Good Samaritan Society - Omaha Metro Home Care

“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 record review, policy and procedure review, and staff interview, the agency failed to include complete Negative Pressure Wound Therapy (NPWT or wound vac) (a type of wound therapy, that uses negative pressure suction to help heal wounds) orders on the initial Plan of Care and/or failed to verify complete wound vac care orders, to include on the initial Plan of Care, for 3 of 5 patient records reviewed for patients who had wound vacs (Patient 2, 3, 4). The total sample size was 6. The census was 57. Findings are: A .Review of the agency’s policy and procedure titled, Wound Care, Home Health, Hospice and Assisted Living – Enterprise, date reviewed/revised 7/30/24, revealed: 1. Wound care was to be provided according to the provider’s order and should include: a. Dressing type to be used. b. Packing type to be used. c. Cleansing solution to be used. B. Review of the agency’s Skills procedure for Negative-Pressure Wound Therapy (Home Health Care) – CE/NCPD, developed in cooperation with LeadingAge, date unavailable, revealed: 1. Practitioner’s orders were to be verified to include the cleansing of the wound and the periwound (skin surrounding the wound) and the specific type of dressing. 2. Staff were to ensure the pressure and mode settings were set as prescribed. C. Review of Patient 2’s clinical records revealed: 1. The Transition Orders and Information for the Continuation of Patient Care, received to the agency from Nebraska Medicine, on 7/23/24, included orders: a. Negative Pressure Wound Therapy. b. Topical skin prep to the periwound. c. Granufoam (black foam) to the wound. d. Continuous suction at 125 mmHg (measurement of negative pressure level). 2. The initial Home Health Certification and Plan of Care (POC) for the certification period 7/24/24 through 9/21/24, included orders for Skilled Nursing (SN) to provide wound vac dressing change 3 x weekly and PRN (as needed). a. The initial POC wound vac orders failed to include: 1. The cleansing of the wound and periwound. 2. The type of foam to be used on the wound. 3. The type of suction for the wound vac (intermittent or continuous) 4. The negative pressure measurement of the suction. D. Review of Patient 3’s clinical record revealed: 1. Review of Lab Order Summary from CHI Health Clinic Orthopedic Surgery- Immanuel, dated 5/23/24, received via fax to the agency on 5/30/24, included orders for wound vac changes to the left ankle. 2. The initial POC for the certification period 5/31/24 through 7/29/24, included orders for SN to provide wound vac care weekly and PRN. 3. The initial POC wound vac orders failed to include: a. The cleansing of the wound and periwound. b. The type of foam to be used on the wound. c. The type of suction for the wound vac (intermittent or continuous) d. The negative pressure measurement of the suction. E. Review of Patient 4’s clinical record revealed: 1. The After Visit Summary from CHI Health Creighton University Medical Center – Bergan Mercy, for services provided 6/7/24 through 6/13/24, included orders for SN to provide wound vac dressing change to the right foot on M,W, F (Monday, Wednesday and Friday), – 125 mmHg. 2. The initial POC for the certification period 6/14/24 through 8/12/24 included an order for SN to change wound vac M,W,F, and PRN. 3. The initial POC wound vac orders failed to include: a. The cleansing of the wound and periwound. b. The type of foam to be used on the wound. c. The type of suction for the wound vac (intermittent or continuous). d. The negative pressure measurement of the suction. F. During an interview on 9/10/24 at 3:30 PM, the Administrator and the RN Case Manager confirmed, the agency failed to follow their policy and procedures to include complete wound vac orders on the initial Plan of Care, and/or failed to verify complete wound care orders to include on the initial Plan of Care, for 3 of 5 patient records reviewed, for patients who had wound vacs (Patient 2, 3, and 4).”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Findings are: Based on record review, policy and procedure review, and staff interview, the agency failed to verify and include complete Negative Pressure Wound Therapy (NPWT or wound vac) (a type of wound therapy that uses negative pressure suction to help heal wounds) orders on the revised Plan of Care for 1 of 2 patient records reviewed for patients who had a wound vac (Patient 5). The total sample size was 6. The census was 57. A. Review of the agency’s policy and procedure titled, Wound Care, Home Health, Hospice and Assisted Living – Enterprise, date reviewed/revised 7/30/24, revealed: 1. Wound care was to be provided according to the provider’s order and should include: a. Dressing type to be used. b. Packing type to be used. c. Cleansing solution to be used. B. Review of the agency’s Skills procedure for Negative-Pressure Wound Therapy (Home Health Care) – CE/NCPD, developed in cooperation with LeadingAge, date unavailable, revealed, practitioner’s orders were to be verified to include the cleansing of the wound and the periwound (skin surrounding the wound), and the specific type of dressing. C. Review of Patient 5’s clinical record revealed: 1. The After Visit Summary from CHI Health Creighton University Medical Center – Bergan Mercy, for services provided 4/1/24 through 4/9/24, included orders: a.. Wound vac changes MWF (Monday, Wednesday, Friday), with negative pressure wound vac. b.. Place adaptic (a non-adhesive dressing) over muscle/bone of sternum and black foam over this. 2.. The revised Home Health Certification and Plan of Care (POC) for the certification period 5/19/24 through 7/17/24, included orders for Skilled Nursing (SN) to change the wound vac dressing on Monday, Wednesday, and Friday and PRN (as needed). 3. The POC orders failed to include: a. The cleansing of the wound and periwound. b. Place adaptic over muscle/bone of sternum and use black foam over the adaptic. c. The type of suction for the wound vac (intermittent or continuous). d. The negative pressure measurement of the suction. D. During an interview on 9/10/24 at 3:30 PM, the Administrator and RN Case Manager confirmed, the agency failed to verify complete wound vac orders and failed to include the complete wound vac orders on the revised POC for Patient 5.”

“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 record review, policy and procedure review, and staff interview, the agency failed to ensure staff administer treatments as ordered on the plan of care for 1 of 7 clinical records reviewed (Patient 2). The census was 51. Findings are: A. Review of the agency policy and procedure titled, Medication Administration, Home Health-Enterprise, reviewed/revised 2/17/23, revealed drugs and treatments are to be administered by agency staff only as ordered. B. Review of Patient 2’s clinical record revealed: 1. The Home Health Certification and Plan of Care (POC) for the certification period of 12/12/23 through 2/9/24 revealed: 2. Orders for Skilled Nurse (SN) to assess wound to right shoulder. 3. Orders to apply Triad Hydrophilic Wound Dressing external paste (a topical cream used to protect skin and promote healing) to the right shoulder wound every other day. 4. A Charts/Clinical Note by the SN, dated 12/29/23, revealed the SN applied an allevyn (a foam dressing) to the bilateral hips and buttocks, applied hydrofera blue (a wound dressing used to promote healing) covered with allevyn to the right shoulder, and applied an allevyn to the scabbed area on the right foot. 5. There were no orders in the clinical record for applying allevyn to the bilateral hips and buttocks, applying hydrofera blue covered with allevyn to the right shoulder, or applying allevyn to the scabbed area of the right foot, as applied by the SN on 12/29/23. C. During staff interview on 1/18/24 at 11:45 AM, the Agency Administrator and the Clinical Manager confirmed the SN did not follow the treatment as ordered on the plan of care for Patient 2’s right shoulder wound, and did not obtain new treatment orders for Patient 2’s new areas of skin breakdown, as identified during the 12/29/23 SN visit.”

“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, policy and procedure review, and staff interview, the agency failed to promptly notify the physician to request a change in treatment orders, when changes in a patient’s skin integrity were identified during the assessment of 1 of 2 patients (Patient 2), who received wound care. The total sample size was 7. The census was 51. Findings are: A. Review of the agency policy and procedure titled, Care Planning and Care Coordination, Home Health and Therapy-Enterprise, last reviewed/revised 2/21/23, revealed: 1. Collaboration and communication relevant to the patient’s care should be ongoing. 2. Significant changes in the patient’s condition are communicated in a timely manner and documented in the patient record. 3. The Plan of care should be reviewed and revised by the provider and the team as frequently as the patient’s condition requires. B. Review of the agency policy and procedure titled, Physician Orders-Home Health, reviewed/revised 12/13/21, revealed: 1. The purpose of the policy is to provide documentation of the providers approval for changes they have made. 2. The order was to be written the day the skilled professional received the order and sent to the physician for signature. C. Review of Patient 2’s clinical record revealed: 1. The Home Health Certification and Plan of Care (POC) for the certification period of 12/12/23 through 2/9/24 revealed: 2. Orders for Skilled Nurse (SN) to assess wound to right shoulder. 3. Orders to apply Triad Hydrophilic Wound Dressing external paste (a topical cream used to protect skin and promote healing) to the right shoulder wound every other day. 4. The patient was admitted with a chronic wound greater than four months which the patient covers with a bandaid at night for protection of the wound. 5. A Charts/Clinical Note by the SN, dated 12/29/23, revealed: a. The patient reported sores to bilateral hips, right shoulder, and right foot. b. The SN assessed the areas, cleansed the wounds, and applied allevyn (a foam dressing) to the bilateral hips and buttocks, applied hydrofera blue (a wound dressing used to promote healing) covered with allevyn to the right shoulder, and applied allevyn to the scabbed area on the right foot. c. There was no documentation in the clinical record to indicate the physician was notified of the new areas of skin breakdown found during the SN visit on 12/29/23, or to request a new physician order to change to the existing wound care treatments to reflect the wound care treatments provided during the SN visit on 12/29/23. D. During staff interview on 1/17/24 at 7:30 AM, the Agency Administrator confirmed there was no documentation in the clinical record to indicate the physician was promptly notified of the changes to Patient 2’s skin conditions or the need to change Patient 2’s wound care treatments.”