We Care Home Health Services Inc.

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on record review and interview, the agency failed to include treatments (wound care) in the Plan of Care for 1 (#5) of 2 patient records reviewed where the agency was providing wound care. The failure placed the patients at risk for inappropriate care that could result in a negative outcome. Patient #5: Record review of Patient #5’s clinical record revealed a Plan of Care dated 3/13/2024 to 5/11/2024. The Plan of Care indicated that Patient #5 started on the agency’s services on 3/13/2024. The Plan of Care listed Peripheral Vascular Disease (systemic disorder that involves the narrowing of peripheral blood vessels) and Non-Pressure Chronic Ulcer of the Left Heel and Midfoot with Muscle Necrosis (pathological process that causes abnormal cell death in muscle fibers caused by severe cellular trauma) as the diagnoses. Patient #5’s clinical record contained a Start of Care Comprehensive assessment that was conducted on 3/13/2024 by Registered Nurse B. Registered Nurse B documented that the primary reason for home health care was open and draining wound to left heel. Registered Nurse B documented that Patient #5’s left heel wound measured 4 centimeters (Length) by 2.5 centimeters (Width) by 2.7 centimeters (Depth). Registered Nurse B cleaned the wound with wound cleanser, patted dry with sterile gauze, packed the wound with Silver Alginate (wound product with antibacterial silver for moderate to highly draining wounds and used on infected wounds or wounds suspected of infection), applied an absorbent pad, wrapped with gauze, then wrapped with 2 ace bandages. The Plan of Care dated 3/13/2024 to 5/11/2024 did not include wound treatment. The Plan of Care contained an order for skilled nurse visits 2 times a week with 3 as needed visits for increased wound drainage. Patient #5’s clinical record contained an order from the wound clinic dated 4/1/2024 to treat Patient #5’s left heel wound by cleaning the wound with normal saline, apply Acticoat (potent antimicrobial barrier dressing) cut to fit the open area, apply QWICK (superabsorbent conformable dressing used on moderate to heavy draining wounds) cover with abdominal pad and secure with gauze roll. Patient #5’s clinical record contained a new Plan of Care for the episode of 5/12/2024 to 7/10/2024. The Plan of Care did not include wound treatment. The Plan of Care contained an order for skilled nurse visits 3 times a week and 3 as needed visits for increased wound drainage. During an interview on 6/24/2024 at 3:05 p.m. with the Administrator/Director of Nursing/Registered Nurse B, the surveyor discussed the Plans of Care did not include the wound care treatments. The surveyor asked why the wound care treatments were not included in the Plans of Care. The Administrator/Director of Nursing/Registered Nurse B reviewed the Plans of Care and stated, “I don’t see it, I will need to write an order. I did the Plan of Care, I don’t know why it’s not there, it should have flowed over.” The Administrator/Director of Nursing/Registered Nurse B informed the surveyor that there were orders for wound care when Patient #5 was admitted, that was the reason for admission. The Administrator/Director of Nursing/Registered Nurse B was going to find the orders for wound care treatment from admission (not provided to the surveyor by survey exit). The surveyor asked if anyone reviewed the Plans of Care. The Administrator/Director of Nursing/Registered Nurse B informed the surveyor that no one else reviews the Plans of Care except that the Alternate Administrator/Alternate Director of Nursing wound review the Plans of Care sometimes. The agency had a policy titled “Plan of Care,” that was labeled TX.6, that was dated 1/13/2018. The policy read in part; “Purpose To develop an individualized Plan of Care which specifies the care and services necessary to meet the patient specific needs and according to state and federal regulations. Policy...Procedure...C. The individualized Plan of Care will specify the care and services necessary to meet the patient specific needs...the Plan of Care will contain the following elements...10. All medications and treatments...””