Tama County Public Health & Ho

“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 agency policy review, clinical record review, and staff interview, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including the types of services and the frequency and duration of visits to be made in 2 of 7 sampled patients ( Patient #1 and #6). Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services, medications and/or treatments according to assessed needs and physician orders. 2. Patient #6 had a start of care date of 5/6/24 and was discharged on 7/26/24. Review of the clinical record revealed: a. The POC, dated 5/6/24 to 7/8/24, included physician orders/interventions for skilled nursing services 1 time a week and home health aide services 1 to 2 times a week. b. The communication note, dated 5/20/24, revealed the skilled nurse clarified with the patient, the home health agency per the patient request with discontinue home health aide services. Personal care provider to be contacted for order. c. The clinical record lacked a physician’s order to discontinue home health aide services. d. The POC, dated 7/9/24 to 9/6/24, included orders for home health aide interventions including: ambulate patient using assistive device walker, oxygen, leave dressings to bilateral heels intact, assist to toilet per patient request, clean bathroom after patient care, wipe wet surfaces with towel, take linens to laundry, assist patient with dressing, denture care, foot care-patient is diabetic, may trim or file any long or uneven finger nails, shampoo at sink, per patient request, shave per patient request, skin care, apply lotion to trunk, back, arms, legs every visit, sponge bath and fall precautions. The POC lacked frequency orders for a home health aide. e. The clinical record lacked documentation of home health aide interventions provided per order or a clarification order to discontinue home health aide interventions. The agency failed to ensure the POC accurately included the type, frequency and duration of the services the patient was receiving. The above findings shared with the Director, Assistant Director and Clinical Manager. According to the agency policy, titled Plan of Care Policy, dated 4/2022, the individualized plan of care must specify the care and services necessary to meet the patient specific needs, including identification of the responsible disciplines and the measurable outcomes. The individualized plan of care must include the frequency and duration of visits to be made and patient specific interventions and measurable outcomes and goals. All patient orders including verbal orders must be recorded in the plan of care. 1.Patient #1 had a start of care date of 5/1/2019. Review of the clinical record revealed: a. The Plan of Care (POC), dated 8/2/24 to 9/30/24, included physician orders/interventions for skilled nursing services 1 time a week and home health aide services 2 to 3 times a week. b. Verbal order, dated 9/30/24, Staff D, RN notified the physician the patient no longer wanted home health aide services. c. The POC, dated 10/1/24 to 11/29/24, included orders for home health aide interventions including: apply lotion to back, arms and legs, assist patient with dressing, assist patient with a sponge bath or shower, foot care, trim or file any long or uneven finger and toe nails, perineal care, shampoo, shave and fall precautions, but lacked an order for home health aide frequency or duration. d. The clinical record lacked documentation of home health aide interventions provided, or a clarification order to discontinue home health aide interventions. e. Interview on 11/20/24 at 9:00 AM, Clinical Manager reported a verbal physicians order was taken by Staff D, Registered Nurse (RN), to discontinue the home health aide service effective 9/30/24, but acknowledged the interventions the home health aide was ordered to perform remained on the updated POC. The agency failed to ensure the POC accurately included the type, frequency and duration of the services the patient was receiving.”

“Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This Element is not met as evidenced by: Based on observations, clinical record reviews, agency policy review and staff interview, the agency failed to ensure the patient’s clinical record included accurate and specific documentation of interventions and maintained pertinent current information in the patient record for 3 of 4 sampled patients (Patients #2, #4 and #7) with wounds. Failure to ensure the patient’s clinical record included pertinent current and accurate documentation of interventions placed agency patients at risk for not receiving the correct interventions and for other disciplines providing services to have unclear or inaccurate information regarding the patient’s condition. Findings include: 3. Patient #7 had a start of care date of 6/12/24 and a discharge date of 7/31/24. Clinical record review revealed the following: a. The POC dated 6/12/2024 to 8/10/2024, included physician orders for skilled nursing services 1-2 times weekly for observation, assessment and education for wound management related pressure ulcers and to perform wound care/dressing change. b. The initial comprehensive assessment, dated 6/12/24, by Staff D, RN, identified a skin tear wound on the penis and included a description of the wound, but lacked measurements of the wound. c. The skilled nurse visit note, dated 6/21/24, by Staff F, RN, identified the wound on the penis as dime sized and included a description of the wound, but lacked measurements. d. The skilled nurse visit notes, dated 6/27/24, 7/3/24, 7/10/24 and 7/17/24, by Staff D, RN, included description of the wound on the penis, but lacked measurements. The skilled nurse failed to document wound measurements for the wound to the penis. The above findings shared with the Director, Assistant Director and Clinical Manager According to the agency policy titled Wound Monitoring Guidelines, dated 1/2023, agency staff are directed to document procedure, including the following, in the patient’s record: condition of wound or pressure ulcer, length, width, depth, drainage, if any, odor, if any, patient’s tolerance of procedure, condition of surrounding tissue, any tissue granulation noted, instructions provided and photo as available to support documentation with patient name and date of picture. During an interview on 11/19/24 at 3:40 PM, the Clinical Manager stated wound measurements to include length, width and depth every 7 days, unless seen by a physician or the wound clinic. 1.Patient #2 had a start of care date of 8/5/24. Clinical record review revealed the following: a. The Plans of Care (POC), dated 8/17/24 to 10/15/24 and 10/16/24 to 12/14/24, included physician orders for skilled nursing services 1-2 times weekly for physical assessment, education or wound management. b. Skilled Nurse visit notes, dated 9/17/24, 10/1/24 and 11/12/24, Staff D, Registered Nurse (RN), included documentation of a diabetic ulcer on the right posterior foot with an onset date of 6/18/23. The notes lacked documentation of wound measurements. The skilled nurse failed to document wound measurements for the wound on the patient’s right posterior foot. 2. Patient #4 had a start of care date of 9/13/24. Clinical record review revealed the following: a. The POC, dated 11/12/24 to 1/10/25, included physician orders for skilled nursing services 2 to 3 times a week to provide wound care/monitoring and management/education related to new onset type 2 diabetes. b. The POC, dated 11/12/24 to 1/10/25, lacked orders for skilled nurse frequency and included orders to provide dressing changes to the right anterior foot amputation surgical incision site. b. Skilled Nurse visit notes, dated 9/20/24, Staff E, RN, included documentation of a right anterior foot amputation surgical incision with an onset date of 9/13/24. The notes lacked documentation of wound measurements. The skilled nurse failed to document wound measurements for the wound on the patient’s right posterior foot.”