Every finding on record at Shands Jacksonville Medical Center Inc

During the recertification survey conducted on 3/18-20/2024 at UF Health Home Care-Jacksonville, Emergency Preparedness was reviewed. UF Health Home Care-Jacksonville is in compliance with Emergency Preparedness per Code of Federal Regulations (CFR) 42, Part 484.22, Condition of Participation for Home Health Agencies.

A recertification survey was completed on March 18-20, 2024 at UF Health Home Care-Jacksonville. The facility was not in compliance with 42, CFR 424.22 Requirements for Home Health Services. .

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on agency policy reviews, record reviews and staff interviews, the agency failed to ensure all physician verbal orders for wound care were recorded in the medical record for 1 (#3) patient out of 3 patients sampled with wound care. The findings include: A review was conducted of the agency policy titled Plan of Care, policy number HH-08-24, with an effective date of 06/17/00 and a revision date of 12/27/2021. The policy documents the Subject: Plan of Care Purpose: Development of the plan of care is a collaborative effort by the registered nurse, therapist, and social worker in conjunction with the patient and the primary physician. 7. The plan of care shall be updated as necessary by obtaining verbal or written orders. All such orders shall be sent to the physician for signature. Documentation of the physician's signature shall be scanned into the medical record prior to releasing the final bill for that episode of care. A review of the agency policy titled Physician Orders policy number HH-825, with an effective date of 06/17/00 and a revision date of 8/16/2023, revealed Policy: "Physician orders must be obtained for all services provided in conjunction with such professional services." A review of the medical record for Patient #3 revealed an admission date of 6/01/2023 and a current certification period of 1/27/2024 through 3/26/2025 with a primary diagnosis of encounter for orthopedic following surgical amputation and a pertinent diagnosis of Type 2 with diabetic angiopathy with gangrene. The plan of care (POC) documented Orders for Discipline and Treatment: Skilled Nursing 3 times a week for 9 weeks. A review of the skilled care intervention on page 3 of 6, the POC revealed orders for skilled nurse "(SN) to perform wound care treatment/dressing change using aseptic technique on each visit and as needed due to problems/complications. Teach the patient/caregiver all aspects of Wound Vac management, dressings, and equipment safety, including settings, managing and drainage, and signs/symptoms of problems/malfunction to report to the SN/physician and the wound vac provider." The POC revealed: Goals/Rehabilitation Potential/Discharge Plans on page 5 of 6: "Wound #1: Type surgical wound, amputation of right 5th toe. Treatment/Dressing order: Cleanse area; pat dry apply Xeroform to wound bed, cover, and secure with kerlix." The POC for DME (Durable Medical Equipment) and supplies for equipment in the home listed: Adult briefs, alcohol prep pads, cane, dressing supplies, exam gloves, glucometer, hand gel, thermometer, walker, and wound vac system. An interview was conducted with the Director of Nursing (DON) on 3/19/2024 at 1:26 PM. The DON confirmed the order for the wound vac had been discontinued. "Patient #3 had a physician appointment on 1/23/2024. The nurse did not update the POC. The order did not make it to the patient's chart." A review of the nursing notes for Patient #3 for 1/25, 1/31, 2/05, 2/07, 2/09, 2/12, 2/16, 2/19, 2/1, 2/23. 2/26, 2/28, 2/01, 3/04, 3/06, 3/08, 3/11, 3/13 and 3/15/2024 reflected: SN for wound care. The wound was washed with wound cleanser and redressed as ordered. An interview was conducted with the DON on 3/19/2024 at 1:34 PM. The DON said that Patient #3 had a physician appointment on 9/26/2023 and the orders were changed to apply Prisma dry sterile dressing on Mondays, Wednesdays, and Fridays (MWF). Patient #3 had a follow-up appointment on 1/23/2024 with Plan: to continue home health care MWF, can discontinue (D/C) Prisma/Collagen and swap to Medihoney, to be changed every other day. "The nurse did not update the POC."