Angels Care Home Health of Iowa

“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 6 of 17 sampled patients (Patients #1, #3, #10, #13, #14 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: 5. Patient #1 had a start of care date of 8/27/23. Clinical record review revealed the following: a. The POC, dated 10/20/24 to 12/18/24, included physician orders for wound care 3 times per week for a diabetic ulcer on the anterior edge of the right foot. Order instructed the skilled nurse to cleanse the wound with soap and water, rinse and pat dry with gauze, cover with a 4 centimeter by 4 centimeter (cm) Mepilex dressing (foam dressing), and secure with a size E tubigrip (compression netting). b. During a home visit observation on 11/25/24 at 10:15 AM, the surveyor observed Staff D, RN, cleanse the wound with normal saline, pat the wound dry with gauze, and cover with a 4 cm by 4 cm Mepilex dressing, but failed to secure with the size E tubigrip dressing. The agency failed to perform wound care to the diabetic wound ulcer on the anterior edge of the right foot as ordered by the physician. 6. Patient #16 had a start of care date of 9/13/24 and a discharge date of 11/11/24. Clinical record review revealed the following: a. The POC, dated 9/13/24 to 11/11/24, included physician orders for skilled nurse to visit 1 time a week for 9 weeks effective 9/13/24. b. The clinical record lacked documentation of skilled nurse services for the week of 10/20/24, and lacked physician notification of missed visits during that week. The agency failed to implement clinical services in accordance with the POC. The above findings were shared with the Administrator/Clinical Manager. 3. Patient #10 had a start of care date of 9/17/24. Clinical record review revealed the following: a. The POCs, dated 9/17/24 to 11/15/24 and 11/16/24 to 1/14/24, included physician orders for skilled nurse to weigh patient every visit and to instruct patient to notify skilled nurse or physician of weight gain of more than 3 pounds in 24 hours. b. The skilled nurse visit note, dated 10/14/24, completed by Staff G, RN, lacked documentation of a weight obtained by the skilled nurse. The skilled nurse failed to assess and document the patient’s weight every visit. 4. Patient #13 had a start of care date of 6/8/24 and discharge from the agency on 7/5/24. Clinical record review revealed the following: a. The POC, dated 6/8/24 to 8/6/24, included physician orders for skilled nurse to weigh patient every visit and to instruct patient to notify skilled nurse or physician of weight gain of more than 3 pounds in 24 hours. b. The skilled nurse visit note, dated 6/11/24, completed by Staff G, RN, lacked documentation of a weight obtained by the skilled nurse. The skilled nurse failed to assess and document the patient’s weight every visit. According to the agency’s policy titled Plan of Care, dated February 2022, the agency develops and implements an individualized Plan of Care (POC) for each patient admitted to the agency. Clinical services are implemented in accordance with a POC established by a provider’s written orders. If a provider orders services that cannot be completed, the provider is consulted to approve additions or modification to the original plan. 1.Patient #3 had a start of care date of 10/15/24. Clinical record review revealed the following: a. The POC, dated 10/15/24 to 12/13/24, included physician orders for skilled nurse to weigh patient every visit and to instruct patient to notify skilled nurse or physician of weight gain of more than 3 pounds in 24 hours. b. The skilled nurse visit note, dated 11/7/24, completed by Staff E, Registered Nurse (RN), lacked documentation of a weight obtained by the skilled nurse. The skilled nurse failed to assess and document the patient’s weight every visit. 2. Patient #14 had a start of care date of 5/18/24 and a discharge date of 6/16/24. Clinical record review revealed the following: a. The POC, dated 5/18/24 to 7/16/24, included physician orders for physical therapy to visit 1 time a week for 1 week effective 5/19/24. b. The clinical record lacked documentation of physical therapy services. c. During an interview on 12/3/24 at 2:30 PM, the Administrator stated the agency had issues getting physical therapy services started timely in patient’s service area. The agency failed to implement clinical services in accordance with the POC.”

“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 and medications used by the patient for 9 of 17 sampled patients (Patients #1, #2, #3, #4, #5, #7, #11, #13 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: 6. Patient #2 had a start of care date of 12/27/23. Clinical record review revealed the following: a. The POC, dated 10/22/24 to 12/20/24, included the following DME used by the patient: cane, elevated toilet seat, rails/grab bars, shower/tub equipment, vital signs equipment, walker, wheelchair, incontinence, urologicals, wound care, wound care advanced. b. The POC, dated 10/22/24 to 12/20/24, included orders for medications the for the patient. The orders included the medication Hydrochlorothiazide (diuretic) 25 mg every morning for blood pressure. c. During a home visit observation on 11/26/24 at 11:20 AM, with Staff E, RN, the surveyor identified the following additional DME in the home: wheelchair cushion. During this same visit, an interview with the patient revealed a type of wheelchair cushion had been utilized since the start of care. d. During the same home visit observation the patient stated he/she had not taken the medication hydrochlorothiazide for a long time. The POC failed to identify all DME the patient required for use including a wheelchair cushion and current medications. 7. Patient #5 had a start of care date of 8/6/24. Clinical record review revealed the following: a. The POC, dated 10/5/24 to 12/3/24, included the following DME used by the patient: wound care, wound care advanced. The POC also included medications ordered for the patient. b. During a home visit observation on 11/26/24 at 11:20 AM, with Staff G, RN, the surveyor identified the following additional DME in the home: shower chair and colostomy supplies. During this same visit, an interview with the patient revealed the DME had been utilized since the start of care. c. During the same home visit observation the patient stated he/she had the medications allergy medication 10 mg daily, Miralax 17 grams daily as needed for constipation and a fiber supplement 2 teaspoons daily as needed for loose stools. The patient identified the medication taken since the start of care. The POC failed to identify all DME the patient required for use including a shower chair and colostomy supplies and current medications. 8. Patient #11 had a start of care date of 11/12/24. Clinical record review revealed the following: a. The POC, dated 11/12/24 to 1/10/25, included the following DME used by the patient: glucometer, incentive spirometer, med planner, respiratory supplies, shower/tub equipment, support surfaces, vital signs equipment, glucose, nursing supplies and physical therapy. The POC included orders to instruct the patient to notify the skilled nurse/physician of weight gain greater than 2 pounds in 24 hours and 4 pounds in one week. b. Review of the medical record lacked documentation of the scale included as the patient’s DME. The POC failed to identify all DME the patient required for use including a scale. 9. Patient #13 had a start of care date of 6/8/24 and discharge date of 7/5/24. Clinical record review revealed the following: a. The POC, dated 6/8/24 to 8/6/24, included the following DME used by the patient: glucometer, incentive spirometer, med planner, walker, rolling walker, nutrient thickeners, ostomy supplies, physical therapy supplies, wound care. The POC included orders to instruct the patient to notify the skilled nurse/physician of weight gain greater than 2 pounds in 24 hours and 4 pounds in one week. b. Review of the medical record lacked documentation of the scale included as the patient’s DME. The POC failed to identify all DME the patient required for use including a scale. The above findings shared with the Administrator/Clinical Manager and Clinical Regional Director. 3. Patient #1 had a start of care date of 8/27/23. Clinical record review revealed the following: a. The POC, dated 10/20/24 to 12/18/24, included the following DME used by the patient: cane, walker, powered wheelchair, commode, elevated toilet seat, oxygen supplies, incontinence supplies, skin and wound care supplies, glucometer, medication planner, rails/grab bars, reacher, shower and tub equipment, vital signs equipment, and PT/INR testing supplies. b. During a home visit observation on 11/25/24 at 10:15 AM, with Staff D, RN, the surveyor identified a scale used to monitor weight changes. During this same visit, an interview with the patient revealed a pressure relief cushion was utilized in the recliner and power chair. The POC failed to identify all DME the patient required for use. 4. Patient #7 had a start of care date of 4/23/24. Clinical record review revealed the following: a. The POC, dated 10/20/24 to 12/18/24 included the following DME used by the patient: cane, rail/grab bars, shower/tub equipment, oxygen supplies, walker, vital sign equipment, glucometer, nebulizer, elevated toilet seat, nursing supplies, skin care, urological supplies, and medication planner. b. During a home visit observation on 12/05/24 at 1:30 PM, with Staff L, Licensed Practical Nurse (LPN), the surveyor identified the following additional DME in the home: scale and vaporizer. During this same visit, an interview with the patient revealed both devices have been utilized since the start of care. The POC failed to identify all DME the patient required for use. 5. Patient #16 had a start of care date of 9/13/214. Clinical record review revealed the following: a. The POC, dated 9/13/24 to 11/11/24, included the following DME used by the patient: cane, shower/tub equipment, glucometer, glucose, incontinence supplies, nursing supplies, skin care supplies, walker, lift, elevated toilet seat, vital sign equipment, and physical therapy supplies. b. The POC, dated 9/13/24 to 11/11/24, included a physician order for the skilled nurse to weigh the patient every visit, the POC failed to include scale as part of the DME utilized by the patient. The POC failed to identify all DME the patient required for use. The above findings were shared with the Administrator/Clinical Manager. According to the agency policy titled Plan of Care, dated February 2022, the agency develops and implements an individualized Plan of Care (POC) for each patient admitted to the agency. The plan of care is reviewed as often as the patient’s condition or need warrants, but at least every 60 days. The contents of the patient’s POC includes, but is not limited to the following: diagnoses and clinical problems, prescribed and over the counter (OTC) medications, medical supplies/equipment, frequency and duration of services and functional limitations. 1.Patient #3 had a start of care date of 10/15/24. Clinical record review revealed the following: a. The POC, dated 10/15/24 to 12/13/24 included the following durable medical equipment (DME) used by the patient: cane and nursing supplies. b. During a home visit observation on 11/26/24 at 11:20 AM, with Staff F, Registered Nurse (RN), the surveyor identified the following additional DME in the home: scale and pill cutter. During this same visit, an interview with the patient revealed both devices have been utilized since the start of care. The POC failed to identify all DME the patient required for use. 2. Patient #4 had a start of care date of 4/9/24. Clinical record review revealed the following: a. The POC, dated 10/6/24 to 12/4/24, included an order for the following medication: Gabapentin 300 milligram (mg) capsule with instructions to take one as needed for nerve pain. b. During a home visit observation on 12/2/24 at 11:30 AM with Staff H, RN, the surveyor identified the bottle of Gabapentin in the home is 300 mg capsules with instructions for the patient to take 1 tablet at bedtime. Staff H, RN confirmed she filled the patients medication box according to the instructions on the bottle. The medication was last filled on 10/8/24. c. The POC, dated 10/6/24 to 12/4/24, included the following DME used by the patient: cane, med planner, rails/grab bars, reacher, shower/tub equipment, vital sign equipment, walker, incontinence supplies and nursing supplies. d. During a home visit observation on 12/2/24 at 11:30 AM with Staff H, RN, the surveyor identified the following DME in the home: scale and right knee immobilizer brace. The patient stated he/she has been utilizing the scale to weigh self for at least a year and he/she has had to wear the immobilizer brace at all times since falling on 10/29/24. The POC failed to identify medication orders with accurate frequency and all DME the patient required for use.”

“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, agency policy review and staff interview, the agency failed to ensure all current physician orders for wound care recorded on the plan of care for 2 of 7 sampled patients with wounds (Patient’s #2 and #6). 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. 2.Patient #6 had a start of care date of 10/11/24. Clinical record review revealed the following: a. The POC, dated 10/11/24 to 12/9/24 included physician orders for skilled nursing services and occupational therapy services. b. The interim physician order, dated 11/27/24, included orders to cleanse abdominal wound with soap and water, apply Vashe soaked gauze to wound bed for 3-5 minutes. Apply skin barrier to peri wound skin area, apply Hydrofera blue foam dressing to wound bed. Cover with mepilex like dressing and change 3 times weekly per nurse and as needed for soiled/wet dressing. May discontinue when wound is healed. c. The updated POC, dated 12/2/24, failed to include the interim order for wound care. The agency failed to record all patient care orders in the plan of care. The above findings were shared with the Administrator/Clinical Manager and the Clinical Regional Director. According to the agency policy, titled Plan of Care, dated February 2022, Plan of Care changes that occur between certification periods are documented with the Plan of Care Update Order. Orders will specify the service hours, frequency and duration, procedures and modalities, as applicable. During an interview on 12/3/24 at 8:59 AM, the Administrator/Clinical Manager, stated all interim physician orders go to an updated Plan of Care. She further stated the nurses typically look at the orders tab from their tablet to view the most current patient orders. 1. Patient #2 had a start of care date of 12/27/23. The clinical record review revealed: a. The Plan of Care (POC), dated 10/22/24 to 12/20/24, included orders for skilled nursing visits three times a week. b. Interim physician order, dated 11/12/24, included wound care orders for the coccyx, cleanse wound with normal saline, then use Vashe as directed to the wound. Apply skin prep around the peri wound. Primary dressing: Exufiber AG plus gelling fiber rope 0.8 by 17.7 inch, then apply mepilex border and secure with tape. Skilled nurse to change 3 times per week until healed. May discontinue when healed. c. The Updated POC, dated 11/26/24, did not include orders for wound care to the coccyx. Agency staff failed to include current wound care orders on the POC.”

“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 policy review, clinical record review and agency staff interview, the agency failed to provide medications, treatments or services only as ordered by the physician for 2 of 17 sampled patients (Patients #1 and #2). Failure to ensure staff obtain physician orders for administration of medications, treatments or services provided by agency staff placed agency patients at risk for inconsistent care/treatment and possible harm. Findings include: 2. Patient #1 had a start of care date of 08/27/24. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 10/20/24 to 12/18/24, included orders for the anticoagulant medication Warfarin (blood thinning medication), and physicians orders for the skilled nurse to monitor anticoagulation therapy and regimen with a home PT/INR machine (device for testing blood coagulation speed). The POC included parameters to call the physician after testing if level is less than 2, but greater than 3. The POC lacked orders for specific time frames for when to perform the blood testing and how often. The clinical record lacked physician orders necessary for how often to perform PT/INR testing in the home . The above findings were reviewed with the Administrator/Clinical Manager According to agency policy, titled Physician Provider Orders, dated May 2020, orders are obtained, reviewed and updated in accordance with laws, regulatory guideline, company policy and as appropriate, according to: changes in the patient’s physical and/or psychosocial status, patient’s responses to care or services, changes in the patient’s diagnosis, treatment, procedures and/or medications and patient’s equipment needs. 1. Patient #2 had a start of care date of 12/27/23. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 10/22/24 to 12/20/24, documented the patient had diagnosis that included neuromuscular dysfunction of the bladder. b. During a observational home visit with Staff E, Registered Nurse (RN), the patient identified he/she required the use of intermittent catheterization 4 to 5 times a day. The clinical record lacked physician orders for intermittent catheterization.”

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on clinical record review, agency policy review, home visit observation and agency staff interview, the agency failed to ensure skilled professional staff involved in the patient’s plan of care completed an ongoing interdisciplinary wound assessment as required by agency policy and expectation for 2 of 7 sampled patients (Patient #1 and #8) with home observation visits. Failure to complete an ongoing interdisciplinary assessment of wounds placed patients at risk unidentified worsening of the wounds. According to agency policy titled Patient Assessment/Reassessment, dated 4/2023, assessments and reassessments will be conducted as frequently as the patients condition warrants. The provider will be contacted when assessment findings warrant a change in the plan of care or treatment plan. In an interview on 12/3/24 at 4:15 pm, the Clinical Manager acknowledged if a patient reported a change in skin integumentary to staff during a visit, the nurse would be expected to assess the concern during that visit, and communicate any change to the physician at the time of the visit. 1.Patient #1 had a start of care date of 8/27/24. Home observation and patient interview revealed the following: a. The Plan of Care (POC), dated 10/20/24 to 12/18/24, included physicians orders for skilled nursing 3 times per week, to assess vital signs and all body systems, to provide skilled monitoring and skilled teaching related to altered skin integrity and pressure ulcer prevention measures and to report significant changes to the physician for early intervention. b. During a home visit observation on 11/25/24 at 10:15 AM, with Staff D, Registered Nurse (RN), the patient reported a concern over a new open area that had been sore on the coccyx. The patient reported to the skilled nurse, the patient’s spouse had been putting a cream on the area and thought it was almost healed. The patient also reported to the nurse that the clinic had sent home the new cushion the patient was using in the recliner and sometimes the powered wheelchair to reduce pressure to the coccyx. c. The skilled nurse completed the home visit without assessing the area to the coccyx. d. The skilled nursing visit note, dated 11/25/24,completed by Staff D, RN, lacked documentation of the patients concern, assessment of the area, and any contact with the physician over the patients concern. The agency failed to complete an assessment of a possible new wound based on the patient’s information provided. 2. Patient #7 had start of care date of 4/23/24. Clinical record review revealed the following: a. The POC, dated 10/20/24 to 12/18/24, included physicians orders for the skilled nurse to visit once a week and included orders to assess vital sings and all body systems, and to report any significant changes to the physician to provide for early intervention. b.The missed visit notification, dated 11/21/24, documented the patient reported he/she had a cyst on his/her buttocks that required surgery and would be not available for the visit until the following week. c. The skilled nursing visit note, dated 11/25/24, revealed the patient reported to the nurse some intermittent rectal pain over the last week and that something was wrong with the rectum. Patient also stated an antibiotic had been prescribed following the procedure on the patient’s rectum, but was not sure what it was and no longer had the bottle. The visit note documented that medical records were requested from the physician, but the visit note failed to document an assessment of the area. d. During a home visit observation on 12/05/24 at 1:30 PM, with Staff L, Licensed Practical Nurse (LPN), the patient reported experiencing occasional pain in his rectal area and he/she was not sure what physician really did during the procedure, but it still was bothersome some of the time. The LPN failed to assess the area during the visit. The agency failed to assess a possible new wound. The above findings were reviewed with the Administrator/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 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 5 of 7 sampled patients (Patient #1, #2, #5, #13 and #17) 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. 2. Patient #2 had a start of care date of 12/27/23. Clinical record review revealed the following: a. The POC, dated 10/22/24 to 12/20/24, included physician orders for skilled nursing services 3 times weekly for physical assessment, education and wound management. b. The skilled Nurse visit notes, dated 10/28/24, 10/30/24 and 11/1/24, Staff E, RN, included documentation of a wound to the coccyx. The notes lacked documentation of wound measurements. The skilled nurse failed to document wound measurements for the wound on the patient’s coccyx. 3. Patient #5 had a start of care date of 8/6/24. Clinical record review revealed the following: a. The POCs, dated 8/6/24 to 10/4/24 and 10/5/24 to 12/3/24, included physician orders for skilled nursing services 2 times weekly for physical assessment, education and wound management. b. The skilled Nurse visit notes, dated 10/8, 10/15, 10/22, 10/25/24, and 11/18/24, Staff G, RN, included documentation of a wound to the abdominal right upper quadrant. The notes lacked documentation of wound measurements. c. The skilled Nurse visit notes, dated 10/11, 10/18/24 and 11/22/24, Staff N, RN, included documentation of a wound to the abdominal right upper quadrant. The notes lacked documentation of wound measurements. d. The skilled nurse note, dated 11/5/24, Staff L, Licensed Practical Nurse, included documentation of a wound to the abdominal right upper quadrant. The measurements included length 5.9 centimeters (cm) by width 3.2 cm. The note lacked documentation of the wound depth. The skilled nurse failed to document wound measurements for the wound on the patient’s abdominal right upper quadrant. 4. Patient #13 had a start of care date of 6/8/24 and discharge date of 7/5/24. Clinical record review revealed the following: a. The POC, dated 6/8/24 to 8/6/24, included physician orders for skilled nursing services 2 times weekly for physical assessment, education and wound management. b. The skilled Nurse visit notes, dated 6/11 and 6/14/24, Staff G, RN, included documentation of a wound to the right knee. The notes lacked documentation of wound measurements. The skilled nurse failed to document wound measurements for the wound on the patient’s right knee. 5. Patient #17 had a start of care date of 8/23/24 and discharge date of 10/21/24. Clinical record review revealed the following: a. The POC, dated 8/23/24 to 10/21/24, included physician orders for skilled nursing services 2 times weekly for physical assessment, education and wound management. b. The skilled nurse note dated, 8/30/24, identified the following wounds: #4 Left distal forearm ruptured blister 1.2 cm x 0.5 cm x 0 cm. #5 anterior distal left great toe blister 2.4 cm x 1.4 cm x 0 cm. #6 anterior distal right forearm multi/scattered blood blisters. Not measured #8 anterior left pretibial mid ruptured blister. Not measured #9 anterior right mid pretibial ruptured blister 1.1 cm x 0.8 cm x 0 cm. #10 right lateral blister. Not measured. #11 mid dorsum blister 1.1 cm x 0.6 cm x 0 cm. #7 mid multi/scattered dermatitis coccyx. Not measured. c. The skilled Nurse visit notes, dated 8/27/24 and 8/28/24, Staff O, RN, included documentation of multiple wounds identified as blisters. The notes lacked documentation of wound measurements. d. The skilled nurse note, dated 10/18/24, Staff H, RN, included documentation of an open blister to the right anterior proximal upper arm. The depth description included partial thickness and measurements included length 11 cm by width 5 cm with no depth measurements documented. The skilled nurse failed to document wound measurements for the identified wounds. The above findings shared with the Administrator/Clinical Manager and Clinical Regional Director. According to the agency policy titled Documentation Practices, dated 2/2022, documentation will facilitate communication, promote good care, inform care providers on an ongoing basis about patients health status and care or services provided and meet professional standards. Clinicians will make accurate notes and use factual based language. During an interview on 12/3/24 at 8:59 AM, the Clinical Manager stated agency expectation for wound measurements were to include length, width and depth on a weekly basis. The Clinical Manager reported the agency has a wound care nurse on staff as a resource, and to assist with education and compliance. 1.Patient #1 had a start of care date of 8/27/23. Clinical record review revealed the following: a. The Plan of Care (POC), dated 10/20/24 to 12/18/24, included physician orders for skilled nursing services 3 times weekly for physical assessment, education and wound management. b. Skilled Nurse visit notes, dated 11/11/24 and 11/13/24, Staff E, Registered Nurse (RN), included documentation of a diabetic ulcer on the anterior edge of the right foot with an onset date of 7/2/24. The notes lacked documentation of wound measurements. The skilled nurse failed to document wound measurements for the wound on the patient’s anterior edge of the right foot.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on clinical record reviews and agency policy review the agency failed to complete and send a transfer summary to physician caring for the patient at an inpatient facility within 2 days of becoming aware of an unplanned transfer and the agency failed to send a completed discharge summary to the primary care provider within 5 business days of the patient’s discharge for 2 of 5 sampled patients (Patients #13 and #14). Failure to send the physician and other healthcare professionals a summary of the patient’s care while receiving services from the agency in a timely manner increases the risk for inadequate or inappropriate follow-up care. Findings include: 2. Patient #13 had a start of care date of 6/8/24 and a discharge date of 7/5/24. Clinical record review revealed the following: a. The skilled nurse visit note, dated 7/5/24, revealed the patient discharged from home health care services. b. The discharge summary, dated 7/16/24, completed by Staff M, RN, 7 business days after the patient’s date of discharge. The agency failed to complete a discharge summary within 5 business days of becoming aware of an unplanned transfer. The above findings shared with the Administrator/Clinical Manager and Clinical Regional Director. According to the agency policy titled Discharge, dated February 2022, a completed transfer summary is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time the agency becomes aware of the transfer. A completed discharge summary is sent to the primary care practitioner or other health care professional responsible for providing care and services to the patient after discharge from the agency within 5 business days of the patient’s discharge. 1.Patient #14 had a start of care date of 5/18/24 and a discharge date of 6/16/24. Clinical record review revealed the following: a. A care coordination note, completed by Staff J, Licensed Practical Nurse, identified a missed visit on 5/31/24 due to patient being hospitalized. b. A home health transfer summary, dated 6/6/24, completed by Staff K, Registered Nurse (RN), 4 business days after transfer to inpatient facility. The agency failed to send a transfer summary to the hospital within 2 business days of becoming aware of an unplanned transfer.”