Interim Healthcare of SE Indiana Inc.

“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 record review and interview, the agency failed to promptly alert relevant physicians and revise the POC in response to a change in patient condition for 1 of 3 closed records reviewed (Patient #8). Findings include: A review of a policy titled “Contents of the Patient/Client Record” indicated but was not limited to: “…Purpose…b) Provide a current and accurate account of the care/services provided to each patient/client…d) Support communication among employees providing, supervising, and managing care/services, and collaboration with other health care providers involved in the delivery of the patient’s/client’s care/service including the physician or allowed practitioner (e.g., NP, PA, CNS)…” A review of a policy titled “Coordination of Care/Services” indicated but was not limited to: “Policy Interim HealthCare maintains regular communication with the patient/client and with others providing patient/client care/services. Actions and goals of Interim HealthCare services are complimentary and reflect cooperative care planning…Procedure…7. The designated Clinical Manager regularly confers with the patient/client/caregiver, the patient’s/client’s physician or allowed practitioner (e.g., NP, PA, CNS) as appropriate, and with other health care team members providing care/service to the patient/client. a) The designated employee contacts the physician or allowed practitioner (e.g., NP, PA, CNS) when any of the following events occurs: i) The patient’s/client’s condition changes; ii) The patient’s/client’s response to care/treatments or medications is not as expected…” The Clinical Record for Patient #8, Certification Period 03/14/2025 - 05/12/2025, evidenced a POC signed and returned by MD 1 (referring doctor) on 03/25/2025 with all the required elements included and specific treatment for wound care on the lateral side of the right foot (Wound #1) for which the patient was admitted to the home health agency. On 03/24/2025, an emergency room visit note indicated 14 staples were administered to a curved laceration (a tear or split in the skin and underlying tissues, often caused by sharp objects or blunt force) on the anterior (refers to the front of the body in anatomical terms) right leg (Wound #2) that showed some bruising with minimal bleeding and the right foot warm with appropriate capillary refill intact. MD 4 (Emergency Medicine) gave discharge instructions for the patient to make an appointment with MD 3 (Primary Care) to have the staples removed. On 03/27/2025, a skilled nursing visit occurred. In the visit summary, RN 2 indicated the wound dressing for Wound #2 was “changed yesterday, no orders for it”. RN 2 wrote an order to increase nursing visits to three (3) times a week starting 04/05/2025 - 04/25/2025. The order was sent to MD 1 on 03/27/2025, signed and returned on 04/08/2025. The record failed to evidence RN 2 communicated wound assessment or request for wound orders for Wound #2 with MD 1 or MD 3. Nursing notes dated 03/31/2025, 04/04/2025, and 04/07/2025 indicated RN 2 assessed Wound #2 and noted no wound orders in each note. The record failed to evidence RN 2 communicated wound assessment or request for wound orders for Wound #2 with MD 1 or MD 3. On 04/03/2025, a case conference note indicated RN 2 discussed the patient with the home health team and Wound #2 “still has no orders for treatment” and reported there were no signs or symptoms of infection. The record failed to evidence RN 2 communicated with MD 1 or MD 3 for wound care orders. On 05/09/2025, a general note indicated MD 1’s office called and left a message at the home health agency. The patient had complaints of pain in the leg wound. RN 2 noted there was no redness or drainage from Wound #2. The record failed to evidence communication with the physician to report change in patient wound. During an interview on 07/25/2025 at 10:39 AM, RN 2 indicated Patient #8 was referred to the home health agency by MD 1, a podiatrist, for a foot wound that had been present for a year and was not healing. After the patient was admitted to the agency for a couple of weeks, the patient was walking out onto the porch and the storm door “sliced” Patient #8’s right lower leg open and the patient was taken to the ER. Staples were used to close the leg wound (Wound #2) and the leg was wrapped. RN 2 indicated after Patient #8 returned from the Emergency Department, he/she was unable to visualize Wound #2 due to the dressing/wrap that was present. RN 2 indicated when the patient returned from the ER after the leg injury, a granddaughter was changing the dressing for Wound #2 until RN 2 received wound care orders. RN 2 indicated he/she communicated with MD 1 who admitted the patient for Wound #1, to obtain orders for Wound #2 as well, however orders were not received right away for Wound #2. During an interview on 07/25/2025 at 1:13 PM, the Director of Clinical Services indicated when the change in condition is related to a wound, the nurse is expected to assess the wound no matter what unless orders are received from a doctor to not remove a dressing. When there are no orders, the nurse should take off the dressing, assess and measure it, then re-dress it with a dry dressing. At that time, the doctor would receive report, and new orders would be requested for treatment of a new wound. The nurse is expected to continue communications and document all changes that occur with the patient’s condition at any time there is a change and ensure all documentation is complete and accurate. 410 IAC 17-13-1(a)(2)”

“Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on record review and interview, the agency failed to coordinate care and communicate changes in patient condition with all physicians involved in the POC for 1 of 3 closed records reviewed (Patient #8). Findings include: A review of a policy titled “Coordination of Care/Services” indicated but was not limited to: “Policy Interim HealthCare maintains regular communication with the patient/client and with others providing patient/client care/services. Actions and goals of Interim HealthCare services are complimentary and reflect cooperative care planning…Procedure…7. The designated Clinical Manager regularly confers with the patient/client/caregiver, the patient’s/client’s physician or allowed practitioner (e.g., NP, PA, CNS) as appropriate, and with other health care team members providing care/service to the patient/client. a)The designated employee contacts the physician or allowed practitioner (e.g., NP, PA, CNS) when any of the following events occurs: i) The patient’s/client’s condition changes; ii) The patient’s/client’s response to care/treatments or medications is not as expected…” The Clinical Record for Patient #8, Certification Period 03/14/2025 - 05/12/2025, evidenced a POC signed and returned by MD 1 (referring doctor) on 03/25/2025 with all the required elements included and specific treatment for wound care on the lateral side of the right foot (Wound #1) for which the patient was admitted to the home health agency. On 03/24/2025, an emergency room visit note indicated 14 staples were administered to a curved laceration (a tear or split in the skin and underlying tissues, often caused by sharp objects or blunt force) on the anterior (refers to the front of the body in anatomical terms) right leg (Wound #2) that showed some bruising with minimal bleeding and the right foot warm with appropriate capillary refill intact. MD 4 (Emergency Medicine) gave discharge instructions for the patient to make an appointment with MD 3 (Primary Care) to have the staples removed. A nursing note on 03/25/2025 indicated RN 2 failed to coordinate the care of Wound #2 with MD 3. Nursing notes on 3/27/2025, 03/31/2025, 03/31/2025, 04/04/2025, 04/07/2025, 04/16/2025, 04/18/2025, 04/19/2025, 04/21/2025, 04/30/2025, 05/07/2025, 05/09/2025, 05/15/2025 indicated RN 2 provided skilled nursing services related to Wound #2 for the patient and failed to evidence coordination of care and communication with all physicians involved in patient’s care. Case Conference notes on 03/27/2025, 04/17/2025, and 04/24/2025 indicated RN 2 reported updates related to Wound #2 and failed to evidence coordination of care and communication with all physicians involved in patient’s care. On 04/07/2025, a medical assistant note in the patient’s record, indicated during an encounter with the patient, MD 2 (primary care office group physician with MD 3) was asked to assess Wound #2. MD 2 removed three (3) Steri-strips (thin, sticky bandages that cover small cuts and some surgical incisions; can apply them across the cut running in the opposite direction to help the two sides of the skin stay tightly closed) along with four (4) staples and observed a very red and swollen right lower leg. MD 2 indicated the patient suffered from a possible allergic reaction to Tegaderm used a day or so prior and advised the medical assistant and patient to only use Bactroban ointment with non-adherent pads secured with surgical tape. The wound was redressed while in the office and MD 2 educated patient on bathing and care instructions while at home. On 05/09/2025, RN 2 wrote an order for changes applied to recertification of the patient for 05/13/2025 - 07/11/2025. The orders indicated skilled nursing to assess and change dressing to right foot and leg three (3) times weekly, an updated goal for the patient to be able to remain in the home and achieve optimal well-being prior to discharge from home services, and the plan was discussed with MD 1. The order was sent to MD 1 on 05/13/2025, signed and returned on 05/14/2025. The record failed to evidence RN 2 added MD 3 to the patient’s POC and failed to evidence coordination of care and communication between all physicians involved in patient’s care. During an interview on 07/25/2025 at 10:39 AM, RN 2 indicated he/she probably forgot to document when the staples were taken out of Patient #8’s right leg wound. RN 2 indicated being pretty sure a primary care physician removed the staples. After reviewing Patient #8’s clinical record, RN 2 indicated MD 2 is who removed the staples per the patient’s clinical record. The RN indicated MD 2 is in a physicians group with MD 3. RN 2 indicated he/she communicated with MD 1 who admitted the patient for the right foot wound (Wound #1), to obtain orders for the right leg wound (Wound #2) as well, however orders were not received right away for Wound #2. The RN indicated he/she couldn’t be for sure if it was MD 1 who removed the staples from Wound #2. RN 2 then indicated actually not being sure who Patient #8’s primary care physician was and indicated MD 2 was who sent the progress note to the agency after the staples were removed from Wound #2. RN 2 indicated he/she did not communicate with MD 2 to follow up after the staples were removed, and instead reached out to MD 1 because that is who was overseeing the orders for Wound #1. During an interview on 07/25/2025 at 1:13 PM, the Director of Clinical Services indicated the referring physician is often who the nurse primarily communicates. Ideally, if the referring physician is a specialist, the primary care physician would be looped into care for updates. The Director of Clinical Services indicated the expectation for nurses who are providing care that if there is a change in condition then the referring physician is contacted regarding the update to determine if new orders need to be implemented. If the referring physician is not willing to provide orders for the condition change, then the primary care physician should be contacted, updated and orders requested for care. Also, all physicians related to patient care should be on the Plan of Care to ensure total coordination of care. 410 IAC 17-14-1(a)(1)(G)”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the clinical record contained complete and accurate clinical notes for 1 of 3 closed records reviewed (Patient #8). Findings include: A review of a policy titled “Entries into the Patient/Client Record,” indicated but was not limited to: “Entries into the patient/client record include at least the following: …Accurate and pertinent data regarding patient/client: i. Assessment; ii. Care/Services delivered; iii. Outcomes and responses to care/services…” On 03/24/2025, an emergency room visit note indicated 14 staples were administered to a curved laceration (a tear or split in the skin and underlying tissues, often caused by sharp objects or blunt force) on the anterior (refers to the front of the body in anatomical terms) right leg that showed some bruising with minimal bleeding and the right foot warm with appropriate capillary refill intact. Nursing notes dated 03/25/2025, 03/27/2025, 03/31/2025, 04/04/2025, indicated RN 2 performed a skilled nursing visit and assessed Wound #2. The record failed to evidence documentation of staples present to Wound #2. On 04/07/2025, a medical assistant note indicated during an encounter with the patient, MD 2 (primary care office group physician with MD 3) was asked to assess Wound #2. MD 2 removed three (3) Steri-strips (thin, sticky bandages that cover small cuts and some surgical incisions; can apply them across the cut running in the opposite direction to help the two sides of the skin stay tightly closed) along with four (4) staples and observed a very red and swollen right lower leg. On 04/07/2025, a skilled nursing visit occurred. RN 2 indicated Wound #2 was observable with light serosanguineous drainage, no odor, pink tissue with closed/hyperkeratotic wound edges visualized, and that an “abdominal pad covered with a clear dressing, No orders, dressing is clean dry and intact no visible s/s of infection noted”. The visit summary indicated possible changes in treatment or doctor based on what MD 1 decided at the upcoming appointment for the week. The record failed to evidence documentation of change in Wound #2, removal of staples. On 04/16/2025, RN 2 measured Wound #2 at 13 cm long X 4 cm wide X 0.3 cm deep, light serosanguinous drainage, no odor, closed/hyperkeratotic wound edges with pink surrounding tissue, no signs of infection with collagen and xeroform applied with a gauze dressing per the new order. The visit summary indicated the patient removed dressings from wounds to take a shower and reports no pain. RN 2 wrote an order to apply collagen and xeroform with sterile gauze to Wound #2. The order was sent to MD 1 on 04/21/2025, signed and returned on 04/22/2025. The record failed to evidence documentation of change in Wound #2, removal of staples. On 05/12/2025, a follow-up visit note with MD 1 after a scheduled MRI test was completed, indicated the wounds on the right lateral foot and the lower tibial region of the right leg had worsened. The MRI showed early acute osteomyelitis. MD 1 noted the patient sustained a laceration to the lower right leg that had 14 staples used to close the wound, then two (2) weeks later, the staples were removed by MD 3. MD 1 reported “fairly large eschar remained present without active drainage or signs of infection”. MD 1 indicated the patient called on 05/09/2025 due to worsening pain with the wounds, so an appointment was scheduled for 05/12/2025 in the wound clinic for evaluation and debridement. During an interview on 07/25/2025 at 10:39 AM, RN 2 indicated being unable to recall when the staples were removed from the right leg wound. The RN indicated he/she probably forgot to document when the staples were taken out of Patient #8’s right leg wound. During an interview on 07/25/2025 at 1:13 PM, the Director of Clinical Services indicated that when the change in condition is related to a wound, the nurse is expected to assess the wound no matter what unless orders are received from a doctor to not remove a dressing. When there are no orders, the nurse should take off the dressing, assess and measure it, then re-dress it with a dry dressing. At that time, the doctor would receive report and new orders would be requested for treatment of a new wound. The nurse is expected to continue communications and document all changes that occur with the patient’s condition at any time there is a change and ensure all documentation is complete and accurate. 410 IAC 17-14-1(a)(1)(E)”