Chickasaw Co Public Health & Home Care Services

“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 staff interview, clinical record reviews and agency policy review, the agency failed to complete wound assessments for 1 of 3 sampled patients with wounds (Patient #1). Failure to accurately and thoroughly complete wound assessments placed patients at an increased risk of inappropriate treatment. Findings include: According to the agency policy titled Guidelines for Wound Measurement/Documentation/Procedures, dated 5/14/2019, wounds should be measured on the same day every week (when possible) and/or as needed to decrease discrepancies. During an interview on 9/16/25 at 2:30 PM, Staff B, Clinical Manager, reported wounds are to be measured weekly. Measurements include length, width and depth in centimeters and documentation needs to include a description of the wound. Patient #1 had a start of care date of 3/30/23. Clinical record review revealed: a. The Plan of Care (POC), dated 7/17/25 to 9/14/25, included orders for skilled nurse services. b. The recertification visit note, dated 9/12/25, by Staff C, Registered Nurse, included documentation the patient has an open area to the left lateral lower leg that originated as a blister and is decreasing in size. Wound care provided as ordered. The note failed to include documentation of measurements of the open area to the left lateral lower leg. The agency failed to document weekly measurements of the patient’s wound to left lateral lower leg. The above findings were reviewed with the Administrator and Clinical Manager.”

“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 clinical record review, agency aide supervision guidelines and agency staff interview, the agency failed to ensure a registered nurse or other appropriate health care professional completed home health aide supervision at least every 14 days for 1 of 3 sampled patients who received hands on personal care services in conjunction with a skilled service provision (Patient #3). The agency reported 9 patients who received home health aide services with every 14 day supervision. Failure to supervise home health aide services, at least every 14 days increased the risk that patients received unsatisfactory or inappropriate care from home health aides. Findings include: According to the agency’s policy titled Home Care Aide Services, dated 8/8/25, if client also receiving skilled nursing service, then supervision will occur no less than every 14 days. The aide does not have to be present. During an interview on 9/16/25 at 2:30 PM the Clinical Manager stated the nurse completes aide supervision every 14 days and documents in the visit section of the patient’s chart. Patient #3 had a start of care date of 6/27/25. The Plan of Care (POC), dated 8/26/25 to 10/24/25, included physician orders for skilled nursing and home health aide services and diagnosis of hypertensive chronic kidney disease. Review of the clinical record included the following: a. The skilled nurse visit note, dated 7/8/25, Staff C, Registered Nurse (RN), included documentation of home health aide supervision. b. The skilled nurse visit note, dated 7/23/25, Staff C, RN, included documentation of home health aide supervision 15 days after the previous home health aide supervision (1 day late). c. The skilled nurse visit note, dated 8/5/25, Staff C, RN, included documentation of home health aide supervision. d. The skilled nurse visit note, dated 8/21/25, Staff C, RN, included documentation of home health aide supervision 16 days after the previous home health aide supervision (2 days late). The agency failed to provide home health aide supervision every 14 days. The above findings were reviewed with the Administrator and Clinical Manager.”