Elara Caring

“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 observation visits, staff and patient/family interview, clinical record review, and policy review, 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 2 of 4 sampled patients with home observation visits. (Patients #1 and #2). Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services, medications and/or treatments according to assessed needs and physician orders. Findings include: According to the policy titled Plan of Care, dated 9/9/20, the Plan of Care (POC), will be individualized and completed in full to include all medical supplies and equipment required in the home. 1.Patient # 1 had a start of care date of 7/11/22, with diagnosis of chronic kidney disease, and hypertension (high blood pressure). Clinical record review, home visit observation and accompanying interviews revealed the following: a. The POC, dated 12/27/24 to 2/24/24, included physician orders for Durable Medical Equipment (DME) that included the following: adaptive living aides, blood pressure cuff, pulse oximeter, and personal protective equipment. b. During a home observation visit on 1/23/24 at 11:30 AM, with Staff B, RN. The patient had a discussion about the progress of their Peritoneal dialysis (treatment for kidney failure that uses the lining of the abdomen to filter the blood) conducted by the patient in his/her home. Staff B, RN also filled two medication planners for the patient during the same home visit. The POC failed to identify dialysis equipment and medication planner as DME utilized by the patient in the home. 2. Patient #2 had a start of care date of 4/25/24 with diagnosis of long term urinary catheter use, obesity, and type two diabetes. Clinical record review, home visit observation and accompanying interviews revealed the following: a. The POC, dated 12/21/24 to 2/18/25, included physician orders for DME and included the following: briefs, catheter supplies, blood pressure cuff, compression wraps, cushion, elevated toilet seat, feeding bags/extension tubing, glucometer, grab bars, lift chair, shower chair, walker, wheelchair and wound care supplies. b. During a home observation visit on 1/23/24 at 10:30 AM, with Staff A, RN, the surveyor observed a Sequential Compression Device (used with air sleeves that provide gentle and consistent compression to the legs). Patient #2 reported the staff at the assisted living facility help her/him with this machine and to get the leg wraps in place and run the machine while she/he sits in the recliner. The POC failed to identify the Sequential Compression Device and accessories as DME utilized by the patient in the home. The findings were reviewed with the Administrator and the Clinical Manager.”

“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 home visit observations, agency staff and patient interviews, agency policy review and clinical record review, the agency failed to provide medications, treatments or services only as ordered by the physician for 2 of 3 sampled patients with wounds. (Patients #1 and #4). 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: According to the policy titled The Plan of Care, dated 9/9/20, Home care services are furnished under the supervision and direction of the patient’s physician and includes the type, frequency and duration of all visits and services. The Plan of Care (POC), will include physician orders for all medications, treatments, and procedures. The POC will be consistently reviewed and updated as necessary with the physician. During interview on 1/29/25, at 12:00 PM, Administrator, stated interim physician orders are incorporated into an updated POC, and acknowledged the POC should have all wound care orders included and current with the treatment that is being provided in the patient’s home. 1.Patient #2 had a start of care date of 4/25/24 with diagnosis of long term use of urinary catheter, obesity and type 2 diabetes. Clinical record review revealed the following: a. The POC, dated 12/21/24 to 2/18/25, included orders for skilled nursing services to assess patient’s skin integrity and instruct patient /caregiver on measures to prevent pressure ulcers. b. Interview on 1/23/25 at 10:25 AM, Administrator stated Patient #2 had intermittent skin issues on her buttocks and that foam dressings were routinely used for treatment and/or prevention of wounds to the patient’s buttock. Administrator stated patient has difficulty getting around and sleeps in the recliner and has a risk of developing pressure areas. c. During home observation visit on 1/23/25 at 10:45 AM, Staff A, RN , removed a large foam dressing from the right buttock and the left buttock, and noted 2 open areas to the left buttock, the first measured at 1 centimeter (cm) in length, by 0.7 cm width, and a depth of 0.2 cm. The second open area measured 0.7 cm length, 0.5 cm width, and 0.2 cm depth. Staff A, RN applied skin prep and then placed large foam dressings over the right and the left buttock. An order was later obtained from the physician to cleanse wounds in the shower and cover with foam dressings twice a week and as needed if dressing becomes soiled or loose. The agency failed to obtain physician orders for wound cares prior to provide wound cares. 2.Patient #4 had a start of care date of 10/14/24 with a diagnosis of diabetic ulcer to the right great toe. Clinical record review revealed the following: a. The POC, dated 10/14/24 to 12/12/24, included all physician orders which included wound orders to the patient’s great toe on the right foot secondary to type 2 diabetes as follows: Cleanse and irrigate the toe with wound cleanser, pat dry, apply non adherent dressing over the wound and wrap with Coban (self stick adhesive wrap), weekly by skilled nurse. b. The skilled nurse note, dated 11/4/24, Staff B, RN, documented the right foot was soaked in epson salt for ten minutes, patted dry and the right great toe wrapped with the dressing. c. The skilled nurse note, dated 11/11/24, Staff B, RN documented the right foot was soaked in epson salt and warm water, patted dry and the right great toe wrapped with the dressing. d. The skilled nurse note dated 11/18/24, Staff B, RN documented the great toe on the right foot was cleansed with wound cleanser, patted dry and wrapped with the dressing. e. The skilled nurse notes, dated 11/25/24 and 12/02/24, Staff B, RN failed to document what wound care was provided to patients right great toe. The agency failed to follow the physician wound care orders for patient’s right great toe. The above findings were reviewed with the Administrator and the Clinical Manager.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on agency policy review, clinical record review, agency staff interview and patient/caregiver interview, the agency failed to report changes in patient clinical findings or changes in patient needs to the physician for 1 of 4 sampled patients with home observation visits. (Patient #1) Failure to communicate the patient’s status with the physician placed agency patients at risk for unidentified worsening of conditions, inappropriate treatments, or unmet home health care needs. Findings include: According to the agency policy titled Medical Supervision, dated 11/12/20, physicians will be contacted when any of the following occurs: condition changes, unexpected response to treatment or medication changes, laboratory results are received, caregiver support or home environment changes and/or any change in client condition or agency services, including non-compliance of the client related to the Plan of Care (POC). If the client is under the care of more than one physician, the agency is responsible to the referring physician until such time as a change in care is agreed to by the client/family and the physician. 1.Patient # 1 had a start of care date of 7/11/22, with diagnosis of chronic kidney disease, and hypertension (high blood pressure). Clinical record review, home visit observation and accompanying interviews revealed the following: a. The POC, dated 12/27/24 to 2/24/24, included physician orders for skilled nurse for assessment and education, to establish support measures to minimize the risk of hospitalization and emergency room use, and to assess pain management and effectiveness of medications. b. The care coordination note dated 1/8/25, Staff B, RN documented Patient #1 was not feeling well today, complained of headache, nausea, dizziness and lethargy. Orthostatic Blood Pressures (taking the blood pressure sitting down and then upon standing to assess for a drop in the readings) were obtained with the patient seated of 120/62 and upon standing was 83/53. Staff B, RN, documented the nurse at the dialysis center was contacted and stated she would call to check on the patient. The clinical record lacked documentation the primary physician was notified. c. During a home observation visit on 1/23/24 at 11:30 AM, with Staff B, RN , Patient expressed concern over dizziness and reported some near falls because of the dizziness, and reported this was more significant lately. Patient also complained about having headaches. Staff B, RN, did obtain orthostatic blood pressure readings, the reading when patient was seated was 112/60 and upon standing dropped to 86/57. Staff B, RN documented the dialysis center nurse had been updated 2 weeks prior about significant drop in orthostatic blood pressures and were aware. The documentation lacked notification to the physician of a condition change and an increased risk for falls. The agency failed to notify the primary physician with a condition change. The above findings were reviewed with the Administrator and the Clinical Manager.”