Indus Home Health Care, Inc.

“Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA’s policies and procedures. This Standard is not met as evidenced by: Based on record review, interview and policy review, the facility failed to ensure a skilled nurse followed the plan of care related to performing ordered wound care. This affected one (Patient #2) of four medical records reviewed. The agency census was 140. Findings include: Review of the medical record of Patient #2 revealed the patient was admitted for services of the agency on 11/20/23 with diagnoses including stage 2 pressure ulcer of the scrotum, type 2 diabetes mellitus, and paraplegia with wheelchair dependence. The psychosocial assessment revealed the patient had cognitive delays and lived in a group home and was dependent on 24/7 care. The certification period reviewed was 07/17/24 to 09/14/24. The physician ordered skilled nursing visits twice the first week, then three times a week for the remaining eight weeks of the certification period. Among other tasks, the skilled nurse was ordered to provide wound care. Directions included cleansing the wound with normal saline, patting dry, applying calcium alginate and an ABD pad kept in place with an incontinent brief. Wound care was ordered three times weekly and as needed for soiled or dislodged dressing. A skilled nursing visit on 07/22/24 noted the patient’s wound to his scrotum was a stage 3 with measurements of 4.2 centimeters (cm) in length, 3.3 cm in width, and 0.1 cm in depth. Documentation from a skilled nursing visit on 07/29/24 revealed the wound to the patient’s scrotum was 1.8 cm in length, 3 cm in width, and 0.1 cm in depth. This wound was a stage 3. Review of the wound measurements from the skilled nursing visits on 08/02/24 and 08/07/24 revealed the wound remained a stage 3 and the measurements were unchanged. A missed visit note on 08/10/24 stated the group home supervisor called and informed the nurse that wound care had been performed by an aide at the group home. The medical record lacked documentation the physician ordered anyone except the skilled nurse to perform wound care. Weekly visits continued the following week. A skilled nurse visit on 08/31/24 noted the status to the wound on the patient’s scrotum was closed. There were no notes that indicated the wound was anything but a stage 3. There were also no notes that indicated there was any drainage. Staff A and Staff B were interviewed on 09/10/24 at 4:20 PM. It was confirmed that allowing an aide from the group home to perform wound care was not appropriate as there was no physician order for anyone except the skilled nurse to perform wound care. It was also confirmed there was no order to train anyone to perform wound care.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on record review, interview and policy review, the facility failed to ensure a skilled nurse performed wound measurements. This affected one (Patient #3) of four medical records reviewed. The agency census was 140. Findings include: Review of the medical record of Patient #3 revealed the patient was admitted for services of the agency on 04/16/24 with diagnoses including a stage 4 pressure ulcer of the left buttock, stage 3 pressure ulcer of the right buttock, paraplegia, colostomy, history of falls. The certification periods reviewed were 06/15/24 to 08/13/24 and 08/14/24 to 10/12/24. Review of the plan of care revealed the physician ordered skilled nursing visits once a week for both certification periods. Among other tasks, the skilled nurse was ordered to perform weekly wound care and to instruct the patient/caregiver on wound care. Wound care included cleansing wounds with normal saline, patting wounds dry, applying skin substitute held in place with steri strips, placing hydrophera blue and bordered foam dressing. Review of the skilled nursing visit for 07/05/24 revealed an open stage 4 pressure injury to the left ischium measuring a length of 1.7 centimeters (cm), width of 1.5 cm, and depth of 0.2 cm. A second stage 3 to the right lower back measured 8 cm in length, 0.2 cm in length, and 0.1 cm in depth. A nurse’s note stated this wound was changed from a stage 4 to a stage 3 after this visit as there was no bone or tendon exposed. A small amount of serosanguineous drainage was noted on both wounds. A missed visit occurred on 07/12/24. A nurse’s note stated the nurse called the patient multiple times but received no returned call. Review of the skilled nursing visit for 07/19/24 revealed an open stage 3 pressure injury to the left buttock measuring a length of 1.7 cm, width of 1.5 cm, and depth of 0.2 cm. A second stage 3 to the right lower back measured 8 cm in length, 0.2 cm in length, and 0.1 cm in depth. A third pressure injury to the patient’s left lower back was also noted and was a suspected deep tissue injury. The medical record lacked documentation wound measurements were obtained for this wound. Staff A and Staff B were interviewed on 09/10/24 at 4:50 PM. It was confirmed that the medical record lacked measurements for this wound. On 09/30/24, a home visit was conducted with Patient #3. The patient reported there had been a couple of missed visits in the past but he stated that overall, he was satisfied with the care being provided by the agency. The patient was asked if the nurse measures wounds at every visit. The patient stated sometimes the nurse measures the wounds but sometimes she doesn’t. Although the patient declined allowing this surveyor visualize the wound, he retrieved a cell phone stating that the nurse had taken pictures of the wound on his left buttock during the last visit. The picture displayed on the cell phone was time stamped for the morning of Friday, 09/27/24. The wound appeared to be approximately 1 centimeter in length. There was no visible drainage. The patient denied that the nurse measured the wound during this visit. Staff B, present during the home visit, confirmed that patient wounds are required to be measured during every visit. The facility policy titled “Client Care”, issued on 04/2007, instructed staff that wounds/skin lesions must be documented stating the type of wound, location, size in centimeters in centimeters with the length by width by depth.”