Every finding on record at Pruitthealth Home Health,Inc.

An onsite recertification survey was conducted October 9, 203-October 10, 2023. Standard level deficiencies to the Emergency Preparedness Plan were identified.

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 review of the “Emergency Operations Plan for Home Health” and staff interviews, the agency failed to review and/or revise the emergency plan at least every two years. Findings included: The “Emergency Operation Plan for Home Health” was provided by the clinical manager on 10/10/23 at 8:30 a.m. The plan had an effective date of 11/15/2017 and a review/revised date of 9/30/2020. The plan stated, “The Emergency Operations Plan will be reviewed and updated, at a minimum, of every two years.” An interview with the nurse consultant on 10/10/23 at approximately 9:00 a.m., confirmed the agency did not have evidence the plan had been reviewed/revised.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) 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 its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) 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. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on review of the “Emergency Operations Plan for Home Health”, review of the “Rehearsals/Drills/Exercise After Action Report Form”, and staff interviews, the agency failed to conduct testing of the emergency plan. Findings included: The “Emergency Operation Plan for Home Health” was provided by the clinical manager on 10/10/23 at 8:30 a.m. The plan had a review/revised date of 9/30/2020. The plan stated, “Agencies must participate in full-scale exercise that is community-based every two years; or When a community-based exercise is not accessible, conduct an individual facility-based functional exercise every two years; or If the agency experiences a natural or man-made emergency that requires activation of the emergency plan, the agency is exempt from engaging in its required community-based exercise or individual facility-based functional exercise following the onset of the emergency event. Agencies must conduct an additional exercise every two years, opposite the year the full-scale or functional exercise…” A review of the facility emergency drills revealed a fire drill was conducted on 6/21/21 and another fire drill on 6/30/23. There was no evidence the agency activated the emergency plan and no evidence of an exercise testing the emergency plan in 2022. An interview with clinical manager on 10/10/23 at approximately 3:00 p.m. confirmed the documented drills occurred on 6/21/21 and 6/30/23.

An onsite recertification survey was conducted October 9, 2023-October 10, 2023. Standard level deficiencies to the Medicare Conditions of Participation were identified.

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 policy review, home visit observation, clinical record review, and patient interview, the agency failed to conduct a comprehensive medication assessment for 2 of 4 patients with home visit observations (#4 and #9). Findings included: A policy, “Medication Management for Home Health” (reviewed/revised 7/21/23), was provided by the clinical manager on 10/10/23 at 1:20 p.m. The policy stated, “The admission staff will reconcile all identified medications with the medication orders given by the patient’s physician. If there is a discrepancy, non-compliance, interactions, precautions, contraindications and/or duplication therapy, or other concerns. [sic]. The nurse will contact the physician and/or pharmacist, verify orders, request changes, and/or instruct the patient/ care giver [sic] regarding the appropriate medication regime…Upon the patient’s admission, all medications, including prescribed, OTC [over the counter] and herbal, will be identified on the medication profile. 2. Patient #9 was admitted on 9/22/23 with Achilles tendinitis (a painful condition that affects the thick band of tissue that connects the calf muscle to the heel bone). The Plan of Care (POC) for 9/22/23-11/20/23 included orders for skilled nursing one time for one week, two times for one week, one time per week for five weeks, then every other week for two weeks; and physical therapy two times per week for four weeks, then weekly for four weeks. A joint home visit was made with RN #2 on 10/10/23 at 9:30 a.m. A medication review was conducted with the patient during the visit. Patient #9 stated that she takes Tylenol 500 mg every night for pain. She stated that she had taken Tylenol since she was discharged from the skilled nursing facility (SNF) prior to home health admission. The medication review also revealed the patient took Miralax 17 grams as needed for constipation since SNF discharge. Melatonin 5 mg nightly for sleep was on the POC. The patient confirmed that she had not taken Melatonin in approximately a year. During the home visit, RN #2 confirmed the medication discrepancies. 1.Patient #4 was admitted on 9/27/23 with diagnoses of cellulitis (infection) of right lower limb and hypertensive heart disease. The Plan of Care (POC) for 9/27/23-11/25/23 included orders for skilled nursing visits 2 times a week for 1 week, and 1 time a week for 8 weeks. A home visit was conducted with the registered nurse on 10/10/23 at 10:30 a.m. A medication review was conducted and revealed the following discrepancy: -Lantus solostar 100 unit/ml (milliliter) take 20 units 2 times a day by subcutaneous injection (into the skin) for diabetes Interview with the patient on 10/10/23 at 10:48 a.m. revealed he isn’t taking 20 units 2 times a day anymore he just takes it as needed per his doctors’ instructions.

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 client record review, and staff interview the agency failed to include PICC (peripherally inserted central catheter) line measurements for 2 of 2 patients with a PICC line (#2 and #7), wound measurements for 1 of 3 patients with wounds (#7). Findings included: 1.Patient #2 was admitted on 12/15/22 with diagnoses of type 2 diabetes and anemia (low hemoglobin in the blood). The plan of care for 12/15/22 to 02/12/23 had orders for skilled nursing 1 time a week for 1 week, 2 times a week for 1 week, and 1 time a week for 7 weeks. Review of the skilled nursing notes for the weeks of 12/15/22, 1/5/23, 1/12/23, and 1/19/23 revealed PICC line measurements were not obtained for these weeks. 2a. Patient #7 was admitted on 05/09/23 with diagnoses of pressure ulcer of left buttock, stage 4, (severe tissue damage) sepsis (infection in blood), encounter for adjustment and management of vascular access device. The plan of care for 09/06/23 to 11/04/23 had orders for skilled nursing 2 times a week for 1 week, 3 times a week for 6 weeks, 6 times a week for 1 week and 3 times a week for 1 week. Orders for skilled nursing included: access site care for infusion access device PICC (peripherally inserted central line) catheter dressing changes once a week and prn (as needed) for loose or soiled dressing. Skilled nurse to change PICC line dressing 1 times a week using sterile technique, document in cm (centimeters) the length of catheter from hub to skin entry. Review of the skilled nursing notes for the weeks of 09/11/23 and 09/18/23 revealed PICC line measurements were not obtained for those weeks. Interview with Employee #2 on 10/10/23 at 1:13 p.m. revealed, “I only changed it on dressing change dates”. Interview with Employee #3 on 10/10/23 at 1:41 p.m. revealed, “our typical measurements are on Mondays for wounds and PICC lines”. 2b. Patient #7 was admitted on 05/09/23 with diagnoses of pressure ulcer of left buttock, stage 4, (severe tissue damage) sepsis (infection in blood), encounter for adjustment and management of vascular access device. The plan of care for 09/06/23 to 11/04/23 had orders for skilled nursing 2 times a week for 1 week, 3 times a week for 6 weeks, 6 times a week for 1 week and 3 times a week for 1 week. Orders for skilled nursing included: skilled nurse to assess and observe integumentary status to identify changes and intervene to minimize complications. Skilled nurse to cleanse wound to left ischium (curved bone of the pelvis) with chlorhexidine prepare peri wound area with skin prep fill entire cavity with grey foam, apply tubing and cover with transparent drape. Change dressing every Monday, Wednesday, and Friday or at least 3 times weekly, may use the following protocol as an alternative dressing as needed – wet to dry dressing. Review of the skilled nursing notes for the weeks of 09/11/23 and 10/2/23 revealed wound measurements were not obtained for these weeks. Interview with Employee #1 on 10/10/23 at 1:32 p.m. revealed,” I’m not seeing any measurements”. Interview with the agency clinical consultant on 10/10/23 at 2:01 p.m. revealed, “once a week is the policy of measuring wounds”.

An unannounced onsite recertification survey was conducted 7/12/21-7/14/21. No deficiencies to the Emergency Preparedness Plan was identified.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review and staff interviews the agency failed to update the Plan of care with the most current medications the patient was using for 2 of 14 charts [#1 and 5]. The findings included: The policy, Plans of Care for Home Health Patients [revised date of 12/20], was provided by the AVP [area vice president] on 7/20/21 at 9:30 am. The policy stated, “…The Plan of care will include the following…All medications and treatments…” 1. Patient # 1 had a Start of Care [SOC] date of 6/15/21 and an admitting diagnosis of chronic venous hypertension with ulcer and inflammation. A review of the Plan of Care [POC] for the certification period 6/15/21 to 8/13/21 contained orders for SN [skilled nursing] 2 times a week for 2 weeks; 1 time a week for 7 weeks. A review of the clinical record revealed on 6/24/21 RN # 4 obtained a urinalysis in accordance with the physician’s order. On 6/29/21 RN # 4 made a routine visit and documented the following information, “…Patient stated that her urine sample had revealed a urinary tract infection. Current treatment is adequate…” A review of the POC [medication profile] does not include the treatment the patient was receiving for the urinary tract infection. An interview was conducted with RN # 4 on 7/14/21 at approximately 11:30 am. During the interview RN # 4 confirmed he failed to update the POC with the new medication. 2. Patient # 5 had a Start of Care [SOC] date of 6/7/61 and admitting diagnoses of COVID-19, other vial pneumonia and dependence of supplemental oxygen. A review of the Plan of Care for the certification period 6/7/21 to 8/5/21 contained orders for PT [physical therapy] 1 time a week for 7 weeks. A review of the discharge orders from ______ [name of the facility] revealed the following orders, “3 liters oxygen by nasal canula.” PT # 5 signed the POC on 6/7/21. A review of the POC revealed Oxygen 2 liters was included on the POC. Oxygen 3 liters was not included on the POC. An interview was conducted with RN # 8 on 7/14/21 at approximately 10:00 am. During the interview RN # 8 confirmed the POC should have included Oxygen 3 liters not 2 liters.

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 agency policy, clinical record review and interviews with staff the agency failed to follow the Plan of Care [POC] related to wound care for 5 of 5 charts with wounds [# 1, 4, 6, 9, 14]; failed to follow skilled nurse visit frequency for 2 of 14 charts with nursing services [# 5 and 7]. The findings included: The policy, Plans of Care for Home Health Patients [revised date of 12/20], was provided by the AVP [area vice president] on 7/20/21 at 9:30 am. The policy stated, “…As determined by the comprehensive assessment, identified patient needs, and physician orders, a patient specific goal-directed plan of care is initiated with measurable outcomes and goals…The plan of care establishes a means of recording the patient’s plan of care, which reflects the current problems, planned interventions and expected outcomes of those interventions relating to the care and services which have been ordered…The plan of care serves to document the specific physician orders for each individual patient…” 1. Patient # 1 had a Start of Care [SOC] date of 6/15/21 and an admitting diagnosis of chronic venous hypertension with ulcer and inflammation. A review of the Plan of Care [POC] for the certification period 6/15/21 to 8/13/21 contained orders for SN [skilled nursing] 2 times a week for 2 weeks; 1 time a week for 7 weeks and “Skilled nurse to perform/teach wound care to right ankle venous stasis ulcer-clean with soap and water and pat dry. Apply Triamcinolone twice daily and leave open to air. Caregiver to care for wound when nurse not available…” A review of the clinical record revealed RN # 4 made routine visits on 6/18/21 and 7/6/21. The RN did not do the wound care on those dates. A review of the clinical record revealed the following documentation by RN # 4 for both dates, “…Wound care not provided. Caregiver completed care…” LPN # 2 made a routine visit on 6/22/21. A review of the clinical record revealed the LPN did not complete the wound care for 6/22/21. LPN # 2 documented,” …Wound care not provided. Caregiver completed care.” An interview was conducted with RN # 4 on 7/14/21 at approximately 11:30 am. During the interview the RN confirmed wound care was not provided in accordance with the POC. 2. Patient # 4 had a Start of Care [SOC] date of 6/10/21 and an admitting diagnosis of aftercare following surgery for neoplasm. A review of the Plan of Care [POC] for the certification period 6/10/21 to 8/8/21 contained orders for SN [skilled nursing] 1 time a week for 1 week; 2 times a week for 5 weeks; 1 time a week for 3 weeks and “Skilled nurse to perform/teach wound care to incision/suture site located on right lower extremity. Cleanse with saline or wound cleanser, pat dry, apply Vaseline then cover with nonstick gauze or band aid…change dressing daily and PRN [as needed] …patient/caregiver may perform wound care in absence of skilled nurse…” A review of the clinical record revealed LPN # 2 made a routine visit. LPN # 2 documented the following information, “…Wound care not provided. Caregiver completed care.” A phone interview was conducted with LPN # 2 on 7/14/21 at approximately 12:00 pm. During the interview LPN # 2 confirmed the she did not do wound care in accordance with the POC. 3. Patient # 6 had a Start of Care [SOC] date of 5/26/21 and an admitting diagnosis of aftercare following surgery for neoplasm. A review of the Plan of Care for the certification period 5/26/21 to 7/24/21 contained orders for 2 times a week for 1 week; 3 times a week for 8 weeks and “Skilled nurse to perform/teach wound care to incision/suture site located LLQ [left lower quad] drain site. Cleanse with wound cleanser or saline, cover with drain sponge and tegaderm…Skilled nurse to perform/teach wound care to incision/suture site located RLQ [right lower quad] drain site. Cleanse with wound cleanser or saline, cover with drain sponge and tegaderm…Patient/caregiver may perform wound care in absence of skilled nurse…” During the admission on 5/26/21 RN # 3 documented the following information related to wound care on the RLQ and LLQ, “Wound care not provided. Caregiver completed care.” On 5/31/21 RN # 4 made a routine visit. In the narrative section of the visit note, RN # 4 documented the following information, “Patient did not want dressing changes…” On 6/1/21 RN # 3 made a routine visit. A review of the wound section revealed the following information, “Wound care not provided. Covered with non-removable dressing.” Further review of the clinical record revealed the wound care was not preformed due to, “caregiver had already completed the care before the nurse arrived.” On 6/11/21 RN # 4 made a routine visit. A review of the wound assessment section revealed the RN did not do the wound care. RN # 4 documented the following information, “…Patient wishes not to have wound care done…” A review of the visits on 6/16/21 and 6/18/21 revealed RN # 3 made the visit. RN # 3 did not do wound care in accordance with the POC. RN # 3 documented, “Wound care not provided…patient refused.” An interview was conducted with RN # 4 on 7/14/21 at approximately 11:30 am. During the interview RN # 4 confirmed the wound care was not do in accordance with the POC on 5/31/21 or 6/11/21. A phone interview was conducted with RN # 3 on 7/14/21 at approximately 12:15 pm. During the interview RN # 3 confirmed wound care was not performed in accordance with the POC on 5/26/21, 6/1/21, 6/16/21 or 6/18/21. “The husband would do it before I arrived, and I didn’t see any reason to redo it behind him.” 4. Patient #9 had a start of care date of 04/22/21 with diagnoses including Traumatic Hemopneumothorax, Pulmonary Embolism, and Stage II Pressure Ulcer. A review of Patient #9’s Plan of Care (POC) for 04/22/21 – 06/20/21 episode of care revealed skilled nursing for one week two then three week seven. The orders included wound care to bilateral elbows: cleanse wounds with Chlorhexidine Gluconate (CHG), then apply ABD pad and cover with bordered foam shaped to fit joint and secure with medipore tape. The orders were for wound care to be performed three times a week. Wound care may be performed by caregiver in absence of nurse following appropriate teaching and return demonstration. A review of Patient #9’s start of care nursing assessment dated 04/22/21 revealed documentation that Employee #3, a Registered Nurse (RN) did not perform wound care to bilateral elbow wounds. There was also no proof of documentation that Employee #3 taught or observed Patient #9’s caregiver performed wound care bilateral elbows. There was no proof of documentation that the physician had been notified that wound care was not performed on Patient #9 on 04/22/21. A review of Patient #9’s nursing visit notes for 04/28/21 and 05/04/21 revealed Employee #1, a Licensed Practical Nurse (LPN) documented she performed the following wound care to bilateral elbows: cleansed with normal saline or wound cleanser, applied Viscopaste and covered with gauze. A review of Patient #9’s nursing visit note for 05/12/21 revealed no wound care was performed to Patient #9’s bilateral elbow wounds by Employee #3 and there was no proof of documentation that the physician had been notified. A review of Patient #9’s clinical record revealed a verbal order dated 05/26/21 written by Employee #2, a LPN, that read: ‘using clean technique cleanse with normal saline and pat dry. Apply iodossorb cream and cover with dry dressing or band aid.’ An interview was conducted on 07/14/21 at 11:21 a.m. with Employee #2. Employee #2 reported she did not remember obtaining the verbal order on 05/26/21 for Patient #9. Employee #2 confirmed all verbal orders should have frequency and what wounds the wound care was written. An interview was conducted on 07/14/21 at 11:44 a.m. with Employee #3. Employee #3 reported she did not remember if she watched Patient #9’s caregiver demonstrate wound care on the 04/22/21 nursing visit. Employee #3 confirmed she did not complete wound care on 04/22/21 nor 05/14/21. Employee #3 reported if she notified the physician that wound care was not completed it would be documented in Patient #9’s nursing note for the day wound care was not performed. An interview was conducted on 077/14/21 at 11:55 a.m. with Employee #1. Employee #1 reported Patient #9’s wound care orders changed frequently, and Employee #1 did not remember what wound care she performed on 04/28/21 and 05/04/21 5. Patient # 14 had a Start of Care [SOC] date of 3/22/21 and admitting diagnoses of pressure ulcer of right buttock, stage 2, pressure ulcer of left buttock, stage 2 and encounter for change or removal of non-surgical wound dressings. A review of the Plan of Care [POC] for the certification period 3/22/21 to 5/20/21 contained orders for SN [skilled nursing] 3 times a week for 3weeks; 2 times a week for 4 weeks; 1 time a week for 2 weeks and “skilled nurse to perform/teach pressure ulcer care to stage 2 pressure ulcers to bilateral buttocks. Cleanse with wound cleanser and pat dry. Apply Zinc Oxide generously. Cover with Viscopaste strips and secure with dry dressing…change daily and PRN [as needed]. May teach caregiver to change dressing when nurse not available.” A review of the clinical record revealed the following information: LPN # 1 made a routine visit on 3/29/21. In the wound assessment section, LPN # 1 documented the following information, “Left Buttock-Wound Care Provided-No, caregiver completed Care. Right Buttock-Wound Care Provided-No, caregiver completed Care.” On 4/5/21 LPN # 2 made a routine visit. A review of the visit note revealed LPN # 2 failed to do the wound care. LPN # 2 documented, “wound care not provided, caregiver completed care.” On 4/9/21 a supplemental order was written to, “Discontinue previous wound care…cleanse wounds with soap and water and pat dry. Apply Zinc Oxide Paste Twice daily and PRN. Wife may perform wound care when nurse not available.” Further review of the clinical record revealed LPN # 2 made routine visits on 4/15/21, 4/21/21 and 4/23/21. LPN # 2 documented, “wound care not provided, caregiver completed care.” On 7/14/21 at approximately 12:00 pm a phone interview was conducted with LPN # 2. LPN # 2 confirmed she did not do the wound care in accordance with the POC. 6. Patient # 5 had a Start of Care [SOC] date of 6/7/61 and admitting diagnoses of COVID-19, other viral pneumonia, and dependence of supplemental oxygen. A review of the Plan of Care [POC] for the certification period 6/7/21 to 8/5/21 contained orders for SN [skilled nursing] 1 time a week for 1 week; 2 times a week for 3 weeks; 1 time a week for 4 weeks. A review of the clinical record revealed only 1 SN visit was made a week of 6/27/21. An interview was conducted with RN # 4 [RN assigned to see the patient] on 7/14/21 at approximately 11:30 am. During the interview RN # 4 confirmed there was no 2nd visit that week and no missed visit information was sent to the physician. “I did the visit note in the computer. I failed to complete it and I didn’t send it to the physician.” 7. Patient # 7 had a Start of Care [SOC] date of 6/18/21 and an admitting diagnosis of other pulmonary embolism [blood clot-lungs]. A review of the Plan of Care [POC] for the certification period 6/18/21 to 8/16/21 contained orders for SN [skilled nursing] 1 time a week for 1 week; 2 times a week for 1 week; 3 times a week for 1 week; 2 times a week for 2 weeks; 1 time a week for 4 weeks. A review of the clinical record revealed only 2 SN visits were made the week of 6/27/21 [should have received 3 SN visits this week]. An interview was conducted with RN # 8 on 7/14/21 at approximately 10:00 am. During the interview, RN # 8 confirmed the POC was not followed related to SN visit frequency.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review and staff interviews the agency failed to coordinate possible changes in the patient’s condition and the patient’s refusal to have dressing changes for 2 of 14 charts [#4 and 6]. The findings included: The policy, “Coordination and Management of Home Health Services [revised date of 12.20], was provided by the AVP [area vice president] on 7/20/21 at 9:30 am. The policy stated, “…All partners providing services shall maintain effective interchange so that all services are effectively coordinated between the members of the Interdisciplinary Team, clearly outlining each member's responsibilities, in an effort to: Assure communication with all physicians involved in the plan of care…” 1. Patient # 4 had a Start of Care [SOC] date of 6/10/21 and an admitting diagnosis of aftercare following surgery for neoplasm. A review of the Plan of Care [POC] for the certification period 6/101/21 to 8/8/21 contained orders for SN [skilled nursing] 1 time a week for 1 week; 2 times a week for 5 weeks; 1 time a week for 3 weeks. A review of the clinical record revealed LPN # 2 made a routine visit on 6/22/21 and documented the following information in the clinical record, “…Client stated burning on urination…This nurse told client she would call her PCP [primary care physician] and ask for a urine sample. Client stated no she didn’t believe is uti…” There is no evidence the LPN made the RN or MD aware of the patient’s complaints. An interview was conducted with LPN # 2 on 7/14/21 at approximately 12:00 pm. During the interview the LPN stated, “I am sure I told the RN. I guess I just didn’t chart it.” An interview was conducted with RN # 8 on 7/14/21 at approximately 10:00 am. The RN reported she was not notified of the patient’s new complaints of dysuria. 2. Patient # 6 had a Start of Care [SOC] date of 5/26/21 and an admitting diagnosis of aftercare following surgery for neoplasm. A review of the Plan of Care for the certification period 5/26/21 to 7/24/21 contained orders for 2 times a week for 1 week; 3 times a week for 8 weeks and “Skilled nurse to perform/teach wound care to incision/suture site located LLQ [left lower quad] drain site. Cleanse with wound cleanser or saline, cover with drain sponge and tegaderm…Skilled nurse to perform/teach wound care to incision/suture site located RLQ [right lower quad] drain site. Cleanse with wound cleanser or saline, cover with drain sponge and tegaderm…Patient/caregiver may perform wound care in absence of skilled nurse…”A review of the clinical record revealed the patient refused to have wound care completed on 5/31/21, 6/11/21, 6/16/21 and 6/18/21. Further review of the clinical record reveals no evidence the physician was contacted regarding the patient’s refusal. An interview was conducted with RN # 4 on 7/14/21 at 11:13 am. During the interview the RN confirmed the MD was not made aware of the patient’s refusal for wound care. “No, I didn’t let him know.”