3hc

“Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) The HHA must— (i) Investigate complaints made by a patient, the patient’s representative (if any), and the patient’s caregivers and family, including, but not limited to, the following topics: (A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; (B) Mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the HHA. This Element is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews the agency failed to document complaints/concerns, investigations, and resolutions for 1 of 1 patient with complaints. (patient #1) Findings included: A policy, Patient Grievances (revised 04/2024) received on 02/17/2025 at 3:07 PM from the Senior Director of Quality Regulation and Compliance stated, “The Director shall document all communication with the patient, family, employee(s) and others. The Director is responsible for ensuring resolution is achieved and must continue to follow the grievance until there is documented closure of the grievance.” Patient #1 was admitted on 08/07/2024 with diagnoses of disruption of external operation (surgical) wound (opening of a previously closed surgical wound) and necrotizing fasciitis (serious bacterial infection that destroys tissue). The plan of care for 10/06/2024-12/04/2024 included orders for skilled nurse (SN) visits 3 times a week for 6 weeks and 6 PRN (as needed). On 11/18/2024 registered nurse (RN) #4 documented, “Wife with raised voice, complaining regarding visit times, visit schedules, etc.…Approximately 1minute later, patient’s wife calls SN and immediately begins berating SN again with raised voice, complaining about supplies… and needing to buy supplies herself… SN calls and speaks with the scheduler and ACD [Assistant Clinical Director].” A review of the agency Patient Grievances for January 2024-March 2025 revealed that no concerns, grievances, or complaints were documented for patient #1. An interview conducted on 02/17/2025 at 3:25 PM with the ACD revealed that patient #1’s spouse contacted the office frequently to voice concerns and the concerns were not documented because the ACD felt like all complaints had been resolved.”

“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 agency policy, clinical record review, and staff interviews, the agency failed to communicate a change in condition for 1 of 1 patient with a change of condition. (patient #3) Findings included: A policy, Home Health-General Policy #04, Coordination of Care (revised 03/2024) received on 02/17/2025 at 4:35 PM from the Senior Director of Quality Regulation and Compliance stated, “Visiting staff shall maintain ongoing communication with the attending physician when services require a physician’s order… Any changes in the patient’s condition.” Patient #3 was admitted on 09/22/2024 with diagnoses of Pressure Ulcer of Sacral region stage 2 (shallow opening, sore, or blister), Pressure Ulcer of Left Heel, stage 1(reddened area that does not turn white when pressed), and sepsis (a life-threatening complication of an infection). The plan of care for 11/21/2024-01/19/2024 included orders for skilled nurse visits 2 times a week for 1 week, 1 time a week for 7 weeks, with 6 PRN (as needed), “Decubitus/Pressure Ulcer Stage 1/Left Lateral Foot Heel. Clinician [nurse] to assess and monitor wound(s) for signs and symptoms of infection and continued healing,” and assess risk factors for skin breakdown/healing/infection. A review of the clinical record revealed that registered nurse (RN) #5 documented on 12/31/2025, “Left Lateral Foot Heel… wound bed Eschar [black dead tissue], Slough [layer of dead tissue] … Drainage… Serosanguinous [pink fluid] Green [sign of infection].” Further review revealed that there was no documentation of the physician being notified.” An interview conducted on 02/17/2025 at 3:11 PM with RN #5 revealed that the physician was not notified about the presence of green discharge from the wound. An interview conducted on 02/17/2025 at 3:32 PM with the assistant clinical director revealed that the expectation is for the nurse to notify the physician [of changes of condition].”