Bayada Home Health Care Inc.

“Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This Standard is not met as evidenced by: Based on clinical record review and staff interviews the agency failed to follow the physician’s order for wound care for 1 of 5 patients with a wound [#1]; and failed to report vital signs outside the given parameters for 1 of 1 patient with a VAD [vascular access device-type of catheter that provides access to blood vessels without the need for repeated needle sticks] [#5]. The findings included: 1. Patient # 1 had a Start of Care [SOC] date of 6/26/23 with admitting diagnoses of type 1 diabetes mellitus with ketoacidosis without coma [body can’t produce enough insulin], pressure ulcer of left heel stage II [top layer of skin has worn away] and pressure ulcer of right heel stage II. Review of the Plan of Care [POC] for the certification period 6/26/23-8/24/23 included orders for SN [Skilled nursing] 2 times a week for 1 week, 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 5 weeks and “SN to perform wound care…Perform wound care to bilateral heel pressure wounds. Cleanse with wound cleanser, apply barrier cream to wound bed, cover with dry gauze…change dressings daily…” Review of the clinical record revealed RN # 10 completed the SOC OASIS [Outcome and Assessment Information Set-comprehensive assessment done that measures quality and outcomes] on 6/26/23. Review of the OASIS documentation revealed the wound measurements of the right heel of 2 cm x 2.5 cm x 0 cm and the left heel measurements of 2 cm x 3 cm x 0.1 cm. Further review of the clinical record revealed no wound care was completed. RN # 10 documented “Wound care not provided; not ordered this visit”. RN # 10 was not available for interview. During an interview with employee # 3 on 3/6/24 at approximately 11:15 am, employee # 3 confirmed the POC did include orders for wound care at the SOC, however, the wound care was not completed by the RN. 2. Patient # 5 had a Start of Care date of 11/26/22 and admitting diagnoses of pressure ulcer of right buttock unstageable [ulcers covered with slough or eschar so wound bed is not visible], pressure ulcer of sacral [base of spine] region stage 2 [top and bottom layer of skin is worn away] and encounter for adjustment and management of VAD [vascular access device-type of catheter that provides access to blood vessels without the need for repeated needle sticks]. Review of the Plan of Care [POC] for the certification period 11/26/22-1/24/23 included orders for SN [skilled nursing] 1 time a week for 7 weeks and “Licensed professional to report vital signs falling outside the following established parameters, temperature greater than 100.4…” Review of the clinical record revealed RN # 7 documented a temperature of 100.5 on 11/26/22. There was no evidence the RN notified the physician. RN # 7 was not available for interview. During an interview with employee # 3 on 3/6/24 at a11 am, employee # 3 confirmed the physician was not notified in accordance with the POC.”

“Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This Standard is not met as evidenced by: Based on agency policy, clinical record view and staff interviews, the skilled nurse failed to assess a wound for 1 of 5 patients with a wound [#3]; failed to write a verbal order related to administration of insulin for 1 of 8 patients with a diagnosis of diabetes [#4]; and failed to obtain wound measurements for 2 of 5 patients with a wound [#5, #13]. The findings included: 4.Patient # 13 had a Start of Care (SOC) date of 2/8/24 and an admitting diagnoses of encounter for surgical aftercare following surgery of circulatory system, heart disease, hypertension, and type 2 diabetes. A review of the Plan of Care (POC) for the certification period 2/8/24 to 4/7/24 revealed orders for skilled nursing 1 time a week for 1 week, 2 times a week for 1 week; and 1 time a week for 3 weeks “…skilled nurse will assess and monitor surgical incision…” A review of the clinical record revealed no wound measurements were obtained for the weeks of 2/19/24 and 2/26/24. Interview with the director of clinical operations on 3/6/24 at 9:18 a.m. confirmed no wound measurements are in the record for those weeks. The policy, “Wound Care-Assessment and Treatment” revised date of 9/9/21 was provided by the agency director on 3/6/24 at 11:04 a.m. The policy stated, “…Wounds should be measured in centimeters once per week and/or per physician’s order…” 1. Patient # 3 had a Start of Care date of 11/12/22 and admitting diagnoses of pressure-induced deep tissue damage [purple or maroon area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear] of right hip, pressure ulcer of sacral [base of spine] region, unstageable [wound bed is covered by slough and or eschar and the wound bed is not visible], pressure ulcer of left hip, stage I [skin is red and non-blanchable] and paraplegia, unspecified [inability to move lower part of body]. Review of the Plan of Care [POC] for the certification period 5/11/23-7/9/23 included orders for SN [skilled nursing] effective 5/14/23 1 time a week for 8 weeks. Review of the clinical record revealed the patient was seen at _____ [name] Wound Care Center on 5/23/23. The wound center identified the following wounds: Stage IV [full-thickness skin loss, extends through the fascia with considerable tissue loss. There may be muscle, bone, tendon, or joint involvement. The depth is unknown because slough and or eschar obscures the extent of tissue damage] to right hip. Stage III [full-thickness tissue loss. Fat may be visible, but bone, tendon or muscle are not exposed. Undermining and tunneling may be present] pressure ulcer of right buttock. Stage II [ulcer presents as a crater] of left buttock. Stage IV ulcer of sacral region [base of spine] RN # 12 made routine visits on 5/25/23 and 5/29/23 and assessed [identified] the wounds located on the right trochanter [pointed upper, outside edge of the femur], sacral area [base of spine] and right buttock. There was no assessment/documentation related to the wound to the left buttock identified by the wound care enter on 5/23/23 or 5/29/23. RN # 12 was not available for interview. An interview was conducted with employee # 3 on 3/6/24 at approximately 12 noon. During the interview, employee # 3 confirmed no assessment was documented of a wound to the left buttock. 2. Patient # 4 had a Start of Care date of 5/28/23 with admitting diagnoses of hypertensive chronic kidney disease, type 2 diabetes mellitus with diabetic chronic kidney disease, unspecified dementia and type 2 diabetes w diabetic peripheral angiopathy without gangrene [narrowing of the arteries caused by diabetes]. Review of the Plan of Care [POC] for the certification period 5/28/23-7/26/23 included orders for SN [skilled nursing] 2 times a week for 1 week, 1 time a week for 2 weeks. With supplemental orders written on 6/13/23 for SN visits 2 times a week for 2 weeks; 6/25/23 SN visits 2 times a week for 3 weeks and 7/9/23 for SN visits 2 times a week for 2 weeks then 1 time a week for 1 week. Review of the clinical record revealed LPN # 9 conducted a routine visit on 7/18/23 and documented the following information, “…Dr_______ [name] office called and notified of blood sugar [514]. RN gave very order for client to administer another 10 units of Humalog [insulin] and recheck blood sugar in 30 minutes…” LPN # 9 conducted another routine visit on 7/20/23 and documented the following, “…MD notified of blood sugar of 467…Per nurse at Dr.______ [name] office client to administer 10 additional units of Humalog…” Further review of the clinical record revealed no evidence the LPN had written the orders for the additional insulin. LPN # 9 was not available for interview. During an interview with employee # 3 on 3/6/24 at 1 pm, employee # 3 confirmed the LPN failed to write the verbal order related to additional administration of insulin. 3. Patient # 5 had a Start of Care date of 11/26/22 and admitting diagnoses of pressure ulcer of right buttock unstageable [ulcers covered with slough or eschar so wound bed is not visible], pressure ulcer of sacral [base of spine] region stage 2 [top and bottom layer of skin is worn away] and encounter for adjustment and management of VAD [vascular access device-type of catheter that provides access to blood vessels without the need for repeated needle sticks]. Review of the Plan of Care [POC] for the certification period 11/26/22-1/24/23 included orders for SN [skilled nursing] 1 time a week for 7 weeks and “Skilled nurse to perform wound care and instruct caregiver to perform wound care. Perform wound care to… stage II pressure ulcer…change dressing weekly and as needed…” Review of the clinical record revealed wound measurements of 4 cm x 2 cm x 0 cm documented on 12/6/22. The clinical record revealed no additional wound measurements after 12/6/22. The patient was discharged on 1/18/23. During an interview with employee # 3 on 3/6/24 at 11:30 am, employee # 3 confirmed the SN should have obtained wound measurements each week.”

“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: G574 Based on agency policy review, clinical record review and patient/staff interviews the Plan of Care [POC] failed to include all current medications the patient was using for 5 of 7 home visits observed (#11,7, 12, 16, & 17); and failed to include a normal saline flush for 1 of 1 patient with a VAD [vascular access device-type of catheter that provides access to blood vessels without the need for repeated needle sticks](#5). The findings included: 2. Patient # 5 had a Start of Care date of 11/26/22 and admitting diagnoses of pressure ulcer of right buttock, unstageable [ulcers covered with slough or eschar so wound bed is not visible], pressure ulcer of sacral [base of spine] region, stage II [top and bottom layer of skin is worn away] and encounter for adjustment and management of VAD [vascular access device-type of catheter that provides access to blood vessels without the need for repeated needle sticks]. Review of the Plan of Care [POC] for the certification period 11/26/22-1/24/23 included orders for SN [skilled nursing] 1 time a week for 7 weeks and “skilled nurse may teach caregiver to infuse 200 ml of vancomycin [antibiotic]…Flush IV access with 5 mls of normal saline…” Review of the POC revealed the normal saline was not listed as a medication. During an interview with employee # 3 on 3/6/24 at approximately 11 am, employee # 3 confirmed the normal saline should have been included on the POC as a medication. 3. Patient # 7 had a Start of Care date of 1/17/24 with an admitting diagnosis of chronic obstructive pulmonary disease [COPD-condition making it difficult to breath]. Review of the Plan of care [POC] for the certification period 1/17/24-3/16/24 included orders for PT [physical therapy] 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 7 weeks. On 3/4/24 at 3:30 pm a joint visit was made with PT # 8. During the visit, a medication review was conducted using a medication profile provided by the agency. The following discrepancy was noted: The medication profile listed Furosemide [fluid medication] 40 mg daily. During an interview with the patient, the patient reported the physician had recently changed this medication to 60 mg each day. During an interview with PT # 8 after the visit, PT # 8 confirmed the POC did not include the correct medications. 4. Patient # 12 had a Start of Care date of 2/10/24 and an admitting diagnosis of bilateral primary osteoarthritis of knee. Review of the Plan of Care [POC] for the certification period 2/10/24-4/9/24 included orders for PT [physical therapy] 1 time a week for 1 week, 2 time a week for 4 weeks. On 3/5/24 at approximately 3 pm, a joint visit was made with PTA [physical therapy assistant] # 5. During the visit, a medication review was conducted using a medication profile provided by the agency. During an interview with the patient, the patient reported using Advil [over the counter pain relief] 200 mg every 6 hours for pain control. Review of the POC did not include Advil. During an interview with employee # 3 on 3/6/24 at approximately 11 am, employee # 3 confirmed the POC did not include all medications the patient was using. 5. Patient # 16 had a Start of Care date of 2/17/24 with admitting diagnoses of acute embolism [blockage in an artery caused by blood clots or other substances] and thrombosis [blood clot in vein] of left femoral vein [vein in the thigh], acute embolism and thrombosis of left popliteal vein [vein behind the knee] and acute embolism and thrombosis of left tibial vein [vein that runs inside of thigh]. Review of the Plan of Care [POC] for the certification period 2/17/24-4/16/24 included orders for OT [occupational therapy] 1 time a week for 5 weeks. On 3/5/24 at approximately 9:30 am a joint visit was made with OTA [occupational therapy assistant] # 4. During the visit, a medication review was conducted using a medication profile provided by the agency. During the visit, an interview was conducted with the patient’s caregiver regarding the current medications the patient was taking. The caregiver presented a bottle of acetaminophen [over the counter pain medication] 325 mg. The caregiver reported the patient takes 2 tablets every 6 hours as needed for pain. Review of the POC did not include acetaminophen. On 3/6/24 at approximately 10 am, an interview was conducted with employee # 3. Employee # 3 confirmed the POC did not include all the medications the patient was taking. 6. Patient # 17 had a Start of Care date of 2/24/24 with an admitting diagnosis of fracture of left lower leg. Review of the Plan of Care [POC] for the certification period 2/24/24-4/23/24 included orders for SN [skilled nursing] 1 time a week for 4 weeks. On 3/5/24 at approximately 11 am, a joint visit was conducted with LPN # 6. During the visit, a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: The medication profile listed Lantus Solostar U-100 [insulin-used to treat diabetes] take 18 units 2 times per week. During the visit, an interview was conducted with the patient. The patient reported taking 18 units of Lantus insulin every morning. The medication profile listed brimonidine [eye drops] 0.1 % 2 times daily. The medication profile failed to include which eye the eye drops would be placed in. During the interview with the patient, the patient reported the eye drops were used in both eyes. The medication profile listed MiraLAX [stool softener] 17 grams. Take 17 grams [1 capful] as needed for constipation. During the interview with the patient, the patient reported, “I don’t take that anymore. I don’t need it.” During an interview with LPN # 6, the LPN confirmed the medications on the POC were incorrect. The policy, “Client Plan of Care”, revised 07/05/21 was provided by the agency director on 03/6/24 at 11:04 a.m. The policy stated, “...the client plan of care includes all medications and treatments…”. 1.Patient #11 was admitted on 02/11/24 with diagnoses of fracture of femur (broken leg bone), heart disease, heart failure, and type 2 diabetes. The Plan of Care (POC) for 02/11/24-04/10/24 included orders for skilled nursing 1 time a week for 4 weeks, physical therapy 2 times a week for 2 weeks, 1 time a week for 6 weeks, and occupational therapy 1 time a week for 8 weeks. A home visit was conducted with the occupational therapist on 03/4/24 at 1:30 p.m. A medication review was conducted and revealed the following discrepancies: -aspirin 81mg (milligrams) 1 by mouth daily as a blood thinner was not included on the plan of care. -fish oil (supplement for cholesterol) daily was not included on the plan of care. Interview with the patient on 03/4/24 at 1:53 p.m. revealed the patient has been using these medicines for a long time.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on clinical record review and staff interviews the skilled nurse failed to document follow-up related to a COVID 19 test for 1 of 1 patient [#1]; and failed to provide accurate documentation related to wounds/measurements of wounds for 1 of 5 patients with a wound [#3]. The findings included: 1. Patient # 1 had a Start of Care [SOC] date of 6/26/23 with admitting diagnoses of type 1 diabetes mellitus with ketoacidosis without coma [body can’t produce enough insulin], pressure ulcer of left heel stage II [top layer of skin has worn away] and pressure ulcer of right heel stage II. Review of the Plan of Care [POC] for the certification period 6/26/23-8/24/23 included orders for SN [Skilled nursing] 2 times a week for 1 week, 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 5 weeks. Review of the clinical record revealed RN # 11 conducted a routine visit on 8/15/23 and documented the following information, “Blood sugar 87, has cough and diarrhea. Had recent visit to the ED [emergency department]. Patient found unresponsive, blood sugar 40. Advised to get COVID test…” Further review of the clinical record revealed no follow-up related to the results of the COVID test. RN # 11 was not available for interview. During an interview with employee # 3 on 3/6/24 at 11:15 am, employee # 3 confirmed the RN should have documented the follow up for the COVID test. 2A. Patient # 3 had a Start of Care date of 11/12/22 and admitting diagnoses of pressure-induced deep tissue damage [purple or maroon area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear] of right hip, pressure ulcer of sacral [base of spine] region, unstageable [wound bed is covered by slough and or eschar and the wound bed is not visible], pressure ulcer of left hip, stage I [skin is red and non-blanchable] and paraplegia, unspecified [inability to move lower part of body]. Review of the Plan of Care [POC] for the certification period 5/11/23-7/9/23 included orders for SN [skilled nursing] effective 5/14/23 1 time a week for 8 weeks and “…Perform wound care to sacral stage 3 pressure [sacral ulcer is listed as unstageable on the diagnosis list] ulcer as follows: cleanse with anasept, wound cleanser, normal saline or soap and water, apply medihoney to wound bed and cover and secure with a foam dressing…change dressing every other day…wound care to right hip unstageable pressure injury [right hip is listed as deep tissue injury on the diagnosis list] cleanse with anasept, wound cleanser, normal saline or soap and water, apply medihoney to wound bed and cover and secure with a foam dressing…change dressing every other day…” RN # 12 completed the POC on 5/7/23 and was not available for interview. During an interview with employee # 3 on 3/6/23 at approximately 12 pm, employee # 3 confirmed the stages of the ulcers documented did not match the orders on the POC. 2B. Patient # 3 had a Start of Care date of 11/12/22 and admitting diagnoses of pressure-induced deep tissue damage [purple or maroon area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear] of right hip, pressure ulcer of sacral [base of spine] region, unstageable [wound bed is covered by slough and or eschar and the wound bed is not visible], pressure ulcer of left hip, stage I [skin is red and non-blanchable] and paraplegia, unspecified [inability to move lower part of body]. Review of the Plan of Care [POC] for the certification period 5/11/23-7/9/23 included orders for SN [skilled nursing] effective 5/14/23 1 time a week for 8 weeks and “…Perform wound care to sacral stage 3 pressure [sacral ulcer is listed as unstageable on the diagnosis list] ulcer as follows: cleanse with anasept, wound cleanser, normal saline or soap and water, apply medihoney to wound bed and cover and secure with a foam dressing…change dressing every other day…wound care to right hip unstageable pressure injury [right hip is listed as deep tissue injury on the diagnosis list] cleanse with anasept, wound cleanser, normal saline or soap and water, apply medihoney to wound bed and cover and secure with a foam dressing…change dressing every other day…” Review of the wound assessments completed by RN # 12 revealed the patient had the following wound measurements: 5/16/23- stage 1 on left greater trochanter [pointed upper, outside edge of the femur] -healed right greater trochanter-unstageable deep tissue injury – 2 cm x 2 cm x 0.3 cm sacral unstageable ulcer – 3.5 cm x 3 cm x 0.5 cm 5/25/23- right greater trochanter-unstageable deep tissue injury – 3.5 cm x 3.5 cm x1 cm sacral unstageable ulcer – 5 cm x 4 cm x 1 cm with extensive depth Further review of the clinical record revealed a wound depth for the deep tissue injury and the unstageable pressure ulcer was documented from 5/16/23-6/26/23. RN # 12 was not available for interview. An interview was conducted with employee # 3 on 3/6/24 at approximately 12 noon. During the interview, employee # 3 confirmed the depth cannot be determined in a deep tissue injury or an unstageable ulcer.”

“Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This Element is not met as evidenced by: Based on clinical record review and staff interviews the skilled nurse failed to communicate with physician when patient refused wound care for 1 of 5 patients with a wound [#5]; and failed to report patient’s inability to monitor blood sugar for 1 of 8 patients with a diagnosis of diabetes [#17]. The findings included: 1. Patient # 5 had a Start of Care date of 11/26/22 and admitting diagnoses of pressure ulcer of right buttock unstageable [ulcers covered with slough or eschar so wound bed is not visible], pressure ulcer of sacral [base of spine] region stage 2 [top and bottom layer of skin is worn away] and encounter for adjustment and management of VAD [vascular access device-type of catheter that provides access to blood vessels without the need for repeated needle sticks]. Review of the Plan of Care [POC] for the certification period 11/26/22-1/24/23 included orders for SN [skilled nursing] 1 time a week for 7 weeks and “Skilled nurse to perform wound care and instruct caregiver to perform wound care. Perform wound care to coccyx [base of spine] stage II pressure ulcer…change dressing weekly and as needed…” Review of the clinical record revealed the wound care was completed on 11/26/22, 11/29/23, 12/6/23 and 12/13/23. The wound care was not completed on 12/20/22, 12/27/22 or 1/3/23. The clinical record revealed the SN documented, “Wound care not provided; refused care.” Further review of the clinical record revealed no evidence the physician was notified that the wound care was not completed by the SN. During an interview with employee # 3 on 3/6/24 at approximately 11:30 am, employee # 3 confirmed the physician was not notified of the patient’s refusal to allow the SN to complete the wound care. 2. Patient # 17 had a Start of Care date of 2/24/24 with an admitting diagnosis of fracture of left lower leg. Review of the Plan of Care [POC] for the certification period 2/24/24-4/23/24 included orders for SN [skilled nursing] 1 time a week for 4 weeks and “Skilled nurse to perform/instruct the client/caregiver to monitor blood glucose as ordered twice daily and PRN [as needed] …Notify physician of blood glucose greater than 350 or less than 70…” During an interview with the patient on 3/5/24, the patient stated, “I can’t check my blood sugars, I don’t have a glucometer…” Further review of the clinical record revealed the physician was not notified that the patient was unable to check his blood sugar. During an interview with employee # 3 on 3/6/24 at approximately 11:30 am, employee # 3 confirmed the physician should have been notified the patient was unable to monitor his blood glucose.”