Elite Health Care Services, LLC

“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 Home Health Agency (HHA) failed to follow the written Plan of Care (POC) for one of 7 sampled patients (Patient 6), when Patient 6 did not receive wound care to her surgical incisions and right leg every visit as documented in the POC. This failure resulted in Patient 6 not receiving the care and treatment ordered by the physician and placed Patient 6 at risk for infection and decline in her health status. A review of Patient 6’s clinical record indicated a SOC (start of care) date of 6/10/26 with a primary diagnosis for aftercare for abdominal surgeries. A review of Patient 6’s POC for the certification period from 6/10/26 through 8/8/26 included physician order for SN (skilled nursing) visits twice a week for three weeks and then once a week for 6 weeks. The POC directed SN to observe Patient 6’s all body systems, focusing on integumentary (skin and everything that protects the outside of person’s body). The POC indicated, “SN for medication and disease process teaching and wound care…Skilled nursing to provide the following wound care: mid line abdominal wound: using standard precautions, cleanse with normal saline [sterile salt water, used for wounds because it is gentle on body tissues], gently pat dry, place sterile gauge, and secure with tape every visit. SN to cleanse RLE [right lower extremity] skin tear with normal saline, apply antibiotic ointment as needed, leave open to air every visit.” The POC indicated further, “Patient’s [Patient 6] wounds will remain free of infection and heal properly by utilizing good wound care management/infection control practices [providing the right treatment to help wounds heal while preventing infection and other complications]. A review of OASIS (Outcome and Assessment Information Set- a detailed assessment that nurses complete to describe patient’s health and care needs), completed 6/15/26 indicated that Patient 6’s surgical incision (operation site) on lower mid abdomen was measured as 5 cm (centimeter, unit of measurement) in length, 0.3 cm wide, and 0.1 cm deep. The assessment indicated the wound had a small amount of serosanguineous (light pink watery fluid that contain a small amount of blood) drainage. The assessment indicated that Patient 6 also had a small surgical incision on her left lower abdomen and a skin tear on right lower leg. A review of the clinical record indicated Patient 6 was seen by SN twice a week as ordered, including 6/12, 6/16, 6/19, 6/23, 6/26, and 6/30/26 visits. There was no documented evidence SN assessed Patient 6’s surgical wounds and right leg skin tear during above visits. There was no documented evidence SN provided wound care to surgical incisions and skin tear as ordered by physician and documented in POC. During a concurrent interview and record review on 7/15/26 at 11:40 a.m., Patient 6’s POC and physician orders for wounds were reviewed with the agency’s administrator (ADM, a nurse by profession). The ADM acknowledged that Patient 6 was admitted with physician orders for care of two surgical wounds on her abdomen and skin tear to right lower leg. The ADM validated that ordered treatments for Patient 6’s abdominal surgical wounds were not provided during SN visits for the first three weeks of service, including 6/12, 6/16, 6/19, 6/23, 6/26 and 6/30/26 visits. The ADM was not able to find any documented evidence that SN applied antibiotic ointment to Patient 6’s right lower leg skin tear as prescribed since the SOC. The ADM stated the expectation was for SN to follow physician orders and POC, assess patient’s wounds every visit, provide ordered treatment and care, accurately document the wounds assessment and upload the assessments into the patient’s clinical record. The ADM stated that it was important to have accurate assessment and documentation to see if there was a progress with wound healing or any complications. A review of the agency’s policy and procedure (P&P) titled, “Care Planning Process,” revised 11/2021, indicated, “Purpose: To provide clinical direction to the clinicians providing care…Services to be provided will be based on the prioritized needs of the patient. Each patient will be monitored for his/her response to care and services provided against established patient goals.” A review of the agency’s P&P titled, “Clinical Services Data Collection,” dated 11/2021 indicated, “Documentation in a clinicals/service record will be timely, detailed, accurate, and reflect the care/services provided…Entries to the clinical/service record will be clear, concise, and specific statements of fact…The clinical/service note will include…What care/service was provided…Treatment…Performed.””

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to ensure the pressure wounds (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) for one of 7 sampled patients (Patient 5) was documented accurately. This failure had the potential for Patient 5 to not receive the appropriate wound care. A review of Patient 5’s clinical record indicated a Start of Care (SOC) on 8/10/25 with diagnoses including type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing). A review Patient 5’s Nursing Progress Note dated 2/18/26 indicated, “…[Patient 5] has new areas on pressure to both buttocks…Areas of skin injury include pressure ulcers Stage 2 [partial-thickness loss of skin, presenting as a shallow open sore or wound) that show signs of progressing towards DTIs [Deep Tissue Injury- presents as localized purple or maroon area of discolored skin due to damage of underlying soft tissue from pressure and/or shear).” A review of Patient 5’s Wound Care Worksheet on 2/18/26, 2/27/26, 3/6/26, 3/13/26, and 3/18/26 indicated Stage 2 pressure ulcer on the left and right buttocks. The wound status on both buttocks indicated “Closed”, and the wound measurements indicated “Undefined”. A review of Patient 5’s Nursing Progress Note dated 3/25/26 indicated, “….[Patient 5] previous skin injuries as Stage 2 can be described as Stage 1 [intact skin with a localized area of redness and/or changes in sensation, temperature, or firmness] pressure injuries on the buttocks. The injuries are intact, non-blanchable [redness on the skin does not fade when pressed], with dark skin discoloration…Apply Calmoseptin [sic, moisture barrier used to protect and soothe irritated skin] to the Stage 1 wounds.” A review of Patient 5’s Wound Care Worksheet on 3/25/26, 4/3/26, 4/10/26, 4/16/26, 4/22/26, 4/29/26, 5/7/26, 5/12/26, 5/20/26, and 5/29/26 indicated Stage 1 pressure ulcer on the left and right buttocks. The wound status indicated “intact”, and the wound measurements indicated “Diffuse [spreads over a large area]”. During a concurrent interview and record review on 7/15/26 starting at 1:43 p.m. with the Licensed Nurse 2 (LN 2), Patient 5’s wound documentation was reviewed. The LN 2 stated Patient 5’s wound note on 2/18/26 indicated Patient 5 had stage 2 on both buttocks. The LN 2 described the area as skin almost breaking down and some parts had dark discoloration. The LN 2 further stated on 3/25/26 Patient 5’s wound note indicated the wounds on both buttocks were stage 1. The LN 2 added she cannot downgrade a wound from stage 2 to stage 1, she should have written the wound appeared like stage 1 instead of changing the stage of the wounds. During an interview on 7/16/26 at 10:40 a.m. with the Administrator (ADM), the ADM stated her expectation was for the licensed nurse to document accurately. A review of the HHA’s policy and procedure revised November 2021 and titled, “CLINICAL/SERVICE DATA COLLECTION” indicated, “…Documentation in the clinical/service record will be…accurate…the record…will be reviewed and updated as necessary.””