Sweetgrace Home Health Services, LLC

The facility failed to ensure they had a performance improvement project (PIP - a concentrated effort on a particular problem in one area of the facility or facility wide; it involves gathering information systematically to clarify issues or problems, and intervening for improvements) in progress…

The facility failed to ensure one Home Health Licensed Vocational Nurse 1 (HHLVN 1) followed infection control guidelines when he placed a clipboard directly on Patient 2’s dining room chair and his (HHLVN 1’s) personal glasses on the patients dining room table without the use of barriers.

The facility failed to ensure patients clinical records are stored in a locked, waterproof file cabinet in a designated clinical record room in accordance with the facility’s policies and procedures.

The facility failed to ensure for one of seven sampled patients (Patient 2) personal health information was kept confidential when the Home Health Licensed Vocational Nurse (HHLVN 1) took a photograph of Patient 2’s abdomen and upper body using HHLVN 1’s personal cell phone.

The facility failed to ensure a review of all medications the patient is taking was conducted (medication reconciliation) for one of three sampled patients (Patient 2), when there were discrepancies in the medications taken at home when compared to Patient 2’s medication profile (a comprehensive…

The agency failed to follow infection control guidelines when: 1. For Patient 3, a nursing supply bag was placed on the kitchen countertop without a barrier.

The agency’s failed to provide for one out of 10 sampled patients (Patient 1) an Outcome and Assessment Information Set (OASIS: a data collection tool used to collect and report assessment data)privacy notice when there was no OASIS privacy notice in Patient 1's admission packets.

The facility failed to ensure for one of 10 sampled patients (Patient 1) personal health information was kept confidential when the Home Health Licensed Vocational Nurse (HHLVN 1) took a photograph of Patient 1's right hip wound using HHLVN 1's personal cell phone.

The agency’s failed to implement their facilitating communication policy and procedure for one out of 10 sampled patients (Patient 1) when there was no information available in the admission packets on how to access auxiliary aids and language services.

The agency failed to identify the proper route of three (3) medications that a patient was taking for one of 10 sampled patients (Patient 10) when: Three medications that Patient 10 was taking were listed to be taken orally, the Plan of Care (a presentation of information that easily describes the…

The facility failed to ensure the Physical Therapy Evaluation and the Physical Therapy Discharge Summary was signed by the physician for one (1) of ten (10) sampled patients (Patient 7).

The agency failed to ensure the Skilled Nurse followed the frequency of visits on the plan of care for two (2) of 10 sampled patients (Patients 8 and 10) when: 1. For Patient 8, four Skilled Nurse (SN -either a Registered Nurse or Licensed Vocational Nurse- provides assessment and teaching, and…

The agency failed to provide supervised visits of the Licensed Vocational Nurse (LVN 1) by the Registered Nurse/Director of Nursing (RN2/DON) in the required 30 day time frame.

This Condition is not met as evidenced by : The agency failed to ensure that the Condition of Participation: E 0001 484.102 Establishment of the Emergency Program (EP) was in compliance as follows: 1. Based on interview and record review, the agency failed to develop and maintain an emergency…

The agency failed to ensure that the Condition of Participation: G 406 484.50: Patient rights was in compliance as follows: 1. Based on observation, interview, and record review, the agency failed to ensure patients' rights were protected when one of 10 sampled patients (Patient 1) with dementia (a…

The agency failed to ensure that the Condition of Participation: G 700 484.75: Skilled professional services was in compliance when: 1. Based on interview and record review, the agency failed to ensure the physician assessed and certified the need for continued home health services for three of 10…

The agency failed to develop and maintain an emergency preparedness communication plan that included contact information for Federal, State, tribal, regional, and local emergency preparedness staff, in a universe of 30 patients.

The agency failed to develop a back-up plan in the event of communications (phone service, including cellular phone and internet) failure during a disaster or emergency, in a universe of 30 patients.

The agency failed to provide training to all staff, as well as contracted staff, for the emergency preparedness policies and procedures and the emergency plan in a universe of 30 patients.

The agency failed to ensure the Outcome and Assessment Information Set (OASIS) data was completed accurately for one of 10 sample patients (Patient 8).

The agency failed to ensure patients' rights were protected when one of 10 sampled patients (Patient 1) with dementia (a disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) was not treated with respect and…

The agency failed to ensure patients' rights were protected when the state toll free home health telephone hot line, its contact information, hours of operation and its purpose to receive complaints was not provided to four of 10 sampled patients (Patients 1, 2, 3 and 4).

The agency failed to ensure a review of all medications the patients were taking was conducted for two of 10 sampled patients (Patients 2 and 3) when: 1. For Patient 2, one medication the patient was taking was not indicated on the medication profile and two medications on the medication profile…

The agency failed to ensure the physician assessed and certified the need for continued home health services for three of 10 sampled patients (Patients 1, 5 and 7).

The agency failed to follow physician's orders documented on the CMS 485 (a form provided by the Centers for Medicare and Medicaid Services-CMS-which documents a patient's plan of care and physician's orders) for two of 10 sampled patients (Patients 3 and 8) when: 1. For Patient 3, a physician's…

The agency failed to ensure it employed qualified personnel for 10 of 10 sampled patients (Patients 1, 2 , 3 4, 5, 6, 7, 8, 9, and 10) when: 1a.

The agency failed to ensure the clinical record contained required items for two of 10 sampled patients (Patients 1 and 3) when: 1. For Patient 1, four skilled nursing visit notes were not in the clinical record within 72 hours of the visit as indicated in the agency's policy and procedure.