Every finding on record at Home Health Agency Indiana LLC

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to perform wound care as indicated on the plan of care for 1 of 2 patients whose clinical record was reviewed for wounds (Patient 2). Finding include: An undated Registered Nurse job description was provided by the Administrator on 3/8/2021 at 3:12 p.m. The job description indicated, but was not limited to, "The Registered Nurse in Home Health provides and directs provisions of nursing care to patients in their homes as prescribed by the physician ... Provides clinical services within the scope of practice ... in accordance with the plan of care ... Implements ... the plan of care in collaboration with the physician..." A revised policy dated 2/1/2021, titled Wound Assessment, Documentation, and Photography was provided by the Alternate Administrator on 3/8/2021 at 12:05 p.m. The policy indicated documentation in the medical record was to include, but was not limited to, "Exact wound care performed, following physician orders." A copy of a revised form dated 6/1/2020, titled Competency Assessment/Peer Review RN for Registered Nurse B was obtained on 3/8/2021 at 2:42 p.m. The form indicated, but was not limited to, "Wound Care/Wound Assessment and Staging" as met, indicated by a checkmark in the "Met" column, using assessment method observation as indicated by a checkmark in the "O" column with initials and a date of 12/23/2020. The form contained the Alternate Administrator's and Registered Nurse B's signatures with a date of 12/23/2020 next to Registered Nurse B's signature. The complete clinical record for Patient 2 was reviewed on 3/8/2021, start of care date 7/28/2020, with a certification period of 1/24/2021 to 3/24/2021, with orders for the skilled nurse to perform wound care. Patient 2's diagnoses were Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, and Type 2 Diabetes with Foot Ulcer. A 2/9/2021 physician order description indicated, but was not limited to, "Wound care order. Left 2nd toe flush with normal saline. Apply betadine. Wrap with light sterile gauze bandage. Left 4th toe paint with betadine and apply padded and protected dressing blister still intact and drying. ... SN [skilled nurse] to do 2 times a week ..." SN visit notes dated 2/17/2021, 2/19/2021, and 2/23/2021, completed by Registered Nurse B, indicated, but was not limited to, wound care provided to left 2nd toe, "Skilled nurse to perform/instruct/reinforce patient/caregiver procedure of wound care to left 2nd toe 2x weekly. Cleanse with soap and water. Apply betadine. Cover with drying dressing using clean technique. Patient tolerated well." During an interview on 3/8/2021 at 2:10 p.m., the Alternate Administrator stated that the tablets [clinicians use for documentation] are different from the "back office." If the clinician clicks on "no change in orders" and not "associate new order," an old order would populate in the wound care visit notes. During an interview on 3/9/2021 at 9:40 a.m., in reference to documented wound care in SN visits 2/17/2021, 2/19/2021, and 2/23/2021, the Administrator stated that the "plan of care overrode orders." "When the plan of care came back signed, it overrode the orders and prepopulated in the visit. The nurse should have verified that the correct wound care order populated in the visit."

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure accurate documentation on wound measurements were recorded for 1 of 2 wound care patients. (Patient 1) Findings include: A 03/01/19 policy titled Home Care Record was provided by the Executive Director/Administrator on 3/9/21 at 10:05 a.m. The policy indicated, but was not limited to, " 8. ... a. All entries recorded in the home care record must be legible and accurate." The complete clinical record for patient 1 was reviewed on 3/8/21, start of care date 1/16/21, for the certification period 1/16/21 to 3/16/21, with a diagnosis of orthopedic aftercare following surgical amputation. The record evidenced the following: Review of the Wound Record Report evidenced the following measurements for the left great toe amputation: Date 1/16/21, 1.3 cm (centimeter) length x 5.5 cm width x 0 depth Dates 1/19/21, 1/22/21, 1/26/21, 1/29/21, "no measurements due" Date 2/2/21, 1.3 cm length x 5.5 cm width x 0 depth Date 2/4/21, 5.5 cm length x 0.3 cm width x 0 depth Date 2/9/21, 5 cm length x 1 cm width x 0 depth Date 2/18/21, 1 cm length x 5 cm width x 0 depth During an interview on 3/8/21 at 11:40 a.m. the Alternate Administrator was asked about the increase in size of the wound from 2/2/21 to 2/4/21, and if the physician was called for an update or orders. The Alternate Administrator was unable to evidence documentation of physician notification. The Alternate Administrator stated he/she called RN A and RN B for more information about the increase in size of wound. Both RN's indicated the length and width of the wound for patient 1 was transposed inadvertently for dates 2/4/21 and 2/9/21. On 3/9/21 at 12:00 p.m. the Executive Director/Administrator indicated wound education was provided to staff in the past and education continues ongoing as well as chart audits.