Adoration Home Health Martin

“Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient’s updated comprehensive assessment, and contain information concerning the patient’s progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This Element is not met as evidenced by: Based on policy review, record review and interview, the facility failed to ensure wound care orders and laboratory orders were followed per plan of care (POC) for 2 of 12 (Patient #2 and #8) active patients reviewed. The findings included: 1.Review of the facility’s “PLAN OF CARE AND PHYSICIAN ORDERS” policy (revised 1/12/2024) revealed, “...Each patient must receive the home health services that are written in the individualized plan of care...In the event of a change in patient condition or needs that suggest outcomes are not being achieved and/or that the patient’s plan of care should be altered, the agency will promptly alert both the responsible physician or allowed practitioner and the physician/allowed practitioner associated with the relevant aspect of care.. Review of the facility’s “WOUND CARE” policy (revised 7/26/2022) revealed, “...All wound care will be performed in accordance with physician orders...All wound assessments, wound care, and teaching will be documented in the clinical record...” 2.Medical record review for Patient #2 revealed a Start of Care (SOC) date of 4/26/24 with diagnoses that included Type 2 Diabetes Mellitus (DM) with foot ulcer. Review of the 6/25/24 through 8/23/24 POC revealed wound care orders that documented, “Remove all dressing material excluding the yellow Xeroform [fine mesh gauze used on exudating wounds] layer. Cleanse the skin around the top and side of the foot with wound spray or Hibiclens [antibacterial/antimicrobial skin cleanser] and pat dry. When applying a new dressing to the right foot, ensure that lots of cushion is used. To achieve this, layer unfolded sterile 4”x4”s on top of one another until a large bolster/fluff is created. Insure [ensure] that the bolster/fluff covers the entire wound. Please insure [ensure] that there is plenty of cushion covering the entire plantar surface!!! Then start with 2 rolls of Kerlix (or similar roll gauze) and secure in place with one roll of Kling [rolled gauze]. Apply a clean stockinet and the patient’s post-op shoe” Review of Skilled Nurse (SN) visit notes beginning 6/28/24 through 7/22/24 revealed LPN #1 documented, “wound care provided per MD [medical doctor] orders” on the 6/28, 7/1, 7/5, 7/8, 7/15, 7/19 and 7/22/24 SN visit notes. There was no documentation of the actual wound care provided on those visit dates. In an interview on 7/24/24 at 10:55 AM, the facility’s Administrator stated the wound care documentation “...should be specific...how else do you know they’re following the right orders...” 3.Medical record review for Patient #8 revealed a SOC date of 6/7/24 with diagnoses that included infection of amputation stump and cellulitis of left lower limb. Review of the 6/7/24 through 8/5/24 POC revealed orders that documented, “Skilled Nurse to obtain CBC [complete blood count], BMP [basic metabolic profile], ESR [erythrocyte sedimentation rate], and CRD [component resolved diagnosis] labs via PICC [peripherally inserted central catheter] line every Monday”. Review of Patient #8’s SN visit notes beginning 6/7/24 revealed week of 7/7/24, the SN visit and ordered lab work was performed on Tuesday, 7/9/24. There was no documentation why the SN visit and ordered lab work was not performed on Monday, 7/8/24, as ordered. Further review of Patient #8’s POC revealed a 7/12/24 supplemental physician order that documented, “...collect wound culture week of 7/15...” Review of week of 7/14/24 SN visit notes revealed no documentation a wound culture was collected as ordered. 4.In an interview on 7/24/24 at 10:00 AM, the facility’s Administrator verified there was no documentation the SN collected a wound culture the week of 7/15/24 and stated, “...they should have had an order to cancel the wound culture since it was done at the physician’s office...””