Every finding on record at Adoration Home Health Care Virginia LLC

An onsite complaint investigation survey was conducted February 15-16, 2021. The allegation of failure to follow the plan of care was substantiated with standard level deficiencies identified.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to document wound assessments for 1 of 3 patients with wounds (#3). Findings include: Patient #3 was admitted on 12/18/20 with a diagnosis of type 2 diabetes with foot ulcer. The Plan of Care (POC) for 12/18/20-2/15/21 included orders for skilled nursing 1 time for 1 week then 3 times per week for 8 weeks. On 1/4/21, the patient was admitted to the hospital due to blood sugar elevated. RN #2 conducted a resumption of care (ROC) visit on 1/7/21. The ROC orders included SN to visit 1 time for 1 week, 3 times per week for 5 weeks, and 1 time for 1 week. The ROC orders also included to "apply Aquacel Ag to right leg wound and apply 2 layer compression." RN #1 conducted the ROC but there was no wound assessment of the right leg. Between 1/7/21 and 2/8/21, the patient had received 11 skilled nurse visits and no wound assessment of the right leg was conducted on 11 of 11 visits. An interview with RN #2 was conducted on 2/16/21 at 11:20 a.m. The RN stated, "he had an open wound" and she had applied Aquacel. She stated, "I cannot remember" if measurements were documented.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, staff interviews, and wound care clinic interview, the agency failed to provide services as ordered by the physician for 2 of 3 patients with wounds (#2 and 3). Findings include: A policy, "Plan of Care" (revised 9/20), was provided by the clinical manager on 2/16/21 at 1:10 p.m. The policy stated, " Services, treatment, and care relative to the needs of the patient as identified in the plan of care, to include emergency situations, shall be provided in a safe, effective manner, coordinated among those responsible in the continuum of care, modified as warranted based on any changing needs of the patient and are reflected by updating the plan of care as ordered ...The plan of care developed in consultation with the agency staff covers all pertinent diagnoses including ...treatments and medications ..." 1. Patient #2 was admitted on 1/15/21 with diagnoses of type 2 diabetes and non-pressure chronic ulcers of the right lower extremity. The Plan of Care (POC) for 1/15/21-3/15/21 included skilled nursing (SN) 1 time per week for 9 weeks to provide wound care to the right lateral foot and right lower anterior leg (2 separate areas). Wound care orders were to "clean wound with wound cleaner, apply Aquacel AG, gauze, and kerlix to wound weekly." LPN #1 conducted a home visit on 1/25/21. The LPN note revealed, "Spoke with ____ at _____ Wound Center regarding sn frequency and date of patient next wound center visit. ____ stated sn frequency is 2x [twice] weekly and next visit is Friday." A "Patient Communication" note on 1/25/21 by LPN #1 stated, " I spoke with _____ at ____[wound care center]. _______ stated that patient should be seen 2x weekly by hh [home health] ...]. On 1/27/21, a "Patient Communication" note by LPN #1 sent to the admitting RN stated, " ...can you adjust the frequency for this patient she should be x2 weekly [sic] ..." As of 2/15/21, the frequency had continued to be weekly. An interview was conducted with LPN #1 on 2/15/21 at 4:17 p.m. The LPN stated, "I originally called to see when wound care center appointment was. I asked how many times per week [patient to be seen]. ______ [wound care center personnel] said 2 times per week." She stated she and the case manager "had a verbal conversation about it" [the increase in frequency]. An interview was conducted on 2/15/21 at 4:30 p.m. with RN #2. The RN stated, "I saw her once for an LPN [supervisory] visit ...All I know is I see her when she is put on my schedule." RN #2 did confirm she was the patient's case manager. An interview was conducted with wound care center employee on 2/16/21 at approximately 9:00 a.m. The interview confirmed the home health agency should have seen patient 2 times weekly for wound care. 2. Patient #3 was admitted on 12/18/20 with a diagnosis of type 2 diabetes with foot ulcer. The Plan of Care (POC) for 12/18/20-2/15/21 included orders for skilled nursing 1 time for 1 week then 3 times per week for 8 weeks. The POC also included wound care order for left heel; Cleanse with wound wash, use skin barrier peri wound to decrease skin irritation. "Window frame" peri wound with transparent film, cut foam to fit wound and apply. Apply Santyl to wound bed. Apply black foam, apply vac 3 times per week. On 12/18/20, 12/21/20, 12/23/20, 12/26/20 there was no evidence that the Santyl was applied as ordered. LPN #1 conducted a visit on 12/30/20 and applied the wound vac, but no evidence of applying the Santyl. On 1/1/21, LPN #1 visit note reveals that hydorfera blue, unna boot, and coban was applied to wound. An interview with LPN #2 was conducted on 2/16/21 at 11:00 a.m. The LPN stated, "I don't recall" where the order for the hydrofera blue was received. On 1/4/21, the patient was admitted to the hospital due to blood sugar elevated. RN #2 conducted a resumption of care (ROC) visit on 1/7/21. The ROC orders included SN to visit 1 time for 1 week, 3 times per week for 5 weeks, and 1 time for 1 week. The ROC orders also included to "SN to cleanse wound [left heel] with wound cleanser or NS [normal saline] and gauze. May apply skin prep to perimeter [sic] periwound [skin around the wound] wound and/or windowpane wound edges with transparent drape. Cut black/green/white foam to fill wound bed. Cover drape, cut small hole for tack pad and apply pad. Secure. Attach dressing tubing to vac tubing on suction canister. Set vacuum at 125 mmG continuous SN may change 4 time as week [sic] and PRN ..." On 1/11/21 and 1/13/21, RN #2 conducted a visit. The visit note stated, "applied Santyl to wound bed ..." There was no order for Santyl to be applied. On 2/16/21 at 11:20 a.m., an interview with RN #2 revealed that the order was for Santyl. The RN stated that Santyl had been applied on every visit since patient admission.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on policy review, clinical record review and staff interview, the agency failed to completet visits for 1 of 3 patients reviewed (#3). Findings include: A policy, "Minimum Record Standards" (revised 5/19), was provided by the clinical manager on 2/16/21 at 1:10 p.m. The policy stated, "Timely and accurate documentation is essential to safe and extraordinary patient care. All HH [home health] filed staff are required to submit documentation within 2 business days for it to be scanned ..." Patient #3 was admitted on 12/18/20 with a diagnosis of type 2 diabetes with foot ulcer. The Plan of Care (POC) for 12/18/20-2/15/21 included orders for skilled nursing 1 time for 1 week then 3 times per week for 8 weeks. On 1/4/21, the patient was admitted to the hospital due to blood sugar elevated. RN #2 conducted a resumption of care (ROC) visit on 1/7/21. The ROC orders included SN to visit 1 time for 1 week, 3 times per week for 5 weeks, and 1 time for 1 week. As of 2/16/21 at 11:00 a.m. visit notes for 2/5/21 and 2/8/21 were not completed. In an interview with RN #2, it was confirmed the patient had a PICC (peripherally inserted central catheter) line and IV antibiotics were administered during these visits. The RN stated she visits were not documented because "orders were not in the chart." She stated she had orders in the home but not electronic record. An interview with the clinical manager on 2/16/1 at 11:30 confirmed the orders were in the record on 2/4/21. The clinical manager also confirmed the documentation was not completed per policy.

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 policy review, clinical record review and staff interview, the agency failed to coordinate with the physician regarding wounds for 1 of 3 patients with wounds (#3). Findings include: A policy, "Coordination of Care, Treatment & Services" (revised 8/20), was provided by the agency director on 2/16/21 at 1:10 p.m. The policy stated, "Coordination of care will occur with all physicians involved in the plan of care and personnel will document in the patient's record the communication with the physician(s). Personnel will integrate all orders from the physicians involved in the plan of care into the patient's record to ensure coordination of all services and interventions provided to the patient." Patient #3 was admitted on 12/18/20 with a diagnosis of type 2 diabetes with foot ulcer. The Plan of Care (POC) for 12/18/20-2/15/21 included orders for skilled nursing 1 time for 1 week then 3 times per week for 8 weeks. The POC also included wound care order for left heel; Cleanse with wound wash, use skin barrier peri wound to decrease skin irritation. "Window frame" peri wound with transparent film, cut foam to fit wound and apply. Apply Santyl to wound bed. Apply black foam, apply vac 3 times per week. On 12/28/20, a nursing visit was not conducted, and the wound vac was not applied. LPN #1 note revealed the patient had stated the physician wanted the wound vac off until 12/30/20. There was no evidence the physician was notified of the missed visit or confirmation of the patient's report to leave the wound vac off. An interview with the clinical manager on 2/16/21 at 11:00 a.m. confirmed there was no evidence the physician was notified. An interview with LPN #1 was conducted on 2/16/21 at 11:30 a.m. The LPN "I don't recall [if I physician was notified]. I don't think I called the doctor."