Every finding on record at Licking Memorial Hospital Home Care

EMERGENCY PREPAREDNESS SURVEY At the time of the Emergency Preparedness Survey completed on 08/04/21, Licking Memorial Hospital Home Care is in compliance with the provisions of 42 CFR Part 484.102, Conditions of Participation for Home Health Agencies.

Partial Extended Recertification Survey The following deficiency is based on the Partial Extended Recertification Survey completed on 08/04/21. Licking Memorial Hospital Home Health is not in compliance with the requirements found at 42 CFR Part 484, Subpart B, C, Home Health Agencies. A COVID 19 Focused Infection Control Survey conducted concurrently revealed the facility is in compliance with the requirements at 42 CFR Part 484.70 related to Infection Control.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner 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 ensure wound measurements were completed weekly as ordered. This affected two (Patients #1 and #6) of four patients reviewed for wound care. This has the potential to affect all patients receiving wound care from the agency. The agency census was 21. Findings include: 1. Review of Patient #1's medical record revealed a start of care date of 06/08/21 with a primary diagnosis of cutaneous abscess of right lower limb. The physician ordered plan of care ordered skilled nursing to assess skin integrity, which included assessment of wound. A dressing change was ordered daily for 60 days to the right knee. The nursing documentation also revealed that wound measurements were to be completed weekly on Mondays. Review of the nursing documentation revealed no weekly wound measurements were completed for the weeks of 06/20/21 through 06/26/21, 06/27/21 through 07/03/21, 07/11/21 through 07/17/21, and 07/25/21 through 07/31/21. During the home visit completed on Monday 08/02/21 at 11:00 A.M., Staff C did not measure the wound as ordered. During interview on 08/03/21 at 3:20 P.M., Staff A verified the wound documentation did not have weekly measurements. Staff A also stated Staff C reported to her that she did not measure the wound. 2. Review of Patient #6's medical record revealed a start of care date of 06/14/21 with a primary diagnosis of paroxysmal atrial fibrillation. The physician ordered plan of care ordered skilled nursing to assess skin integrity, which included assessment of wound. A dressing change was ordered three times a week to the four pressure ulcers on the coccyx area. Review of the nursing documentation from 06/14/21 to 07/13/21 revealed no wound measurements were performed. During interview on 08/03/21 at 1:50 P.M., Staff A verified the wound measurements were not completed. Review of the agency policy titled "Wound Assessment and Documentation", revealed wound measurements are to be documented at least weekly.