Providence Medford Home 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 medical record review, policy review, and interview, it was determined that the agency failed to ensure that services ordered by the physician as indicated in the plan of care were being followed for 1 of 3 patient records reviewed (Patient #3). Findings: Review of the medical record for Patient #3 included Plan of Care, visit notes from the SN, physician orders, case communications, and media records made between 12/09/2024 to 01/25/2025. Review of the medical record for Patient #3 revealed a document titled, “Home Health SOC/Recert Plan of Care 12/12/24 and Last Updated: 12/26/2024” The document reflected a diagnosis of “Pressure ulcer of right buttock, stage 2.” A section of the document titled, “Care Plan,” revealed “Problem: “HH SN Wound ... Intervention: HH SN Wound Care ... Wound Type ulceration due to pressure Location right buttock; ... Wound Care: ... Frequency: Weekly. Measure and photograph wound weekly by SN, caregivers to complete wound care on other days. Teach caregiver (Name of Caregivers) to perform on non-home health visit days and if needed for disruption.” Review of SN visit documentation on 01/07/2025 at 12:45 PM revealed, “LDA and Wound Assessment Wound ... Pressure Injury Right ischial tuberosity ... Assessments ... unable to visualize dressing changed by caregiver.” The medical record lacked evidence of measures and photograph of wound as ordered by physician at this weekly SN visit. Review of SN visit documentation on 01/14/2025 at 2:40 PM revealed, “LDA and Wound Assessment Wound ... Pressure Injury Right ischial tuberosity ... Assessments ... unable to visualize dressing changed by caregiver.” The medical record lacked evidence of measures and photograph of wound as ordered by physician at this weekly SN visit. Review of SN visit documentation on 01/20/2025 at 1:30 PM revealed, “LDA and Wound Assessment Wound ... Pressure Injury Right ischial tuberosity ... Assessments ... unable to visualize dressing changed by caregiver.” The medical record lacked evidence of measures and photograph of wound as ordered by physician at this weekly SN visit. Review of policy titled, “HH Wound Standards 205-4, Last reviewed 09/2024” revealed a section titled, “6. Notifying the provider ... B. Clinician to notify the provider of: 1. Failure of wound to improve after two weeks of a specific treatment regimen. 2. Any wound complications or deterioration noted. 3. Any signs or symptoms of infection.” During an interview on 12/08/2025 beginning at 3:00 PM with employees #1, #2, #3, #4, and #5, the above information was presented. No additional information was provided by the employees.”

“Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This Element is not met as evidenced by: Based on medical record review, policy review, and interview, it was determined that the agency failed to ensure the Patient and Caregiver(s) were provided education on the technique of offloading as it pertains to wound care and to refrain from wound care on days the HH SN is to make visits for 1 of 3 patient records reviewed (Patient #3). Review of the documentation in the medical record for Patient #3 dated 01/07/2025 at 12:45 PM revealed a section titled, “LDA and Wound Assessment ... Pressure Injury Right ischial tuberosity ... Assessments ... unable to visualize wound due to dressing changed by caregiver.” Documentation for this SN visit lacked education provided to Caregiver(s) that dressing change is to be done by SN on visit days as ordered by Physician. Review of the documentation in the medical record for Patient #3 dated 01/14/2025 at 2:40 PM revealed a section titled, “LDA and Wound Assessment ... Pressure Injury Right ischial tuberosity ... Assessments ... unable to visualize dressing changed by caregiver.” Documentation for this SN visit lacked education provided to Caregiver(s) that dressing change is to be done by SN on visit days as ordered by Physician. Review of the documentation in the medical record for Patient #3 dated 01/16/2025 at 1:00 PM revealed new orders for wound care which included, “(Patient) can only be up in (Patient) wheelchair for no longer than 2 hours before offloading in bed.” Review of the documentation in the medical record for Patient #3 dated 01/20/2025 at 1:30 PM revealed a section titled, “LDA and Wound Assessment ... Pressure Injury Right ischial tuberosity ... Assessments ... unable to visualize dressing changed by caregiver.” Documentation for this SN visit lacked education/teaching provided to Caregiver(s) to include dressing change to be done by SN on visit days, length of time in wheelchair and offloading technique as ordered by Physician on 01/16/2025. Review of policy titled, “HH Wound Standards 205-4, Last reviewed 09/2024” revealed a section titled, “7. Patient Education A. All education ... provided will be documented in the patient’s electronic medical record (EMR). B. Clinician will document patient and/or caregiver response to teaching in the patient’s electronic medical record (EMR) ...” During an interview on 12/08/2025 beginning at 3:00 PM with employees #1, #2, #3, #4, and #5, the above information was presented. No additional information was provided by the employees.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on medical record review and interview, it was determined that the agency failed to ensure that documentation of clinical notes written by the SN contain information as it applies to the home visit on the day the note is written. Findings: Review of the medical record for Patient #3 revealed a SN visit made on 01/07/2025 at 3:30 PM. In a section titled, “Encounter Notes” the following entry is revealed, “Assessment: Clinical Impression of patient status and progress towards goals: VSS. Pt continues to have unmanaged pain ... Ostomy device changed without difficulty ... Catheter is intact ... Pt’s caregiver completed wound care before RN arrived because pt was in extreme pain while in bed and (Patient) wanted to get into (their) chair as soon as possible ...” Review of the medical record for Patient #3 revealed a SN visit made on 01/14/2025 at 2:25 PM. In a section titled, “Encounter Notes” the following entry is revealed, “Assessment: Clinical Impression of patient status and progress towards goals: VSS. Pt continues to have unmanaged pain ... Ostomy device changed without difficulty ... Catheter is intact ... Pt’s caregiver completed wound care before RN arrived because pt was in extreme pain while in bed and (Patient) wanted to get into (their) chair as soon as possible ...” Comparing the two “Encounter Notes” made on two different visits, it was discovered the two entries were indistinguishable in the summary of information for each visit that was 7 days apart. During an interview on 12/08/2025 beginning at 3:00 PM with employees #1, #2, #3, #4, and #5, the above information was presented. No additional information was provided.”

“Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This Element is not met as evidenced by: Based on medical record review, policy review, and interview, it was determined that the agency failed to ensure that communication with the physician occurred when a physician order was not followed or the patient condition changed. Findings: Review of the medical record for Patient #3 revealed SN visits were made on 01/01/2025, 01/07/2025, 01/14/2025, 01/17/2025, 01/20/2025, and 01/24/2025. Documentation for each visit lacked physician notification of wound care orders not being followed and/or changes to wound. Review of policy titled, “HH Wound Standards 205-4, Last reviewed 09/2024” revealed a section titled, “6. Notifying the provider ... B. Clinician to notify the provider of: 1. Failure of wound to improve after two weeks of a specific treatment regimen. 2. Any wound complications or deterioration noted. 3. Any signs or symptoms of infection.” During an interview on 12/08/2025 beginning at 3:00 PM with employees #1, #2, #3, #4, and #5, the above information was presented. No additional information was provided by the employees.”