St Peter's Health Home Health and Hospice

Findings include: - The agency failed to identify and monitor quality specific areas, including measures derived from OASIS, for improved patient outcomes, and failed to track and trend HH specific data for improved safety of services and quality of care provided.

Findings include: - The agency failed to ensure staff utilized appropriate infection control protocols for the use of PPE during the removal of a peripherally inserted midline IV catheter.

Findings include: - Failed to ensure skilled nursing staff utilized professional standards of care when removing a peripherally inserted midline intravenous catheter (See G984).

The agency failed to ensure all staff completed initial training on the agency's emergency preparedness policies and procedures.

The agency failed to encode and electronically transmit each completed OASIS assessment to the CMS system within 30 days of completing the assessment for 25 (#s 14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37, and 38) of 25 sub-sampled patients.

The agency failed to accurately encode a start of care OASIS assessment for pressure ulcers for 1 (#1); and failed to accurately encode a SOC OASIS for high-risk medications for 1 (#3) of 13 sampled patients.

The agency failed to ensure the provider was consulted to approve the delayed start of therapy services for occupational therapy (OT) as ordered on the referred plan of care for 2 (#s 1 and 5) of 13 sampled patients.

The agency failed to identify and monitor quality specific areas, including measures derived from OASIS, for improved patient outcomes; failed to track and trend HH specific data for improved safety of services and quality of care provided; and failed to have the frequency and detail of the data…

The agency failed to track patient adverse events and perform a root cause analysis for identification and implementation of interventions.

The agency's governing board failed to ensure the agency program was implemented and maintained based on the specific quality measures identified for improved patient outcomes specific to the agency . Findings include: During an interview on 5/6/26 at 12:40 p.m., staff member A stated she had not…

The agency failed to ensure staff utilized appropriate infection control protocols for the use of PPE during the removal of a peripherally inserted midline IV catheter.

The agency failed to maintain an agency program for the surveillance and investigation of infections and failed to ensure surveillance and investigation findings were included in the QAPI process.

The agency failed to ensure infection control education, training, and competencies were provided to skilled nursing staff to ensure staff adhered to infection prevention requirements for the removal of an indwelling peripherally inserted midline intravenous (IV) catheter for 1 (# M) of 1 sampled…

The agency failed to complete the initial evaluation assessment within 48 hours of receiving the referral for 1 (#8); failed to ensure the completion of the initial assessment within 48 hours of the original referral without requesting a different start of care to ensure compliance with the…

The agency failed to develop an individualized plan of care which included the ordered therapy services, the frequency and duration of visits, modality interventions, measurable outcomes, and goals for therapy services for 2 (#s 1 and 5); and failed to ensure the plan of care accurately reflected…

The agency failed to notify the physician of abnormal findings during a start of care evaluation for 1 (#11) of 13 sampled patients.

The agency failed to ensure skilled nursing staff utilized professional standards of care when removing a peripherally inserted midline intravenous (IV) catheter (a midline catheter is a flexible tube inserted into a peripheral vein in the upper arm, with the tip resting near the armpit.

The agency failed to develop and implement an emergency preparedness (EP) communications plan which includes contact information for federal, state, tribal, regional, or local emergency preparedness staff, and the State Licensing and Certification Agency.

The agency failed to accurately reflect the status of the referral on the SOC OASIS for 3 (#s 1, 2, and 3); failed to accurately reflect the status of an UTI on the Discharge OASIS for 1 (#1); and failed to accurately reflect the status of a pressure ulcer on the Discharge OASIS for 1 (#2) of 10…

The agency failed to provide patients with the toll-free HHA hotline phone number.

The agency failed ensure the RN completed a SOC assessment within 48-hours of receiving the referral for 2 (#s 3 and 10) of 10 sampled patients.

The agency failed to ensure PT completed the initial assessment visit within 48 hours of the physician referral; and did not obtain an order to change the patients start of care date to accommodate the availability of the agency for 3 (#s 2, 5, and 8) of 10 sampled patients.

The agency failed to ensure MSW services were provided for the patient as ordered by the physician for 1 (#4) of 10 sampled patients.

The agency failed to ensure the RN completed and documented onsite, supervisory visits of the LPN for 3 (#s 3, 4 and 6) of 10 sampled patients.