Every finding on record at Adoration Home Health Care Virginia LLC

An unannounced onsite complaint investigation was conducted 6/27/22. The complaint was substantiated and standard level deficiencies to the Medicare CoP were identified.

Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) (i) Investigate complaints made by a patient, the patient's representative (if any), and the patient's caregivers and family, including, but not limited to, the following topics: This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review and staff interviews the agency failed to document/investigate a patient complaint/concern for 1 of 3 records reviewed [#2]. The findings included: The policy, Complaint Resolution [revised 12/14/2021], was provided by the branch director on 6/27/22 at approximately 10 am. The Policy stated, “Patients, patient representatives, and the patient’s caregiver and family have the right to voice grievances and complaints related to the Agency’s services without fear of reprisal. The Agency will document the receipt, investigation and resolution of complaints…” Patient # 2 had a Start of Care [SOC] date of 1/31/22. A review of the Plan of Care [POC] for the certification period 4/1/22 to 5/30/22 revealed the following diagnoses: Pressure ulcer of sacral [area near the lower back and spine] region, Stage 4 [an ulcer that reaches the muscle, ligament or bone] Pressure ulcer of left buttock, stage 4, Pressure ulcer of right heel, unstageable [an ulcer that has full thickness tissue loss but is either covered by extensive necrotic tissue or by an eschar] and Pressure ulcer of right buttock, stage 2 [ulcer that has broken through the top of the skin and part of the layer below]. Further review of the POC included orders for SN [skilled nursing]1 time a week for 1 week, 3 times a week for 8 weeks, 1 time a week for 1 week. A review of the clinical record revealed LPN # 1 made a routine visit on 5/23/22 and documented the following information, “Pt [patient] irritable about wound status, discussing blame on nurses doing wound care stating her wound got contaminated which caused her infection [sic] I assured her that new gloves are used each time as well as sterile bandages, reminded her of the week she was ill and refused to have wound care is when her wound opened back up. Discussed new wound care orders and that foam sacral dressings have been ordered, she states she doesn’t think she will be able to apply per self d/t her balance…” A review of the agency complaint/grievance log did not include the concern voiced to LPN # 1 on 5/23/22. LPN # 1 was not available for an interview. An interview was conducted with the branch director on 6/27/22 at approximately 4 pm. During the interview the branch director confirmed Patient # 2’s concerns should have been treated as a complaint and recorded in the log.

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 clinical record review and staff interviews the agency failed to follow physician’s orders related to wound care for 1 of 3 records [#2]. Patient # 2 had a Start of Care [SOC] date of 1/31/22 and admitting diagnoses of Pressure ulcer of sacral region [area near the lower back and spine], stage 4 [an ulcer that reaches the muscle, ligament or bone], Pressure ulcer of left buttock, stage 4, Pressure ulcer of right heel, unstageable [an ulcer that has full thickness tissue loss but is either covered by extensive necrotic tissue or by an eschar]. A review of the Plan of Care [POC] for the certification period 1/31/22 to 3/31/22 included orders for SN [skilled nursing] 3 times a week for 3 weeks, 2 times a week for 3 weeks, 1 time a week for 3 weeks and 3 PRN [as needed] for changes in wound status, new skin problems, falls without injuries, changes in cardiopulmonary status, problems with ostomy and “…SN to instructed [sic] and demonstrate wound care to sacrum [area near the lower back and spine] and gluteus[buttocks] as follows: clean with normal saline, pat dry, apply Exudry, cover with abdominal pads and secure with hypafix tape daily. Teach pt/cg [patient/caregiver] wound care procedure. [sic] pt/cg to perform when nurse does not I assist [sic]…” A supplemental wound care order was written on 2/18/22 for SN to clean wound on sacrum with normal saline, apply Mupiricion [Bactroban] ointment, cover with Exudry dressing, Abd pad and Hypafix. Tape in a picture frame manner to secure. Dressing changes by home health 3 times per week. 15 routine visits were made by LPN # 1 after the 2/18/22 supplemental order. A review of the clinical record revealed LPN # 1 failed to apply the Mupiricion to the sacral wound in accordance with the order during any of the 15 visits. LPN # 1 was not available for interview. An interview was conducted with the branch director on 6/27/22 at approximately 4 pm. During the interview the branch director confirmed the LPN failed to apply the Mupiricion ointment in accordance with the physician’s order.

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 clinical record review and staff interviews the agency failed to obtain an order for wound care for 1 of 1 record with a wound [#2]. The findings included: Patient # 2 had a Start of Care [SOC] date of 1/31/22. A review of the Plan of Care [POC] for the certification period 4/1/22 to 5/30/22 included the following diagnoses: Pressure ulcer of sacral region [area near the lower back and spine], stage 4 [an ulcer that reaches the muscle, ligament or bone], Pressure ulcer of left buttock, stage 4, Pressure ulcer of right heel, unstageable [an ulcer that has full thickness tissue loss but is either covered by extensive necrotic tissue or by an eschar] and Pressure ulcer of right buttock, stage 2[ulcer that has broken through the top of the skin and part of the layer below]. The POC included orders for SN [skilled nursing] 1 time a week for 1 week, 3 times a week for 8 weeks, 1 time a week for 1 week, 3 PRN [as needed] for changes in wound status, new skin problems, falls without injuries, changes in cardiopulmonary status, problems with ostomy. A review of the clinical record revealed LPN # 1 made a routine visit on 4/29/22. During the visit the LPN identified a new area of breakdown to the right plantar foot. The LPN entered the following description, “WOUND 7 - Location: Rt plantar foot, Status: Open , Onset Date: 04/19/2022 [nothing documented prior to 4/29/22 about the area on the foot] , Type: Pressure Injury , Stage:2 , Size: Length: 2cm, Width: 0.6cm, Depth: 0.2cm , Wound Bed: , Granulation: 80% , Epi: 20% , Wound Edges: Attached , Epithaelization [sic] , Drainage: Serosanguineous , Amount: Small , Odor: None , Surrounding Tissue: Intact , Fragile , Macerated Treatment: Wound care performed as ordered , Patient Response To Treatment: Pt tolerated well without pain , Wound Pain: None…” The area on the right plantar foot was addressed for 8 visits [4/29/22, 5/2/22, 5/4/22, 5/6/22, 5/9/22, 5/11/22, 5/13/22 and 5/16/22] with “wound care performed as ordered” before the order was written on 5/17/22. LPN # 1 was not available for an interview. An interview was conducted with the branch director on 6/27/22 at approximately 4 pm. During the interview the branch director confirmed there was no order for treatment of the right plantar foot until 5/19/22.

Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This STANDARD is not met as evidenced by: Based on clinical record review and staff interviews the agency failed to assess a wound for 1 of 3 records [#2]. The findings included: Based on clinical record review and staff interviews the agency failed to assess a wound for 1 of 3 records [#2]. The findings included: 1A. Patient # 2 had a Start of Care [SOC] date of 1/31/22 and admitting diagnoses of Pressure ulcer of sacral region [area near the lower back and spine] [, stage 4 [an ulcer that reaches the muscle, ligament or bone], Pressure ulcer of left buttock, stage 4, Pressure ulcer of right heel, unstageable [an ulcer that has full thickness tissue loss but is either covered by extensive necrotic tissue or by an eschar]. A review of the Plan of Care [POC] for the certification period 1/31/22 to 3/31/22 included orders for SN [skilled nursing] 3 times a week for 3 weeks, 2 times a week for 3 weeks, 1 time a week for 3 weeks and 3 PRN [as needed] for changes in wound status, new skin problems, falls without injuries, changes in cardiopulmonary status, problems with ostomy, and “…Assessment of patient with Pressure ulcer of sacral region, stage 4,Pressure ulcer of left buttock, stage 4,Pressure ulcer of right heel, unstageable… SN to instructed [sic] and demonstrate wound care to sacrum and gluteus as follows: clean with normal saline, pat dry, apply Exudry, cover with abdominal pads and secure with hypafix tape daily. Teach pt/cg [patient/caregiver] wound care procedure. pt/cg to perform when nurse does not I assist [sic]…” A review of the SOC OASIS [Outcome and Assessment Information Set] Wound Care Worksheet revealed the following documentation by RN # 4, “WOUND 1 - Location: Sacrum, Status: Open , Present on Admission , Type: Pressure Ulcer , Stage:III , Size: Length: 3cm, Width: 3cm, Depth: 0.1cm , Wound Bed: Red , Pink/Red: 100% , Wound Edges: Attached , Drainage: Serosanguineous , Amount: Moderate , Odor: None , Surrounding Tissue: Intact Treatment: Clean with normal saline, pat dry apply exudry then abdominal pad and secure with hypafix tape daily. Pt/cg to perform when nurse does not visit. , Patient Response To Treatment: Patient tolerated procedure well Additional Information: Son in independent with wound care procedure… WOUND 5 - Location: Right heel, Status: Closed , Present on Admission , Type: Pressure Ulcer , Stage: Unstageable , Size: Length: N/A,Width: N/A,Depth: N/A , Eschar: 100% , Surrounding Tissue: Intact Treatment: Patient to keep clean and dry Additional Information: Patient refused to allow this writer to take a picture.” Further review of the SOC OASIS [Outcome and Assessment Information Set] revealed the following documentation under the Skilled Intervention: Assessment/Instruction/Performance Section, “Patient is paraplegic with decreased sensation to lower extremities and is wheelchair bound. She has a healing stage 4 pressure ulcer in her buttocks and sacrum which per referral has been improving and decreasing in size…She also has a [sic]unstageable wound on her right heel with black firm intact eschar [a dry, dark scab or falling away dead skin] tissue and refused to have picture or measurements done. She said she floats her heels in bed.” A review of the Skilled Nursing Visit dated 2/2/22 revealed LPN # 1 conducted a routine visit. Further review of the visit revealed the LPN documented she did not assess the wound on the left gluteus or the right heel. LPN # 1 and RN # 4 conducted 21 routine visits from 2/2/22-3/30/22 [recertification visit]. The right heel was not assessed during any of 21 routine visits nor was there any reason given why the heel was not assessed. LPN # 1 nor RN # 4 were available for interview. An interview was conducted with the branch director on 6/27/22. During the interview the branch director stated, “I reviewed the chart and I saw the exact same thing.” 1B. Patient # 2 had a Start of Care [SOC] date of 1/31/22. A review of the Plan of Care [POC] for the certification period 4/1/22 to 5/30/22 included the following diagnoses: Pressure ulcer of sacral [area near the lower back and spine] region, stage 4 [an ulcer that reaches the muscle, ligament or bone], Pressure ulcer of left buttock, stage 4, Pressure ulcer of right heel, unstageable[an ulcer that has full thickness tissue loss but is either covered by extensive necrotic tissue or by an eschar] and Pressure ulcer of right buttock, stage 2 [ulcer that has broken through the top of the skin and part of the layer below]. The POC included orders for SN [skilled nursing] 1 time a week for 1 week, 3 times a week for 8 weeks, 1 time a week for 1 week, 3 PRN [as needed] for changes in wound status, new skin problems, falls without injuries, changes in cardiopulmonary status, problems with ostomy and “Assessment of patient with Pressure ulcer of sacral region, stage 4,Pressure ulcer of left buttock, stage 4,Pressure ulcer of right heel, unstageable, Pressure ulcer of right buttock, stage 2…SN to instructed [sic] and demonstrate wound care to sacrum and gluteus as follows: warm water and gentle cleanser, pat dry, apply mupirocin cover with exudry then abd pad abdominal pads [sic] and secure with hypafix tape in a window frame manner to secure manner 3xweek by nurse, son may change prn…”A review of recertification visit completed by RN # 4 on 3/30/22 revealed the following documentation, “Wound Status: Active, Location: unstageable right heel ulcer, Document all pertinent details and a description of the wound: dark eschar [a dry, dark scab or falling away dead skin], patient refused to have clinician palpate…She also has a unstageable wound on her right heel with dress [sic] intact and refused to have picture or measurements done. She said she floats her heels in bed.” A review of the Skilled Nursing Visit Note dated 4/1/22 by LPN # 1 revealed no wound assessment [sacrum, left gluteus, right gluteus or right heel]. Further review of the Skilled Nursing Notes dated 4/4/22-4/27/22 [22 routine visits] revealed no assessment of the right heel nor any reason why the right heel was not assessed. During an interview with the branch director on 6/27/22 at approximately 4 pm. During the interview the branch director stated “I saw the same thing you did in the chart.”

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview the agency failed to communicate with the physician when a patient developed a new wound for 1 of 3 records [#2]. The findings included: The policy, Coordination of Care, Treatment and Services Policy and Procedure [Revised 4/18] was provided by the branch director on 6/27/22 at 4 pm. The policy stated, “Purpose: 1. To ensure that throughout the provision of care, treatment and services the patient will be match appropriately with internal and external resources in order to meet the patient’s ongoing needs in a timely manner…” 1A. Patient # 2 had a Start of Care [SOC] date of 1/31/22 and admitting diagnoses of Pressure ulcer of sacral region [area near the lower back and spine], stage 4 [an ulcer that reaches the muscle, ligament or bone], Pressure ulcer of left buttock, stage 4, Pressure ulcer of right heel, unstageable[an ulcer that has full thickness tissue loss but is either covered by extensive necrotic tissue or by an eschar]. A review of the Plan of Care [POC] for the certification period 1/31/22 to 3/31/22 included orders for SN [skilled nursing] 3 times a week for 3 weeks, 2 times a week for 3 weeks, 1 time a week for 3 weeks and 3 PRN [as needed] for changes in wound status, new skin problems, falls without injuries, changes in cardiopulmonary status, problems with ostomy. A review of the clinical record revealed LPN # 1 made a routine visit on 3/23/22 and documented a new wound to the right gluteus. The wound description was as follows, “WOUND 6 - Location: Right gluteus, Status: Open , Present on Admission , Type: Pressure Ulcer , Stage:II , Size: Length: 0.8cm, Width: 1.2cm, Depth: 0cm , Wound Bed: , Granulation: 50% , Epi: 50% , Wound Edges: Attached , Epithaelization [sic] , Drainage: None , Amount: None , Odor: None , Surrounding Tissue: Intact Treatment: Wound care performed as ordered , Patient Response To Treatment: Pt tolerated well without pain , Wound Pain: None.” A review of the clinical record revealed no wound care order for the right gluteus. LPN # 1 was not available for interview. An interview was conducted with the branch on 6/27/22 at approximately 4 pm. During the interview the branch director stated, “I can’t find an order for the right gluteus, and I do not see where the physician was notified to obtain any orders.” 1B. Patient # 2 had a Start of Care [SOC] date of 1/31/22. A review of the Plan of Care [POC] for the certification period 4/1/22 to 5/30/22 included the following diagnoses: Pressure ulcer of sacral region [area near the lower back and spine], stage 4 Pressure ulcer of left buttock, stage 4, Pressure ulcer of right heel, unstageable[an ulcer that has full thickness tissue loss but is either covered by extensive necrotic tissue or by an eschar] and Pressure ulcer of right buttock, stage 2 [ulcer that has broken through the top of the skin and part of the layer below]. The POC included orders for SN [skilled nursing] 1 time a week for 1 week, 3 times a week for 8 weeks, 1 time a week for 1 week, 3 PRN [as needed] for changes in wound status, new skin problems, falls without injuries, changes in cardiopulmonary status, problems with ostomy… “SN to instructed [sic] and demonstrate wound care to sacrum and gluteus as follows: warm water and gentle cleanser, pat dry, apply mupirocin cover with exudry then abd pad abdominal pads [sic] and secure with hypafix tape in a window frame manner to secure manner 3xweek by nurse, son may change prn…”A review of the Skilled Nurse Visit noted dated 4/27/22 revealed RN # 4 documented the wounds to the right gluteus and left gluteus were “closed-healed”. On 5/7/22, LPN # 1 documented the right and left gluteus had “reopened”. The documentation stated, “…WOUND 2 - Location: Left gluteus, Status: Open , Present on Admission , Type: Pressure Injury , Stage:4 , Size: Length: 2cm, Width: 3cm, Depth: 0cm , Wound Bed: , Granulation: 100% , Wound Edges: Attached , Drainage: Serous , Amount: Small , Odor: None , Surrounding Tissue: Intact , Fragile Treatment: Wound care performed as ordered , Patient Response To Treatment: Pt tolerated well without pain , Wound Pain: None… WOUND 6 - Location: Right gluteus, Status: Open , Present on Admission , Type: Pressure Injury , Stage:2 , Size: Length: 1.5cm, Width: 2cm, Depth: 0cm , Wound Bed: , Granulation: 90% , Slough: 10% , Wound Edges: Attached , Rolled , Drainage: Serosanguineous , Amount: Small , Odor: None , Surrounding Tissue: Intact , Fragile Treatment: Wound care performed as ordered , Patient Response To Treatment: Pt tolerated well without pain , Wound Pain: None…”Further review of the clinical record revealed no evidence the physician was notified related to the right and left gluteus “reopening” and no wound care order was noted for either gluteus from 5/7/22 until the patient was discharged on 6/8/22. LPN 1 nor RN # 4 were available for an interview. An interview was conducted with the branch director on 6/27/22 at approximately 4 pm. During the interview the branch director confirmed the physician was not notified of the areas “reopening” and no orders for wound care were noted on the chart.