Winnebago County Phns

“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 clinical record reviews and agency policy review, the agency failed to follow a Plan of Care established and periodically reviewed by a physician or notify the physician of the need to vary frequency of visits or inability to perform treatments/services as originally ordered on the Plan of Care for 2 of 2 sampled patients with missed visits (Patients #6 and #7). Failure to follow a Plan of Care established by a physician placed patients at risk of not receiving safe, individualized and consistent care designed to meet each patient’s health care needs. Findings include: 2. Patient #6 had a start of care date of 5/10/24 and was discharged on 7/17/24. Clinical record review revealed the following: a. The POC, dated 5/10/24 to 7/8/24, identified the patient had a diagnosis of a pressure ulcer. The POC included physician orders for skilled nursing visits 3 times a week. b. The electronic medical record failed to identify skilled nurse missed visits the weeks of 5/26/24 to 6/1/24, 6/2/24 to 6/8/24 and 7/14/24 to 7/17/24 and failed to notify the physician of missed visits. Agency staff failed to notify the physician of missed skilled nurse visits. The above findings reviewed with the Clinical Manager. According to the agency policy titled Missed Visits, dated 3/9/22, the physician will be notified of missed visits when the agency is made aware of a missed visit, if out of order compliance. 1.Patient #7 had a start of care date of 8/26/24 and was discharged on 9/12/24. Clinical record review revealed the following: a. The Plan of Care (POC), dated 8/26/24 to 10/24/24, identified the patient had a diagnosis of Wedge compression fracture of unspecified lumbar vertebra sequela. The POC included physician orders for home health aide services one time a week for one week effective 8/27/24 and 2 times a week for four weeks effective 9/1/24. b. The electronic medical record failed to identify home health aide missed visits the weeks of 8/25/24 to 8/31/24, 9/1/24 to 9/7/24, and 9/8/24 to 9/14/24 and failed to notify the physician of missed visits. The agency failed to notify the physician of the home health aide missed visits.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on clinical record review, agency policy review and home visit observation, the agency failed to ensure staff provided care in accordance with accepted infection control practices observed during a home visit for 1 of 3 sampled patients with home visits (Patient #3). Failure to follow accepted standards of practice for infection control may put the patient at risk for receiving unsafe care or care that allows the spread of infection. Findings include: According to the agency policy, titled Infection Control for the Nursing Bag, dated 3/26/24, agency staff directed that nursing bags require a clean and dirty pocket. The inside of the nursing bag shall be regarded and maintained as a clean area. Dirty items should never be placed inside bag unless cleaned. Patient #3 had a start of care date of 12/18/24. Clinical review review revealed the following: 1.The plan of care (POC), dated 12/18/24 to 1/15/25, identified the patient had a diagnosis of chronic obstructive pulmonary disease. The POC included physician orders for skilled nursing visits 1 time a week. 2. During a home observation visit on 1/15/24 at 9:30 AM, with Staff D, Registered Nurse (RN), the surveyor observed equipment for vital signs assessment placed on a clean barrier. Staff D assessed the patient’s vital signs. After use, Staff D placed the contaminated equipment back on the barrier, including on top of the individual equipment cases they were stored in. The thermometer placed inside a cloth bag. Staff then cleansed the equipment and replaced it back on the contaminated barrier, including touching the cases. The thermometer placed back into the contaminated cloth bag. The equipment then returned to the contaminated bags and placed into the nursing bag without sanitizing the items.. Staff D, RN failed to sanitize all contaminated items prior to returning to the nursing bag. The above findings were reviewed with the Clinical Manager.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: (1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on clinical record review, agency policy review, and agency staff interview, the agency failed to provide a complete comprehensive assessment for patients with wounds during start of care, resumption of care and discharge assessments of 3 of 4 patient’s with wounds (Patient #2, #6 and #7). Failure to accurately and thoroughly complete wound assessments or provide a comprehensive assessment placed patients at an increased risk of unidentified condition changes. Findings include: 2. Patient #2 had a start of care date of 1/24/22. Clinical record review revealed the following: a. The POC, dated 11/9/24 to 1/7/25, identified the patient had a wound to left side abdomen and included orders for skilled nursing services 1 time a week. b. The resumption of care comprehensive assessment, dated 11/4/24, included documentation the patient had an abdominal left surgical wound/surgical incision. The wound described to have a wound bed, clean, epithelializing, and 100% beefy red. The description included wound edges intact with scant, sanguinous/bloody drainage. The wound measured 3 cm by 2.5 cm by 2.5 cm (length by width by depth). c. The skilled nurse visit notes, dated 11/20/24, 11/27/24, 12/4/24, 12/11/24 and 12/18/24 failed to include documentation of wound assessments and measurements. The agency failed to document weekly wound assessments and measurements of the patient’s abdominal wound to left side. 3. Patient #7 had a start of care date of 8/26/24 and a discharge date of 9/12/24. Clinical record review revealed the following: a. The POC, dated 8/26/24 to 10/24/24, identified the patient had wounds to left foot on the second toe, skin tear to left outer arm forearm, skin tear to right upper arm elbow, skin tear to right lower arm elbow and other/right foot and included orders for skilled nursing services 3 times a week. b. The start of care comprehensive assessment, dated 8/26/24, included the following documentation of wounds: 1) Left foot 2nd toe: wound described to have a clean wound bed, 25% pink and 75% yellow. The description included dry and crusty wound edges, edematous peri wound skin and no drainage. The wound measured 1.2 cm by 2.6 cm. The measurements lacked a depth measurement. 2) Left outer arm forearm/skin tear: wound described to have a clean wound bed, 100% beefy red. The description included jagged wound edges, bruised and fragile peri wound skin with small, sanguinous/bloody drainage. The wound measured 21.1 cm by 6.2 cm. The measurements lacked accurate depth measurement and identified 0 cm depth. 3) Right lower arm elbow/skin tear: wound described to have a clean wound bed, 75% red and 25% yellow. The description included jagged wound edges, bruised peri wound skin with scant amount of serous drainage. The wound measured 0.6 cm by 0.9 cm. The measurements lacked accurate depth measurement and identified 0 cm depth. 4) Right upper arm elbow/skin tear: wound described to have a clean wound bed, 90% yellow and 10% black. The description included small amount of serous drainage. The wound measured 1 cm by 1 cm. The measurements lacked accurate depth measurement and identified 0 cm depth. c. Skilled nurse visit note, dated 9/2/24, included the following documentation of wounds: 1) Left foot 2nd toe: wound described to have a clean wound bed, 25% pink and 75% yellow. The description included wound edges within normal limits, peri wound skin within normal limits and small, serosanguinous drainage. The wound measured 1.2 cm by 2.6 cm. The measurements lacked a depth measurement. 2) Left foot great toe/venous stasis ulcer onset 8/27/24: wound described to have a clean wound bed, 50% pink and 50% yellow. The description included macerated wound edges, edematous peri wound skin and small, sanguinous/bloody drainage. The wound measured 1.2 cm by 2.2 cm. The measurements lacked a depth measurement. The agency failed to include accurate and complete comprehensive assessments of wound measurements. The above findings were reviewed with the Clinical Manager. According to the agency policy, revised 3/4/22, the case manager of the client will be scheduled first visit of the week when possible to ensure picture/assessment and measurements have been completed for the week. Length is measured from patient’s head to toe, width is measured from one side of the patient to the other. Use wound measuring device with measurements on the stick. If unable to use measuring device with measurements on stick, measure depth by gently inserting sterile cotton tip stick into the deepest part of wound. Mark off swab at the imaginary surface of the wound with your thumbnail and forefinger, hold the marked off swab positioned along the ruler to measure depth. During an interview on 1/14/25 at 10:15 AM, the Clinical Manager stated the expectation of staff to include weekly wound measurements that include length, width and depth and are documented in the skilled visit note. 1. Patient #6 had a Start of Care date of 5/10/24 and a Discharge date of 7/17/24. Clinical record review revealed the following: a. The plan of care (POC), dated 5/10/24 to 7/8/24 and 7/9/24 to 9/6/24, identified the patient had a diagnosis of a stage 3 (full thickness tissue loss, Subcutaneous fat may be visible but bone tendon or muscle is not exposed) pressure ulcer of the right heel and included orders for skilled nursing services 3 times a week. b. The comprehensive assessment at discharge, dated 7/17/24, included documentation the patient had a Stage 3 pressure ulcer to the right posterior heel. The wound described to have a wound bed, clean and red 50% and black 50%. The description included an open wound with a scant amount of serosanguinous drainage. The wound measured length 0.5 cm by 0.3 cm. The measurements lacked accurate depth measurement and identified 0 cm depth. The agency nurse failed to include an accurate comprehensive assessment of wound measurements.”

“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 observations, patient interviews, clinical record reviews and agency policy review, the agency failed to complete an accurate drug regimen review with each comprehensive assessment and failed to identify patient specific medication issues for 3 of 7 sampled patients (Patients #3, #4 and #5). Failure to ensure medications reviewed at the time of each drug regimen review are current and accurate placed the patients at risk for increased potential unidentified medication interactions, side effects and duplication of medications. Findings include: 2. Patient #3 had a start of care date of 12/18/24. Clinical record review revealed the following: a. The POC, dated 12/18/24 to 2/15/25, identified the patient had diagnosis of Chronic Obstructive Pulmonary Disease. The POC included physician orders for medications and skilled nursing services. Medication orders included the order for Palmetto (supplement) 1 tablet daily. b. The recertification comprehensive assessment, dated 12/18/24, completed by Staff D, RN, included documentation a DRR was completed and severe drug interactions possible. c. During a home observation visit on 1/15/24 at 9:30 AM with Staff D, RN, the surveyor noted the bottle of supplement Palmetto included both Palmetto 160 milligrams (mg) and zinc (supplement) 15 mg. The DRR failed to identify what the possible severe drug interactions were and failed to identify the dosage of the supplements administered. 3. Patient #5 had a start of care date of 11/26/24. Clinical record review revealed the following: a. The POC, dated 11/26/24 to 1/24/25, identified the patient had diagnosis of a surgical wound. The POC included physician orders for medications and skilled nursing services. b. The start of care comprehensive assessment, dated 11/26/24, completed by Staff D, RN, included documentation a DRR was completed and potential for severe interactions noted. The DRR failed to identify what the noted severe drug interactions were. The above findings were reviewed with the Clinical Manager. According to the agency Drug Regimen Review policy, dated 11/3/2017, a drug regimen review (DRR) of all prescription and over the counter medications is completed with each comprehensive assessment. The nurse identifies any ineffective drug therapy, significant side effects, drug interactions, duplicate drug therapy, high risk medication therapy and noncompliance with drug therapy. The physician is informed of any identified problems. 1. Patient #4 had a start of care date of 8/15/24. Clinical record review revealed the following: a. The POC, dated 12/12/24 to 2/9/25, identified the patient had diagnoses of Bipolar disorder and Type 2 diabetes mellitus without complications. The POC included physician orders for medications and skilled nursing services. b. The recertification comprehensive assessment, dated 12/11/24, completed by Staff D, Registered Nurse (RN), included documentation a DRR was completed and severe drug interactions possible. The DRR failed to identify what the possible severe drug interactions were.”

“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 agency staff interview, patient interview, clinical record review and agency policy review, the agency failed to follow physician orders for treatments for 6 of 7 sampled patients. (Patient’s #2, #3, #4, #5, #6 and #7). Failure to ensure staff obtain and follow physician orders for treatments provided by agency staff placed agency patients at risk for inconsistent care/treatment and possible harm. 4. Patient #2 had a start of care date of 1/24/22. Clinical record review revealed: a. The POC, dated 1/8/25 to 3/8/25, identified the patient had diagnosis of Chronic systolic (congestive) heart failure and included orders for skilled nursing visits one time a week. b. The POC included physician orders for medications and treatments, which included oxygen via nasal cannula 1 to 2 liters per minute, continuous for hypoxia (shortness of breath). The order failed to include direction for when the patient should use 1 liter or increase to 2 liters per minute for oxygen administration. c. During a home observation visit on 1/15/25 at 9:00 AM with Staff, E, Registered Nurse (RN), interview with Patient #2 stated he/she only wears oxygen at night. Agency staff failed to include oxygen orders specific for the patient. 5. Patient #4 had a start of care date of 8/15/24. Clinical record review revealed the following: a. The POCs, dated 10/13/24 to 12/11/24 and 12/12/24 to 2/9/24, identified the patient had a diagnosis of Bipolar disorder and included orders for skilled nursing visits one time a week. b. The POCs included standing orders to notify the physician for weight gain over 3 pounds within a 24 hour period or 5 pounds in one week. c. Skilled nurse visit notes, dated 11/15/24, 11/21/24, 11/26/24, 12/6/24, 12/19/24, 12/26/24, 1/2/25 and 1/9/25 lacked documentation of the patient’s weight. Agency staff failed to document the patient’s weight every visit. 6. Patient #7 had a start of care date of 8/26/24 and a discharge date of 9/12/24. Clinical record review revealed the following: a. The POC, dated 8/26/24 to 10/24/24 identified the patient had a diagnosis of Wedge compression fracture of unspecified lumbar vertebra sequela and included orders for skilled nursing visits three times a week. b. The POC included standing orders to notify the physician for weight gain over 3 pounds within a 24 hour period or 5 pounds in one week and wound care to be done every Monday, Wednesday and Friday. c. Skilled nurse visit notes, dated 8/28/24, 8/30/24, 9/2/24, 9/4/24 and 9/6/24 lacked documentation of the patient’s weight. d. Skilled nurse visit note, dated 9/4/24 lacked documentation of wound care to right foot. Agency staff failed to document the patient’s weight every visit and failed to completed wound care every Monday, Wednesday and Friday. The above findings were reviewed with the Clinical Manager. According to the agency policy, titled Physician’s Orders, dated 10/21/22, drugs and treatments shall be administered by agency staff only, as ordered by the physician. During an interview on 1/14/25 at 10:15 AM, the Clinical Manager stated the agency uses vital sign parameters and they are listed on the patient’s plan of care. 1. Patient #3 had a start of care date of 12/18/24. The clinical record review revealed: a. The Plan of Care (POC), dated 12/18/24 to 2/15/25, identified the patient had a diagnosis of chronic pulmonary disease and included orders for skilled nursing visits one time a week. b. The POC included physician orders for medications and treatments, which included oxygen 2 to 3 liters per minute, continuous for shortness of breath. The order failed to include direction for when the patient should use 2 liters or increase to 3 liters per minute for oxygen administration. The plan of care also included standing orders to notify the physician for weight gain over 3 pounds within a 24 hour period or 5 pounds in one week. c. The skilled nurse visit notes, dated 12/27, 12/31/24 and 1/8/25, lacked documentation of the patient’s weight. Agency staff failed to include oxygen orders specific for the patient and failed to document the patients weight every visit. 2. Patient #5 had a start of care date of 11/26/24. The clinical record review revealed: a. The POC, dated 11/26/24 to 1/24/25, identified the patient had a diagnosis of a surgical wound and included orders for skilled nursing visits one time a week. The POC lacked documentation of diagnosis diabetes mellitus. b. The POC included physician orders for medications and treatments, which included standing orders to notify the physician for weight gain over 3 pounds within a 24 hour period or 5 pounds in one week. The POC also included orders to notify the physician for fasting blood sugars less than 60 or greater than 300. c. The skilled nurse visit notes, dated 12/3, 12/11, 12/17, 12/23/24 and 1/6/25, lacked documentation of the patient’s weight. d. The skilled nurse visit notes, dated 11/26/24, 12/3, 12/11, 12/17, 12/23/24, 1/2 and 1/6/25, lacked documentation of blood sugar assessments. Agency staff failed to include oxygen orders specific for the patient and failed to document the patient’s weight or blood sugars every visit. 3. Patient #6 had a start of care date of 5/10/24 and discharge date of 7/17/24. The clinical record review revealed: a. The POC, dated 5/10/24 to 7/17/24, identified the patient had a diagnosis of a pressure ulcer and included orders for skilled nursing visits three times a week. b. The POC included physician orders for medications and treatments, which included standing orders to notify the physician for weight gain over 3 pounds within a 24 hour period or 5 pounds in one week. c. The skilled nurse visit notes, dated 5/24, 5/27, 5/29, 5/31/24, 6/7, 6/12, 6/14, 6/21, 6/26 and 6/28/24, lacked documentation of the patient’s weight. Agency staff failed to document the patient’s weight every visit.”