Petersburg Medical Center Home

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on record review, observation, and interview, the agency failed to ensure the plan of care (POC) included all supplies and equipment required and all medication and treatments ordered for 1 of 3 home visits observed (#3). This failed practice had the potential to decrease the quality and safety of patient care. Findings Patient #3 Record review from 5/27-29/25 revealed a Start of Care (SOC) date of 3/31/25 and diagnosis of infection/inflammatory reaction due to internal right hip prosthesis. Included in the record was the Home Health Care Certification and Plan of Care for the Certification Period of 3/31/25 to 5/29/25 with a diagnosis of dependence on supplemental oxygen. Safety measures failed to include oxygen safety measures. Supplies failed to include a nasal cannula or oxygen tubing. Treatments/Orders and Medications failed to include oxygen use. Further review of a Physical Therapy Visit Note, dated 4/1/25 and signed by PT #1, revealed the following: “Oxygen saturation 96 percent at rest with oxygen...Pt on 2 L [liters] supplemental oxygen.” Further review of a Skilled Nurse Visit note, dated 4/4/25 and signed by LN #3, revealed the following note: “Patient denies pain, only slight SOB [shortness of breath] with exertion but doing well on 2 L oxygen via NC [nasal cannula].” Further review of a Skilled Nurse Visit note, dated 4/9/25 and signed by LN #2, revealed the following note: “Patient is on 2 LPM [liters per minute] via nasal cannula and oxygen was 94 % after walking from bedroom to living room.” Further review of a Skilled Nurse Visit note, dated 4/11/25 and signed by LN #3, revealed the following note: “Vitals stable on 2 L oxygen via NC.” Further review revealed a “Final Report” for Patient #3, dated 5/14/25 completed by the APRN (Advanced Practice RN). This report stated the patient was using a home oxygen concentrator. During an observation and concurrent interview on 5/27/25 at 1:00 PM, Patient #3’s home was observed to contain an oxygen concentrator. Patient #3 was not using the concentrator at this time. Patient #3 stated he/she was using the oxygen concentrator at night at times. During an interview on 5/29/25 at 3:48 PM, the Manager stated the oxygen use should be listed as an order and that the plan of care was not complete.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure complete clinical notes for 1 of 6 active records reviewed (#3). This failed practice had the potential to slow the patient’s progress toward healing. Findings Patient #3 Record review from 5/27-29/25 revealed a Start of Care (SOC) date of 3/31/25 and diagnosis of infection/inflammatory reaction due to internal right hip prosthesis. Included in the record was the Home Health Care Certification and Plan of Care for the Certification Period of 3/31/25 to 5/29/25 with orders for Skilled Nursing to assess and evaluate 3 times a week for 8 weeks and 6 visits as needed for wound care, assessments, change in condition, and medication management. The following skilled nurse visits failed to have complete wound measurements with a lack of height, width, and depth measurements of the Right Lower Torso/Decubitus/Pressure Ulcer Unstageable (This was a wound on the patient’s right side in the hip area caused by pressure. The wound bed in unstageable is unable to viewed.] Further review of the record revealed “RN SOC OASIS-E1,” (Registered Nurse Start of Care Outcome and Assessment Set or a comprehensive assessment tool to collect and report data on patients receiving skilled services) or a SOC nursing visit note, dated 3/31/25 and completed by Licensed Nurse (LN) #2. This document revealed, “Right Lower Torso/Decubitus/Pressure Ulcer Unstageable ... Tunneling/Undermining: 6 o’clock 1 cm[centimeter] Tunnel; 12-4 o’clock 0.5 cm undermining....” This note failed to have complete measurements of the wound including a lack of the height and width of the wound. Further review of the record revealed “Skilled Nursing Visit Note,” dated 4/1/25 and completed by LN #2. This note included these measurements of the Right Lower Torso Hip Pressure Ulcer: Tunneling/Undermining-Location/Size #1 60 o’clock 1 cm Tunnel, #2 12-3 o’clock 0.5 cm, undermine. There was a lack of height and width measurement. Wound care was completed. Further review of the record revealed “Skilled Nursing Visit Note,” dated 4/2/25 and completed by LN #2. This note failed to include measurements of the Right Lower Torso Hip Pressure Ulcer. Wound care was completed. Further review of the record revealed “Skilled Nursing Visit Note, dated 4/4/25 and completed by LN #2. This note failed to include measurements of the Right Lower Torso Hip Pressure Ulcer. Wound care did not occur. Further review of the record revealed “Skilled Nursing Visit Note,” dated 4/7/25 and completed by LN #2. This note failed to include measurements of the Right Lower Torso Hip Pressure Ulcer. Wound care was completed. Further review of the record revealed “Skilled Nursing Visit Note,” dated 4/9/25 and completed by LN #2. This note included depth measurements of the Right Lower Torso Hip Pressure Ulcer: “Tunneling/ undermining - Location/size #1 6 o’clock, 0.25 cm Tunnel.” There were no measurements of the height or width of the wound. Wound care completed. Further review of the record revealed “Skilled Nursing Visit Note,” dated 4/11/25 and completed by LN #3. This note failed to include measurements of the Right Lower Torso Hip Pressure Ulcer. Wound care completed. Further review of the record revealed “Skilled Nursing Visit Note,” dated 4/14/25 and completed by LN #2. This note failed to include measurements of the Right Lower Torso Hip Pressure Ulcer. Wound care completed. Further review of the record revealed “Skilled Nursing Visit Note,” dated 4/16/25 and completed by LN #2. This note failed to include measurements of the Right Lower Torso Hip Pressure Ulcer. Wound care completed. Further review of the record revealed “Skilled Nursing Visit Note,” dated 4/21/25 and completed by LN #3. This note failed to include measurements of the Right Lower Torso Hip Pressure Ulcer. Wound care completed. Further review of the record revealed “Skilled Nursing Visit Note,” dated 4/23/25 and completed by LN #2. This note failed to include measurements of the Right Lower Torso Hip Pressure Ulcer. Wound care completed. Further review of the record revealed “Skilled Nursing Visit Note,” dated 4/25/25 and completed by LN #2. This note included the following measurement: 12 o’clock 0.5 cm Tunnel. The narrative note revealed, “Wound is healing well. Wound is producing significantly less exudate and has new pink tissue filling in. Undermining is completely gone and tunneling is significantly less diameter and approximately 0.5 cm in depth.” The height and depth were not measured. Further review of the record revealed “Skilled Nursing Visit Note,” dated 4/28/25 and completed by LN #2. This note failed to include measurements of the Right Lower Torso Hip Pressure Ulcer. Wound care completed. Further review of the record revealed “Skilled Nursing Visit Note,” dated 4/30/25 and completed by LN #2. This note failed to include measurements of the Right Lower Torso Hip Pressure Ulcer. Wound care completed. Further review of the record revealed “Skilled Nursing Visit Note,” dated 5/2/25 and completed by LN #3. This note failed to include measurements of the Right Lower Torso Hip Pressure Ulcer. Wound care completed. Further review of the record revealed “Skilled Nursing Visit Note,” dated 5/5/25 and completed by LN #2. The note failed to include measurements of the Right Lower Torso Hip Pressure Ulcer. Wound care completed. Further review of the record revealed “RN ROC [resumption of care] OASIS-E1,” dated 5/8/25 and completed by LN #2. The note failed to include measurements of the Right Lower Torso Hip Pressure Ulcer. Further review of the record revealed “Skilled Nursing Visit Note,” dated 5/12/25 and completed by LN #3. The note failed to include measurements of the Right Lower Torso Hip Pressure Ulcer. Wound care completed. Further review of the record revealed “Skilled Nursing Visit Note,” dated 5/14/25 and completed by LN #2. The note failed to include measurements of the Right Lower Torso Hip Pressure Ulcer. Wound care completed. Further review of the record revealed “Skilled Nursing Visit Note,” dated 5/16/25 and completed by LN #2. The note failed to include measurements of the Right Lower Torso Hip Pressure Ulcer. Wound care completed. Further review of the record revealed “Skilled Nursing Visit Note,” dated 5/19/25 and completed by LN #2. The note failed to include measurements of the Right Lower Torso Hip Pressure Ulcer. Wound care completed. Further review of the record revealed “Skilled Nursing Visit Note,” dated 5/21/25 and completed by LN#2. The note failed to include measurements of the Right Lower Torso Hip Pressure Ulcer. Wound care was completed by LN #2. Further review of the record revealed “Wound Flowsheet,” for Patient #3 with no signature of which skilled professional had completed these measurements. An active wound on the right lower torso hip with a description of Decubitus/Pressure Ulcer/Unstageable was assessed on dates from 3/31-5/27/25. Wound measurements were blank for every visit completed. Under a section titled “Tunneling/Undermining” were measurements on the flowsheet for the dates of 3/31/25, 4/1/25, 4/9/25, and 4/25/25. These measurements failed to provide complete measurements. Complete measurements were not completed on the following dates: 4/2/25, 4/7/25, 4/14/25, 4/16/25, 4/18/25, 4/21/25, 4/23/25, 4/28/25, 4/30/25, 5/2/25, 5/5/25, 5/8/25, 5/12/25, 5/14/25, 5/16/25, 5/19/25, 5/21/25, and 5/27/25. During an interview on 5/29/25 at 9:45 AM, the Manager stated these wound care assessments were not acceptable and there was a plan in place to fix this error. Review of the agency policy “Home Health Standards of Client Care,” revised 1/2023, revealed, “3. Interventions are the activities performed by the professional during ongoing assessments. a. The patient will receive treatments, teaching, interventions, and assessments based upon the individuals Plan of Care [POC] which is a document signed by the physician and dated by the physician and serves as a physician order. b. Intervention documentation will be kept in the patient’s electronic medical record. 4. Evaluation of the patient’s POC incorporates the collection of data at each visit and the clinician collaboration and communication with the physician and other disciplines in changing the POC for the patient’s condition and response to interventions. a. Patients will receive care based upon the evaluation of his/her condition and response to the intervention by the professionals caring for the client. They will monitor and evaluate the quality and appropriateness of the care provided to each client.” Review of the agency policy “Home health Wound Assessment and Documentation,” revised 7/2023, revealed, “Wound Assessment and documentation at Petersburg Medical Center [PMC] Home Health Agency are necessary as a source of baseline, a cornerstone for plan of care, and progress measurement ...Wound Assessment and documentation will be done in the Electronic Medical Record [EMR]. Elements of wound documentation include: 1. Anatomical location a. Measurement of wound L[length] X W [width] X D [depth] in centimeters [cm] ... Measurements are taken following wound cleaning and debridement.””