Elara Caring Xviii

“Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This Standard is not met as evidenced by: Based on record review and interview, the Skilled Nurse failed to obtain weights or ankle measurements as ordered on the POC for one (#7) of thirteen (#1 - #13) records reviewed. Patient #7 A review of the POC for Patient #7 for the re-certification period 11/12/23 to 01/15/24 revealed a primary diagnosis of Sepsis and secondary diagnosis of Heart Failure and Paraplegia. Review of the POC revealed orders for “weight to be obtained by SN every SN visit and weight gain of 2 lbs overnight or 5 lbs in 1 week to be reported to the Physician. If unable to weigh patient, SN to obtain measurement of ankles in CM at each visit and report an increase of 1 CM to Physician”. Further review of SN Visit documentation failed to provide evidence of weights or ankle measurements as ordered for SN visits conducted 11/12/23 - 1/15/24. On 01/19/24 at 10:00 AM, the Administrator stated the SN failed to obtain weights or measurements as ordered on the POC for Patient #7.”

“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 and interview, the Skilled Nurse failed to obtain wound measurements as required for one (#1) of thirteen (#1 - #13) records reviewed. Patient #1 A review of the POC for Patient #1 for the re-certification period 12/30/23 to 02/27/24 revealed a primary diagnosis of Aftercare of Surgical Wound and secondary diagnosis of Quadriplegia. Review of the POC revealed orders for SN or Caregiver to provide Wound care to the unstageable pressure ulcer of the Right distal ankle 3 times a week. Further review of the Wound Care Report indicated Wound #4 was activated on 09/01/23 and inactivated on 10/06/23. SN Visit documentation failed to provide evidence of wound measurements for weekly SN visits for the weeks of 9/3, 9/7, 9/17, 9/24 and 10/1. On 01/19/24 at 10:00 AM, the Administrator stated the SN failed to obtain wound measurements as required for Patient #1.”

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on record review and interview, the Physical Therapist failed to conduct an evaluation within 5 days of the SOC as part of the comprehensive assessment for one (#3) of six (#2, #3, #8 - #10, #12) records reviewed with orders for Physical Therapy evaluation. Patient #3 A review of the POC for Patient #3 for the initial certification period 11/29/23 to 01/27/24 revealed a primary diagnosis of Chronic Obstruction Pulmonary Disease. The referral orders and the POC included orders for “Physical Therapy to evaluate...”. Further review of Physical Therapy Notes revealed the Physical Therapy Evaluation was conducted on 12/05/23 (6 days after the Initial Start of Care Visit) and no documentation was evident as to the reason for delay. On 01/19/23 at 10:00 AM, the Administrator stated the Physical Therapist failed to conduct the evaluation within 5 days as required for Patient #3.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observation, record review and interview, the Skilled Nurse failed to conduct a review of all medications the patient was taking and maintain a current medication list for one (#3) of thirteen (#1 - #13) records reviewed. Patient #3 During a home observation visit on 01/18/24 at 2:00PM, Pt#3 informed this Surveyor that she requires Oxygen most of the day and placed her Oxygen on during the interview per nasal cannula at 2 liters per minute. A review of the POC for Patient #3 for certification period 11/29/23 to 01/27/24 revealed the last Drug Regimen Review was conducted 11/30/23 during the SOC RN visit. Further review of the “Client Medication Record” failed to provide evidence Oxygen was included on the medication list. On 01/19/24 at 10:00 AM, the Supervising Nurse stated Oxygen was not included on the agency’s medication list for Patient #3.”