice affected 2 of 6 MR of patients with wounds including Home Visit (HV) # 5, HV # 6, and had the potential to affect all patients with wounds.




Findings include:




Agency Policy: Wound Care




Last Review and Revision: 04/2018




...Policy




2.1 Wound measurements and photos are done on ... a weekly basis...




2.4 Wound assessments and reassessments will be completed on each skilled nursing visit.




...Documentation




5.1 Document ... length, width, and depth of wound. Include location and measurements of any undermining and/or tunneling...




















2. HV # 6 was admitted to the agency on 3/10/22 with diagnoses including Essential (Primary) Hypertension and Acute Embolism and Thrombosis Unspecified Deep Veins of Unspecified Lower Extremity.




Review of the HHC and POC orders dated 3/10/22 to 5/8/22 revealed a SN frequency of 1WK9 (one time per week for nine weeks)




Review of the SN VNR dated 3/16/22 revealed a new wound to the left lower calf and wound care orders implemented, but no documentation of a wound assessment or measurement.




Review of the SN VNR dated 3/22/22 revealed wound care completed to left calf using clean technique and sterile supplies per MD orders but no wound assessment or measurement was documented.




An interview conducted on 5/12/22 at 12:50 PM with EI # 9, Clinical Educator confirmed the wound was not assessed and measured per policy.







1. HV # 5 was admitted to the agency on 3/25/22 with diagnoses including Encounter for Surgical Aftercare Following Surgery on the Digestive System, Perforation of Intestine, and Peritoneal Abscess.




Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 3/25/22 revealed a Skilled Nurse (SN) frequency of 2 x a week x 2 weeks, 3 x a week x 2 weeks, then 1 x a week x 2 weeks.




Review of the SN Visit Note Reports (VNR) for the week of 4/3/22 including 4/4/22 and 4/6/22 revealed no documentation of weekly wound measurements.




In an interview conducted on 5/12/22 at 1:00 PM, Employee Identifier (EI) # 8, Registered Nurse (RN), Supervisor, confirmed wound measurements were not performed weekly per agency policy.



















G0714 Patient and caregiver education
CFR(s): 484.75(b)(5)

Patient and caregiver education;


This ELEMENT is not met as evidenced by:
Based on review of agency policy and procedure, medical record (MR) reviews and staff interviews, it was determined the agency failed to ensure patients and/or caregivers were educated on:




1. Wound care to include teaching with return demonstration.




2. Diabetes care to include blood glucose testing and insulin injections.




This deficient practice affected 2 of 6 records reviewed with wounds and did affect Home Visit (HV) # 6, MR # 10, and 1 of 3 records reviewed with a diagnosis of diabetes and did affect MR # 8, and had the potential to affect all patients served by the agency.




Findings include:




Agency Policy:




Oasis (Outcome and Assessment Information Set) Based Admission and Resumption of Care Assessments




Policy Revised Date: 1/20




Procedure:




4.4, c. Patient/Caregiver will provide and get a return demonstration of ALL procedures specified to be performed in the POC (Plan of Care) between the specified Skilled Nurse (SN) Frequency and documented in the EMR (Electronic Medical Record).








3. MR # 8 was admitted to the facility on 4/12/22 with diagnoses including Unspecified Fracture Right Patella, Subsequent for Open Fracture Type 3A/B/C with Routine Healing, and Unspecified Fracture Lower End of Right Tibia, Subsequent for Closed Fracture with Routine Healing.




Review of the HHC and POC dated 4/12/22 to 6/10/22 revealed a SN frequency of 1 WK 9.




Further review of the HHC and POC revealed orders for the SN for instructions/ reinforcement of diabetic care to include: ...blood glucose testing... and administration of insulin.




Further review of the HHC and POC revealed the following orders:




Skilled nurse for administration of SQ (Subcutaneous) insulin PRN (as needed).




Skilled nurse for instructions/ reinforcement of administration of prescribed insulin injection.




Review of the RN (Registered Nurse) Oasis Admission, dated 4/12/22, revealed no documentation the nurse obtained a return demonstration for blood glucose testing or administration of insulin from the patient or caregiver.




Review of the following 2 weeks VNR's, dated 4/19/22 and 4/26/22, revealed no documentation of return demonstration for blood glucose testing or administration of insulin.




An interview was conducted on 5/12/22 at 11:15 AM with EI # 9, who confirmed staff failed to document a return demonstration for blood glucose testing or insulin administration.






























2. MR # 10 was admitted to the agency on 4/25/22 with diagnoses including Pyogenic Arthritis, Methicillin Susceptable Staphylococcus Aureus, and Essential (Primary) Hypertension.




Review of the HHC and POC dated 4/25/22 revealed orders including SN 2 x a week for 1 week then 1 x a week for 8 weeks and SN to perform/teach wound care to incision/suture site located on right shoulder.




Further review of the HHC and POC dated 4/25/22 revealed orders for wound care including "cleanse with SNS, pat dry, apply Mepilex AG Foam, Cover with gauze...Patient to perform daily in the absence of SNV..."




Review of the SN VNR dated 4/25/22, 4/27/22, and 4/2/22 revealed no documentation of patient or caregiver teaching or return demonstration of wound care.




Review of the SN VNR dated 5/11/22 revealed MR # 10 was re-admitted to the hospital on 5/3/22.




In an interview conducted on 5/12/22 at 11:22 AM, EI # 8, Supervisor, confirmed there was no documentation of patient or caregiver teaching or return demonstration in either of the 3 visit notes.







1. HV # 6 was admitted to the agency on 3/10/22 with diagnoses including Essential (Primary) Hypertension and Acute Embolism and Thrombosis of Unspecified Deep Veins of Unspecified Lower Extremity.




Review of the Home Health Certification (HHC) and POC) dated 3/10/22 to 5/8/22 revealed a SN frequency of 1WK9 (Once per Week for Nine Weeks).




Review of the SN Visit Note Report (VNR) dated 3/16/22 revealed, "New wound assessed to left calf. Wound care orders implemented and instructions given to check the wound daily for signs of infection."




Review of the Physician Order dated 3/23/22 revealed SN to perform/teach wound care to left lateral mid lower extremity; using clean technique, cleanse with wound cleanser/SNS (Sterile Normal Saline), pat dry, apply foam island dressing.




Review of the SN VNR's dated 3/23/22 and 3/29/22 revealed wound care provided..."change dressing 3 times a week, CG (Caregiver) to perform WC (Wound Care) between nurse visit." There was no documentation of caregiver teaching with return demonstration.




Review of the Physician Order dated 4/5/22 revealed SN to perform/teach wound care to left lateral mid lower extremity; using clean technique, cleanse with wound cleanser/SNS, pat dry, apply medihoney to wound bed, cover with foam island dressing.




Review of the SN VNR's dated 4/5/22, 4/14/22, 4/27/22 and 5/4/22 revealed an on-going wound to the left calf and no documentation the SN had taught wound care with a return demonstration by the patient and/or caregiver.




Review of the HHC and POC dated 5/9/22 to 7/7/22 revealed SN frequency of 1WK9 and orders for skilled nurse to perform/teach wound care to left lateral mid lower extremity trauma superficial injury using clean technique as follows: Cleanse with wound cleanser/SNS, pat dry, apply medihoney to wound bed, and cover with foam island dressing. Wound care to be completed each visit. Wound care to be performed daily in the absence of the SN.




A home visit was conducted on 5/11/22 to observe the SN provide wound care to the left calf. During the visit the caregiver reported to the SN that he/she had only changed the dressing to the left calf one time since the patient has had the wound. The patient reported to the nurse that he/she does not change the dressing and the only time the dressing is changed is when the SN visits one time per week.




An interview conducted on 5/12/22 at 12:50 PM with Employee Identifier (EI) # 9, Clinical Educator confirmed the SN did not provide patient/caregiver teaching of wound care with a return demonstration per policy.
G0716 Preparing clinical notes
CFR(s): 484.75(b)(6)

Preparing clinical notes;


This ELEMENT is not met as evidenced by:
Based on review of agency policy, medical records (MR) and interviews, it was determined the agency failed to ensure medical record documentation was accurate and complete with all events, and treatments administered which included OASIS (Outcome and Assessment Information Set) documentation and …..




This affected 1 of 12 active MRs including MR # 9, and 1 of 4 discharge records including MR # 4, and had the potential to negatively affect all patients served by this agency.




Agency Policy: OASIS Based Admission and Resumption of Care Assessments




Last Review & Revision: 1/20




Section 2: Policy




2.3 A Start of Care/Resumption of Care Form Utilizing OASIS, will be completed by an RN/PT/ST (Registered Nurse/Physical Therapist/Speech Therapist) within 48 hours of referral or on the physician ordered start of care date (admission)...




Section 5: Documentation




5.1 Documentation on assessments for Start of Care... are to be complete and adequately describe the patients/client’s condition.





1. MR # 9 was admitted to the agency on 4/4/22 with diagnoses including Other Chronic Pain and Pain in Left Knee and Joints of Left Foot.




Review of the Transitional Care Worksheet revealed the referral date was 3/30/22.




Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 4/4/22 to 6/2/22 revealed, "PT: 2wk4,1wk1 (2 times a week for 4 weeks, then 1 time a week for 1 week).




Review of the PT OASIS Admission dated 4/4/22 revealed the PT documented "4/4/22" to the question, "Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA (Home Health Agency)". The PT failed to accurately document the date of referral, which was 3/30/22.




An interview was conducted on 5/12/22 at 10:58 AM with Employee Identifier (EI) # 8, RN Supervisor, who confirmed the referral date was 3/30/22 and the PT failed to accurately document the date of referral in the OASIS Start of Care Assessment as directed per agency policy.




2. MR # 4 was admitted to the agency on 9/15/21 with diagnoses including Unilateral Primary Osteoarthritis Right Knee and Presence of Right Artificial Knee Joint.




Review of the HHC and POC dated 9/15/21 to 11/13/21 revealed, "PT: 2wk1,3wk1,1wk1.




Review of the 9/29/21 PT Discharge From Agency Visit Note revealed, "Yes" to the question, "Has this patient been treated for a urinary tract infection (UTI) in the past 14 days?". There was no documentation in the medical record that MR # 4 had been treated for a UTI in the past 14 days.




An interview was conducted 5/12/22 at 12:38 PM with EI # 9, Clinical Educator, who stated MR # 4 had not been treated for a UTI in the past 14 days. EI # 9 confirmed the PT failed to accurately document in the MR per agency policy.
G0798 Home health aide assignments and duties
CFR(s): 484.80(g)(1)

Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist).


This STANDARD is not met as evidenced by:
Based on review of agency policy, medical record (MR) review and interview with staff it was determined the agency failed to ensure the Registered Nurse (RN) developed and maintained an individualized Home Health Aide (HHA) assignment to meet the needs of each patient.






This deficient practice affected 1 of 4 MR’s reviewed with HHA services and did affect MR # 11 and had the potential to negatively affect all patients receiving HHA services.






Findings include:






Agency Policy: Plan of Care/Description of Services/Health Care Finance Administration (HCFA) 485 and 487




Date Revised: 1/19




Purpose:




Section 1 Purpose/Objective




1.1 To provide… coordinated and comprehensive format that addresses patient/client physical… needs.




1.2 To establish and maintain a measurable and quantifiable method of evaluating the care process.




Agency Policy: Section 2 Policy









2.1 On admission and recertification a Plan of Care (POC) shall be developed under the direction of the attending physician.




2.3 The POC will be individualized…




2.4 The POC will be updated and revised as needed.




1. MR # 11 was admitted to the agency on 4/7/2020 and recertified on 4/7/22 with diagnoses including Type 2 Diabetes Mellitus Without Complications and Unspecified Osteoarthritis, Unspecified Site.








Review of the Home Health Certification and Plan of Care dated 4/7/22 to 6/5/22 revealed the HHA was to visit once a week for eight weeks and provide HHA services for assistance with personal care and ADL's (Activities of Daily Living) secondary to functional limitation which prevent self-care.






Review of the physician’s order dated 11/24/2021 states, “skilled nurse (SN) to remove patient’s Foley catheter on Wednesday, December 1, 2021.”




Review of Aide Care Plan Report dated 4/7/2022 revealed routine catheter care at every visit and empty urinary drainage bag per patient request.




Review of the Aide Visit Note Reports dated 4/8/22, 4/13/22, 4/20/22 and 5/5/22 revealed the HHA documented catheter care and emptied urinary drainage bag each visit.




Review of the SN Visit Note Reports dated 4/13/22, 4/20/22, 4/27/22, and 5/9/22 revealed genitourinary system, "bladder incontinent". There were no indications the patient had a Foley catheter.






An Interview conducted on 5/12/22 at 11:30 AM with Employee Identifier (EI) # 8, Nurse Supervisor, confirmed the SN failed to update the aide care plan after removal of the Foley catheter.






G0800 Services provided by HH aide
CFR(s): 484.80(g)(2)

A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training.


This ELEMENT is not met as evidenced by:
Based on review of agency policies and procedures, medical record (MR) review and staff interview, it was determined the agency failed to ensure the Home Health Aide (HHA) provided care as ordered in the plan of care.




This deficient practice affected 2 of 4 MR’s reviewed receiving HHA services and did affect MR # 11, and HV (Home Visit) # 3, and had the potential to negatively affect all patients receiving HHA services.




Findings include:




Agency Policy: Home Health Aide




Date Revised: 1/21




Procedure:




The role of the HHA includes… The HHA is responsible for reporting any abnormal issues to the Clinical Supervisor at time of visit.




Agency Policy: Supervision for Home Health Aide




Date Revised: 3/20




Agency Policy: Section 2 Policy




2.1 All HHA shall … carry out assigned responsibilities …




Procedure:




Section 4: Procedure




4.5 The HHA Care Plan will be utilized by the Aide and maintained by the Nurse to ensure that the care provided follows an Established Plan of Care.




Agency Policy: Home Health Aide




Date Revised: 1/21




HHA is responsible for reporting any abnormal issues to the Clinical Supervisor at time of visit.


2. HV # 3 was admitted to the agency on 12/28/21, and recertified for care 4/27/22 to 6/25/22, with diagnoses including Encounter for Attention to Gastrostomy, and Dysphagia Following Cerebral Infarction.




Review of the Home Health Certification and Plan of Care dated 4/27/22 to 6/25/22 revealed a HHA effective 5/1/22, 1 WK (Week) 7.




Review of the Aide Plan of Care, effective date 4/27/22, included orders for perineal care, every visit.




A HV was conducted on 5/10/22 at 12:30 PM to observe care provided by EI # 6, HHA. During the visit, the CG stated she/he had recently changed the patient's briefs. EI # 6 did not perform perineal care.




Review of the Aide Visit Note dated 5/10/21 revealed the aide documented the following for perineal care, "N" (No) CG (caregiver) changed briefs and washed perineal and bottom areas." There was no documentation the aide notified the nurse of tasks not performed, per policy.




An interview was conducted on 5/12/22 at 8:14 AM with EI # 1, Director of Nursing, who confirmed the aide failed to notify the nurse of tasks not completed.





















1. MR # 11 was admitted on 4/7/2020 and recertified on 4/7/22 with diagnoses including Type 2 Diabetes Mellitus Without Complications and Unspecified Osteoarthritis, Unspecified Site.




Review of the Home Health Certification and Plan of Care dated 4/7/22 to 6/5/22 revealed orders for HHA services once a week for eight weeks and to provide assistance with personal care and Activity of Daily Living (ADL)…




Review of the Aide Care Plan report dated 4/7/22 revealed orders of Foley catheter care every visit and empty urinary drainage bag per patient request.




Review of the aide visit note reports dated 4/8/22, 4/13/22, 4/20/22 and 5/5/22 revealed Foley catheter care and empty urinary drainage bag was completed.




Review of the Skill Nurse (SN) Visit Note Reports dated 4/13/22, 4/20/22, 4/27/22 and 5/9/22 revealed there was no documentation that the patient had a Foley catheter.




An Interview conducted on 5/12/22 at 11:30 AM with Employee Identifier (EI) # 8, Registered Nurse Supervisor confirmed the HHA failed to notify the nurse MR # 11 did not have a Foley catheter. EI # 8 also confirmed the HHA documented incorrectly that Foley catheter care was provided, and urinary drainage bag was emptied.