Every finding on record at Global Nursing Services Inc

Purpose: Recertification Survey Entrance Date: 9/19/2022 Census: Licensed and Certified - 57 patients The agency was in compliance with 42 CFR Part 484.22, Emergency Preparedness requirements for Home Health Agencies.

Purpose: Recertification Survey Entrance Date: 9/19/2022 Census: Licensed and Certified - 57 patients

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to accurately reflect the patient's current health status in the comprehensive assessments for 1 (#2) of 1 patient record reviewed where the patient required dialysis and wound care. The failure placed the agency's patients at risk that their individualized medical, nursing, and discharge needs would not be identified and incorporated into the Plan of Care that could result in a negative patient outcome. Patient #2: Record Review of Patient #2's clinical record revealed a Plan of Care dated 5/21/2022 to 7/19/2022. The Plan of Care indicated that Patient #1 started on the agency's services on 5/21/2022. The Plan of Care listed Encounter for Change or Removal of Surgical Wound Dressing, Chronic Kidney Disease Stage 4 Severe, and Dependence on Renal Dialysis as diagnoses. Registered Nurse C conducted a Start of Care Comprehensive assessment on 5/21/2022. Registered Nurse C documented that Patient #2 had intravenous access (type of intravenous access, location, assessment of site, and reason were not included), had an arteriovenous shunt (location, site assessment not included), and had pressure ulcers to the right heel, outer aspect of the right foot, sacral, right flank, and a surgical wound to right groin area/right upper thigh. The right groin area wound had a wound vacuum that was not due for change. Registered Nurse C did not include wound measurements or wound assessment for the pressure wounds. Licensed Vocational Nurse D conducted a skilled nurse visit on 5/25/2022. Licensed Vocational Nurse D documented that Patient #2 had a shunt with bruit and thrill present in the left arm, had an intravenous central line in the right chest, and had been receiving dialysis through the new right inguinal port. Licensed Vocational Nurse D documented the following wounds: 1.Right Inguinal wound measured 11.5 centimeters x 3.0 centimeters x 0 (sic) centimeters with 1.3 centimeters tunneling at 2:00. 2. Right Heel wound measured 4.9 centimeters x 3.7 centimeters x 0.2 centimeters 3. Right Lateral Foot measured 3.3 centimeters x 2.0 centimeters x 0.1 centimeters 4. Right Great Toe wound measured 1.0 centimeters x 0.5 cm x 0 centimeters Registered Nurse C conducted a Recertification Comprehensive assessment on 7/19/2022. Registered Nurse C documented that Patient #2 had intravenous access (type of intravenous access, location, assessment of site, and reason were not included), had a arteriovenous shunt (location, site assessment not included), and had pressure ulcers to the right heel, outer aspect of the right foot, wound to right groin area, and a wound to the right upper thigh. Registered Nurse C did not include wound measurements or assessments of the wound in the comprehensive assessment. A home visit was conducted on 9/21/2022 to Patient #2's home. Patient #2's family member was interviewed due to Patient #2 had dementia. Patient #2's family member informed the surveyor that Patient #2 had a wound to the right heel; Patient #2 went to dialysis three times a week; and Patient #2 received dialysis through the central line in the right chest. During an interview with Registered Nurse C on 9/22/2022 at approximately 9:30 a.m., Registered Nurse C was asked about Patient #2's wounds, the central line in the right chest, and Patient #2's dialysis access site, and whether Patient #2 received dialysis through a shunt in the left arm. Registered Nurse C stated that, "the left arm was used a long time ago. They attempted to place dialysis access in the right inguinal area, but it was not successful." Registered Nurse C informed the surveyor that Patient #2 did not have dialysis through the inguinal port but had it through the central line in the right chest. Registered Nurse C informed the surveyor that Registered Nurse C was not aware that the wound assessments were not included in the comprehensive assessments. Registered Nurse C stated that Patient #2 had a "lot of changes." During an interview on 9/20/2022 at approximately 2:00 p.m. with the Administrator and Director of Nursing, the surveyor asked about the agency's policy regarding the comprehensive assessments when patients had intravenous accesses, wounds, and dialysis. The Administrator informed the surveyor that those should be included in the comprehensive assessment, sites assessed, and wounds measured. The Director of Nursing stated, "Wounds should be measured weekly." The Administrator and Director of Nursing did not dispute that the comprehensive assessments did not include wound measurements, wound assessments, intravenous access location and site assessment, dialysis access location and site assessment. The agency had a policy titled "Initial Patient/Client Comprehensive Assessment," labeled PE.3 with a review date of 1/1/2022. The Policy read in part: "Purpose To identify data collection needed on multiple aspects of the patient/client and the environment as a basis for individualized interventions and outcome-oriented care. Policy Each patient/client will receive a specific comprehensive assessment...The assessment will accurately reflect the patient's/client's current health status...Procedure...VI. The comprehensive assessment will include, but not limited to the following: A. The patient's/client's current health, psychosocial, functional, and cognitive status...D. The patient's/client's medical, nursing, rehabilitative, social, and discharge planning needs...I. Incorporation of the current version of the Outcome and Assessment Information Set items...to include...integumentary status...elimination status..." The agency had a policy titled "Medical Record Content," labeled IM.5 with a revision date of 2/1/2029. The policy read in part: "Purpose To ensure each medical record, whether paper, electronic or combination, contains complete information which identifies the patient/client, describes problems and needs of the patient/client, justifies patient/client care, and accurately describes care provided, results, significant events and continuity among disciplines. Policy I. The agency will initiate and maintain a clinical record containing past and current information for every patient/client accepted by the Agency and receiving home health services....Procedure I. Each medical record will contain the following...B. The patient's/client's needs information, including the current comprehensive assessment...which reflect...4. Physical assessment..."