Sterling Medcare Home Health Inc.

“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 individualized plan of care included complete orders for interventions or treatments, in 1 of 1 patients receiving Foley (urinary) catheter care (Patient #5). Findings include: 1. The clinical record for Patient #2 was reviewed on 4/25/25. The plan of care for the certification period dated 3/6/25 to 5/4/25 revealed a start of care date of 3/11/24; diagnoses included encounter for fitting and adjustment of urinary device, presence of urogenital implants, multiple sclerosis, acute kidney failure, anemia, neuromuscular dysfunction of bladder and personal history of urinary tract infections. Plan of care orders include skilled nursing (SN) services once monthly for three months to perform straight catheter procedure and measure and record residual once a month and as needed. a) The agency failed to ensure the plan of care included complete Foley (urinary) catheter orders. Review of the plan of care dated 3/6/25 to 5/4/25 revealed orders for SN to assess genitourinary status, instruct patient on indwelling catheter self-management and using aseptic technique, perform/teach patient to perform straight catheter procedure once a month and as needed and to measure residual and record. However, the catheter care orders did not include the size of the catheter to be used, what size balloon and how to secure it. Review of the physician orders, dated 2/29/24, showed “Please change catheter once monthly w/16 Fr coude” (16 French (Fr) refers to the catheter’s diameter and “coude” refers to the type of catheter used). During an interview on 4/28/25 at 3:52 p.m. Registered Nurse (RN) #5 stated she typically documented the frequency of catheter changes and the type of catheter used on the plan of care. She further stated she should document the balloon size, but didn’t. RN #5 confirmed the plan of care for Patient #5 did not contain any information on the type of catheter used, the tube or balloon size or any indication of how the catheter was to be secured and stated information like that was usually relayed verbally from clinician to clinician and that was how she remembered receiving the information from the patient’s previous nurse. During an interview on 4/29/25 at 10:54 a.m. the administrator and director of nursing (DON) stated the agency’s expectation for documentation of catheter orders on the plan of care would include the type and size of the catheter and the frequency of the catheter change. She stated the orders should be transcribed from the physician order to the plan of care and then to the nursing visit note. She confirmed the patient-specific catheter information was not documented on the plan of care for Patient #5.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on interviews and record reviews, the agency failed to ensure services and treatments were administered by agency staff only as ordered by a physician in 5 of 7 patient records reviewed (Patients #1, #2, #3, #6 and #7). This deficiency was cited previously during a federal recertification survey on 4/27/22. Although the agency corrected the deficiency, based on the findings below, the agency has not maintained compliance with this regulatory requirement. Findings include: A. The agency failed to ensure physician orders were received prior to the provision of care following the initial start of care assessment. 1. The clinical record for Patient #3 was reviewed on 4/25/25. The plan of care for the certification period dated 4/13/25 to 6/11/25 revealed a start of care date of 4/13/25; diagnoses included encounter for change or removal of nonsurgical wound dressing, pressure ulcers multiple sites, right sided hemiplegia, polyneuropathy, radiculopathy, repeated falls, and dependence on wheelchair and supplemental oxygen. Plan of care orders included skilled nurse (SN) visits once weekly for one week, three times weekly for eight weeks and as needed (PRN) for pressure ulcer care to multiple areas using aseptic technique, wound care management based on physician orders and patient instruction on wound care performance and assess wound progression or decline. a) The agency failed to ensure the SN provided services only as ordered by the physician. Review of the plan of care for the certification period dated 4/13/25 to 6/11/25 revealed Patient #3 was to receive wound care three times weekly. Review of SN visit notes revealed RN #6 provided wound care on 4/15/25, 4/19/25, 4/21/25 and 4/23/25. The plan of care had not been signed to date and there was no evidence the agency received a verbal order from Patient #3’s physician establishing the plan of care and authorizing SN care and services following the start of care assessment completed on 4/13/25. During an interview on 4/28/25 at 2:41 p.m., the agency’s intake coordinator confirmed she was responsible for ensuring plans of care were signed by the physicians and the agency received verbal orders timely. She stated if the physician was local, she would often go to the physician’s office and receive a physical signature from the physician but if they were not local, she sent the plan of care via facsimile (fax) to be signed by the physician. She confirmed she was aware some of the plans of care were not being signed by the physician before services were rendered and stated “that’s how it’s always been.” During an interview on 4/29/25 at 10:51 a.m., the administrator/director of nursing (DON) stated the agency sometimes had a difficult time getting orders signed by physicians in a timely manner. She stated the agency believed having the referral order for the start of care was sufficient. She confirmed services were being provided to Patient #3 before the physician approved and authorized the plan of care and would work to change the agency’s process moving forward to ensure the agency demonstrated compliance and had physician approval for care and services. 2. Similar findings of services and treatments being provided to patients prior to the physician authorizing and approving the plan of care was found with Patients #1, #6 and #7. B. The agency failed to ensure wound care was provided only as ordered by the physician. 1. The clinical record for Patient #2 was reviewed on 4/25/25. The plan of care for the certification period dated 3/5/25 to 5/3/25 revealed a start of care date of 1/4/25; diagnoses included encounter for change or removal of nonsurgical wound dressing, venous insufficiency, type 2 diabetes mellitus, edema, lymphedema and unspecified moderate dementia. Plan of care orders included SN visits once weekly for one week, then twice weekly for eight weeks for wound care to bilateral lower extremity stasis ulcers. Wound care orders included “cleanse with wound cleanser, apply xeroform to wound beds, wrap with kerlix and coban 2x/wk [twice weekly] until healed.” a) The agency failed to ensure the SN provided wound care only as ordered by the physician. Review of the plan of care for the certification period dated 3/5/35 to 5/3/25 revealed wound care orders which included wound cleanser, xeroform, kerlix and coban. However, review of the SN visit note, dated 4/4/25, showed RN #5 documented “toe wound cleansed, dressed with neosporin and bandages at patient request.” The clinical record failed to reveal a physician’s order for the use of neosporin, a deviation from the established plan of care orders for wound care. During an interview on 4/25/25 at approximately 9:00 a.m., RN #5 confirmed she applied the neosporin because the patient requested it and she did not have a physician’s order to do so. During an interview on 4/29/25 at 10:53 a.m. the administrator/DON stated she was not aware RN #5 had deviated from the established wound care orders for Patient #2. She stated agency RNs should know they need to have an order for every treatment provided to the patient.”