Greatland Home Health Services, Inc.

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on review of clinical records, staff interview and policy review, it was determined for 1 of 3 (Pt. #1) clinical records reviewed, the Agency failed to ensure the Skilled Nurse documented all necessary information in the clinical notes. Findings include: 1. Patient (Pt.) #1 was admitted to home health services on 11/02/2023 and discharged on 06/25/2024. The clinical record was reviewed on 08/21/2024. The clinical record included plans of care, clinical notes, physician orders and discharge notes. The record lacked clinical notes documenting disposal of medication and physician notification in reference to Employee (E) #3 disposing of unidentifiable medications while filling Pt. #1’s pill box. 2. An interview was conducted with E #3 on 08/21/2024 at 1:30 PM. During the interview E #3 stated she remembered taking care of Pt. #1. She stated the pill box for Pt. #1 was filled by the family or by “me”. E #3 stated she recalled a day when she filled the pill box and had to dispose of unidentifiable medication for patient’s safety. She stated, she didn’t remember if she documented information regarding disposal of medication. 3. The policy for medication disposal was reviewed. The policy included, “…Medication can be disposed of by the staff after notifying the physician or pharmacy and in agreement with the client for safety for the following reasons… 5. Drugs not in original medication container and unidentifiable…” The clinical record lacked documentation that the physician was notified of medication disposal. 4. During interviews with the Administrator and Director of Clinical Services on 08/21/2024, the above findings were confirmed.”

“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 clinical record review, policy review and staff interviews, it was determined for 3 of 3 (Pts. # 1, 2 and 3) clinical records reviewed, the Agency failed to ensure care and/or services were provided in conformance with the orders of the physician and as indicated in the Plan of Care. Findings include: 1. Pt. #1 was admitted to home health services on 4/14/24 with a diagnosis of Pressure Ulcer of Sacral Region Stage 3. Pt. #1’s record included a Plan of Care for the certification period of 4/14/24 to 6/12/24 which required: “Skilled Nurse to perform/teach wound care to sacrum; Goals…Wound status will improve as evidenced by a decrease in size, drainage, absence of infection…” The SN note/Wound Record Report dated 4/14/24, 4/25/24 and 4/29/24 lacked documentation of wound measurements. The Plan of care also required: “Frequency/Duration of Visits: SN 2WK8, 1WK1.” The clinical record lacked documentation of a SN visit and/or documentation of a physician notification of a missed visit for the week of 5/5/24 to 5/11/24. 2. Pt. #2 was admitted to home health services on 1/19/24 with the diagnosis of Pressure Ulcer of Other Site Stage 2. Pt. #2’s record included a Plan of Care for the certification period of 3/19/24 to 5/17/24 which required: “Skilled Nurse to perform/teach wound care to left buttocks; Goals…Wound status will improve as evidenced by a decrease in size, drainage, absence of infection…” The SN notes/ Wound Record Report dated 3/26/24, 4/4/24, 4/11/24 and 4/17/24 lacked documentation of wound measurements. 3. Pt. #3 was admitted to home health services on 9/29/23 with the diagnosis of Pressure Ulcer of Sacral Region Stage 3. Pt. #3’s record included a Plan of Care for the period of 3/27/24 to 5/25/24 which required, “Skilled Nurse to perform/teach wound care to left buttock; Goals…Wound status will improve as evidenced by a decrease in size, drainage, absence of infection…” The SN notes/Wound Record Report from 4/19/24 through 6/5/24 lacked documentation of wound measurements. The record also included a physician order dated 4/9/24: “Per MD see patient 2x per week until wound heals… SN effective 4/7/24, 2WK7.” The SN notes/Client Calendar Report lacked documentation of 2 SN visits or physician notification of the missed visits for the week of 5/12/24 to 5/18/24. 4. The Policy titled, “Clinical Documentation” was reviewed and required: “Purpose: To document conformance with the Plan of Care…1. All skilled services provided by Nursing…will be documented in the clinical record. 6. Services not provided and the reason for the missed visits will be documented and reported to the physician.” 5. The Policy titled, “Missed Visit Policy” was reviewed and required: “If the scheduled missed visit cannot be completed within the same week: i) the nurse must notify the doctor of the reason of the missed visit and follow doctor’s order if he recommends the visit be made up. ii) complete the missed visit as scheduled or document the missed visit in the coordination note. 6. A telephone interview was conducted with E#3 (Registered Nurse) on 6/17/24 at 2:59 PM. E#3 stated that wound measurements are to be done weekly and should be documented on the medical record. E#3 also stated that if a visit is missed, it should be rescheduled within the same week and if not, the physician should be notified of the missed visit. 7. A telephone interview was conducted with E#4 (Registered Nurse) on 6/17/24 at 3:10 PM. E#4 stated that the SN visits are conducted based on the visit frequency as ordered by the physician. E#4 stated that the if a visit is missed, it should be rescheduled within the same week, and to call the physician if the visit is missed and document in the record. E#4 stated that wound measurements are to be done weekly and documented on the electronic record to determine if the wound has improved or deteriorated, and also to know there is a need to change the wound treatment. 8. An interview with the Administrator (E#1) on 6/17/24 at 4:00 PM. E#1 stated that nurses are sent to see patients according to the Plan of Care or physician orders. E#1 stated that if a visit is missed, it should be rescheduled during the same week, if not possible, then the doctor should be notified. E#1 also confirmed that the Agency practice is to measure the wound weekly to determine if the wounds have improved or deteriorated, and to document the measurements in the electronic record. During the same interview, the above findings were confirmed.”