Centerwell Home Health

“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 staff interviews, 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 9 of 17 sampled patients (Patients #1, #3, #4, #6, #10, #11, #13, #15 and #16). Failure to follow a Plan of Care established by home health clinical associates in collaboration with the patient’s physician, placed patients at risk of not receiving safe, individualized and consistent care designed to meet each patient’s health care needs. Findings include: 7. Patient #3 had a start of care date of 8/10/24. The clinical record review revealed: a. Plan of Care, dated 8/10/24 to 10/8/24, included orders for skilled nurse to observe/assess cardiovascular system and to report weight gain of 2-3 pounds per day or 5 pounds per week. b. Start of Care comprehensive assessment, dated 8/10/24, included a weight of 209 pounds. c. Skilled nurse visit notes, dated 9/3/24, 9/9/24, 9/18/24 and 9/24/24, lacked documentation of a weight obtained by the skilled nurse or weights obtained by the patient on days the skilled nurse did not visit. The skilled nurse failed to assess the patient weight on skilled nurse visits. 8. Patient #6 had a start of care date of 7/8/24. The clinical record review revealed: a. Plans of Care, dated 7/8/24 to 9/5/24 and 9/6/24 to 11/4/24, included orders for skilled nurse to observe/assess cardiovascular system and to report weight gain of 2-3 pounds per day or 5 pounds per week. b. Recertification comprehensive assessment, dated 9/4/24, lacked documentation of a weight obtained by the skilled nurse or weights obtained by the patient on days the skilled nurse did not visit. c. Skilled nurse visit notes, dated 9/9/24, 9/16/24, 9/23/24 and 9/30/24, lacked documentation of a weight obtained by the skilled nurse or weights obtained by the patient on days the skilled nurse did not visit. The skilled nurse failed to assess the patient weight on skilled nurse visits. 9. Patient #13 had a start of care date of 4/3/24 and a discharge date of 5/24/24. The clinical record review revealed: a. Plan of Care, dated 4/3/24 to 6/1/24, included orders for skilled nurse to observe/assess cardiovascular system and to report weight gain of 2-3 pounds per day or 5 pounds per week. b. Start of Care comprehensive assessment, dated 4/3/24, included a weight of 183 pounds. c. Skilled nurse visit notes, dated 4/8, 4/19, 4/26, 5/3, 5/10, 5/17 and 5/24/24, lacked documentation of a weight obtained by the skilled nurse or weights obtained by the patient on days the skilled nurse did not visit. The skilled nurse failed to assess the patient weight on skilled nurse visits. The surveyor reviewed the above findings with the Administrator and Clinical Manager. 2. Patient #1 had a start of care date of 5/23/24. The clinical record review revealed: a. The Plans of Care, dated 7/10/24 to 9/7/24 and 9/8/24 to 11/6/24, included orders for skilled nurse to observe/assess cardiovascular system and to report weight gain of 2-3 pounds per day or 5 pounds per week. b. The skilled nurse notes, dated 7/30/24, 8/2, 8/7, 8/14, 8/21, 8/27/24, 9/4, 9/12 and 9/19/24, lacked documentation of a weight obtained by the skilled nurse or weights obtained by the patient on days the skilled nurse did not visit. The skilled nurse failed to assess the patient weight on skilled nurse visits. 3. Patient #4 had a start of care date of 8/29/24. The clinical record review revealed: a. The POC, dated 8/29/24 to 10/27/24, included orders for skilled nurse to observe/assess cardiovascular system and to report weight gain of 2-3 pounds per day or 5 pounds per week. b. The skilled nurse note on admission, dated 8/29/24, included documentation of the patient’s weight of 127 pounds. c. The skilled nurse notes, dated 9/3, 9/6, 9/12, 9/16, 9/20 and 9/26/24, lacked documentation of a weight obtained by the skilled nurse or weights obtained by the patient on days the skilled nurse did not visit. The skilled nurse failed to assess the patient weight on skilled nurse visits. 4. Patient #10 had a start of care date of 8/12/24. The clinical record review revealed: a. The POC, dated 8/12/24 to 10/10/24, included orders for skilled nurse to observe/assess cardiovascular system and to report weight gain of 2-3 pounds per day or 5 pounds per week. b. The skilled nurse note on admission, dated 8/29/24, included documentation of the patient’s weight of 170 pounds. c. The skilled nurse notes, dated 9/1, and 9/3/24, lacked documentation of a weight obtained by the skilled nurse or weights obtained by the patient on days the skilled nurse did not visit. The skilled nurse failed to assess the patient weight on skilled nurse visits. 5. Patient #4 had a start of care date of 5/23/24 to 7/21/24 and date of discharge of 6/27/24. The clinical record review revealed: a. The POC, dated 5/23/24 to 7/21/24, included orders for skilled nurse to observe/assess cardiovascular system and to report weight gain of 2-3 pounds per day or 5 pounds per week. b. The skilled nurse note on admission, dated 5/23/24, included documentation of the patient’s weight of 98 pounds . c. The skilled nurse notes, dated 5/26, 5/28, 5/31/24, 6/3, 6/6, 6/10, 6/13, 6/17, 6/20 and 6/27/24, lacked documentation of a weight obtained by the skilled nurse or weights obtained by the patient on days the skilled nurse did not visit. The skilled nurse failed to assess the patient weight on skilled nurse visits. 6. Patient #16 had a start of care date of 2/21/24 and discharge date of 3/7/24. The clinical record review revealed: a. The POC, dated 2/21/24 to 4/20/24, included orders for skilled nurse to observe/assess cardiovascular system and to report weight gain of 2-3 pounds per day or 5 pounds per week. b. The skilled nurse note on admission, dated 8/29/24, included documentation of the patient’s weight of 110 pounds. c. The skilled nurse notes, dated 6/26/24, lacked documentation of a weight obtained by the skilled nurse or weights obtained by the patient on days the skilled nurse did not visit. The skilled nurse failed to assess the patient weight on skilled nurse visits. According to the agency policy titled Care Planning, dated 9/2024, the Plan of Care (POC) serves to ensure effective utilization and management of services, resources, discipline specific visit frequency and duration as needed to address a patient’s condition, skilled needs or unique situation in accordance with physician/allowed practitioner written orders. The professional disciplines must assume responsibility for providing services ordered by the physician/allowed practitioner as indicated in the POC/interim orders. 1.Patient #11 had a start of care date of 9/17/24. Clinical record review revealed the following: a. The POC, dated 9/17/24 to 11/15/24, included physician orders for skilled nursing services one time per week for one week, two times per week for four weeks and one time a week for three weeks effective 9/22/24. b. An interim physician order, dated 9/28/24, identified skilled nurse to assess/instruct on daily weight and keeping a log. Notify physician of weight gain of 2-3 pounds in 24 hours or 5 pounds in a week. If patient is unable to weigh, obtain lower extremity circumference each visit and notify physician of increase of 2 centimeters (cm) or greater. c. The skilled nurse visit note, dated 10/1/24, completed by Staff E, Licensed Practical Nurse (LPN) failed to document a weight or lower extremity circumference. The agency failed to follow interim physician orders on the POC.”

“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 home visit observations, patient interviews, staff interviews, clinical record reviews and agency policy review, the agency failed to perform complete and accurate drug regimen reviews with each comprehensive assessment and identify patient specific medication issues for 5 of 17 sampled patients (Patients #2, #4, #5, #6 and #17). 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: 5. Patient #6 had a start of care date of 7/8/24. The clinical record review revealed the recertification comprehensive assessment, dated 9/4/24, lacked documentation of a drug regimen review. The skilled nurse failed to complete a drug regimen review with the recertification comprehensive assessment. The surveyor reviewed the above findings with the Administrator and Clinical Manager. 4. Patient #3 had a start of care date of 8/29/24. Clinical record review revealed the following: a. The POC, dated 8/29/24 to 10/27/24, included orders for medications and skilled nursing services. b. The agency medication list, dated 10/1/24, included orders for levothyroxine 75 mcg 1 time weekly on Sunday. The list documented a DRR completed on 8/31/24 and 9/2/24. c. The assisted living medication list, dated 10/1/24, included orders for levothyroxine 75 mcg 1 time weekly on Sunday and levothyroxine 150 mcg on Monday, Tuesday, Wednesday, Thursday, Friday and Saturday. The agency failed to include all medications during the DRR. According to the agency policy titled Medication Review and Documentation, dated 10/2022, the home health agency will assess all medications the patient is taking, both prescription and over the counter (OTC). A drug regimen review (DRR) and medication reconciliation will include all patient medications and will be performed during the initial comprehensive assessment, each comprehensive assessment thereafter and when a new medication is added to the patient plan of care. All medication and all issues/concerns will be reported to the patient’s physician/allowed practitioner to include the following: dosage errors, omissions, drug reactions, duplicate therapy, ineffective drug therapy, non compliance issues, side effects and drug interactions. On 10/1/24 at 1:39 PM, an interview with the Administrator and Clinical Manager identified DRRs are completed at start of care, recertifications, resumptions of care and discharges. 1.Patient #2 had a start of care date of 7/29/24. Clinical record review revealed the following: a. The Plan of Care (POC), dated 9/27/24 to 11/25/24 included physician orders for medications and skilled nursing services. b. The recertification comprehensive assessment, dated 9/23/24, completed by Staff G, Registered Nurse (RN), identified a DRR was completed and no changes were made to medications. c. During a home visit observation on 10/1/24 at 8:00 AM, with Staff E, Licensed Practical Nurse (LPN), an interview with the patient revealed the patient sets up his/her own medication. The patient identified the following medication discrepancies: 1)The POC identified the patient takes Gabapentin 600 milligram (mg) tablets with instructions to take one tablet by mouth three times a day. The bottle in the home is Gabapentin 400mg capsules take one capsule by mouth three times a day. The bottle was last filled on 8/8/24. Patient reports taking the medication per the instruction on the bottle. 2) The POC identified the patient has a Lidocaine pain relief 4% topical patch with instructions to apply one patch every morning. The patient reported he/she does not have pain patches in the home and hasn’t utilized them since returning from the hospital on 9/20/24. 3) The POC identified the patient takes Melatonin 3mg tablets with instructions to take one tablet by mouth at bedtime. The patient reported that he/she has not taken melatonin for one or two months. 4) The POC identified the patient takes Methocarbamol 750mg tablets with instructions to take one tablet by mouth three times daily. The patient reported he/she didn’t know what that medication was and thinks it was something he/she was given while hospitalized. 5) The POC identified the patient takes Tylenol extra strength 500mg tablets with instructions to take two tablets by mouth three times daily. The patient reported he/she takes Tylenol 325 mg tablets as needed. The DRR failed to include an accurate review of all the medications taken by the patient. 2.Patient #5 had a start of care date of 6/4/24. Clinical record review revealed the following: a. The POCs, dated 8/3/24 to 10/1/24 and 10/2/24 to 11/30/24 included physician orders for medications and skilled nursing visits. b. The recertification comprehensive assessments, dated 7/30/24 and 9/27/24, completed by Staff G, RN, identified a DRR was completed and no changes were made to medications. c. During a home visit observation and interview on 10/2/24 at 10:00 AM, with Staff G, RN, an interview with the patient revealed the patient’s daughter sets up his/her medication. The surveyor identified the following medication discrepancy: The POCs identified the patient takes Oxybutynin Chloride 2.5mg tablets with instructions to take one tablet by mouth three times a day. The bottle in the home is Oxybutynin Chloride 5mg tablets take one tablet by mouth one time a day. The bottle was last filled on 6/3/24. An interview with Staff G, RN, revealed she was unaware of the discrepancy. The DRR failed to include an accurate review of medications taken by the patient. 3.Patient #7 had a start of care date of 9/17/24. Clinical record review revealed the following: a. The POC, dated 9/17/24 to 11/15/24, included physician orders for medications, skilled nursing visits, physical therapy and occupational therapy. b. The initial comprehensive assessment, dated 9/17/24, completed by Staff C, RN, included documentation a DRR was completed. c. During a home visit observation on 10/1/24 at 11:30 AM, with Staff D, Occupational Therapist (OT), an interview with the patient revealed the patient sets up his/her own medication. The patient identified the following medication discrepancies: 1) The POC identified the patient takes Eliquis 2.5mg tablets with instructions to take one tablet by mouth two times daily. The patient reported this was discontinued upon discharge from the nursing home on 9/10/24. 2) The POC identified the patient takes Ergocalciferol (Vitamin D2) 1,250 micrograms (mcg) capsules with instructions to take one capsule by mouth two times a week; Sunday and Thursday. The bottle in the home says Ergocalciferol 1,250mcg capsules take one capsule by mouth once a week. The bottle was last filled on 6/20/24. The patient reported he/she has taken the medication per the instruction on the bottle for several years. 3) The POC identified the patient takes Metformin Extended Release (ER) 500mg tablets with instructions to take two tablets by mouth every evening. The bottle in the home says Metformin ER 500mg tablets take four tablets by mouth every evening. The medication was last filled on 6/19/24. The patient reported he/she has taken the medication per the instruction on the bottle for several years. 4) The POC failed to identify the patient is taking Pioglitazone Hydrocholoride (HCL) 30mg tablets with instructions to take one tablet by mouth every day. The bottle was filled last on 6/4/24. Patient reported he/she has taken this medication for several years. 5) The POC failed to identify the patient is taking Pantoprazole Sodium (SOD) 40mg tablets with instructions to take one tablet by mouth every day. The bottle was filled last on 9/30/24. Patient reported he/she has taken this medication for several years. 6) The POC failed to identify the patient is taking Simvastatin 20mg tablets with instructions to take one tablet by mouth at bedtime. The bottle was filled last on 5/16/24. Patient reported he/she has taken this medication for several years. 7) The POC failed to identify the following supplements the patient is taking: Fish Oil 1000mg softgels, Psyllium Husk 500mg capsules, Ceylon Cinnamon 1800mg capsules, CoQ10 200mg capsules and Chromium Picolinate 200mcg tablets. The agency failed to identify the medication discrepancies during the DRR on 9/17/24.”

“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 home visit observations, patient interviews, clinical record reviews and agency policy reviews, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies/equipment used by the patient for 5 of 17 sampled patients (Patients #2, #4, #7, #15 and #16). Failure to maintain complete and accurate Plans of Care with current orders placed patients at risk to not receive services, medications, supplies and/or treatments according to assessed needs and physician orders. Findings include: 3. Patient #4 had a start of care date of 8/29/24. Clinical record review revealed the following: a. The POC, dated 8/29/24 to 10/27/24, included the following DME used by the patient: cane, elevated toilet seat, quad cane, rails/grab bars, Reacher, scale, shower/tub equipment, support surfaces, table/chair, vital sign equipment, walker, wheelchair, dressing-alginate/hydro fiber, foam, gauze, gauze border, gauze rolled, honey, hydrocolloid, silver alginate, silver foam, gloves, moisturizer, skin protectant, wound cleanser. b. The skilled nurse visit note at admission, dated 8/29/24, identified the patient incontinent of urine. c. During a home visit observation on 10/1/24 at 10:30 AM, with Staff F, Physical Therapist, the surveyor identified the following DME in the home: incontinent briefs. The POC failed to include the DME incontinent briefs. 4. Patient #15 had a start of care date of 5/23/24 and discharge from the agency on 6/27/24. Clinical record review revealed the following: a. The POC, dated 5/23/24 to 7/22/24, included the following DME used by the patient: cane, commode, elevated toilet seat, rails/grab bars, Reacher, scale, shower/tub equipment, walker-rolling, wheelchair, wheelchair cushion, wheelchair-powered, alginate/hydro fiber, cotton applicator, foam dressing, gauze, hydrofera and cleanser b. The skilled nurse visit note at admission, dated 5/23/24, identified the patient incontinent of bowel and bladder. The note also identified the patient utilized a shoe horn, sock aide and leg lifting strap. The POC failed to include the DME incontinent supplies, shoe horn, sock aide and leg lifting strap. 5. Patient #16 had a start of care date of 2/21/24 and discharge from the agency on 3/7/24. Clinical record review revealed the following: a. The POC, dated 2/21/24 to 4/20/24, included the following DME used by the patient: commode, roho w/c cushion, scale, vital signs equipment, walker, foam dressing, gauze, wound cleanser. b. The skilled nurse visit note at admission, dated 2/21/24, identified the patient utilized grab bars and a wheelchair. The POC failed to include the DME grab bars and wheelchair. The above items shared with the Administrator and clinical manager. According to the agency policy titled Care Planning, dated 9/2024, the individualized plan of care is developed for the patient 60 day episode of care and must include (but is not limited to): types of services, supplies and equipment required, all medications and treatments, discipline specific visits, frequency and duration, rehabilitation potential and nutritional requirements. 1.Patient #2 had a start of care date of 7/29/24. Clinical record review revealed the following: a. The Plans of Care (POC), dated 7/29/24 to 9/26/24 and 9/27/24 to 11/25/24 included the following durable medical equipment (DME) used by the patient: Diabetic supplies, elevated toilet seat, oxygen/oxygen supplies, rails/grab bars, reacher (grabbing device), respiratory supplies, scooter, shower/tub equipment, supports/braces, lift chair, walker with wheels and wheelchair. b. During a home visit observation on 10/1/24 at 8:00 AM, with Staff E, Licensed Practical Nurse (LPN), the surveyor identified the following DME in the home: Medication cassette (container for holding medication), blood pressure cuff, scale and lifeline button. During this same visit, an interview with the patient revealed he/she has been utilizing the medication cassette, blood pressure cuff, scale and lifeline button for approximately 5 months (when he/she moved into the assisted living facility). The POC failed to include the DME medication cassette, blood pressure cuff, scale and lifeline button. 2.Patient #7 had a start of care date of 9/17/24. Clinical record review revealed the following: a. The POC, dated 9/17/24 to 11/15/24, included the following DME used by the patient: Diabetic supplies, commode, continuous positive airway pressure (CPAP) machine, elevated toilet seat, glucometer, grab bars, reacher, respiratory supplies, roho cushion (pressure ulcer prevention) for wheelchair, scale, shower/tub equipment, supports/braces, vital sign equipment, walker and incontinent supplies. b. During a home visit observation on 10/1/24 at 11:30 AM, with Staff D, Occupational Therapist (OT), the surveyor identified the patient was using medication cassettes. During this same visit, an interview with the patient revealed he/she has been utilizing the medication cassettes for years. The POC failed to identify the DME medication cassettes.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on observations, staff interviews, clinical record reviews and agency policy reviews, the agency failed to update the Plan of Care with new physician orders for 8 of 17 sampled patients with interim physician orders (Patients #1, #3, #6, #9, #11, #12, #13 and #15). Failure to update the Plan of Care increased the potential for medication errors in administration and/or inaccurate provision of care. Findings include: 4. Patient #3 had a start of care date of 8/10/24. The clinical record review revealed: a. Plan of Care, dated 8/10/24 to 10/8/24, included orders for skilled nurse to perform/teach wound care to right lower extremity and left lower extremity stasis ulcer, cleanse with normal saline, apply wound gel, cover with nonstick pad, secure with rolled gauze and tape. b. Interim physician order, dated 8/13/24, included orders for wound location right lower foot, left foot malleolus and inner sole of foot, cleanse with normal saline, periwound skin prep, apply aquacell, apply small amount saline to activate, gauze pad, secure with roll gauze and paper tape; and left inner ankle, cleanse with normal saline, periwound skin prep, apply medihoney (medical grade honey used for wound care), non-woven gauze 4x4, roll gauze, secure with paper tape. c. Interim physician order, dated 8/30/24, included orders for left medial ankle, left lateral ankle, right lateral calcaneus and right lateral lower leg, clean with normal saline, mepilex AG foam (antimicrobial foam dressing with silver), conforming rolled gauze, secure with paper tape. d. Interim physician order, dated 9/16/24, included orders for left medial ankle, left lateral ankle, right lateral calcaneus, right lateral lower leg and left posterior lower leg, clean with normal saline, paint peri-wound with iodine and allow to dry, AG foam dressing cut slightly larger than wound, ABD pad, conforming rolled gauze secured with paper tape. e. Interim physician order, dated 9/20/24, included orders for left medial ankle, clean with normal saline, AF foam cut slightly larger than wound, ABD pad, conforming rolled gauze and paper tape; left lateral ankle, clean with normal saline, AG foam cut slightly larger than wound, conforming rolled gauze and paper tape; right lateral calcaneus, right lateral lower leg, left posterior lower leg, paint peri-wound with iodine and allow to dry, conforming rolled gauze and secure with paper tape. f. Interim physician order, dated 9/27/24, included orders for left medial ankle and left lateral ankle, clean with normal saline, AG foam cut slightly larger than wound, conforming rolled gauze and paper tape; right lateral calcaneus, right lateral lower leg and left posterior lower leg, paint peri-wound with iodine and allow to dry, conforming rolled gauze and secure with paper tape. g. Updated Plan of Care, dated 10/3/24, lacked documentation of the current wound care orders. The skilled nurse failed to update the plan of care with all interim physician orders. 5. Patient #6 had a start of care date of 7/8/24. The clinical record review revealed: a. Plan of Care, dated 9/6/24, included orders for skilled nurse to perform/teach wound care to right posterior lower leg, right medial lower leg and right lateral distal lower leg, clean with normal saline, aquacel AG, ABD pad, wrap with kerlix, secure with paper tape, apply tubigrip (compression stocking) size G 2 layers; right medial ankle and right anterior lower leg, clean with normal saline or vashe (wound cleanser), aquacel AG, ABD, wrap with kerlix, secure with paper tape, apply tubigrip size G 2 layers; left medial lower leg, clean with normal saline or vashe, aquacel AG, ABD pad and multilayer compression wrap lite. b. Interim physician order, dated 9/6/24, included orders for left medial lower leg, cleanse with normal saline or vashe as directed, aquacel AG, ABD pad, rolled gauze and tape, compression tubigrip size F 2 layers; right posterior lower leg, right medial lower leg, right lateral distal lower leg and right posterior lower leg, clean with normal saline, aquacel AG, multilayer compression wrap lite. c. Interim physician order, dated 9/13/24, included orders for left medial lower leg, clean with normal saline or vashe as directed, aquacel AG, ABD pad, secure with rolled gauze and tape, apply tubigrip size F 2 layers; right posterior lower leg, right medial lower leg, right lateral distal lower leg, right lower leg, right posterior lower leg, clean with normal saline, AG foam dressing, ABD pad, secure with kerlix and tape, apply tubigrip size F 2 layers. d. Interim physician order, 9/27/24, included orders for left medial lower leg, right medial lower leg, right lateral distal lower leg, right lower leg, right posterior lower leg, left lateral lower leg, cleanse with normal saline, AG foam dressing, ABD pad, secure with rolled gauze and tape, apply tubigrip size F 2 layers. e. Updated Plan of Care, dated 10/3/24, lacked documentation of the current wound care orders. 6. Patient #9 had a start of care date of 8/28/24. The clinical record review revealed: a. Plan of Care, dated 8/28/24 to 10/25/24, included orders for skilled nurse to perform/teach pressure ulcer care to posterior left leg and right lateral leg, cleanse with soap and water, rinse, pat dry, apply triad hydrophilic wound paste to the wound bed and skin directly around the wound bed, cut plain foam (mepilex dressing) to be 2 centimeters (cm) larger than wound base on all sides and apply, secure in place with kerlix and tape; right posterior heel, left posterior proximal leg and left posterior heel, cleanse with normal saline, pat dry, cut plain foam to be 2 cm larger than wound base on all sides and apply, secure in place with kerlix and tape. Skilled nurse to perform/teach wound care to right lateral thigh surgical wound, cleanse with soap and water, rinse and let dry, apply triad hydrophilic wound paste to wound bed and skin directly around wound bed, cut plain foam to be 2 cm larger than wound base on all sides and apply, secure with tape. b. Interim physician order, dated 9/5/24, included orders patient allowed 50 pounds weight bearing the next 2 weeks, then 100 pounds until follow up appointment. Pull back if painful, must use brace when up, modalities okay. c. Interim physician order, dated 9/10/24, included orders for right lateral upper leg, clean with normal saline or soap and water, dermacol AG (antimicrobial silver dressing) to wound bed, cover with ABD pad, secure with medipore tape; left posterior lower leg, clean with normal saline or soap and water, apply triad paste to wound bed, calmoseptine to periwound, cover with foam dressing, secure with roll gauze and tape; right heel and left heel, cleanse with normal saline or soap and water, cover with foam dressing, secure with roll gauze and tape. Heel suspension boot to bilateral feet or float heels at all times. d. Interim physician order, dated 9/16/24, included orders for skilled nurse to remove foley catheter due to leaking, if further problems with urination, patient will need to be seen by physician. e. Interim physician order, dated 9/18/24, included orders for right heel and left heel, cleanse with normal saline or soap and water, place collagen AG into wound, cover with foam dressing, secure with roll gauze and tape. f. Interim physician order, dated 9/26/24, included orders for right lateral upper and lower leg, clean with normal saline or soap and water, dermacol AG to wound bed, cover with ABD pad, secure medipore tape; left posterior lower leg, wound vac applied, leave in place for 1 week. g. Updated Plan of Care, dated 10/3/24, lacked documentation of the current wound care orders and all interim physician orders. 7. Patient #12 had a start of care date of 8/5/24. The clinical record review revealed: a. Plan of Care, dated 8/5/24 to 10/3/24, included orders for physical therapy and occupational therapy services. b. Interim physician order, dated 8/15/24, included order for missed physical therapy visit on 8/15/24 and make up missed visit the week of 8/18/24. c. Interim physician order, dated 9/24/24, included order for missed occupational therapy visit on 9/20/24, visit to not be made up. d. Updated Plan of Care, dated 10/3/24, lacked documentation of the missed and extra therapy visits. 8. Patient #13 had a start of care date of 4/3/24 and a discharge date of 5/24/24. The clinical record review revealed: a. Plan of Care, dated 4/3/24 to 6/1/24, included orders for skilled nurse to perform/teach wound care to left lower extremity stasis ulcer, cleanse with normal saline, apply Silvadene cream, cover with ABD pads, secure with rolled gauze and tape. b. Interim physician order, dated 4/10/24, included order to left lower leg, clean with saline, Silvadene cream, cover with ABD pad, wrap with kerlix, secure with tape, apply tubigrip size F on during the day may remove at bedtime. c. Interim physician order, dated 4/19/24, included order for skilled nurse to check INR (International Normalized Ratio-blood test measuring how long it takes for blood to clot) 4/29/24 during next scheduled skilled nurse visit. d. Interim physician order, dated 4/29/24, included order for skilled nurse to check INR on 5/28/24. e. Interim physician order, dated 5/17/24, included order for skin tear to right arm, cleanse with saline, apply bordered foam dressing. f. Interim physician order, dated 5/24/24, included order for missed physical therapy visit 5/17/24 that will not be made up due to discharge plan. g. Interim physician order, dated 5/24/24, included order for missed occupational therapy visit 5/17/24 that will not be made up due to patient request. h. Updated plan of care, dated 10/7/24, lacked documentation of the current wound care orders and all interim physician orders. The surveyor reviewed the above findings with the Administrator and Clinical Manager. 2. Patient #1 had a start of care date of 7/10/24. Clinical record review revealed the following: a. The POC, dated 7/10/24 to 9/7/24 and 9/8/24 to 11/6/24, included physician orders for skilled nursing and physical therapy services. b. The interim physicians order, dated 7/11/24, included orders to teach intermittent catheterization with 16 size Fr catheter daily and as needed for urinary retention. c. The updated plan of care, dated 7/10/24 to 9/7/24, failed to include the interim order for catheter size. The clinical record lacked documentation of plan of care updates for the catheter order. 3. Patient #15 had a start of care date of 5/23/24 and discharge date of 6/27/24. Clinical record review revealed the following: a. The POC, dated 5/23/24 to 7/21/24, included physician orders for skilled nursing, physical therapy, occupational and home care aide services. b. The interim physicians order, dated 6/24/24, included orders to cleanse the pressure ulcer to sacral region with saline. Pat dry, apply sacral foam bordered dressing of size. Change dressing twice weekly and as needed if loose or soiled. The order also included to cleanse the blister to right great toe with saline, pat dry. Apply idosorb gel to wounds. Cover with non woven gauze and secure with tape. Change dressing twice weekly and as needed if loose or soiled. c. The updated plan of care, dated 5/27/24 to 7/21/24, failed to include the orders for wound care. The clinical record lacked documentation of plan of care updates for the catheter order. According to the agency’s policy titled Care Planning, dated 9/2024, the Plan of Care (POC) will be developed in collaboration with the physician/allowed practitioner and home health clinical associates following the initial/comprehensive assessment and will contain integrated orders from all physicians or allowed practitioners involved in the POC to assure coordination of all services and interventions provided to the patient. The POC will be reviewed and updated as necessary to meet the changing needs of the patient in the most effective and efficient manner to achieve desired outcomes. The POC will be sent to the physician/allowed practitioner for review and signature when updates occur (examples: change orders, interim orders) and at time of recertification. 1.Patient #11 had a start of care date of 9/17/24. Clinical record review revealed the following: a. The POC, dated 9/17/24 to 11/15/24, included physician orders for skilled nursing, physical therapy and occupational therapy services. b. The resumption of care comprehensive assessment, dated 9/28/24, completed by Staff C, Registered Nurse (RN), identified the patient was discharged from the hospital on antibiotics and Furosemide. c. During an interview on 10/3/24 at 11:10 AM, the Administrator printed the patient’s discharge instructions, dated 9/26/24, from the hospital that identified the patient is to take Furosemide 40 milligram (mg) tablets with instructions to take one tablet orally one time a day and Cephalexin 500mg capsules with instructions to take one capsule four times daily. The clinical record lacked documentation of plan of care updates for the medication changes.”

“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, clinical record review and agency policy review, the agency failed to follow physician orders for wound care for 3 of 12 sampled patients with wounds (Patient’s #3, #6 and #13). 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. Findings include: According to the agency policy, titled Wounds: Assessment/Care/Clinical Oversight, dated 08/2024, for all wound/post-operative care/dressings, a physician/allowed practitioner order will be obtained a part of the patient plan of care. Physician/allowed practitioner written orders will specify: cleansing agent, products/treatments, specific sites/locations, outer dressing to be applied, treatment frequency, and discipline to perform treatment. During an interview on 10/1/24 at 1:39 PM, Clinical Manager reported clinicians document wound care provided on visit notes. 1. Patient #3 had a start of care date of 8/10/24. The clinical record review revealed: a. Plan of Care, dated 8/10/24 to 10/8/24, included orders for skilled nursing visits one time a week. b. Interim physician order, dated 9/27/24, included wound location left medial ankle, cleanse with normal saline, primary dressing AG foam (antimicrobial foam dressing with silver) cut slightly larger than wound, secure with conforming rolled gauze and paper tape; wound location left lateral ankle, cleanse with normal saline, primary dressing AG foam cut slightly larger than wound, secure with conforming rolled gauze and paper tape. During a home observation visit on 10/1/24 at 9:00 AM with Staff C, RN (registered nurse), surveyor observed Staff C, RN complete wound care to left medial and lateral ankle. Staff C, RN, cleansed wounds with normal saline, cut AG foam dressing and placed on wounds, placed ABD (abdominal gauze) pad over medial ankle wound and secured with conforming gauze and paper tape. Staff C, RN, applied ABD pad to left medial ankle wound. Staff C, RN, failed to complete wound care as ordered to the left medial ankle wound. 2. Patient #6 had a start of care date of 7/8/24. The clinical record review revealed: a. Plan of Care, dated 9/6/24 to 11/4/24, included orders for skilled nursing visits one time a week. b. Interim physician order, dated 9/27/24, included wound location left medial lower leg, clean with normal saline, AG foam dressing, ABD pad, secure with rolled gauze and tape, compression tubigrip size F 2 layers; and wound location left lateral lower leg, right medial lower leg, right lateral distal lower leg, right lower leg, right posterior lower leg; clean with normal saline, AG foam dressing, ABD pad, secure with kerlix and tape, compression tubigrip size F 2 layers. During a home observation visit on 10/2/24 at 2:00 PM with Staff C, RN, surveyor observed Staff C, RN complete wound care to all wounds. Staff C, RN, removed the old dressings and cleaned all wounds with Vashe wound cleanser, placed AG foam dressing, covered with ABD pad, secured with rolled gauze and tape, applied compression tubigrip size F 2 layers. Staff C, RN, cleaned all wounds with Vashe wound cleanser instead of normal saline. Staff C, RN, failed to complete wound care as ordered. 3. Patient #13 had a start of care date of 4/3/24 and a discharge date of 5/24/24. The clinical record review revealed: a. Interim physician order, dated 4/18/24, included wound location left lower leg, clean with saline, Silvadene cream, cover with ABD pad, wrap with kerlix, secure with tape, cover with tuibgrip size F during the day may remove at bedtime. b. Skilled nurse visit note, dated 4/19/24, included wound cleansed with saline, Silvadene cream, covered with ABD pad, wrapped with kerlix, secured with tape. c. Interim physician order, dated 5/1/24, included wound location left lower leg, clean with saline, Silvadene cream, cover with 2 ABD pads, wrap with kerlix, secure with tape, cover with tuibgrip size F during the day may remove at bedtime. d. Skilled nurse visit note, dated 5/3/24, included wound cleansed with saline, Silvadene cream, covered with 2 ABD pads, wrapped with kerlix, secured with tape. e. Interim physician order, dated 5/8/24, included wound location left lower leg, clean with saline, Silvadene cream, cover with 2 ABD pads, wrap with rolled gauze, secure with tape, cover with tuibgrip size F during the day may remove at bedtime. f. Skilled nurse visit note, dated 5/10/24, included wound cleansed with saline, Silvadene cream, covered with 2 ABD pads, wrapped with rolled gauze, secured with tape. g. Interim physician order, dated 5/16/24, included wound location left lower leg, clean with saline, dakins dampened gauze dressing, cover with 2 ABD pads, secure with rolled gauze and tape, cover with tubigrip size F during the day may remove at bedtime. h. Skilled nurse visit note, dated 5/17/24, included wound cleansed with saline, Silvadene cream, covered with 2 ABD pads, wrapped with rolled gauze, secured with tape. The skilled nurse failed to complete wound care as ordered. The above findings were reviewed with the Administrator and Clinical Manager.”

“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 observation, clinical record review, agency policy review and staff interview, the agency failed to ensure the patients clinical record included accurate and specific documentation of interventions and maintained pertinent current information in the patient record for 6 of 12 sampled patients (Patients #1, #2, #6, #8, #9 and #15) 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. 5. Patient #6 had a start of care date of 7/8/24. The clinical record review revealed: a. Plan of Care, dated 9/6/24, included orders for skilled nurse to perform/teach wound care. b. Skilled nurse visit note, dated 9/23/24, included wound measurements for right mid pretibial and right multi/scat mid pretibial wounds and documentation wound measurements not due for left mid pretibial wound. Skilled nurse failed to document weekly wound measurements. 6. Patient #9 had a start of care date of 8/28/24. The clinical record review revealed: a. Plan of Care, dated 8/28/24 to 10/25/24, included orders for skilled nurse to perform/teach pressure ulcer care and wound care. b. Start of Care comprehensive assessment, dated 8/28/24, included documentation of right heel pressure ulcer, measured 1.4 centimeters (cm) x 1.5 cm x 0 cm, with a depth description of partial thickness; and left medial proximal calf pressure ulcer, measured 0.3 cm x 0.3 cm x 0 cm, with a depth description of partial thickness. c. Skilled nurse visit note, dated 9/4/24, included documentation of right heel pressure ulcer, measured 1.5 cm x 2 cm x 0 cm, with a depth description of full thickness; and left heel pressure ulcer, measured 0.7 cm x 1.2 cm x 0 cm, with a depth description of full thickness. d. Skilled nurse visit note, dated 9/19/24, included documentation of left heel pressure ulcer, measured 0.5 cm x 1 cm x 0 cm, with a depth description of partial thickness. e. Skilled nurse visit note, dated 9/24/24, included documentation of left heel pressure ulcer, measured 0.3 cm x 0.3 cm x 0 cm, with a depth description of partial thickness. The skilled nurse failed to accurately document wound depth. The surveyor reviewed the above findings with the Administrator and Clinical Manager. 2. Patient #1 had a start of care date of 7/10/24. The clinical record review revealed: a. The POCs, dated 7/10/24 to 9/7/24 and 9/8/24 to 11/6 24, included orders for skilled nurse to perform/teach wound care. b. Skilled nurse visit note, dated 8/27/24, included wound measurements for the wound to the right buttock. The wound measured 0.1 centimeters (cm) length by 0.1 cm width by 0 cm depth. The wound identified the depth of the wound a partial thickness. c. Skilled nurse visit note, dated 9/12/24, included wound measurements for the wound to the right buttock that measured 0.2 cm length by 0.2 cm width by 0 cm depth with partial thickness wound identified. The wound to the left lower buttock measured 0.6 cm by 0.8 cm by 0 with partial thickness wound identified. The skilled nurse failed to document complete weekly wound measurements to include depth measurements. 3. Patient #1 had a start of care date of 8/5/24. The clinical record review revealed: a. The POC, dated 8/5/24 to 10/3/24, included orders for skilled nurse to perform/teach wound care. b. The skilled nurse visit note, dated 8/5/24, included wound measurements for the wound to the right anterior pretibial mid venous stasis ulcer. The wound measured 4 cm length by 4 cm width by 0 cm depth. The wound identified the depth of the wound a partial thickness. The skilled nurse failed to document complete weekly wound measurements to include depth measurements. 4. Patient #15 had a start of care date of 5/23/24 and discharge date of 6/27/24. The clinical record review revealed: a. Plan of Care, dated 5/23/24 to 7/21/24, included orders for skilled nurse to perform/teach wound care. b. The skilled nurse visit note, dated 6/13/24, included documentation the patient had a new intact blister on the left great toe. The note lacked documentation of measurements of the wound. c. The skilled nurse visit note, dated 6/20/24, included documentation the patient had a new non intact blister on the top of the left great toe and a non intact blister on the bottom of the right great toe. The note also identified the sacral area deteriorated and had an open area. The note lacked documentation of measurements of any of the wounds. The skilled nurse failed to document complete weekly wound measurements to include depth measurements. According to the agency policy titled Wounds: Assessment/Care/Clinical Oversight, dated 8/2024, Registered Nurses (RNs) perform the initial assessment for open wounds and surgical incisions upon admission and as ordered by the physician. Wound dressings will be removed to assess wounds unless a physician order is received restricting dressing removal. A Licensed Practical Nurse (LPN) may provide treatment and collect data on wound status as assigned by the RN. Wound assessments will be performed as ordered by the physician but no less than once weekly. Wound assessments will include general observations, drainage amount and type, wound bed appearance and surrounding skin condition. At least weekly, the assessments will include wound measurements (length by width by depth in centimeters). Review of the agency’s policy titled Care Planning, dated 9/2024, identified the LPN may collect data on wound status. The RN is responsible for reassessment visits every two week to include verification of data collected/reported and evaluate effectiveness of the current care regimen to ensure progress toward goals. 1.Patient #2 had a start of care date of 7/29/24. a. The Plan of Care (POC), dated 9/27/24 to 11/25/24, included physician orders for skilled nursing services one time a week to observe skin tear to left arm weekly for skin integrity monitoring effective 9/29/24. b. During a home visit observation on 10/1/24 at 8:00 AM, with Staff E, LPN, Staff E identified the wound was covered and she would not uncover it; she would communicate with the assisted living staff regarding the wound. c. A skilled nurse visit note, dated 10/1/24, completed by Staff E, LPN, identified she observed the wound, the assisted living facility staff is providing daily wound care, and the patient tolerated wound observation without complaints of pain or discomfort. Staff E, LPN reported the wound was not due to be measured. The agency failed to remove the dressing to observe the wound weekly per physician orders and failed to obtain weekly measurements per the agency policy.”