Every finding on record at Green Pine Home Healthcare Services, Inc

The following reflects the findings of the California Department of Public Health during a Complaint Validation Survey. Intake No. 62615 Representing the Department of Public Health: Surveyor ID #25046, Health Facilities Evaluator Nurse Surveyor ID #44186, Health Facilities Evaluator Nurse Census: 139 Sample Size: 5 Home Visits: 2 Record Review: 2 Closed Records: 1 The following Conditions of Participation were not met: 484.55 Comprehensive Assessment of Patients 484.60 Care planning, coordination, quality of care 484.75 Skilled Professional Services

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to meet the Condition of Participation for Comprehensive Assessment of Patients as follows: 1. The HHA failed to conduct an accurate comprehensive assessments of wounds and failed to reflect in the clinical record the current wounds status for one of 5 sampled patients (Patient 1). Refer to G 526. 2. The HHA failed to update the patient's medication profile after it was clarified with the physician for one of five sampled patients (Patient 1). Refer to G 536. The cumulative effect of these systemic practices resulted in the home health agency's inability to ensure the provision of quality health.

Content of the comprehensive assessment CFR(s): 484.55(c) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency staff failed to ensure the pressure ulcers (injuries to the skin due to prolong pressure on the skin) on the left hip, mid back, and on the bilateral gluteal (buttocks) were assessed accurately to reflect current wound status, and the bilateral gluteal wounds were assessed both right and left side for one of 5 sampled patients (Patient 1). This deficient practice placed the patient at risk for delayed wound healing and infection on the wound sites. A review of Patient 1's clinical record indicated a start of care date of 12/29/2021, with diagnosis of unspecified open wound, Stage III (worsened sore and extends into the tissue beneath the skin, forming a small crater) pressure ulcer of left buttocks. A review of Patient 1's plan of care for the certification period dated 12/29/2021 through 2/26/2022, included an order for skilled nursing visits three times a week for one week, six times a week for one week, four times a week for one week, and once a week for one week to perform assessment to open wound and Stage 3 pressure ulcer of left buttock. A review of Patient 1's Outcome Assessment and Information Set (OASIS) dated 12/29/2021, indicated the patient had the following wounds: Left hip – Stage II (abrasion, blister) pressure ulcer (4 cm x 2 cm x 0.8 cm)Middle back – Stage II pressure ulcer (5 cm x 3 cm x 0.8 cm)Bilateral rectal – Stage I (redness) pressure ulcer (3 cm x 3 cm x 0.2 cm) A review of Patient 1's SN Wound Care and Wound Care Worksheet indicated following discrepancies/inconsistencies: On 12/30/2021 – SN Wound Care indicated the patient had Stage III pressure ulcer on the left hip and mid back while the Wound Care Worksheet indicated Stage II on the left hip and middle back. On 12/31/2021 - SN Wound Care indicated the patient had Stage III pressure ulcer on the left hip and mid back while the Wound Care Worksheet indicated Stage II on the left hip and middle back. On 1/3/2022 - SN Wound Care indicated the patient had Stage III pressure ulcer on the left hip and mid back while the Wound Care Worksheet indicated Stage II on the left hip and middle back. On 1/4/2022 – SN Wound Care indicated the patient had Stage II pressure ulcers on mid lower and left hip while “Addendum Page” of SN wound Care indicated Stage 3-4 pressure ulcer on the lower back. On 12/30/2021 to 1/10/2022 - SN Wound Care indicated the patient had Stage I pressure ulcer on the bilateral buttocks [3 cm x 3 cm x 0.2 cm (on 12/20/2021) to 4 cm x 3 cm x 0.3 cm (on 1/10/2022)]. There was only one measurement on each assessment, and there was no indication the measurement was the right side or the left side. On 1/8/2022, 1/9/2022, and 1/10/2022 - SN Wound Care indicated the patient had Stage I pressure ulcer on the bilateral buttocks sized 4 cm x 3 cm x 0.3 cm. However, it indicated the wound status was opened with serous drainage and fecal odor. On 5/5/2022, at 12:35 p.m., during an interview and concurrent review of the pictures on the bilateral buttocks with the Director of Patient Care Services (DPCS), she stated the pressure ulcer on the bilateral buttocks on 1/8/2022, 1/9/2022, and 1/10/2022 was at least Stage II, not Stage I and the assessment was not accurate. On 5/6/2022, at 12:40 p.m., during an interview with Licensed Vocational Nurse 1 (LVN 1), she stated she had not measured pressure ulcers on both right and left side of buttocks because they looked the same size to her, and she made mistakes that she had documented Stage I pressure ulcer on the bilateral buttocks. LVN 1 stated she should have documented as the Stage II instead of Stage I for pressure ulcers on bilateral buttocks. On 5/6/2022, at 1:45 p.m., during an interview with the DPCS, she stated the nursing staff should have assessed the pressure ulcer accurately. A review of the Transfer Summary Form (Home Care to Hospital or other Facilities) dated 1/14/2022 indicated Patient 1 was transferred to the acute hospital with diagnoses of non-healing surgical wound on the left hip and Stage 3-4 decubitus on lower back. A review of the agency’s undated “Wound Protocol” indicated staging is the assessment of the depth of tissue damage. Stage I is non-blanchable erythema of intact skin (redness). Stage II is the partial thickness skin loss involving epidermis or dermis only, superficial and may appear as blister or abrasion. A review of the agency’s policy and procedure titled “Pressure Ulcer Prevention and Managing Skin Integrity” revised in July 2020 indicated a full wound assessment, including its location, size, and description of the tissue involved, should be completed. Wound assessment should reflect current status.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the home health agency (HHA) failed to ensure the patient’s current medication profile matches the medications the patients are taking at home for two of five sampled patients (Patients 2 and 5). This deficient practice had the potential to affect the safety of patients by putting them at risk for medication error and adverse (serious) drug reactions. b. A review of Patient 5's clinical record indicated a start of care date of 03/15/22, with diagnoses that included non-pressure chronic ulcer (open sores or lesions) left foot. The plan of care ordered by the physician for the certification period of 03/15/22 through 5/13/22, indicated for the skilled nurse to visit once for a week, three times for the next week, twice a week for four weeks to instruct and assess the patient’s cardiovascular function (pertaining to the heart), neurological status (pertaining to the nerves), pain management, and medication regimen dose, indications, side effects and interactions. On 5/04/22, at 10:25 a.m., during a joint home visit with the license nurse at Patient 5's residence, Patient 5 was observed sitting on a chair and the license nurse interacting with the patient in his own dialect. On 5/04/22, at 11:00 a.m., a review of Patient 5's medications was conducted with the licensed nurse. The medication profile did not contain a new medication ordered by the patient’s physician to treat the patient’s wound on his foot. The new medication Clindamycin HCL 300mg twice daily was ordered on 4/25/2022. On 5/04/22, at 11:15 a.m., the DPCS was informed of the deficient practice and the DPCS stated the medication profile of the patient should be updated within 24 hours after a new medication was ordered by the physician. The agency's policy and procedure titled, “Medication Profile”, revised July 2013, indicated patients receiving medications will have a current, accurate medication profile in the clinical record. Medication profile will be updated for each change to reflect current medications and new and/or discontinued medications. a. A review of Patient 2's clinical record disclosed a start of care (SOC) dated 2/4/2022, with diagnoses which included Stage IV pressure ulcer of sacral region, sepsis and diabetes mellitus (DM). The Plan of Care (POC) for the certification period from 4/5/2022 to 6/3/2022, included order for the Skilled Nurse (SN) visit two times a week for 8 weeks. The SN was to assess if the patient/caregiver can verbalize an understanding of the indication for each medication, and to instruct on medication regimen dose, indication, side effects, and interactions. On 5/4/2022, at 10:40 a.m., during a joint home visit with Registered Nurse 1 (RN 1) and RN 2, Patient 2 was lying in the hospital bed and Family member 1 was next to Patient 2. At 11:45 a.m., during Patient 2's medication review with RN 1 compared with the medication profile, following was noticed. Zinc Sulfate 220 milligram (mg) – Patient did not have Zinc Sulfate at home, but it was listed in the medication profile.Docusate Sodium 100 mg – Patient did not have Docusate Sodium at home, but it was listed in the medication profile.Aspirin 81 mg – Patient had a bottle of Aspirin 81 mg at home, but it was not listed in the medication profile.Tylenol 500 mg - Patient had a bottle of Tylenol 500 mg at home, but it was not listed in the medication profile. During an interview with Family member 1 at 11:50 a.m., she stated the patient had never been administered Zinc Sulfate. She stated Docusate Sodium was discontinued since two months ago, Aspirin 81 mg had been administered since 2 months ago, and Tylenol 500 mg two tablets had been administered two or three times a day since “long time”. During an interview with RN 1 at the same time, he stated the SN should have physically checked the patients' medication comparing with the medication profile, should have clarified with the physician, and provided education to the patient/caregiver. A review of the agency's policy titled " Medication profile " revised on July 2013, indicated Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen.

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: This Condition is not met as evidenced by: Based on observation, interview and record review, the home health agency (HHA) failed to ensure the Condition of Participation for Care planning, coordination, and quality of care was met to ensure the physician's treatment orders were followed for three of five sampled patients (Patient 1, 2, 4). 1. For Patient 1, the agency failed to ensure the Duoderm (dressing used to treat bed sores) and SSD cream (cream is used to prevent and treat wound infection) were applied on the patient's wound as ordered by the physician. For Patient 2, the Skilled Nurse (SN) failed to change gloves and washed/sanitized hands after removal of the soiled dressing. For Patient 4, the agency failed to do Wound Vac treatment (a type of wound treatment to help wounds heal) every other day as ordered. These deficient practices had the potential to cause delayed wound healing and worsening of the wound of the affected patient, and placed the patients at risk for infection on the wound site (Refer to G 580). 2. The agency failed to revise the POC when the caregiver was not competent with the wound treatment for one of five sampled patients (Patient 1). Refer to G 592. The cumulative effect of these systemic practices resulted in the home health agency's inability to ensure the provision of quality health care.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on observation, interviews and record review, the agency failed to provide wound care treatment as ordered by the physician for three of five sampled patients (Patient 1, 2 and 4). 1. For Patient 1, the agency failed to ensure the Duoderm (dressing used to treat bed sores) and SSD cream (cream is used to prevent and treat wound infection) were applied on the patient's wound as ordered by the physician. 2. For Patient 2, the Skilled Nurse (SN) failed to change gloves and washed/sanitized hands after removal of the soiled dressing. 3. For Patient 4, the agency failed to do Wound Vac treatment (a type of wound treatment to help wounds heal) every other day as ordered. These deficient practices had the potential to cause delayed wound healing and worsening of the wound of the affected patient, and placed the patients at risk for infection on the wound site. c. A review of Patient 4's clinical record indicated a start of care (SOC) of 2/15/22, with diagnoses which included cutaneous abscess (a localized collection of pus in the skin) of left foot. The plan of care (POC) for the certification period from 2/15/22 to 4/15/22, included an order for Skilled Nurse (SN) to visit daily for 3 days, four times in one week, three times a week for four weeks, twice a week for two weeks. SN was to continue doing skin assessment and observation and to perform, demonstrate, instruct patient and patient caregiver wound care treatment on patient’s left foot. A review of Patient 4’s physician’s order dated 3/18/22, indicated to apply a wound vac (a type of wound treatment to help wounds heal) to wound every other day for two weeks. A review of Patient 4's Skilled Nurse Visit Notes indicated a wound vac therapy was performed on the following dates: - 3/18/22, 3/20/22, 3/23/22, 3/25/22, 3/29/22, 4/01/22, 4/05/22, and 4/08/22. A further review of Patient 4's clinical record indicated there was no documented evidence, except on 3/22/22 when wound vac treatment was not done due to Patient 1’s doctor’s appointment, why the agency was not consistently doing a wound vac treatment every other day as ordered by the physician. On 5/06/2022, at 10:00 a.m., during an interview with the DPCS (director of patient care services), the DPCS stated wound vac treatment was not done on the dates between 3/25/22 to 3/29/22, between 3/29/22 to 4/01/22, between 4/01/22 to 4/05/22, and between 4/05/22 to 4/08/22. DPCS stated the agency should follow physician’s order and should have apply wound vac every other day. The agency's policy and procedure titled, “Standards of Care and Practice”, revised July 2013, indicated Green Pine Home Healthcare Services will identify and define standards of care and practice to guide the provision of patient care for home health services, in addition to the policies defined which support standards of care. All clinicians will practice and provide care based on MD (physician) orders and update orders as new orders are received. Findings: a. A review of Patient 1's clinical record indicated a start of care date of 12/29/2021, with diagnosis of unspecified open wound, Stage III pressure ulcer of left buttocks. A review of Patient 1's plan of care (POC) for the certification period dated 12/29/2021 through 2/26/2022, included an order for skilled nursing visits three times a week for one week, six times a week for one week, four times a week for one week, and once a week for one week to perform assessment of open wound and treatment. A review of Patient 1's Outcome Assessment and Information Set (OASIS) dated 12/29/2021, indicated the patient had following wounds: Left hip – Stage II pressure ulcer (4 cm x 2 cm x 0.8 cm)Middle back – Stage II pressure ulcer (5 cm x 3 cm x 0.8 cm)Bilateral rectal – Stage I pressure ulcer (3 cm x 3 cm x 0.2 cm) There was a physician’s order dated 12/29/2021 as follows: Left hip – cleanse with normal saline, pat dry with gauze, apply duoderm every 72 hours and as needed for two weeksMid Lower back – cleanse with normal saline, pat dry with gauze, apply SSD cream and wet and dry dressing, then secure with tape for two weeks and as needed when the dressing is soiled. Bilateral gluteal – cleanse with normal saline, pat dry with gauze, apply 4 x 4 and SSD cream as needed to prevent infection and then to secure with tape for two weeks. A review of Patient 1's clinical record indicated as follow: 12/30/2021 – No documented evidence Duoderm was applied on the left hip and no documented evidence SSD cream was applied on the Mid lower back and bilateral gluteal area. 12/31/2021 – No documented evidence SSD cream was applied on the Mid back. Instead, Duoderm patch was applied on the Mid back and bilateral gluteal area.1/3/2022 - No documented evidence SSD cream was applied on the Mid back. Instead, Duoderm patch was applied on the Mid back and bilateral gluteal area. A review of the SN Wound Care (Addendum Page) dated 1/4/2022 indicated the patient had Stage 3-4 pressure ulcer on the lower back estimated wound site of 5.4 cm x 3.2 cm x 1.2 cm There was a communication note to Physician 1 dated 1/4/2022 indicated Patient 1’s family member had called and concerned that the wound was not healing yet. On 5/6/2022, at 12:40 p.m., during an interview with Licensed Vocational Nurse 1 (LVN 1), she stated she had not applied SSD cream on the midback on above days because SSD cream was not available. When asked the physician was informed, she stated she did not inform the physician. b. A review of Patient 2's clinical record disclosed a start of care (SOC) dated 2/4/2022, with diagnoses which included Stage IV pressure ulcer of sacral region, sepsis and diabetes mellitus (DM). The Plan of Care (POC) for the certification period from 4/5/2022 to 6/3/2022, included order for the Skilled Nurse (SN) visit two times a week for 8 weeks for assessment of the patient with Stage 4 pressure ulcer of sacral region. The SN was to cleanse with normal saline, pat dry, apply skin barrier wipe to peri wound, lightly moisten gauze roll with Dakin solution, lightly fill open cavity, cover filled cavity with xeroform and then abdominal pad, secure with paper tape daily and as needed when dressing is soiled. There was a physician’s order dated 4/23/2022, indicated wound care of Stage IV pressure ulcer on the sacral region. The physician’s order indicated to wash hand, wear gloves, remove old dressing, wash hands with hand sanitizer, and to wear new pairs of gloves. Then to cleanse with normal saline/Dakin’s solution, pat dry with gauze, apply skin barrier wipe, pack with normal saline moist gauze, cover with dry gauze and ABD pad (Abdominal pad - highly absorbent padding and protection for large wounds) and then secure with paper tape. On 5/4/2022, at 10:40 a.m., during a joint home visit with Registered Nurse 1 (RN 1) and RN 2, Patient 2 was lying in the hospital bed and Family member 1 was next to Patient 2. At 11:10 a.m., RN 1 washed hand, wore gloves, removed old dressing from the pressure ulcer site on the sacral region. The old dressing was observed soaked with brownish drainage. Without changing gloves and sanitizing hands, RN 1 proceeded treatment. RN 1 cleaned the pressure ulcer site with normal saline, pat dried with dry gauze, applied packing of wet/moist gauze, put ABD pad and taped. During an interview with RN 1 on 5/4/2022, at 11:55 a.m., he stated he should have removed gloves that touched the soiled dressing, washed / sanitized hands, and put new gloves before he proceeded treatment. A review of the agency’s policy titled “Hand Hygiene” revised in May 2009 indicated 60 percent to 90 percent of alcohol sanitizer should be used between gloves changes during the procedures at all times. A review of the agency’s policy and Procedure titled “Standards of Care and Practice” revised in July 2013 indicated all clinicians will practice and provide care based on the physician’s order and update orders as new orders are received.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to ensure the Skilled Nurse (SN) visit frequency in the Plan of Care was revised to provide adequate services for one of five sampled patients (Patient 1). Patient 1's primary caregiver (PCG) was evaluated as not competent to perform pressure ulcer treatment to Patient 1. This deficient practice resulted in patient being at risk for delayed wound healing and infection on the wound sites. A review of Patient 1's clinical record indicated a start of care date of 12/29/2021, with diagnosis of unspecified open wound, Stage III pressure ulcer (bed sore looks like a crater and may have a bad odor) of left buttocks. A review of Patient 1's plan of care (POC) for the certification period dated 12/29/2021 through 2/26/2022, included an order for skilled nursing visits three times a week for one week, six times a week for one week, four times a week for one week, and once a week for one week to perform and instruct the patient/PCG to demonstrate treatment. A review of the physician’s order dated 12/29/2021 indicated as follows: Left hip – cleanse with normal saline, pat dry with gauze, apply Duoderm every 72 hours and as needed for two weeksMid Lower back – cleanse with normal saline, pat dry with gauze, apply SSD cream and wet and dry dressing, then secure with tape for two weeks and as needed when the dressing is soiled. Bilateral gluteal – cleanse with normal saline, pat dry with gauze, apply 4 x 4 and SSD cream as needed to prevent infection and then to secure with tape for two weeks. A review of Patient 1's Outcome Assessment and Information Set (OASIS) dated 12/29/2021, indicated the following wounds: Left hip – Stage II pressure ulcer (4 cm x 2 cm x 0.8 cm)Middle back – Stage II pressure ulcer (5 cm x 3 cm x 0.8 cm)Bilateral rectal – Stage I pressure ulcer (3 cm x 3 cm x 0.2 cm) On 5/5/2022, at 2:40 p.m., when a telephone interview was conducted with Family member 2 (FM 2), with translation by the Language line service, she stated the agency nursing staff did not teach/educate her how to take care Patient 1’s wounds. FM 2 stated the agency nurse never asked her to show them how FM 2 took care Patient 1’s wounds. FM 2 stated she had just watched the nurse during SN visit days. FM 2 stated when she showered Patient 1, she saw many wounds Patient 1 had, and pus was there. FM 2 got really scared so she called 911 and transferred Patient 1 to the acute hospital. The acute hospital informed FM 2 that Patient 1 had infections on the wounds. A review of the Skilled Nurse Wound Care notes (section of Response to Skilled intervention) indicated as follows: On 12/30/2021 - Caregiver’s “Verbalized understanding” scored 50 percent and “Return Demonstration” scored 40 percent. On 12/31/2021 - Caregiver’s “Verbalized understanding” scored 50 percent and “Return Demonstration” scored 40 percent. On 1/3/2022 - Caregiver’s “Verbalized understanding” scored 50 percent and “Return Demonstration” scored 40 percent. On 1/4/2022 - Caregiver’s “Verbalized understanding” scored 50 percent and “Return Demonstration” scored 0 percent. On 1/5/2022 - Caregiver’s “Verbalized understanding” scored 40 percent and “Return Demonstration” scored 0 percent. On 1/8/2022 - Caregiver’s “Verbalized understanding” scored 40 percent and “Return Demonstration” scored 40 percent. On 1/9/2022 - Caregiver’s “Verbalized understanding” scored 40 percent and “Return Demonstration” scored 40 percent. On 1/10/2022 - Caregiver’s “Verbalized understanding” scored 60 percent and “Return Demonstration” scored 60 percent A review of Patient 1’s record indicated there was no documented evidence the agency staff had communicated/discussed with the interdisciplinary group/physician regarding FM 2’s incompetency of skilled intervention and revised the POC to provide qualified nursing service continuously on non- SN visit days. On 5/5/2022, at 3:20 p.m., during an interview with the Director of Patient Care Services (DPCS) she was not able to provide the documented evidence the agency staff had communicated/discussed with the interdisciplinary group/physician regarding FM 2’s incompetency of skilled intervention and revised the POC to ensure Patient 1 received qualified nursing service on non-SN visit days. A review of the agency’s policy titled, “Pressure Ulcer Prevention and Managing Skin Integrity” revised in July 2020 indicated to evaluate plan of care including patient ability/willingness to maintain compliance with the plan. The Skilled Nurse should discuss case with the case manager to continue wound care visit if there is care incompetency noted.

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 interview, and record review, the Home Health Agency (HHA) failed to ensure that the Condition of Participation for Skilled Professional Services was met as follows: The HHA failed to provide education/instruction to the patient’s caregiver on the use of low air loss mattress (a mattress design to provide airflow to help keep skin dry, relieve pressure and help prevent pressure ulcers [a localized injury to the skin or underlying tissue, usually over a bony prominence, as a result of unrelieved pressure]), and the indwelling catheter (a flexible sterile plastic tubes that drains urine from the bladder into a bag outside the body), drainage bag was placed below the patient's bladder (a hollow organ in the lower abdomen that stores urine), for one of 5 sampled patients (Patient 2). Patient 2 who had stage 4 pressure ulcer (characterized by a deep wound that reaches the muscles, ligaments, or even bone), on the sacral area (bottom of the spine and lies between the fifth segment of the lumbar spine (L5) and the coccyx (tailbone). Refer to G 714The HHA failed to notify/communicate with the physician on the change of the patient's pressure ulcer status for one of 5 sampled patients (Patient 1). Patient 1 who had stage 3 and 4 pressure ulcer on the middle back area. Refer to G 718 The cumulative effect of these systemic practices resulted in the home health agency's inability to ensure the provision of quality health care.

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA) staff failed to provide education/instruction to the patient and/or patient caregiver about the use of the low air loss mattress (LAL mattress) and the proper placement of the indwelling catheter drainage bag for one of five sampled patients (Patient 2). This deficient practice has the potential to delay wound healing that could result in the decline of the condition of the wound, and the potential to manifest urinary tract infection related to the improper placement of the urinary catheter. a. A review of Patient 2's clinical record disclosed a start of care (SOC) dated 2/4/2022, with diagnoses which included Stage IV pressure ulcer of sacral region, sepsis, and diabetes mellitus (DM). The Plan of Care (POC) for the certification period from 4/5/2022 to 6/3/2022, included an order for the Skilled Nurse (SN) visit two times a week for 8 weeks. The SN was to change Foley catheter [16 French (Fr)/10 cubic centimeter (cc)] every month, and to instruct the patient/caregiver on proper Foley care. The SN was to have 2 additional visits for dislodgement, blockage, or leakage of Foley catheter or drainage system. On 5/4/2022, at 10:40 a.m., during a joint home visit with Registered Nurse 1 (RN 1) and RN 2, Patient 2 was lying in the hospital bed with two side rails up. Patient 2 had a Foley catheter in place, and the urinary drainage bag was hung on the side rail at the same level as the patient’s bladder. Family member 1 (FM 1) was next to Patient 2. During an interview with FM 1 at 11 a.m., she stated that nobody instructed her to put the drainage bag below the patient’s bladder level. During an interview with RN 1 at the same time, he stated the urinary drainage bag should have been placed below the bladder level. A review of Patient 2's record indicated there was no documented evidence the agency staff provided education/instruction to the caregiver regarding the placement of the urinary drainage bag. On 5/6/2022, at 1:45 p.m., during an interview with the Director of Patient Care Services (DPCS), she was not able to provide the documented evidence the agency staff had educated/instructed the caregiver regarding the placement of the urinary drainage bag, and stated the staff should have educated/instructed the caregiver. A review of the agency’s “Nursing Patient Care Policy and Procedure” revised in July 2020 indicated to keep drainage bag below the level of bladder at all times. b. During the home visit Patient 2 was also observed lying in the hospital bed, on the LAL mattress. Patient 2 was also wearing an adult briefs in bed. The LAL mattress was covered with one linen, one draw sheet, and one chux (bed pad that protects the bed and other surfaces from bodily fluids). During an interview with FM 1 at 11 a.m., she stated she did not know the layers on the LAL mattress should be limited. During an interview with RN 1 at the same time, he stated there shouldn’t be no more than two layers on the LAL mattress. A review of Patient 2’s record indicated there was no documented evidence the agency staff had provided education/instruction to the caregiver regarding the limited layers on the LAL mattress. On 5/6/2022, at 1:45 p.m., during an interview with the Director of Patient Care Services (DPCS), she was not able to provide the documented evidence the agency staff had educated/instructed the caregiver regarding the limited layers on the LAL mattress. A review of the agency’s policy and procedure titled “Pressure ulcer Prevention and Management Skin Integrity” revised in July 2020 indicated to minimize the layers of linens on interface pressure to one layer.

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 Home Health Agency (HHA) staff failed to communicate with the physician regarding the significant changes of the patient's wounds manifesting signs of infection that included pus, drainage, and foul odor for one of 5 sampled patients (Patient 1). This deficient practice placed the patient at risk for delayed wound healing and treatment that could result to severe wound infection and complications. A review of Patient 1's clinical record indicated a start of care date of 12/29/2021, with diagnosis of unspecified open wound and Stage III pressure ulcer of left buttock. A review of Patient 1's plan of care (POC) for the certification period dated 12/29/2021 through 2/26/2022, included an order for skilled nursing visits three times a week for one week, six times a week for one week, four times a week for one week, and once a week for one week to perform assessment of open wound and Stage 3 pressure ulcer of the left buttock. A review of Patient 1's Outcome Assessment and Information Set (OASIS) dated 12/29/2021, indicated the patient had the following wounds: Left hip – Stage II pressure ulcer (4 cm x 2 cm x 0.8 cm)Middle back – Stage II pressure ulcer (5 cm x 3 cm x 0.8 cm)Bilateral rectal – Stage I pressure ulcer (3 cm x 3 cm x 0.2 cm) A review of Patient 1's SN Wound Care note (Addendum page) dated, 1/8/2022, indicated the patient had pressure ulcers on lower back area, left hip, and bilateral buttock with pus and foul odor. A review of Patient 1's SN Wound Care note (Addendum page) dated, 1/9/2022, indicated the patient had pressure ulcers on middle back area, left hip, and sacral/rectal that had serum with pus and foul odor. A review of Patient 1's SN Wound Care note (Addendum page) dated, 1/10/2022, indicated the patient had pressure ulcer on middle back area, left hip, and sacral/rectal that had serum with pus, drainage, and foul odor. A review of Patient 1’s record indicated there was no documented evidence the agency’s staff had notified/communicated with the physician regarding Patient 1’s wound with pus, drainage and foul odor. A review of the “Transfer Summary Form – Home Care to Hospital or other Facilities” dated 1/14/2022 indicated Patient 1 went to the acute hospital with non-healing surgical wound on left hip, Stage 3-4 decubitus on the lower back, DM and hypertension. On 5/5/2022, at 2:40 p.m., a telephone interview was conducted with Family Member 2 (FM 2), with translation by the Language line service, she stated the agency nursing staff did not teach/educate her on how to take care of Patient 1’s wounds. FM 2 stated the agency nurse never asked her to show them how FM 2 took care Patient 1’s wounds. FM 2 stated when she showered the patient back in January 2022, she saw Patient 1 had many wounds with pus. FM 2 got really scared so she called 911 and transferred Patient 1 to the acute hospital. The acute hospital informed FM 2 that Patient 1 had infections on the wounds. On 5/5/2022, at 4 p.m., during a telephone interview with Registered Nurse 3 (RN 3), she stated when she had visited Patient 1 on 1/10/2022, the pressure ulcers on the middle back area, left hip, and sacral/rectal had a lot of drainage and looked infected. However, she stated she did not notify the physician because the family stated they were going to notify their family doctor. RN 3 stated she should have notified the physician on 1/10/2022, when she saw the pressure ulcers looked infected. A review of the agency’s undated “Wound Protocol” indicated any changes in wound status must be reported to the agency’s case manager, Nurse Supervisor and/or the physician within 2 hours.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure the patient's clinical record was maintained and current in accordance with accepted professional standards of practice one of 5 sample patients (5). This deficient practice has the potential to affect the patient's continuity of care to meet the patient's healthcare needs. a. A review of Patient 1's plan of care (POC) for the certification period from 12/29/2021 through 2/26/2022, indicated a start of care date of 12/29/2021, with diagnosis of unspecified open wound of right hip, and Stage III pressure ulcer of the left buttock. A review of Patient 1's Outcome Assessment and Information Set (OASIS) dated 12/29/2021, indicated the patient had the following wounds: Left hip – Stage II pressure ulcer (4 cm x 2 cm x 0.8 cm)Middle back – Stage II pressure ulcer (5 cm x 3 cm x 0.8 cm)Bilateral rectal – Stage I pressure ulcer (3 cm x 3 cm x 0.2 cm) A review of Patient 1’s record indicated there was no documented evidence the open wound on the right hip was assessed or treated. On 5/5/2022, at 12:55 p.m., during an interview with the Director of Patient Care Services (DPCS), she stated the documentation on the POC was incorrect. The DPCS stated Patient was admitted with the diagnoses of pressure ulcer on the left hip, not right hip and Stage II pressure ulcer, not Stage III. Physician 1 who signed the POC was not able to be contacted during the survey. b. A review of Patient 1's SN Wound Care and Wound Care Worksheet indicated following discrepancies/inconsistency were noted: 12/30/2021 – SN Wound Care indicated the patient had Stage III pressure ulcer on the left hip and mid back while the Wound Care Worksheet indicated Stage II on the left hip and middle back. 12/31/2021 - SN Wound Care indicated the patient had Stage III pressure ulcer on the left hip and mid back while the Wound Care Worksheet indicated Stage II on the left hip and middle back. 1/3/2022 - SN Wound Care indicated the patient had Stage III pressure ulcer on the left hip and mid back while the Wound Care Worksheet indicated Stage II on the left hip and middle back. 1/4/2022 – SN Wound Care indicated the patient had Stage II pressure ulcers on mid lower and left hip while “Addendum Page” of SN wound Care indicated Stage 3-4 pressure ulcer on the lower back.12/30/2021 to 1/10/2022 - SN Wound Care indicated the patient had Stage I pressure ulcer on the bilateral buttocks [3 cm x 3 cm x 0.2 cm (on 12/20/2021) to 4 cm x 3 cm x 0.3 cm (on 1/10/2022)]. There was only one measurement on each assessment, and there was no indication the measurement was the right side or the left side.1/8/2022, 1/9/2022, and 1/10/2022 - SN Wound Care indicated the patient had Stage I pressure ulcer on the bilateral buttocks sized 4 cm x 3 cm x 0.3 cm. However, it indicated the wound status was opened with serous drainage and fecal odor. On 5/5/2022, at 12:35 p.m., during an interview and concurrent review of the pictures of both buttocks with the Director of Patient Care Services (DPCS), she stated the pressure ulcers on both buttocks on 1/8/2022, 1/9/2022, and 1/10/2022 were at least Stage II, not Stage I and the assessment was not accurate. On 5/6/2022, at 1:45p.m., during an interview with the DPCS, she stated the nursing staff should have assessed and documented the pressure ulcers accurately, and the patient’s clinical record should be documented accurately. A review of the agency’s undated policy and procedure titled “Clinical Record Documentation” indicated the clinical records are to be complete, comprehensive, legible, readily accessible and documented accurately in a timely manner. The clinical record shall contain sufficient information to identify the patient clearly, to justify the diagnosis and treatment, to document the results accurately, and to support coding and billing related to the visit.