Every finding on record at Celtic Healthcare of Westmoreland, LLC

Based on the findings of an unannounced onsite Medicare complaint investigation completed on March 31, 2023, Allegheny Health Network Healthcare at Home Home Health was found not to be in compliance with the following requirements of Title 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

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 a review of agency policy, process/procedure, clinical records (CR) and staff interviews, the agency failed to develop a plan of care which covered all medications and treatments for two (2) of thirteen (13) CRs reviewed (CRs 8 and 11). Findings include: Agency policy review on 3/23/23: Provision of Care and Record Management ...Care Planning Process ...Policy No.4-001.1 ...Policy ...Definitions ... 1. Individualized Plan of Care: The patient specific clinical plan of care includes: ...M. Medications including dose/frequency/route. P. Supplies and equipment required. " Agency policy review on 3/23/23: Provision of Care and Record Management ...Initial and Comprehensive Assessment ...Policy No. 4-018.1 ...Procedure ... 4. During the initial and comprehensive patient assessment ...relevant information will be documented in the patient ' s clinical record ...O. Review of medication history, as applicable to care and service and current medication use, including prescription, over-the-counter medications and herbal medications ... " An onsite review of clinical records revealed: 3/27/23 at 12:04 PM CR8 was reviewed: Start of Care (SOC) 10/18/22, Certification Period Reviewed (CP) 2/15/23 - 4/15/23, agency 485 Plan of Care (POC) titled: " Home Health Certification and Plan of Care, " read, " ... Orders of Discipline and Treatments: ...HOME HEALTH NURSE TO INSTRUCT PATIENT/CAREGIVER AND ADMINISTER WOUND CARE TO L HEEL ULCER ...CLEANSE WITH CYTOTOXIC CLEANSING AGENT, PAT DRY, APPLY MEDIHONEY TO WOUND. " No documentation of " Medihoney " wound and burn dressing within POC sections labeled " Medication " or " DME and Supplies. " . 3/27/23 1:41 PM CR11 was reviewed: SOC 2/15/23, CP 2/15/23 - 4/15/23, agency 485 Plan of Care (POC) titled: " Home Health Certification and Plan of Care, " read, " ...Orders of Discipline and Treatments: ...HOME HEALTH NURSE TO INSTRUCT PATIENT/CAREGIVER AND ADMINISTER WOUND CARE TO LEFT LOWER ABD WOUNDREMOVE OLD DRESSING ...APPLY MEDIHONEY COVER WITH GAUZE. " No documentation of " Medihoney " wound and burn dressing within POC sections labeled " Medication " or " DME and Supplies. " An exit conference was conducted on 3/28/23 at approximately 12:30 pm with the agency Senior Director of Quality and SD (EMP2) and Senior Director of OPS and Administrator (EMP3). The above findings were reviewed.

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 a review of clinical records (CR) and staff interview (EMP), the agency failed to administer treatments in accordance with the written orders of the physician for one (1) of thirteen (13) clinical records reviewed (CR2). Findings Included: 3/24/23 10:30 AM CR2 reviewed: Start of Care (SOC) 2/27/23, Certification Period Reviewed 2/27/23-4/27/23. Physician Order Date: 3/3/2023 ...Add RN (registered nurse) Visit for 3/4/23 or 3/5/23 for RLE and LLE wound assessment and treatment recommendations ...RLE and LLE Wound care: cleanse with soap and water, apply xeroform gauze to wounds and cover gauze ...may secure with gauze and tape daily and PRN (as needed) ...Service changes: Calendar Frequency SN (skilled nurse) EFFECTIVE 03/05/2023 2WK1, 1EVERY2WK6, 1WK1 CR2 discipline visits for period reviewed revealed the following: 3/6/23 PT Visit, Assessment ...Integumentary ...Indicate Integumentary assessment findings ...Wounds ...Indicate location of wound ... L Lower Leg ...Describe Lesions/Wounds ...Covered with nonremovable dressing ...Integumentary ...Nurse is monitoring the open wound the dressing is clean dry and intact. ...Wound Assessment: Wound Care Provided: " Wound care not provided: Not ordered this visit " 3/7/23 SN Visit, " Assessment ...Patients wound to left lower leg weeping saturated dressing and saturated sock 2+ edema to leg, continue with skilled nursing to monitor wound healing and provide education. ...Narrative ...Patient seen today for skilled nursing visit and wound care to left lower extremity. Patients wound to left lower leg weeping, saturated dressing and saturated sock 2+ edema to leg. Wound care provided to left lower leg wound as ordered and 2 ABD pads applied to help absorb weeping serous fluid from leg. Education provided to patient to change dressing daily and as needed if dressing saturated ... " 3/13/23 PT Visit, Wound Assessment ...Wound Care Provided ...Physical Therapist may assist with wound care as per current nursing wound care orders Patient reports that dressing has been changed one time only since last PT visit (3-9-23) when his neighbor assisted him. Narrative: ...dressing saturated with serosang drainage. Dressing changed ... patient education re importance of daily wound care. He reports he is unable to do this. Reported to therapy supervisor ... " CR2 visit notes for certification period reviewed did not provide wound care frequency as per the written orders of the physician. Verbal order obtained on 3/3/2023 specified daily and as needed dressing changes. Dressing changes were not provided by agency staff on 3/6/23, the period of 3/9/23 - 3/12/23, 3/14/23, and 3/15/23. A telephone exit conference regarding the above information was conducted with the EMP3, Senior Director of OPS and Administrator on March 31, 2023, at 10:00AM.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on a review of agency policy, clinical records (CR), and interviews with staff (EMP), the agency failed to ensure that agency professional personnel promptly alerted the physician to a change in patient status related to patient ability to perform self wound care for one (1) of thirteen (13) clinical records reviewed (CR2). Findings included: Agency Policy Review on 3/23/23: Employee Job Description: Job Title: Physical Therapist ...Primary Duties and Responsibilities: 5. Evaluate effects of treatment at various stages and adjust treatments to achieve maximum benefits. ... 9. Confer with the patient, medical practitioners and appropriate others to plan, implement and assess the intervention program. ...16. Refer to the appropriate practitioner if a finding is revealed out of the scope of the practice. Agency Policy Review on 3/28/23: Employee Job Description: " Job Title: Clinical Field Staff Supervisor (CFSS) ...Primary Duties and Responsibilities: 1. Provide supervision and direction for field staff and act as a liaison between field and office staff. 4. Evaluate and address customer concerns, including documentation and resolution. 9. Review staff ...Obtains physician orders for field staff from physicians ...as needed. " 3/24/23 at 10:30 am CR2 was reviewed: Start of Care (SOC) 2/27/23, Certification Period Reviewed (CP) 2/27/23-4/27/23. Physician order 3/3/2023 ... Order Description: RN Visit for 3/4/23 or 3/5/23 for RLE and LLE wound assessment and treatment recommendations ...RLE and LLE Wound care: cleanse with soap and water, apply xeroform gauze to wounds and cover gauze ...may secure with gauze and tape daily and PRN ...Service changes: Calendar Frequency SN EFFECTIVE 03/05/2023 2WK1, 1EVERY2WK6, 1WK1 3/7/23 SN (skilled nursing) Visit, Narrative...Patient seen today for skilled nursing visit and wound care to left lower extremity. Patients wound to left lower leg weeping, saturated dressing and saturated sock 2+ edema to leg. Wound care provided to left lower leg wound as ordered and 2 ABD pads applied to help absorb weeping serous fluid from leg. Education provided to patient to change dressing daily and as needed if dressing saturated...patient...stated...sometimes...just didn't feel like changing it." 3/13/23 PT (physical therapy) Visit, Wound Assessment ...Wound Care Provided ...Physical Therapist may assist with wound care as per current nursing wound care orders Patient reports that dressing has been changed one time only since last PT visit (3-9-23) when...neighbor assisted ...Narrative: ...dressing saturated with serosang drainage. Dressing changed ... patient education re importance of daily wound care. [patient] reports...is unable to do this. Reported to therapy supervisor ... " 3/16/23 SN (skilled nursing) PRN Visit, Assessment: Cardiovascular: Edema, Lower right, Lower left, 4+ ...Wound Assessment ...LengthxWidthxDepth(CM) ... 5.5x8.15x0 ... Wound Care Provided ...Spoke with [employee] at [md] office; skilled nurse cleansed with derma cleanse pat dry applied medihoney to wound bed and covered with foam boarder dressing for wound care done only for 3/16/17 to be changed 3/20 to UNA Z wrap to bilateral legs, order written change Monday, Wednesday and Friday ... Narrative: Patient reports...called MD regarding wound care and nursing. " 3/16/23 Physician order... Order Description...Spoke with [employee] at [md] office; skilled nurse cleansed with derma cleanse pat dry applied medihoney to wound bed and covered with foam boarder dressing for wound care done only for 3/16/17 to be changed on 3/20 to una z wrap to bilateral legs, order written change monday, wednesday, and friday. There was no documented evidence of timely physician notification on 3/13/23 for patient CR2 change in status related to patient inability to perform self wound care. New physician order for plan of treatment revision obtained 3/16/23 post SN visit and assessment, 3 days after patient status change identified. CR2 visit notes for certification period reviewed did not document evidence of coordination with the physician and/or the agency supervisory/management team to resolve patient issues with wound care management and a change in condition of patient/caregiver ability to perform wound care orders as directed. A visit note from 3/8/23 documented a statement from the physical therapist regarding patient inability to perform wound care, " Discussed this with Therapy Supervisor as patient reports he/she is not going to be able to perform wound care on [their] own." a verbal order from 3/8/23 did not address a change in agency visit frequency to provide increased wound care by SN or PT. A visit note from 3/13/23 documented, " Patient reports that dressing has been changed one time only since last PT visit (3-9-23) when ... neighbor assisted him." and that, "(the patient) reports ... is unable to do this (change the dressing). Reported to therapy supervisor ... " no documentation was provided in which the physical therapist or clinical field staff supervisor notified the physician of the patient's change in condition in order to provide an adjustment in service scheduling for wound care. An exit conference was conducted on 3/28/23 at approximately 12:30 pm with the agency Senior Director of Quality and SD (EMP2) and Senior Director of OPS and Administrator (EMP3). The above findings were reviewed.