Unitypoint at Home

“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 clinical record review and agency staff interview, the agency failed to update the Plan of Care with all new physician orders for 1 of 5 sampled patients with interim orders. (Patient #2). Failure to update the Plan of Care increased the potential for medication errors in administration or inaccurate provision of care. Findings include: Patient #2 had a start of care date of 7/30/23 and a discharge date of 6/19/24. Clinical record review revealed: a. Plan of Care, dated 7/30/23 to 9/27/23, included an order for staff to not measure depth of wounds. b. Plans of Care, dated 9/28/23 to 11/26/23, 11/27/23 to 1/25/24, 1/26/24 to 3/25/24, 3/26/24 to 5/24/24 and 5/25/24 to 7/23/24, lacked an order for staff to not measure depth of wounds. During an interview on 7/24/24 at 10:35 AM, Staff C, Clinical Supervisor reported wound depths were not measured per a recommendation from Wound Clinic provider, this is not a physician order and would not be identified in the clinical record. During an interview on 7/24/24 at 1:44 PM, Staff B, Clinical Manager reported initial Plan of Care, dated 7/30/23 to 9/27/23, included an order for staff to not measure depth of wounds. This order fell off the recertification Plan of Care, dated 9/28/23 to 11/26/23, and all following plans of care for the episode. The agency did not document all verbal orders on a working care plan as required by regulation. The surveyor reviewed the above stated findings with Staff A, Administrator, and Staff B, Clinical Manager. The agency provided no additional information prior to the end of the survey.”

“Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient’s updated comprehensive assessment, and contain information concerning the patient’s progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This Element is not met as evidenced by: Based on clinical record review, agency policy review and agency staff interview, the agency failed to include current information regarding wounds from the patient’s updated comprehensive assessment concerning the patient’s progress toward the measurable outcomes and goals identified by the agency and patient in the revised plan of care for 1 of 3 sampled patients with wounds (Patients #2 and #5). Failure to include current assessment information pertaining to patient’s progress toward identified outcomes/goals placed patients at risk of receiving inadequate or inappropriate care. Findings include: According to the agency process manual, titled Wound Collaborative Management, dated 3/27/23, identified skin alterations requiring monitoring and management are photographed and measured a minimum of weekly with skilled assessments, significant changes in condition and at OASIS time points. The wound assessment will need to contain measurements, including length, width, and depth. Wound measurement of length, width and depth will be completed weekly. Open areas with skin loss have depth. Wound with superficial loss of epithelial layer; the depth measurement should be documented as “0.1 cm” (centimeter). Fluid filled blisters or other raised lesions require documentation of length and width and enter “0” for depth. During an interview on 7/24/24 at 10:35 AM, Staff A, Administrator reported the agency staff are unable to enter a “0” for depth measurement in the current electronic medical record, staff are expected to leave this area blank for wounds with no depth or wounds that are unable to be measured. 1. Patient #2 had a start of care date of 7/30/23 and a discharge date of 6/19/24. Clinical record review revealed: a. Skilled nursing visit notes, dated 5/15/24 and 6/12/24, included documentation patient instructed in wound care and verbalized understanding of strategies to prevent infection, but lacked documentation of wound measurements. b. Skilled nursing visit note, dated 5/17/24, included documentation wound care performed per orders, but lacked documentation of wound measurements. Clinical record lacked wound measurements for the weeks starting 5/12/24 and 6/9/24. c. Skilled nursing visit notes, dated 5/8/24 and 5/29/24, included documentation wound care completed as ordered for scrotal incision, perianal wound and abdominal wound; abdominal wound measured 6 cm by 2 cm but lacked a wound depth; and scrotal incision and perianal wound lacked measurements. d. Recertification comprehensive assessment visit note, dated 5/22/24, included documentation wound care completed, abdominal wound measured 4 cm by 1.8 cm but lacked a wound depth; and scrotal incision and perianal wound lacked measurements. Clinical record lacked complete wound measurements for the weeks starting 5/5/24, 5/19/24 and 5/26/24. During an interview on 7/24/24 at 1:44 PM, Staff A, Administrator and Staff B, Clinical Manager, reported home health staff are able to view wound measurements taken at the wound clinic in the electronic medical record, they do not document these measurements in the home health clinical record. During an interview on 7/24/24 at 3:48 PM, Wound Clinic provider reported 2 of the wounds were fistulas and were ordered to not measure a wound depth, the abdominal wound would be able to have a depth measured. 2. Patient #5 had a start of care date of 6/3/24 and a discharge date of 7/19/24. Clinical record review revealed: a. Start of Care comprehensive assessment visit note, dated 6/3/24, included documentation wound care completed to left foot, but lacked documentation of wound measurements. b. Skilled nursing visit notes, dated 6/10/24, 6/14/24 and 6/28/24, included documentation left foot incision dressing changed, but lacked documentation of wound measurements. c. Skilled nursing visit notes, dated 6/12/24 and 6/24/24, included documentation left foot incision wound cares done per orders, but lacked documentation of wound measurements. Clinical record lacked wound measurements for the weeks starting 6/3/24, 6/10/24 and 6/23/24. During an interview on 7/24/24 at 2:32 PM, Staff B, Clinical Manager reported she reviewed the clinical record and confirmed no wound measurements were completed at the start of care on 6/3/24. d. Skilled nursing visit notes, dated 6/17/24, included documentation of new wound to right foot toe, measured 2.5 cm by 3 cm but lacked depth measurement. e. Skilled nursing visit notes, dated 6/19/24 and 6/21/24, included documentation wound cares done per orders, but lacked documentation of left foot or right foot toe wounds measurements. Clinical record lacked complete wound measurements for the week starting 6/16/24. The surveyor reviewed the above stated findings with Staff A, Administrator, and Staff B, Clinical Manager. The agency provided no additional information prior to the end of the survey.”