Archcare at Home

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on clinical record review and staff interviews, the agency failed to ensure that all patients are informed of the frequency and duration of the services they are expected to receive, ensure the care to be provided is based on a complete and comprehensive assessment; and that all patient rights are respected and encouraged. This was evident in one (1) of four (4) clinical records reviewed (Patient #4). Failure to ensure that all patients are informed of the frequency and duration of services they are expected to receive, ensure the care to be provided is based on a complete and comprehensive assessment; and that patient rights are respected and encouraged has the potential for negative patient outcomes. The findings are: 2) Patient #3 has a start of care date of 3/25/2024 and a discharge date of 4/18/2024, with diagnoses that include Congestive Obstructive Pulmonary Disease, Laceration right Lower Leg, Acute Bronchitis and Dependence on Oxygen, Neuromuscular Dysfunction of Bladder as documented on the “Home Health Certification and Plan of Care” for the Certification Period of 3/25/2024 to 5/23/2024. The “Home Health Certification and Plan of Care” for the Certification Period of 3/25/2024 to 5/23/2024 documents: “Frequency and Duration of visits: Skilled Nurse twice a week for three weeks, once a week for four weeks, Physical Therapy twice a week for five weeks, Occupational Therapy effective 3/31/2024 once a week for one week, Home Health Aide three times a week for three weeks”. The “ Archcare Admission Consent” form dated 3/25/2024 documents: “Skilled Nurse twice a week for two weeks, once a week for six weeks. Physical Therapy once a week for one week. Other one”. There is no documented evidence the patient was informed about the frequency and duration of Occupational Therapy and Home Health Aide Services. 3) Patient #4 has a start of care date of 7/12/2023 and a discharge date of 5/24/2024 with diagnoses that include Cutaneous Abscess of Back Except Buttocks, Infection following a Procedure, Other Surgical Site, Presence of Cerebrospinal Fluid Drainage Device as documented on the “Home Health Certification and Plan of Care” for the Certification Period of 5/7/2024 to 7/5/2024. The “Home Health Certification and Plan of Care” for the Certification Period of 5/7/2024 to 7/5/2024 documents: “Skilled Nurse once a week for two weeks, twice a week for one week”. The “ Archcare Admission Consent” form dated 7/12/2023 documents: “Skilled Nurse Admission 7/12/2023, Physical Therapy Evaluation”. There is no documented evidence the patient was informed about the frequency and duration of skilled Nursing services the patient is about to receive. On 7/30/2024 at 11:15 AM, the Director of Patient Services was interviewed and did not have an explanation for the findings. 1) Patient # 1 has a start of care date of 1/27/24 and a transfer date of 7/5/24 with diagnoses of laceration without foreign body of right upper arm, laceration without foreign body of right lower leg, laceration without foreign body of left lower leg, Essential Hypertension, Type 2 Diabetes, Mellitus without Complications, Vascular Dementia, Bilateral Primary Osteoarthritis of Knee, Rheumatoid Arthritis, other skin changes due to chronic exposure to nonionizing radiation, and personal history of other Malignant Neoplasm of Skin documented on the home Health Certification and Plan of Care for Certification Period 5/26/24 to 7/24/24. The Home Health Certification and Plan of Care for Certification Period 5/26/24 to 7/24/24 documents, “Skilled Nursing 2 visits per week times 8 weeks, 1 visit per week time 1 week; skilled nurse to assess/evaluate co-morbid conditions including other conditions that present themselves during the course of this episode to identify changes and intervene to minimize complications; skilled nurse to perform/teach wound care to incision/suture site located upper bilateral and lower bilateral skin tears clean with normal saline cover with hydrogel wafer cover with gauze secure with Kling wrap 2 times a week; referral made for Physical Therapy/Occupational Therapy, Life Alert Device”. The clinical record documents the following wound assessments for wound #1: On 06/21/2024: Onset date: 1/27/2024 Mid Pretibial, Right, Partial thickness depth description: Part Thick; total necrotic tissues slough: 0-25%; total necrotic tissues eschar: 0-25%; On 07/01/2024: Measurement length x width x depth: 2x2x0.1 cm Depth Description: Full Thick; Total Necrotic Tissues Slough: 0- 25%; Total Necrotic Tissues Eschar: 0-25%; skin color surrounding wound bright red; Exudate Type: serous The clinical record documents the following wound assessments for wound #2: On 06/21/2024: Onset date: 3/8/2024; Pretibial, Mid, Left; depth description: full Thick; total necrotic tissues slough: 0-25%; total necrotic tissues eschar: 0-25%; skin color surrounding wound bright red On 07/01/2024: Measurement length x width x depth: 2x2x0.1 cm Depth Description: Full Thick; Total Necrotic Tissues Slough: 0- 25%; Total Necrotic Tissues Eschar: 0-25%; Depth Description; Exudate Type: serous. The clinical record documents the following wound assessments for wound #9: On 06/21/2024: onset date:5/20/24; Lateral-Proximal Forearm, left; depth description: full Thick; total necrotic tissues slough: 0-25%; total necrotic tissues eschar: 0-25%; skin color surrounding wound: bright red, exudate type: bloody On 07/01/2024: Measurement length x width x depth: 2.5 x 2.5 x 0.1 cm Depth Description: Full Thick; Total Necrotic Tissues Slough: 26- 50%; Total Necrotic Tissues Eschar: 0-25%; skin color surrounding wound bright red; Exudate Type: serous Peripheral Tissue edema: non pitting less than 4 cm. The clinical record documents the following wound assessments for wound #10: On 06/21/2024 Onset date: 6/14/24; Posterior Achilles Tendon, left skin tear; depth description: full Thick; total necrotic tissues slough: 0-25%; total necrotic tissues eschar: 0-25%; skin color surrounding wound bright red, exudate type bloody. On 07/01/2024: Measurement length x width x depth: 3x3x0.1 cm; Depth Description: full Thick; Total Necrotic Tissues Slough: 26- 50%; Total Necrotic Tissues Eschar: 0-25%; skin color surrounding wound bright red; Exudate Type: serous The clinical record documents the following wound assessment for wound #11: Onset Date: 7/1/2024 Measurement length x width x depth: 3 x 3 x 0.1 cm; depth description: full Thick; total necrotic tissues slough: 26- 50%; total necrotic tissues eschar: 0-25%; skin color surrounding wound bright red; Exudate Type: serous. There is no documented evidence the patient and/or representative was given choices for any other services/care such as consultation with physician and/or wound clinic to evaluate the wounds progress/status and presence of slough and necrotic/eschar tissues. There is no documented evidence the patient/family was informed of the wound changes identified. On 7/30/2024 at 11:15 AM, the Director of Patient Services was interviewed and did not have an explanation for the findings.”

“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 clinical record review and interviews, the agency failed to promptly notify the physician of changes in patients’ status which may require alteration in Plans of Care. This was evident for one (1) of four (4) clinical records reviewed. (Patient #1). Failure to notify the physician of changes in the patient’s status which may require alteration in Plans of Care has the potential for negative patient outcomes. Findings: 2. Patient #3 has a start of care date of 3/25/2024 and a discharge date of 4/18/2024 with diagnoses that include Congestive Obstructive Pulmonary Disease, Laceration right Lower Leg, Acute Bronchitis and Dependence on Oxygen, Neuromuscular Dysfunction of Bladder as documented on the “Home Health Certification and Plan of Care” for the Certification Period of 3/25/2024 to 5/23/2024. The” Home Health Certification and Plan of Care” for the Certification Period of 3/25/2024 to 5/23/2024 documents:” Frequency and Duration of visits: Skilled Nurse twice a week for three weeks, once a week for four weeks. Skilled to perform observation/ assessment of genitourinary status and intervene to minimize complications of disease process. Skilled Nurse to instruct patient and caregiver on indwelling urinary catheter management including care of foley catheter, signs and symptoms of complications, perineal care, tube, and bag replacement. Home Health Aide three times a week for three weeks”. There is no documented evidence of Foley Catheter care and instructions for Foley Catheter care on the Plan of Care. There is no specific instructions and procedure to empty the urinary bag and the frequency for changing the urinary bag in the Plan of Care. The “Client Episode Coordination Notes Report” dated 4/1/2024 documents:” Reason for call: Check up on patient Any changes or concerns since last visit? Daughter stated that patient seemed more confused, and urine seems darker. Daughter suspected urinary tract infection since these symptoms were familiar. Writer encouraged daughter to consider taking the patient to the emergency room to rule out urinary tract infection”. The “Client Episode Coordination Notes Report” by Registered Nurse dated 4/10/2024 documents:” Addendum to 4/5 visit: Diffuse yellow sores noted to vaginal opening when inserting Foley Catheter. Patient daughter states they were canker sores”. The” Client Episode Coordination Notes Report” by Registered Nurse dated 4/16/2024 documents:” Cloudy urine, 250 cc yellow urine. Denies infection symptoms. Vagina reddened with cottage cheese resembling discharge noted. Call placed to physician to report symptoms. Registered Nurse instructed in symptoms to report to physician as fever, chills, altered consciousness, lethargy. Registered Nurse to monitor and provide wound care next visit”. There is no documented evidence the physician was promptly alerted about the need to obtain orders Foley Catheter care and instructions for Foley Catheter care and, procedure to follow to empty the urinary bag and the frequency, for changing the urinary bag in the Plan of Care. There is no documented evidence the physician was promptly alerted of the canker sores observed on the “ canker sores noted on the patient’s vaginal area on 4/5/2024. There is no documented evidence of any follow-up from the physician after call was made to report about discharge resembling cottage cheese in the vaginal area on 4/16/2024. There is no documented evidence the patient’s condition or needs were reported to the physician and/or that the plan of care was altered to meet the patient care needs. On 7/30/2024 at 11:15 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. 1. Patient # 1 has a start of care date of 1/27/24 and a transfer date of 7/5/24 with diagnoses of laceration without foreign body of right upper arm, laceration without foreign body of right lower leg, laceration without foreign body of left lower leg, Essential Hypertension, Type 2 Diabetes, Mellitus without Complications, Vascular Dementia, Bilateral Primary Osteoarthritis of Knee, Rheumatoid Arthritis, other skin changes due to chronic exposure to nonionizing radiation, and personal history of other Malignant Neoplasm of Skin documented on the home Health Certification and Plan of Care for Certification Period 5/26/24 to 7/24/24. The home Health Certification and Plan of Care for Certification Period 5/26/24 to 7/24/24 documents, “Skilled Nursing 2 visits per week times 8 weeks, 1 visit per week time 1 week; skilled nurse to assess/evaluate co-morbid conditions including other conditions that present themselves during the course of this episode to identify changes and intervene to minimize complications; skilled nurse to perform/teach wound care to incision/suture site located upper bilateral and lower bilateral skin tears clean with normal saline cover with hydrogel wafer cover with gauze secure with Kling wrap 2 times a week; referral made for Physical Therapy/Occupational Therapy, Life Alert Device”. The following “Visit Note Report” Wound Assessments by RNs documents: 6/21/24- wound #1 onset date: 1/27/2024 Mid Pretibial, Right depth description: Part Thick; total necrotic tissues slough: 0-25%; total necrotic tissues eschar: 0-25%; Wound #2 onset date:3/8/24; Pretibial, Mid, Left; depth description: full Thick; total necrotic tissues slough: 0-25%; total necrotic tissues eschar: 0-25%; skin color surrounding wound bright red, Wound #9 onset date:5/20/24; Lateral-Proximal Forearm, left; depth description: full Thick; total necrotic tissues slough: 0-25%; total necrotic tissues eschar: 0-25%; skin color surrounding wound bright red; exudate type bloody Wound #10 onset date: 6/14/24; Posterior Achilles Tendon, left skin tear; depth description: full Thick; total necrotic tissues slough: 0-25%; total necrotic tissues eschar: 0-25%; skin color surrounding wound bright red, exudate type bloody. 6/28/24 wound #1 onset date: 1/27/24; Mid Pretibial, Right depth description: Part Thick; total necrotic tissues slough: 0-25%; total necrotic tissues eschar: 0-25%; Exudate type: serosanguinous Wound #2 onset date:3/8/24; Pretibial, Mid, Left; depth description: full Thick; total necrotic tissues slough: 0-25%; total necrotic tissues eschar: 0-25%; skin color surrounding wound bright red, Wound #9 onset date:5/20/24; Lateral-Proximal Forearm, left; depth description: full Thick; total necrotic tissues slough: 0-25%; total necrotic tissues eschar: 0-25%; skin color surrounding wound: bright red, exudate type: bloody Wound #10 onset date: 6/14/24; Posterior Achilles Tendon, left skin tear; depth description: Part Thick; total necrotic tissues slough: 0-25%; total necrotic tissues eschar: 0-25%; skin color surrounding wound bright red, exudate type serosanguinous. 7/1/24 wound #1 onset date: 1/27/24; Mid Pretibial, Right Measurement length x width x depth: 2x2x0.1 cm Depth Description: Full Thick; Total Necrotic Tissues Slough: 0- 25%; Total Necrotic Tissues Eschar: 0-25%; skin color surrounding wound bright red; Exudate Type: serous wound #2 onset date: 1/27/24; Pretibial, Mid, Left Measurement length x width x depth: 2x2x0.1 cm Depth Description: Full Thick; Total Necrotic Tissues Slough: 0- 25%; Total Necrotic Tissues Eschar: 0-25%; skin color surrounding wound bright red; Exudate Type: serous. wound #9 onset date: 5/20/24; Lateral-Proximal Forearm, left Measurement length x width x depth: 2.5 x 2.5 x 0.1 cm Depth Description: Full Thick; Total Necrotic Tissues Slough: 26- 50%; Total Necrotic Tissues Eschar: 0-25%; skin color surrounding wound bright red; Exudate Type: serous Peripheral Tissue edema: non pitting less than 4 cm. wound #10- onset 6/14/24; Posterior Achilles Tendon, left skin tear Measurement length x width x depth: 3x3x0.1 cm; Depth Description: full Thick; Total Necrotic Tissues Slough: 26- 50%; Total Necrotic Tissues Eschar: 0-25%; skin color surrounding wound bright red; Exudate Type: serous wound #11 –Onset Date: 7/1/2024 Measurement length x width x depth: 3 x 3 x 0.1 cm; depth description: full Thick; total necrotic tissues slough: 26- 50%; total necrotic tissues eschar: 0-25%; skin color surrounding wound bright red; Exudate Type: serous. The following “Client Episode Coordination Notes Report” by RNs documents: “6/28/24-patient observed to grimace flinch or sometimes vocalize complaint during wound care. Suggested to aide that the patient may benefit from pre medication with pain med before wound care and voice message left for daughter; wound care performed with assistance from caregiver; noted to have 2 skin tears left forearm with bleeding and on right wrist and dorsal side right lectured with lower extremity. 2 small tears; aide notes that patient sometimes picks at skin or bandages.” “6/22/24- “patient alert and oriented x2 with dementia with periods of confusion and some aggressive behavior during wound care, patient unable to communicate to questions due to the Dementia, patient unable to comprehend care plan, patient unable to verbalized when experiencing pain but is able to groan and be protective when wound care is performed with assistance from care giver since patient gets aggressive when being treated.” On 7/29/24 and 7/30/24 the following interviews were conducted: On 7/29/24 at 2:18 PM the surveyor requested an interview with the Agency’s Medical Director. The Director of Patient Services and the Quality Director states, “the Medical Director does not know about this patient we never discuss this case with the Medical Director, no need to interview him.” 3:48 PM Employee #3 (primary field RN) contacted by the Director of Patient Services and interview conducted via telephone -when asked about the documented evidence of slough/necrotic tissue in wound assessment- the RN states “the classification of the wounds should have been unstageable; I did not contact the physician, I did discuss with the field manager, but I did not document any of the communication with the clinical field Manager. on 7/5/24 I called the patient’s daughter to confirm visit-the daughter states that they are going to call the ambulance to take the patient to the hospital. On 7/6/24 I followed up with the patient’s daughter and was informed that patient is admitted and is on antibiotic for Urinary Tract Infection; 7/13/24 I followed up with the patient’s daughter- I was informed that patient pass away, but I did not get the actual date the patient expired.” On 7/30/24 at 11:43 AM employee # 3 (Primary Field RN) came in person to get access to the patient record and complete interview. Employee #3 states, “patient has dementia confused, does a lot of skin picking, uses wheelchair pedal to scratch the back her heels- did develop a skin tear back of the heel. Patient requires continuous separation of hands and legs during wound care/dressing change- the aide would assist with constantly separating arms and legs; patient became weaker couple months ago, patient would slam herself down when sitting, aide would grab leg and move leg to side during wound care and hold her arms during wound care, there is no documentation of conversation regarding status/changes for this patient.” 12:01 PM employee#1 (Field Clinical Manager)- “Patient has fragile skin; patient would bump into everything, and the skin would break.” 12:26PM employee#4 (Covering Field RN)- “Patient has dementia, has a private aide, aggressive during wound care; has plenty wounds- more than 5 wounds, the arms wrapped from wrist to elbow; patient has bruising because skin is delicate.” There is no documented evident the physician was promptly notified of the patient getting weaker/decline in physical condition, skin color surrounding wound bright red; presence of slough and necrotic tissue in the wounds, full thickness of the wound; changes in the patient mental/behavioral status such as skin picking causing bruising, patient groaning and flinching during wound care. On 7/30/2024 at 11:15 AM, the Director of Patient Services was interviewed and did not have an explanation for the findings. Patient # 1 has a start of care date of 1/27/24 and a transfer date of 7/5/24 with diagnoses of laceration without foreign body of right upper arm, laceration without foreign body of right lower leg, laceration without foreign body of left lower leg, Essential Hypertension, Type 2 Diabetes Mellitus without Complications, Vascular Dementia, Bilateral Primary Osteoarthritis of Knee, Rheumatoid Arthritis, other skin changes due to chronic exposure to nonionizing radiation, and personal history of other Malignant Neoplasm of Skin documented on the Home Health Certification and Plan of Care for Certification Period 5/26/24 to 7/24/24. The Home Health Certification and Plan of Care for Certification Period 5/26/24 to 7/24/24 documents, “Skilled Nursing 2 visits per week times 8 weeks, 1 visit per week time 1 week; skilled nurse to assess/evaluate co-morbid conditions including other conditions that present themselves during the course of this episode to identify changes and intervene to minimize complications; skilled nurse to perform/teach wound care to incision/suture site located upper bilateral and lower bilateral skin tears clean with normal saline cover with hydrogel wafer cover with gauze secure with Kling wrap 2 times a week; referral made for Physical Therapy/Occupational Therapy, Life Alert Device”. On 6/28/24, the clinical record documented the following wound assessment: Wound #9 location: Left Lateral-Proximal Forearm has an onset date of 5/20/24; described as 0-25 percent necrotic/slough, peripheral tissue edema: none. 0 to 25 percent necrotic/eschar tissues, bloody drainage, full thickness depth and skin color surrounding wound is bright red. On 7/1/24 the clinical record documents the following wound assessments: Wound #9 location: Left Lateral-Proximal Forearm has an onset date of 5/20/24; described as peripheral tissue edema (swelling) non pitting less than 4 cm, 26 to 50 percent necrotic/slough, 0 to 25 percent necrotic/eschar tissues,, full thickness depth and skin color surrounding wound is bright red. On 6/28/24, the clinical record documented the following wound assessment: Wound #10 onset date: 6/14/24; Posterior Achilles Tendon, left skin tear; described as 0 to 25 percent necrotic/slough, 0 to 25 percent necrotic/eschar tissues, bloody drainage, full thickness depth and skin color surrounding wound is bright red. On 7/1/24 the clinical record documents the following wound assessments: Wound #10 onset date: 6/14/24; Posterior Achilles Tendon, left skin tear; described as 26 to 50 percent necrotic/slough, 0 to 25 percent necrotic/eschar tissues, full thickness depth and skin color surrounding wound is bright red. wound #11 –Onset Date: 7/1/2024 described as ; 26 to 50 percent necrotic/slough, 0 to 25 percent necrotic/eschar tissues, full thickness depth and skin color surrounding wound is bright red. The following Registered Nurse visit notes titled “Client Episode Coordination Note Report” documents: “6/28/24-patient observed to grimace flinch or sometimes vocalize complaint during wound care. Suggested to aide that the patient may benefit from pre medication with pain med before wound care and voice message left for daughter; wound care performed with assistance from caregiver; noted to have 2 skin tears left forearm with bleeding and on right wrist and dorsal side right lectured with lower extremity. 2 small tears; aide notes that patient sometimes picks at skin or bandages.” “6/22/24- “patient alert and oriented x2 with dementia with periods of confusion and some aggressive behavior during wound care, patient unable to communicate to questions due to the Dementia, patient unable to comprehend care plan, patient unable to verbalized when experiencing pain but is able to groan and be protective when wound care is performed with assistance from care giver since patient gets aggressive when being treated.” On 7/29/24 and 7/30/24 the following interviews were conducted: On 7/29/24 at 3:48 PM Employee #3 states “The classification of the wounds should have been unstageable; I did not contact the physician, I did discuss with the field manager, but I did not document any of the communication with the clinical field Manager.” On 7/30/24 at 11:43 AM Employee # 3 states, “patient has dementia confused, does a lot of skin picking, uses wheelchair pedal to scratch the back her heels- did develop a skin tear back of the heel. Patient requires continuous separation of hands and legs during wound care/dressing change- the aide would assist with constantly separating arms and legs; patient became weaker couple months ago, patient would slam herself down when sitting, aide would grab leg and move leg to side during wound care and hold her arms during wound care, there is no documentation of conversation regarding status/changes for this patient.” On 7/30/24 at 12:01 PM Employee #1 states, “Patient has fragile skin; patient would bump into everything, and the skin would break”. On 7/30/24 at 12:26 PM Employee # 4 states, “Patient has dementia, aggressive during wound care; has plenty wounds- more than 5 wounds, the patient’s arms wrapped from wrist to elbow; patient has bruising because skin is delicate.” There is no documented evident the physician was promptly notified of the patient changes in physical condition, including: skin color surrounding wound bright red, presence of slough and necrotic tissue in the wounds, full thickness of the wound; or changes in the patient mental/behavioral status such as skin picking causing bruising, patient groaning and flinching during wound care. On 7/30/2024 at 11:15 AM, the Director of Patient Services was interviewed and did not have an explanation for the findings.”

“Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient’s updated comprehensive assessment, and contain information concerning the patient’s progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This Element is not met as evidenced by: Based on clinical records review and staff interviews, the Agency failed to ensure that the Plan of Care was updated and revised to reflect the patient’s current care needs. This was evident for one (1) of four (4) clinical records reviewed (Patient #1). Failure to ensure that the Plan of Care is updated and revised has the potential for negative patient outcomes. Findings: Patient # 1 has a start of care date of 1/27/24 and a transfer date of 7/5/24 with diagnoses of laceration without foreign body of right upper arm, laceration without foreign body of right lower leg, laceration without foreign body of left lower leg, Essential Hypertension, Type 2 Diabetes, Mellitus without Complications, Vascular Dementia, Bilateral Primary Osteoarthritis of Knee, Rheumatoid Arthritis, other skin changes due to chronic exposure to nonionizing radiation, and personal history of other Malignant Neoplasm of Skin documented on the home Health Certification and Plan of Care for Certification Period 5/26/24 to 7/24. The Home Health Certification and Plan of Care for Certification Period 5/26/24 to 7/24/24 documents, “Skilled Nursing 2 visits per week times 8 weeks, 1 visit per week time 1 week; skilled nurse to assess/evaluate co-morbid conditions including other conditions that present themselves during the course of this episode to identify changes and intervene to minimize complications; skilled nurse to perform/teach wound care to incision/suture site located upper bilateral and lower bilateral skin tears clean with normal saline cover with hydrogel wafer cover with gauze secure with Kling wrap 2 times a week; referral made for Physical Therapy/Occupational Therapy, Life Alert Device”. 6/22/24 Registered Nurse visit note documents, “patient with dementia with periods of confusion and some aggressive behavior during wound care, patient unable to communicate to questions due to the Dementia, patient unable to comprehend care plan, patient unable to verbalized when experiencing pain but is able to groan and be protective when wound care is performed with assistance from care giver since patient gets aggressive when being treated.” 6/28/24 Registered Nurse visit note documents: “patient observed to grimace flinch or sometimes vocalize complaint during wound care. Suggested to aide that the patient may benefit from pre medication with pain med before wound care and voice message left for daughter; wound care performed with assistance from caregiver.” There is no documented evidence the plan of care was revised to include the need for pain management. On 7/30/24 at 1:00 PM the Administrator and the Director of Patient Services were interviewed. They did not provide any explanation.”

“Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This Element is not met as evidenced by: Based on clinical record review and staff interview the agency failed to ensure services provided by the Home Health Aide are consistent with the aide’s training in one (1) of four (4) records reviewed (Patient # 3). Failure to ensure Home Health Aide Services are provided in accordance with the aide’s training has the potential to result in negative patient outcomes. The findings are: Patient #3 has a start of care date of 3/25/2024 and a discharge date of 4/18/2024 with diagnoses that include Congestive Obstructive Pulmonary Disease, Laceration right Lower Leg, Acute Bronchitis and Dependence on Oxygen, Neuromuscular Dysfunction of Bladder as documented on the “Home Health Certification and Plan of Care” for the Certification Period of 3/25/2024 to 5/23/2024. The “Home Health Certification and Plan of Care” for the Certification Period of 3/25/2024 to 5/23/2024 documents:” Frequency and Duration of visits: Skilled Nurse twice a week for three weeks, once a week for four weeks. Skilled to perform observation/ assessment of genitourinary status and intervene to minimize complications of disease process. Skilled Nurse to instruct patient and caregiver on indwelling urinary catheter management including care of foley catheter, signs and symptoms of complications, perineal care, tube and bag replacement. Home Health Aide three times a week for three weeks”. The Aide of Care dated 3/25/2024 documents;” Foley Bag daily. Foley Catheter Care”. The “Client Episode Coordination Notes Report” dated 4/8/2024 documents:” Received call from daughter requesting a nurse visit due to aide unable to empty the urine bag, called aide and tried to talk her through the process but she was unable to do it. Assigned to visit and teach aide.” On 7/30/2024, the surveyor requested documentation of foley catheter care education provided to the aide assigned to care for Patient # 3 on 4/8/24. No documentation was provided. There is no documented evidence the aide received training regarding foley catheter care prior to the 4/8/2024 visit. On 7/30/2024 at 11:25 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings.”