Every finding on record at Centerwell Certified Healthcare Corp.

An investigation of complaint TN00061508 was conducted on 5/31/2022 – 6/1/2022 at Kindred At Home. Deficiencies were cited under 42 CFR Part 484, Requirements for Home Health Agencies.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on agency policy review, medical record review, and interview, the agency failed to ensure a Registered Nurse (RN) performed an accurate admission assessment of wounds for 1 patient (Patient #5) of 6 patients reviewed for wounds. The findings include: Review of the agency policy titled, "Wound Care Assessment and Clinical Oversight," dated 3/2021, showed "...The Registered Nurse (RN) performs the initial assessment for open wounds and surgical incisions upon admission...Wound dressings will be removed in order to assess the wound...Physicians orders will be obtained for all wound treatments will specify...Specific sites/locations..." Medical Record review showed Patient #5 was admitted to the agency on 12/6/2021 with diagnoses including Stable Burst Fracture of the Fourth Vertebrae, Essential Hypertension, and Type 2 Diabetes Mellitus. Review of coordination note dated 12/7/2022, showed the Physical Therapist (PT) was requesting SN (Skilled Nurse) orders due to wound care clinic treatment for multiple wounds. Review of Patient #5’s PT admission visit note dated 12/6/2021, showed “…Referral for SN for wound care and medication management…” Review of Patient #5’s RN evaluation visit note dated 12/8/2021, showed “…Integumentary not assessed…not appropriate at time of evaluation…Monitor wounds. Wound care orders to be requested. Did not dress wounds as patient reports wounds dressed earlier today and not due. She goes to [name of wound care clinic] wound care clinic for care…” Further review showed no documentation of the location of the wounds or number of wounds the patient had at the time of the RN assessment and no documentation that wound care orders were obtained. Review of Patient #5’s visit note dated 12/13/2021, showed the patient had a venous stasis ulcer to the left lower leg and a venous stasis ulcer to the right lower leg. Further review revealed “…SN obtained orders from PCP [Primary Care Physician] office to assess and treat patient wounds…" Review of Patient #5’s physician order dated 12/13/2021, showed “…Perform and teach the following wound care for BLE [Bilateral Lower Extremities] venous stasis ulcers…" During an interview on 6/1/2022 at 1:48 PM, the branch Director (BD) confirmed the RN did not assess the number of wounds or location of the wounds the patient had on the admission assessment dated 12/8/2021. The BD confirmed the wound assessment for the admission assessment was incomplete.

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 medical record review and interview, the agency failed to provide skilled nurse visits as ordered for 2 patients (Patient #3 and #5) of 5 patients reviewed. The findings include: Medical record review showed Patient #3 was admitted to the facility on 10/6/2020 with diagnoses including Chronic Obstructive Pulmonary Disease, Pressure Ulcer of Left Buttock, Pressure Ulcer of Right Buttock, and Type 2 Diabetes mellitus. Review of the Home Health Certification and Plan of Care date 10/1/2021-11/29/2021, showed the patient was to have skilled nursing visits completed 1 time per week for 8 weeks. Review of a Physician’s order dated 11/29/2021, showed “…moved certification to week of 11/29/2021 due to CG [caregiver] refusal…” Medical record review showed no visit had been made for the week of 11/29/2021 with no missed visit documentation and no physician notification. During an interview on 5/31/2022 at 3:56 PM, the Branch Director (BD) confirmed Patient #3 did not have a visit completed the week of 11/29/2021 and confirmed the physician had not been notified of the missed visit. The BD confirmed the physician should be notified of missed visits the next day after the visit was missed. During an interview on 6/1/2022 at 4:06 PM, Regional Vice President of Operations (RVPO) confirmed Patient #3 had a missed visit on 11/29/2021 with no documentation of the missed visit and no documentation the physician had been notified. Medical Record review showed Patient #5 was admitted to the agency on 12/6/2021 with diagnoses including Stable Burst Fracture of the Fourth Vertebrae, Essential Hypertension, and Type 2 Diabetes Mellitus. Review of Patient #5’s physician order dated 12/13/2021, showed “…Perform and teach the following wound care for BLE [Bilateral Lower Extremities] venous stasis ulcers…increase SNV [Skilled Nurse Visit] to 3WK7 [3 times per week for 7 weeks]…” Review of Patient #5’s visits for the certification periods of 12/6/2021-2/13/2022, showed the patient had a missed visit the week of 12/27/2021, she was ordered to have 3 visits per week. She had a visit on 12/27/2021 and had a documented missed visit on 12/31/2021. There was no documentation of the third visit for that week. Further review showed the patient had no visit for the week of 1/9/2022. She was ordered to have 1 visit per week and no visit was completed. During an interview on 6/1/2022 at 1:48 PM, the BD confirmed the patient was ordered to have weekly visits for the week of 1/9/2022. The BD confirmed there was no visit completed that week and no missed visit documentation. During an interview on 6/1/2022 at 4:06 PM, RVPO, confirmed Patient #5 had no documentation of the third visit for the week of 12/27/2021 and no documentation of the missed visit for the week of 1/9/2022 and no documentation the physician had been notified of the missed visits.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on agency policy review, medical record review, and interview, the agency failed to obtain a physician's order for wound care timely for 2 patients (Patient #4 and #5) of 6 patients reviewed for wound care. The findings include: Review of the agency policy titled, "Wound Care Assessment and Clinical Oversight," dated 3/2021, showed "...Physician orders will be obtained for all wound treatments and will specify...Specific sites/locations..." Medical record review showed Patient #4 was admitted to the agency on 7/27/2021 with diagnoses including Venous Insufficiency, Surgical Aftercare Following Surgery of the Digestive System, and Persona History of TIA. Review of Patient #4’s visit note dated 11/23/2021, showed the patient had a lower abdominal wound with onset date 11/23/2021. Review of Patient #4’s visit note date 12/2/2021, showed the patient had a lower abdominal wound with a reactivated date of 11/23/2021. The patient had a left toe wound with onset date of 12/2/2021, a venous stasis ulcer to the right 2nd finger with an onset date of 12/2/2021, and a stage 3 pressure ulcer to the left heel with an onset date of 12/2/2021. Further review showed “…Wounds assessed. Patient has 4 total wounds. 3 have been added to the wound addendum. Wound measurement and pics [pictures] obtained…Patient performed her own wound care d/t [due to] no wound care orders transcribed to the 485 [plan of care] on recert [recertification]. SN [Skilled Nurse] has emailed [names of Registered Nurse Case Managers at the agency] about orders..." Review of Patient #4’s physician’s orders showed an order dated 12/23/2021, for wound care to the right second finger, abdominal wound, left great toe, and left heel. Further review showed no order had been obtained on 11/23/2021 when the abdominal wound was noted or on 12/2/2021 when the wounds on the left second finger, left great toe, and left heel were noted. During an interview on 6/1/2022 at 1:48 PM, the Branch Director (BD) confirmed Patient #4 did not have wound care orders obtained for the abdominal wound noted on the 11/23/2021 visit and for the 3 new wounds noted on the 12/2/2021 visit until 12/23/2021. She confirmed the nurse who noted the wounds should have called the physician to obtain a wound care order. She confirmed the physician should have been notified on 11/23/2021 to obtain a wound care order for the abdominal wound and the physician should have been notified on 12/2/2021 to obtain orders for wound care to the 3 new wounds. Medical Record review showed Patient #5 was admitted to the agency on 12/6/2021 with diagnoses including Stable Burst Fracture of the Fourth Vertebrae, Essential Hypertension, and Type 2 Diabetes Mellitus. Review of coordination note dated 12/7/2022, showed the Physical Therapist (PT) was requesting SN (Skilled Nurse) orders due to wound care clinic treatment for multiple wounds. Review of Patient #5’s PT admission visit note dated 12/6/2021, showed “…Referral for SN for wound care and medication management…” Review of Patient #5’s Registered Nurse (RN) evaluation visit note dated 12/8/2021, showed “…Integumentary not assessed…not appropriate at time of evaluation…Monitor wounds. Wound care orders to be requested. Did not dress wounds as patient reports wounds dressed earlier today and not due. She goes to [name of wound clinic] wound care clinic for care…” Further review showed no documentation of the location of the wounds or number of wounds the patient had, and wound care orders had not been obtained at the time of the RN assessment. Review of Patient #5’s visit note dated 12/13/2021, showed the patient had a venous stasis ulcer to the left lower leg and a venous stasis ulcer to the right lower leg. Further review revealed “…SN obtained orders from PCP [Primary Care Physician] office to assess and treat patient wounds…" Review of Patient #5’s physician order dated 12/13/2021, showed “…Perform and teach the following wound care for BLE [Bilateral Lower Extremities] venous stasis ulcers…" During an interview on 6/1/2022 at 1:48 PM, the BD confirmed wounds were noted on the RN admission assessment dated 12/8/2021. The BD confirmed the nurse did not assess the number of wounds or location of wounds the patient had. The BD confirmed the physician’s order for treatment was not obtained until 12/13/2021.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on facility policy review, medical record review, and interview, the agency failed to completed discharge summaries for 3 patients (Patient #3, #6, and #7) of 9 patients reviewed for discharge. The findings include: Review of the agency policy titled, "Discharge or Transfer," last revised 5/2022, showed "...A copy of the discharge summary will be sent to the physician...and will include the following information...Date and reason for discharge...a summary of the care provided including medication profile...Progress toward achieving goals, post discharge goals of care and treatment preferences..." Medical record review showed Patient #3 was admitted to the facility on 10/6/2020 with diagnoses including Chronic Obstructive Pulmonary Disease, Pressure Ulcer of Left Buttock, Pressure Ulcer of Right Buttock, and Type 2 Diabetes mellitus. Review of the Home Health Certification and Plan of Care date 10/1/2021-11/29/2021, showed the patient was to have skilled nursing visits completed 1 time per week for 8 weeks. Review of a Physician’s order dated 11/29/2021, showed “…moved certification to week of 11/29/2021 due to CG [caregiver] refusal…” Medical record review showed no visit had been made for the week of 11/29/2021 with no missed visit documentation and no physician notification. Medical record review showed no discharge summary had been completed for Patient #3 after the recertification was not completed the week of 11/29/2021. During an interview on 5/31/2022 at 3:56 PM, the Branch Director (BD), confirmed the patient’s recertification was due to be completed on 11/29/2021. The recertification had not been completed and there had been no follow up completed to see if a late recertification needed to be completed or if the patient/care giver wanted to be discharged from services. The BD stated the nurse should have notified the Branch Director so follow up could have been done. The BD confirmed no discharge was completed, the case was not closed, and no discharge summary had been completed. Medical record review showed Patient #6 was admitted to the agency on 9/7/2021 with diagnoses including Pick’s Disease, Dementia, and Hypothyroidism. Review of a coordination note dated 12/16/2021, showed the patient was discharged from services due to goals met. Medical record review showed no discharge summary had been completed for Patient #6. Medical record review showed Patient #7 was admitted to the agency on 12/9/2020 with diagnoses including Metabolic Encephalopathy, Type 2 Diabetes Mellitus, and Chronic Obstructive Pulmonary Disease. Review of a coordination note dated 7/23/2021, showed “…Recert pending clinician assessment…” Medical record review revealed no documentation of recertification completion, and no visits were completed after 7/23/2021. Further review showed no discharge summary had been completed for Patient #7. During an interview on 6/1/2022 at 12:37 PM, the Regional Vice President of Operations (RVPO) confirmed discharge summaries should be completed on the day of the discharge. She stated discharge summaries are sent to the physicians to notify them of the patient’s discharge. During an interview and review of medical records on 6/1/2022 at 2:36 PM, the RVPO and the BD, confirmed Patient #6 had a planned discharge from the agency. Her last visit was completed on 12/3/2021 and a case conference for the discharge had been completed. The RVPO confirmed Patient #6 did not have a discharge summary completed. Further interview and review of Patient #7’s medical record showed the patient had refused all visits scheduled for the month of 6/2021. Further review and interview showed the recertification was pending on 7/23/2021 and was not completed. The RVPO confirmed Patient #7 did not have a discharge summary completed. She confirmed the clinical manager should attempt to call the patients to let them know if they continue to miss visits, they will be discharged from the agency. The RVPO confirmed the agency had not completed discharge summaries for patients #3, #6, and #7.