Elara Caring

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on record review and interview, the agency failed to document all known significant events (change of condition in wound) for 1 (Client #1) of 3 clients. The failure placed the clients at risk that interventions could be duplicated or omitted resulting in a negative client outcome. Findings included: Record Review of Client 1’s record revealed a Home Health Certification and Plan of Care for certification period of 4/11/2026 to 6/9/2026 stating Client 1 was to receive skilled nursing services once a week for nine weeks. Further review under “Orders of Discipline and Treatment” revealed that skilled nurse was to perform wound care for right heel wound. Record Review of text messages between Client 1 and LPN C revealed text exchange from Client 1 to LPN C on 5/1/2026 2:27PM which read: Client 1 to LPN C “Hey [LPN C]…I think my wound is infected…what should I do?”. LPN C to Client 1 “Call your doctor and see if we can get orders to collect a sample from the wound. Having a fever? Chills? Abnormal heat from the wound?” Client 1 to LPN C “[PA A from Wound Care Center 1] ordered some antibiotics so hopefully that will help but thank you for replying.” Further review revealed text exchange from LPN C to Client 1 on 5/3/26 at 6:46 PM which read: LPN C to Client 1 “Good Evening [Client 1], How are you doing? I was wondering if I could come and see you for tomorrow around 4:30pm-5:30pm?” Client 1 to LPN C “I’m currently in the hospital now for this wound… the infection was bad” Record Review of Client 1’s record revealed no documentation of the information contained in the above text message exchange. Interview via phone with LPN C on 6/15/2026 at 12:56 PM, LPN C was asked if he was familiar with Client 1 and he confirmed he was. When asked whether Client 1 had contacted him regarding concerns of an infected wound, LPN C stated he recalled he received a text message from Client 1 which indicated the wound might be infected. Surveyor asked whether he still had the text message exchange, and LPN C confirmed he did and retrieved it on his phone. LPN C verbally reviewed the exchange with the surveyor. LPN C was asked whether he had notified the HHA or documented in Client 1’s clinical record the information received in the text messages, and LPN C stated that he had not. Interview with Administrator 6/15/2026 at 1:43PM. Surveyor reviewed the above interview and text messages with Administrator. The Administrator was asked what the process was for documenting any significant changes in a patient’s condition. The Administrator stated that when the initial clinician became aware that a patient had been prescribed antibiotics, the clinician was expected to complete an infection report in [Agency 1’s Electronic Medical Record]. The Clinical Coordinator or CTM (clinical team manager) would then review and follow up on the report. The Administrator confirmed that an infection report was not in Client 1’s medical record for this occurrence and stated the infection report would be initiated within a visit note and since no visit had occurred, the clinician would not have been able to document via an infection report. The Administrator stated ideally in this situation LPN C would have contacted the appropriate team member on the date the first text message was received and a communication note documented in the patient’s record. When asked who would have been responsible for receiving notification, the Administrator stated it would have been RN A, but then confirmed RN A was no longer employed by the agency. The Administrator agreed that documentation of the information should have been recorded in the patient’s record and was not. The Administrator confirmed Client 1 was discharged from HHA on 5/3/2026 due to hospitalization. Surveyor left voice mail message requesting a call back from RN A on 6/15/2026 at 2:10 PM. Review of Agency’s policy #SHH.113 “Plan of Care and Coordination of Care” Effective 3/4/2025 under “Procedures” reads in part “Changes in the patient’s condition that require a change in the plan of care will be documented in the patient’s clinical record.””