Delcorp Home Health Services Inc.

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on interview and record review, the hospice failed to ensure that each patient received the home health services that were written in an individualized plan of care which was established, periodically reviewed, and signed by a doctor of medicine, osteopathy (a branch of medicine that focuses on manipulation of the bones, joints, and muscle), or podiatry (a branch of medicine that focuses on care of the feet) acting within the scope of his or her state license, certification, or registration for 2 of 3 (Patient #1) patients reviewed who had received skilled nursing services from agency staff for wound care services in that: 1.) The agency failed to ensure Patient #1 received wound care services from the Administrator/Supervising Nurse as ordered by the physician in the written plan of care; and 2.) The agency failed to ensure Patient #2 received wound care services from the Administrator/Supervising Nurse as written in an individualized plan of care which was established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. These failures could result in the patients’ wounds not healing appropriately. The findings included: Record review of the clinical record for Patient #1, included a plan of care, for the certification period of 11/13/25 – 01/11/26, which indicated the patient had a start of care date of 11/13/25 and diagnoses of pressure ulcer (a wound caused by pressure applied to the skin and underlying tissues) of sacral (tailbone) region, stage 4 (a pressure injury involving full thickness loss of tissue with exposed muscle, tendon, or bone), pressure ulcer of right hip, stage 4, pressure ulcer of left hip, stage 4, and paraplegia (inability to move or have full sensation and feeling to the lower body). The plan of care indicated the patient was to receive skilled nurse visits three to five times a week for sixty days with one to two PRN (as needed) visits and indicated the skilled nurse was to provide wound care to “all wounds” with the following wound care: cleanse with NS (a solution of salt and water) or wound cleanser (a medical solution used to clean wounds), then place gauze soaked with Vashe (a type of wound cleanser) to all wounds for five to ten minutes, apply Gentamycin (a type of topical medication used to treat or prevent infection) to Hydrofera Blue (a type of foam dressing used to treat or prevent infections which helps to create a moist wound environment for wound healing) and place into wounds, including all undermining areas (areas where the wound continue under the surface of the skin), leaving a tail for easy removal (a small piece is left outside the wound for easy removal of the dressing), lightly moisten with NS to activate then cover remaining wound with Aquacel AG (an absorbent wound dressing containing silver to treat or prevent infection of the wound) lightly moistened with a thin layer of Gentamycin cream, then cover with Drawtex (a type of wound dressing used to provide a moist environment for wound healing), ABD pads (a type of absorbent wound care dressing), and secure with tape. The plan of care indicated a service goal of “SN continue wound care as prescribed.” Record review of a skilled nurse’s note, dated 11/13/25, signed by the Administrator/Supervising Nurse, indicated wound care was provided to the patient’s right and left trochanter (hip) stage 4 pressure ulcers. There was no documentation to indicate wound care was provided to the stage 4 sacral pressure injury during this visit as ordered by the physician in the written plan of care. The skilled nurse’s note did not include documentation to indicate Aquacel AG was applied to the Stage 4 pressure injuries to the left and right hip/trochanter pressure injuries as ordered by the physician in the written plan of care during this visit. Record review of a skilled nurse’s note, dated 11/15/25, signed by the Administrator/Supervising Nurse, indicated wound care was provided to the patient’s right hip/trochanter and sacral area stage 4 pressure ulcers. There was no documentation to indicate wound care was provided to the stage 4 pressure injury to the left hip/trochanter during this visit as ordered by the physician in the written plan of care. The skilled nurse’s note did not include documentation to indicate Aquacel AG was applied to the Stage 4 pressure injuries to the sacral and right hip/trochanter pressure injuries as ordered by the physician in the written plan of care during this visit. Record review of a skilled nurse’s note, dated 11/17/25, signed by the Administrator/Supervising Nurse, indicated wound care was provided to the patient’s right hip/trochanter and sacral wounds. There was no documentation to indicate wound care was provided to the stage 4 pressure injury to the left hip/trochanter during this visit as ordered by the physician in the written plan of care. The skilled nurse’s note did not include documentation to indicate Aquacel AG was applied to the Stage 4 pressure injuries to the sacral and right hip/trochanter pressure injuries as ordered by the physician in the written plan of care during this visit. Record review of the clinical record for Patient #1, for the time-period of 11/13/25 – 11/17/25, did not include physician orders to change the wound care to be performed by the skilled nurse which was ordered in the written plan of care, for the time-period of 11/13/25 – 01/11/26. Record review of a physician’s order/wound care clinic visit note, dated 11/18/25, indicated the patient was to receive the following wound care as of 11/18/25 to the right and left trochanter/hip and sacral wounds: provide wound care every other day and as needed, cleanse with wound care or normal saline and gauze. Then place gauze soaked with Vashe to all wounds and allow to soak for five to ten minutes prior to applying new dressings. Apply Cuticirin (a type of mesh wound dressing used to avoid damage to the wound when removing the dressing) to wound bed to the sacral wound only, next apply Gentamicin to Hydrofera Blue and place into undermining areas leaving a tail for easy removal. Lightly moisten with NS to activate. Cover with Aquacel AG lightly covered with a thin layer of Gentamicin cream, then cover with Drawtex, ABD pads, and Convamax (a type of absorbent wound care dressing used to prevent damage to the skin surround the wound) and secure with tape. Record review of a skilled nurse’s note, dated 11/19/25, signed by the Administrator/Supervising Nurse, indicated wound care was provided to the patient’s right hip/trochanter and sacral wounds. There was no documentation to indicate wound care was provided to the stage 4 pressure injury to the left hip/trochanter during this visit as ordered by the physician in the written plan of care. The skilled nurse’s note did not include documentation to indicate Aquacel AG was applied to the Stage 4 pressure injuries to the sacral and right hip/trochanter pressure injuries as ordered by the physician in the written plan of care during this visit. There was no documentation to indicate Cuticirin was applied to the wound bed to the sacral wound during this visit or to indicate the left and right trochanter/hip and sacral wounds were covered with Convamax during this visit as ordered by the physician in the written plan of care. Record review of a skilled nurse’s note, dated 11/22/25, signed by the Administrator/Supervising Nurse, indicated wound care was provided to the patient’s right hip/trochanter and sacral wounds. There was no documentation to indicate wound care was provided to the stage 4 pressure injury to the left hip/trochanter during this visit as ordered by the physician in the written plan of care. The skilled nurse’s note did not include documentation to indicate Aquacel AG was applied to the Stage 4 pressure injuries to the sacral and right hip/trochanter pressure injuries as ordered by the physician in the written plan of care during this visit. There was no documentation to indicate Cuticirin was applied to the wound bed to the sacral wound during this visit or to indicate the left and right trochanter/hip and sacral wounds were covered with Convamax during this visit as ordered by the physician in the written plan of care. Record review of a skilled nurse’s note, dated 11/24/25, signed by the Administrator/Supervising Nurse, indicated wound care was provided to the patient’s right hip/trochanter and sacral wounds. There was no documentation to indicate wound care was provided to the stage 4 pressure injury to the left hip/trochanter during this visit as ordered by the physician in the written plan of care. The skilled nurse’s note did not include documentation to indicate Aquacel AG was applied to the Stage 4 pressure injuries to the sacral and right hip/trochanter pressure injuries as ordered by the physician in the written plan of care during this visit. There was no documentation to indicate Cuticirin was applied to the wound bed to the sacral wound during this visit or to indicate the left and right trochanter/hip and sacral wounds were covered with Convamax during this visit as ordered by the physician in the written plan of care. Record review of a skilled nurse’s note, dated 11/25/25, signed by the Administrator/Supervising Nurse, indicated a PRN visit was made to perform wound care as the dressings had become soiled. The note indicated wound care was provided to the patient’s right hip/trochanter and sacral wounds. There was no documentation to indicate wound care was provided to the stage 4 pressure injury to the left hip/trochanter during this visit as ordered by the physician in the written plan of care. The skilled nurse’s note did not include documentation to indicate Aquacel AG was applied to the Stage 4 pressure injuries to the sacral and right hip/trochanter pressure injuries as ordered by the physician in the written plan of care during this visit. There was no documentation to indicate Cuticirin was applied to the wound bed to the sacral wound during this visit or to indicate the left and right trochanter/hip and sacral wounds were covered with Convamax during this visit as ordered by the physician in the written plan of care. Record review of a skilled nurse’s note, dated 11/27/25, signed by the Administrator/Supervising Nurse, indicated wound care was provided to the patient’s right hip/trochanter and sacral wounds. There was no documentation to indicate wound care was provided to the stage 4 pressure injury to the left hip/trochanter during this visit as ordered by the physician in the written plan of care. The skilled nurse’s note did not include documentation to indicate Aquacel AG was applied to the Stage 4 pressure injuries to the sacral and right hip/trochanter pressure injuries as ordered by the physician in the written plan of care during this visit. There was no documentation to indicate Cuticirin was applied to the wound bed to the sacral wound during this visit or to indicate the left and right trochanter/hip and sacral wounds were covered with Convamax during this visit as ordered by the physician in the written plan of care. Record review of a skilled nurse’s note, dated 11/29/25, signed by the Administrator/Supervising Nurse, indicated wound care was provided to the patient’s right hip/trochanter and sacral wounds. There was no documentation to indicate wound care was provided to the stage 4 pressure injury to the left hip/trochanter during this visit as ordered by the physician in the written plan of care. The skilled nurse’s note did not include documentation to indicate Aquacel AG was applied to the Stage 4 pressure injuries to the sacral and right hip/trochanter pressure injuries as ordered by the physician in the written plan of care during this visit. There was no documentation to indicate Cuticirin was applied to the wound bed to the sacral wound during this visit or to indicate the left and right trochanter/hip and sacral wounds were covered with Convamax during this visit as ordered by the physician in the written plan of care. Record review of a skilled nurse’s note, dated 12/01/25, signed by the Administrator/Supervising Nurse, indicated wound care was provided to the patient’s right hip/trochanter and sacral wounds. There was no documentation to indicate wound care was provided to the stage 4 pressure injury to the left hip/trochanter during this visit as ordered by the physician in the written plan of care. The skilled nurse’s note did not include documentation to indicate Aquacel AG was applied to the Stage 4 pressure injuries to the sacral and right hip/trochanter pressure injuries as ordered by the physician in the written plan of care during this visit. There was no documentation to indicate Cuticirin was applied to the wound bed to the sacral wound during this visit or to indicate the left and right trochanter/hip and sacral wounds were covered with Convamax during this visit as ordered by the physician in the written plan of care. Record review of a skilled nurse’s note, dated 12/03/25, signed by the Administrator/Supervising Nurse, indicated wound care was provided to the patient’s right hip/trochanter and sacral wounds. There was no documentation to indicate wound care was provided to the stage 4 pressure injury to the left hip/trochanter during this visit as ordered by the physician in the written plan of care. The skilled nurse’s note did not include documentation to indicate Aquacel AG was applied to the Stage 4 pressure injuries to the sacral and right hip/trochanter pressure injuries as ordered by the physician in the written plan of care during this visit. There was no documentation to indicate Cuticirin was applied to the wound bed to the sacral wound during this visit or to indicate the left and right trochanter/hip and sacral wounds were covered with Convamax during this visit as ordered. Record review of a skilled nurse’s note, dated 12/05/25, signed by the Administrator/Supervising Nurse, indicated wound care was provided to the patient’s right hip/trochanter and sacral wounds. There was no documentation to indicate wound care was provided to the stage 4 pressure injury to the left hip/trochanter during this visit as ordered by the physician in the written plan of care. The skilled nurse’s note did not include documentation to indicate Aquacel AG was applied to the Stage 4 pressure injuries to the sacral and right hip/trochanter pressure injuries as ordered by the physician in the written plan of care during this visit. There was no documentation to indicate Cuticirin was applied to the wound bed to the sacral wound during this visit or to indicate the left and right trochanter/hip and sacral wounds were covered with Convamax during this visit as ordered by the physician in the written plan of care. Record review of a skilled nurse’s note, dated 12/08/25, signed by the Administrator/Supervising Nurse, indicated wound care was provided to the patient’s right hip/trochanter and sacral wounds. There was no documentation to indicate wound care was provided to the stage 4 pressure injury to the left hip/trochanter during this visit as ordered by the physician in the written plan of care. The skilled nurse’s note did not include documentation to indicate Aquacel AG was applied to the Stage 4 pressure injuries to the sacral and right hip/trochanter pressure injuries as ordered by the physician in the written plan of care during this visit. There was no documentation to indicate Cuticirin was applied to the wound bed to the sacral wound during this visit or to indicate the left and right trochanter/hip and sacral wounds were covered with Convamax during this visit as ordered by the physician in the written plan of care. Record review of a skilled nurse’s note, dated 12/10/25, signed by the Administrator/Supervising Nurse, indicated wound care was provided to the patient’s right hip/trochanter and sacral wounds. There was no documentation to indicate wound care was provided to the stage 4 pressure injury to the left hip/trochanter during this visit as ordered by the physician in the written plan of care. The skilled nurse’s note did not include documentation to indicate Aquacel AG was applied to the Stage 4 pressure injuries to the sacral and right hip/trochanter pressure injuries as ordered by the physician in the written plan of care during this visit. There was no documentation to indicate Cuticirin was applied to the wound bed to the sacral wound during this visit or to indicate the left and right trochanter/hip and sacral wounds were covered with Convamax during this visit as ordered by the physician in the written plan of care. Record review of the clinical record for Patient #1, for the time-period of 11/18/25 – 12/10/25, did not include physician orders to change the wound care to be performed by the skilled nurse as ordered in the physician’s order, dated 11/18/25, after that date. During an interview conducted on 12/17/25 at 2:00 p.m., with Patient #1, when asked about the wound care provided by the Administrator/Supervising Nurse, Patient #1 said she was not sure of the exact wound care the nurse utilized but she knew the nurse was applying the “blue stuff (Hydrofera Blue).” When asked if the skilled nurse was applying the Aquacel AG, the patient said no, but the silver stuff (Aquacel AG) was very good for wound healing. The patient confirmed she had three wounds located at both hips and the tailbone area and confirmed the Administrator/Supervising Nurse provided wound care to all three wounds during each skilled nurse visit. Record review of the clinical record for Patient #2, included a plan of care, for the certification period of 12/11/24 – 02/08/25, which indicated the patient had a start of care date of 08/13/24 and diagnoses of Quadriplegia (an inability to move and/or loss of sensation to the limbs of the body), and pressure injuries, stage 4, of the sacral area and right and left heels. The plan of care indicated the following wound care was to be provided: cleanse wounds with wound cleanser, apply Medihoney (a type of wound care dressing containing medical grade honey used for wound healing), and cover with absorbable dressing or ABD and secure with tape. The plan of care indicated effective 12/11/24, the patient was to receive skilled nurse visits two to three times a week and then two to five times a week for sixty days with two to three PRN visits as needed. The plan of care was signed by the physician and dated 03/15/25. Record review of skilled nurse’s notes, dated 12/11/24 and 12/14/24, signed by the Administrator/Supervising Nurse, indicated the following wound care was provided to the patient’s sacral wound: cleansed with wound cleanser, applied Iodoflex (a medical dressing used to prevent infection and assist with wound healing) to wound bed, covered with Alginate (a type of absorbent wound dressing made with seaweed), Medihoney, ABD, and secured with tape. The notes indicated the following wound care was provided to the patient’s left heel pressure injury: cleansed with wound cleanser, applied Alginate, Medihoney, covered with a foam dressing and secured with tape. The skilled nurse’s notes did not indicate wound care was provided to the patient’s right heel wound. Record review of the clinical record, for the time-period of 12/11/24 – 02/08/25, indicated the patient was transferred to the hospital on 12/15/24 and her care was resumed by the agency on 01/17/25. The record did not include updated physician’s orders for wound care to the sacral and right and left heel pressure injuries, dated on or after 01/17/25, when the agency resumed care of the patient. Record review of skilled nurse’s notes, dated 01/17/25 and 01/19/25, signed by the Administrator/Supervising Nurse, indicated the following wound care was provided to the patient’s stage 4 pressure injury to the sacral area: cleansed with wound cleanser, 0.25% Dakin moistened dressing to wound bed, covered with 4x4 gauze, and a bordered foam dressing. The notes indicated the following wound care was provided to the right heel stage 4 pressure injury: cleansed with wound cleanser, applied Medihoney to wound bed, covered with Alginate, 4x4 gauze, and a bordered foam dressing. The notes did not indicate wound care was provided to the left heel stage 4 pressure injury. Record review of a skilled nurse’s note, dated 01/21/25, signed by the Administrator/Supervising Nurse, indicated the following wound care was provided to the sacral wound: cleansed with wound cleanser, applied Iodoflex to wound bed, covered with Alginate, Medihoney, and an ABD, and secured with tape. The note indicated the following wound care was provided to the right heel wound: cleansed with wound cleanser, applied Medihoney, covered with Alginate, four-by-four gauze, and bordered foam dressing. There was no documentation to indicate wound care was provided to the left heel wound. During an interview conducted on 12/18/25 at 10:00 a.m., Patient #2 said the Administrator/Supervising Nurse was wonderful. The patient said the wound care center had “lost” her orders for wound care but did not express any concerns regarding the wound care provided by the Administrator/Supervising Nurse. During an interview conducted on 12/19/25 at 10:50 a.m., the Administrator/Supervising Nurse said Patient #2 was referred to the agency from Hospital #1 for services at the time of her admission to the agency (08/13/24) and the agency was told that the patient would be receiving wound care from the wound care clinic associated with Hospital #1, Wound Care Clinic #1. The Administrator/Supervising Nurse said when the agency attempted to schedule the visit with Wound Care Clinic #1 the agency was informed the patient was no longer under the services of Wound Care Clinic #1 as she had been removed as a patient for non-compliance and failure to attend appointments. The Administrator/Supervising Nurse said the agency was not made aware of that when the agency accepted Patient #2 for services. The Administrator/Supervising Nurse said the agency then attempted to get the patient on services with Wound Care Clinic #2. The Administrator/Supervising Nurse said the client went to Wound Care Clinic #2 two to four times with the last visit occurring in September or October 2025. The Administrator/Supervising Nurse said the patient’s wheelchair broke and they attempted to get it repaired but it took “forever” to get her insurance to approve the repairs and once it was repaired the visit with the wound care clinic was rescheduled with Wound Care Clinic #2. The Administrator/Supervising Nurse said after the visit with Wound Care Clinic #2 she made a visit to the patient, and the patient informed her the wound care clinic had not seen her and had removed her as a patient of the clinic. The Administrator/Supervising Nurse said the patient had no wound care center overseeing her care at that time. The Administrator/Supervising Nurse said she asked the patient who her PCP was, and the patient said she did not know. The Administrator/Supervising Nurse said she located the physician the patient used to see but that physician said he would not accept her as a patient again. The Administrator/Supervising Nurse said the patient was scheduled with Physician #1 who saw her one or two times. The Administrator/Supervising Nurse said in the meantime while these events were occurring the agency had continued to care for the patient and they had gone through two episodes of care with no signed plan of care because they were unable to locate a physician for the patient to sign the plan of care. The Administrator/Supervising Nurse said the agency continued to search for a physician who was willing to oversee the patient’s care and sign her plan of care and finally had to advise the patient that as she didn’t have a physician and there was no physician to sign orders for her care the agency needed to discharge her from services. The Administrator/Supervising Nurse said the agency was finally able to get the patient’s plan of care signed by a physician after the patient’s discharge from the agency (on 03/15/25), but prior to that the agency had not received physician orders for her care. When asked how the agency knew what care to provide to the patient, the Administrator/Supervising Nurse said the initial orders came from Hospital #1 when she was first discharged and the agency was advised to continue to follow those orders until new orders were obtained. During an interview conducted on 12/19/25 at 1:04 p.m., with the Administrator/Supervising Nurse, when asked how many wounds Patient #1 had during the time-period of 11/13/25 – 12/11/25, the Administrator/Supervising Nurse said the Patient #1 had three wounds located to the left and right trochanter/hips and the sacral area, and she provided wound care to all three. The Administrator/Supervising Nurse said during the skilled nurse visits she provided wound care to all three wounds and provided the same wound care to all three wounds. The Administrator/Supervising Nurse said the patient’s wound care orders changed frequently and if the agency did not have the ordered wound care supplies in stock the agency would have to order the supplies, and the orders might change again before the supplies were received. The Administrator/Supervising Nurse said wound care supplies were expensive, and she did not keep a stock of all types of supplies. The Administrator/Supervising Nurse said that was why there was a discrepancy between what was ordered by the physician to be provided and the wound care she provided to the patient. The Administrator/Supervising Nurse said the patient went to the wound care center every other week and the physician orders from the wound care center should be present in the patient’s clinical record. The Administrator/Supervising Nurse reviewed the patient’s clinical record and confirmed the only physician orders for Patient #1 were the plan of care, for the time-period of 11/13/25 – 01/11/26, and the physician’s order, dated 11/18/25. When asked if the agency contacted the physician when they did not have the ordered supplies to notify the physician that they were unable to provide the ordered wound care and request new orders, the Administrator/Supervising Nurse said, “We don’t usually call,” and said the agency usually just ordered the supplies ordered by the physician in the physician’s order and provided them to the patient as quickly as possible. The Administrator/Supervising Nurse said sometimes the wound care center would send wound care supplies home with the patient. When asked what wound care was provided during the skilled nurse visits during the time-period of 11/13/25 – 12/11/25, the Administrator/Supervising Nurse said she had to use the wound care supplies that were available in the home during visits. When asked if what she documented on the skilled nurse notes, for the time-period of 11/13/25 – 12/11/25, was accurate for the wound care she had provided during those visits, the Administrator/Supervising said, yes. When asked the agency’s policy and procedure for what to do if a physician’s order could not be followed, the Administrator/Supervising Nurse said usually she would call the wound care clinic and speak with the nurse and they would say to keep doing what they had previously been doing but she didn’t speak with the physician or get a physician’s order for what wound care to provide until the wound care supplies ordered by the physician were received. The Administrator/Supervising Nurse said sometimes they would ask for a verbal order from the physician for the wound care to be provided until the ordered wound care supplies were received and would then send the verbal order to the physician for signature if there was something major going on with the patient’s care but the agency had not done this recently and said since the patient was going to the wound care clinic every two weeks the agency had not done this for Patient #1. The Administrator/Supervising Nurse said she was responsible for notifying the physician if an order could not be followed and she was responsible for ensuring the wound care provided to the patient was in accordance with the physician’s orders and provided as ordered in the written plan of care. The Administrator/Supervising Nurse said there was no adverse outcome to the patient related to the failure to provide care according to the physician’s orders and written plan of care for Patient #1. When asked regarding the agency’s policy/procedure regarding provision of care and services according to the written plan of care and physician’s orders, the Administrator/Supervising Nurse said the agency was required to have physician orders and a written plan of care and followed them unless the orders were changed by the physician within the certification period. When asked how the agency monitored to ensure care was provided according to the written plan of care and physician orders, the Administrator/Supervising Nurse said the electronic medical records system had a quality assessment feature which allowed the agency staff to go back and review the notes, but the agency did not utilize this feature much. The Administrator/Supervising Nurse said the agency competed patient clinical record audits upon patient discharge from the agency or occasionally. When asked who at the agency was responsible for ensuring care and services were provided in accordance with the written plan of care and physician orders, the Administrator/Supervising Nurse said the Administrator/Supervising Nurse was responsible. The Administrator/Supervising Nurse said she was not sure the agency’s policy/procedure/expectation for providing care in accordance with the written plan of care and physician’s orders was one hundred percent followed for Patient #1. The Administrator/Supervising Nurse said the issue with Patient #1 was that she was not always able to obtain the wound care supplies ordered by the physician before the wound care orders changed. When asked who was responsible for ensuring each patient had a written plan of care and/or physician orders provided by a physician or qualified practitioner in place prior to providing patient care, the Administrator/Supervising Nurse said that she (the Administrator/Supervising Nurse) was responsible. When asked the importance of ensuring care and services were provided in accordance with a written plan of care and physician’s orders and the potential outcome to patients from the failure to do so, the Administrator/Supervising Nurse said the failure could result in the wound not healing. When asked regarding Patient #2, the Administrator/Supervising Nurse said Patient #2 had a wound to the sacrum which was a stage 4 pressure injury and an unstageable pressure injury to the right heel. The Administrator/Supervising Nurse said the patient did not have a wound to the left heel during the time-period reviewed (12/11/24 – 02/08/25) and said it had been a while since the patient last had a wound to the left heel. The Administrator/Supervising Nurse said the agency was just providing padding to the area for protection. When asked what wound care was provided to Patient #2’s wounds during the time-period of 12/11/24 – 02/08/25, the Administrator/Supervising Nurse said the initial wound care was provided by cleaning the wounds with Dakins and then the patient was seen by the wound care clinic and they added Medihoney to the treatment and then the patient went to the hospital (on 12/15/24) and when she came home from the hospital (on 01/17/25) the patient had no specific orders for wound care. The Administrator/Supervising Nurse said the order only said for the agency to admit the patient for wound care. The Administrator/Supervising Nurse said when the agency called the hospital for more specific wound care orders they were told to just keep doing what the agency had been doing until the patient was seen by a wound care clinic but then the patient was not able to be seen at the wound care clinic and so the agency had no physician orders for the wound care. The Administrator/Supervising Nurse clarified that after the patient went back to the hospital on 12/14/24 and then returned to the agency’s services the agency had no wound care orders for the patient. The Administrator/Supervising Nurse said the agency kept the patient on services for too long because they were worried about leaving her without care. The Administrator/Supervising Nurse said the agency was finally able to get Physician #1 to sign the written plan of care after the patient’s discharge from the agency. The Administrator/Supervising Nurse said Physician #1 had never given the agency orders for the patient’s wound care while she was on services, but he did sign the plan of care after the patient was discharged. The Administrator/Supervising Nurse said because the agency did not have physician orders for the patient’s wound care, she (the Administrator/Supervising Nurse) provided wound care according to her nursing judgement. The Administrator/Supervising Nurse said the hospital just told her to continue doing what she (the Administrator/Supervising Nurse) had been doing and said the last order received from the hospital before the patient’s admission to services was the order on the written plan of care. The Administrator/Supervising Nurse said when the patient went to the hospital on 12/14/24 the hospital changed her wound care but did not give the agency orders for new wound care for what the hospital physician wanted performed. The Administrator/Supervising Nurse said the hospital staff told the agency to continue with what the agency had been doing and not what was done in the hospital after the admission on 12/14/24. The Administrator/Supervising Nurse said the agency used the supplies that were in the home and made decisions about what to use based on what seemed to be working. The Administrator/Supervising Nurse said the agency would try things and if they worked, they would continue using those supplies/dressings for the wound care. When asked what specific wound care the skilled nurse had provided during the time-period of 12/11/24 – 01/23/25, when the patient was readmitted to the hospital, the Administrator/Supervising Nurse said she didn’t know how to tell the surveyor what care was provided because the patient didn’t have a doctor to tell them what to do and so they did what they thought was working for the wound. The Administrator/Supervising Nurse said she could not say if what was documented on the written plan of care, for the time-period of 12/11/24 – 02/08/25, was what the agency had provided and could not say if what was documented on the skilled nurse’s notes for that time-period was what was provided or not. The Administrator/Supervising Nurse said the agency’s electronic medical records system had a problem with auto-populating the wound care documentation from previous skilled nurse’s notes and then if the nurse failed to overwrite the auto-populated documentation the note might not be updated for the wound care that was actually provided during that visit. The Administrator/Supervising Nurse said there was no adverse outcome to Patient #2 related to these issues and said the patient was now going to the hospital for wound care because she still did not have a physician. Record review of an agency policy titled, “Physician’s Plan of Treatment, Change Orders,” not dated, indicated, “The physician’s plan of treatment (Medicare’s Plan of Care) is an individualized plan for care and treatment prepared by the client’s physician with assistance from the nurse and/or therapist who establish the plan based upon the current assessment of the client … The Agency will provide care/services consistent with the plan of treatment … The physician shall be notified immediately of any changes in the client’s condition which indicate changes to the plan of treatment.””

“Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure that each patient record included documentation of all interventions, including treatments and services, provided for 1 of 3 (Patient #3) patients reviewed who received skilled nursing services from agency staff. This failure could affect the proper healing of the wound due to inaccurate and/or untimely documentation of the care provided. The findings included: Record review of the clinical record for Patient #3 included a plan of care, for the certification period of 10/09/25 – 12/07/25, which indicated the patient had a start of care date of 10/09/25 and a diagnosis of Type 2 Diabetes Mellitus (a medical condition in which the body cannot effectively regulate the amount of sugar in the blood) with foot ulcer (wound). The plan of care indicated the patient was to receive skilled nurse visits three to four times a week for sixty days with one to two PRN (as needed) visits. The plan of care indicated the skilled nurse was to provide the following wound care to the right second toe and left foot: Cleanse with NS (a solution of salt and water) or wound cleanser, apply Iodoflex (a medical dressing used to prevent infection and assist with wound healing) to wound bed, cover with Alginate plain (a type of absorbent wound dressing made with seaweed) and gauze, secure with Medipore tape (a type of Medical tape), and place felt (padding applied to relieve pressure) to foot. Record review of a physician’s order, dated 10/22/25 indicated the following wound care was to be provided to the left foot: cleanse with wound cleanser or NS, apply Alginate with silver (a type of absorbent wound dressing made with seaweed and containing silver for treatment or prevention of infection) and gauze, secure with Medipore tape and place felt to foot. Record review of skilled nurse’s notes, dated 10/24/25 and 10/27/25, signed by the Administrator/Supervising Nurse, in the agency’s electronic medical record system on 12/18/25, indicated the following wound care was provided to the patient’s left foot: cleansed with NS or wound cleanser, applied Iodoflex to wound bed, covered with Alginate plain and gauze, secured with Medipore tape, and applied felt to the foot. The notes did not indicate the skilled nurse applied Alginate with silver as ordered by the physician in the written plan of care as ordered on 10/22/25 during these visits. The notes did not indicate the physician ordered for Iodoflex to be applied to the left foot wound during these visits in the written plan of care as ordered on 10/22/25 during these visits. The surveyor requested printed copies of the skilled nurse’s notes for 10/24/25 and 10/27/25 on 12/18/25 at 3:30 p.m. This documentation was not provided on 12/18/25. The skilled nurse’s notes, dated 10/24/25 and 10/27/25, were provided on 12/19/25 at 11:20 a.m. Record review of the skilled nurse’s notes, dated 10/24/25 and 10/27/25, on 12/19/25 at 11:30 a.m., indicated the wound care provided to the left foot wound was provided according to the physician’s order dated 10/22/25. During an interview conducted on 12/19/25 at 11:29 a.m., with the Administrator/Supervising Nurse, when asked if she had changed the documentation on the skilled nurse’s notes for 10/24/25 and 10/27/25 as what was documented for wound care to the left foot on the notes provided on 12/19/25 was not the same wound care that was documented on the notes reviewed in the electronic medical record system on 12/18/25. The Administrator/Supervising Nurse said there was a problem with the agency’s electronic medical record system that caused the documentation to not be uploaded properly which she noted after reviewing the records yesterday after the surveyor requested copies of the skilled nurse’s notes. The Administrator/Supervising Nurse said when she noted the problem the system was corrected overnight on 12/18/25 to 12/19/25 and the correct documentation was uploaded. The Administrator/Supervising Nurse said what was documented on the skilled nurse’s notes provided on 12/19/25 was correct for the wound care she actually provided during the visits on 10/24/25 and 10/27/25. During an interview conducted on 12/19/25 at 1139 a.m., Patient #3 said he had been happy with the services from the agency so far and had been happy with the services provided by the skilled nurse when she was providing his services. Patient #3 said that his wounds had healed while on services with the agency. Patient #3 said as far as he knew the nurse had followed the physician’s orders when providing wound care and had communicated and coordinated with the physician, but he did not have a lot of communication with the physician regarding that. Patient #3 said he had no concerns or complaints regarding the services provided by the agency. During an interview conducted on 12/19/25 at 1:04 p.m., the Administrator/Supervising Nurse said Patient #3 had two wounds, one to the toe and one to the left foot. The Administrator/Supervising Nurse said the wound care provided on the updated skilled nurse’s notes provided to the surveyor on 12/19/25 was accurate for the wound care provided on the dates documented on the notes. The Administrator/Supervising Nurse said there was a problem with the agency’s electronic medical records system that resulted in the notes that were reviewed by the surveyor in the electronic medical record system on 12/18/25 being inaccurate for the wound care provided on those dates. The Administrator/Supervising Nurse said the wound care provided to Patient #3 was performed per the written physician’s orders. The Administrator/Supervising Nurse said the agency did not have a plan in place to monitor the patient clinical records and documentation for accuracy or issues with the system which could result in inaccuracies and said if the agency noticed an issue, they would contact technical support for the electronic medical records system who would assist them to correct the issue. The Administrator/Supervising Nurse said the reason for the failure to maintain a clinical record with accurate and timely documentation of treatments and services for Patient #3 was related to a problem with the agency’s electronic medical record system not updating the information. The Administrator/Supervising Nurse said the agency documented the wound care provided during each visit in the skilled nurse’s note and would not document this anywhere else. When asked regarding the agency’s policy and procedure for ensuring accurate and timely documentation of all services/treatments provided, the Administrator/Supervising Nurse said she (the Administrator/Supervising Nurse) was responsible for ensuring the agency maintained patient clinical records with accurate and timely documentation of all services/treatments provided and said the documentation of a skilled nurse visit note should be completed within one to two weeks of the skilled nurse visit. The Administrator/Supervising Nurse said the documentation for Patient #3 was not always accurate for all services and treatments provided and said the reason was that sometimes the agency had problems with the electronic medical records system. When asked the importance of ensuring patient clinical records were maintained with accurate and timely documentation of all care and services provided and the potential outcome to patients if the agency failed to do so, the Administrator/Supervising Nurse said the failure could affect the proper healing of the wound depending on the physician’s order and what the change to the wound care ordered was. Record review of an agency policy titled, “Clinical Record Contents and Maintenance/Retention,” not dated, indicated, “The Agency will maintain a clinical record for all clients, initiated during the initial visit from data collected during the assessment process. The record will contain pertinent past and current medical, nursing, social and other information as appropriate to the care and treatment for the client. A standardized format will be maintained for documenting all client services. The clinical record will be maintained in such a manner that all information is assembled and filed in a timely manner and in accordance with law and regulation.””