Every finding on record at Goodwin Home Healthcare Services Inc.

An Emergency Preparedness recertification survey was initiated on 09/10/2025. Census: Licensed and Certified- 2 Licensed Home Health- 0 Personal Assistance Services- 0 Agency remained in compliance with Conditions of Participation for Emergency Preparedness, no deficiencies were cited.

A recertification survey was initiated on 09/10/2025. Census: Licensed and Certified- 2 Licensed Home Health- 0 Personal Assistance Services- 0 Acronyms: POC- Plan of Care SOC- Start of Care SN- skilled nurse DON- Director of Nurses LVN- Licensed Vocational nurse RN- Registered nurse

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on record review, observation and interview, the agency failed to integrate services to ensure agency staff documented communication with the wound care provider, Identifier B, regarding the patient’s request to change the wound care frequency for 1 (Patient #1) of 2 active records reviewed. The failure to integrate services and document coordination of care regarding wound care frequency, potentially placed the patient at risk of infection and poor wound healing outcome. FINDINGS INCLUDE: Patient #1: Record review revealed a POC dated 08/04/2025 to 10/02/2025 with a SOC date 02/05/2025. The POC included in the section titled, “… Orders For Discipline And Treatments, SN Frequency: 2WK9 (twice a week for nine weeks), Beginning week of 08/04/2025 …” A comprehensive reassessment completed by RN C on 08/01/2025 included on page 24, “… MEDICAL NECESSITY, … Patient (Client) is going to the (wound clinic) 1 (time) a weekly and SN to perform wound care 2 (times) week, …” Review of the patient record revealed LVN A provided wound care at home visits on the following dates: 08/04/2025; 08/12/2025; 08/18/2025; 09/02/2025 and 09/08/2025. The SN visited the patient once weekly. A provider’s order dated 09/09/2025 stated, “Increase home health wound care to twice weekly nursing visits.” During a home visit on 09/11/2025, Patient #1 reported to the surveyor that wound care visits had increased from 2 to 3 times a week (increased to twice weekly from the agency and continued once weekly from the wound care provider). The patient also stated wound care was done 09/10/2025. Wound care was not provided to the patient during the surveyor’s home visit. Review of the entire patient record revealed no documented coordination of care with the patient’s wound care provider, Identifier B, regarding SN visits changed to once a week performed by the agency for Patient #1. In a phone interview with LVN A on 09/16/2025 at 10:30 AM, the surveyor asked about the care and service frequency provided to Patient #1. LVN A stated the patient received SN visits once a week for wound care. The surveyor asked why wound care was not provided twice a week by the agency, as noted in the POC. LVN A stated she had been told the patient wanted the nurses (from the agency) to only visit once a week. But Identifier B had recently ordered agency SN visits twice a week and the wound care provider would continue to see the patient once weekly. In an interview with the DON on 09/16/2025 at 1:00 PM, the surveyor asked who was responsible to coordinate care with Identifier B. The DON stated that either the nurses or care managers could coordinate. The surveyor asked about the frequency of SN visits for wound care. The DON stated at the beginning of the episode, the patient told the nurse he only wanted the nurses to come once a week and the wound care provider (Identifier B) to come once a week. The agency complied with the patient’s request and visited only once a week. The agency notified Identifier B of the patient’s request for SN visits only weekly. Last week, Identifier B increased the SN visits back to twice a week and the patient has agreed to the visit increase. The surveyor asked if there was any documentation of the patient’s request for the frequency changing or anything from Identifier B to reflect the SN visits changed to once weekly for the agency. The DON stated, “We have very good communication with the wound care provider, but unfortunately we don’t have that part documented.” Agency policy, dated 05/01/2024, quoted in part, “Monitoring Patient/Client Care/Coordination of Care, PC. 45, Purpose: To ensure coordination of patient/client care and treatment. Policy: … II. The Agency will collaborate with other organizations providing services … to ensure appropriate coordination of care… Procedure … II. When other organizations are involved in the patient’s/client’s care, … This communication will be documented in the medical record….”