Every finding on record at Sterling Medcare Home Health Inc

A recertification survey was completed on 4/29/25. Two deficiencies were cited.

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 interview, and record review, the agency failed to ensure the individualized plan of care included complete orders for interventions or treatments, in 1 of 1 patients receiving Foley (urinary) catheter care (Patient #5). Findings include: 1. The clinical record for Patient #2 was reviewed on 4/25/25. The plan of care for the certification period dated 3/6/25 to 5/4/25 revealed a start of care date of 3/11/24; diagnoses included encounter for fitting and adjustment of urinary device, presence of urogenital implants, multiple sclerosis, acute kidney failure, anemia, neuromuscular dysfunction of bladder and personal history of urinary tract infections. Plan of care orders include skilled nursing (SN) services once monthly for three months to perform straight catheter procedure and measure and record residual once a month and as needed. a) The agency failed to ensure the plan of care included complete Foley (urinary) catheter orders. Review of the plan of care dated 3/6/25 to 5/4/25 revealed orders for SN to assess genitourinary status, instruct patient on indwelling catheter self-management and using aseptic technique, perform/teach patient to perform straight catheter procedure once a month and as needed and to measure residual and record. However, the catheter care orders did not include the size of the catheter to be used, what size balloon and how to secure it. Review of the physician orders, dated 2/29/24, showed "Please change catheter once monthly w/16 Fr coude" (16 French (Fr) refers to the catheter's diameter and "coude" refers to the type of catheter used). During an interview on 4/28/25 at 3:52 p.m. Registered Nurse (RN) #5 stated she typically documented the frequency of catheter changes and the type of catheter used on the plan of care. She further stated she should document the balloon size, but didn't. RN #5 confirmed the plan of care for Patient #5 did not contain any information on the type of catheter used, the tube or balloon size or any indication of how the catheter was to be secured and stated information like that was usually relayed verbally from clinician to clinician and that was how she remembered receiving the information from the patient's previous nurse. During an interview on 4/29/25 at 10:54 a.m. the administrator and director of nursing (DON) stated the agency's expectation for documentation of catheter orders on the plan of care would include the type and size of the catheter and the frequency of the catheter change. She stated the orders should be transcribed from the physician order to the plan of care and then to the nursing visit note. She confirmed the patient-specific catheter information was not documented on the plan of care for Patient #5.

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 interviews and record reviews, the agency failed to ensure services and treatments were administered by agency staff only as ordered by a physician in 5 of 7 patient records reviewed (Patients #1, #2, #3, #6 and #7). This deficiency was cited previously during a federal recertification survey on 4/27/22. Although the agency corrected the deficiency, based on the findings below, the agency has not maintained compliance with this regulatory requirement. Findings include: A. The agency failed to ensure physician orders were received prior to the provision of care following the initial start of care assessment. 1. The clinical record for Patient #3 was reviewed on 4/25/25. The plan of care for the certification period dated 4/13/25 to 6/11/25 revealed a start of care date of 4/13/25; diagnoses included encounter for change or removal of nonsurgical wound dressing, pressure ulcers multiple sites, right sided hemiplegia, polyneuropathy, radiculopathy, repeated falls, and dependence on wheelchair and supplemental oxygen. Plan of care orders included skilled nurse (SN) visits once weekly for one week, three times weekly for eight weeks and as needed (PRN) for pressure ulcer care to multiple areas using aseptic technique, wound care management based on physician orders and patient instruction on wound care performance and assess wound progression or decline. a) The agency failed to ensure the SN provided services only as ordered by the physician. Review of the plan of care for the certification period dated 4/13/25 to 6/11/25 revealed Patient #3 was to receive wound care three times weekly. Review of SN visit notes revealed RN #6 provided wound care on 4/15/25, 4/19/25, 4/21/25 and 4/23/25. The plan of care had not been signed to date and there was no evidence the agency received a verbal order from Patient #3's physician establishing the plan of care and authorizing SN care and services following the start of care assessment completed on 4/13/25. During an interview on 4/28/25 at 2:41 p.m., the agency's intake coordinator confirmed she was responsible for ensuring plans of care were signed by the physicians and the agency received verbal orders timely. She stated if the physician was local, she would often go to the physician's office and receive a physical signature from the physician but if they were not local, she sent the plan of care via facsimile (fax) to be signed by the physician. She confirmed she was aware some of the plans of care were not being signed by the physician before services were rendered and stated "that's how it's always been." During an interview on 4/29/25 at 10:51 a.m., the administrator/director of nursing (DON) stated the agency sometimes had a difficult time getting orders signed by physicians in a timely manner. She stated the agency believed having the referral order for the start of care was sufficient. She confirmed services were being provided to Patient #3 before the physician approved and authorized the plan of care and would work to change the agency's process moving forward to ensure the agency demonstrated compliance and had physician approval for care and services. 2. Similar findings of services and treatments being provided to patients prior to the physician authorizing and approving the plan of care was found with Patients #1, #6 and #7. B. The agency failed to ensure wound care was provided only as ordered by the physician. 1. The clinical record for Patient #2 was reviewed on 4/25/25. The plan of care for the certification period dated 3/5/25 to 5/3/25 revealed a start of care date of 1/4/25; diagnoses included encounter for change or removal of nonsurgical wound dressing, venous insufficiency, type 2 diabetes mellitus, edema, lymphedema and unspecified moderate dementia. Plan of care orders included SN visits once weekly for one week, then twice weekly for eight weeks for wound care to bilateral lower extremity stasis ulcers. Wound care orders included "cleanse with wound cleanser, apply xeroform to wound beds, wrap with kerlix and coban 2x/wk [twice weekly] until healed." a) The agency failed to ensure the SN provided wound care only as ordered by the physician. Review of the plan of care for the certification period dated 3/5/35 to 5/3/25 revealed wound care orders which included wound cleanser, xeroform, kerlix and coban. However, review of the SN visit note, dated 4/4/25, showed RN #5 documented "toe wound cleansed, dressed with neosporin and bandages at patient request." The clinical record failed to reveal a physician's order for the use of neosporin, a deviation from the established plan of care orders for wound care. During an interview on 4/25/25 at approximately 9:00 a.m., RN #5 confirmed she applied the neosporin because the patient requested it and she did not have a physician's order to do so. During an interview on 4/29/25 at 10:53 a.m. the administrator/DON stated she was not aware RN #5 had deviated from the established wound care orders for Patient #2. She stated agency RNs should know they need to have an order for every treatment provided to the patient.

A recertification survey was completed on 4/27/22. Two deficiencies were cited.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure each patient received home health services in accordance with a written plan of care established and periodically reviewed by a physician. This failure occurred for 1 of 2 discharged patient records reviewed (Patient #7). This deficiency was previously cited during a federal certification inspection on 7/24/19. Although the agency corrected the deficiency, based on the findings below, the agency had not maintained compliance with this regulatory requirement. Findings include: AGENCY POLICY According to the policy, "Physician Orders," undated (in part): "All medications, treatments and services provided to the clients must be ordered by a physician. The orders may be initiated via telephone or in writing and must be countersigned by the physician in a timely manner. Orders may be obtained via facsimile; however the agency is responsible for obtaining an original signature if it would be required by surveyors or other regulatory personnel. A system will be used by the agency to ensure the telephone orders are signed and dated by the physician and returned to the client's clinical record within an appropriate time frame. Agency will implement a tracking system to assure timely response." According to the policy, "Medical Supervision," undated (in part): "The client's primary physician shall be responsible for providing signed orders, and for establishing and reviewing the client's Plan of Care throughout the time the client is receiving services. To assure the participation of physicians in the development and maintaining of the client plan of care. The physician-signed Plan of Care will include: -Description of client needs. -Clients' goals. -Description of specific services to be provided and supplies necessary to carry out the services. -A list of actions to be taken for delivery of care including type, frequency, and duration of actions. Tracking will be done to facilitate return of signed medical orders within an appropriate time frame. (Note: State/Agency Specifies) If problems are encountered in obtaining orders or if a physician refuses to sign orders, the Director of Clinical Services/designee will be notified." 1. During an interview on 4/25/22 at 3:44 p.m., the administrator stated once a patient was admitted to the agency, the admitting clinician would obtain a verbal order from the physician for services prior to completing the plan of care. She stated the administrative assistant, Employee #9, was responsible for printing out all orders needing physician signatures (verbal orders and plans of care) and taking them to the physician's offices to obtain the signatures. 2. The clinical record for Patient #7 was reviewed on 4/27/22. The plan of care for the certification period dated 1/29/22 to 3/29/22, revealed a start of care date of 1/29/22; diagnoses included encounter for change or removal of surgical wound dressing, mechanical complication of internal right hip prosthesis, infection/inflammation reaction due to internal right hip prosthesis, streptococcus, and encounter for therapeutic drug monitoring. Plan of care orders included skilled nursing (SN) once weekly for 10 weeks for venipuncture to obtain labs weekly, perform intravenous (IV) access via PICC (Peripherally inserted central catheter) line, perform weekly sterile dressing changes to right upper extremity PICC line; and physical therapy (PT) services twice weekly every three weeks then once weekly for five weeks. a) The RN failed to obtain plan of care orders in a timely manner after the initial evaluation. Review of the plan of care for the certification period dated 1/29/22 to 3/29/22 revealed Patient #7 initiated services with the agency on 1/29/22 to receive PICC line dressing changes and venipuncture lab draws weekly. There was no indication the registered nurse (RN) who completed the initial comprehensive assessment, RN #10, obtained verbal orders to establish the plan of care. Additionally, there was no physician signature indicating the physician reviewed, approved and established the plan of care for SN care and services. Review of the discharge summary for Patient #7, completed by RN #10, showed the patient was discharged from the agency on 3/23/22, following removal of the PICC line, with recommendations to continue with outpatient services. The plan of care for the certification period dated 1/29/22 to 3/29/22 signed by the physician was requested from the agency on 4/27/22 at 10:12 a.m. and again at 11:28 a.m. At 11:30 a.m., the administrator provided the requested plan of care that was signed and dated by the physician on 4/27/22, 89 days following the initial start of care and 35 days following the patient's discontinuance of agency services. During an interview on 4/27/22 at 12:02 p.m., the administrator confirmed Employee #9 was responsible for obtaining physician signatures on verbal orders and plans of care. During an interview on 4/27/22 at 12:10 p.m., Employee #9 stated the alternate administrator reviewed all plans of care through the agency's quality assurance. She stated when the alternate administrator completed the review of a document, she put a "sticky note" on it that stated "Approved Print" and that notified Employee #9 to print a physical copy of the plan of care and either physically take them to the local physician offices for signature or send them via facsimile (fax) to physicians who were not local. Employee #9 continued to state she typically called the physician's office if she hadn't received the signed orders after approximately seven to 10 days. She stated, if she had difficulty receiving signed orders from physicians, she notified the administrator or alternate administrator. Employee #9 reviewed the electronic medical record (EMR) of the patient's she had sent orders out for physician signature and she thought the agency had already received the signed plan of care for Patient #7. Employee #9 further stated once signed physicians orders were received by the agency, she uploaded the signed order into the patient's EMR and checked the checkbox that indicated the signed order had been received. During an interview on 4/27/22 at 12:16 p.m., the administrator stated the checkbox in the EMR next to the plan of care for the certification period dated 1/29/22 to 3/29/22 for Patient #7 must have been inadvertently checked off and therefore the missing signed order would not populate on a report as pending. However, she further stated she was not currently running any reports to show orders with pending physician signatures but that it would be a good idea to start doing so.

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 services and treatments were administered by agency staff only as ordered by a physician for 1 of 1 patient records reviewed who received certified nurse aide (CNA) services (Patient #4). Findings include: AGENCY POLICY According to the policy, "Physician Orders," undated (in part): "All medications, treatments and services provided to the clients must be ordered by a physician. The orders may be initiated via telephone or in writing and must be countersigned by the physician in a timely manner. All medications and treatments, that are part of the client's plan of care, must be ordered by the physician." 1. The clinical record for Patient #4 was reviewed on 4/27/22. The Plan of Care for the certification period dated 1/26/22 to 3/26/22 revealed a start of care date of 9/7/12; diagnoses included autistic disorder, attention deficit hyperactivity disorder, eating disorder, morbid obesity, delayed physical development and, fecal and urinary incontinence. Plan of care orders included skilled nurse (SN) visits for recertification and certified nurse aide (CNA) supervision (no frequency was noted), and parent CNA visits for five hours per day, seven days per week to assist with activities of daily (ADLs), independent activities of daily (IADLs), assistance in toileting, meal preparation, light housekeeping and protective oversight. Subsequent plan of care orders for the certification period dated 3/27/22 to 5/25/22 included SN visits for recertification and CNA supervision (no frequency was noted), and parent CNA visits for five hours per day, seven days per week to assist with ADLs, IADLs, assistance in toileting, meal preparation, light housekeeping and protective oversight. a) The agency failed to ensure the CNA provided services only as ordered by the physician. i. Review of the plan of care for the certification period dated 1/26/22 to 3/26/22 revealed CNA #6 was to provide services to Patient #4 four visits daily, for approximately five hours per day, seven days weekly for bathing, toileting, peri care, skin care, oral care, hair care, nail care, dressing, meal preparation, cueing for safe eating, protective oversight and light housekeeping. The plan of care was signed by the physician on 1/31/22. There was no evidence the agency received a verbal order from Patient #4's physician establishing the plan of care and authorizing CNA care and services after the end of the previous certification period on 1/25/22. Review of a comprehensive reassessment, completed by registered nurse (RN) #12 on 1/25/22, revealed Patient #4 continued to require skilled services and care coordination was completed with CNA #6. There was no evidence of care coordination with the physician for Patient #4. Review of completed visit notes from 1/26/22 through 3/26/22 revealed Patient #4 received CNA services daily for approximately five hours each day. However, the record failed to reveal evidence of a verbal physician order or intermittent physician order establishing the plan of care for the certification period dated 1/26/22 to 3/26/22 until 1/31/22. This was a period of five days CNA #6 provided care and services to Patient #4 without physician authorization and approval. ii. Review of the plan of care for the certification period dated 3/27/22 to 5/25/22 revealed CNA #6 was to provide services to Patient #4 four visits daily, for approximately five hours per day, seven days weekly for bathing, toileting, peri care, skin care, oral care, hair care, nail care, dressing, meal preparation, cueing for safe eating, protective oversight and light housekeeping. There was no evidence the agency received a verbal order from Patient #4's physician establishing the plan of care and authorizing CNA care and services after the end of the previous certification period on 3/26/22. Review of a comprehensive reassessment, completed by RN #12 on 3/25/22, revealed Patient #4 continued to require skilled services and care coordination was completed with CNA #6. There was no evidence of care coordination with the physician for Patient #4. Review of completed visit notes from 3/27/22 through 4/27/22 revealed Patient #4 received CNA services daily for approximately five hours each day. However, the record failed to reveal evidence of a verbal physician order until 3/28/22 establishing the plan of care for the certification period dated 3/27/22 to 5/25/22, one day after the beginning of the certification period and two days after the comprehensive reassessment was completed indicating the continued need for skilled services. 2. During an interview on 4/27/22 at 11:45 a.m., CNA #6 confirmed she provided services to Patient #4 daily. She stated the nurse came to assess Patient #4 approximately every two months and provided her (CNA #6) with an assignment of duties that she followed to complete her daily timesheets and which she returned to the agency every two weeks. During an interview on 4/27/22 at 10:34 a.m., the administrator stated she reviewed the record for Patient #4 and was unable to find any documentation of communication with Patient #4's physician indicating plan of care orders were received prior to the provision of services for the certification periods dated 1/26/22 to 3/26/22 and 3/27/22 to 5/25/22. She confirmed the plan of care for those periods were not established by the physician until after services had been rendered. She stated the agency process was to coordinate with the physician regarding the upcoming certification period and receive orders from the physician prior to agency clinicians rendering services. However, she acknowledged that process was not being followed with patients whose CNAs were also their parents.