UPMC Home Healthcare

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on review of agency policy, clinical records (CR), and staff (EMP) interview, the agency failed to coordinate care delivery to meet the patient’s needs and involve the caregiver in the coordination of care activities for one (1) of three (3) clinical records with wounds (CR1). Findings included: Review of agency policy on August 6, 2024, at 11 a.m. showed, “Assessment / Reassessment of Patients - Policy #150 ... 12. For social service referrals ... An emergent care situation would be addressed as needed.” Review of agency policy on August 6, 2024, at 11:15 a.m. showed, “Coordination of Patient Care - Policy #310 ... All personnel providing services to the patient will communicate and coordinate the care and services ... Evidence of care coordination may be documented in the patient medical record on the following forms: a. Visit notes ... Interdisciplinary referral from ... communication is: ... d. timely ... Ongoing communication is maintained ... Information is provided on a timely basis. This information may include: ... e. Changes in caregiver support or the environment.” Review of agency policy on August 8, 2024, at 11 a.m. showed, “Professional Staff Nurse ... Job Summary ... The Professional Staff Nurse is responsible for the delivery of skilled nursing services to patients in their homes according to the physician’s plan of care, agency policies and procedures ... Initiates, coordinates and ensures ongoing communication with the physician and other members of the interdisciplinary health care team, including evaluating patients and family centered health teaching. Provides direct patient care, evaluates outcomes, and adjusts nursing care process as indicated to ensure optimal patient care. Assigns other interdisciplinary team members as appropriate to assist in the appropriate delivery of services as ordered on the plan of care to the patient.” Review of CR1 on August 6, 2024, at 9:30 a.m. showed a physician ordered plan of care with an initial certification period from 7/1/2024 to 8/29/2024. The patient was admitted to the agency with wound care orders for multiple pressure wounds that were stage 4 (deep tissue) and unstageable (most likely deep tissue) located on his/her sacral/buttocks area. Orders included skilled nursing (SN) twice a week for wound care, “Assess, instruct and or perform treatments as per orders on this plan of care. ... instruct patient and/or caregiver in wound care. ... [Wound care] Right Gluteus Medius [buttocks area] Pressure Ulcer - Stage 4 ... Perform 2 Time(s) a Day ... [Wound care] Left Gluteus Medius [buttocks area] Pressure Ulcer - Unstageable ... Perform 2 Time(s) a Day.” The initial comprehensive assessment was completed on 7/1/2024. The assessment revealed the patient was dependent for wound care (could not perform on his/her own). At this time, there was no documented wound care instructions provided to the caregiver. A SN telehealth visit note from 7/3/2024 showed the husband was the patient’s caregiver, “Husband is caregiver and does dressing changes.” On 7/5/2024, new wound care orders were obtained from the patient’s wound care center (WCC) that were to be completed daily but SN visits were only ordered twice a week. These new WCC orders were initiated during a SN visit on 7/9/2024. The patient’s wound care orders were revised on 7/11, 7/15, and 7/23/2024 to include different treatment modalities and frequencies. For instance, on 7/11/2024, new wound care orders were to be completed 3 times per week; on 7/15/2024 new and different wound care orders were to be completed daily. A review of five (5) SN visit notes over 12 days from 7/12 to 7/23/2024 and just prior to patient’s hospitalization, when wound care was to be performed daily, showed the patient was not receiving daily SN visits. The patient received no further visits after 7/23/2024 and was discharged from the agency on 7/28/2024. There was nothing to show the husband was instructed on above ongoing wound care orders or that he was independent with wound care during the entire episode to ensure the patient’s wounds were addressed when agency nurses (SN) were not present to perform. Additionally, an SN visit note from 7/20/204 showed, “[Patient] had been sitting/sleeping in chair and was covered in stool. [His/her] whole buttocks area was red and irritated. ... Plan For Next Visit ... Referrals / Authorizations ... Possible SW [social worker] C/S [consult].” Review of SN visit note from 7/23/2024 showed, “Plan For Next Visit ... Referrals / Authorizations ... Possible SW C/S.” SN was scheduled to see the patient on 7/25 but the patient was not available at the time of the scheduled visit. SN was to see the patient on 7/27/2024 but the patient was not available for the scheduled because she was admitted to the hospital that day. There were no further SN visits made and the patient was discharged from the agency on 7/28/2024. Further review of CR1 did not show that a social worker consult was made or that a social worker saw the patient. During an interview with EMP2 (administrator) on August 6, 2024, at 11:30 a.m., he/she reviewed CR1 and confirmed there was no documented wound care teaching provided to the patient’s husband, and no referral made for social services.”

“Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This Element is not met as evidenced by: Based on review of agency policy, clinical record (CR), and staff (EMP) interview, the registered nurse failed to provide caregiver education as outlined in the plan of care for one (1) of three (3) clinical records with wounds (CR1). Findings include: Review of agency policy on August 6, 2024, at 11 a.m. showed, “Patient/caregiver Education - Policy #250 ... Patient/caregiver education is an integral part of health care. ... Each patient/caregiver will receive on-going education and training regarding the care and services identified in the plan of care. ... The patient/caregiver will be provided with the information and skills required to meet immediate and ongoing health care needs. ... Documentation of the education should be evident in the medical record or electronic health record.” Review of agency policy on August 8, 2024, at 11 a.m. showed, “Professional Staff Nurse ... Job Summary ... The Professional Staff Nurse is responsible for the delivery of skilled nursing services to patients in their homes according to the physician’s plan of care, agency policies and procedures ... Initiates, coordinates and ensures ongoing communication with the physician and other members of the interdisciplinary health care team, including evaluating patients and family centered health teaching. Provides direct patient care, evaluates outcomes, and adjusts nursing care process as indicated to ensure optimal patient care. Assigns other interdisciplinary team members as appropriate to assist in the appropriate delivery of services as ordered on the plan of care to the patient.” Review of CR1 on August 6, 2024, at 9:30 a.m. showed a physician ordered plan of care with an initial certification period from 7/1/2024 to 8/29/2024. The patient was admitted to the agency with wound care orders for multiple pressure wounds that were stage 4 (deep tissue) and unstageable (most likely deep tissue) located on his/her sacral/buttocks area. Orders included skilled nursing (SN) twice a week for wound care, “Assess, instruct and or perform treatments as per orders on this plan of care. ... instruct patient and/or caregiver in wound care. ... [Wound care] Right Gluteus Medius [buttocks area] Pressure Ulcer - Stage 4 ... Perform 2 Time(s) a Day ... [Wound care] Left Gluteus Medius [buttocks area] Pressure Ulcer - Unstageable ... Perform 2 Time(s) a Day.” The initial comprehensive assessment was completed on 7/1/2024. The assessment revealed the patient was dependent for wound care (could not perform on his/her own). At this time, there was no documented wound care instructions provided to caregiver. A SN telehealth visit note from 7/3/2024 showed the husband was the patient’s caregiver, “Husband is caregiver and does dressing changes.” On 7/5/2024, new wound care orders were obtained from the patient’s wound care center (WCC) that were to be completed daily but SN visits were only ordered twice a week. These new WCC orders were initiated during a SN visit on 7/9/2024. The patient’s wound care orders were revised on 7/11, 7/15, and 7/23/2024 to include different treatment modalities and frequencies. For instance, on 7/11/2024, new wound care orders were to be completed 3 times per week; on 7/15/2024 new and different wound care orders were to be completed daily. A review of five (5) SN visit notes over 12 days from 7/12 to 7/23/2024 and just prior to patient’s hospitalization, when wound care was to be performed daily, showed the patient was not receiving daily SN visits. The patient received no further visits after 7/23/2024 and was discharged from the agency on 7/28/2024. There was nothing to show the husband was instructed on above ongoing wound care orders or that he was independent with wound care during the entire episode to ensure the patient’s wounds were addressed when agency nurses (SN) were not present to perform. During an interview with EMP2 (administrator) on August 6, 2024, at 11:30 a.m., he/she reviewed CR1 and confirmed there was no documented wound care teaching provided to the patient’s husband.”

“Coordinate referrals; CFR(s): 484.105(c)(3) Coordinating referrals, This Element is not met as evidenced by: Based on review of agency policy, clinical records (CR), and staff (EMP) interview, the clinical manager failed to make a necessary referral for social services for one (1) of three (3) records with wounds (CR1). Findings include: Review of agency policy on August 8, 2024, at 10 a.m. showed, “Clinical Manager ... Job Summary ... The Clinical Manager position is an on-site position that is accountable and responsible for the overall quality of service, overseeing the planning, developing, organizing, integrating, of clinical care and coordination of assigned patients and designated teams, in support of the organizational goals and commitments. ... Responsibilities ... Ensures patient care is delivered according to established care guidelines, Plan of Care, physician orders, agency policies and procedures ... Plans, directs, and participates in the delivery of client care services, including case assignment and visit scheduling activities ... Recommends, implements, and interprets policies and procedures relevant to the provision of patient care services ... Communicates effectively with assigned staff, to monitor the changing needs of the patient and family ... Leads regularly scheduled Clinical meetings and Case Conferences ... Participates in the after hours on-call process to ensure client care policies and procedures are followed and staffing issues resolved ... Facilitates patient care coordination and operations including organization and management within established policies, procedures, standards of care.” Review of CR1 on August 6, 2024, at 9:30 a.m. showed a physician ordered plan of care with an initial certification period from 7/1/2024 to 8/29/2024. The patient was admitted to the agency with wound care orders for multiple pressure wounds that were stage 4 (deep tissue) and unstageable (most likely deep tissue) located on his/her sacral/buttocks area. The plan of care showed that wound care was to be done twice a day and skilled nursing (SN) was to see the patient twice a week. The initial comprehensive assessment was completed on 7/1/2024. The assessment revealed the patient was dependent for wound care (could not perform on his/her own). A SN telehealth visit note from 7/3/2024 showed the husband was the patient’s caregiver, “Husband is caregiver and does dressing changes.” Review of an SN visit note from 7/20/204 showed, “[Patient] had been sitting/sleeping in chair and was covered in stool. [His/her] whole buttocks area was red and irritated. ... Plan For Next Visit ... Referrals / Authorizations ... Possible SW [social worker] C/S [consult].” Review of SN visit note from 7/23/2024 showed, “Plan For Next Visit ... Referrals / Authorizations ... Possible SW C/S.” Further review of CR1 did not show that a social worker consult was made or that a social worker saw the patient. SN was scheduled to see the patient on 7/25 but the patient was not available at the time of the scheduled visit. SN was to see the patient on 7/27/2024 but the patient was not available for the scheduled because she was admitted to the hospital that day. There were no further SN visits made and the patient was discharged from the agency on 7/28/2024. During an interview with EMP2 (administrator) on August 6, 2024, at 11:30 a.m., he/she reviewed CR1 and confirmed above findings.”