Mederi Caretenders

“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 interview and record review the agency failed to ensure nurses followed physician orders for 1 of 3 patients reviewed for wound care of a total sample of 17 patients, (#11). Findings: Review of patient #11’s medical record revealed a Start of Care date of 4/26/25. His diagnoses included sepsis and urinary tract infection. Review of patient #11’s Plan of Care for the certification period of 4/26/25 to 6/24/25 revealed the following wound care order, Skilled Nurse (SN) to perform wound care to stage 2 pressure ulcer to the left heel, cleanse with normal saline, apply zinc oxide ointment, and cover with foam dressing. The wound care order did not specify how often it needed to be performed. The SN frequency for the episode was twice a week for nine weeks. Review of patient #11’s physician orders revealed a wound care order for the left heel dated 5/20/25 which indicated to cleanse the wound with wound cleanser, pat dry with gauze, apply skin prep to peri wound, apply Medihoney to wound bed, apply adaptive to keep Santyl in place, cover with calcium alginate, and cover with gauze border dressing. The order directed SN to perform wound care on Wednesday and Friday. Review of SN notes revealed a visit was performed on Tuesday 5/20/25. Registered Nurse (RN) A indicated wound was not assessed and wound care was not provided because the caregiver had completed the care. There was no SN visit done on Wednesday, 5/21/25. Review of SN notes revealed a visit was performed on Friday 5/23/25. Licensed Practical Nurse (LPN) D documented wound care performed to left heel as “cleanse with NSS (normal saline solution), apply zinc oxide ointment, cover with foam dressing.” Subsequent SN visits performed by LPN D on 5/27/25, 5/30/25, 6/06/25, 6/11/25, and 6/13/25 showed she documented wound care performed to left heel as “cleanse with NSS, apply zinc oxide ointment, cover with foam dressing.” On 7/30/25 at 1:14 PM, Patient Care Manager (PCM) E reviewed the wound care orders and SN visit notes for patient #11. PCM E validated the physician’s wound care order was not followed during the SN visits performed on 5/23/25, 5/27/25, 5/30/25, 6/06/25, 6/11/25, and 6/13/25. On 7/31/25 at 2:00 PM, the Administrator stated nurses were expected to follow the physician orders and communicate with the physician for any questions. He explained all wound care orders should include how often the wound care needed to be done. Review of the agency’s Wound Assessment, Documentation, and Photography policy revised on 9/01/24 revealed a purpose “To ensure the accurate and consistent assessment and documentation of wounds.” The document noted performance of wound care would be according to their clinical skill guidelines and physician orders.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency failed to ensure Home Health Aide (HHA) supervisory visits were done for 3 of 3 patients reviewed for HHA services of a total sample of 17 patients, (#11, #12, and #15). Findings: 1.Review of patient #11’s medical record revealed a Start of Care (SOC) date of 4/26/25. His diagnoses included sepsis and urinary tract infection. Review of patient #11’s Plan of Care (POC) for the certification period of 6/25/25 to 8/23/25 revealed the services and frequency included Skilled Nursing (SN) twice a week for nine weeks (2WK9) and HHA 2WK4, effective 6/29/25. Review of patient #11’s HHA notes revealed visits were performed by HHA C on 7/01/25, 7/03/25, 7/08/25, and 7/11/25. Review of patient #11’s SN notes revealed a visit performed by Registered Nurse (RN) B on 7/11/25. The Supervisory Functions section of the note, which asked if supervisory functions were performed, was answered, “No.” The Narrative section included the patient’s spouse had requested to cancel HHA visits. Review of patient #11’s SN notes revealed a visit performed by RN A on 7/16/25. The Supervisory Functions question was answered yes and the employee being evaluated was listed as Licensed Practical Nurse (LPN). 2. Review of patient #12’s medical record revealed a SOC date of 7/07/25. His diagnoses included sepsis and urinary tract infection. Review of patient #12’s POC for the certification period of 7/07/25 to 9/04/25 revealed the services and frequency included SN 2WK1, 1WK8 and HHA 3WK1, 2wk3. Review of patient #12’s HHA notes revealed HHA C performed visits on 7/10/25, 7/11/25, 7/14/25, 7/17/25, 7/21/25, 7/24/25, and 7/28/25. Review of patient #12’s SN notes revealed a visit performed by RN B on 7/18/25. The Supervisory Functions question was answered, “No.” Review of patient #12’s SN notes revealed a visit performed by RN F on 7/28/25. The Supervisory Functions question was answered, “No.” 3. Review of patient #15’s medical record revealed a SOC date of 6/12/25. Her diagnoses included urinary tract infection, sepsis, and type 2 diabetes. Review of patient #15’s POC for the certification period of 6/12/25 to 8/10/25 revealed the services and frequency included SN 1WK4, 1every2WK4, 1WK1 and HHA 2WK4, effective 6/15/25. Review of patient #15’s HHA notes revealed HHA C performed visits on 6/17/25, 6/20/25, 6/23/25, 6/27/25, 7/01/25, 7/03/25, 7/07/25, and 7/11/25. Review of patient #15’s SN notes revealed a visit performed by RN G on 6/25/25. The Supervisory Functions question was answered, “No.” Review of patient #15’s SN notes revealed a visit performed by RN A on 7/02/25. The Supervisory Functions question was answered, “No.” On 7/30/25 at 1:50 PM, Patient Care Manager (PCM) E stated supervisory visits were scheduled for patients #11, #12, and #15. She explained they used visit code RN10 to identify the required supervisory visits. PCM E reviewed the visit notes and acknowledged the HHA supervisory was not done as required. She indicated subsequent visits, coded SN11, would not have included the supervisory functions question. She stated the HHA supervision was required every 2 weeks. On 7/30/25 at 3:40 PM, during a telephone interview, RN A stated when a patient needed the services of a HHA, she obtained a physician order and created an aide care plan. RN A stated she was not aware she had to supervise HHAs and was only aware of LPN supervision. On 7/31/25 at 11:59 AM, RN B stated she knew the code RN10 was a supervisory visit. She indicated HHA supervisory visits were to be done every two weeks. She mentioned she was under the impression the HHA had to be present during her visit. She stated since the HHA was not present during her RN10 visits, she did not perform the supervisory functions. She stated she did not ask her supervisor if her action was correct and may need to clarify with the PCM. She shared no one had addressed this before and she had always answered no to the supervisory question when the HHA was not present during her visit. On 7/31/25 at 2:00 PM, the Administrator stated he noticed nurses missed some HHA supervisory visits. He validated HHAs supervision was to be done every 14 days. Review of the agency’s Home Health Aide Supervision policy revised on 12/01/24 revealed the intent of the policy was to supervise the HHAs according to State and Federal Conditions of Participation to ensure the quality and appropriateness of the HHAs services. The document showed for the State of Florida, the supervision was required “At least every 14 days, with or without aide present.””

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on record review and interview the agency failed to ensure that discharge summaries were successfully sent to the patients’ practitioners for 2 of 5 discharged patient records reviewed (#2 and #3) of a total sample of 17 patients. Findings: Review of patient #2’s medical record revealed a start of care date of 7/29/24 and a discharge date of 11/22/24. Patient #2 had been provided nursing and physical therapy visits during her time on service with the agency during this period. The fax status report of the discharge summary indicated that it had failed fax status in being sent to patient #2’s physician with a submitted time of 11/27/24 and a scheduled date and time of 11/28/24. Review of patient #3’s medical record revealed a start of care date of 8/22/24 and a discharge date of 12/9/24. Patient #3 had been provided nursing visits during her time on service with the agency during this period. The fax status report of the discharge summary indicated that it had failed fax status in being send to patient #3’s physician with a submitted times of 12/20/24 and 12/23/24 and scheduled times of 12/21/24 and 12/24/24. On 7/31/25 at 12:28 PM, concurrently reviewed with the Business Office Manager and the Business Office Manager Assistant the Fax Status Reports for patient #2 submitted date 11/27/24 and patient #3 submitted 12/20/24 and 12/23/24 regarding the patients’ discharge summaries. The Business Office Manager whose name appeared in the fax from section of the Fax Status Report dated 11/27/24 regarding patient #2 could not explain why she had not attempted to resend the discharge summary to patient #2’s physician. She said she should have. The Business Office Manager Assistant whose name appeared in the fax from section of patient #3’s Fax Status Report dated 12/20/24 and 12/23/24 stated that she thought that even though the fax failed in sending the discharge summary to patient #3’s physician this event left her active to be done workflow and she did not know that the fax had failed. On 7/31/25 at 2:50 PM, the Administrator reviewed the Fax Status Reports for patient #2, related to the discharge summary submitted 11/27/24, and patient #3, related to the discharge summary submitted 12/20/24 and 12/23/24, which indicated fax status failures. He verified that the agency had no additional documentation that either discharge summary was successfully sent to the patients’ physicians. He also confirmed that patient #3’s discharge summary was delayed in being submitted to patient #3’s provider, over 5 business days from the date of discharge to the date of being submitted. Review of the policy regarding patient discharge/transfer process with a most recent revised date of 10/01/23, policy number 2.1.004 indicated that a discharge summary would include admission and discharge dates, a brief summary of the care provided, services provided to the patient, and is sent to the physician or other healthcare professional responsible for care after discharge within 5 business days of the patient’s discharge.”