Every finding on record at Gmac Pathway Inc

An Emergency Preparedness Recertification Survey was initiated on 05.12.2023 at 10:40 AM with the Alternate Administrator/Alternate Director of Nurses. Census: 8 Licensed and Certified- 0 Licensed Home Health- 0 Personal Assistance Services- 8 An exit conference was conducted on 05.24.23 at 2:30 PM with the Alternate Administrator/Alternate Director of Nurses. The preliminary findings were discussed. The agency was given an opportunity to provide additional information. The agency was found in substantial compliance with the Medicare Conditions of Participation for Emergency Preparedness.

A Recertification Survey was initiated on 05.12.2023 at 10:40 AM with the Alternate Administrator/Alternate Director of Nurses. Census: 8 Licensed and Certified- 0 Licensed Home Health- 0 Personal Assistance Services- 8 An exit conference was conducted on 05.24.23 at 2:30 PM with the Alternate Administrator/Alternate Director of Nurses. The preliminary findings were discussed. The agency was given an opportunity to provide additional information. Acronyms used: AV- arterio-venous POC- Plan of Care SOC- Start of Care SN- Skilled Nurse AA- Alternate Administrator DON- Director of Nurses S/S- signs and symptoms WNL- within normal limits

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record reviews and interview, the agency failed to ensure the patients’ plan of care was complete and included all the required elements for 1 (Patient # 3) of 2 records reviewed who received wound care and 1 (Patient #3) of 1 patient who received dialysis treatment. This failure placed the patient at risk of infection at the wound site and complications with performance of the AV shunt access when the SN did not have written wound care and AV shunt site assessment orders. FINDINGS: Definitions: AV Graft- an access made by using a piece of soft tube to join an artery and vein in your arm. Reference: National Kidney Foundation resources May 2023. According to Nursing 2021 Clinical Do’s and Don’ts: in protecting a hemodialysis fistula, the arm with a fistula should be assessed by feeling for a thrill (vibration) by palpating (gentle presses) the fistula and listening for a bruit (whoosh or heartbeat sound) by auscultating (listening to) the area with a stethoscope. This assessment is done to prevent stenosis and ensure proper functioning of the fistula. Patient #3: Record review revealed a POC dated 01/22/2021-03/22/2021 with a SOC date 01/22/2021. The POC listed the diagnosis of Pressure ulcer of sacral region, Stage 3. and SN visits were ordered daily. The POC included the following physician orders, “… SN to instruct Patient/Caregiver on wound care orders to include: location, technique, frequency, supplies, end date and proper disposal of soiled dressings. SN to perform wound care as follows: location, technique, frequency, supplies, end date and proper disposal of soiled dressings. Disposal of soiled dressings per OSHA guidelines (double bagged technique) ….” A SOC comprehensive assessment, dated 01/22/2021 included on page 13, “WOUND CARE SHEET, … #2 Sacral region, pressure ulcer, size: (in centimeters) length- 3.0, width-3.0, depth-1.5, Stage 3, surrounding skin WNL, no edema, no odor, wound bed appearance- pink.” On page 16, “… Is Patient on Dialysis? Yes.” The assessment included the patient received Hemodialysis and had an AV Graft/Fistula site and “Central Venous Catheter Access Site: L (left).” A SN visit note dated 01/23/2021 included an assessment of the Bruit (location unidentified) and the comment, “Using an aseptic technique, SN cleansed … sacral wound with sterile normal saline, SN pat dry with 4x4 guaze [sic], apply santyl ointment to wound beds as ordered. Cover with sterile 4x4 guaze [sic], secured with tape….” Review of the entire patient record revealed no physician order for wound care to the sacral region or to assess the patients’ AV graft site. In an interview with the AA/DON on 05/24/2023 at approximately 11:30 AM, the surveyor asked why the POC did not include wound care orders for the sacral region and an order for the SN to assess the patients’ AV graft site? The AA/DON stated, “there would have to be wound care orders for me to have done wound care and discontinued wound care after the wound was healed.” Surveyor asked why there were no wound care order in the patients’ electronic or paper record. The AA/DON provided additional documentation, but no wound care orders were included. The AA/DON asked to look through her emails. Surveyor allowed time for email reviews. AA/DON stated, “it was so long ago” and no wound care orders were found. No additional evidence of a physician’s order for wound care to the sacral region was provided. The surveyor asked why the POC did not include orders for a SN to assess the patients’ AV shunt. The AA/DON stated, “no reason, it’s documented on the SN notes.” The surveyor stated the SN notes documented the bruit was assessed but, not the thrill and asked why the POC did not include instructions for all SN to assess the patients’ AV shunt for bruit, thrill, and s/s of infection. AA/DON stated, “it’s not there.” Agency policy, undated, quoted in part, “PLAN OF CARE Policy 4.13, POLICY: A client is provided a service that is established and authorized in writing by a physician that is based on an evaluation of the client’s immediate and long-term needs…. PROCEDURE: … 3. The POC is established by a physician in consultation with agency staff and covers the following: … Types of services and equipment required, … Medications and treatments, … Orders, …”