Every finding on record at Sanford Home Care

An unannounced onsite investigation survey regarding a complaint was completed on July 29, 2025. During the complaint investigation, the agency was found noncompliant with regulatory requirements.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review, policy review, and staff interview, the Agency failed to ensure the registered nurse (RN) conducted the initial assessment to determine the immediate care and support needs of the patient and determine Medicare eligibility within 48 hours of referral or return home for 1 of 1 sampled patient (Patient #1) reviewed with a wound VAC (vacuum-assisted closure; a medical device used to promote healing by applying negative pressure to the wound site). Failure to perform the initial assessment within 48 hours of Patient #1's return home did not allow the nurse to determine his immediate wound care needs. Findings include: Review of the agency policy titled "Admissions Process, Home Health" occurred on 07/29/25. This policy, dated 12/12/24, stated, ". . . Patients who are accepted for service should be admitted into the agency within 48 hours of referral unless otherwise specified by the provider. . . . When skilled nursing is ordered, the RN [registered nurse] must conduct an initial assessment visit to determine the immediate care and support needs of the patient. . . ." Review of Patient #1's medical record occurred on 07/29/25. Diagnoses included diabetes mellitus with foot ulcer, non-pressure chronic ulcer of right foot with necrosis (premature cell or tissue death), diabetic peripheral angiopathy (blood vessel disease of lower limbs), atherosclerosis (hardening of arteries) of right leg, and left leg below the knee amputation. A physician's order, dated 06/06/25, stated, "Clinic referral Home Health . . . Referral (New Request): . . . Reason: Continuity of Care . . . Type: Home Health Evaluation . . . Start Date: 6/6/2025 . . . Surgical Case Request: versijet [sic] debridement [method used for removal of damaged tissue from a wound] of right foot ulceration with application of integra [synthetic material used for wound healing] and a wound VAC 5/23/2025-6/30/2025 . . . Comments: Duration of care, frequency of visits, and homebound status to be assessed by Home Health. . . ." A nurse's initial assessment, dated 06/13/25, stated, ". . . Problem: Orders and Wound Therapy: Starting:6/13/2025 . . . Intervention: Negative pressure wound therapy orders . . . Encounter Notes: Home Health by [nurse's name] at 6/13/2025 12:20 PM . . . Primary focus of care: diabetic foot ulcer . . . Plan for future visits: SN [skilled nurse] 2x [two times] week . . . Additional Narrative: SN removed wound vac per orders and was unable to remove fully as staples have molded to vac drape and have to be removed in order to remove wound vac. . . ." A nurse's note, dated 06/18/25 at 10:30 a.m., stated, ". . . Transferred to an inpatient facility . . . wound infection . . ." During an interview on 07/29/25 at 3:15 p.m., a supervisory nurse (#1) verified the agency received Patient #1's referral order on 06/06/25. Failure to conduct the initial assessment within 48 hours of referral may have contributed to the nurse's inability to change the wound dressing and the patient's subsequent infection.