Ascension at Home

“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 observation, record review and interview, the agency failed to ensure skilled nursing services were provided in accordance with the individualized plans of care (POC) for 2 of 5 patient records reviewed (Patient #1 and #2). Findings include: Review of agency policy and procedure “Care coordination and Plan of Care” dated 07/29/2025 revealed in part, “Content of the Plan of Care: 2. All patient care orders…12. All medications and treatments…16. Patient-specific interventions and education…Review/update to the plan of care: 1 The individualized plan of care is reviewed and revised by the physician treatments…practitioner who is responsible for the home health plan of care and the agency as frequently as the patient’s condition or needs require…the agency promptly alerts the relevant physicians or allowed practitioners to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and that the plan of care should be altered…Coordination of Care: 2. Integrate orders from all physicians or allow practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient;3. Integrate services …to assure the identification the of patient needs and factors that could affect patient safety and treatment effectiveness…” Review of agency policies and procedures revealed no policy addressing documentation of patient treatment refusal of ordered treatment or interventions. Review of Patient #1’s POC for certification period 01/05/2026 through 03/05/2026 revealed primary diagnoses of right buttock laceration/open wound, stage 3 pressure ulcer of left buttock with secondary diagnosis of Type 2 diabetes and venous insufficiency. Frequency and duration of visits revealed Skilled nursing (SN) was ordered at one visit per week for nine weeks. The POC “Orders of Discipline and Treatments” revealed “SN to assess/evaluate open wound of right buttocks and comorbid conditions including pressure ulcer of left buttock…SN to provide monitoring for the presence of skin lesions on the lower extremities and teaching/reinforcement regarding proper diabetic foot care.” Review of Patient #1’s SN visit notes dated 1/08/2026, 01/15/2026 and 1/20/2026 revealed RN B documented integumentary system was assessed, stating “poor turgor and wounds”. RN B documented wound specific assessments to right and left buttocks and documented wound care. There was no documentation for an assessment or monitoring of Patient #1’s lower extremities or patient refusal of intervention. SN visit on 01/20/2026, RN B documented stable vitals; no documentation identifying weaknesses, fatigue or change in Patient #1’s condition. Review of Patient #2’s POC for certification period 07/23/2026 through 09/20/2026 revealed primary diagnosis of displaced bimalleolar fracture of the left lower leg with secondary diagnosis of Type 2 diabetes. Frequency and duration of visits revealed SN services ordered at one visit a week for 5 weeks and 1 visit every other week for 4 weeks. The POC “Orders of Discipline and Treatments” revealed “Wound #2 left heel…SN to monitor and perform treatment 1x weekly… SN to provide monitoring for the presence of skin lesions on the lower extremities and teaching/reinforcement regarding proper diabetic foot care.” Review of Patient #2’s SN visit notes dated 08/27/2026. 09/03/2026 and 09/10/2026 revealed RN B documented integumentary system was assessed, stating “poor turgor”. RN B documented wound specific assessments to heel and documented wound care. No documentation of an assessment or monitoring of Patient #2’s lower extremities or patient refusal of intervention. During an observation of Patient #2’s home visit on 09/17/2026 at 12:45 PM, RN B was observed providing wound care to Patient #2’s left heel and obtaining vital signs. RN B was not observed assessing or monitoring Patient #2’s lower extremities for presence of skin lesions. During an interview on 09/17/2026 at 12:45 PM, RN B stated Patient #1 would often not allow her to look at his legs and stated Patient #1 had a mobile wound clinic that would provide treatments. RN B stated she didn’t know if the refusals were documented. RN B stated that the interventions she was ordered to provide for Patient #2 included “heel wound treatment and teaching”. During an interview on 09/17/2026 at 11:00 AM, Director C stated that there is random audits by the directors of client records and visits but otherwise no one is checking to ensure the nurse is following the plan of care. Director C stated that if a patient refused a treatment or intervention it was expected that the nurse would document this in the narrative.”