Every finding on record at Medical Professionals, LLC

A survey for compliance with CMS Appendix Z Emergency Preparedness Requirements, was conducted on 4/1/24 to 4/3/24, during a recertification survey. The facility is NOT in compliance with the Appendix Z Emergency Preparedness Requirements. The Condition of Participation: Establishment of the emergency program at 42 CFR 484.102, E0001 was found not met.

Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: Based on interview, and document review, the HHA failed to develop an emergency preparedness program that met all of the standards specified within the condition, including a comprehensive approach to meet the health, safety and security needs of the staff and client population during an emergency or disaster situation. The plan also lacked how the agency would communicate with staff and the whole community during an emergency or disaster. This had the possibility to affect all staff and clients that received care from the agency. The Condition of Participation: Establishment of the emergency program 42 CFR at 484.102 Findings include: Review of the facility emergency preparedness plan revealed the facility had not utilized an all-hazards approach to establish an emergency procedures program; failed to develop a risk assessment, identifying both community and agency-based risk; failed to develop policies and procedures based on an emergency plan, failed to develop a communication plan, and failed to develop processes for training and testing. On 4/3/24, at 11:19 a.m. the administrator stated he was not aware of the Appendix Z regulations. As a result, no work had been done to meet the requirements at Appendix Z, Emergency Preparedness.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on interview and document review, the facility failed to ensure compliance with all applicable Federal, State and local emergency preparedness requirements. The facility failed to develop, establish and maintain, a comprehensive emergency preparedness program that meets the requirements of this section. The facility failed to develop an Emergency Plan and failed to review and update the plan as required. This had the possibility to affect all staff and clients that received care from the agency. Findings include: A review of the facility policy Emergency Preparedness dated 12/18/23, lacked a complete emergency plan that was reviewed and updated as required. The facility also failed to ensure the following of their emergency preparedness program: -§484.102(a)(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. -§484.102(a)(2) Include strategies for addressing emergency events identified by the risk assessment. -§484.102(a)(3) Address patient population, including, but not limited to, the type of services the HHA has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. -§484.102(a)(4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the HHA’s efforts to contact such officials and, when applicable, of its participation in collaborative and cooperative planning efforts. During an interview on 4/3/24 at 11:19 a.m., the administrator stated they were not aware of any comprehensive emergency plan that discussed the facility and community risk assessment using an all-hazards approach or a comprehensive list of outside organizations the agency could work with if needed.

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on interview and document review, the home health agency (HHA) failed to conduct a comprehensive all-hazards community-based risk assessment to determine potential disasters which could impact the HHA and develop corresponding policies and procedures to ensure patient safety and quality care during a disaster. This had the possibility to affect all staff and clients that received care from the agency. Findings include: Review of the facility policy Emergency Preparedness dated 12/18/23, revealed the plan did not contain the following standard policies and procedures: -§484.102(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. -§484.102(b)(1) The plans for the HHA’s patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. -§484.102(b)(2) The procedures to inform State and local emergency preparedness officials about HHA patients in need of evacuation from their residences at any time due to an emergency situation based on the patient’s medical and psychiatric condition and home environment. -§484.102(b)(3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. -§484.102(b)(4) A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains the availability of records. -§484.102(b)(5) The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State or Federally designated health care professionals to address surge needs during an emergency. During interview on 4/3/24 at 3:21 p.m., the administrator stated he had not developed policies and procedures for all identified hazards based on the risk assessment for the home health agency.

Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.542(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. This STANDARD is not met as evidenced by: . Based on interview and document review, the home health agency failed to develop in its emergency preparedness plan (EPP) a written emergency communication plan that contained a description of how the facility will coordinate patient care within the facility, across healthcare providers, and with state and local public health departments in order to protect the health and safety of their patients/residents. This had the possibility to affect all staff and clients that received care from the agency. Findings include: The facility policy emergency preparedness, dated 12/18/23, was reviewed. There was no information of a communication plan that included the following: -§484.102(c) Communication plan. The HHA must develop and maintain an emergency preparedness communication plan that complies with Federal, State, and local laws and must be reviewed and updated at least annually. -§484.102(c)(1) Names and contact information for the staff entities providing services under arrangement, patients’ physicians, and volunteers. -§484.102(c)(2) Contact information for Federal, State, tribal, regional, or local emergency preparedness staff, as well as other sources of assistance. -§484.102(c)(3) Primary and alternate means for communicating with the HHA’s staff, Federal, State, tribal, regional, and local emergency management agencies. -§484.102(c)(4) A method for sharing information and medical documentation for patients under the HHA’s care, as necessary, with other health care providers to maintain the continuity of care. -§484.102(c)(5) A means of providing information about the general condition and location of patients under the facility’s care as permitted under 45 CFR 164.510(b)(4). -§484.102(c)(6) A means of providing information about the HHA’s needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. During interview at 11:19 a.m. on 4/3/24, the facility administrator said the facility had not established a plan for communication for emergency preparedness, and there was no policy for communication.

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on document review and interview, the agency failed to develop and maintain an emergency preparedness training and testing program based on the emergency plan, risk assessment, policies and procedures and an appropriate communication plan. This had the possibility to affect all staff and clients that received care from the agency. Review of the facility's emergency preparedness policy dated 12/18/23, revealed the facility had not developed and implemented training and testing policies and procedures that included the following: -§484.102(d) Training and testing. The HHA must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. -§484.102(d)(1) Training program. The HHA must do all of the following: Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. Provide emergency preparedness training at least annually. Maintain documentation of the training. Demonstrate staff knowledge of emergency procedures. -§484.102(d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: Participate in a full-scale exercise that is community-based or when a community-based exercise is not accessible, an individual, facility-based. If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in a community-based or individual, facility-based full-scale exercise for 1 year following the onset of the actual event. Complete a second full-scale that is community-based or individual, facility-based. Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. During interview on 4/3/24 at 11:19 a.m., the administrator stated there was no testing or training policies and procedures. He also stated the agency had not performed any tabletop or live drills since 2022.

On 4/1/24 to 4/3/24 a recertification survey was conducted. This resulted in a partial extended survey at Firstat Nursing Services. The agency was found to have met the requirements at 42 CFR. Part 484 for Home Health Agencies. Unduplicated census previous 12 months: 1 Total home visits conducted: zero- The facility last Skilled Client discharged in 4/13/23 and only had Patient care assistant (PCA) services being given since that point. List Parent Location visited, including the addresses as verified while on site-93 LIttle Canada Rd W suite 312, LIttle Canada MN 55117 List all other branch offices for this agency and identify which of these were visited during this survey and which you pulled records from No branches List Hours of Operation: 9:00 a.m. to 5:00 p.m. List total number of records reviewed: 7

An abbreviated survey was conducted at your agency on 3/15/2021. Firststat Nursing Services was found NOT to be in compliance with requirements at 42 CFR Part 484, requirements for Home Health Agencies. The following complaint was substantiated H8087009C (MN00070657) with deficiencies cited at G570, G590 and G710. In addition, the Conditions of Participation Care Planning, Coordination and Quality of Care §484.60 at G570, was found NOT met. As a result a partially extended survey was completed. The facility's plan of correction (POC) will serve as your allegation of compliance upon the Department's acceptance. Federal Law as specified in 42 CFR 484.80 (f)(3), prohibits any home health agency to offer and/or conduct home health aide training and/or competency testing which, within the previous two years has been subjected to an extended (or partially extended) survey as a result of having been found to have a Federal Condition of Participation not met at the extended survey.

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: Based on interview and document review, the agency was found not to be in compliance with the Condition of Participation at 484.60, Care Planning, Coordination, Quality of Care. The agency failed to notify the provider of potential signs and symptoms of infection and change in condition of a wound, including odor, for 1 of 3 patients (P1) reviewed for wound care. The cumulative effect of these systemic problems resulted in the home health agency's inability to ensure the provision of quality of care. Findings include: Refer to G590: Based on interview and document review the agency failed to notify the provider of potential signs and symptoms of infection and change in condition of a wound, including odor, for 1 of 3 patients (P1) reviewed for wound care.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on interview and document review the agency failed to notify the provider of potential signs and symptoms of infection and change in condition of a wound, including odor, for 1 of 3 patients (P1) reviewed for wound care. Findings include: P1 was admitted to the agency on 2/12/21, with diagnoses including; infection following a procedure other surgical site, schizoaffective disorder and chronic pain syndrome. P1's plan of care for certification period 2/12/21 to 4/12/21, indicated P1 received skilled nursing three times a week for eight weeks for wound care, and one visit as needed in case the wound vacuum (device that decreases air pressure on wound to help in wound healing) had issues requiring nursing evaluation. The plan of care also indicated the skilled nurse was to report significant changes to the physician, provide negative pressure wound therapy to the stomach, assess and instruct the patient on signs and symptoms of infection and to assess the skin/wound for any signs and symptoms of infection. P1's plan of care for wound care directed the nurse to cleanse/irrigate the wound on the stomach with normal saline, dry with gauze, prepare skin to peri-wound (tissue surrounding wound) with skin prep, fill the cavity with sponge foam, cover and secure with drape and apply tubing, then apply negative pressure at 125 mmHg (millimeters of mercury) continuously. In addition, the plan indicated nursing could use wet to dry dressing as an alternative as needed or until machine was available. The skilled nurse was also to perform wound care to a left ankle incision using normal saline, pat dry, cover with gauze, secure with tape, and cover with ACE bandage. An incident reported by the Home Care Agency to the State Agency dated 3/4/21, indicated on 3/1/21, P1 had been seen by the wound clinic team who discovered a sponge had been left in P1's wound at some point, causing it to grow into the tissue enough that it required surgical removal on 3/3/21. According to the facility's report, the agency administrator (who was also the director of nursing) questioned whether licensed practical nurse (LPN)-A had reviewed the wound vac and wound cares instructions thoroughly during a skilled nursing visit on 2/15/21, or subsequent visit, and as a result had removed only one sponge instead of two as she did not realize there had been two sponges in the stomach wound cavity. The administrator indicated during the investigation, registered nurse (RN)-A, a case manager who had completed the start of care (SOC) on 2/12/21, had taken a photo supporting no material had been left inside the wound cavity, before she applied two sponges inside the wound cavity prior to applying the wound vac. The report further indicated P1 had told the wound clinic nurse she no longer wanted the agency to provide wound care and preferred to go to the wound clinic three times a week, as P1 was upset that the agency likely caused this issue. During a review of P1's medical record the following was revealed: -A start of care progress noted documented by RN-A dated 2/12/21, referenced a SOC OASIS (Outcome and Assessment Information Set) assessment dated 2/12/21, indicating P1 had a recent surgery to her stomach for ventral hernia repair and the wound had been infected more than once with trouble healing. According to the note, during the visit RN-A indicated the wound showed no signs and symptoms of infection. RN-A indicated at the time of arrival into P1's home it was observed P1 had a wet to dry dressing in place because the wound vac had come off. The note indicated RN-A had removed the dressing, cleansed the wound with normal saline, patted the area dry, placed 2 pieces of sponge to the wound bed to cover the depth of the wound, covered sponge/wound with drape, cut hole in drape, applied wound vac to sponge, covered with drape and set the wound vac at 125 mmHg continuous. -A nursing visit note dated 2/15/21, indicated after LPN-A had removed two sponges from inside P1's wound, she measured the wound, cleansed the abdomenal wound with normal saline, cut a sponge cut to fit, applied a drape over the sponge, and the wound vac was attached to the drape with good suction. LPN-A documented P1's wound bed granulation was 100%, the drainage was serosanguinous (a substance comprised of both blood cells and serum) with moderate drainage amount, and documented the wound had a slight odor. The nursing visit note also indicated during the visit P1's abdominal surgical wound had been measured, with a moderate amount of serosanguinous drainage noted. The note did not include a description of the wound bed or surrounding tissue. -A nursing visit note by LPN-A dated 2/17/21, documented the old dressings had been removed, the abdomen wound was cleansed with normal saline, the sponge was cut to fit, drape was placed over sponge, the wound vac was attached to drape and the suction was good. LPN-A further documented there were no concerns at the time. -A nursing visit note documented by LPN-A dated 2/19/21, indicated P1's dressing had been removed with covering and sponges, and a slight odor was noted as present. It was also noted P1 had stated she had changed the canister (container in a wound vac for collecting drainage). The note indicated LPN-A had cleansed P1's abdomen wound with normal saline, a sponge was cut to fit, a drape placed over sponge, wound vac attached to drape and the suction was good. -A communication note documented by RN-A dated 2/19/21, indicated RN-A had received a call from LPN-A who reported having received a call from P1 indicating she [P1] felt air in the dressing on her abdomen. RN-A stated she had called P1 back and asked if the wound vac had any alarms going off which P1 denied. The note indicated RN-A had instructed P1 to call back with further concerns and P1 had acknowledged understanding. -A nursing visit note documented by LPN-A dated 2/22/21, indicated P1 was laying in bed for wound care, the old dressings were removed, and a slight odor was noted as present. The note indicated P1 had stated she had changed the canister. LPN-A's note described the care, P1's abdomen wound was cleansed with normal saline, drape was then placed, hole cut to fit sponge, the sponge was cut to fit, the drape was placed over sponge, the wound vac was attached to the drape, and the suction was good. LPN-A documented there were no signs or symptoms of infection noted, and P1 was educated on signs/symptoms of infection. Additionally, LPN-A documented that during the visit P1's abdominal surgical wound had been measured and a moderate amount of serosanguinous drainage had been noted however, there was no documented description of the wound bed and surrounding tissue. -A communication note dated 2/22/21, indicated LPN-A had called the wound clinic and spoken to a nurse there who stated P1 needed to be seen by the surgeon, but did not indicate why LPN-A had contacted them. Further the note indicated when LPN-A had called the surgeon's office she was told P1 should be seen by the wound clinic instead. The note indicated LPN-A had called the wound clinic back again and was told by the wound clinic nurse they would be in touch with P1 to schedule a follow up appointment. The note did not indicate whether LPN-A had notified either the surgeon's office, or the nurse at the wound clinic of the odor noted in P1's wound. -A nursing visit note documented by LPN-A dated 2/24/21, indicated when P1's old dressings were removed, there was a slight odor noted to be present. The note indicated the abdomen wound was cleansed with normal saline, a drape was placed, the hole was cut to fit sponge, then the sponge was cut to fit, the drape was placed over sponge, was attached to the wound vac, and was suctioning good. LPN-A's note indicated there were no signs or symptoms of infection noted, and P1 was educated on signs/symptoms of infection. The note did not indicate whether LPN-A had asked P1 about any follow up from the wound clinic to verify an appointment had been made. -A nursing visit note documented by LPN-A dated 2/26/21, indicated P1's old dressings were removed, the abdominal wound was cleansed with normal saline, the drape was placed, the hole was cut to fit sponge, the sponge was cut to fit, the drape was placed over sponge, and the wound vac was attached to the drape which was suctioning good. LPN-A's documentation did not indicate any assessment of the wound's odor. Further, the note indicated the skilled nurse was to follow up with P1's wound clinic about a follow up appointment scheduled for 3/1/21. During an interview on 3/15/21, at 2:12 p.m. RN-A stated she had completed the SOC visist for P1 on 2/12/21, and at the time when she arrived, P1 had a wet to dry dressing in the abdominal wound with no wound vac attached. RN-A stated she took a photo of the wound which showed there was nothing inside the cavity. RN-A then stated she applied two pieces of sponge to the wound cavity after she had cleansed the wound and draped it appropriately then attached the wound vac. RN-A also stated after the SOC, LPN-A was assigned to conduct the follow up wound care visits. RN-A described P1's wound at the SOC, as not deep even at the deep part of the wound, the wound bed was pink, and the physician's order was to put two sponges in the deeper part of the wound. RN-A also stated there was no odor noted at the SOC. RN-A stated she had not been informed P1's wound had a "slight odor" during subsequent visits completed by LPN-A until P1 had gone to the clinic on 3/1/21. RN-A stated she would have expected LPN-A to notify her, or the medical provider right away to notify them there was an odor present. RN-A stated, "When there is anything out of the normal, nursing staff are to notify the case manager. When I see a new patient I will send a note and if there is wound care ordered, I will let the nurse know how the visit went. I sent a note to [LPN-A] on 2/13/21, to tell her how many sponges needed to be put into the wound." RN-A stated on 2/15/21, LPN-A had responded by text letting her know she hadn't had a chance to look at P1's orders before going to see P1, and hadn't seen the text until later that day. RN-A stated when she received LPN-A's response, she thought LPN-A had not read the orders before she went to see P1 and by the time she'd messaged LPN-A back, her visit was already completed. RN-A stated LPN-A swore she had not left any sponge in the wound. RN-A further stated the agency policy was all the nurses were supposed to review the wound orders which included the referral documents before completing wound care. During an interview on 3/15/21, at 2:49 p.m. LPN-A stated she provided wound care to P1 which involved a wound vac. LPN-A stated during a visit she would also review the patient's body systems and gather vital signs. LPN-A stated when she had called RN-A before the first visit with P1, she'd had a few questions about the orders but RN-A was not available, so she had just proceeded to do the visit. LPN-A stated when she first saw P1, she had applied 2 sponges into the abdominal wound after she'd cleansed the wound. LPN-A then stated, "The wound was deep, and I had to use my finger to feel around, and I guess I missed the sponge. I was not able to see the base of the wound." LPN-A acknowledged in the initial and subsequent visits she had not documented how many sponges she had used, or removed from the wound bed. LPN-A also acknowledged she had not updated the RN-A, the case manager, when she first noted the wound had an odor. LPN-A stated, "I should do that [update the case manager] more often." LPN-A stated after she had noticed the odor, that was when she had called the surgeon and the wound clinic arrange to have P1 seen. LPN-A stated she had not followed through to make sure the wound clinic had gotten in contact with P1 timely. LPN-A also acknowledged she had not documented why she had contacted the wound clinic and the surgeon. LPN-A said she should have assisted P1 to follow up with the wound clinic during and after her visits on 2/22/21 and 2/24/21, as P1 had not heard from the wound clinic. LPN-A sated, "that was something I should have done." During an interview on 3/15/21, at 3:17 p.m. the administrator/DON (director of nursing) stated she would have expected the physician and the case manager to have been notified when LPN-A first noticed the odor from the wound 2/15/22. The administrator/DON stated she had not heard about anything regarding the wound until right P1's 3/1/21 wound clinic appointment when they discovered the sponge. The administrator/DON stated when she was made aware of the allegation she had initiated an investigation and interviewed both LPN-A and RN-A. The administrator/DON stated from her interviews, she believed LPN-A had not reviewed the wound care orders for P1 prior to making her first visit on 2/15/21. The administrator/DON stated she thought that may have been when the sponge was left in P1's abdominal wound cavity. The administrator/DON also stated following the incident she had also reached out to P1 but had been unsuccessful reaching her. She stated moving forward, part of the new process would be to ask LPN-A to make sure she reviewed the orders before a visit. The administrator/DON also stated she was going to require the RN to do one visit weekly for all patient's with wound care to make sure they were aware of the condition of the wounds. She also said the RN would be responsible to review the notes for improvement and provide education as needed. The administrator/DON stated currently the agency did not have anyone on a wound vac and said she was going to review LPN-A's nursing skills to make sure she was competent. She said she was going to have LPN-A report everything to the RN case manager per the agency's protocols. The administrator/DON stated, "We will be looking at our wound policies and documentation moving forward because we do not want this to happen again." During an interview on 3/16/21, at 5:01 p.m. P1 stated initially she had been going to the wound clinic for her wound care but had fallen and broken her ankle so was not able to go out, so she was admitted to the agency for wound care. P1 stated the first time RN-A had come to do the SOC she had completed the wound care and applied the wound vac. P1 also stated RN-A had told her for subsequent visits, LPN-A would be completing the visits. P1 stated the first visit by LPN-A was on 2/15/21. P1 stated, "On Monday [2/15/21] when [LPN-A] came the first time, she took one sponge out and put two more in the wound." P1 said, "[LPN-A] took the top sponge and the top dressing off and put the dressing back with two sponges but never removed the other sponge. I didn't ask her because I thought she knew her job. I kept telling her my wound was smelling and then another week went by and at this time the wound looked like it was closed up and did not need the wound vac or wound care anymore I thought." P1 also stated LPN-A had seen her for two weeks, and in the third week on 3/1/21, when she [P1] went to the wound clinic, the nurse there asked her if she had noticed the odor of the wound. P1 said she told the nurse it had been smelling the previous weeks, and she and LPN-A were trying to figure out the smell. P1 stated, "During the wound clinic visit, the doctor saw the sponge and when they had tried to pull it out, it was breaking in pieces because the skin had grown over the sponge. They had to do surgery remove it. I don't know how she did not see the sponge because she stood over me looking into my stomach wound. You could see the sponge standing over me. I could tell there was something in my stomach and if she was standing over me, she had to have seen it. I had to go through another surgery to remove the sponge. She was supposed to help me to get better from the surgery I had in December, but now I am still not well." The agency's undated policy Nursing Services 24/7, directed the nurses to inform the physician, and other staff of changes in a client's condition/needs. In addition, the policy directed staff to coordinate services including referral to other services as needed, and services were to be furnished in accordance with the patient's specified plan of care which was accessible 24 hours a day, 7 days per week.

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 interview and document review, the agency failed to assess wounds as directed in the plan of care (POC), to show progress towards goals, for 3 of 3 patients (P1, P2, P3), reviewed who received wound care treatment as reviewed for wound care. Findings include: P1 was admitted to the agency on 2/12/21, with diagnoses which included infection following a procedure other surgical site, schizoaffective disorder and chronic pain syndrome. P1's plan of care for certification period 2/12/21 to 4/12/21, indicated P1 had three wounds on the left lateral ankle, medial left ankle and the abdomen from a hernia surgery. The plan of care also identified P1 received skilled nursing (SN) three times a week for eight weeks for wound care and one visit as needed in case the wound vacuum (device that decreases air pressure on wound to help in wound healing) had issues and the nurse needed to see P1. In addition, the plan of care indicated skilled nursing was to assess and perform a complete physical assessment with each visit with emphasis on wounds. During review of the skilled nursing visits completed by both the registered nurse (RN) and the licensed practical nurse (LPN) it was revealed although the skilled visits had been completed on 2/12/21, through 2/26/21, the wound documentation assessments did not include the undermining/tunneling (occurs when the tissue under the wound edges becomes eroded, resulting in a a pocket beneath the skin at the wound's edge), pain in the wound, tissue loss, wound edges, surrounding tissue description and the tissue type/color. P2 was admitted to the agency on 12/13/19, with diagnoses which included pressure ulcer of left heel, stage 3 (full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia.) pressure ulcer of left ankle, stage 4 (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling) and paraplegia (impairment in motor or sensory function of the lower extremities). P2's plan of care for the certification period of 12/7/20 to 2/4/21, and 2/5/21 to 4/5/21, indicated P2 received SN three times a week for wound cares. The plan of care also indicated the skilled nurse was to perform a complete physical assessment at each visit with emphasis on wounds. During a review of the skilled nursing visit notes completed by both LPN's and RN's it was revealed although visits for both recertification periods had been completed on 12/7/20 through 3/15/21, the wound documentation assessments did not include the undermining/tunneling, pain in the wound, tissue loss, wound edges, surrounding tissue description and the tissue type/color. P3 was admitted to the agency on 1/25/21, with diagnoses which included Hidradenitis suppurativa (a condition that causes painful bumps under the skin in the hair roots near some of the sweat glands) and type 2 diabetes mellitus without complications. P3's plan of care for certification period of 1/25/21 through 3/25/21, identified P3 had recently had surgery to the back of his head for hidradenitis excision thus the back of his head was completely open. In addition, the plan of care indicated P3 received SN twice daily for wound care and directed the skilled nurse to perform a complete physical assessment each visit with emphasis on wounds. During a review of the skilled nursing visit notes completed by both LPN's and RN's it was revealed although visits had been completed on 1/25/21 through 3/15/21, the wound documentation assessments did not include the undermining/tunneling, pain in the wound, tissue loss, wound edges, surrounding tissue description and the tissue type/color. During an interview on 3/15/21, at 2:12 p.m. RN-A stated after she completed the start of care assessments the LPN's did the follow up weekly visits and would only fill in with vacations, sick days, busy schedules and recertification's. RN-A stated wound assessment and measurements was completed on Mondays and this was mostly completed by the LPN. RN-A stated she would assess the wound every 60 days with recertification's unless she had seen the patient on the day the wound was to be measured. RN-A reviewed all three patient medical records and verified the wound documentation on the wound flow sheet did not include the undermining/tunneling, pain in the wound, tissue loss, wound edges, surrounding tissue description and the tissue type/color. RN-A acknowledged the nurses were doing the assessments for the wounds however thought they may not be charting thoroughly as it was part of their job to assess and document the wounds accurately. During an interview on 3/15/21, at 3:17 p.m. the administrator/director of nursing (DON) stated she was going to require the registered nurse to do one visit weekly for all the wounds just to make sure they were aware of the wound condition and the RN would review the notes for improvement and provide education as needed. The administrator/DON also stated "We will be looking at our wound policies and documentation moving forward because we do not want this to happen again." The agency's undated Nursing Services 24/7 policy, directed the nurses to inform the physician, and other staff of changes in a client's condition/needs. In addition, the policy directed staff to coordinate services including referral to other services as needed and services were to be furnished in accordance with the patient's specified in the plan of care which was accessible 24 hours a day, 7 days per week.