Fairfield Home Care LLC

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on record review, interview, and policy review, the agency failed to ensure staff nurses provided skilled visits as ordered by a physician and failed to ensure wound care was documented. See G572.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on record review, interview and policy review, the agency failed to ensure the nursing staff followed a physician order to provide skilled nursing visits and failed to documented ordered wound care. This affected Patient #3. Findings include: Review of the medical record of Patient #3 revealed the patient was admitted for services of the agency on 05/21/24 with diagnoses including congestive heart failure and hypertension. Review of the plan of care for the certification period of 07/20/24 to 09/17/24 revealed physician orders for skilled nursing three times a week and once in 60 days for recertification and a home health aide 10 hours per week for the entire 9 week certification period. An Admission Follow Up Form, submitted on 08/16/24, noted the services of a registered nurse would be provided with a start date of 08/19/24. The days and times for the registered nurse would vary. The medical record lacked documentation of any skilled nursing visit notes during the certification period of 07/20/24 to 09/17/24. Review of the certification period of 09/18/24 to 11/16/24 revealed a transfer OASIS, completed on 09/25/24, as the patient was transferred to an inpatient facility. The inpatient facility discharge summary noted the patient was hospitalized from 09/24/24 to 09/27/24 with cellulitis (a potentially serious bacterial skin infection where the affected skin is swollen and inflamed and can be painful and warm to the touch). A physician discharge order requisition ordered for wound care as follows: Adaptic, DrySee dressing (wound dressing that uses a liquid indicator to alert the wearer when the dressing is compromised), Ace wrap compression three times a week. Review of the skilled nursing visits revealed the initial visit occurred on 10/02/24, from 2:00 PM to 2:45 PM. Under skilled interventions, the staff nurse was advised to check all that apply. The nurse placed a check next to teaching, wound care, and diet. A check was placed next to fatigue easily for homebound status. Vital signs were blood pressure 118/64, 97.9 degrees Fahrenheit, pulse 65 beats per minute, respirations 18. Gastrointestinal, genitourinary, neurological, musculoskeletal, cardiovascular, pulmonary, pain, psychosocial, and skin/intergumentary assessments were blank. Details of wound care performed, including site, length, width, depth, wound bed, exudate odor and patient response were also blank. The skilled visits on 10/04/24, 10/07/24, 10/09/24, 10/11/24, 10/14/24, 10/16/24, 10/18/24, 10/21/24, 10/23/24, 10/25/24, 10/28/24, 10/30/24, 11/01/24, 11/04/24, 11/06/24, 11/08/24, 11/11/24, 11/13/24, and 11/15/24 were also blank except vital signs. Although wound care was checked as performed on each visit, details of the wound care performed were blank. None of the skilled nursing visit notes were signed by the nurse providing the care. During an interview on 12/03/24 at 2:44 PM, Staff A and Staff B confirmed that the agency was ordered to perform skilled nursing visits. It was also confirmed that the agency acknowledged this start of care via the Follow Up Form, however, the medical record lacked documentation skilled nursing visits were made for five weeks. It was also confirmed that the patient was hospitalized for three days after failure of the agency to initiate nursing services. Staff B stated there was a mix-up due to there being another patient with the same first name as the SP. They also confirmed the medical record lacked documentation of services provided by the nurse specifically the wound care. The facility policy titled “Medical Records and Documentation”. undated, stated it is the policy of the agency to have an effective mechanism in place to ensure that all data and information in the medical record is timely, accurate, complete, and maintained according to acceptable standards of practice. Each discipline shall have a designated area in the record to document care, which should include observations, interventions, and patient outcomes. Each entry shall be accurate, signed, and dated with the date of entry with signature and title of the individual making the entry. All documentation will be completed in black ink. Clinical and progress notes should be written the day service is rendered, submitted each week on Mondays by 5:00 PM.”