Regional Medical Center Home Care

“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 patient interview and agency staff interview, clinical record review, and agency policy review, the agency failed to ensure accurate and thorough completion of all pertinent components of each comprehensive assessment for 2 of 7 sampled patients. (Patient #4 and #6) Failure to accurately and thoroughly complete comprehensive assessments to address individualized pertinent areas of health to obtain baseline findings placed patients at an increased risk of unidentified condition changes. Findings include: The agency policy titled Comprehensive Assessment, dated 11/2024, the content of the comprehensive assessment will include: the patient’s current health, psychosocial, functional and cognitive status, the patient’s medical, nursing, rehabilitative, social and discharge planning needs, and the most current version of the Outcome and Assessment Information Set (OASIS) items, will be incorporated into the comprehensive assessment, if applicable. The agency policy titled Wound Assessment, dated 10/2024, directs the agency to complete a thorough assessment and include effective documentation as an essential component in the management of wounds and skin impairments. The agency will assess a client’s wounds/skin impairments and document status on scheduled visit days. The status of open wounds will be documented in the electronic health record. Additionally, any skin areas (even if there is no impairment) that are being monitored and treated will be documented including measurements in the patient’s electronic health record. During a interview on 1/15/25, at 1:33 PM, the Clinical Manager stated, the wound policy allowed for generalization and approximation of areas of bruising or rashes, but that any closed wound or incision did not require measurements. The Clinical Manager also stated that pressure ulcers definitely needed assessment and measurements at least weekly. 1.Patient #6 had a start of care date of 5/9/24. Clinical record review revealed the following: a. The Plan of Care (POC), dated 5/9/24 to 7/7/24, included diagnosis of diabetes, kidney disease , and stage 2 pressure ulcer (shallow open wound) to the right buttock. The POC included orders for skilled nurse weekly for medication management, diabetic education and instruction, and for wound assessment, treatment and education. b. The comprehensive initial assessment completed on 5/9/24, by Staff B, Registered Nurse (RN), included documentation of an unhealed pressure ulcer stage 2 on the right buttock, but lacked measurements of the stage 2 pressure ulcer to the right buttock. The agency failed to obtain measurements for the pressure ulcer. 2. Patient #4 had a start of care date of 7/26/24. Clinical record review revealed the following: a. The POC, dated 11/23/24 to 1/21/25, included diagnosis of heart failure with fluid overload, Parkinson’s, and anemia. The POC included orders for skilled nursing services to evaluate and assess a right ankle wound and provide wound care 2 times per week. b. Physician orders received from the wound care clinic effective 12/3/24, ordered agency not to remove the dressing that was placed weekly at the wound care clinic. To only reinforce the outer dressing, if necessary when soiled, or drainage had come through the initial dressing, until new physician orders were given. The non removable dressing did not allow the agency to assess or measure the wound per agency policy. c. Physician orders effective 12/30/24, included the following: Clean wound with Normal Saline and Pat dry. Apply Multidex (a wound gel used to maintain a moist environment to promote healing) to wound bed, cover with Hydrofera blue (type of foam dressing) and secure with mepilex (an absorbent outer dressing). Change dressing 2-3 times per week with 1 of those days being in the wound clinic. The other day to be completed by home health or by the caregiver. Skilled nurse to assess wound and complete dressing change on 1/2/24. d. Skilled nurses note dated 1/2/24, completed by Staff C, Licensed Practical Nurse, included a description of the wound, but lacked measurements for the wound. The agency failed to document measurements to the wound on the right ankle. The above findings were reviewed with the Administrator and the Clinical Manager.”

“Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This Element is not met as evidenced by: Based on staff interview, policy review and clinical record review, the agency failed to ensure home health aides provided care to agency patients only as ordered by the physician in the Plan of Care and/or as directed by the skilled professional assigning the home health aide to the patient for 2 of 3 sampled patients receiving home health aide services (Patients #2 and #5). The agency reported 39 patients who received care provided by a home health aide. Failure to ensure that home health aide services are provided only as ordered by the physician and according to the home health aide care plan increased the risk that patients’ personal care needs were not adequately met. 2.Patient #5 had a start of care date of 1/5/25. Clinical record review revealed the following: a. The Plan of Care, dated 1/5/25 to 3/5/25, included primary diagnosis of subdural hematoma (accumulation of blood in the brain) and transient ischemic attack (temporary blockage of the flow of blood to the brain), with physician orders for physical therapy, skilled nursing and home health aide services. b. The home health aide assignment, with an effective date of 1/5/25, directed the aides to apply cologne, deodorant and lotion per patient request, to clean glasses, to apply Nystatin powder (antifungal powder) if skin folds are red or patient request, to assist the client to clean hard to reach areas, assist the client to dress and undress, to pat dry ensuring all skin folds are completely dried, to gather items for the shower, assist the client to transfer in and out of shower and directions to provide spongebath rather than a shower per patient request. c. The electronically completed home health aide visit note, dated 1/6/25, included documentation all tasks were performed and included, apply cologne, deodorant and lotion per patient request, to clean glasses, to apply Nystatin powder (antifungal powder) if skin folds are red or patient request, to assist the client to clean hard to reach areas, assist the client to dress and undress, to pat dry ensuring all skin folds are completely dried, to gather items for the shower, assist the client to transfer in and out of shower and directions to provide spongebath rather than a shower per patient request. d. The agency failed to document the specific tasks the home health aide completed, and documented both shower activities completed and spongebath per patient request completed. The above findings were reviewed with the Administrator and the Clinical Manager. Findings include: According to the agency policy titled, Clinical Record, dated 11/2024, identified the clinical record will contain at a minimum, all the assessments from the most recent home health admission, clinical notes, all interventions, including treatments and services, and responses to those interventions provided by the agency. Staff will review documentation for accuracy prior to electronically signing them. During an interview on 1/15/25 at 1:33 PM, the Clinical Manager reported aides are to document refusal of tasks not completed on the visit notes. 1.Patient #2 had a start of care date of 12/9/22. Clinical record review revealed: a. The Plan of Care, dated 11/28/24 to 1/26/25, included primary diagnosis of multiple sclerosis and physician orders for skilled nursing and home health aide services. b. The home health aide assignment, with an effective date of 2/28/23, directed the aides to apply a thin layer of Desenex to abdomen, groin, breast, and knee folds if not red or open; apply lotion to arms and legs; assist with sponge bath; assist with undressing and dressing; be sure to wash skin folds well and pat dry; change bedding if sheets get very wet from shampoo boat and spouse is not around to change; change incontinence pads/brief with each visit; client is cognitively able to participate in care decisions; and wash hair with each visit using shampoo boat. Task apply Baza anti-fungal (cream) to any red/moist skin fold areas/under breasts or groin with an effective date 12/30/24, task apply resinol (medicated cream) to top of crack between the buttocks after bathing and dry with an effective date of 1/6/25, and task remove abdominal binder and nubby pad (pressure relieving pad) from left and right upper thigh areas and wash and dry, spouse to reapply with an effective date 1/2/25. c. The electronically completed home health aide visit note, dated 1/8/25, included the task apply resinol (medicated cream) to top of crack between the buttocks after bathing and dry. The note lacked documentation of the additional tasks of apply a thin layer of Desenex to abdomen, groin, breast, and knee folds if not red or open; apply lotion to arms and legs; assist with sponge bath; assist with undressing and dressing; be sure to wash skin folds well and pat dry; change bedding if sheets get very wet from shampoo boat and spouse is not around to change; change incontinence pads/brief with each visit; client is cognitively able to participate in care decisions; and wash hair with each visit using shampoo boat, Baza anti-fungal (cream) to any red/moist skin fold areas/under breasts or groin, and remove abdominal binder and nubby pad (pressure relieving pad) from left and right upper thigh areas and wash and dry, spouse to reapply.”