Every finding on record at Concepts in Eldercare

An unannounced Complaint survey #2020007276 and #2022011858 was conducted on 09/06/2022 at Concepts in Eldercare, Home Health Agency provider. The provider was not in compliance with 42 CFR, Part 484 Subpart A-C, Conditions of Participation for 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 record review and interview, the Home Health Agency failed to include all medications and treaments in the Plan of Care for 1 of 3 sampled patients (Patient #1). The findings included: Review of the record reveals Patient #1's start of care date was 09/29/21 with diagnoses ldocumented on the Plan of Care, dated 9/29/21 that included Pathological Fracture of Left Femur, Chronic Embolism and Thrombosis Unspecified Deep Veins of Lower Extremities Bilateral, and Essential Hypertension; lived in an Assisted Living Facility and received Skilled Nursing services for wound care to Left Hip, assess wound for signs and symptoms of infection, wound deterioration and complications, and assess for skin breakdown. There was no evidence on the Plan of Care documenting any medications and or treatments to be provided by the Skilled Nurse. A review of the "Skilled Nurse Visit Note," dated 10/11/21 reveals the wounds on Left Hip are healed and no symptoms of infection are noted. Skilled Nurse assessed skin for breakdown. A review of the "Skilled Nurse Visit Note," dated 10/13/21 reveals, "Patient present new wounds on Left Heel and Bilateral Buttocks. SN (Skilled Nurse) performed wound care to BLE (Bilateral Lower Extremities) as MD (Physician) order (see wound worksheet) under aseptic technique, universal precautions, infection control measures, and proper waste disposal. The measurement for the Left Heel Wound was a length of 3.8 centimeters(cm), width of 4.2 cm, and depth of 0.1 cm. The wound on the Right Buttock measured 2.3 cm in length, 4.7 cm in width, and 0.1 cm in depth. Pressure Ulcer Stage 2, serosanguieous drainage, and minimal drainage amount. The wound on the Left Buttock measured 0.9 cm in length, 0.6 cm width, and 0.1 cm depth. Pressure Ulcer Stage 2, serosanguineous drainage, and inimal drainage amount. Treatment performed was: Clean affected area with Dakin's (Anitseptic) Solution, pat dry gently, apply Mepillex AG (type of dressing), secure with tape. Pressure Ulcers Stage 2 are superficial with a pale pink wound bed and serous drainage." An interview was conducted on 09/06/22 at 1:22 PM with Staff A, Registered Nurse (RN) who was the nurse taking care of Patient #1 who stated she did not have a doctor's order for wound care; she called the (Home Health Agency)'s office to let them know, and did wound care "per protocol;" stated she told the Administrator at the Assisted Living Facility where the patient lived; thought the doctor would see the patient there and Staff A did not notifiy the Physician of a change in condition for Patient #1 and did not update the Plan of Care to include treatment orders.

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 record review, interview and review of the Home Health Agency's Policy and Procedure review, the Home Health Agency failed to obtain Physician's orders for wound care for 1 of 3 sampled patients (Patient #1). The findings included: Review of the record reveals Patient #1 resided in an Assisted Living Facility; was receiving Slilled Nursing visits by Staff A, a Registered Nurse (RN) for observation of a surgical wound. On 10/13/21 Staff A idocumented, on the "Visit Note" that Patient #1 has a Left Heel Blister and a Pressure Ulcer Stage 2 on the Left and Right Buttock. A review of the Plan of Care for Patient #1 does not reveal any treatment orders for wound care. A review of the patient's record reveals no Physician's orders at all for wound care. Continued review reveals Staff A performed wound care on Patient #1 without a Physician order from 10/13/21-10/28/21. On 11/01/21, a "Transfer Discharge Outcome and Assessment Information Set (OASIS)" was done and the transfer narrative documents, "Home Health services to put on hold today 11/01/21 due to patient was transferred and admitted to ... (name of) hospital due to wound infection or deterioration." An interview was conducted with Staff A on 09/06/22 at 1:22 PM who stated that she called the (Home Health Agency)'s office on 10/13/21 and notified the Director of Nurses (DON) and the Case Manager that Patient #1 had wounds on the Left Heel and Right and Left Buttocks; stated the DON instructed her to do wound care "per protocol" and Staff A notified the Administrator at the Assisted Living Facility and thought that the physician there would see the wound and prescribe wound care. An interview was conducted with the Owner of the Home Health Agency on 09/06/22 at 4:15 PM regarding the protocol for wound care who stated that they have a manual with Policies and a Policy titled, "Pressure Ulcer Dressing Change" which gives guidance for the nurse when she first sees a wound before she gets a physician's order for wound care; stated that it was never meant to be the wound care order and never meant to last more than a day or two. Review of the "Policy," under documentation guidelines, reveals evidence of "Physician notification".

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 record review and interview, the Home Health Agency failed to notify the physician of the development of wounds for 1 of 3 sampled patients (Patient #1). The findings included: Record review reveals Patient #1 resided in an Assisted Living Facility and was receiving Skilled Visits by Staff A, a Registered Nurse (RN) for observation of a surgical wound. On 10/13/21 Staff A documented, on the "Visit Note" that Patient #1 has a Left Heel Blister and a Pressure Ulcer Stage 2 on the Left and Right Buttock. A review of the Plan of Care for Patient #1 does not reveal any treatment orders for wound care. A review of the record reveals no Physician orders at all for wound care. Further review reveals Staff A performed wound care on Patient # without a Physician's order from 10/13/21-10/28/21. An interview was conducted with Staff A on 09/06/22 at 1:22 PM who stated that she called the (Home Health Agency's) office and notified the Director of Nurses (DON) and the Case Manager on 10/13/21 that Patient #1 had wounds on the Left Heel and Right and Left Buttocks; stated the DON instructed her to do wound care "per protocol;" notified the Administrator at the Assisted Living Facility and thought that the physician there would see the wound and prescribe wound care. There is no evidence of documentation that Staff A notified the Physician of the development of the patient's wounds.