Every finding on record at Altru Health System

A recertification survey conducted on May 23-26, 2022 found Altru's Home Health in compliance with the requirements of 42 CFR § 484.102, Home Health Agency (HHA) Emergency Preparedness.

For the standard Medicare/Medicaid recertification survey, started on 05/23/22 and completed on 05/26/22, the sample included 7 records reviewed with home visits and 10 records reviewed with no home visits.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on record review, review of facility policy, and staff interview, the Home Health Agency (HHA) failed to ensure all patient care orders were included in the plan of care for 1 of 17 sampled patients (Patient #8). Failure to include all patient care orders in the plan of care may result in inconsistent care delivery. Findings include: Review of the facility policy titled "Planning Care, Treatment, and Services" occurred on 05/26/22. This policy, revised October 2020, stated, ". . . Procedure . . . The home health RN [registered nurse] and/or qualified therapist oversees the plan of care and makes necessary revisions. . . . The plan of care is revised based on the patient's needs identified in the ongoing assessments. . . . Appropriate home health staff will promptly alert the attending physician or allowed practitioner to any changes that suggest a need to alter the plan of care. The RN or therapist will make any necessary revisions to the plan of care based on the physician or allowed practitioner orders. . . ." Review of Patient #8's medical record occurred on May 25-26, 2022. Diagnoses included Type II Diabetes Mellitus with foot ulcer. The record identified Patient #8 went to the wound clinic on 05/17/22 and received a new treatment order which included the use of Medihoney (an ointment used to aid in wound healing). A visit note, dated 05/20/22, identified the nurse did not use Medihoney and performed the dressing change according to wound care orders prior to 05/17/22. An RN note, dated 05/21/22, stated, ". . . SN [skilled nurse] brought patient Medihoney for the wound dressing change on Monday. SN did not see the new order changes before visit on 5/20. . . ." The current attending physician's orders and plan of care failed to identify the updated wound care orders. During an interview on the morning of 05/26/22, a supervisory nurse (#1) stated staff should have sent an order to the primary doctor for review/signature, so they could incorporate it into the current plan of care.