Every finding on record at Mizell Memorial Hospital Homecare, LLC

A recertification survey was conducted from 4/8/25 to 4/10/25. The agency was found to be in substantial compliance with the Conditions of Participation for Emergency Preparedness.

A recertification survey was conducted at LHC Homecare of South Alabama from 4/8/25 to 4/10/25. Standard level deficiencies were cited and will require an acceptable Plan of Correction.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on review of medical records (MR), observations, agency policy and procedure, and interviews with staff, it was determined the agency failed to ensure agency policy and procedure for infection prevention were followed. This deficient practice did affect three of seven home visits (HV) including HV # 4, HV # 5, and HV # 7, and had the potential to affect all patients receiving care by this agency. Agency Policy: Cleaning of Re-Useable Equipment Policy Number: 8.006 Revised: 6/1/22 Purpose: To ensure equipment required for patient care is clean and sanitized to prevent the spread of infections. Equipment that comes in contact with non-intact skin will undergo intermediate level disinfection. Definition: Intermediate-Level Disinfection: destroys vegetative bacteria, mycobacterium tuberculosis and most fungi. It neutralizes most viruses but does not kill bacterial spores. Agency Policy and Procedure: Hand Hygiene Policy Number: 8.004 Revised: 5/1/19 Purpose: To help prevent the spread of microorganisms and infection by cross-contamination and to provide practice guidelines. Policy: Staff are required to perform hand hygiene prior to, at specified points during, and following patient contact. Hand hygiene will be performed using soap and water or an alcohol-based hand sanitizer. Procedure: 1...f. before and after removal of personal protective equipment (PPE). 3. HV # 7 was admitted on 3/14/25 with diagnoses including Chronic Diastolic (Congestive) Heart Failure, Chronic Kidney Disease, and Cellulitis of Left Lower Limb. Review of the Home Health Certification and Plan of Care dated 3/14/25 revealed physician's orders for SN one visit per week for nine weeks to perform procedure of wound care to wound # 1, distal pretibial venous stasis ulcer, # 2 distal lower leg venous stasis ulcer, and wound # 3 distal lower leg venous stasis ulcer. A HV was conducted on 4/9/25 at 9:25 AM to observe wound care provided by EI # 5, Registered Nurse. EI # 5 removed dressing from left lower leg with gloved hands then removed the gloves, failed to perform hand hygiene, and donned new gloves and measured the wound. EI # 5 then cleansed the wound with 4 x 4 soaked with normal saline, removed the gloves then donned new gloves and applied clean dressing to the wound. EI # 5 failed to perform hand hygiene after removing contaminated gloves. An interview was conducted on 4/10/25 at 3:50 PM with EI # 1, who confirmed the staff failed to follow agency hand hygiene policy. 1. HV # 4 was admitted on 3/15/25 with diagnoses including Non-ST Elevation (NSTEMI) Myocardial Infarction, and Type 2 Diabetes Mellitus (DM) with Foot Ulcer. Review of the Home Health Certification and Plan of Care dated 3/15/25 revealed physician's orders for Skilled Nurse (SN) one visit per week for one week then two visits per week for eight weeks to perform procedure of wound care to wound # 5, left mid-dorsum, surgical incision, # 6, right mid-edge foot, diabetic ulcer, and wound # 7, right posterior edge foot, diabetic ulcer. A HV was conducted on 4/8/25 at 11:35 AM with Employee Identifier (EI) # 3, Licensed Practical Nurse (LPN) to observe wound care. EI # 3 performed hand hygiene, donned gloves, removed soiled bandage from patient's right foot wound with bandage scissors, and placed scissors on table with clean wound supplies. EI # 3 picked up the bandage scissors from table, cut clean wound dressing, and applied to wound bed on right foot. EI # 3 failed to cleanse the bandage scissors after removing soiled bandage, and prior to cutting wound dressing. An interview was conducted on 4/10/25 at 3:20 PM with EI # 1, Executive Director (ED) who confirmed staff failed to follow the agency policy for cleaning of re-useable equipment. 2. HV # 5 was admitted on 11/26/24 with diagnoses including Other Complications of Procedures, Necrotic, and Type 2 DM with Other Specified Complication. Review of the Home Health Certification and Plan of Care dated 3/26/25 revealed physician's orders for SN one visit per week for one week, then two visits per week for eight weeks to perform procedure of wound care to wound # 2, left fifth toe, diabetic ulcer. A HV was conducted on 4/9/25 at 9:05 AM with EI # 4, Registered Nurse (RN) to observe wound care. EI # 4 performed hand hygiene, donned gloves, removed soiled bandage from patient's left foot wound with bandage scissors, and placed scissors on table with clean wound supplies. EI # 4 picked up the bandage scissors from table, cut clean wound dressing, and applied to wound bed on left foot. EI # 4 failed to cleanse the bandage scissors after removing soiled bandage, and prior to cutting wound dressing. An interview was conducted on 4/10/25 at 3:22 PM with EI # 1, who confirmed staff failed to follow the agency policy for cleaning of re-useable equipment.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on medical record review, agency policy, and interview with staff, it was determined the agency failed to ensure wounds were assessed and measured per agency policy. This deficient practice affected one of nine patients reviewed with wounds including Home Visit (HV) # 7 and had the potential to affect all patients with wounds. Agency Policy: Wound Assessment, Documentation, and Photography Policy Number: 2.2.001 Revised: 9/1/24 Purpose: To ensure the accurate and consistent assessment and documentation of wounds. Policy: Upon initial and subsequently as indicated below, all wounds will be assessed with appropriate documentation in the medical record... Unless otherwise ordered by the physician, the qualified clinician ... will assess wounds at least: Weekly for patients ... receiving daily wound care performed by the agency, have an infected wound... Every other week for patients receiving wound care by the agency at least at a frequency less than daily... The assessment includes measurement of the length, width, and depth... 1. HV # 7 was admitted on 3/14/25 with diagnoses including Chronic Diastolic (Congestive) Heart Failure, Chronic Kidney Disease, and Cellulitis of Left Lower Limb. Review of the Home Health Certification and Plan of Care dated 3/14/25 revealed physician's orders for Skilled Nurse (SN) 3 times a week for eight weeks to perform procedure of wound care to wound # 1, distal pretibial venous stasis ulcer, wound # 2 distal lower leg venous stasis ulcer, and wound # 3, distal lower leg venous stasis ulcer. Review of the SN Visit Note Reports for the week of 3/16/25, 3/23/25 and 3/30/25 revealed no documentation of each of the wound measurements. An interview was conducted on 4/10/25 at 3:40 PM with Employee Identifier # 1, Executive Director, who confirmed the staff failed to measure wounds per agency policy.

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on review of Medical Records, agency policy and procedure, and interview, it was determined the agency failed to ensure wound care education with return demonstration was provided. This deficient practice affected two of nine patients with wounds reviewed including Home Visit (HV) # 1, HV # 2, and had the potential to affect all patients requiring wound care education. Findings include: Agency Policy: Patient Education Policy Number: 3.001 Revised: 11/1/17 ...Policy: The agency plans, supports, and coordinates patient and caregiver education designed to promote optimal patient health... Procedure: ...3. The patient and caregiver receive ongoing information specific to the identified needs...including... b. Patient/caregiver plan of care responsibilities... 1. HV # 1 was admitted on 2/2/25 with diagnoses including Displaced Fracture of Left Tuberosity, Unspecified Fracture of Left Patella, and Essential (Primary) Hypertension. Review of the Home Health Certification and Plan of Care revealed physician's orders for Skilled Nurse (SN) one visit per week for nine weeks to perform/instruct patient/caregiver the procedure for wound care to pressure ulcer of the coccyx. Patient/caregiver to cleanse wound with warm soap and water, pat dry with clean towel, and cover with foam dressing daily. Review of the SN Visit Note Reports from 2/2/25 through 2/20/25 revealed no documentation the patient or caregiver was provided instructions for wound care or return demonstration. The wound was healed on 2/20/25 and the wound care was discontinued. An interview was conducted on 4/10/25 at 3:20 PM with Employee Identifier (EI) # 1, Executive Director, who confirmed the staff failed to provide patient and or caregiver education for care of the wound. 2. HV # 2 was admitted on 3/8/25 with diagnoses including Encounter for Change or Removal of Nonsurgical Wound Dressing, and Abrasion of Left Upper Arm. Review of the Home Health Certification and Plan of Care dated 3/8/25 revealed physician's orders for SN one visit per week for nine weeks. SN to perform/instruct patient/caregiver procedure of wound care to wound # 8 mid forearm and wound # 9 left elbow, cleanse with warm soap and water, dry using a clean towel, and leave open to air. Review of the SN Visit Note Reports dated 3/8/25 through 4/3/25 revealed no documentation the patient or caregiver was provided education for the care of the wounds. An interview was conducted on 4/10/25 at 3:45 PM with EI # 1 who confirmed the staff failed to provide patient and or caregiver education for care of the wounds.

An onsite recertification survey was conducted on 5/10/22 to 5/12/22. LHC Homecare of South Alabama was found to be in substantial compliance with the Centers for Medicare and Medicaid Services requirements for Emergency Preparedness.

A recertification survey was conducted on 5/12/22 at LHC Homecare of South Alabama and standard level deficiencies were cited.

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 observations, review of medical records (MR), agency policy, and interviews, it was determined the agency failed to ensure staff reconciled medications in 2 of 5 Home Visits (HV) conducted, including HV # 2, HV # 5, and had the potential to negatively affect all patients receiving services by this agency. Findings include: Agency Policy: Monitoring Medications Policy Number: 10.008 Revised Date: 5/1/19 Purpose: To provide process to ensure continuous monitoring of medications in the patient's home. Policy: A drug regimen review will be performed on all patients in conjunction with all comprehensive assessments. Additionally, all clinicians will participate in medication review and reconciliation throughout the episode. For patients receiving skilled nursing and therapy services, the skilled nurse is responsible for medication review and reconciliation throughout the episode. The therapist will participate by monitoring and reporting any identified medication issues...to the Patient Care Manager. 2. HV # 5 was admitted 4/20/22 with diagnoses including Non-ST Elevation (NSTEMI) Myocardial Infarction and Sepsis. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 4/20/22 revealed orders for the skilled nurse to visit 2 times per week for 3 weeks, then 1 time per week and Occupational Therapy (OT) was to visit 1 time per week for 2 weeks, 2 times per week for 2 weeks, then 1 time per week. A HV was conducted 5/10/22 at 1:15 PM with EI # 6, OT, to observe care provided. EI # 2 was also present. The medications in the home were compared with the Client Medication Report (CMR) provided by the agency and the following discrepancies were found and confirmed by the patient and EI # 2: a. Promethazine 25 mg (milligrams) one every 12 hours as needed for nausea was in the home and not listed on the CMR. The patient confirmed this was a current medication prior to admission to home health and had been taken yesterday. b. Ventolin 90 mcg (micrograms) 2 puffs every 6 hours as needed was in the home, currently in use, and not on the CMR. The patient confirmed he/she was on this inhaler prior to admission to home health. c. Dulera 100 mcg / 5 mg 2 puffs twice daily was in the home, currently in use, and not listed in the CMR. The patient confirmed he/she was on this inhaler prior to admission. d. Hydrocodone 7.5 mg / 325 mg 1 three times per day as needed for pain was in the home, currently in use and the CMR had Hydrocodone 10 mg / 325 mg listed. The patient stated it had always been 7.5 mg tablets since prior to admission. During the HV, EI # 2 confirmed the medication list was not accurate and up to date. 1. HV # 2 was admitted to the agency on 4/14/22 with diagnoses including Transient Cerebral Ischemic Attack, Unspecified and Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. A HV was conducted on 5/10/22 at 11:04 AM with Employee Identifier (EI) # 3, Physical Therapy Assistant, to observe care performed. EI # 2, Clinical Director, was present during the HV. During the HV the patient's in home medications were compared to the Medicine List, printed on 5/10/22, provided by the agency to the surveyor. Lantus Insulin 100 Units/ml (units/milliter) Subcutaneous (SQ) injection 75 Units daily was found in home with the bottle dated 4/27/22. The caregiver confirmed via phone the patient was taking 75 Units daily and had been on the 75 Units for "...awhile". Review of the agency Medicine List revealed documentation of Lantus Insulin 100 Units/ml SQ 55 Units every pm (evening). An interview was conducted with EI # 1, Executive Director, who confirmed HV # 2's Medication List had not been updated per the agency policy.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on Medical Record (MR) review and staff interview it was determined the agency staff failed to document conformance with physician orders for the following: 1. Insertion of Peripheral Intravenous (IV) catheter. 2. Flushing of IV prior to and post IV medication administration. 3. Skilled Nurse (SN) and Physical Therapy to Assess Capillary Blood Glucose (CBG) every visit. This deficient practice did affect 1 of 1 MR reviewed with IV administration of medication, including Home Visit (HV) # 4, and had the potential to affect all IV patient's served by the agency and HV # 2, MR # 2 and MR # 6, 3 of 6 MR's reviewed with Diabetes and had the potential to negatively affect all patient's served by the agency with Diabetes. Findings Include: 4. MR # 6 was admitted 4/23/21 with diagnoses of Non-Displaced Fracture of Greater Trochanter Right Femur and Essential (Primary) Hypertension. Review of the HHC and POC dated 4/23/21 to 6/21/21 revealed Physician orders for the Physical Therapist (PT) ...Assess CBG every visit, notify MD if CBG is less than 70 (mg/dl) or greater than 250 mg/dl... Review of the PT visit notes dated 4/27/21, 4/29/21, 5/1/21, 5/4/21, 5/19/21, and 5/26/21 revealed no documentation of CBG was assessed. An interview was conducted on 5/11/21 at 2:38 PM with EI # 2, Clinical Director, who confirmed there was no documentation of CBG assessments on those dates. 1. HV # 4 was admitted to the agency on 3/18/22 with diagnoses including Encounter for Orthopedic Aftercare following Surgical Amputation and Type 2 Diabetes mellitus with Other Specified Complication. Review of the Physician Order dated 3/24/22 revealed an order for the Skilled Nurse (SN) to administer Dalvance 1500 mg (milligrams) IV weekly times 2 weeks by "...attach 10 ml (milliter) of Normal Saline and flush before IV medication administration... Remove IV tubing after infusion.... Attach 10 ml Normal Saline and flush..." and to "...insert peripheral IV as follows: prep (preparation) site with alcohol swab x (times) 1. Insert # 22 or # 24 Gauge Jelco..." Review of the SN Visit Note Report (VNR) dated 3/24/22 revealed documentation a 20 Gauge Jelco was inserted for the peripheral IV access. There was no documentation of what was used to prep the IV site. Further review revealed the IV was flushed before and after IV infusion of Dalvance with Dextrose. The SN failed to follow physician orders for the gauge of Jelco to be used for IV access and solution used to flush IV site prior to and post infusion. Review of the SN VNR dated 4/1/22 revealed documentation a 22 Gauge Jelco was insert for the peripheral IV access. There was no documentation of what was used to prep the IV site. Further review revealed the IV was flushed before and after IV infusion of Dalvance with Dextrose. The SN failed to follow physician orders the solution used to flush IV site prior to and post infusion. An interview was conducted on 5/11/22 at 3:22 PM with Employee Identifier (EI) # 2, Clinical Director, who confirmed SN failed to follow physician orders for the prep of the IV site, flushing of the IV before and after IV infusion on the above dates and gauge of the Jelco used on 3/24/22. 2. HV # 2 was admitted to the agency on 4/14/22 with diagnoses including Transient Cerebral Ischemic Attack, Unspecified and Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 4/14/22 to 6/12/22 revealed a SN frequency of once a week for 4 weeks and an order for "patient/caregiver to perform blood glucose testing 3 times daily...and record in healthcare journal. SN to review healthcare journal and notify MD (Medical Doctor) of CBG outside of therapeutic range. Patients therapeutic CBG range is 60 mg/dl (milligrams per decilitre) to 250 mg/dl." Review of the SN VNR dated 4/20/22 revealed no documentation of a CBG assessment to assess if the patients CBG was within physician ordered therapeutic range. An interview was conducted on 5/11/22 at 2:14 PM with EI # 1, Executive Director, who confirmed there was no documentation of a CBG assessment on 4/20/22. 3. MR # 2 was admitted to the agency on 4/21/22 with diagnoses including Hypertensive Chronic Kidney Disease with Stage 1-4 Unspecified Chronic Kidney Disease and Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. Review of the HHC and POC dated 4/21/22 to 6/19/22 revealed a SN frequency of once a week for 9 weeks and orders for the patient to perform CBG testing 4 times daily with a therapeutic range of 60 mg/dl to 300 mg/dl and for the agency staff to report a CBG below 60 or above 300 to the physician. Review of the SN VNR dated 4/25/22 and 5/7/22 revealed no documentation of a CBG assessment to assess if the patients CBG was within physician ordered therapeutic range. An interview was conducted on 5/11/22 at 1:49 PM with EI # 1, who confirmed there was no documentation of a CBG assessment on 5/7/22.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on review of agency policy and procedure, medical records, (MR) and interviews it was determined the agency failed to ensure physician verbal orders were written and submitted to the ordering physician for signature. This affected 2 of 13 records reviewed including HV # 5, MR # 8, and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Physician Orders Policy Number: 2.1.008 Effective Date: 11/01/21 Policy: No medications, treatments...will be administered without the order of a qualified physician...and that order be reduced to writing and signed/dated by the ordering physician. Procedure: 11. Orders containing medication must be entered...and include... a. Name of the medication, dose... g. Signature/date of physician/authorized practitioner. 1. HV # 5 was admitted 4/20/22 with diagnoses including Non-ST Elevation (NSTEMI) Myocardial Infarction and Sepsis. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 4/20/22 revealed orders for the skilled nurse (SN) to visit 2 times per week for 3 weeks, then 1 time per week. Review of the SN visit note dated 4/26/22 revealed the SN contacted the physician, completed a verbal order and updated the medication list. Review of the physician's order dated 4/27/22 revealed DC (discontinue) Entresto 24 mg (milligram) - 26 mg tablet. The order was marked "Do Not Send" in the physician signature line and was not signed by the physician. An interview conducted 5/11/22 at 3:30 PM with Employee Identifier (EI) # 1, Executive Director, confirmed the order to DC the medication was not sent / signed by the physician and it should have been sent for signature. 2. MR # 8 was admitted 2/14/21 with diagnoses including Fractured Pelvis and Malignant Neoplasm of Left Breast. Review of the HHC and POC dated 2/14/21 revealed the SN was to visit 3 times per week for 1 week, 2 times per week for 1 week, then 1 time per week. Review of the SN visit note dated 2/14/22 revealed the caregiver requested the SN contact the physician for a pain medication that could be given every 4 hours to keep pain at bay. Review of the physician's order dated 2/15/22 revealed Ibuprophen 200 mg take 2 tablets 3 times per day as needed for pain. The order was marked "Do Not Send" in the physician signature line and was not signed by the physician. An interview conducted 5/11/22 at 2:35 PM with EI # 2, Clinical Director, confirmed the verbal order was not sent / signed by the physician and should have been submitted for signature.

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 review of Medical Records (MR), agency policy and procedure and interviews it was determined the agency staff failed to notify the physician with changes in: 1. Wound measurements 2. Daily weights 3. Capillary Blood Glucose (CBG) outside of ordered parameters This deficient practice affected 1 of 4 MR's reviewed with wounds, including Home Visit (HV) # 4, and HV # 1, 1 of 2 MRs reviewed with daily weights including MR # 6 and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Coordination of Care, From Admit through Discharge Policy Number: 2.1.017 Revised Date: 8/1/19 Purpose: To establish processes and criteria so that the coordination of patient care will be optimal from admit through discharge. Policy: The agency provides care and services within an integrated continuum of care system... Procedure: ...4. Coordination of care with physician: At admission, throughout care...coordination of services is promoted through routine communication with the patient's physician: a. When changes occur in the patient's condition or response to treatment... 2. HV #1 was admitted 5/16/21 and recertified for care 3/12/22 to 5/10/22 with diagnoses Pressure Ulcer of Right Heel, Stage Two and Venous Insufficiency (Chronic) (Peripheral). Review of the HHC and POC dated 3/7/22 revealed the following Physicians Orders: SN to obtain weights each visit and notify Registered Nurse (RN)/ Medical Doctor (MD) of weight gain of 3 pounds (lbs) or greater overnight or five lbs or greater in one week... Review of the SN visit note dated 4/20/22, revealed the SN recorded the patient's weight as 165 lbs. Review of the SN visit note dated 4/24/22,revealed the patient's weight was documented as 171 lbs. This is a gain of 6 lbs. in five days There was no documentation that the MD was notified of the 6 lb weight gain.. Review of the SN visit note 5/2/22, the patient's weight was documented as 175 lbs. This is a gain of 10 lbs. in 12 days. There was no documentation that the MD was notified of the 10 lb weight gain. An interview was conducted on 5/12/22 at 8:44 AM with Employee Identifier (EI) #1, Executive Director, who confirmed SN should have notified MD of the 6 -10 lb increase in the patient's weight. 3. MR #6 was admitted 4/23/21 with diagnoses Non-Displaced Fracture of Greater Trochanter of Right Femur, and Essential (Chronic) (Primary) Hypertension. Review of the HHC and POC dated 4/23/21 revealed the following Physician's orders: Physical Therapist (PT) ...Assess Capillary Blood Glucose (CBG) every visit, notify MD if less than 70 milligrams per deciliter (mg/dl) or greater than 250 mg/dl. Review of the PT visit note dated 4/23/21 revealed the PT documented patient's CBG as 268 mg/dl. There was no documentation that MD was notified of CBG greater than 250 mg/dl. Review of the PT visit note dated 5/12/21 revealed the PT documented a CBG of 251 mg/dl. There is no documentation that MD was notified of CBG greater than 250 mg/dl. An interview was conducted on 5/11/22 at 2:38 PM with EI #2 who confirmed the PT did not and should have notified the Physician of the elevated CBG's. 1. HV # 4 was admitted to the agency on 3/18/22 with diagnoses including Encounter for Orthopedic Aftercare following Surgical Amputation and Type 2 Diabetes mellitus with Other Specified Complication. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 3/18/22 to 5/16/22 revealed a Skilled Nurse (SN) frequency of once a week for 1 week, then three times a week for 8 weeks, then once a week for 1 week. Review of the Physician Order dated 4/15/22 revealed an order for SN to perform wound care to wound # 4 Right Medial Distal Dorsum, surgical incision 3 times weekly as follows: Cleanse wound with Normal Saline and gauze, pat dry with gauze, apply skin prep to peri wound and allow to air dry. Apply Santyl 250 mg (milligrams) to plantar slough then allow to air dry. Window pane peri wound area with transparent dressing/drape, pack undermined or tunneled areas with white foam, apply black foam to wound bed and secure with drape...attach tubing to negative pressure device at 125 mm/hg (millimeters of mercury) continuous negative pressure... Review of SN Visit Note Reports (VNR) dated 4/29/22 revealed wound measurement documentation for wound # 4 as 4 centimeters (cm) in length, 4.5 cm in width, and 0.1 cm in depth. Review of the SN VNR dated 5/2/22 revealed wound measurement documentation for wound # 4 as 3.6 cm in length, 8 cm in width, and 0.1 cm in depth, which was an increased wound width of 3.5 cm. There was no documentation the physician was notified of the wound's increased width. An interview was conducted on 5/11/22 at 3:22 PM with Employee Identifier # 2, Clinical Director, who confirmed there was no documentation the physician was notified of wound # 4's increased width on 5/2/22.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on Medical Record (MR) review, agency procedure and staff interview it was determined the agency staff failed to document Wound VAC (negative-pressure wound therapy vacuum assisted closure) wound filler dressing per agency procedure. This deficient practice did affect 1 of 1 MR's reviewed with a wound VAC, including Home Visit (HV) # 4, and had the potential to affect all patient's with wound VAC served by the agency. Findings Include: Agency Procedure: Alert Date: No date When using negative-pressure wound therapy (NPWT)... Document the number of pieces of wound filler (black foam) dressing that are applied and removed from the wound with every dressing change... 1. HV # 4 was admitted to the agency on 3/18/22 with diagnoses including Encounter for Orthopedic Aftercare following Surgical Amputation and Type 2 Diabetes mellitus with Other Specified Complication. Review of the Home Health Certification and Plan of Care dated 3/18/22 to 5/16/22 revealed a Skilled Nurse (SN) frequency of once a week for 1 week, then three times a week for 8 weeks, then once a week for 1 week to perform wound care to wound # 4 Right Medial Distal Dorsum, surgical incision 3 times weekly as follows: "...apply black foam (cut to fit) to wound bed and secure with drape..." Review of SN Visit Note Report(s) (VNR) dated 3/18/22, 3/23/22, 4/1/22, 4/13/22 and 4/15/22 revealed the SN documented wound care was performed by the SN and black foam was added to the wound bed of wound # 4. There was no documentation of how many pieces of black foam were removed from wound # 4 nor how many pieces of black foam were applied to wound # 4. An interview was conducted on 5/11/22 at 3:22 PM with Employee Identifier # 2, Clinical Director, who confirmed there was no documentation on the above dates of how many pieces of black foam were removed nor added to wound # 4 per the agency procedure.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on review of medical records (MR), agency policy and procedure, and interview, it was determined the agency failed to ensure medical record documentation was complete and accurate with exact wound care provided. This affected 1 of 1 MRs reviewed with a wound VAC (Vacuum Assisted Closure) including Home Visit (HV) # 4, and had the potential to negatively affect all patients served by this agency. Findings include: Agency Policy: 2.2.001 Subject: Wound Assessment, Documentation, and Photography Date Revised: 12/1/21 Purpose: To ensure the accurate and consistent...documentation of wounds. Policy: Upon initial visit and subsequently as indicated below, all wounds will be assessed with appropriate documentation within the MR. Procedure ...3. Document the following in the MR: ...i. Exact wound care performed, following physician orders. 1. HV # 4 was admitted to the agency on 3/18/22 with diagnoses including Encounter for Orthopedic Aftercare following Surgical Amputation and Type 2 Diabetes mellitus with Other Specified Complication. Review of the Home Health Certification and Plan of Care dated 3/18/22 to 5/16/22 revealed a Skilled Nurse (SN) frequency of once a week for 1 week, then three times a week for 8 weeks, then once a week for 1 week to perform wound care to wound # 4 Right Medial Distal Dorsum, surgical incision 3 times weekly as follows: "...pack underminded (undermined) or tunneled areas with white foam, apply black foam (cut to fit) to wound bed and secure with drape..." Review of 10 of 13 SN Visit Note Reports (VNR) dated from 3/18/22 to 4/14/22 revealed documentation wound # 4 had no undermining nor tunneling. Further review of the SN VNR's dated 3/18/22 to 4/14/22 revealed SN documentation of wound care to wound # 4 as "...packed underminded (undermined) or tunneled areas with white foam..." Review of the Physician Orders dated 4/15/22 revealed an order for SN to perform wound care to wound # 4 Right Medial Distal Dorsum, surgical incision 3 times weekly as follows: "...pack underminded (undermined) or tunneled areas with white foam, apply black foam (cut to fit) to wound bed and secure with drape..." Review of 11 of 11 SN VNR dated from 4/15/22 to 5/10/22 revealed documentation wound # 4 had no undermining nor tunneling. Further review of the SN VNR's dated 4/15/22 to 5/10/22 revealed SN documentation of wound care to wound # 4 as "...packed underminded (undermined) or tunneled areas with white foam..." A HV was conducted on 5/11/22 at 9:10 AM with Employee Identifier (EI) # 4, Licensed Practical Nurse, to observe a wound care to HV # 4 using wound VAC. During the observation, the surveyor observed EI # 4 placement of black foam into the wound with no white foam used. The surveyor asked EI # 4, if there was white foam in the patient's home. EI # 4 looked through the wound care supplies and verbalized there was no white foam in the home and to his/her knowledge no white foam has ever been in the home because it has not been used for the HV # 4's wound care. An interview was conducted on 5/11/22 at 3:22 PM with EI # 2, Clinical Director, who verbalized white foam has never been applied by the agency staff to HV # 4's wound and confirmed the white foam should not have been documented as applied in the SN VNRs dated 3/18/22 to 5/10/22.