Every finding on record at First Colorado Home Health Care Inc

A complaint survey prompted by CO97276 was completed on 5/10/23. Based on findings and ongoing investigation of the complaint and due to the scope of deficient practice identified, two Conditions of Participation were out of compliance: 484.60- CARE PLANNING, COORDINATION OF CARE AND QUALITY OF CARE 484.75- SKILLED PROFESSIONAL SERVICES In addition, 7 standard level deficiencies were cited. Refer to CFR 484.36(a)(2)(i) guidelines. An agency, which has a Condition of Participation out of compliance with any of the requirements is precluded from conducting (if approved) or applying to conduct a Nurse Aide Training Program or Competency evaluation for two (2) years from the exit date

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation 484.60, CARE PLANNING, COORDINATION AND QUALITY OF CARE was out of compliance. A total of 6 clinical records were reviewed for compliance with the Condition and Standards of Care Planning, Coordination and Quality of Care. Record review revealed a pattern of failures in regard to the home health agency ensuring care and services provided met the patient's needs. Review revealed the agency had not coordinated services with physicians and had provided care without a physician's order as well as maintained an individualized plan of care to ensure patient needs were met. These failures had the potential to affect all patients served by the home health agency. Findings include: 1. During an interview on 5/8/23 at approximately 11:45 a.m., the alternate administrator and director of nursing (DON) stated the agency had not accepted patients with complex wound care that required specialized training and current patients that had complex wound care, which included a wound vacuum assisted closure (V.A.C.), were referred to a wound clinic within the local hospital system. The DON stated when the skilled nurse (SN) completed a visit to the patient and determined the patient had a complex wound the SN coordinated wound care with the hospital. The DON stated the agency did not have any qualified practitioners who had received specialized training in the provision of complex wound care. 2. On 5/8/23, a review of Patient #4's record revealed a start of care date of 5/4/22. According to a resumption of care (ROC) assessment dated 3/24/23 for the certification period dated 3/9/23 to 5/7/23, Patient #4 received skilled nursing (SN) one hour a week for nine weeks for wound care and catheter change every other week and as needed (PRN) for catheter dislodgement, occlusion or malfunction; and a home health aid (HHA) for twenty eight hours per week for eight weeks and sixteen hours for one week for assistance with activities of daily living (ADLs) related to the primary diagnoses of neuromyelitis optica and unstageable pressure ulcer of sacral region, unstageable pressure ulcer of left heel; Type 1 diabetes mellitus with diabetic neuropathy, unspecified and thrombocytopenia. a. The agency failed to ensure patients were accepted for treatment only on the reasonable expectation that the home healthcare agency could meet the patient's medical needs in their place of residence. Review of the record revealed Patient #4 had been admitted to the hospital between 3/13/23 to 3/23/23. Review of hospital discharge physician orders dated 3/24/23 to the agency revealed wound V.A.C. dressing applied to six of the eight wounds and Patient #4 required wound V.A.C. dressing change twice weekly by SN. Review of the ROC assessment completed by the DON on 3/24/23 revealed Patient #4 had eight wounds and received treatment via wound V.A.C.; however, the specific wound(s) treated by wound V.A.C. was unspecified in the documentation. Review of the ROC orders for discipline and treatment revealed SN indicated for wound care management based on physician orders due to the inherent complexity of the wound or no able/willing caregiver to perform wound care. Further review of this note revealed a face to face addendum admission narrative which revealed the DON stated the wound V.A.C. was complicated to be managed at home level and Patient #4's primary caregiver reported the wound V.A.C. was to be managed by the hospital outpatient wound care team two days per week. The ROC assessment failed to reveal care coordination completed by the DON with Patient #4's physician or the hospital outpatient wound care team to verify coordinated services were to be provided to Patient #4 and that the agency plan of care (POC) met their needs. Review of a communication note written by the DON on 3/27/23 revealed Patient #4's primary caregiver notified the agency that the agency was to provide the wound V.A.C. dressing changes for Patient #4, not a hospital outpatient wound care team and coordinated a home visit for that day with the agency DON for the wound V.A.C. dressing change. Review of a communication note written by the administrator on 3/27/23 revealed the administrator documented this agency had maintained physician orders from the hospital at discharge to complete the wound V.A.C. dressing changes. Review of an SN visit note on 3/27/23 revealed the DON had documented within the visit narrative Patient #4 had been seen for wound V.A.C. dressing change by two nurses, the DON and RN #6; however, were unable to achieve a full seal of wound V.A.C. due to leakage and inadequate wound V.A.C. supplies available to complete dressing change. The DON documented communication with the hospital case management and the agency informed Patient #4's caregiver to utilize emergency services for hospital admission for wound V.A.C. dressing change. Review of a communication note on 3/27/23 revealed the DON had documented based on SN assessment and Patient #4's condition, the hospital setting had been more appropriate and documented the hospital wound care team and physician had been notified via fax. Review of a communication note on 3/30/23 revealed the administrator spoke with Patient #4's physician's office regarding the complicated wound V.A.C. dressing change, utilization of emergency services for wound V.A.C. dressing change on 3/27/23 and had requested further guidance regarding the severity of this wound not having been appropriate for home healthcare services. The record failed to reveal continued documentation by Patient #4's physician regarding referral to a higher level of care. Review of a transfer of information (TIF) summary dated 3/31/23 revealed Patient #4 had utilized emergency services for hospitalization on 3/30/23 following an SN visit by the DON. The TIF narrative read the agency had not had enough staff to change the wound V.A.C. dressing as well as were missing pertinent supplies for the wound V.A.C. dressing change at the visit. During an interview on 5/9/23 at approximately 3:00 p.m., the DON stated after review of hospital discharge information and the order for wound V.A.C. dressing change, the agency determined two SNs would be necessary to complete wound V.A.C. dressing change and the administrator hired RN #6 on 3/27/23 to provide assistance to Patient #4 as he had wound care experience and education to provide the treatment, three days after accepting the referral from the hospital. During an interview on 5/9/23 at 4:15 p.m., the alternate administrator stated the agency administrator had reviewed hospital discharge physician orders for wound V.A.C. dressing changes to be completed by this agency prior to discharge and had accepted Patient #4 for home healthcare admission due to having known Patient #4 for approximately one year while receiving services from this agency. The alternate administrator stated the administrator believed the agency would be able to provide Patient #4 with the medical and SN care required with the assistance of hiring RN #6 who had wound care experience and education. During an interview on 5/10/23 at approximately 1:30 p.m., RN #6 stated he had wound care experience and education from a history of work within hospital systems and home heathcare which included wound V.A.C. dressing changes. RN #6 stated due to the size, location and number of wounds Patient #4 had been ordered to be treated by one wound V.A.C. machine, Patient #4's wound V.A.C. dressing change was complex. RN #6 stated he had not completed treatment on a wound V.A.C. dressing change as complex as Patient #4 had required. During an interview on 5/10/23 at approximately 2:50 p.m., the administrator stated the agency generally had not accepted patients with complex wound care due to the agency had not had qualified staff to complete wound care dressing changes; however, due to knowing Patient #4 the agency had wanted to continue to work with her and provide her treatment. The administrator stated the agency had contacted the wound care supplier coordinated by the hospital at discharge to ensure wound care supplies were in the home prior to SN visit on 3/27/23 and had contacted the hospital wound care team on 3/28/23 for a case conference to discuss the wound V.A.C. orders and request assistance with the wound care; however, the administrator was not able to find documentation of either care coordination. The administrator stated due to inadequate wound care supplies in the home following hospital discharge and care coordination with the hospital, the agency was not able to safely maintain Patient #4 as a patient of the agency and recommended a higher level of care following utilization of emergency services for hospitalization on 3/30/23. B. Based on record review and interview, the agency failed to ensure the plan of care had been reviewed by the physician as frequently as the patient's condition or healthcare needs required but no less frequently than once every 60 days in 3 of 5 patient records reviewed who were patients of the agency for longer than 60 days at time of the survey (Patient's #1, #4 and #6). Cross Reference G588 C. Based on interview and record review the agency failed to include all pertinent information on the plan of care. Specifically, the plan of care was missing all wound care orders and diagnoses in 2 of 2 discharged patient records reviewed (Patients #4, and #5 ). Cross Reference G574 D. Based on record review and interview, the agency failed to ensure qualified practitioner's documented within the patient record and authenticated physician verbal orders in 6 of 6 patient's records reviewed (Patients #1, #2, #3, #4, #5 and #6). Cross Reference G584

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 interview and record review the agency failed to include all pertinent information on the plan of care. Specifically, the plan of care was missing all wound care orders and diagnoses in 2 of 2 discharged patient records reviewed (Patients #4, and #5). Findings include: 1. On 5/8/23, a review of Patient #4's record revealed a 5/4/22 start of care date. According to a plan of care for certification period dated 3/9/23 to 5/7/23, Patient #4 received skilled nursing (SN) visits one hour a week for nine weeks for wound care and catheter change every other week and as needed (PRN) for catheter dislodgement, occlusion or malfunction; and a home health aide (HHA) for twenty eight hours per week for eight weeks and sixteen hours for one week for assistance with activities of daily living (ADLs) related to the diagnosis of neuromyelitis optica, unstageable pressure ulcer of sacral region, unstageable pressure ulcer of left heel, Type 1 diabetes mellitus with diabetic neuropathy and thrombocytopenia. a. The agency failed to include all of Patient #4's wound interventions on the Plan of Care in order for the registered nurse (RN) to know what wound care was required. Review of the Plan of Care dated and signed 3/24/23 by the director of nursing (DON) revealed the agency was to provide wound care to Patient #4's left heel, buttock and sacrum and there were only three wounds listed. The Plan of Care failed to include all of Patient #4's wounds to be assessed and cared for by the agency according to the resumption of care assessment performed on 3/24/23. Review of the resumption of care assessment dated 3/24/23 completed by the DON revealed Patient #4 had one surgical wound, four or more stasis ulcers, one stage 2 pressure ulcer, four stage three pressure ulcers, one stage 4 pressure ulcer and four stage 1 pressure ulcers for a total of at least 15 wounds. There was no evidence to show the additional 12 wounds were included on the Plan of Care developed from this assessment in order for the RN to assess and care for all of Patient #4's wounds. During an interview on 5/9/23 at approximately 3:30 p.m., the DON stated when completing a comprehensive assessment, all information is required to be accurate and updated to reflect the patients' current status. The DON reviewed the recertification assessment, dated 3/9/23 and the ROC assessment completed on 3/24/23 and acknowledged the ROC assessment and the recertification assessment contained primarily the same information; however, the ROC assessment additionally included documentation from hospitalization and wound care dressing change on 3/23/23. The DON acknowledged the ROC assessment had not reflected all of Patient #4's wound information. b. The agency failed to include all wound V.A.C. (Vacuum Assisted Closure) related supplies required to provide care to Patient #4 on the plan of care. Review of the Plan of Care dated and signed by the DON on 3/24/23 revealed Patient #4 required a hospital bed, motorized wheelchair and Hoyer lift and no supplies were listed under the DME (durable medical equipment) and supplies section. There was no evidence to show what wound care supplies (type of sponge, canister, skin protectant, dressing kit, etc.) were required for Patient #4's wound care or that a wound V.A.C. was to be utilized. Review of hospital referral orders dated 3/23/23 showed the physician ordered wound V.A.C. dressing changes twice weekly. During an interview on 5/9/23 at 3:15 p.m., the coordinator stated that when the agency received orders it usually coordinated supplies. However, On the 3/30/23, the DON's note showed supplies were not available to provide Patient #4's wound V.A.C. dressing change, so the patient returned to the hospital. The DON admitted that on 3/30/23, he and RN #6 tried to perform the dressing change, but did not have a "spare connection to the lining" and we sent her to the hospital where the equipment was available as we did not have the supplies to complete the wound V.A.C. dressing change. During an interview on 5/9/23 at 3:15 p.m., the alternate administrator reviewed the expectation of the agency that the DON review for all necessary treatment supplies and DME. In continued interview, at approximately 3:30 p.m., the DON stated he had needed to call the physician regarding discharge orders to clarify the wound V.A.C. dressing changes and supplies; however, acknowledged this conversation had not been documented and the supplies discussed were not included within the Plan of Care. 2. On 5/8/23, a review of Patient #5's record revealed a start of care date of 12/10/22. According to the plan of care for the certification period dated 2/8/23 to 4/8/23, Patient #5 received SN visits one time every sixty days for continuation of care and HHA supervision; and HHA visits for twenty eight hours for one week, forty nine hours for eight weeks, and three hours PRN for assistance with ADLs as indicated by primary diagnosis of bilateral sensorineural hearing loss. a. The agency failed to include all of Patient #5's diagnoses on the plan of care. Specifically, the agency did not include Autism Spectrum Disorder in the listed diagnoses. Review of a Visit Intervention note included in the SOC assessment signed by the DON on 12/10/22 stated, "The patient requires services of a Home Health Aide (HHA) to provide or assist with personal care and ADLs due to autism spectrum disorder." Review of the Plan of Care dated 2/8/23 and signed by the DON showed the diagnosis of sensorineural hearing loss and nocturnal enuresis. There was no evidence the plan of care included autism spectrum disorder. During an interview on 5/10/23 at 2:28 p.m., the administrator stated that individualized plans of care accurately reflected the consumers' current condition and updated diagnoses. The administrator stated plans of care were updated before any recertifications. However, Patient #5's care plan did not accurately convey an autism diagnosis. Based on interview and record review the agency failed to include all pertinent information on the plan of care. Specifically, the plan of care was missing all wound care orders and diagnoses in 2 of 2 discharged patient records reviewed (Patients #4, and #5). Findings include: 1. On 5/8/23, a review of Patient #4's record revealed a 5/4/22 start of care date. According to a plan of care for certification period dated 3/9/23 to 5/7/23, Patient #4 received skilled nursing (SN) visits one hour a week for nine weeks for wound care and catheter change every other week and as needed (PRN) for catheter dislodgement, occlusion or malfunction; and a home health aide (HHA) for twenty eight hours per week for eight weeks and sixteen hours for one week for assistance with activities of daily living (ADLs) related to the diagnosis of neuromyelitis optica, unstageable pressure ulcer of sacral region, unstageable pressure ulcer of left heel, Type 1 diabetes mellitus with diabetic neuropathy and thrombocytopenia. a. The agency failed to include all of Patient #4's wound interventions on the Plan of Care in order for the registered nurse (RN) to know what wound care was required. Review of the Plan of Care dated and signed 3/24/23 by the director of nursing (DON) revealed the agency was to provide wound care to Patient #4's left heel, buttock and sacrum and there were only three wounds listed. The Plan of Care failed to include all of Patient #4's wounds to be assessed and cared for by the agency according to the resumption of care assessment performed on 3/24/23. Review of the resumption of care assessment dated 3/24/23 completed by the DON revealed Patient #4 had one surgical wound, four or more stasis ulcers, one stage 2 pressure ulcer, four stage three pressure ulcers, one stage 4 pressure ulcer and four stage 1 pressure ulcers for a total of at least 15 wounds. There was no evidence to show the additional 12 wounds were included on the Plan of Care developed from this assessment in order for the RN to assess and care for all of Patient #4's wounds. During an interview on 5/9/23 at approximately 3:30 p.m., the DON stated when completing a comprehensive assessment, all information is required to be accurate and updated to reflect the patients' current status. The DON reviewed the recertification assessment, dated 3/9/23 and the ROC assessment completed on 3/24/23 and acknowledged the ROC assessment and the recertification assessment contained primarily the same information; however, the ROC assessment additionally included documentation from hospitalization and wound care dressing change on 3/23/23. The DON acknowledged the ROC assessment had not reflected all of Patient #4's wound information. b. The agency failed to include all wound V.A.C. (Vacuum Assisted Closure) related supplies required to provide care to Patient #4 on the plan of care. Review of the Plan of Care dated and signed by the DON on 3/24/23 revealed Patient #4 required a hospital bed, motorized wheelchair and Hoyer lift and no supplies were listed under the DME (durable medical equipment) and supplies section. There was no evidence to show what wound care supplies (type of sponge, canister, skin protectant, dressing kit, etc.) were required for Patient #4's wound care or that a wound V.A.C. was to be utilized. Review of hospital referral orders dated 3/23/23 showed the physician ordered wound V.A.C. dressing changes twice weekly. During an interview on 5/9/23 at 3:15 p.m., the coordinator stated that when the agency received orders it usually coordinated supplies. However, On the 3/30/23, the DON's note showed supplies were not available to provide Patient #4's wound V.A.C. dressing change, so the patient returned to the hospital. The DON admitted that on 3/30/23, he and RN #6 tried to perform the dressing change, but did not have a "spare connection to the lining" and we sent her to the hospital where the equipment was available as we did not have the supplies to complete the wound V.A.C. dressing change. During an interview on 5/9/23 at 3:15 p.m., the alternate administrator reviewed the expectation of the agency that the DON review for all necessary treatment supplies and DME. In continued interview, at approximately 3:30 p.m., the DON stated he had needed to call the physician regarding discharge orders to clarify the wound V.A.C. dressing changes and supplies; however, acknowledged this conversation had not been documented and the supplies discussed were not included within the Plan of Care. 2. On 5/8/23, a review of Patient #5's record revealed a start of care date of 12/10/22. According to the plan of care for the certification period dated 2/8/23 to 4/8/23, Patient #5 received SN visits one time every sixty days for continuation of care and HHA supervision; and HHA visits for twenty eight hours for one week, forty nine hours for eight weeks, and three hours PRN for assistance with ADLs as indicated by primary diagnosis of bilateral sensorineural hearing loss. a. The agency failed to include all of Patient #5's diagnoses on the plan of care. Specifically, the agency did not include Autism Spectrum Disorder in the listed diagnoses. Review of a Visit Intervention note included in the SOC assessment signed by the DON on 12/10/22 stated, "The patient requires services of a Home Health Aide (HHA) to provide or assist with personal care and ADLs due to autism spectrum disorder." Review of the Plan of Care dated 2/8/23 and signed by the DON showed the diagnosis of sensorineural hearing loss and nocturnal enuresis. There was no evidence the plan of care included autism spectrum disorder. During an interview on 5/10/23 at 2:28 p.m., the administrator stated that individualized plans of care accurately reflected the consumers' current condition and updated diagnoses. The administrator stated plans of care were updated before any recertifications. However, Patient #5's care plan did not accurately convey an autism diagnosis.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure qualified practitioner's documented within the patient record and authenticated physician verbal orders via signature in 6 of 6 patient records reviewed (Patients #1, #2, #3, #4, #5 and #6). Findings include: 1. On 5/8/23, a review of Patient #4's record revealed a start of care date of 5/4/22. According to a resumption of care (ROC) dated 3/24/23 for the certification period dated 3/9/23 to 5/7/23, Patient #4 received skilled nursing (SN) one hour a week for nine weeks for wound care and catheter change every other week and as needed (PRN) for catheter dislodgement, occlusion or malfunction; and a home health aid (HHA) for twenty eight hours per week for eight weeks and sixteen hours for one week for assistance with activities of daily living (ADLs) related to the primary diagnoses of neuromyelitis optica and unstageable pressure ulcer of sacral region, unstageable pressure ulcer of left heel, Type 1 diabetes mellitus with diabetic neuropathy, unspecified and thrombocytopenia. a. The agency failed to ensure qualified practitioner's documented all physician verbal orders within the patient record and authenticated physician verbal orders with a signature for Patient #4. Review of the record revealed a plan of care (POC) for the certification period dated 3/9/23 to 5/7/23 had been faxed to Patient #4's physician for review and signature on 3/10/23. Review of the record communication notes and POC for this certification period failed to reveal a verbal order for the POC prior to the start of this recertification date on 3/9/23. Review of the record revealed Patient #4 had been admitted to the hospital between 3/13/23 to 3/23/23. Review of hospital discharge physician orders dated 3/24/23 to the agency revealed wound V.A.C. (Vacuum Assisted Closure) dressing applied to six of the eight wounds and Patient #4 required wound V.A.C. dressing changes twice weekly by SN; which were cares Patient #4 had not received prior to hospitalization. Review of the ROC assessment completed by the director of nursing (DON) after the hospitalization on 3/24/23 failed to reveal documentation the DON had contacted Patient #4's physician regarding the resumption of care following a change of condition for a verbal order to resume treatment and under a revised POC moving forward. Review of a SN visit note on 3/27/23 revealed the DON had went to Patient #4's home to complete wound care; however, had not had enough supplies to complete the wound care and therefore informed Patient #4's caregiver to call emergency services for transportation to the hospital for the wound care to be completed. Review of the SN visit note failed to reveal the DON had contacted Patient #4's physician regarding the visit and that emergency services had been contacted for the completion of wound care dressing changes. Review of Patient #4's record revealed Patient #4 had been admitted to the hospital on 3/31/23 and the agency had not been able to contact Patient #4 or an authorized representative after that date. The record revealed a discharge date of 5/8/23 from the agency after hospitalization; however, failed to reveal documentation that Patient #4's physician had been notified or that the agency had obtained a verbal order for discharge from the agency prior to 5/8/23.. Continued review of the record failed to reveal additional faxed documentation attempts, phone calls or other communication attempts to Patient #4's physician for review of the POC or discharge from the agency; therefore, the last documentation the agency had of a physician's order was a reviewed POC on 2/7/23; which was three months prior to agency discharge. During an interview on 5/9/23 at 3:30 p.m., the DON stated documentation of verbal orders and communication with physicians regarding any orders and POC review were documented within an SN visit note or communication note, however record review did not show this. Additionally, the DON stated he had contacted Patient #4's physician regarding recertification prior to 3/9/23; the hospital wound care team for clarification of wound care orders following hospital discharge on 3/23/23; contacted Patient #4's physician for POC orders following the resumption of care visit on 3/24/23 and contacted Patient #4's physician regarding utilization of emergency services for wound care on 3/27/23. The DON reviewed documentation within the record and acknowledged the record had failed to reveal documentation of orders received from physicians regarding treatment. 2. On 5/8/23, a review of Patient #2's record revealed a start of care date of 12/15/22. According to a POC for the certification period dated 4/14/23 to 6/12/23, Patient #2 received SN one time per week or nine weeks for disease process education and a HHA sixteen hours for one week, fifty-six hours for eight weeks and sixteen hours for one week for assistance with ADLs related to the primary diagnosis of hypothyroidism. a. The agency failed to ensure qualified practitioner's documented all physician verbal orders within the patient record and authenticated physician verbal orders with a signature for Patient #2. Review of the POC for the certification period dated 4/14/23 to 6/12/23 failed to reveal documentation the DON, who completed the recertification assessment from the previous certification period, had contacted Patient #2's physician for a verbal order for recertification or the POC moving forward prior to the recertification date of 4/14/23. Review of the communication notes in Patient #2's record failed to reveal documentation the DON, or other qualified practitioner, had contacted the physician for verbal orders for recertification and the POC for ongoing treatment of Patient #2. 3. On 5/8/23, a review of Patient #5's record revealed a start of care date of 12/10/22. According to a POC certification period dated 2/8/23 to 4/8/23, Patient #5 received SN one time every sixty days for continuation of care and HHA supervision; and a HHA for twenty eight hours for one week, forty nine hours for eight weeks, and three hours PRN for assistance with ADLs as indicated by primary diagnosis of bilateral sensorineural hearing loss. a. The agency failed to ensure qualified practitioner's documented all physician verbal orders within the patient record and authenticated physician verbal orders with a signature for Patient #5. Review of the POC for the certification period dated 2/8/23 to 4/8/23 failed to reveal documentation the DON, who completed the recertification assessment from the previous certification period, had contacted Patient #5's physician for a verbal order for recertification or the POC prior to the recertification date of 2/8/23. Review of the communication notes in Patient #5's record failed to reveal documentation the DON, or other qualified practitioner, had contacted the physician for verbal orders for recertification and the POC for ongoing treatment of Patient #5. Further review of the record failed to reveal documentation the DON, or other qualified practitioner, had contacted Patient #5's physician for a verbal order prior to discharge from the agency on 4/8/23. 4. On 5/8/23, a review of Patient #6's record revealed a start of care date of 1/10/23. According to a POC for the certification period dated 3/11/23 to 5/9/23, Patient #6 received SN one time every sixty days for continuation of care and a HHA supervision; and a HHA twenty hours for one week, twenty eight hours for seven weeks, and twenty hours for one week for assistance with ADLs related to limitations of function due to the primary diagnosis of cervicalgia. a. The agency failed to ensure qualified practitioner's documented all physician verbal orders within the patient record and authenticated physician verbal orders with a signature for Patient #6. Review of the POC for the certification period dated 1/10/23 to 3/10/23 failed to reveal documentation the DON, or other qualified practitioner, had contacted Patient #6's physician for verbal orders of the POC prior to treatment following the start of care assessment dated 1/10/23. Review of the POC for the certification period dated 3/11/23 to 5/9/23 failed to reveal documentation the DON, or other qualified practitioner, had contacted Patient #6's physician for a verbal order for recertification or for the POC for continued treatment prior to recertification on 3/11/23. The record additionally failed to reveal documentation Patient #6's physician had reviewed and approved the POC ending 5/9/23; therefore, the record failed to reveal a qualified practitioner had obtained a physician verbal order or written order for treatment since the start of care assessment almost five months prior to the survey. 5. On 5/8/23, a review of Patient #1's record revealed a start of care date of 6/21/22. According to a POC for the certification period dated 4/17/23 to 6/15/23, Patient #1 received SN one time per week for nine weeks for medication management and disease process education; and a HHA twelve hours for one week, sixteen hours for seven weeks, and twelve hours for one week for assistance with ADLs related to limitations of function due to the primary diagnosis of malignant neoplasm of connective and soft tissue of the lower limb including the hip. a. The agency failed to ensure qualified practitioner's documented all physician verbal orders within the patient record and authenticated physician verbal orders with a signature for Patient #1. Review of the POC for the certification period dated 2/16/23 to 4/16/23 failed to reveal a signature or documented verbal order for treatment indicating Patient #1's physician had reviewed Patient #1's POC or provided a verbal recertification order for continued treatment at the agency prior to recertification on 2/16/23. Review of the POC for the certification period dated 4/17/23 to 6/15/23 failed to reveal a signature or documented verbal order for treatment indicating Patient #1's physician had reviewed Patient #1's POC or provided a verbal recertification order for continued treatment at the agency prior to recertification on 4/17/23. Review of the communication notes between 2/1/23 to 5/9/23 failed to reveal documentation that a qualified practitioner had obtained a verbal order or written order from Patient #1's physician prior to treatment. 6. On 5/9/23, a review of Patient #3's record revealed a start of care date of 3/17/23. According to a POC certification period dated 3/11/23 to 5/9/23, Patient #3 received SN one time every sixty days for continuation of care and HHA supervision; and a HHA for four hours for one week, twenty hours for eight weeks, and four hours for one week for assistance with ADLs related to the primary diagnosis of torus fracture of the lower end of the right fibula. a. The agency failed to ensure qualified practitioner's documented all physician verbal orders within the patient record and authenticated physician verbal orders with a signature for Patient #3. Review of the record revealed on 3/15/23, Patient #3's physician provided a verbal order for SN assessment for home health care services to be provided with a start of care date of 3/17/23. Review of the record revealed on 3/18/23, the POC for the certification period dated 3/17/23 to 5/15/23 was faxed to Patient #3's physician for review; however, had failed to reveal documentation that a qualified practitioner had obtained a verbal order or written order from Patient #1's physician prior to treatment. 7. During an interview on 5/8/23 at approximately 11:30 a.m., the alternate administrator stated verbal orders were obtained by the SN case manager and were documented to include the qualified practitioner (SN) who received the order, the practitioner who provided the order, the date and time and the specifics of the order for treatment prior to treatment being provided to any patients . The alternate administrator further stated the SN contacting the physician, documented either in the SN visit note or in a communication log every attempt to communicate with the physician including verbal order or written order requests for treatment, however record review did not show this. During an interview on 5/10/23 at 12:30 p.m., the alternate administrator was asked to provide all documentation of physician communication including all phone calls, faxes, orders received, or attempts to contact the physician in the most recent two certification periods for Patients #1, #2, #3, #4, #5 and #6 for review as this information had not been revealed in the patient records. During an interview on 5/10/23 at 2:10 p.m., the alternate administrator was asked to provide all previously requested documentation to the surveyors for review as soon as possible. During an interview on 5/10/23 at 2:30 p.m., the administrator stated the agency did not complete a recertification or any treatments detailed on the POC unless the agency had received a verbal order or written order to provide the treatment. The administrator stated he was aware agency SN's had not documented verbal orders in the POC, though they had received it, and stated he would review requirements for documentation of all received orders with the agency's qualified practitioners. During an interview on 5/10/23 at approximately 3:00 p.m., the alternate administrator provided all documentation of physician communication including all phone calls, faxes, orders received, or attempts to contact the physician in the most recent two certification periods for Patients #1, #2, #3, #4, #5 and #6 that were maintained in the patient records and stated any information that was not provided for review had not been documented and therefore could not be verified as completed.

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the plan of care had been reviewed by the physician as frequently as the patient's condition or healthcare needs required but no less frequently than once every 60 days in 3 of 5 patient records reviewed who were patients of the agency for longer than 60 days at the time of the survey (Patient's #1, #4 and #6). Findings include: 1. On 5/8/23, a review of Patient #4's record revealed a start of care date of 5/4/22. According to a resumption of care (ROC) assessment dated 3/24/23 for the certification period dated 3/9/23 to 5/7/23, Patient #4 received skilled nursing (SN) one hour a week for nine weeks for wound care and catheter change every other week and as needed (PRN) for catheter dislodgement, occlusion or malfunction; and a home health aid (HHA) for twenty eight hours per week for eight weeks and sixteen hours for one week for assistance with activities of daily living (ADLs) related to the primary diagnoses of neuromyelitis optica and unstageable pressure ulcer of sacral region, unstageable pressure ulcer of left heel; Type 1 diabetes mellitus with diabetic neuropathy, unspecified and thrombocytopenia. a. The agency failed to ensure the plan of care had been reviewed by the physician as frequently as the patient's condition or healthcare needs required but no less frequently than once every 60 days for Patient #4. Review of the record for Patient #4 revealed a physician signed plan of care (POC) for the certification period dated 1/8/23 to 3/8/23 had been reviewed and signed on 2/7/23. Review of the record revealed a plan of care (POC) for the certification period dated 3/9/23 to 5/7/23 had been faxed to Patient #4's physician for review and signature on 3/10/23. Review of the record communication notes and POC for this certification period failed to reveal a verbal order for the POC prior to this certification date on 3/9/23. Additionally, review of the POC failed to reveal a signature had been obtained from Patient #4's physician to provide treatment in accordance with the POC prior to the end of the certification on 5/7/23. Review of the record revealed Patient #4 had been admitted to the hospital between 3/13/23 to 3/23/23. Review of hospital discharge physician orders dated 3/23/23 to the agency revealed wound V.A.C. (Vacuum Assisted Closure) dressing applied to six of the eight wounds and Patient #4 required wound V.A.C. dressing change twice weekly by SN. Review of the ROC assessment completed by the director of nursing (DON) after the hospitalization on 3/24/23 failed to reveal documentation the DON had contacted Patient #4's physician regarding the resumption of care following a change of condition and review of the agency's POC for treatment of Patient #4 moving forward. Review of an SN visit note on 3/27/23 revealed the DON had documented within the visit narrative Patient #4 had been seen for wound V.A.C. dressing change by two nurses, the DON and RN #6; however, were unable to achieve a full seal of wound V.A.C. due to leakage and inadequate wound V.A.C. supplies available to complete the dressing change. The DON documented communication with the hospital case management and the agency utilized emergency services for hospital admission for wound V.A.C. dressing change. The SN visit note failed to reveal documentation the DON or RN #6 had contacted Patient #4's physician regarding services attempted that day. Review of a communication note on 3/27/23 revealed the DON had documented based on SN assessment and Patient #4's condition, the hospital setting had been more appropriate and documented the hospital wound care team and physician had been notified via fax; however, failed to reveal documentation Patient #4's physician had been contacted for notification or confirmation of receipt of the fax. Review of a communication note on 3/30/23 revealed the administrator documented he spoke with Patient #4's physician's office regarding the complicated wound V.A.C. dressing change and utilization of emergency services for wound V.A.C. dressing change on 3/27/23; which was three days following the attempted wound care dressing change and six days after the ROC assessment had been completed by the DON. The administrator had documented he had requested further guidance regarding the severity of this wound not having been appropriate for home healthcare services from the physician. The record failed to reveal continued documentation with Patient #4's physician regarding referral to a higher level of care or any recommendations from the physician. Review of Patient #4's record revealed a transfer of information (TIF) regarding a hospitalization on 3/31/23 was faxed to Patient #4's physician for review on the same date of 3/31/23; however, failed to reveal documentation Patient #4's physician had been provided the ROC POC completed by the DON on 3/24/23. Review of Patient #4's record revealed a discharge date of 5/8/23 from the agency after hospitalization beginning on 3/31/23 and the agency had not been able to contact Patient #4 or authorized representative after discharge from the hospital. The record failed to reveal documentation that Patient #4's physician had been notified of the discharge from the agency. Continued review of the record failed to reveal additional faxed documentation attempts, phone calls or other communication attempts to Patient #4's physician for review of the POC or discharge from the agency; therefore, the last documentation the agency had that Patient #4's physician had reviewed the POC was on 2/7/23; which was three months prior to agency discharge. 2. On 5/8/23, a review of Patient #6's record revealed a start of care date of 1/10/23. According to the POC for the certification period dated 3/11/23 to 5/09/23, Patient #6 received SN one time every sixty days for continuation of care and HHA supervision; and a HHA twenty hours for one week, twenty eight hours for seven weeks, and twenty hours for one week for assistance with ADLs related to limitations of function due to the primary diagnosis of cervicalgia. a. The agency failed to ensure the plan of care had been reviewed by the physician as frequently as the patient's condition or healthcare needs required but no less frequently than once every 60 days for Patient #6. Review of the record revealed a POC for the certification period dated 1/10/23 to 3/10/23 had been faxed to Patient #6's physician for review and signature on 1/20/23. Review of the record communication notes and POC for this certification period failed to reveal a verbal order for the POC following SN start of care assessment on 1/10/23. Additionally, review of the POC failed to reveal a signature had been obtained from Patient #6's physician to provide treatment in accordance with the POC prior to the end of the certification on 3/10/23. Review of the record revealed a POC for the certification period dated 3/11/23 to 5/9/23 had been faxed to Patient #4's physician for review and signature on 3/11/23. Review of the record communication notes and POC for this certification period failed to reveal a verbal order for the POC prior to the recertification date on 3/11/23. Additionally, review of the POC failed to reveal a signature had been obtained from Patient #6's physician to provide treatment in accordance with the POC prior to the end of the certification on 5/9/23. Continued review of the record failed to reveal additional faxed documentation attempts, phone calls or other communication attempts to Patient #6's physician for review of the POC; therefore, Patient #6 had not had a physician review any POCs since the start of care assessment almost five months prior to the survey. 3. On 5/8/23, a review of Patient #1's record revealed a start of care date of 6/21/22. According to a POC for the certification period dated 4/17/23 to 6/15/23, Patient #1 received SN one time per week for nine weeks for medication management and disease process education; and a HHA twelve hours for one week, sixteen hours for seven weeks, and twelve hours for one week for assistance with ADLs related to limitations of function due to the primary diagnosis of malignant neoplasm of connective and soft tissue of the lower limb including the hip. a. The agency failed to ensure the plan of care had been reviewed by the physician as frequently as the patient's condition or healthcare needs required but no less frequently than once every 60 days for Patient #1. Review of the record for Patient #1 revealed a physician signed POC for the certification period dated 12/18/22 to 2/15/23 had been reviewed and signed on 2/6/23. Review of the record revealed a POC for the certification period dated 2/16/23 to 4/16/23 had been faxed to Patient #1's physician for review and signature on 2/20/23. Review of the record communication notes and POC for this certification period failed to reveal a verbal order for recertification or the POC prior to the certification date on 2/16/23. Additionally, review of the POC failed to reveal a signature had been obtained from Patient #1's physician to provide treatment in accordance with the POC prior to the end of the certification on 4/16/23. Review of the record revealed a POC for the certification period dated 4/17/23 to 6/15/23 had been faxed to Patient #1's physician for review and signature on 4/20/23. Review of the record communication notes and POC for this certification period failed to reveal a verbal order for recertification or the POC prior to the certification date on 4/17/23. Further review of the record revealed a communication note on 4/25/23 written by the administrator the the POC for this certification period had been faxed to Patient #1's physician for review; however, failed to reveal a signature or a verbal order had been obtained for the current POC. Continued review of the record failed to reveal additional faxed documentation attempts, phone calls or other communication attempts to Patient #1's physician for review of the POC(s); therefore, Patient #1 had not had a physician review any POCs since 2/6/23; which was three months prior to the survey. 4. During an interview on 5/8/23 at approximately 11:30 a.m., the alternate administrator stated the SN case manager created the POC for all patients after every assessment or change in healthcare needs and the POC was manually faxed to the patient's physician for review. The alternate administrator stated the agency had difficulty with obtaining physician signatures on patient POCs indicating the physician had reviewed and approved the POC; however, the agency continued to fax and to call the physician's office until a signature had been obtained prior to the end of the certification period. The alternate administrator further stated the SN contacting the physician documented either within the SN visit note or within a communication log every attempt to communicate with the physician to include the date and times POC's were sent for review, however record review failed to show this. During an interview on 5/10/23 at 12:30 p.m., the alternate administrator was asked to provide all documentation of physician communication including phone calls, faxes, orders received, or attempts to contact the physician in the most recent two certification periods for Patients #1, #2, #3, #4, #5 and #6 for review as this information had not been revealed in the patient records. During an interview on 5/10/23 at 2:10 p.m., the alternate administrator was asked again to provide all previously requested documentation to the surveyors for review as soon as possible. During an interview on 5/10/23 at 2:30 p.m., the administrator stated that the agency had a thirty day policy to receive a POC returned by the patient's physician to ensure the physician was informed of the agency POC; however, stated the agency had difficulty receiving reviewed POCs from patient physicians. The administrator stated if the POC had not been returned prior to the end of the certification period, the agency did not complete a recertification unless the agency received a verbal order or written order to continue to provide treatment. During an interview on 5/10/23 at approximately 3:00 p.m., the alternate administrator provided all documentation of physician communication including all phone calls, faxes, orders received, or attempts to contact the physician in the most recent two certification periods for Patients #1, #2, #3, #4, #5 and #6 that were maintained in the patient records and stated any information that was not provided for review had not been documented and therefore could not be verified as completed. There was no further evidence to show the physicians for Patients #1, #4 and #6 had reviewed and approved the POCs.

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation 484.75, SKILLED PROFESSIONAL SERVICES was out of compliance. A total of 6 clinical records were reviewed for compliance with the Condition and Standards of Skilled Professional Services. Record review revealed a pattern of failures in regard to the home health agency ensuring care and services provided met the patient's needs. Review revealed the agency had failed to continually assess patients, only provide services that were authorized, ensure coordination with all healthcare providers involved in patient care in order to ensure needs were met and failed to prepare comprehensive clinical documentation to maintain a complete patient record of all services. These failures had the potential to affect all patients served by the home health agency. Findings include: A. Based on interview and record review, the director of nursing (DON) failed to ensure clinical records contained accurate documentation of pertinent past and current findings in accordance with accepted professional standards for 1 of 1 patient records reviewed who received wound care (Patient #4). Crosswalk G716 B. Based on interview and record review, the agency failed to ensure the registered nurse (RN) communicated with all physicians involved in the plan of care and other health care practitioners (as appropriate) for 1 of 1 skilled nursing wound care patient records reviewed (Patient #4). Crosswalk G7168 C. Based on interview and record review, the agency failed to ensure nursing professional services provided care in conformance with physician's orders and as indicated in the plan of care for 1 of 1 skilled nursing wound care patient records reviewed (Patient #4). Crosswalk G710 D. Based on interview and record review, the agency failed to ensure ongoing interdisciplinary assessment by the registered nurse (RN) who failed to re-evaluate the needs of the patient for 1 of 1 patients who received wound care (Patient #4). Crosswalk G706

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 interview and record review, the agency failed to ensure ongoing interdisciplinary assessment by the registered nurse (RN) who failed to re-evaluate the needs of the patient for 1 of 1 patients who received wound care (Patient #4). Findings include: 1. The clinical record for Patient #4 was reviewed on 5/8/23. The Plan of Care for the certification period dated 3/9/23 to 5/7/23 revealed a start of care date of 5/4/22; diagnoses included neuromyelitis optica, unstageable pressure ulcer of sacral region, unstageable pressure ulcer of left heel, type 1 diabetes mellitus with diabetic neuropathy and thrombocytopenia. Plan of Care orders included skilled nursing (SN) visits once weekly for assessment, wound care and catheter change and home health aide (HHA) visits 28 hours per week for assistance with activities of daily living (ADLs). a) The RN failed to regularly assess Patient #4's needs regarding her multiple wounds. Subsequently, Patient #4 was hospitalized with more wounds than were documented by the RN. Review of the plan of care dated 1/8/23 to 3/8/23 showed Patient #4 was ordered to receive wound care once weekly, however no specific instructions were provided or the number of wounds to be cared for. Further review showed Patient #4 was diagnosed with an unstageable pressure ulcer of the sacral region and an unstageable pressure ulcer on the left heel. The physician signed and approved the plan of care on 2/7/23. Review of the plan of care dated 3/9/23 to 5/7/23 showed Patient #4 was to receive wound care once weekly for three wounds on her left heel, sacrum and buttock, however the physician never approved and signed the plan of care. Further review showed no evidence of specific instructions, instead showing wound care was performed as follows: - Left heel; "Previous dressing removed. Cleansed wound and periwound with cleanser and 4x4 gauze. Performed conservative excisional sharp debridement using scissors and forceps to remove 1 cm2 [centimeter squared] callused and lifting tissue from boggy heel exposed deeper wound underneath. Cleansed wound with wound cleaner and gauze. Unable to debride slough from wound bed as thick and adherent to wound bed. Small area of slough scored with scissors. Skin-prep to periwound. Medihoney gel to entirety of open wound bed. Covered with thick foam and secured with medipore tape." - Sacrum/L buttock; "Previous dressing removed. Cleansed full area w/ wound cleanser and 4x4 gauze using light pressure to remove previous layer of triad cream. SN may teach patient/caregiver to perform wound care." Continued review of the 3/9/23 to 5/7/23 plan of care showed measurements of Patient #4's wounds as follows: - left heel measured 1 cm by 1.2 cm by 0.8 cm; - left buttock measured 1.1 cm by 0.7 cm by 0.1 cm; and - no measurements of the sacrum wound. Review of Patient #4's record showed no evidence of any verbal or written orders authorized by the physician following the plan of care dated 1/8/23 to 3/8/23. Review of Patient #4's record showed one SN visit was conducted on 2/2/23 completed by the director of nursing (DON). The DON documented "I ask the patient to see the if there is wound in buttock since her aunt marry is doing wound care in her coccyx using to but Mepilex Border Sacrum, but patient refuses left the patient home safely." There was no evidence the DON had assessed Patient #4's wounds or addressed Patient #4's wound care needs. Further review of Patient #4's records failed to show evidence an agency RN had conducted the weekly visits to provide assessment and care to Patient #4's wounds from 1/8/23 to 3/13/23 with the exception of the 2/2/23 visit. There was no evidence the agency dispatched a RN to conduct eight visits for assessment and performance of wound care to Patient #4 during this time. Review of a communication note dated 3/13/23 completed by the office manager (Employee #9) revealed Patient #4's caregiver informed the agency Patient #4 was admitted to the hospital the evening of 3/12/23 with a heart beat issue. Review of a transfer of care assessment dated 3/14/23 completed by the DON revealed Patient #4 was admitted to the hospital with wound infection or deterioration. The DON further documented the same information from the 3/13/23 communication note. Review of a referral order dated 3/23/23 revealed Patient #4 was ordered to receive wound VAC (Vacuum Assisted Closure) dressing changes twice weekly on Mondays and Thursdays and twice weekly dressing changes to the left heel with Xeroform and Mepilex. Review of a hospital nursing note dated 3/13/23 which was attached to the 3/23/23 referral order showed Patient #4 had eight wounds the day after being admitted to the hospital as follows: - left heel measuring 2.5 cm by 2 cm; - unstageable left scapula measuring 3.7 cm by 2.5 cm; - unstageable right scapula, no measurements; - left back measuring 2 cm by 1.2 cm; - right back measuring 1 cm by 2.2 cm; - right ischium measuring 2.5 cm by 3.9 cm; - left ischium measuring 2.7 cm by 7.4 cm; and - unstageable sacral wound measuring 13.4 cm by 10.2 cm by 1.6 cm. Review of a resumption of care assessment dated 3/24/23 completed by the DON revealed the DON documented Patient #4 had one Stage 2, four Stage 3, one Stage 4, four Stage 1 and four or more stasis ulcers along with a surgical wound under the integumentary status for a total of at least 15 wounds. Further review showed the DON assessed eight wounds in the narrative section as follows: - Stage 3 left upper back measured 2.2 cm by 2 cm by 0.8 cm; - Stage 3 left lower back measured 2 cm by 1.8 cm by 0.7 cm; - Stage 3 right upper back measured 3 cm by 3 cm by 1.2 cm; - Stage 3 right lower back measured 1.8 cm by 2 cm by 0.9 cm; - Stage 4 coccyx measured 14 cm by 9 cm by 1.8 cm with 5.4 cm undermining from 7:00 to 4:00, 25% bone, 25% adipose tissue and 50% red and granulated; - Stage 4 right ischium measured 4.8 cm by 4.5 cm by 1 cm with 3 cm undermining from 2:00, bone is palpable but not visible; - Stage 4 left ischium measured 4.8 cm by 9 cm by 1.2 cm with 2 cm undermining- from 11:00 to 2:00; - left heel measured 1.8 cm by 2.2 cm by 0.1 cm Review of a SN visit note dated 3/27/23 completed by the DON revealed the DON documented Patient #4 was seen for wound VAC dressing change by two agency nurses, however the dressing change was unable to be completed due to leakage and the inability to achieve a seal. There was no skin barrier paste and the hospital case manager was contacted, however no contact was made with anyone that could help. The DON informed Patient #4's caregiver to contact emergency services to send Patient #4 back to the hospital. The DON documented two wounds on the left heel and buttock, however there was no evidence the DON had assessed or addressed Patient #4's six other wounds. Review of Patient #4's record revealed no evidence she had been seen by emergency services or taken to a hospital following the 3/27/23 SN visit. Review of a SN visit note dated 3/30/23 completed by the DON revealed the DON and another nurse again were unable to provide the wound VAC dressing change due to not successfully achieving a seal. Patient #4's caregiver called emergency services and Patient #4 was transported to the hospital. There was no evidence the DON or other nurse had assessed and addressed Patient #4's seven other wounds. During an interview on 5/9/23 at approximately 3:00 p.m., the DON stated he had been providing wound care to Patient #4's heel and back (unspecified) three times per week prior to Patient #4's primary caregiver stating she would complete all wound care instead of the agency SN, although record review failed to show these visits. The DON stated he discussed with Patient #4's primary caregiver when wound care supplies were required to complete wound care and the DON would assist in providing. The DON continued to state after Patient #4's hospitalization he went to the home to complete an assessment for resumption of care, dated 3/24/23; however, Patient #4 refused wound assessment by the DON at that time. During further interview, the DON stated himself and RN #6 met with Patient #4 in her home for wound VAC dressing change on 3/27/23; however, prior to removing the wound VAC, they discovered the wound supplies were inadequate. The DON stated himself and RN #6 attempted to re-seal the wound VAC, which was leaking, and were unable to. They called for emergency services to escort Patient #4 to the hospital for wound VAC dressing change, however there was no evidence to show this occurred. The DON stated on 3/30/23 he found the wound VAC dressing supplies at the home continued to be inadequate and utilized emergency services for transportation to the hospital for wound VAC dressing change without removal of the wound VAC to assess the wound(s). The administrator spoke with Patient #4's physician regarding admission to a higher level of care due to complexity of wound care had been too great for home healthcare. During continued interview on 5/9/23 at 4:18 p.m., the DON reviewed the resumption of care assessment completed on 3/24/23 and hospital record documentation of wound care completed inpatient on 3/23/23; which included measurements of eight wounds. The DON stated again he had not assessed these wounds on 3/24/23 during agency assessment and had utilized measurements provided within hospital documentation within the resumption of care assessment. During an interview on 5/10/23 at 1:30 p.m., RN #6 stated during the visit on 3/27/23, himself and the DON had removed the wound VAC dressing to assess the wound; however, RN #6 was not able to recall whether the DON had completed measurements of the wound(s) prior to the attempt to re-seal the wound VAC dressing and discovering dressing changes in the home were inadequate. RN #6 stated at this time he was in training and had not documented the SN visit. RN #6 stated he was not present for the wound VAC dressing change on 3/30/23 and could not speak to this visit. b) The RN failed to assess Patient #4's physical therapy (PT) needs post hospitalization as ordered on the referral. Review of a referral order dated 3/23/23 revealed the agency was ordered to have nursing assess Patient #4's PT needs. Review of a resumption of care assessment dated 3/24/23 completed by the DON revealed the DON documented Patient #4 had poor balance, atrophy and muscle weakness under the musculoskeletal section. The DON further documented Patient #4 was dependent with all ADLs. Further review showed the DON documented Patient #4's PT need was not applicable as there was no case mix group defined by the assessment. During an interview on 5/9/23 at 3:50 p.m., the DON stated the agency administrator had discussed PT order with the hospital prior to discharge and had begun to call a contracted PT to provide this service to Patient #4 following discharge. The DON stated he had addressed PT during the resumption of care assessment completed on 3/24/23 and Patient #4's primary caregiver declined agency PT as Patient #4 had a PT prior they preferred to work with. The DON stated he notified the administrator of this conversation. The DON reviewed his documentation of the resumption of care assessment and acknowledged this discussion was not documented within the visit narrative. During an interview on 5/10/23 at approximately 2:30 p.m., the administrator stated following the hospital PT order, the administrator contacted Patient #4's primary caregiver and authorized representative, who had declined receiving contracted PT services through this agency as Patient #4 had a preferred PT with another agency prior. The administrator stated he had documented this communication within a communication note; however, was not able to locate this documentation.

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 interview and record review, the agency failed to ensure nursing professional services provided care in conformance with physician's orders and as indicated in the plan of care for 1 of 1 skilled nursing wound care patient records reviewed (Patient #4). Findings include: 1. The clinical record for Patient #4 was reviewed on 5/8/23. The Plan of Care for the certification period dated 3/9/23 to 5/7/23 revealed a start of care date of 5/4/22; diagnoses included neuromyelitis optica, unstageable pressure ulcer of sacral region, unstageable pressure ulcer of left heel, type 1 diabetes mellitus with diabetic neuropathy and thrombocytopenia. Plan of Care orders included skilled nursing (SN) visits once weekly for assessment, wound care and catheter change and home health aide (HHA) visits 28 hours per week for assistance with activities of daily living (ADLs). a. The registered nurse (RN) failed to provide wound care and foley catheter change for Patient #4 according to the physician's orders. Review of the plan of care dated 1/8/23 to 3/8/23 showed Patient #4 was ordered to receive catheter change every other week and wound care once weekly, however no specific instructions were provided or the number of wounds to be cared for. Further review showed Patient #4 was diagnosed with an unstageable pressure ulcer of the sacral region and an unstageable pressure ulcer on the left heel (two wounds). The physician signed and approved the plan of care on 2/7/23. During the certification period 1/8/23 to 3/8/23, there was only one documented SN visit on 2/2/23. The DON's signed note dated 2/2/23 revealed he requested to assess Patient #4's wounds, stating Patient #4's caregiver was providing wound care to the coccyx at that time; however, the patient refused to allow the DON to assess all buttocks wounds. This same skilled nurse visit report stated that catheter changes were managed by the agency and read that the last foley catheter change was performed on 10/1/22. There was no evidence the DON had performed wound care or a catheter change as ordered on the plan of care during the visit. Review of Patient #4's record showed no evidence any other SN visits had been performed for the certification period 1/8/23 to 3/8/23. There was no evidence Patient #4 received her weekly wound care and every other week catheter changes as ordered on the plan of care, a total of eight undocumented visits. Review of Patient #4's record showed no evidence of any verbal or written orders authorized by the physician between 1/8/23 to 3/8/23 which indicated any changes from the plan of care were ordered. Review of a referral order dated 3/23/23, following a hospitalization between 3/13/23 and 3/23/23, revealed Patient #4 was ordered to receive wound V.A.C. (Vacuum Assisted Closure) dressing changes twice weekly on Mondays and Thursdays and twice weekly dressing changes to the left heel with Xeroform and Mepilex. Hospital discharge orders stated to continue foley catheter changes as per physician order prior to hospitalization and noted the last foley catheter change was completed on 3/13/23. Review of a resumption of care assessment dated 3/24/23 completed by the DON revealed the DON documented Patient #4 had one Stage 2, four Stage 3, one Stage 4, four Stage 1 and four or more stasis ulcers along with a surgical wound under the integumentary status for a total of at least 15 wounds. There was no evidence to show wound care or catheter change was performed during the visit. Further review showed the DON assessed eight wounds in the narrative section as follows: - Stage 3 left upper back measured 2.2 cm by 2 cm by 0.8 cm; - Stage 3 left lower back measured 2 cm by 1.8 cm by 0.7 cm; - Stage 3 right upper back measured 3 cm by 3 cm by 1.2 cm; - Stage 3 right lower back measured 1.8 cm by 2 cm by 0.9 cm; - Stage 4 coccyx measured 14 cm by 9 cm by 1.8 cm with 5.4 cm undermining from 7:00 to 4:00, 25% bone, 25% adipose tissue and 50% red and granulated; - Stage 4 right ischium measured 4.8 cm by 4.5 cm by 1 cm with 3 cm undermining from 2:00, bone is palpable but not visible; - Stage 4 left ischium measured 4.8 cm by 9 cm by 1.2 cm with 2 cm undermining- from 11:00 to 2:00; - left heel measured 1.8 cm by 2.2 cm by 0.1 cm Review of the SN visit note dated 3/27/23 and completed by the DON revealed the DON completed a home visit in order to change Patient #4's wound V.A.C. dressing change; however, due to inadequate supplies and inability to establish a seal on the wound V.A.C., the DON was unable to complete the dressing change. The DON requested Patient 4's caregiver call emergency services for transport of Patient #4 to the hospital due to their inability to establish a seal on the wound V.A.C. There was no evidence the DON had performed wound care to all of Patient #4's wounds, including the wounds which had not required the wound V.A.C., or a catheter change as ordered by the physician. Review of SN visit note dated 3/30/23 completed by the DON revealed the DON and RN #6 were unable to provide the wound V.A.C. dressing change due to not successfully achieving a seal. The DON called emergency services for Patient #4 to be transported to the hospital. There was no evidence the DON or RN #6 had performed wound care or a catheter change for Patient #4. During an interview on 5/9/23 at approximately 3:00 p.m., the DON stated himself and RN #6 met with Patient #4 in her home for a wound V.A.C. dressing change on 3/27/23; however, prior to removing the wound V.A.C.,they discovered the wound supplies were inadequate. The DON stated himself and RN #6 attempted to re-seal the wound V.A.C., which was leaking, and were unable to. They called for emergency services to escort Patient #4 to the hospital for a wound V.A.C. dressing change, however there was no evidence to show this transport occurred. During an interview with the DON on 5/9/23 at 3:09 p.m., he stated that he had been performing wound care for Patient #4's wounds located on her heels and her back, three times weekly and that once they were healed he turned the cares over to Patient #4's caregiver. The DON was not able to recall at what time these wounds were healed and cares turned over ot Patient #4's caregiver. During this same interview at approximately 3:30 p.m., the DON admitted that during his 3/30/23 visit, he assessed the wound; however, when he attempted to do the wound V.A.C. dressing change he was unsuccessful due to lacking the supplies needed to complete the dressing change. During an interview on 5/9/23, the DON stated that a scheduled virtual meeting on 3/28/23 with the hospital physician regarding their unsuccessful wound V.A.C. dressing change was canceled. The DON stated that he notified Patient #4's primary physician of the agency's decision to decline providing further services for Patient #4 citing a lack of supplies and skilled RNs, however there was no verification that the physician had received or acknowledged this communication. There was no evidence the RN had coordinated with the physician regarding declining further services for Patient #4 or attempts to obtain supplies to perform the wound care.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on interview and record review, the director of nursing (DON) failed to ensure clinical records contained accurate documentation of pertinent past and current findings in accordance with accepted professional standards for 1 of 1 patient records reviewed who received wound care (Patient #4). Findings include: 1. The clinical record for Patient #4 was reviewed on 5/8/23. The Plan of Care for the certification period dated 3/9/23 to 5/7/23 revealed a start of care date of 5/4/22; diagnoses included neuromyelitis optica, unstageable pressure ulcer of sacral region, unstageable pressure ulcer of left heel, type 1 diabetes mellitus with diabetic neuropathy and thrombocytopenia. Plan of Care orders included skilled nursing (SN) visits once weekly for assessment, wound care and catheter change and home health aide (HHA) visits 28 hours per week for assistance with activities of daily living (ADLs). a. Clinical record review revealed the registered nurse (RN) failed to ensure documentation accurately reflected Patient #4's current condition on the plan of care. Review of the plan of care dated 3/9/23 to 5/7/23 showed Patient #4 was to receive wound care once weekly for three wounds on her left heel, sacrum and buttock, however the physician never approved and signed the plan of care nor had an agency staff. Further review showed no evidence of specific instructions, instead showing wound care was performed as follows: "SN to perform wound care to L heel, B buttock, and sacrum. L Heel Measurements: 1.0 x 1.2 x 0.8 cm Puffy pink base filled w/ 30% thick yellow slough to center of wound, minimal drainage, no odor. L Buttock and Sacrum. Measurements: 1.1 x 0. 7 x 0.1 cm Shallow open wound to L buttock just lateral to gluteal fold, no drainage or odor. Surrounding areas with scattered but blanchable spots. Fully healed areas of previous stage 2 ulcers. Wound Care Interventions: L heel: Previous dressing removed. Cleansed wound and periwound with cleanser and 4x4 gauze. Performed conservative excisional sharp debridement using scissors and forceps to remove 1 cm2 callused and lifting tissue from boggy heel exposed deeper wound underneath. Cleansed wound again with wound cleanser and gauze. Unable to debride slough from wound bed as thick and adherent to wound bed. Small area of slough scored with scissors. Skin-prep to periwound. Medihoney gel to entirety of open wound bed. Covered with thick foam and secured w/medipore tape. Sacrum/L buttock: Previous dressing removed. Cleansed full area with wound cleanser and 4x4 gauze using light pressure to remove previous layer of triad cream. SN may teach patient/caregiver to perform wound care. SN indicated for wound care management based on physician orders due to the inherent complexity of the wound or no able/willing caregiver to perform wound care. SN to instruct patient/caregiver on wound care performance and assess wound progression or decline. SN to assess genitourinary status, identify any signs and symptoms of impaired genitourinary function. SN to instruct patient on disease process, including who to contact if signs and symptoms persist or worsen as well as dietary, hydration measures and medication management where indicated." Review of a subsequent plan of care for the period 3/9/23 to 5/7/23 signed by the DON on 3/24/23 which was developed following a hospitalization and resumption of care on 3/24/23 revealed the DON documented the exact same care as on the previous plan of care despite Patient #4 now having 15 or more wounds with differing measurements. The DON failed to document the new wounds and Patient #4's current condition, instead documenting: "SN to perform wound care to L heel, B buttock, and sacrum.L Heel Measurements: 1.0 x 1.2 x 0.8 cm Puffy pink base filled w/ 30% thick yellow slough to center of wound, minimal drainage, no odor. L Buttock and Sacrum. Measurements: 1.1 x 0. 7 x 0.1 cm Shallow open wound to L buttock just lateral to gluteal fold, no drainage or odor. Surrounding areas with scattered but blanchable spots. Fully healed areas of previous stage 2 ulcers. Wound Care Interventions: L heel: Previous dressing removed. Cleansed wound and periwound with cleanser and 4x4 gauze. Performed conservative excisional sharp debridement using scissors and forceps to remove 1 cm2 callused and lifting tissue from boggy heel exposed deeper wound underneath. Cleansed wound again with wound cleanser and gauze. Unable to debride slough from wound bed as thick and adherent to wound bed. Small area of slough scored with scissors. Skin-prep to periwound. Medihoney gel to entirety of open wound bed. Covered with thick foam and secured w/medipore tape. Sacrum/L buttock: Previous dressing removed. Cleansed full area with wound cleanser and 4x4 gauze using light pressure to remove previous layer of triad cream. SN may teach patient/caregiver to perform wound care. SN indicated for wound care management based on physician orders due to the inherent complexity of the wound or no able/willing caregiver to perform wound care. SN to instruct patient/caregiver on wound care performance and assess wound progression or decline. SN to assess genitourinary status, identify any signs and symptoms of impaired genitourinary function. SN to instruct patient on disease process, including who to contact if signs and symptoms persist or worsen as well as dietary, hydration measures and medication management where indicated." During an interview on 5/9/23 at 2:53 p.m., the DON stated that while he had not assessed or debrided these wounds as his documentation indicated, he felt it necessary to utilize measurements provided by hospital documentation within his resumption of care assessment in order to "embed" the hospital's information in his documentation for Patient #4. The DON acknowledged that in addition to charting the same care as the hospital, he did not accurately, thoroughly or consistently document his own wound care leading up to, during and after Patient #4's hospitalizations. b. The RN failed to document the provision of care to Patient #4. During an interview on 5/9/23 at 3:09 p.m., the DON stated he had been working with Patient #4 for about a year, providing wound care on her heel(s) and back, three times per week until all her wounds were healed and Patient #4's caregiver said she would take over all wound care. However, there was no documentation of the DON providing wound care; no documentation that wound care supplies were ordered and no evidence supporting the DON's assertion that Patient #4's wounds were healed. Review of SN visit notes from 1/8/23 to 3/8/23 revealed the DON completed one visit on 2/2/23, however there was no documentation completed by the DON regarding the other eight ordered visits or the 26 visits the DON stated he performed. Review of the 2/2/23 SN visit note completed by the DON revealed the DON documented "I ask the patient to see the if there is wound in buttock since her aunt marry is doing wound care in her coccyx using to but Mepilex Border Sacrum, but patient refuses left the patient home safely." There was no evidence the DON had assessed Patient #4's wounds, performed Patient #4's wound care or completed a catheter change. Review of a SN visit note dated 3/27/23 completed by the DON revealed the DON documented that Patient #4 was seen for wound V.A.C. dressing change by two agency nurses, however the dressing change was unable to be completed due to leakage and the inability to achieve a seal, stating there was no skin barrier paste.The DON informed Patient #4's caregiver to call for emergency transport to send Patient #4 back to the hospital. There was no evidence Patient #4's wounds had been assessed, wound care performed to the left heel or wounds not treated by the wound V.A.C. and/or a catheter change. Review of a SN visit note dated 3/30/23 completed by the DON revealed the DON and another nurse again were unable to provide the wound V.A.C. dressing change due to not successfully achieving a seal. Patient #4's caregiver called emergency services and Patient #4 was transported to the hospital. There was no evidence Patient #4's wounds were assessed, wound care performed or a catheter change was completed. During an interview on 5/9/23 at 3:30 p.m., the DON stated documentation of verbal orders and communication with physicians regarding any orders and POC review were documented within an SN visit note or communication note. Additionally, the DON stated he had contacted Patient #4's physician regarding recertification Plan of Care prior to 3/9/23, the hospital wound care team for clarification of wound care orders following hospital discharge on 3/23/23; contacted Patient #4's physician for POC orders following the resumption of care visit on 3/24/23 and contacted Patient #4's physician regarding utilization of emergency services for wound care on 3/27/23. The DON reviewed documentation within the record and acknowledged the record had failed to reveal documentation of orders received from physicians regarding treatment.

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 interview and record review, the agency failed to ensure the registered nurse (RN) communicated with all physicians involved in the plan of care and other health care practitioners (as appropriate) for 1 of 1 skilled nursing wound care patient records reviewed (Patient #4). Findings include: 1. The clinical record for Patient #4 was reviewed on 5/8/23. The Plan of Care for the certification period dated 3/9/23 to 5/7/23 revealed a start of care date of 5/4/22; diagnoses included neuromyelitis optica, unstageable pressure ulcer of sacral region, unstageable pressure ulcer of left heel, type 1 diabetes mellitus with diabetic neuropathy and thrombocytopenia. Plan of Care orders included skilled nursing (SN) visits once weekly for assessment, wound care and catheter change and home health aide (HHA) visits 28 hours per week for assistance with activities of daily living (ADLs). a. The RN failed to coordinate with the physician regarding Patient #4's wounds. Review of the plan of care dated 1/8/23 to 3/8/23 showed Patient #4 was ordered to receive wound care once weekly, however no specific instructions were provided or the number of wounds to be cared for. Further review showed Patient #4 was diagnosed with an unstageable pressure ulcer of the sacral region and an unstageable pressure ulcer on the left heel (two wounds). The physician signed and approved the plan of care on 2/7/23, however there was no evidence the RN coordinated with the physician regarding Patient #4's wounds and to obtain specific wound care instructions for the care of those wounds. Review of the plan of care dated 3/9/23 to 5/7/23 showed Patient #4 was to receive wound care once weekly for three wounds on her left heel, sacrum and buttock (three wounds), however the physician never approved and signed the plan of care. Further review showed no evidence the RN coordinated with the physician regarding an additional wound, the status of Patient #4's wounds or to obtain orders with specific instructions for the care of those wounds. Continued review of the 3/9/23 to 5/7/23 plan of care showed measurements of Patient #4's wounds as follows: - left heel measured 1 cm by 1.2 cm by 0.8 cm; - left buttock measured 1.1 cm by 0.7 cm by 0.1 cm; and - no measurements of the sacrum wound. Review of Patient #4's record showed no evidence of any verbal or written orders authorized by the physician following the plan of care dated 1/8/23 to 3/8/23. Further review showed the agency had faxed plans of care and communication notes to the physician, however there was no verification that the physician had reviewed the communication. There was no evidence the RN had coordinated with the physician regarding the status of Patient #4's wounds or to obtain specific wound care orders for the care of her wounds. Review of SN visit notes from 1/8/23 to 3/30/23 revealed the director of nursing (DON) conducted three visits on 2/2/23, 3/27/23 and 3/30/23. There was no evidence the DON had assessed Patient #4's wounds in order to coordinate the wound status or obtain specific wound care instructions from the physician. Further review of Patient #4's records failed to show evidence an agency RN had conducted the weekly visits to provide assessment and care to Patient #4's wounds from 1/8/23 to 3/13/23 with the exception of the 2/2/23 visit. There was no evidence the agency dispatched a RN to conduct eight visits for assessment and performance of wound care to Patient #4 in order to coordinate with the physician regarding the status of Patient #4's wounds. Furthermore, there was no evidence the physician was contacted regarding the RN not providing the ordered weekly visits. From 1/8/23 to 3/13/23. Review of a communication note dated 3/13/23 completed by the office manager (Employee #9) revealed Patient #4's caregiver informed the agency Patient #4 was admitted to the hospital the evening of 3/12/23 with a heart beat issue. Review of a transfer of care assessment dated 3/14/23 completed by the DON revealed Patient #4 was admitted to the hospital with wound infection or deterioration. The DON further documented the same information from the 3/13/23 communication note. There was no evidence the physician was contacted regarding Patient #4's hospital admission. Review of a referral order dated 3/23/23 revealed Patient #4 was ordered to receive wound V.A.C. (Vacuum Assisted Closure) dressing changes twice weekly on Mondays and Thursdays and twice weekly dressing changes to the left heel with Xeroform and Mepilex. Review of a hospital nursing note dated 3/13/23 which was attached to the 3/23/23 referral order showed Patient #4 had eight wounds the day after being admitted to the hospital and four days after the DON last documented Patient #4 had three wounds on the 3/9/23 plan of care. Patient #4's wounds were documented as follows: - left heel measuring 2.5 cm by 2 cm; - unstageable left scapula measuring 3.7 cm by 2.5 cm; - unstageable right scapula, no measurements; - left back measuring 2 cm by 1.2 cm; - right back measuring 1 cm by 2.2 cm; - right ischium measuring 2.5 cm by 3.9 cm; - left ischium measuring 2.7 cm by 7.4 cm; and - unstageable sacral wound measuring 13.4 cm by 10.2 cm by 1.6 cm. Review of a resumption of care assessment dated 3/24/23 completed by the DON revealed the DON documented Patient #4 had one Stage 2, four Stage 3, one Stage 4, four Stage 1 and four or more stasis ulcers along with a surgical wound under the integumentary status for a total of at least 15 wounds. Further review showed the DON assessed eight wounds in the narrative section as follows: - Stage 3 left upper back measured 2.2 cm by 2 cm by 0.8 cm; - Stage 3 left lower back measured 2 cm by 1.8 cm by 0.7 cm; - Stage 3 right upper back measured 3 cm by 3 cm by 1.2 cm; - Stage 3 right lower back measured 1.8 cm by 2 cm by 0.9 cm; - Stage 4 coccyx measured 14 cm by 9 cm by 1.8 cm with 5.4 cm undermining from 7:00 to 4:00, 25% bone, 25% adipose tissue and 50% red and granulated; - Stage 4 right ischium measured 4.8 cm by 4.5 cm by 1 cm with 3 cm undermining from 2:00, bone is palpable but not visible; - Stage 4 left ischium measured 4.8 cm by 9 cm by 1.2 cm with 2 cm undermining- from 11:00 to 2:00; - left heel measured 1.8 cm by 2.2 cm by 0.1 cm Continued review of the 3/24/23 assessment showed no evidence the DON contacted the physician regarding Patient #4's care having been resumed by the agency, the increase in wounds, the status of the wounds and the care to be provided. Review of a SN visit note dated 3/27/23 completed by the DON revealed the DON documented Patient #4 was seen for wound V.A.C. dressing change by two agency nurses, however the dressing change was unable to be completed due to leakage and the inability to achieve a seal. There was no skin barrier paste and the hospital case manager was contacted. The DON informed Patient #4's caregiver to contact emergency services to send Patient #4 back to the hospital. There was no evidence Patient #4's physician had been contacted regarding the inability to perform wound care, the status of Patient #4's wounds, the lack of supplies needed to perform the wound care or that Patient #4 was to go back to the hospital. Review of Patient #4's record revealed no evidence she had been seen by emergency services or taken to a hospital following the 3/27/23 SN visit. Review of a SN visit note dated 3/30/23 completed by the DON revealed the DON and another nurse again were unable to provide the wound V.A.C. dressing change due to not successfully achieving a seal. Patient #4's caregiver called emergency services and Patient #4 was transported to the hospital. The DON documented the physician was notified via facsimile although there was no evidence to show what the physician was informed of. There was no evidence the DON or other nurse had assessed Patient #4's wounds and coordinated with the physician regarding the status of the wounds, the inability to perform wound care, the lack of supplies or that Patient #4 was sent to the hospital. During an interview on 5/9/23 at approximately 3:00 p.m., the DON stated himself and RN #6 met with Patient #4 in her home for wound V.A.C. dressing change on 3/27/23; however, prior to removing the wound V.A.C., they discovered the wound supplies were inadequate. The DON stated himself and RN #6 attempted to re-seal the wound V.A.C., which was leaking, and were unable to. They called for emergency services to escort Patient #4 to the hospital for wound V.A.C. dressing change, however there was no evidence to show this occurred. The DON stated on 3/30/23 he found the wound V.A.C. dressing supplies at the home continued to be inadequate and utilized emergency services for transportation to the hospital for wound V.A.C. dressing change without removal of the wound VAC to assess the wound(s). The administrator spoke with Patient #4's physician regarding admission to a higher level of care due to complexity of wound care had been too great for home healthcare. During an interview on 5/10/23 at 1:30 p.m., RN #6 stated during the visit on 3/27/23, himself and the DON had removed the wound V.A.C. dressing to assess the wound; however, RN #6 was not able to recall whether the DON had completed measurements of the wound(s) prior to the attempt to re-seal the wound V.A.C. dressing and discovering dressing changes in the home were inadequate, however the DON had previously stated the wound V.A.C. dressing had not been removed prior to them noticing the inadequate supplies. RN #6 stated at this time he was in training and had not documented the SN visit. RN #6 stated he was not present for the wound V.A.C. dressing change on 3/30/23 and could not speak to this visit. During continued interview on 5/9/23 at 4:18 p.m., the DON reviewed the resumption of care assessment completed on 3/24/23 and hospital record documentation of wound care completed inpatient on 3/23/23; which included measurements of eight wounds. The DON stated again he had not assessed these wounds on 3/24/23 during agency assessment and had utilized measurements provided within hospital documentation for the resumption of care assessment. During an interview on 5/9/23 at 3:30 p.m., the DON stated documentation of verbal orders and communication with physicians regarding any orders and POC review were documented within an SN visit note or communication note. Additionally, the DON stated he had contacted Patient #4's physician regarding recertification Plan of Care prior to 3/9/23, the hospital wound care team for clarification of wound care orders following hospital discharge on 3/23/23; contacted Patient #4's physician for POC orders following the resumption of care visit on 3/24/23 and contacted Patient #4's physician regarding utilization of emergency services for wound care on 3/27/23. The DON reviewed documentation within the record and acknowledged the record had failed to reveal documentation of orders received from physicians regarding treatment.