Atrium Health at Home Blue Ridge

“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 policy review, observation, client record review, and staff interviews, the agency failed to include all medications on the plan of care for 3 of 7 home visits conducted (12,11,and 14 ). Findings included: 2. Patient # 11 had a Start of Care date of 5/1/24 and an admitting diagnosis of hypertensive heart disease [complications of high blood pressure that affective the heart] with heart failure [heart does not pump effectively]. Review of the plan of care for the certification period 12/27/24-2/24/25 included orders for SN [skilled nurse] 2 times a week for 1 week, 1 time a week for 7 weeks and “skilled nurse to review medication profile and reconcile medications as needed...” On 2/3/25 at approximately 12 pm, a joint visit was conducted with RN # 5. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancy was noted: The patient presented a tube of Betamethasone cream [steroid medication] with the following directions “May use BID [2 times a day] PRN [as needed] for itching. The patient reported she used this medication for her eczema [dry itchy skin often with a rash] on her back. The medication profile did not include the Betamethasone. During an interview with the RN, the RN confirmed the POC did not include all the medications the patient was using. 3. Patient # 14 had a Start of Care date of 1/19/24 with admitting diagnoses of encounter for fitting and adjustment of urinary device and benign prostatic hyperplasia with lower urinary tract symptoms [enlarged prostate]. Review of the plan of care [POC] for the certification period 1/13/25-3/13/25 included orders for SN [skilled nursing] 2 times a week for 9 weeks and “skilled nurse to review medication profile and reconcile medications as needed...” A joint visit was conducted with RN # 4 on 2/3/25 at approximately 10:30 am. 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 Zinc [supplement] 30 mg. Take 1 capsule daily. The patient presented a bottle of Zinc 50 mg and advised this is the medication he currently takes. During an interview with the RN, it was confirmed the POC did not include all the current/correct medications the patient was taking. Review of a policy “MM 017 AH AH Medication Reconciliation”, revised 8/7/2024 was received from the agency director on 2/5/25 at 11:05 AM. The policy stated, “… at the time of comprehensive assessment, the clinician will create and document a complete list of medications that patient is taking including dose, route and frequency…”. 1.Patient #12 was admitted on 1/22/25 with diagnoses of secondary malignant neoplasm of right kidney and renal pelvis, chronic obstructive pulmonary disease, chronic diastolic heart failure, and hyperlipidemia (high cholesterol). Orders were for occupational therapy 1 time a week for 3 weeks. A home visit was conducted on 2/3/25 at 1:30 PM with the occupational therapist. A review of the current medications was conducted with the patient/caregiver during the home visit. The review revealed the following discrepancy: triamcinolone acetonide cream 0.1% (steroid cream). Per interview with the wife the patient has using the cream for a while if his skin gets irritated with radiation.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on policy review, client record review, and staff interview the agency failed to include wound measurements for 2 of 8 records reviewed with wounds (6 and 16). Findings included: Review of policy “Wound Assessment, home care”, revised 2/20/24 was received from the agency director on 2/5/25 at 11:05 AM. The policy stated,” …a thorough wound assessment should consist of objective criteria and measurements that promote accurate, consistent comparisons to determine the extent of the wound and the effectiveness of wound healing…” 1.Patient #6 was admitted on 12/23/23 with diagnoses of encounter for orthopedic aftercare following surgical amputation, paroxysmal arial fibrillation, heart failure, type 2 diabetes, and acquired absence of left leg. Review of the plan of care for 12/17/24-2/14/25 had orders for skilled nursing were 2 times a week for 1week, and 3 times a week for 5 weeks. Skilled nursing wound care orders were to clean site with wound cleanser, apply adaptic, cover with dry gauze/ABD pad, wrap with roll gauze and secure with tape. Review of skilled nursing notes revealed wound measurements were missing for the weeks of 12/30/24, 1/6/25, 1/13/25, 1/20/25, and 1/27/25. Interview with the Accreditation Coordinator on 2/3/25 at 3:55 PM confirmed no other wound measurements were in the medical record. 2. Patient #16 was admitted on 12/22/24 with diagnoses of special stenosis (spinal narrowing), type 2 diabetes, abrasion left lower leg and blister of left foot. Review of the plan of care for 12/22/24-2/19/25 had orders for skilled nursing 3 times a week for 1 week, 2 times a week for 1 week, and 1 time a week for 7 weeks. Skilled nursing wound care orders were to cleanse wound with wound cleanser, apply aquacel AG (silver), cover with gauze, secure with tape or wound retention sheets. Review of the skilled nursing notes revealed wound measurements were missing for the week of 12/30/24. Interview with the Accreditation Coordinator on 2/4/25 at 3:35 PM confirmed no measurements were documented for the week of 12/30/24.”