Progressive Home Care - Auburn

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure the plan of care (POC) was followed regarding pain management for one of 18 sampled patients (Patient 8). This failure placed the patient at a potential risk for ineffective pain management. A review of Patient 8’s clinical record indicated the agency admitted her on 4/17/24, with multiple diagnoses including diabetes, heart failure and chest pain. A review of Patient 8’s plan of care for the certification period of 4/17/24 through 6/15/24 included skilled nursing (SN) visits twice a week for 2 weeks and once a week for 3 weeks and physical therapy visits once a week for one week and 2 times a week for 3 weeks. The POC indicated that Patient had functional limitations related to pain control. According to the POC, the clinicians were to assess/evaluate pain, assess the effectiveness of pain management including pain medications and alternative relief measures. The physician ordered acetaminophen 325 milligram (mg, unit of measurement) daily as needed for pain and ice pack to the right leg 3 to 5 times a day for 20 to 30 minutes. The clinicians were to instruct Patient 8 regarding pain control and management. The POC indicated the physician should be notified if Patient 8’s pain was not controlled. A review of SN visit note dated 4/19/24 indicated Patient 8 was assessed with right foot pain, rated at 3 out of 10. The SN documented that Patient 8 experienced intermittent aching pain which impacted patient’s mobility. The SN documented, “Pt [patient] is having difficulty due to pain and the current pain medication is not quite effective per [caregiver]…SN called [hospital name] …requested for Norco [stronger pain medication] for pain management.” A review of Patient 8’s clinical records indicated there was no new order or other interventions implemented for pain management after 4/19/24 SN visit. A review of a physical therapy visit note dated 4/23/24 indicated that there was no change in Patient 8’s medication regimen. The PT documented that Patient 8 was experiencing dull and aching right ankle pain which was worse with patient’s movement and walking. During an interview and a concurrent record review with Director of Patient Care Services (DPCS) on 4/24/24 at 2:45 p.m., the DPCS validated that there was no follow up with physician regarding Patient 8’s pain management. The DPCS was not able to find any records that Patient 8 had any new medication or other interventions added to ensure effective pain management. A review of the agency’s policy titled, “Pain Assessment,” dated 12/2018, indicated that pain assessments will be documented in the clinical records. The policy indicated, “Pain assessments will be…documented to facilitate regular reassessment and follow up by clinicians.””

“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 observation, interview, and record review, the Home Health Agency (HHA) failed to provide accurate medication profiles for 3 of 18 sampled patients (Patient 4, Patient 5, and Patient 19) when the patients’ medication profiles did not reflect the medications they were currently taking. This failure had the potential for adverse effects including harmful medication interactions, missed medications, and ineffective medication outcomes. 2. A review of Patient 5’s Plan of Care (POC) for certification period 4/12/24 to 6/10/24, indicated Patient 5 was admitted to the HHA with Start of Care (SOC) date of 4/12/24 for diagnosis of left total knee arthroplasty (replacement of knee joint). A review Patient 5’s POC further indicated visit frequencies: “...Active...PT [Physical Therapist] /PTA [Physical Therapy Assistant]: 2 x [times] week for 2 weeks starting 04/14/2024 (week 2) ...Completed or Discontinued PT/PTA: 1 x week for 1 week starting 04/12/2024 (week 1) ...” A review of Patient 5’s “Medication Profile,” dated 4/12/24, indicated an order for Citalopram Hydrobromide [brand name Celexa], 10 milligram tablets to be taken 1 tablet daily for pain. A review of Patient 5’s “Physical Therapy Visit Note,” dated 4/24/24, indicated “...Patient/spouse have his Celexa supply in an unlabeled bottle and the cut half pieces in an old zoloft [brand name antidepressant medication for Sertraline] rx [prescription] bottle...” During a concurrent observation and interview on 4/24/24 at 9:55 a.m. with Patient 5’s family member and Physical Therapist (PT) 2 during a home visit, PT 2 stated medications were reconciled on the SOC visit, and he received a hand off report from the PT who opened the case. PT 2 stated at each visit medication bottles are reviewed, and patient is asked if there are any new medications. Patient 5’s family member provided a medication bottle containing half a tablet labeled “Sertraline [brand name Zoloft] 25 mg [milligrams] tablet... Take 1 tablet daily...” Patient 5’s family member stated she was not sure that was the correct label. Patient 5’s family member then provided another unlabeled medication bottle containing the same tablets. Patient 5’s family member stated she was not sure what medications were in the bottles, but Patient 5 takes half a tablet two times a day. During a subsequent interview on 4/24/24 at 11:12 a.m. with PT 2, PT 2 acknowledged that Zoloft was not on Patient 5’s “Medication Profile” and it was unclear what medication the unlabeled bottle contained. PT 2 stated the process is to go through medications at each visit. PT 2 stated he picked up the case after the initial SOC by another PT. PT 2 confirmed that the bottle of medication labeled Zoloft and the unlabeled medication bottle did not match Patient 5’s “Medication Profile.” PT 2 also acknowledged that Patient 5’s “Medication Profile” indicated patient was taking Celexa, but Patient 5 did not have a bottle labeled with Celexa in the home. PT 2 acknowledged that the discrepancy between the Celexa, Zoloft, and the “Medication Profile,” was missed on the SOC visit and on subsequent visits. A review of Patient 19’s POC for certification period 3/21/24 to 5/10/24, indicated Patient 19 was admitted to the HHA with SOC date 3/21/24 for lacerations (deep cut in the skin) of right and left lower leg. A review of Patient 19’s POC further indicated visit frequencies “...Active RN [Registered Nurse] /LVN [Licensed Vocational Nurse]: 3 x week for 4 weeks starting 03/24/2024 (week 2) ...Completed or Discontinued RN/LVN: 2 x week for 1 week starting 03/21/2024 (week 1) ...” A review of Patient 19’s “Medication Profile,” dated 3/21/24, indicated an order for Aprixiban (Eliquis) 1 tablet 2.5 mg be taken daily to treat and prevent blood clots. The “Medication Profile” did not reflect an order for Atorvastatin (Lipitor). During a concurrent observation and interview on 4/24/24 at 11:32 a.m. with Patient 19 and Skilled Nurse (SN) 2 during a home visit, observed medication bottle labeled “Atorvastatin Calcium Generic for Lipitor 40 mg tabs [tablets] Take 1 tablet by mouth every day.” Also observed medication bottle labeled “Eliquis tab 2.5mg Take 1 tablet twice a day.” Patient 19 confirmed that these medications were long- standing medications and she was currently taking them according to the instructions on the label. SN 2 acknowledged that Patient 19’s “Medication Profile” did not reflect the Lipitor and the “Medication Profile” had incorrect administration frequency instruction for Eliquis. SN 2 stated medications are reconciled once a week. SN 2 then stated, “Should have been caught at the beginning by nursing.” During an interview on 4/24/24 at 2:16 p.m. with the Director of Patient Care Service (DPCS), reviewed with the DPCS the inaccurate “Medication Profiles” for Patient 5 and Patient 19. The DPCS stated, “Should have been clarified at the beginning. Should have been followed up.” The DPCS further stated, “Ideally medications should be reconciled every visit or, at the minimum, at least weekly.” A review of the HHA Policy and Procedure (P&P) titled “Medication Profile,” revised 12/18, indicated “...Patients receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications, new, and/or discontinued medications...Upon admission to the organization, the admitting clinician will initiate a medication profile to document the current medication regimen, including name, dose, strength, route, frequency, date and time of administration...A drug regimen review will be performed at the time of admission...During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver as well as other clinicians understand the medication regimen...” Findings: 1. Patient 4 had a Start of Care (SOC) date on 4/16/24 with diagnoses that included aftercare for total knee replacement surgery. During the home visit on 4/24/24 starting at 2:25 p.m., the Physical Therapy Assistant 1 (PTA 1) performed medication reconciliation for the patient’s medications with the medication profile and noted the following discrepancies: a. Medication profile included Albuterol-Budesonide and Ciclesonide for lung problem and Polyethylene Glycol for constipation that were not in use. b. Medication profile did not include supplements and vitamins such as fish oil, Calcium, Vitamin D3, Dynamic brain, and CoenzymeQ10 that were in use. Review of the Agency’s policy and procedure, revised December 2018, Medication Profile, stipulated, “Medication profiles will be updated for each change to reflect current medications, new, and/or discontinued medications.” Review of Patient 4’s care plan included a physician order, dated 4/16/24, for PT/PTA visit the patient two times per week for 3 weeks starting 4/16/24. In an interview on 4/24/24 at 3:25 p.m., PTA 1 acknowledged the discrepancies noted during the medication reconciliation. PTA 1 stated the agency policy was to ensure patient’s accurate medication profile for staff to conduct face-to-face medication reconciliation on each home visit. PTA 1 acknowledged that all prescription medications, over-the-counter medicines and supplements could interact and cause side effects that might lead to new symptoms or worsening existing symptoms. PTA 1 stated Patient 4’s medication profile was not updated and indicated face to face medication reconciliation should have been provided to accurately reflect the patient’s medication regimen. In an interview on 4/24/24 at 3:30 p.m., Patient 4 and the patient’s spouse both stated it was the first face-to-face medication reconciliation that the agency staff provided since the SOC. In an interview on 4/25/24 at 10:30 a.m. the Director of Patient Care Services (DPCS) stated it was the agency’s expectation for staff to reconcile the patient’s medication face-to-face, each visit to reflect the patient current medications accurately including vitamins and supplements.”

“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 interview and record review, the agency failed to ensure the plan of care (POC, a document which contains patient’s medical history, physician’s orders, clinical interventions and direction to clinicians providing direct patient care) developed for one of 18 sampled patients (Patient 17), was accurate and complete and reflected Patient 17’s diagnoses and accurate medication list. These failures had the potential for Patient 17 to not receive the care and treatment the patient needed and placed her at risk for health complications. A review of Patient 17’s clinical record indicated a start of care (SOC) date of 4/4/24. Resident 17’s clinical records contained a document titled “CONSULT TO HOME HEALTH” dated 3/31/24. The document included home health orders and the physician’s certification that the patient required home health services. The document listed the patient’s diagnoses, including a recent fall which resulted in the fracture of left thumb, diabetes, hypertensive kidney disease (a medical condition when high blood pressure caused damages to the kidneys), anemia (not having enough healthy red blood cells to carry oxygen), low oxygen levels in the patient’s blood and tissues, and obesity. A review of Patient 17’s plan of care for certification period of 4/4/24 through 6/2/24 included orders for services and treatment, activities, functional limitations, equipment required, and patient’s goals. The POC did not contain Patient 17’s diagnoses. A review of Patient 17’s POC included physician orders for SN (skilled nursing) visits for once a week starting the week of 4/4/24 and then two times a week. The POC indicated the skilled nurses were to “assess/instruct [Patient 17] on disease process…on medication regimen …medication management and compliance.” A review of SN visit note dated 4/18/24 indicated “medications [were] reconciled and there were no medication changes identified since the last visit. During a home visit observation on 4/24/24 at 8:30 a.m., Patient 17’s current medications were compared with the medication list on the agency’s provided POC. The medications listed on patient’s POC did not match the medications observed in Patient 17’s supply. The POC did not contain Amlodipine 2.5 milligram (mg, unit of measurement; medication to lower blood pressure), Lovastatin 20 mg (a medication used to treat high cholesterol), and Magnesium 250 mg (a mineral supplement). During an interview with Patient 17 on 4/24/24 at 8:45 a.m., the patient stated that lately she had been having issues with high blood pressure and her physician ordered Amlodipine a few weeks ago. Patient 17 stated she had been taking her cholesterol pill (Lovastatin) and magnesium for a long time. When Patient 17 was asked if clinicians assessed her medications during home visits, she stated, “Not every time, but they check here and there.” An interview and a concurrent record review of Patient 17’s clinical records were conducted with Director of Patient Care Services (DPCS) on 4/24/24 at 2:45 p.m. The DPCS acknowledged that the patient’s diagnoses were not listed on her POC. The DPCS explained that Patient 17’s POC should have her diagnoses listed upon initiating the plan of care and should have reflected all medications the patient was currently taking. The DPCS stated her expectation for all clinicians was to review medications with the patient during each visit and if the new medications were identified, the clinicians were expected to document the medications on resident’s POC and medication profile. A review of the facility’s ‘Care Planning Process’ policy dated 12/2018, indicated, “PURPOSE: To provide clinical direction to the clinicians providing direct patient care…At the time of the initial assessment, the clinician…will develop the patient plan of care…The patient-specific plan of care includes…Pertinent primary and secondary diagnoses…All medications and treatments.””

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the services provided for one of 18 sampled patients (Patient 16) were based on physician’s orders and the physician signed a plan of care (POC) in a timely manner as indicated in the agency’s policy. This failure resulted in Patient 16 receiving services and treatments not reviewed and not signed by the patient’s physician. A review of Patient 16’s clinical record indicated she was admitted to the agency on 7/30/23 with multiple diagnoses which included aftercare following right knee surgery, migraine, fibromyalgia (a chronic disorder characterized by pain, tenderness and fatigue throughout the body), and orthostatic hypotension (a drop in blood pressure when moving from a laying down to standing up position). A review of Patient 16’s plan of care for certification period from 7/30/23 through 9/27/23 indicated the physician orders for skilled nursing visits (SN) 2 times a week during the first two weeks of service and once a week for the following two weeks, for physical therapy (PT) 2 times a week for 3 weeks, and occupational therapy (OT) once a week for one week. A review of Patient 16’s visit calendar indicated the SN, PT, and OT visits were conducted from 7/30/23 until 8/18/23. Patient 16’s records indicated she was discharged from the agency on 8/18/23. Patient 16’s clinical record indicated the physician did not sign the POC which included all orders for services and treatments until 9/12/23, more than 3 weeks after Patient 16’s discharge. An interview and concurrent record review for Patient 16 was conducted with Director of Patient Care Services (DPCS) on 4/24/24 at 2:15 p.m. The DPCS validated that the physician did not sign the POC in a timely manner. The DPCS stated the clinician obtained telephone orders upon start of care for Patient 16 and confirmed that the services and treatments were not authenticated and not signed by the physician. The DPCS stated the timeframe for obtaining a physician’s signature on verbal or telephone orders was 30 days or earlier. A review of the agency’s ‘Verification of Physician Orders’ policy dated 12/2018 indicated the purpose of the policy was to ensure that accurate physician orders were obtained from a licensed physician before care was provided. Signed orders will be in clinical records within 30 days of initiation of care.””

“Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient’s updated comprehensive assessment, and contain information concerning the patient’s progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This Element is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure plan of care (POC) was revised for one of 18 sampled patients (Patient 3) when the physician’s orders for wound care were not updated. This failure resulted in the POC not reflecting the patient current health and care status and placed the patient at increased risk for inadequate care. Patient 3 had a Start of Care (SOC) of 1/19/24 and currently was in his second certification period started 3/19/24. The patient’s diagnoses included unspecified open wound to his right toes. Review of Patient 3’s POC included a physician’s wound care order, “Cleanse with Gentle soap and water, dry week (sic), Apply Isosorb to wound bed, Cover with gauze Secure with tape prn [as needed]; DC [Discontinue] when healed. Once wounds are resolved use lambs wool in between toes. Start Effective Date: 04/05/2024 Discontinued Date: 4/12/2024.” In the patient POC included Cedexomer Iodine (iodosorb) was discontinued on “02/01/2024.” During a home visit on 4/24/24 starting at 1 p.m., Skilled Nursing 1 (SN 1) assessed Patient 3’s wounds to the right toes and stated it was macerated between toes. SN 1 cleaned the wounds with soap and water and applied iodosorb, an antibacterial ointment, to the 4x4s (sterile gauze pad) and packed them between toes. SN 1 applied moisturizing cream to his right foot but did not secure the wound with tape while the wounds were not healed. SN 1 put a sock and then a soft boot to his right foot. In an interview and record review on 4/24/24 at 1:50 p.m., SN 1 stated the physician orders in the POC were for the 1st episode of care and it did not reflect the current physician’s orders. SN 1 stated iodosorb had been reinstated 4/12/24. Review of the agency’s policy and procedure, Care Planning Process, revised December 2018, stipulated the care plan was to provide clinical directions to the clinicians, therefore, the agency was to review and revise the POC at least every 60 days. In an interview on 4/25/24 at 10:30 a.m., the Director of Patient Care Services (DPCS) acknowledged Patient 3’s POC did not reflect the current care provided. The DPCS stated the new POC should have been created when the 2nd episode began so that clinicians knew how to take care of the patient appropriately.”

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure visit frequency was followed according to the Plan of Care (POC) when 4 of 18 sampled patients (Patient 7, Patient 14, Patient 18, and Patient 19) did not have documentation of missed visits. This failure had the potential for patients’ services to lack continuity of care if providers were not aware of services missed. 4. A review of Patient 18’s Plan of Care (POC) for the certification period from 3/11/24 to 5/9/24, indicated the start of care (SOC) was dated 3/11/24, with a diagnoses including surgical aftercare for a left foot abscess (occurs when an area of tissue becomes infected and the body’s immune system tries to fight and contain it). The POC included Skilled Nurse (SN) visits 3 times a week for 8 weeks starting 3/11/24 to preform wound care to Patient 18’s left heel. A review of Patient 18’s clinical record indicated the SN had missed 1 of 3 visits the week of 3/24/24 through 3/30/24, 1 of 3 visits the week of 4/7/24 through 4/13/24, and 1 of 3 visits the week of 4/14/24 through 4/20/24. During an interview and record review with the Director of Patient Care Services (DPCS) on 4/25/24 at 10 a.m., the DPCS verified Patient 18 had a total of 3 missed visits on 3/25/24, 4/8/24, and 4/19/24. The DPCS further verified the SN had not written any missed visit notes or physician notification regarding the missed visits. The DPCS stated, “It is my expectation regardless of reason that any missed visits should have a missed visit note and the physician notified.” Lastly, the DPCS stated, “A pattern of 3 or more missed visits, the nurse should have notified her as well.” A review of the agency’s policy titled, “Missed Visits” dated 12/2018 indicated, “Missed visits will be communicated to the clinical supervisor and the patient’s physician. A missed visit note will be documented in the clinical record.” Findings: 1. A review of Patient 19’s POC for certification period 3/21/24 to 5/10/24, indicated Patient 19 was admitted to the HHA with SOC date 3/21/24 for lacerations (deep cut in the skin) of right and left lower leg. A review of Patient 19’s POC further indicated visit frequencies “...Active RN [Registered Nurse]/LVN [Licensed Vocational Nurse]: 3 x week for 4 weeks starting 03/24/2024 (week 2) ...Completed or Discontinued RN/LVN: 2 x week for 1 week starting 03/21/2024 (week 1) ...” A review of Patient 19’s “Patient Schedule” for April 2024, indicated that Patient 19 had two missed visits on 4/3/24 and 4/12/24. A review of Patient 19’s “Skilled Nurse Visit Notes” in the clinical record did not reflect a “Missed Visit” note for 4/3/24 or 4/12/24. During an interview on 4/24/24 at 11:32 a.m. with Patient 19, Patient 19 stated she had two missed visits due to doctor’s appointments. During an interview and record review on 4/24/24 at 2:16 p.m. with the Director of Patient Care Services (DPCS), reviewed Patient 19’s “Patient Schedule” for April 2024 and “Skilled Nurse Visit Notes.” The DPCS confirmed missed visits for Patient 19 on 4/3/24/ and 4/12/24 and acknowledged that “Missed Visit” notes were not done. The DPCS stated, “Should have been documented and sent to the physician.” A review of the HHA Policy and Procedure (P&P) titled “Missed Visits,” revised 12/18, indicated “Purpose To ensure that missed visits are documented and does not affect the quality of patient care Policy Missed visits will be communicated to the clinical supervisor and the patient’s physician...Missed visits will be documented in the clinical record...Document in the patient’s clinical record the following information...Reason for the missed visit...Physician notification including date, time, physician name, method of notification and the staff reporting the information...” 2. Patient 14 had a start of care (SOC) date of 9/30/23 and diagnoses included stage two pressure ulcer of sacral region (an open wound that has broken through the top layer of skin and occurs when a bony prominence is subjected to prolonged pressure). A review of Patient 14’s Plan of Care (POC) for the certification period 9/30/23 to 11/28/23 indicated orders for skilled nurse (SN) visits three times a week for one week and two times a week for four weeks. A review of Patient 14’s clinical record on 4/25/24 indicated only two SN visits were made during the week of 10/1/23, instead of three as ordered. Patient 14’s clinical record revealed only one SN visit was made the week of 10/22/23, instead of 2 as ordered, and no SN visits were made after that visit until the patient was discharged on 11/24/23. In a concurrent interview and record review on 4/25/24 at 10:48 a.m. with the Director of Patient Care Services (DPCS), the DPCS confirmed there were only two SN visits made during the week of 10/1/23 instead of three as ordered, and only one SN visit was made during the week of 10/22/23, instead of two as ordered. The DPCS verified there were no visits made after 10/25/23 until Patient 14’s discharge. The DPCS confirmed there were no missed visit notes or documentation as to why the visits were missed and stated, “They [staff] don’t have any acceptable reasons for missing those visits.” During a review of the facility’s policy and procedure (P&P) titled, “Missed Visits,” revised 12/2018, the P&P indicated, “Missed visits will be communicated to the clinical supervisor and the patient’s physician. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record…D. The clinical supervisor will track the number and reasons for missed visits to assess patterns and to assure that the plans of care contain the correct number of planned visits.” 1. A review of Patient 7’s plan of care (POC) for certification period from 4/7/24 through 6/5/24 indicated she was admitted to the agency with multiple diagnoses which included fracture of the spine, chronic pain, and history of stroke. A review of Patient 7’s POC included orders for home health aide (HHA) one time a week for 3 weeks starting 4/12/24. The POC directed the HHA to assist Patient 7 with bathing and personal care for activities of daily living. A review of Patient 7’s visit calendar indicated there were no HHA visits completed from 4/12/24 through 4/23/24 and her clinical records had no missed visits documented. There was no documented evidence that the agency informed Patient 7’s physician of missed visits or attempted to reschedule the missed visits. During an interview and concurrent record review on 4/23/24 at 1:55 p.m., the Administrative Support (AS) validated that Patient 7 was scheduled to have HHA services the week of 4/12/24. The AS acknowledged that there were no HHA visit completed the week of 4/12/24 and no HHA visit scheduled for 4/17/24. The AS stated the HHA should have completed the missing visit notes and notified the physician of the reasons the visits were not made. The AS validated that Patient 7’s clinical record had no missed visits documented.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on interview and record review, the agency failed to furnish nursing services in accordance with physician order and as indicated in the plan of care (POC) for one of 18 sampled patients (Patient 16), when Patient 16’s orthostatic blood pressure was not obtained during each visit. This failure had the potential for the patient not to receive adequate care and delay her recovery. A review of Patient 16’s clinical record indicated she was admitted to the agency on 7/30/23 with multiple diagnoses which included aftercare following right knee surgery and orthostatic hypotension (a drop in blood pressure when moving from a laying down to standing up position). A review of Patient 16’s plan of care for certification period from 7/30/23 through 9/27/23 indicated the physician ordered skilled nursing visits (SN) two times a week during the first two weeks of service and once a week for the following two weeks. The POC indicated that the SN were to obtain orthostatic blood pressure at each visit. A review of Patient 16’s visit calendar and nursing visit notes indicated that the SN visits were completed on 8/4/23, 8/11/23, and 8/18/23. There was no documented evidence that Patient 16’s orthostatic blood pressure was obtained on 8/4/23, 8/11/23, and 8/18/23. During an interview and a concurrent record review with the Director of Patient Care Services (DPCS) on 4/24/24 at 2:45 p.m., the DPCS validated there was no documentation that Patient 16’s orthostatic blood pressure was obtained as ordered. A review of the agency’s ‘Care Planning Process’ policy dated 12/2018 indicated that the patient’s plan of care will be developed based upon the physician’s orders and will reflect the specific treatments and services to meet patient’s individualized needs. A review of the policy titled “Clinical Record Review,” dated 12/2018 indicated, “Clinical records will be reviewed on an ongoing basis for …Compliance with the established plan of care …The accuracy of clinical records …Adequacy of care to meet the patient’s needs.””

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to document the presence of wound and wound care treatment consistently for one of four sampled patients (Patient 1), when nurse’s visit notes did not reflect Patient 1’s Stage 1 Pressure Ulcer (alteration in intact skin color due to pressure) to the right heel. This failure had the potential to result in Patient 1’s pressure ulcer (PU) worsening, be infected and cause pain. Findings: A review of Patient 1’s Plan of Care (POC), for certification period 12/8/23 to 2/5/24, indicated Patient 1 had start of care date with the HHA on 12/8/23 for diagnoses including heart failure (heart does not pump blood as well as it should), chronic kidney disease (kidneys do not filter waste as they should) and diabetes (too much sugar in the blood). A review of Patient 1’s “OASIS [Outcome and Assessment Information Set- assessment tool used to plan care] Nurse Start of Care,” dated 12/8/23, indicated “...Skin Conditions/Integumentary [skin related]...No pressure ulcers but at risk...Wound(s) identified? No...) A review of Patient 1’s “OASIS Nurse Resumption of Care,” dated 12/20/23, indicated “...Skin Conditions/Integumentary...PU Stage 1 or above...Wound(s) identified? Yes...Wound #1 Location: Right heel...Stage: Stage 1 pressure injury...Length: 3.5 cm [centimeters] Width: 5 cm...Depth: 0 cm Undermining: None Tunneling: None...Wound Bed Tissue...Healthy...Assessment Summary...rehospitalized due to shortness of breath...diagnosed with pleural effusion...Patient has stage one pressure ulcer on his right heel, skilled nurse instructed patient to keep pressure of [sic] the area to prevent worsening of the pressure sore. Patient verbalized understanding. Daughter ordered boots for patient to help him keeping the weight off....” A review of Patient 1’s “Physician’s Order-Wound Care,” received 1/15/24, indicated “...Wound care for right heel stage 1 pressure ulcer...SN [skilled nurse[ Integumentary Interventions: Wound care to right heel skin ulcer. SN/ caregiver to paint the wound with betadine [topical antiseptic to protect from infection] twice daily or prn [as needed], cover with betadine soaked gauze and secure with dry gauze and tape...Wound/skin- Observation and skilled assessment of areas for possible breakdown: including heels...” A review of Patient 1’s “Skilled Nurse Visit Note(s),” dated 12/22/23, 12/27/23, 1/3/24, 1/6/24, and 1/8/24, indicated “...Integumentary...Wound(s) identified? No...” A review of Patient 1’s “Skilled Nurse Visit Note,” dated 1/13/24, indicated “...Integumentary...Wound(s) identified? No...Wound #1 Location: Right heel Type: Pressure Ulcer/Injury...Stage 1 pressure injury Length: 2.0 cm Width: 2.0 cm...Depth: 0 cm Undermining: None Tunneling: None...Wound Bed Tissue: Healthy...Wound Care Provided...Dressed with: Betadine paint Covered with: open to air...Patient instructed to use foam boots at home to keep pressure off...” A review of Patient 1’s “Skilled Nurse Visit Note,” dated 1/19/24, indicated “...Integumentary...Wound(s) identified? Yes...Wound #1 Location: Right heel Type: Pressure Ulcer/Injury...Stage: Stage 1 Pressure Injury Length: 2 cm Width: 2 cm...Depth: 0 cm...Wound Bed Color: Black Wound Bed Tissue: Healthy...Interventions/Education Provided...Instructed in materials used in wound care. However, even with proper treatment, a wound infection may occur. Check the wound daily for signs of infection like increased drainage or bleeding from the wound that won’t stop with direct pressure, redness in or around the wound, foul odor or pus coming from the wound, increased swelling around the wound and fever above 101.0 F [Fahrenheit] or shaking chills...” A review of Patient 1’s “Skilled Nurse Discharge/Transfer Summary (Visit},” dated 1/23/24, indicated “...Integumentary...Wound(s) identified? Yes Wound #1 Location: Right heel Type: Pressure Ulcer Stage: 1 Length: 2 cm Width: 2 cm...Depth: 0 cm Undermining: None Tunneling: None...Wound Bed Color: Black Wound Bed Tissue: Eschar...Wound Care Provided...Dressed with: Betadine paint...Skilled Care Provided This Visit...SN Integumentary Interventions: Wound care for right heel skin ulcer. SN/Caregiver to paint the wound with betadine twice daily or prn, cover with betadine soaked gauze and secure with dry gauze and tape...” During an interview on 3/7/24 at 11:38 a.m. with the Director of Patient Care Services (DPCS), the DPCS stated Patient 1 did not have any pressure ulcers when admitted to HHA on 12/8/23. Patient 1 returned to the hospital on 12/16/23 and was discharged from the hospital on 12/19/23. The nurse made a visit on 12/20/23 to resume home health services. A Stage 1 PU on right heel was identified. The DPCS, when asked if there should have been an order for wound care for right heel PU on 12/20/23, stated, “Not much to do except pressure relief, but there probably should have been some kind of order.” The DPCS stated wounds are assessed every visit and measured once a week. Reviewed “Skilled Nurse Visit Note(s)” dated 12/22/23, 12/27/23, 1/3/24, 1/6/24, and 1/8/24 with the DPCS. The DPCS acknowledged that the documentation did not reflect that Patient 1’s right heel PU had been identified or assessed during those visits. The DPCS stated, “May have been a mistake in not checking the ‘Wound(s) identified?’ yes or wound may have resolved and then returned. Unable to know from the charting.” Reviewed “Skilled Nurse Visit Note,” dated 1/13/24, with DPCS. The DPCS acknowledged that documentation indicated Patient 1’s right heel PU was dressed with betadine but did not receive physician’s order until 1/15/24. The DPCS stated, “Should have been an order.” Reviewed “Skilled Nurse Visit Note,” dated 1/19/24, with the DPCS. The DPCS acknowledged that the documentation for education to Patient 1 for wound care did not indicate it was to be done twice daily or as needed. During a telephone interview on 3/7/24 at 1:15 p.m. with SN, the SN stated she saw Patient 1 for all visits. The SN stated Patient 1 had Stage 1 PU on right heel, that was slightly black in color. The SN stated she instructed Patient 1’s caregiver to paint PU with betadine and to use foam boot for pressure relief. SN stated she obtained physician order to use betadine but did not recall the date. Reviewed Skilled Nurse Visit Note(s)” dated 12/22/23, 12/27/23, 1/3/24, 1/6/24, and 1/8/24, with the SN and the documentation that indicated “Wounds identified? no.” The SN stated, “If I did not do wound care, I may not have checked the box for wound present. If not treating wound then didn’t measure it. Should have checked the box even if no wound, even if no measurement or treatment. It was [a] mistake the “Wounds identified? was not marked yes.” Reviewed “Skilled Nurse Visit Note,” dated 1/19/24, with SN that education documentation did not indicate that caregiver was instructed that the betadine dressing was ordered two times a day or as needed. The SN stated, “May not have written in notes, but was instructed to do two times a day.” The SN stated she provided education and teaching to Patient 1’s caregiver at discharge from nursing services on 1/23/24. A review of the HHA Policy and Procedure (P&P) titled “Standards, Policies and Procedures Subject : Wound Care,” revised 6/28/23, “...Skilled Nurse will provide a patient specific wound care assessment that accurately reflects the patients current wound status and progress toward achievement of desired goals and outcomes...Each wound will have the Wound Care Orders listed separately...SN must address the wound at every visit on the SN nursing notes...””