Every finding on record at Total Care Home Health of North Carolina, LLC

An unannounced onsite complaint investigation was conducted 1/4/22-1/5/22. The allegation was substantiated. Deficiencies to the Medicare CoP were identified.

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 review, clinical record review and staff interviews the agency failed to follow the Plan of Care [POC] for visit frequency for 1 of 3 charts [#1]; failed to perform wound care as ordered in the POC for 1 of 3 charts [#2]. The findings included: The policy, Care Planning [8/21], was provided by the agency director on 1/5/22 at 10 am. The policy stated, “…Each patient must receive an individualized written Plan of Care [POC] including any revisions or additions. The individualized POC must specify…Care and services to meet the patient-specific needs…” Patient # 1 had a Start of Care [SOC] date of 8/7/21 and admitting diagnoses of Venous Insufficiency, Non Pressure Chronic Ulcer other part right lower leg and Non Pressure Chronic Ulcer other part left lower leg. A review of the Plan of Care for the certification period 10/6/21 to 12/4/21 revealed orders for SN [skilled nurse] 2 times a week for 1 week; 3 times a week for 8 weeks; 2 PRN [as needed] for wound/dressing complications. A review of the clinical record revealed no SN visit was made the first week of the certification period [10/6/21-10/9/21]. An interview was conducted with the agency director on 1/5/22 at approximately 12:00 pm. During the interview the agency director confirmed the visit frequency was not followed in accordance with the POC.Patient # 2 had a Start of Care [SOC] date of 11/3/21 and an admitting diagnosis of Type 2 Diabetes Mellitus with Foot Ulcer. A review of the Plan of Care [POC] for the certification period 11/3/21 to 1/1/22 revealed orders for SN [skilled nursing] 1 time a week for 1 week; 2 times a week for 7 weeks; 1 time a week for 1 week; 1 PRN [as needed] for labs/infusion and “Skilled nurse to perform/teach wound care to diabetic ulcer right heel. Cleanse with anasept spray paint peri wound with non-sting prep fill wound bed with aquacel ag cover with dry gauze [sic], secure with kerlix and tape using clean/aseptic technique. Change dressing every 48 hours and PRN soiling/dislodgement…” A review of the clinical record revealed RN # 1 made routine visits on 11/15/21, 11/29/21, 12/6/21 and 12/13/21. Further review of the clinical record revealed the following documentation by RN # 1, “…wound care not provided…caregiver completed care…” An interview was conducted with the agency director on 1/5/22 at approximately 12 pm. During the interview the director confirmed the POC related to wound care was not followed by RN # 1.