Every finding on record at Omega Plus Home Health Care LLC

A survey, prompted by CO#102465, was completed on 11/28/23. One deficiency was cited.

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 interview and record review, the agency failed to ensure wound care treatments were administered by agency staff only as ordered by a physician for 1 of 1 patients reviewed who received wound care (Patient #4). Findings include: 1. The clinical record for Patient #4 was reviewed on 11/28/23. The plan of care for the certification period dated 11/6/23 to 1/4/24 revealed a start of care date of 7/14/22; diagnoses included stage four chronic kidney disease, dependance on renal dialysis, osteomyelitis, post-traumatic stress disorder (PTSD), anxiety and depression, edema, hypertension, type 2 diabetes mellitus with other skin conditions, sleep apnea and insomnia, muscle weakness, heart failure and gastro-esophageal reflux disease (GERD). The plan of care orders included skilled nursing (SN) services three times weekly for medication management, medication set up, teaching, monitoring side effects, blood glucose monitoring as needed (PRN) and insulin administration reminder; and certified nurse aide (CNA) services once weekly to assist with activities of daily living (ADLs). a) The agency failed to ensure wound care was provided only as ordered by the physician. Review of Patient #4's recertification verbal order, received on 11/3/23, revealed Patient #4 was to receive SN services three times weekly for medication management, medication set up, teaching, monitoring side effects, blood glucose monitoring PRN and insulin administration reminder; and CNA services once weekly to assist with ADLs. Review of the plan of care for the certification period dated 11/6/23 to 1/4/24 included the following order for wound care to the left great toe: "cleanse wound with wound cleanser, pat dry, skin prep surrounding the wound, apply silversorb [sic] gel, cover surrounding with xeroform, cover wound with 2x2 gauze, secure tape using aseptic technique". Further review of the plan of care failed to show the physician signed and authorized the services being provided to the patient after the previous certification period ended on 11/5/23. Clinical record review revealed Registered Nurse (RN) #1, who was also the agency administrator and director of nursing (DON), provided wound care to the left great toe for Patient #4 on 11/6/23, 11/8/23, 11/10/23, 11/13/23, 11/15/23, 11/17/23, 11/20/23, 11/22/23, 11/24/23 and 11/27/23. This was a total of 10 visits conducted and wound care completed without the authorization of the physician. During an interview on 11/28/23 at 2:22 p.m., both RN #1 and Employee #2 confirmed the plan of care for Patient #4 for the certification period dated 11/6/23 to 1/4/24 had not yet been signed by the physician. Employee #2 continued to state the agency had faxed the plan of care to the physician multiple times but had not yet received a physician authorized plan of care. During a further interview at 2:31 p.m., RN #1 reviewed the verbal order and confirmed it did not include orders for wound care. She stated the wound care for Patient #4 was routine and hadn't changed from the previous certification period. She stated she thought since the wound care hadn't changed, the agency could continue to provide the wound care in accordance with the previous certification orders and had 30 days to receive the physician signed plan of care for the new certification period.