Nursing Services Inc.

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on review of agency documentation, staff interviews and review of an agency policy, for one of one patients (Patient #2) in the survey sample, the agency nurses failed to perform necessary assessments. The findings include: Patient #2 had a start of care date of 09/15/2025 with diagnoses that included chronic kidney disease, congestive heart failure and type II diabetes. The physician’s orders for the certification period of 09/15/2025 to 11/13/2025 included nursing services once per week for nursing assessments, monitoring the Patient’s weight for a gain of five (5) pounds or more in one (1) week and blood glucose levels that were greater than 400 mg (milligrams/dl) or less than 50 mg/dl fasting or random. Review of Patient #2’s nursing visits notes for the months of September, October and November of 2025, failed to identify the nurses monitored the Patient’s weight on 09/24/2025 and 10/01/2025 and failed to monitor the Patient’s blood glucoses on 09/22/2025, 09/24/2025, 10/30/2025, 10/31/2025, 11/03/2025, 11/06/2025 and 11/13/2025. Interview and review of Patient #2’s clinical record with the Supervisor of Clinical Services on 12/04/2025 at 11:45 AM, identified the agency’s expectation was for the Patient’s weights and blood glucose to be monitored at each visit and documented within the patient’s clinical record.”

“Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA’s policies and procedures. This Standard is not met as evidenced by: Based on clinical record reviews, review of agency policies and interviews with agency personnel, for one of two patients (Patient #1) requiring nursing services for assessments and wound care, the agency failed to follow agency policies. The finding includes: a. Patient #1 was admitted to the home healthcare agency on 09/13/2023 with diagnosis that included type II diabetes mellites, dementia, and high blood pressure. The physician’s orders for the certification period of 11/12/2023 through 01/10/2024, included nursing services once per month for nursing assessments and blood glucose monitoring. Patient #1 was non-ambulatory, bed-bound, required a Hoyer lift (a mechanical lift used to transport patients from a chair to a bed or a bed to a chair) and ambulance transportation to all medical appointments. Additionally, Patient #1 had a twenty-four-hour live-in caregiver provided by a community-based program for the elderly. Review of Patient #1’s nurse’s note dated 12/13/2023, identified Registered Nurse (RN) #1 visited the Patient on 12/13/2023 for the once per month nursing visit. Patient #1’s live-in caregiver identified the Patient had developed a new wound to the coccyx in early December of 2023. RN #1 identified the wound appeared to be a stage III pressure ulcer to the coccyx (a full thickness tissue loss wound which may expose fat, but bone, muscle or tendon is not visible). Patient #1’s wound measured 3 centimeters (cm) in length, 2 cm in width and 0.25 cm in depth. The live-in caregiver was covering the wound with foam dressings daily. RN #1 requested new wound care orders and an antibiotic for a possible wound infection, but Patient #1’s primary healthcare provider declined to provide orders until the Patient was seen in the clinic for an assessment on 01/08/2024. Review of RN #1’s communication note dated 12/21/2024, identified Patient #1 had an appointment scheduled at a wound care clinic on 12/21/2023. RN #1 attempted to schedule an ambulance transport to the medical appointments but was informed by Patient #1’s case manager from the community-based program for the elderly that there was no mechanism to provide transportation for the Patient. RN #1 indicated she encouraged Patient #1’s responsible person to send the Patient to the emergency department on 12/13/2023 for a wound assessment and treatment, but the responsible person declined and agreed to send the Patient on 12/14/2023. Review of Patient #1’s nurse’s note dated 12/21/2023, identified the Patient was admitted to the hospital on 12/21/2023 for the assessment and treatment of the coccyx wound. Review of Patient #1’s hospital discharge summary dated 12/26/2023, identified the Patient arrived at the emergency department by ambulance on 12/21/2023 with an infected sacrococcygeal pressure ulceration which required surgical intervention (pressure ulceration staging or measurements of the wound were not documented in the discharge summary). Review of the hospital physician’s orders dated 12/26/2023, included cleaning the sacrococcygeal pressure ulceration with normal saline, applying a barrier cream to the wound edges, applying medi-honey calcium alginate (a honey based dressing used for moderate to heavily draining wounds) to the deep middle portion of the wound, filling the wound bed with gauze, applying a thin layer of triad paste (a zinc oxide based wound dressing that adheres to wet, eroded skin) to the left and right areas of the wound and covering the entire wound with a large foam dressing (the frequency of the wound care was not documented in the order). Patient #1 was prescribed an antibiotic Amoxicillin-Clavulanate 875-125 milligrams (mg) one tablet by mouth twice per day for five days, Eliquis (a medication used to treat and prevent blood clots) 5 mgs two tablets by mouth every twelve hours for six days then one tablet by mouth every twelve hours, Magnesium Oxide 400 mgs one tablet by mouth twice per day and Metoprolol Tartrate 25 mgs one tablet by mouth twice per day. Review of Patient #1’s start of care nurse’s note dated 12/27/2024, identified Patient #1 returned home on 12/26/2023 with the responsible person. RN #1 identified the Patient had an indwelling urinary catheter, was prescribed three new medications without refills, and could not attend scheduled medical appointments due to the lack of appropriate transportation. RN #1 indicated the sacrococcygeal pressure ulceration measured 6 cm in length, 5 cm in width and 2 cm in depth with a large amount of black eschar (dead tissue) surrounding the wound. RN #1 identified the Patient required an assessment by the home healthcare agency’s wound care certified nurse (RN #2) on 01/03/2024. Additionally, RN #1 identified the wound care would be performed by a nurse three times per week and a caregiver would perform the wound care once competence was demonstrated. RN #1 indicated care coordination occurred with the Patient’s healthcare provider, and Supervisor of Clinical Services (SCS) #1 but failed to document the details of the care coordination. Review of Patient #1’s clinical record, identified the Patient was seen by RN #1 on 12/28/2023, 12/30/2023 and 01/01/2024. On 12/30/2023, Patient #1’s sacrococcygeal pressure ulceration measured 6 cm in length, 5 cm in width and 2 cm in depth. Additionally, the 12/28/2023, 12/30/2023 and 01/01/2024 nurses’ notes failed to identify a caregiver was taught and returned demonstrated wound care to the sacrococcygeal pressure ulceration. Review of Patient #1’s nurse’s note dated 01/03/2024, identified RN #1 performed a joint visit with the wound care certified nurse (RN #2). RN #1 identified the Patient’s sacrococcygeal pressure ulcer measured 7 cm in length, 11 cm in width, and no depth due. RN #1 identified the wound was deteriorating from a persistent infection and could not be managed in the home setting. Patient #1 was transferred to the emergency room and admitted to the hospital on 01/03/2024. i. Interview with RN #1 on 01/23/2024 at 10:10 AM, identified visiting Patient #1 on 12/13/2023 for the monthly visit. Patient #1’s live-in caregiver identified the Patient developed a new wound to the coccyx in early December of 2023. The live-in caregiver covered the wound with foam dressings daily. RN #1 identified the wound appeared to be a stage III pressure ulceration to the coccyx. RN #1 contacted the Patient’s primary healthcare provider for wound care orders and an oral antibiotic for a possible wound infection. The healthcare provider declined to provide orders until the Patient was seen in-person for an assessment. After multiple attempts RN #1 was unable to arrange ambulance transportation for the Patient’s scheduled appointments. RN #1 encouraged the Patient’s responsible person to send the Patient to the emergency department, but the responsible person declined and agreed to send the Patient on 12/14/2023. RN #1 identified the Patient was not transported to the hospital until 12/21/2023. RN #1 indicated from 12/14/2023 until 12/21/2023, she contacted the Patient’s responsible person to encourage sending the Patient to the emergency department but failed to document the communications in the clinical record. RN #1 identified the Patient was discharged from the hospital to home on 12/27/2023 with an indwelling urinary catheter, wound care orders and new medications, but lacked refills for the new medications, wound and urinary catheter supplies, and the appropriate transportation for follow up appointments. RN #1 indicated the Patient should have been discharged from the hospital to a skilled nursing facility due to the complexity of Patient #1’s wound, lack of wound and catheter supplies and medication refills. ii. Interview with RN #2 on 01/23/2024 at 11:00 AM, identified RN #2 as wound care certified. RN #2 performed a joint visit with RN #1 on 01/03/2024 and indicated the sacrococcygeal pressure ulceration measured 7 cm in length, 11 cm in width and had no depth due to necrotic tissue with a large amount of purulent drainage (thick yellow drainage indicating infection). Furthermore, RN #2 identified the Patient’s wound care should have been performed twice per day not three times per week and determined the Patient’s wound could not be appropriately managed in the home setting. Patient #1 was transferred to the emergency department and admitted to the hospital on 01/03/2024. iii. Interview with the Administrator on 01/23/2024 at 11:50 AM, identified the agency should have notified Elderly Protective Services (a state agency that is designed to safeguard people 60 years and older from physical, mental, emotional abuse, neglect and exploitation) when Patient #1’s responsible person failed to send the Patient to the emergency department until 12/21/2023 and the agency should have provided the Patient with follow up nursing visits during the period of 12/14/2023 through 12/21/2023. Additionally, the Administrator identified the Patient’s discharge from the hospital to home on 12/26/2023 was unsafe due to the complex nature and condition of the Patient’s wound which was out of the agency’s scope of practice, the lack of wound and urinary catheter supplies in the home, and the lack of appropriate transportation to medical appointments. The Administrator identified the Patient should have been transferred back to the hospital on 12/27/2023 and the Patient’s plan of care dated 12/27/2023 failed to address Patient #1’s individual care needs to ensure appropriate care was provided. Review of the agency’s Admission policy identified individuals are admitted to service and continued under care based on an assessment in the home by the primary care nurse to determine that the patient can be safely cared for in the home and the willingness of the family or other individual to participate in the service program. The agency would not provide services if the patient’s needs could not be met by the patient or family, or the patient’s life situation was not conducive to providing maintenance and supervision. Review of the agency’s Change in Condition policy, identified when the primary care nurse notices the patient’s change in condition, 911 would be called if appropriate and notification of the Supervisor of Clinical Services. Review of the agency’s Not Taken onto Services or NTU policy, identified a not taken onto services would occur after reviewing the referral or attempting to start the care. The agency may not admit a patient if upon the start of care or the resumption of care, the nurse questions whether the patient is safe at home. At this point, the nurse must call the SCS to discuss if the patient is appropriate for services.”

“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 clinical record reviews. review of agency policy and interviews with agency personnel, for one of two patients (Patient #1) in the survey sample, the agency failed to ensure the plan of care addressed the patient’s individual care needs. The finding includes: a. Patient #1 was admitted to the home healthcare agency on 09/13/2023 with diagnosis that included type II diabetes mellites, dementia, and high blood pressure. The physician’s orders for the certification period of 11/12/2023 through 01/10/2024, included nursing services once per month for nursing assessments and blood glucose monitoring. Patient #1 was non-ambulatory, bed-bound, required a Hoyer lift (a mechanical lift used to transport patient from a chair to a bed or a bed to a chair) and ambulance transportation to all medical appointments. Additionally, Patient #1 had a twenty-four-hour live-in caregiver provided by a community-based program for the elderly. Review of Patient #1’s nurse’s note dated 12/13/2023, identified Registered Nurse (RN) #1 visited the Patient on 12/13/2023 for the once per month nursing visit. Patient #1’s live-in caregiver identified the Patient had developed a new wound to the coccyx in early December of 2023. RN #1 identified the wound appeared to be a stage III pressure ulcer to the coccyx (a full thickness tissue loss wound which may expose fat, but bone, muscle or tendon is not visible). Patient #1’s wound measured 3 centimeters (cm) in length, 2 cm in width and 0.25 cm in depth. The live-in caregiver was covering the wound with foam dressings daily. RN #1 requested new wound care orders and an antibiotic for a possible wound infection, but Patient #1’s primary healthcare provider declined to provide orders until the Patient was seen in the clinic for an assessment on 01/08/2024. Review of RN #1’s communication note dated 12/21/2024, identified Patient #1 had an appointment scheduled at a wound care clinic on 12/21/2023. RN #1 attempted to schedule an ambulance transport to the medical appointments but was informed by Patient #1’s case manager from the community-based program for the elderly that there was no mechanism to provide transportation for the Patient. RN #1 indicated she encouraged Patient #1’s responsible person to send the Patient to the emergency department on 12/13/2023 for a wound assessment and treatment, but the responsible person declined and agreed to send the Patient on 12/14/2023. Review of Patient #1’s nurse’s note dated 12/21/2023, identified the Patient was admitted to the hospital on 12/21/2023 for the assessment and treatment of the coccyx wound. Review of Patient #1’s hospital discharge summary dated 12/26/2023, identified the Patient arrived at the emergency department by ambulance on 12/21/2023 with an infected sacrococcygeal pressure ulceration which required surgical intervention (pressure ulceration staging or measurements of the wound were not documented in the discharge summary). Review of the hospital physician’s orders dated 12/26/2023, included cleaning the sacrococcygeal pressure ulceration with normal saline, applying a barrier cream to the wound edges, applying medi-honey calcium alginate (a honey based dressing used for moderate to heavily draining wounds) to the deep middle portion of the wound, filling the wound bed with gauze, applying a thin layer of triad paste (a zinc oxide based wound dressing that adheres to wet, eroded skin) to the left and right areas of the wound and covering the entire wound with a large foam dressing (the frequency of the wound care was not documented in the order). Patient #1 was prescribed an antibiotic Amoxicillin-Clavulanate 875-125 milligrams (mg) one tablet by mouth twice per day for five days, Eliquis (a medication used to treat and prevent blood clots) 5 mgs two tablets by mouth every twelve hours for six days then one tablet by mouth every twelve hours, Magnesium Oxide 400 mgs one tablet by mouth twice per day and Metoprolol Tartrate 25 mgs one tablet by mouth twice per day. Review of Patient #1’s start of care nurse’s note dated 12/27/2024, identified Patient #1 returned home on 12/26/2023 with the responsible person. RN #1 identified the Patient had an indwelling urinary catheter, was prescribed three new medications without refills, and could not attend scheduled medical appointments due to the lack of appropriate transportation. RN #1 indicated the sacrococcygeal pressure ulceration measured 6 cm in length, 5 cm in width and 2 cm in depth with a large amount of black eschar (dead tissue) surrounding the wound. RN #1 identified the Patient required an assessment by the home healthcare agency’s wound care certified nurse (RN #2) on 01/03/2024. Additionally, RN #1 identified the wound care would be performed by a nurse three times per week and a caregiver would perform the wound care once competence was demonstrated. RN #1 indicated care coordination occurred with the Patient’s healthcare provider, and Supervisor of Clinical Services (SCS) #1 but failed to document the details of the care coordination. Review of Patient #1’s clinical record, identified the Patient was seen by RN #1 on 12/28/2023, 12/30/2023 and 01/01/2024. On 12/30/2023, Patient #1’s sacrococcygeal pressure ulceration measured 6 cm in length, 5 cm in width and 2 cm in depth. Additionally, the 12/28/2023, 12/30/2023 and 01/01/2024 nurses’ notes failed to identify a caregiver was taught and returned demonstrated wound care to the sacrococcygeal pressure ulceration. Review of Patient #1’s nurse’s note dated 01/03/2024, identified RN #1 performed a joint visit with the wound care certified nurse (RN #2). RN #1 identified the Patient’s sacrococcygeal pressure ulcer measured 7 cm in length, 11 cm in width, and no depth due. RN #1 identified the wound was deteriorating from a persistent infection and could not be managed in the home setting. Patient #1 was transferred to the emergency room and admitted to the hospital on 01/03/2024. i. Interview with RN #1 on 01/23/2024 at 10:10 AM, identified visiting Patient #1 on 12/13/2023 for the monthly visit. Patient #1’s live-in caregiver identified the Patient developed a new wound to the coccyx in early December of 2023. The live-in caregiver covered the wound with foam dressings daily. RN #1 identified the wound appeared to be a stage III pressure ulceration to the coccyx. RN #1 contacted the Patient’s primary healthcare provider for wound care orders and an oral antibiotic for a possible wound infection. The healthcare provider declined to provide orders until the Patient was seen in-person for an assessment. After multiple attempts RN #1 was unable to arrange ambulance transportation for the Patient’s scheduled appointments. RN #1 encouraged the Patient’s responsible person to send the Patient to the emergency department, but the responsible person declined and agreed to send the Patient on 12/14/2023. RN #1 identified the Patient was not transported to the hospital until 12/21/2023. RN #1 indicated from 12/14/2023 until 12/21/2023, she contacted the Patient’s responsible person to encourage sending the Patient to the emergency department but failed to document the communications in the clinical record. RN #1 identified the Patient was discharged from the hospital to home on 12/27/2023 with an indwelling urinary catheter, wound care orders and new medications, but lacked refills for the new medications, wound and urinary catheter supplies, and the appropriate transportation for follow up appointments. RN #1 indicated the Patient should have been discharged from the hospital to a skilled nursing facility due to the complexity of Patient #1’s wound, lack of wound and catheter supplies and medication refills. ii. Interview with RN #2 on 01/23/2024 at 11:00 AM, identified RN #2 as wound care certified. RN #2 performed a joint visit with RN #1 on 01/03/2024 and indicated the sacrococcygeal pressure ulceration measured 7 cm in length, 11 cm in width and had no depth due to necrotic tissue with a large amount of purulent drainage (thick yellow drainage indicating infection). Furthermore, RN #2 identified the Patient’s wound care should have been performed twice per day not three times per week and determined the Patient’s wound could not be appropriately managed in the home setting. Patient #1 was transferred to the emergency department and admitted to the hospital on 01/03/2024. iii. Interview with the Administrator on 01/23/2024 at 11:50 AM, identified the agency should have notified Elderly Protective Services (a state agency that is designed to safeguard people 60 years and older from physical, mental, emotional abuse, neglect and exploitation) when Patient #1’s responsible person failed to send the Patient to the emergency department until 12/21/2023 and the agency should have provided the Patient with follow up nursing visits during the period of 12/14/2023 through 12/21/2023. The Administrator identified the Patient’s discharge from the hospital to home on 12/26/2023 was unsafe due to the complex nature and condition of the Patient’s wound which was out of the agency’s scope of practice, the lack of wound and urinary catheter supplies in the home, and the lack of appropriate transportation to medical appointments. The Administrator identified the Patient should have been transferred back to the hospital on 12/27/2023 and the Patient’s plan of care dated 12/27/2023 failed to address Patient #1’s individual care needs to ensure appropriate care was provided. Review of the agency’s Care Planning policy, identified the physician would develop an individual care plan in consultation with the home healthcare agency for each patient to address specific problem areas and to ensure appropriate services and care were provided to meet the patient’s needs. The plan of care for each service provided to the patient and family would address needs as they relate to home health services. The plan of care is developed from data collected through initial and ongoing patient assessments. Care plans would be reviewed and revised via conferences by the primary care nurse, physicians and others providing care on an ongoing basis to ensure care was appropriate for each patient’s needs and treatment goals.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on clinical record review, and interviews with agency personnel for one of two patients (Patient’s #1) who required nursing services for assessments and wound care, the agency failed to ensure coordination of care delivery to meet the patient’s needs. The finding includes: a. Patient #1 was admitted to the home healthcare agency on 09/13/2023 with diagnosis that included type II diabetes mellites, dementia, and high blood pressure. The physician’s orders for the certification period of 11/12/2023 through 01/10/2024, included nursing services once per month for nursing assessments and blood glucose monitoring. Patient #1 was non-ambulatory, bed-bound, required a Hoyer lift (a mechanical lift used to transport patients from a chair to a bed or a bed to a chair) and ambulance transportation to all medical appointments. Additionally, Patient #1 had a twenty-four-hour live-in caregiver provided by a community-based program for the elderly. Review of Patient #1’s nurse’s note dated 12/13/2023, identified Registered Nurse (RN) #1 visited the Patient on 12/13/2023 for the once per month nursing visit. Patient #1’s live-in caregiver identified the Patient had developed a new wound to the coccyx in early December of 2023. RN #1 identified the wound appeared to be a stage III pressure ulcer to the coccyx (a full thickness tissue loss wound which may expose fat, but bone, muscle or tendon is not visible). Patient #1’s wound measured 3 centimeters (cm) in length, 2 cm in width and 0.25 cm in depth. The live-in caregiver was covering the wound with foam dressings daily. RN #1 requested new wound care orders and an antibiotic for a possible wound infection, but Patient #1’s primary healthcare provider declined to provide orders until the Patient was seen in the clinic for an assessment on 01/08/2024. Review of RN #1’s communication note dated 12/21/2024, identified Patient #1 had an appointment scheduled at a wound care clinic on 12/21/2023. RN #1 attempted to schedule an ambulance transport to the medical appointments but was informed by Patient #1’s case manager from the community-based program for the elderly that there was no mechanism to provide transportation for the Patient. RN #1 indicated she encouraged Patient #1’s responsible person to send the Patient to the emergency department on 12/13/2023 for a wound assessment and treatment, but the responsible person declined and agreed to send the Patient on 12/14/2023. Review of Patient #1’s nurse’s note dated 12/21/2023, identified the Patient was admitted to the hospital on 12/21/2023 for the assessment and treatment of the coccyx wound. Review of Patient #1’s hospital discharge summary dated 12/26/2023, identified the Patient arrived at the emergency department by ambulance on 12/21/2023 with an infected sacrococcygeal pressure ulceration which required surgical intervention (pressure ulceration staging or measurements of the wound were not documented in the discharge summary). Review of the hospital physician’s orders dated 12/26/2023, included cleaning the sacrococcygeal pressure ulceration with normal saline, applying a barrier cream to the wound edges, applying medi-honey calcium alginate (a honey based dressing used for moderate to heavily draining wounds) to the deep middle portion of the wound, filling the wound bed with gauze, applying a thin layer of triad paste (a zinc oxide based wound dressing that adheres to wet, eroded skin) to the left and right areas of the wound and covering the entire wound with a large foam dressing (the frequency of the wound care was not documented in the order). Patient #1 was prescribed an antibiotic Amoxicillin-Clavulanate 875-125 milligrams (mg) one tablet by mouth twice per day for five days, Eliquis (a medication used to treat and prevent blood clots) 5 mgs two tablets by mouth every twelve hours for six days then one tablet by mouth every twelve hours, Magnesium Oxide 400 mgs one tablet by mouth twice per day and Metoprolol Tartrate 25 mgs one tablet by mouth twice per day. Review of Patient #1’s start of care nurse’s note dated 12/27/2024, identified Patient #1 returned home on 12/26/2023 with the responsible person. RN #1 identified the Patient had an indwelling urinary catheter, was prescribed three new medications without refills, and could not attend scheduled medical appointments due to the lack of appropriate transportation. RN #1 indicated the sacrococcygeal pressure ulceration measured 6 cm in length, 5 cm in width and 2 cm in depth with a large amount of black eschar (dead tissue) surrounding the wound. RN #1 identified the Patient required an assessment by the home healthcare agency’s wound care certified nurse (RN #2) on 01/03/2024. Additionally, RN #1 identified the wound care would be performed by a nurse three times per week and a caregiver would perform the wound care once competence was demonstrated. RN #1 indicated care coordination occurred with the Patient’s healthcare provider, and Supervisor of Clinical Services (SCS) #1 but failed to document the details of the care coordination. Review of Patient #1’s clinical record, identified the Patient was seen by RN #1 on 12/28/2023, 12/30/2023 and 01/01/2024. On 12/30/2023, Patient #1’s sacrococcygeal pressure ulceration measured 6 cm in length, 5 cm in width and 2 cm in depth. Additionally, the 12/28/2023, 12/30/2023 and 01/01/2024 nurses’ notes failed to identify a caregiver was taught and returned demonstrated wound care to the sacrococcygeal pressure ulceration. Review of Patient #1’s nurse’s note dated 01/03/2024, identified RN #1 performed a joint visit with the wound care certified nurse (RN #2). RN #1 identified the Patient’s sacrococcygeal pressure ulcer measured 7 cm in length, 11 cm in width, and no depth due. RN #1 identified the wound was deteriorating from a persistent infection and could not be managed in the home setting. Patient #1 was transferred to the emergency room and admitted to the hospital on 01/03/2024. i. Interview with RN #1 on 01/23/2024 at 10:10 AM, identified visiting Patient #1 on 12/13/2023 for the monthly visit. Patient #1’s live-in caregiver identified the Patient developed a new wound to the coccyx in early December of 2023. The live-in caregiver covered the wound with foam dressings daily. RN #1 identified the wound appeared to be a stage III pressure ulceration to the coccyx. RN #1 contacted the Patient’s primary healthcare provider for wound care orders and an oral antibiotic for a possible wound infection. The healthcare provider declined to provide orders until the Patient was seen in-person for an assessment. After multiple attempts RN #1 was unable to arrange ambulance transportation for the Patient’s scheduled appointments. RN #1 encouraged the Patient’s responsible person to send the Patient to the emergency department, but the responsible person declined and agreed to send the Patient on 12/14/2023. RN #1 identified the Patient was not transported to the hospital until 12/21/2023. RN #1 indicated from 12/14/2023 until 12/21/2023, she contacted the Patient’s responsible person to encourage sending the Patient to the emergency department but failed to document the communications in the clinical record. RN #1 identified the Patient was discharged from the hospital to home on 12/27/2023 with an indwelling urinary catheter, wound care orders and new medications, but lacked refills for the new medications, wound and urinary catheter supplies, and the appropriate transportation for follow up appointments. RN #1 indicated the Patient should have been discharged from the hospital to a skilled nursing facility due to the complexity of Patient #1’s wound, lack of wound and catheter supplies and medication refills. ii. Interview with RN #2 on 01/23/2024 at 11:00 AM, identified RN #2 as wound care certified. RN #2 performed a joint visit with RN #1 on 01/03/2024 and indicated the sacrococcygeal pressure ulceration measured 7 cm in length, 11 cm in width and had no depth due to necrotic tissue with a large amount of purulent drainage (thick yellow drainage indicating infection). Furthermore, RN #2 identified the Patient’s wound care should have been performed twice per day not three times per week and determined the Patient’s wound could not be appropriately managed in the home setting. Patient #1 was transferred to the emergency department and admitted to the hospital on 01/03/2024. iii. Interview with the Administrator on 01/23/2024 at 11:50 AM, identified the agency should have notified Elderly Protective Services (a state agency that is designed to safeguard people 60 years and older from physical, mental, emotional abuse, neglect and exploitation) when Patient #1’s responsible person failed to send the Patient to the emergency department until 12/21/2023 and the agency should have provided the Patient with follow up nursing visits during the period of 12/14/2023 through 12/21/2023. The Administrator identified the Patient’s discharge from the hospital to home on 12/26/2023 was unsafe due to the complex nature and condition of the Patient’s wound which was out of the agency’s scope of practice, the lack of wound and urinary catheter supplies in the home, and the lack of appropriate transportation to medical appointments. The Administrator identified the Patient should have been transferred back to the hospital on 12/27/2023 and the Patient’s plan of care dated 12/27/2023 failed to address Patient #1’s individual care needs to ensure appropriate care was provided.”

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on clinical record reviews, agency policy review and interviews with agency personnel, for one of two patients (Patient #1) in the survey sample, the agency failed to ensure a comprehensive ongoing interdisciplinary assessment of the patient to meet the patient’s needs. The finding includes: a. Patient #1 was admitted to the home healthcare agency on 09/13/2023 with diagnosis that included type II diabetes mellites, dementia, and high blood pressure. The physician’s orders for the certification period of 11/12/2023 through 01/10/2024, included nursing services once per month for nursing assessments and blood glucose monitoring. Patient #1 was non-ambulatory, bed-bound, required a Hoyer lift (a mechanical lift used to transport patients from a chair to a bed or a bed to a chair) and ambulance transportation to all medical appointments. Additionally, Patient #1 had a twenty-four-hour live-in caregiver provided by a community-based program for the elderly. Review of Patient #1’s nurse’s note dated 12/13/2023, identified Registered Nurse (RN) #1 visited the Patient on 12/13/2023 for the once per month nursing visit. Patient #1’s live-in caregiver identified the Patient had developed a new wound to the coccyx in early December of 2023. RN #1 identified the wound appeared to be a stage III pressure ulcer to the coccyx (a full thickness tissue loss wound which may expose fat, but bone, muscle or tendon is not visible). Patient #1’s wound measured 3 centimeters (cm) in length, 2 cm in width and 0.25 cm in depth. The live-in caregiver was covering the wound with foam dressings daily. RN #1 requested new wound care orders and an antibiotic for a possible wound infection, but Patient #1’s primary healthcare provider declined to provide orders until the Patient was seen in the clinic for an assessment on 01/08/2024. Review of RN #1’s communication note dated 12/21/2024, identified Patient #1 had an appointment scheduled at a wound care clinic on 12/21/2023. RN #1 attempted to schedule an ambulance transport to the medical appointments but was informed by Patient #1’s case manager from the community-based program for the elderly that there was no mechanism to provide transportation for the Patient. RN #1 indicated she encouraged Patient #1’s responsible person to send the Patient to the emergency department on 12/13/2023 for a wound assessment and treatment, but the responsible person declined and agreed to send the Patient on 12/14/2023. Review of Patient #1’s nurse’s note dated 12/21/2023, identified the Patient was admitted to the hospital on 12/21/2023 for the assessment and treatment of the coccyx wound. Review of Patient #1’s hospital discharge summary dated 12/26/2023, identified the Patient arrived at the emergency department by ambulance on 12/21/2023 with an infected sacrococcygeal pressure ulceration which required surgical intervention (pressure ulceration staging or measurements of the wound were not documented in the discharge summary). Review of the hospital physician’s orders dated 12/26/2023, included cleaning the sacrococcygeal pressure ulceration with normal saline, applying a barrier cream to the wound edges, applying medi-honey calcium alginate (a honey based dressing used for moderate to heavily draining wounds) to the deep middle portion of the wound, filling the wound bed with gauze, applying a thin layer of triad paste (a zinc oxide based wound dressing that adheres to wet, eroded skin) to the left and right areas of the wound and covering the entire wound with a large foam dressing (the frequency of the wound care was not documented in the order). Patient #1 was prescribed an antibiotic Amoxicillin-Clavulanate 875-125 milligrams (mg) one tablet by mouth twice per day for five days, Eliquis (a medication used to treat and prevent blood clots) 5 mgs two tablets by mouth every twelve hours for six days then one tablet by mouth every twelve hours, Magnesium Oxide 400 mgs one tablet by mouth twice per day and Metoprolol Tartrate 25 mgs one tablet by mouth twice per day. Review of Patient #1’s start of care nurse’s note dated 12/27/2024, identified Patient #1 returned home on 12/26/2023 with the responsible person. RN #1 identified the Patient had an indwelling urinary catheter, was prescribed three new medications without refills, and could not attend scheduled medical appointments due to the lack of appropriate transportation. RN #1 indicated the sacrococcygeal pressure ulceration measured 6 cm in length, 5 cm in width and 2 cm in depth with a large amount of black eschar (dead tissue) surrounding the wound. RN #1 identified the Patient required an assessment by the home healthcare agency’s wound care certified nurse (RN #2) on 01/03/2024. Additionally, RN #1 identified the wound care would be performed by a nurse three times per week and a caregiver would perform the wound care once competence was demonstrated. RN #1 indicated care coordination occurred with the Patient’s healthcare provider, and Supervisor of Clinical Services (SCS) #1 but failed to document the details of the care coordination. Review of Patient #1’s clinical record, identified the Patient was seen by RN #1 on 12/28/2023, 12/30/2023 and 01/01/2024. On 12/30/2023, Patient #1’s sacrococcygeal pressure ulceration measured 6 cm in length, 5 cm in width and 2 cm in depth. Additionally, the 12/28/2023, 12/30/2023 and 01/01/2024 nurses’ notes failed to identify a caregiver was taught and returned demonstrated wound care to the sacrococcygeal pressure ulceration. Review of Patient #1’s nurse’s note dated 01/03/2024, identified RN #1 performed a joint visit with the wound care certified nurse (RN #2). RN #1 identified the Patient’s sacrococcygeal pressure ulcer measured 7 cm in length, 11 cm in width, and no depth due. RN #1 identified the wound was deteriorating from a persistent infection and could not be managed in the home setting. Patient #1 was transferred to the emergency room and admitted to the hospital on 01/03/2024. i. Interview with RN #1 on 01/23/2024 at 10:10 AM, identified visiting Patient #1 on 12/13/2023 for the monthly visit. Patient #1’s live-in caregiver identified the Patient developed a new wound to the coccyx in early December of 2023. The live-in caregiver covered the wound with foam dressings daily. RN #1 identified the wound appeared to be a stage III pressure ulceration to the coccyx. RN #1 contacted the Patient’s primary healthcare provider for wound care orders and an oral antibiotic for a possible wound infection. The healthcare provider declined to provide orders until the Patient was seen in-person for an assessment. After multiple attempts RN #1 was unable to arrange ambulance transportation for the Patient’s scheduled appointments. RN #1 encouraged the Patient’s responsible person to send the Patient to the emergency department, but the responsible person declined and agreed to send the Patient on 12/14/2023. RN #1 identified the Patient was not transported to the hospital until 12/21/2023. RN #1 indicated from 12/14/2023 until 12/21/2023, she contacted the Patient’s responsible person to encourage sending the Patient to the emergency department but failed to document the communications in the clinical record. RN #1 identified the Patient was discharged from the hospital to home on 12/27/2023 with an indwelling urinary catheter, wound care orders and new medications, but lacked refills for the new medications, wound and urinary catheter supplies, and the appropriate transportation for follow up appointments. RN #1 indicated the Patient should have been discharged from the hospital to a skilled nursing facility due to the complexity of Patient #1’s wound, lack of wound and catheter supplies and medication refills. ii. Interview with RN #2 on 01/23/2024 at 11:00 AM, identified RN #2 as wound care certified. RN #2 performed a joint visit with RN #1 on 01/03/2024 and indicated the sacrococcygeal pressure ulceration measured 7 cm in length, 11 cm in width and had no depth due to necrotic tissue with a large amount of purulent drainage (thick yellow drainage indicating infection). Furthermore, RN #2 identified the Patient’s wound care should have been performed twice per day not three times per week and determined the Patient’s wound could not be appropriately managed in the home setting. Patient #1 was transferred to the emergency department and admitted to the hospital on 01/03/2024. iii. Interview with the Administrator on 01/23/2024 at 11:50 AM, identified the agency should have notified Elderly Protective Services (a state agency that is designed to safeguard people 60 years and older from physical, mental, emotional abuse, neglect and exploitation) when Patient #1’s responsible person failed to send the Patient to the emergency department until 12/21/2023 and the agency should have provided the Patient with follow up nursing visits during the period of 12/14/2023 through 12/21/2023. Additionally, the Administrator identified the Patient’s discharge from the hospital to home on 12/26/2023 was unsafe due to the complex nature and condition of the Patient’s wound which was out of the agency’s scope of practice, the lack of wound and urinary catheter supplies in the home, and the lack of appropriate transportation to medical appointments. The Administrator identified the Patient should have been transferred back to the hospital on 12/27/2023 and the Patient’s plan of care dated 12/27/2023 failed to address Patient #1’s individual care needs to ensure appropriate care was provided. Review of the agency’s Nursing Assessment policy, identified it was the policy of the home healthcare agency to provide appropriate individualized care for each patient as determined by the initial, resumption of care and ongoing assessments of the patient’s problem areas and response to teaching and treatments. The data from the initial assessment would be analyzed and utilized to develop the patient’s care plan and determine the need for further assessment within specific need areas.”