Jol Healthcare

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on record review and interview, the agency failed to enforce the agency’s policy to provide care in accordance with physician’s or allowed practitioner’s orders in 1 (Client 5) of 17 patients in that the PT did not remove the wound vac (a negative pressure wound therapy system that applies controlled suction to a wound through a sealed dressing) prior to the patient’s discharge as ordered. This failure potentially placed the patient at risk of adverse outcomes by not following a physician’s order to remove the wound vac prior to discharge from home health services. Findings included: Record review of Client 5’s medical record revealed a Home Health Certification Plan of Care with a start of care date of 7/11/26 and patient was to receive PT services for aftercare following joint replacement surgery of the right knee. Further review revealed an order dated 7/9/26 signed by Physician A on 7/11/26 which read “VO RECEIVED HH PT TO EVAL/TX, HH PT TO REMOVE WOUND VAC AT THE END OF TREATMENT.” Additional review revealed a discharge visit completed by PT A on 7/21/26 and under “Wound Assessment” under “Wound # / Location / Type / Source” read in part “#1 MID - PATELLAR [kneecap], RT [right], SURGICAL” and “WOUND CARE NOT PROVIDED: COVERED BY NON-REMOVABLE DRESSING OR DEVICE.” Further review revealed the visit note was signed by PT A and Client 5 on 7/21/26. Interview with the Administrator and the Regional Physical Therapy Director (via telephone) on 8/12/26 at 2:53PM. The above order was reviewed with the Administrator and the Regional Physical Therapy Director along with the 7/21/26 PT visit note completed by PT A. When asked, the Administrator acknowledged it appeared based on documentation PT A did not remove the wound vac prior to discharge. The Regional Physical Therapy Director stated he spoke with PT A prior to this interview and PT A stated he did not remember if the patient had a dressing on and thought perhaps it was already removed. When asked whose responsibility it was to ensure the orders were completed, the Administrator stated it would be the clinician who was conducting the visit. The Administrator and the Regional Physical Therapy Director stated they were unable to provide any additional information regarding the order and the interview was concluded. An interview was conducted via telephone with PT A on 8/13/26 at 7:30 AM. PT A began the interview by clarifying that, during his previous conversation with the Regional Physical Therapy Director, he had been responding from memory and had mistakenly confused the patient in question with another patient, and as a result, his previous statement that he believed the patient did not have a dressing in place had been inaccurate. PT A was asked whether he was familiar with Client 5 and he acknowledged that he was. When asked whether he had removed the wound vac prior to discharge, PT A stated that he had not removed the wound vac because he had never removed a wound vac from any patient. The verbal order referenced above was reviewed with PT A and he confirmed that he had been unaware of the order to remove the wound vac. PT A confirmed that he had access to review orders contained in client’s medical records, however he stated that it was uncommon for a surgeon to instruct another clinician to remove a wound dressing and therefore it was not something he would typically have looked for. PT A acknowledged that his failure to review the order and remove the wound vac prior to discharge had been an oversight. Left message with a request for call back with Client 5 on 8/12/26 at 4:36PM. Review of the agency’s Administrative Policy Manual last reviewed 041423 under “Order for Care PC.30” under “Purpose” read “To ensure patient/client care is provided in accordance with a physician or allowed practitioner order and federal and state laws and regulations.” Further review revealed under “Policy” read in part “The Agency will obtain orders and provide care in accordance with physician’s or allowed practitioner’s orders…””

“Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on record review and interview, the agency failed to communicate with the ordering physician to ensure patient care was coordinated among other providers of health care services for 1 of 3 patients (Patient #1) for which records were reviewed when the agency didn’t notify the physician regarding barriers to providing services as ordered in the plan of care, in that: Patient #1’s FM refused to allow the nurses from the agency to perform wound care, and FM refused to allow therapy services to perform an evaluation as ordered by the physician. This failure placed the patient at risk of wound deterioration and possible muscle loss by not receiving physical therapy due to not receiving services as ordered by the physician. Findings Included: Review of the clinical record for Patient #1 revealed a start of care date of 05/06/2025 with a diagnosis of pressure ulcers to his legs and one foot. Review of the plan of care dated 05/06/2025 revealed orders for skilled nursing care 2 times per week for 9 weeks. Wound care orders were: Skilled Nurse to perform/teach pressure ulcer care to BLE (bilateral lower extremities), cleanse with cleanser solution, pat dry with gauze, apply nonadherence dressing (Xeroform), cover with ABD (abdominal) pad. Secure with rolling gauze and ace bandage using clean/aseptic technique. SN change dressing 2 times per week and as needed. Review of a start of care Visit Note Report dated 05/06/2025 by RN-A, revealed wound care was provided per MD orders. Review of the narrative note indicated Client #1 was bedbound, with contractures (stiffening) of his hands and legs, paralysis due to a prior stroke, a pacemaker due to his history of a heart attack and kidney disease. Physical therapy, speech therapy and occupational therapy evaluations were ordered. FM #1 refused to allow therapy evaluations. FM #1 stated the client was only on service for wound care. RN- A failed to notify MD that therapy evaluations were declined and that they were not allowed to complete a head-to-toe assessment of Client #1. Review of a SNV note dated 05/20/2025 by LVN-A revealed bilateral lower extremity dressings had been removed earlier in the day by FM #1 and left open to air. Zinc based ointment noted applied by FM #1 to both legs. FM #1 stated she removed the dressings due to excess drainage and concern that surrounding skin would worsen, stating “I put this on him to help protect the skin. I just left the dressings off because I knew you were coming.” LVN-A attempted to gently remove zinc-based ointment. Removal was difficult due to the fragile condition of the client’s legs and discomfort caused to the client. Client tolerated with minimal verbal cues of discomfort. Education provided to FM #1 on importance of keeping dressings in place per physician’s orders and contacting (Agency) for as needed dressing changes or wound care if dressings became soiled or dislodged. FM #1 was advised that if FM #1 feels the need to change dressings herself, to follow current physician orders. Wound care was performed per physician order and documented in the icc (intensive care coordination). LVN-A failed to notify the physician that FM #1 declined to allow the client to be turned so that a skin assessment of the backside of the client could be completed. Review of a SNV note dated 05/23/2025 by LVN- A revealed wound pictures and measurements were obtained. LVN- A failed to notify the physician that she was unable to complete an assessment of the client. Review of MD orders dated 06/06/2025 revealed wound care orders were changed. New orders were SN to perform/teach pressure ulcer care to BLE (bilateral lower extremities), cleanse with cleanser solution, pat dry with gauze, apply calcium alginate (provides wound healing) to wound bed, cover with ABD (abdominal) pad, secure with rolling gauze and ace bandage. Using clean/aseptic technique, SN change dressing 2 times per week and as needed. Review of MD orders dated 06/10/2025 revealed wound care orders were changed for wounds to the client’s right leg and left toe: Cleanse with NS (normal saline)/wound cleanser/or soap and water, pat dry apply Xeroform and calcium alginate (cut to fit wound), cover with bordered foam dressing (a type of dressing to aide healing), wrap with Kerlix (rolling gauze) or dry dressing. Change 2 times per week and as needed for dislodgement. Review of a SNV narrative note dated 06/25/2025 by RN- B read, “Upon arrival, client (Patient #1) was found lying prone (lying face down) on his bed with no clothing or blanket. A dressing was noted on the coccyx (backside) area, reportedly placed by FM #1. Bilateral lower legs were visibly bleeding. The left leg was positioned underneath the right, and the client was audibly crying out in pain. FM #1 was present throughout the visit and was resistant to skilled nursing wound care as ordered. She declined wound care intervention to coccyx stating she provides all care herself. FM #1 refused to let the RN look at the wound to the coccyx. She insisted on continuing her personal wound care practices, including spraying the client’s wound with tap water using a spray bottle while the water pooled under the client. This method appeared to result in bed saturation. FM #1 confirmed this was her routine practice.” RN- B contacted DCS/BD and reported her concerns. RN- B was advised to file an APS report. The agency failed to notify the physician of the incident. A telephone interview was conducted on 07/09/2025 at 8:35 AM with LVN- A. LVN-A stated 80% of the time the patient’s dressings would be clean and dry. FM #1 advised she changed the dressings because there was a lot of drainage. FM #1 refused to follow wound care orders. She had a spray bottle of liquid she used to loosen dressings. LVN-A stated FM #1 told her it was tap water. LVN-A stated the wounds were initially really bad. The wounds would start to get better but then regressed. A referral was sent to a wound care company for an assessment, but FM #1 refused and was very angry because the referral was sent without her approval. LVN-A stated FM #1 alleged a prior home health agency and wound care company caused excessive bleeding and Patient #1 had to go to the hospital. LVN-A stated Patient #1 was always supine in his hospital bed, naked with his private area covered with a cushion. There were no sheets or blankets on his bed. LVN-A stated she was never allowed to complete a thorough assessment of the patient. No one was allowed to assess the back side of the patient. LVN- A stated FM #1 told her “You’re just here for his legs.” Surveyor asked if the MD was notified. LVN- A stated she did not contact the physician. A telephone interview was conducted with RN-A on 07/09/2025 at 9:01 AM. RN-A stated she conducted SN visits on 05/06/2025, 05/27/2025 and 06/06/2025. RN-A stated FM #1 said, “You’re just here for his legs”. FM #1 refused to allow a thorough assessment of the patient. FM #1 did not allow the patient to be moved from his supine position and RN was not allowed to assess the back side of the patient. RN-A stated Patient #1 was always naked with the perineal area covered and no bedding, just lots of pillows to position him. Surveyor asked RN-A if wound reports were sent and if the physician was notified that the caregiver (FM #1) interfered with nursing care and refused to follow wound care orders. RN- A stated she did not contact the physician but reported the issues to DCS/BD. A telephone interview was conducted on 07/09/2025 at 4:08 PM with physician’s office RN-C. Surveyor asked if the physician was aware of the incident on 06/25/2025 with FM #1 and the home health agency. RN-C stated FM #1 called and said she fired the agency, and she was looking for a new agency. RN- C stated FM #1 was advised when she chose an agency RN-C would send a referral. Surveyor asked if the agency coordinated with the physician to provide care for Patient #1. RN-C stated, “They called if they felt they needed to change orders, had any questions, or concerns.” Surveyor asked if the physician or NP knew there was a sacral wound. RN-C stated they were not aware of a wound on his sacrum. Surveyor asked if the MD was notified that FM #1 would not allow a full assessment, refused to follow wound care orders, refused education, refused therapy and was aggressive and verbally abusive to agency staff. RN-C stated they were not aware of those issues. An interview was conducted on 07/10/2025 at 9:45 AM with A/ASN, AA/SN and DCS/BD. Surveyor advised a telephone interview was conducted with RN-C on 07/09/2025. Issues of concern were: The agency didn’t inform them that they could not complete a full assessment of the patient due to interference from FM #1. The agency did not provide any wound care reports or wound photos to the physician’s office. The agency did not report that FM #1 would not allow the nurses to complete wound care as ordered and that she sprayed the wound with tap water, regularly removed the dressings and spread petroleum jelly and zinc oxide ointment on the wounds. A/ASN stated, “We only send wound reports when there is a decline in the wound.” All agreed there was a lack of communication and coordination with the physician. Review of the agency’s online policy and procedure manual revealed a policy titled “Monitoring Patient Care/Coordination of Care, PC.45, Reviewed 050124,” which read “The agency will monitor, evaluate, and report the patient’s/client’s progress toward achieving goals established on the plan of care. The agency will assure effective communication with all physicians and/or non-physician practitioners involved in the plan of care.””