Almost Family

“Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure physician wound orders were followed in 1 of 3 patients with wounds (Patient #1) in a total of 7 patient records reviewed. Findings include: Review of agency policy and procedure titled “Plan of Care” dated 12/01/2021 “Purpose: To ensure that physician/authorized practitioners’ orders are followed. Procedure: 2. The Plan of Care includes: n. All patient care orders.” Review of agency policy and procedure titled “Wound Assessment, Documentation and Photography” dated 08/04/2021 “Policy: Unless otherwise ordered by the practitioner, the RN (Registered Nurse) or PT (Physical Therapist) will assess wounds at least weekly. Reassessments will be documented within the Medical record. The assessment includes measurement of the length, width, depth, undermining and tunneling, wound bed description, wound edges, exposed tissue types, drainage and the condition of the peri wound.” Record review of Patient #1’s “Home Health Certification and Plan of Care” with start of care date 09/12/2018 and Plan of Care dated 10/16/2023 to 12/14/2023 revealed “Principal Diagnosis: Pressure Ulcer of other site, stage 4. Other Pertinent Diagnoses: Type 2 Diabetes Mellitus without Complications. Quadriplegia. Orders for Discipline and Treatments: SN (Skilled Nurse) visit every other week starting 10/16/2023. SN to assess/observe progress towards wound healing. SN to measure wounds length, width, and depth once a week as allowed and as needed or requested by the client. Current measurements 3.0cm (centimeter) by 3.0 cm. Provide wound care to left ischium as allowed by client.” Record review of Patient #1’s “Revision to Plan of Care” orders dated 11/17/2023 revealed “SN to assess/observe progress towards wound healing. SN to measure wounds length, width, and depth once weekly, or per patient request, unless obtained by wound clinic that week. Wound care to left ischium, change twice daily and as needed for soiling or dislodgement. Okay to increase visits for wound care to 2 times/day.” Record review of Patient #1’s “Revision to Plan of Care” orders dated 12/08/2023 revealed “SN to assess/observe progress towards wound healing. SN to measure wounds length, width, and depth once weekly, or per patient request, unless obtained by wound clinic that week. Wound care to left ischium, change once daily and as needed for soiling or dislodgement. SN daily Monday through Friday.” Record review of Patient #1’s SN visit documentation of wound assessments and measurements from 10/16/2023 to 12/14/2023 revealed the week of 10/22/2023, 11/05/2023, 11/12/2023, 11/19/2023, and 11/26/2023, no measurements were taken of the left ischial wound. The week of 11/12/2023, no measurements or assessments were taken of the left ischial wound. The home health agency’s medical record did not contain any shared wound assessment or measurement information from the wound clinic. The above findings regarding missing wound assessments and/or measurements for Patient #1 were reviewed during an interview with Administrator A on 12/11/2023 at 2:15 PM. When asked what the expectation would be, that if a patient is seen at the wound clinic and getting measurements taken of the wound, how would the agency know how the wound is progressing and would there be updates within the patient’s home health medical record, Administrator A replied, “Yes, that is what I would expect.” During an interview with Administrator A on 12/11/2023 at 2:30 PM, Administrator A stated, “We looked in the record under summaries or scanned note from the wound clinic and don’t see anything. I will check with the LPN (Licensed Practical Nurse) who sees this patient regularly.” During an interview with RN B on 12/11/2023 at 2:58 PM, when discussed Patient #1’s ischial wound missing measurements and/or assessments in the SN visits, RN B replied, “Patient #1 went to the wound clinic a month ago or so and missed some visits at the wound clinic. There have been compliance issues with Patient #1. We don’t have any other wound visits or updates from the wound clinic in this record. I talked with LPN C to make aware that LPN C is not measuring weekly and should be.” During an interview with Patient #1 on 12/12/2023 at 9:00 AM, when discussed Patient #1’s left ischial wound, Patient #1 stated, “My bottom healed up in one area but then opened into another. I haven’t been able to go to the wound clinic because I need a caregiver to go with.””

“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 ensure plan of care goals were measurable and individualized to meet the patient needs in 7 of 7 records reviewed (Patient’s #1, #2, #3, #4, #5, #6, and #7). Record review of Patient #4’s “Home Health Care Certification and Plan of Care” dated 10/19/2023 - 12/17/2023 revealed “Goals: Patient will not require hospitalization by 12/17/2023. Progress Toward Goal: Met. Patient’s vital signs will remain within range by 12/17/2023. Progress Toward Goal: Met. Patient/Caregiver will be compliant with medication/treatment regimen. Progress Towards Goal: Met, however forgot dose recently. Patient’s safety will be maintained with mediation administration by 12/17/2023. Progress Toward Goal: Met. Patient will have minimal episodes of chest pain by 12/17/2023. Progress Towards Goal: Met. Patient will experience minimal edema by 12/17/2023. Progress Towards Goal: Met, edema is much improved from admission. Goal Other, Patient will complete daily foot checks by 12/17/2023. Progress Towards Goal: Met. Patient will have positive response from pain regimen by 12/17/2023. Progress Towards Goal: Met.” The Plan of Care goals were not measurable or individualized to meet the patient’s needs. Record review of Patient #5’s “Home Health Care Certification and Plan of Care” dated 10/31/2023 - 12/29/2023 revealed “Goals: Other Clients needs will be met with current services by 12/29/2023. Progress Towards Goal: Met. Patient will not require hospitalization by 12/29/2023. Progress Toward Goal: Met. Patient Identified Goal: Client’s mental health will remain at current baseline and not decline by 12/29/2023. Progress Towards Goal: Met. Patient’s vital signs will remain within range by 12/29/2023. Progress Toward Goal: Met. Chronic Left chest wall wound will remain free from infection by 12/29/2023. Progress Towards Goal: Met. Patient will be transferred safely without falls or injuries by 12/29/2023. Progress Towards Goal: Met. Patient will have positive response from pain regimen by 12/29/2023. Progress Towards Goal: Met. Patient/Caregiver will be knowledgeable in-home safety and emergency plan by 12/29/2023. Progress Towards Goal: Met.” The Plan of Care goals were not measurable or individualized to meet the patient’s needs. Record review of Patient #6’s “Home Health Care Certification and Plan of Care” dated 09/08/2023 - 11/06/2023 revealed “Goals: Patient will not require hospitalization by 11/06/2023. Progress Toward Goal: Met. Patient’s vital signs will remain within range by 11/06/2023. Progress Toward Goal: Met. Patient/Caregiver will be compliant with medication/treatment regimen. Progress towards goal: Partially met. Patient’s safety will be maintained with mediation administration by 11/06/2023. Progress Toward Goal: Met. Patient will experience minimal edema by 11/06/2023. Progress Towards Goal: Partially met. Patient will be free of adverse effects to Anti-Coagulation therapy by 11/06/2023. Progress Towards Goal: Met. Patient will be free of diabetic lesions by 11/06/2023. Progress Towards Goal: Met. Patient/Caregiver will be knowledgeable of S/S of Urinary Tract Infection by 11/06/2023. Progress Towards Goal: Met. Patient’s Skin Integrity will remain intact by 11/06/2023. Progress Towards Goal: Met. Patient will be transferred safely without falls or injuries by 11/06/2023. Progress Towards Goal: Met.” The Plan of Care goals were not measurable or individualized to meet the patient’s needs. Record review of Patient #7’s “Home Health Care Certification and Plan of Care” dated 07/13/2023 - 09/10/2023 revealed “Goals: Patient will not require hospitalization by 09/10/2023. Progress Toward Goal: Start of Care. Patient/Caregiver will be compliant with medication/treatment regimen by 09/10/2023. Progress Towards Goal: Start of Care. Patient’s safety will be maintained with medication administration by 09/10/2023. Progress Towards Goal: Start of Care. Patient will experience minimal edema by 09/10/2023. Progress Towards Goal: Start of Care. Patient’s blood sugar will remain within range by 09/10/2023. Progress Towards Goal: Start of Care. Patient will be free of Diabetic Lesions by 09/10/2023. Progress Towards Goal: Start of Care. Patient’s skin integrity will remain intact by 09/10/2023. Progress Towards Goal: Start of Care. Patient will be transferred safely without falls or injuries by 09/10/2023. Progress Towards Goal: Start of Care.” The Plan of Care goals were not measurable or individualized to meet the patient’s needs. During an interview with Administrator A on 12/12/2023 at 11:45AM, when reviewed plan of care goals for Patient’s #1 through Patient #7 and asked what the agency expectations would be for goals on the plan of care, Administrator A replied., “Goals should be client specific related to the disease process, attainable and time specific. Acute care patients should be more specific, but we have a lot of chronic patients.” Review of Patient #2’s “Home Health Certification and Plan of Care” dated 12/3/2023 - 1/31/2024 revealed in part, “Goals: Patient’s PT/INR (a lab test) will be within range by 1/31/24. Progress towards goal: MET. Patient will maintain adequate bowel elimination by: 1/31/24. Progress towards goal: MET. Patient will maintain adequate urinary output by: 1/31/24. Progress toward goal: MET. Patient/Caregiver will be compliant with frequent rotation by: 1/31/24. Progress towards goal: MET.” The Plan of Care goals were not measurable or individualized to meet the patient’s need. Review of Patient #3’s “Home Health Certification and Plan of Care” dated 11/7/2023 - 1/5/2024 revealed in part, “Goals: Patient/Caregiver will be compliant with frequent rotation by 1/5/2024. Progress towards goal: Met. Patient will have positive response from pain regimen by 1/5/24. Progress towards goal: MET. Patient’s needs will be met with current in-home supports and services by 1/5/24. Progress towards goal: MET.” The Plan of Care goals were not measurable or individualized to meet the patient’s need. Findings Include: Review of agency’s Policy and Procedure titled “Plan of Care (POC)” dated 05/04/1999, revised 12/01/2021 revealed under Procedure “2. The POC includes I. Patient specific interventions and education; measurable outcomes and goals identified by the agency and patient.” Record review of Patient #1’s “Home Health Care Certification and Plan of Care” dated 10/16/2023 to 12/14/2023 revealed “Goals: Other: ‘Heal wound with stem cells’ by 12/14/2023. Progress Toward Goal: New Goal. Patient will not require hospitalizations by 12/14/2023. Progress Towards Goal: Met. Patient/caregiver will recognize need for cardiac intervention by 12/14/2023. Progress Towards Goals: Met. Patient/caregiver will be knowledgeable in signs/symptoms of urinary tract infections by 12/14/2023. Progress Towards Goals: Met. Patient/caregiver will be knowledgeable in urinary catheter care and management by 12/14/2023. Progress Towards Goals: Met. Patient will be free of urinary tract infections by 12/14/2023. Progress Towards Goal: Met. Patient’s wounds will be free of infection by 12/14/2023. Progress Towards Goal: Met. Patient/Caregiver will be compliant with frequent rotation by 12/14/2023. Progress Towards Goals: Partially Met. Patient wounds will be free of infection by 12/14/2023. Progress Towards Goals: Met. Patient will be free of diabetic lesions by 12/14/2023. Progress Towards Goas: Met. Patient’s wound(s) will heal 75% by 12/14/2023. Progress Towards Goals: Not Met. Patient/Caregiver will be knowledgeable in-home safety and emergency plan by 12/14/2023. Progress Towards Goals: Met.” The Plan of Care goals were not measurable or individualized to meet the patient’s needs.”