Personal Home Healthcare and Hospice

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on review of agency policies/procedures, documentation and clinical records, and based on patient interview (Patients #6, #7 and #9) and interview with the administrator (Employee #9), the agency failed to ensure complete medication and treatment orders were included on initial “Home Health Certification and Plan of Care” for four (4) of eight (8) active patients. (Patients #6, #7, #9 and #13) Findings include: On December 18, 2024 at approximately 1:22 PM, review of the agency titled “Plan of Care-CMS #485 and Physician/Practitioner Orders” revealed the following under “Procedure”: 2. Each patient must receive an individualized written plan of care…The individualized plan of care must specify the care and services necessary to meet the patient specific needs… 4. The individualized plan of care must include the following…All medications and treatments… Patient #6: On December 17, 2024 at approximately 1:43 PM, review of the clinical record revealed a total of eight (8) medication orders are included on the “Home Health Certification and Plan of Care” for the initial certification period of 12/13/2024 through 02/10/2025: During home visit conducted on 12/17/2024 at approximately 9:25 AM, review of home medication records revealed the patient is prescribed a total of 19 medications which includes, but is not limited to, Protonix (gastric reflux medication), Spiriva (inhaler) and Ubrelvy (migraine medication). During the interview conducted during the home visit, the patient confirmed the patient’s medication regime includes all 19 medications. There was no documentation which provided evidence that the “Home Health Certification and Plan of Care” includes all medications prescribed to the patient. Patient #7: On December 17, 2024 at approximately 1:57 PM, review of the clinical record revealed a total of 12 medication orders are included on the “Home Health Certification and Plan of Care” for the initial certification period of 12/02/2024 through 01/30/2025: During home visit conducted on 12/17/2024 at approximately 10:15 AM, review of home medication records revealed the patient is prescribed a total of 14 medications which included Remeron (anti-depressant) and Xarelto (blood thinner-anticoagulant). During the interview conducted during the home visit, the patient confirmed the patient’s medication regime included all 14 medications. There was no documentation which provided evidence that the “Home Health Certification and Plan of Care” includes all medications prescribed to the patient. Patient #9: On December 17, 2024 at approximately 2:30 PM, review of the clinical record revealed a total of five (5) medication orders are included on the “Home Health Certification and Plan of Care” for the initial certification period of 12/08/2024 through 02/05/2025: During home visit conducted on 12/18/2024 at approximately 8:25 AM, review of home medication records revealed the patient is prescribed a total of six (6) medications which included aspirin. During the interview conducted during the home visit, the patient confirmed the patient’s medication regime included all six (6) medications. There was no documentation which provided evidence that the “Home Health Certification and Plan of Care” includes all medications prescribed to the patient. Patient #13: On December 18, 2024 at approximately 11:30 AM, review of the clinical record revealed SN goals included on the “Home Health Certification and Plan of Care” for the initial certification period of 12/06/2024 through 02/03/2025 include the following: Wound(s) will decrease in size by half by the end of episode. Review of wound treatment details included under “Orders/Treatments” on the initial “Home Health Certification and Plan of Care” included the following: Right anterior thigh: Calcium alginate daily; and Right anterior hip: Needs to be changed BID (twice a day). Review of the SN visit note dated 12/06/2024 revealed the RN (Employee #5) documented that the above referenced wounds were open and draining and that wound care was provided as per physician orders. There was no documentation in the clinical record which provided evidence that initial “Home Health Certification and Plan of Care” includes complete wound treatment orders for the above refenced wounds. During interview conducted on December 18, 2024 at approximately 1:45 PM, the administrator confirmed that there was no documentation in the clinical record which provided evidence the “Home Health Certification and Plan of Care” included complete medication and wound treatment orders for the above identified patients.”

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on review of agency policies/procedures and clinical records, and based on interview with the administrator (Employee #9), the agency failed to ensure registered nursing (RN) staff performed skilled nursing (SN) assessments as per agency policy/procedure for three (3) of six (6) active patients for whom wound orders/treatments and/or goals were included on the “Home Health Certification and Plan of Care”. (Patients #5, #12 and #13) Findings include: On December 18, 2024 at approximately 1:25 PM, review of the agency titled “Skilled Professional Services” revealed the following under “Policy”: Patients receiving skilled professional services all receive appropriate assessments, reassessments…and care per physician/practitioner orders. Patient #5: On December 17, 2024 at approximately 1:20 PM, review of the clinical record revealed the “Home Health Certification and Plan of Care” for the initial certification period of 11/23/2024 through 01/21/2025 includes the following SN goals: Midline abdominal wound: Cleanse, pack with saline soaked gauze, ABD (thick dressing). Change daily. Review of the SN nursing visit note details revealed wound depth is included under in wound assessment category. Review of the SN visit note dated 12/04/2024 revealed the depth of the midline abdominal wound was 1.5 centimeters (cm). There was no documentation in the clinical record which provided evidence the registered nurse (RN-Employee #5) assessed the depth of the midline abdominal wound during the start of care visit on 11/23/2024. Patient #12: On December 18, 2024 at approximately 11:30 AM, review of the clinical record reveal the “Home Health Certification and Plan of Care” for the initial certification period of 11/20/2024 through 01/18/2025 includes the following SN orders/treatments: Patient to receive skilled nursing two (2) times a week for nine (9) weeks for wound assessment and wound care to left heel. Review of the SN nursing visit note details revealed wound depth is included under in wound assessment category. Review of the SN visit note dated 12/16/2024 revealed the depth of the left heel wound was 0.2 cm. There was no documentation in the clinical record which provided evidence the RN (Employee #10) assessed the depth of the left heel wound during the start of care visit on 11/20/2024. Patient #13: On December 18, 2024 at approximately 11:30 AM, review of the clinical record reveal the “Home Health Certification and Plan of Care” for the initial certification period of 12/06/2024 through 02/03/2025 includes the following SN goals: Wound(s) will decrease in size by half by the end of episode. Review of the SN nursing visit note details revealed wound depth is included under in wound assessment category. Review of the SN visit note dated 12/06/2024 revealed the RN (Employee #5) documented that the right anterior (front) thigh wound was open and that measurements of the wound included length and width. There was no documentation in the clinical record which provided evidence the RN (Employee #5) assessed the depth of the right anterior thigh wound during the start of care visit on 12/06/2024. During interview conducted on December 18, 2024 at approximately 1:55 PM, the administrator confirmed that there was no documentation in the clinical record which provided evidence the above identified RN’s assessed the wound depth for the above referenced wounds/patients.”