Every finding on record at Unitypoint at Home

The State Survey Agency (SA), at the direction of the Centers for Medicare and Medicaid (CMS) Kansas City Regional Office (KCRO) staff, performed an on-site investigation of complaints 97175-C and 97391-C from 5/4/23 through 5/10/23. The survey team investigated the Conditions of Participation for 42 CFR 484.50 Patient Rights, 42 CFR 484.60 Care Planning, Coordination and Quality of Care, 42 CFR 484.80 Home Health Aide Services and 42 CFR 484.110 Clinical Records. The complaint survey found the home health agency operating out of compliance with the following Conditions of Participations: 1) 42 CFR 484.80 Home Health Aide Services was substantiated 2) 42 CFR 484.60 Care Planning, Coordination and Quality of Care was substantiated 3) 42 CFR 484.110 Clinical Records was substantiated

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on clinical record review, agency policy review, family interview and agency staff interview, the agency failed to ensure agency staff provided treatments and services only as ordered by a physician. The effects of this practice resulted in the agency's failure to ensure they promoted and supported the coordination of safe and effective delivery of care to patients.

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 clinical record review, policy review, a patient's family member interview and staff interview, the agency staff failed to provide treatment as ordered by the physician for 1 of 3 sampled patients (Patient #6) with a wound requiring treatment. Failure to ensure staff follow physician orders for wound care placed agency patients at risk for inconsistent care/treatment and possible harm. Review of the agency policy, titled Physician Orders/Plans of Treatment, dated 12/2022, revealed the plan of treatment will include all diagnostic and therapeutic orders. Review of the agency policy, titled Care Coordination, dated 12/2008, revealed the nurse case manager is responsible for identifying the initial needs and appropriate services to meet those needs. The clinician or clinical leader enter new verbal orders into the computer. To assure coordination, the clinician responsible for supervising or furnishing care reviews new orders prior to providing care. Review of the agency policy, titled Patient Notification of Changes in Care/Services, dated 12/2008, revealed agency staff will notify the patient of any significant changes in the agreed upon schedule or clinical plan of care. Patient #6 had a start of care date of 3/25/23 and discharged from agency services per the patient's request on 3/31/23. Review of the clinical record revealed the following: a. A verbal physician order by the patient's primary care physician, dated 3/25/23, included the following: skilled nursing visit one time a week for one week, instruct on disease process and management principals, signs and symptoms to report to the provider, emergency and safety measures, medication effects and side effects, new and changed medications and activity restrictions, perform a physical assessment with a focus on the pulmonary status, teach and train on chest tube management and Foley (urinary catheter) care. b. The Plan of Care (POC) with a certification period, dated 3/25/23 to 5/23/23, identified a diagnosis of pulmonary effusion (fluid in the lungs) and included the following physician orders by the patient's primary care physician (PCP) and received by Staff K, Registered Nurse (RN): effective 3/25/23, the skilled nurse is to change the patient's chest tube dressing every Monday, Wednesday and Friday and as needed for "soilage" ; note the color, clarity and amount of drainage; empty the canister (for the chest tube drainage) to keep from being full; and, monitor the sutures to remain in place with each dressing change. The same POC included conflicting physician orders signed by the patient's PCP for skilled nursing 2 times per week for one week (instead of 3 times per week to complete the chest tube dressing change per orders), effective 3/26/23 to 4/1/23, and 3 as needed skilled nursing visits per week for pulmonary issues effective 3/25/23 to 5/23/23. The POC, dated 3/25/23 to 5/23/23, did not include a physician order the family or whoever the family designated, would be responsible for emptying the patient's chest tube canister and completing the chest tube dressing change on the days the skilled nurse was not present. c. The comprehensive assessment completed at the start of care by Staff K, RN, dated 3/25/23 (a Saturday), included documentation the patient had discharged from the hospital on 3/24/23. Staff K, RN, documented the patient's chest tube dressing was intact. The nurse documented that she emptied the canister for the chest tube drainage. The nurse documented the patient had an incision located at the placement of the chest tube, but the nurse was unable to view the incision due to an unremovable dressing being in place. The POC, dated 3/25/23 to 5/23/23, lacked a physician order which specified the chest tube dressing was to be removed on a Saturday. Without performing a dressing change, the Staff K, RN could not clean or inspect the condition of patient’s skin, or check for any signs/symptoms of infection at the chest tube insertion site, or check for the presence of air leaks under the skin (sign that the chest was not working properly), or determine if the sutures holding the chest tube in place were intact. d. The clinical record lacked documentation of a skilled nursing visit on 3/27/23, a Monday, and lacked a reason why the visit did not occur on this day (Interview with Staff B, Patient Care Coordinator, revealed the order for the skilled nursing visits to change the patient's chest tube dressing every 2 days did not show up in the electronic computer system until 3/28/23 and resulted in the missed visit on Monday, 3/27/23). The clinical record lacked documentation of contact with the physician to notify the physician of the missed visit for 3/27/23. e. A skilled nursing visit completed by Staff H, RN, dated 3/28/23 (Tuesday), included documentation the nurse changed the chest tube dressing, assessed the incision site and emptied 150 milliliters (ml) of watery, red drainage from the canister. The patient did not have a chest tube dressing change until 4 days after admission to the home health agency. f. The clinical record included documentation of the following verbal interim (a physician order received after the completion of the Plan of Care and prior to the end of the current certification period) physician order by the patient's PCP and received by Staff H, RN, dated 3/28/23 at 4:17 PM, with an effective date of 3/25/23: dressing change every 2 days and as needed for "soilage"; note the color, clarity and amount of drainage; empty the canister (for the chest tube drainage) to keep from being full; and monitor the sutures to remain in place with each dressing change. The order did not specify who was responsible for emptying the chest tube canister and changing the dressing when home health staff where not scheduled to provide wound care. On 5/8/23 at 2:35 PM, during an interview, Staff B, Patient Care Coordinator (responsible for supervision of the care provided by agency staff), reported the physician order written by Staff K, RN on 3/25/23, to complete the chest tube dressing change should have specified the caregiver providing the wound care on the days the home health nurse was not scheduled. Staff B, Patient Care Coordinator, agreed the POC, dated 3/25/23 to 5/23/23, included the following: a physician order for skilled nursing for 2 times per week and 3 as needed skilled nursing visits per week ordered for the pulmonary issues and a conflicting order for the skilled nurse to complete a chest tube dressing change on Mondays, Wednesdays and Fridays and as needed. Staff B, Patient Care Coordinator, agreed the physician order in the electronic medical record as an interim physician order, dated 3/28/23, included an order for the skilled nurse to change the patient's chest tube dressing every 2 days starting 3/25/23. Staff B, Patient Care Coordinator, confirmed the agency did not provide a skilled nursing visit on 3/27/23, (Monday) that was 2 days after the start of care visit. On 5/9/23 at 10:32 AM, during an interview, Staff B, Patient Care Coordinator, explained there had been a problem with the order for the chest tube dressing change not showing in the electronic medical record until 3/28/23, 3 days after admission. Staff B explained the original order had been for the chest tube dressing change every 2 days and as needed. On 3/28/23, Staff H, RN, completed a clarifying order to the physician to complete the chest tube dressing change on Mondays, Wednesdays and Fridays. The order dated 3/28/23, ended up on the POC and the original order entry (dressing change every 2 days) looked like it was an interim order on the POC. Staff B, Patient Care Coordinator, explained she was not sure what happened, but reported, because of the delay in the original order not showing up in the electronic medical record until 3/28/23 (Tuesday), the skilled nursing visit did not occur on 3/27/23 (Monday). Staff B, Patient Care Coordinator, reported the issue had been reported to the electronic medical record provider in an effort to determine how the problem with the orders had occurred. On 5/10/23 at 10:06 AM, during an interview, Staff H, RN, reported the order she obtained on 3/28/23 was a clarification order. Staff H, RN explained she received a physician order to change the chest tube dressing for every Monday, Wednesday and Friday. On 5/10/23 at 9:17 AM, during an interview, Patient #6’s spouse reported the agency nurse was to come to their home and change the patient’s chest tube dressing on 3/27/23 (Monday), and did not. The agency did not come to their home until the next day on 3/28/23 (Tuesday) to change the chest tube dressing. On 3/29/23 (Wednesday), the spouse contacted the agency due to the patient’s urinary catheter leaking. The spouse reported at first the agency staff told her/him the agency did not have anyone to send. An hour later, the agency staff called to report a nurse was coming. A nurse did come out on 3/29/23 and changed the urinary catheter bag and completed a chest tube dressing change. According to the spouse, the nurse that came out on 3/29/23 told the spouse the spouse would need to learn how to do the chest tube dressing change and would need to over the chest tube dressing changes. The spouse did not feel comfortable doing the chest tube dressing changes and decided to call another home health agency. The spouse reported the patient was currently doing well and was no longer receiving home health services. The agency nursing staff failed to provide care and services as ordered per the POC and physician orders and failed to ensure the coordination of the patient's care in order to meet the needs of the patient. The Administrator received the above findings and agency staff provided no further information prior to the end of the survey.

Home health aide services CFR(s): 484.80 Condition of participation: Home health aide services. All home health aide services must be provided by individuals who meet the personnel requirements specified in paragraph (a) of this section. This CONDITION is not met as evidenced by: Based on clinical record review, agency policy review, patient, patient's family member, health practitioner and staff interviews, the agency failed to do the following: 1) ensure agency home health aides provided care in accordance with their competency training (G0800); and, 2) ensure agency home health aides reported changes in the patient's condition to the registered nurse (G0804). The cumulative effect of these practices resulted in the agency's failure to have a process in place to ensure agency staff met the health and safety needs of the patients receiving home health aide service.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on clinical record review, policy review, agency complaint log review, review of agency home health aide personnel files, patient interview, family member interview, health practitioner interview and staff interview, a home health aide failed to transfer a patient via a Hoyer lift consistent with the home health aide's training for 1 of 5 sampled patients (Patient #1) with home health aide services. Failure of the home health aide to competently transfer the patient using the Hoyer lift and failing to notify the registered nurse case manager, or other supervisory staff of the home health aide's inability to competently complete the transfer, resulted in the patient receiving injuries and a delay in treatment for those injuries. Review of the agency policy, titled Care Coordination, dated 12/2008, revealed the clinical case manager is responsible for developing the aide plan of care including any special instructions. The clinical case manager provides written instruction and orientation to the patient's care. The home health agency complaint log included the following: On 4/3/23, agency staff entered a complaint for an event that occurred on 3/19/23. The log included documentation a home health aide had issues with the Hoyer lift and had incorrectly attached the sling straps to the Hoyer for Patient #1. The straps for the Hoyer sling were color coded and needed to be attached in a specific pattern which the home health aide did not follow. The patient ended up with their head near their knees, their body and head below the wheelchair seat and almost touching the ground and the Hoyer slip was wrapped around the wheelchair. The complaint log included documentation of reported injuries to the patient's buttocks area. Patient #1 had a start of care date of 7/22/15, discharged from the agency on 4/30/23 and readmitted on 5/1/23 due to a change in payor source. On 5/9/23 at 6:55 AM, during a home visit observation, Staff C, HHA, completed personal cares on the patient. During the course of providing cares, Staff C, HHA, assisted the patient with rolling to right side and washed buttocks area around wound dressings on the left and right buttocks. Staff C, HHA, removed the wound dressing on the left wound and applied Santyl, gauze and Tegaderm to left buttock wound. The right wound had a black tape covering the site. The surveyor was unable to observe this wound area. The patient refused to get up for the day, and the surveyor was unable to observe the Hoyer lift transfer. The surveyor did see the Hoyer lift in the home and noted a bath sling and regular hoyer sling. On 5/9/23 at 1:03 PM, during an interview, Patient #1 reported being a quadriplegic since 1/30/1983. The patient reported knowing Staff E, HHA, for approximately 8 to 9 years. The patient denied Staff E, HHA, had problems with the Hoyer lift transfer prior to 3/10/23. Staff E, HHA, typically worked with the patient one weekend a month and sometimes one or two times during the month to fill in for another home health aide. The patient reported on both Friday, 3/10/23, and on Sunday, 3/19/23, Staff E, HHA, attempted to assist the patient with transferring from the bed to the patient’s electric wheelchair. On both occasions, Staff E, HHA, applied the straps from the sling wrong onto the Hoyer lift and had the patient positioned wrong in the sling. The patient explained the Hoyer sling straps are color coded and go in a specific order which Staff H, HHA, did not follow on both 3/10/23 and 3/19/23. The patient ended up positioned too low in the sling to transfer to the patient’s chair, or back to the bed. On 3/10/23, the patient was stuck hanging in the sling and Staff E, HHA, had to call Staff C, HHA, to assist Staff E, HHA with getting the patient transferred. On 3/19/23, the patient reported when Staff E, HHA, went to ease the patient off the bed, the patient dropped in the sling below the bed and ended up contorted with the patient’s head about 6 inches from the patient’s stomach, one leg under the chair and one leg outside of the chair. The patient’s parents were present, but were unable to help. The patient reported the legs of the Hoyer lift were stuck under the patient’s chair. The patient’s body was rocking back and forth, as Staff E, HHA attempted to get the legs of the Hoyer unstuck. The patient’s buttocks hit the chair during this time. The patient ended up hitting the button on the patient’s emergency response necklace, and paramedics came and assisted with getting the patient back into bed. Staff E, HHA, asked the patient to not say anything about what happened. The patient reported liking Staff E, HHA, and did not want to get Staff E, HHA in trouble. The patient reported he/she told Staff C, HHA, about the 3/19/23 incident with Staff E HHA on 3/20/23. The patient reported feeling a weird feeling in his/her buttocks all week after the incident on 3/19/23. The patient explained Staff G, Registered Nurse (RN) noted bruises on each buttock cheek on Friday, 3/24/23. Staff G, RN, thought the patient’s bruising was associated with the patient’s use of a washcloth with sugar water on it. The patient explained he/she has used a washcloth with sugar water for 7-8 years for hemorrhoids. The patient reported he/she has not had buttocks wound issues for 10 years. The patient reported not having services on 3/25 and 3/26/23 due to going to the patient’s parents home for the weekend. The patient reported he/she contacted the wound clinic about his/her buttocks the next week. The patient went to the wound clinic on 3/28/23. The patient had deep tissue wound injuries on the right and left buttocks, and the wound on the right was open. The patient told Staff G, RN, about the incident with the Hoyer lift involving Staff E, HHA, the next visit (3/30/23). The patient reported none of the other home health aides had problems with operating the lift, or problems with the lift not working correctly. The patient reported there were instructions for using the Hoyer lift in the patient’s bedroom on the mirror. During the same interview with the patient, the patient’s family member reported on 3/19/23, seeing the patient with one leg under the wheelchair, the other leg outside it and the patient’s body squashed in the Hoyer lift. The patient's family member reported the Hoyer lift was stuck under the wheelchair. Staff E, HHA, tried to jerk the legs out causing the patient to swing in the sling and hit the wheelchair. On 5/9/23 at 1:59 PM, during an interview with Staff E, HHA, the surveyor asked Staff E HHA what happened with the Patient # 1 during the incident on 3/19/23. Staff E, HHA, reported she was getting the patient out of bed. Staff E, stated, “I asked how high do you want your chair, and (the patient) responded you should know after 8 years.” Staff E, HHA, explained she only worked with the patient every 5th weekend. Staff E, HHA, reported the patient gave her “attitude”. Staff E, HHA, stated, “I told (the patient) if it’s not right, it’s on you.” Staff E, HHA, explained she was being funny with the patient and "you have to be able to have fun and joke on the job." Staff E, HHA, stated, “When I got (the patient) up in the Hoyer, (the patient) said the chair wasn’t right; it was too low.” Staff E, HHA, stated, “I tried to move the Roho (type of pressure relieving cushion located on the wheelchair) and I tried to adjust the chair and Hoyer, but the patient was stuck.” Staff E, HHA, explained the legs on the Hoyer lift were sticking up against the wheelchair. Staff E, HHA, reported the patient was complaining, but she did not drop the patient. Staff E, HHA, reported she called Staff C, HHA, and asked for assistance. Staff C, HHA, came over to Patient # 1's house and helped transfer the patient. The surveyor asked for clarification, as the surveyor understood the incident involving Staff C, HHA, occurred on 3/10/23. Staff E, HHA, confirmed that Staff C, HHA, assisted her on 3/10/23. Staff E, HHA, explained the second time occurred on a Friday, 3/19/23. Staff E, HHA, reported a family member in the home was having medical issues and could not help. Staff E, HHA, explained the patient was already up in Hoyer and Staff E was having problems with the Hoyer lift. Staff E, HHA, reported Staff E pressed the patient’s emergency response button and the patient spoke with the paramedics. The paramedics did come and assist the patient. Staff E, HHA, denied asking the patient not to tell anyone. Staff E, HHA, stated, “I had to tell the supervisor, but then I forgot because I had Monday off.” Staff E, HHA, reported the patient said it was no big deal and the patient stated the patient would not say anything. Staff E, HHA, then stated, “I told the supervisor (the patient) had made advances on me”, and one time the patient told Staff E, HHA, to kiss the patient’s butt. Staff E, HHA, reported Staff E had been going to the patient’s home for about 9 years to provide cares. When asked if Staff E, HHA, notified a supervisor or anyone else about their difficulty with transferring the patient, Staff E, HHA, responded, “ I didn’t notify anybody I had trouble. I just figured it was the patient just being moody.” When asked if Staff E, HHA, had the straps connected wrong to the Hoyer, Staff E, HHA responded, “I could have had the straps hooked up wrong; (the patient) had me so flustered. It happened so long ago, I can’t remember. It doesn’t take much to get me mad; (the patient) makes me so mad at times. I’m okay with not going back.” Staff E, HHA, reported the Administration asked Staff E not to go back into the patient’s home. Staff E, HHA, stated, “They wanted to know if I needed training. It was just one incident, and it was all the patient.” Staff E, HHA, confirmed there were instructions on the patient’s mirror in the bedroom on using the Hoyer lift. Staff E, HHA, reported Staff E completed competency training on the patient with the nurse observing when she first started working with the patient. On 5/9/23 at 2:14 PM, during an interview, Staff C, HHA reported that on 3/10/23, Staff E, HHA, called and told Staff C she couldn’t get the patient into the power wheelchair and wanted to know if Staff C, HHA could come help. Staff C, HHA, reported it was Staff C's day off, but Staff C did come and help. Staff C, HHA, denied telling a supervisor or anyone else about the incident at the time. Staff C, HHA, explained Staff C assumed Staff E, HHA, would report it, but “it didn’t get reported”. Staff C, HHA, reported Staff E, HHA, had the patient in the Hoyer sling when Staff C arrived. Staff C, stated, “The sling was hooked up incorrectly.” Staff C, HHA, explained she told Staff E, HHA, the hoyer was not hooked up correctly. Staff C, HHA, stated, “Both the straps were not connected to the right spot on the Hoyer lift and the sling was positioned wrong; it was not far enough under (the patient).” Staff C, HHA, reported she helped with transferring the patient back to the bed, reconnected the sling correctly and assisted with transferring the patient to the chair. When asked if the patient told Staff C, HHA, about the incident on 3/19/23 during the visit on 3/20/23, Staff C, HHA, reported she did not recall the patient telling her about it. Staff C, HHA, reported the patient told her about the ambulance being there for the patient's family member. Staff C, HHA, was not sure when Staff C became aware of the incident that occurred on 3/19/23. Staff C, HHA explained that Staff C is at Patient #1's home everyday and it all runs together. Staff C, HHA, reported Staff C had been working with the patient for about 4 and half years. Staff C, HHA, reported being competency trained on the use of the Hoyer lift with Patient #1 during the first 1 to 2 months of working for the agency. Staff C, HHA, confirmed instructions for how to use the patient's Hoyer were in the patient's bedroom on the dresser and mirror. On 5/9/23 at 2:27 PM, during an interview, Staff F, LPN, explained the first time anyone saw a wound on the patient’s buttocks was when Staff G, RN, saw it on the Friday after the incident. Staff F, LPN, reported they did not remember if the wound was open when they completed a visit on 3/28/23. Staff F, LPN reported about 1- 2 weeks after the incident, Staff F found out about the incident. Staff F, LPN, explained the patient told Staff F the buttocks wound were related to issues with the sling; she was not aware of anything else. On 5/9/23 at 3:28 PM, during an interview, Staff G, RN, reported going to the patient’s home on that Monday, 3/20/23, 1 day after the incident with the Hoyer lift occurred. Staff G, RN, reported no one said anything to Staff G about the incident with the Hoyer lift. Staff G, RN, explained the next visit she had with the patient on 3/24/23, the patient complained of some pain and that’s when Staff G discovered the deep tissue wounds on the right and left buttocks. Staff G, RN, initially thought this was due to the patient leaving a wet washcloth with sugar water on it between the patient’s legs. Staff G, RN, reported it was not until the next week, during a visit after the patient had been to the wound clinic, that the patient’s mother told Staff G, RN, about the patient falling from the Hoyer lift on 3/19/23 and sustaining an injury. Staff, G RN, reported Patient #1 then told Staff F, RN about Staff E, HHA, not putting the straps on the Hoyer lift on correctly and the patient falling. Staff G, RN, reported the patient told Staff G the wound clinic staff reported a deep tissue injury could lead to a wound and the injury could take as many as 5 to 10 days to appear. Staff G, RN, immediately informed her supervisor about the incident and completed an incident report. Staff G, RN, never spoke with Staff C, HHA, about the incident, as the supervisor investigated it. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 2/10/23 to 4/10/23, identified a diagnosis of a quadriplegia and included physician orders for skilled nursing services varying from 3 to 4 times per week and home health aide services daily for 60 days. The POC included instructions for the home health aide to complete the following tasks: range of motion on the lower extremities, urinary catheter care, transfer the patient with a Hoyer lift, apply compression stockings, bathing assist to include either a shower or sponge bath, shampoo, assist with shaving, foot care, oral care, apply lotion to the skin, file and clean fingernails, hair care, assist with dressing, apply Nystatin to the groin, wash the left ankle/heel with soap and water and paint the sore with Betadine and apply 4 x4 split gauze around tracheostomy site. b. A home health aide visit, dated 3/10/23, included documentation Staff E, Home Health Aide (HHA), completed the following tasks: transferring the patient with the Hoyer, shower, shave, shampoo, dressing, oral care, foot care and catheter care. The visit note included a section for the home health aide to document any variances/concerns in care to the registered nurse (RN) case manager. Staff E, HHA, documented "Patient refused" in variances/concern section of the visit note. Staff E, HHA, documented the patient refused range of motion, wound care to the left ankle, tracheostomy care, fingernail filing, application of lotion, compression stocking application and application of the Nystatin powder. The visit note lacked any documentation of a problem with transferring the patient with the Hoyer lift. c. A home health aide visit, dated 3/19/23, included documentation Staff E, HHA, completed the following tasks: transferring the patient with the Hoyer, shower, shave, shampoo, dressing, oral care, inspect skin, apply lotion, foot care and catheter care. The visit note included a section for the home health aide to document any variances/concerns in care to the RN case manager. Staff E, HHA, documented "Patient refused" in variances/concern section of the visit note. Staff E, HHA, documented the patient refused range of motion, wound care to the left ankle, tracheostomy care, fingernail filing, compression stocking application and application of the Nystatin powder. The visit note lacked any documentation of a problem with transferring the patient with the Hoyer lift. d. The week of 3/19/23 included documentation of daily home health aide visits and documentation of skilled nursing visits on 3/20/23, 3/22/23 and 3/24/23. The skilled nursing visit note, dated 3/24/23, included documentation of the identification of the patient's development wounds on the right and left buttock. On 3/24/23, Staff G, RN, documented the observation of a deep tissue wound on the right and left buttock. Staff G, RN, documented the patient denied having skin issues the night before the visit. The nurse observed the patient had a moist washcloth with sugar on it. The patient reported applying this to the patient's hemorrhoids. The nurse questioned if the injuries were caused by the patient lying on the washcloth. The nurse instructed the patient to stop using the washcloth and to offload the patient's weight off the areas. e. A skilled nursing visit, dated 3/28/23, included documentation Staff F, Licensed Practical Nurse (LPN), documented the patient reported intermittent aching pain in the coccyx area, had two deep tissues wounds, one on the right and one on the left coccyx. The nurse documented the patient's left buttock wound measured 0.2 centimeters (cm) in length, 0.2 cm in width and 0 depth. The patient's right buttock wound measured 3.5 cm in length and 1.5 cm in width and had no depth. The nurse documented the patient was going to an appointment at the wound clinic for new areas on the patient's coccyx. f. The wound clinic visit (documented in the agency's electronic medical record), dated 3/28/23, included documentation by the Advanced Registered Nurse Practitioner (ARNP) which identified the patient had a wound on the right gluteal cleft fold caused by trauma and complicated by pressure. The ARNP documented the patient believed the injury occurred when the home health aide was getting the patient up into the Hoyer lift. The ARNP documented the right gluteal wound measured 4.8 cm in length, 3 cm in width and 0.1 cm in depth. The ARNP documented the fat layer of the skin was exposed and there was a medium amount of blood-tinged drainage. The wound had a large amount of red granulation tissue (highly vascular tissue and considered unhealthy unless pink in color) and a small amount of necrotic (dead) tissue in the wound bed. The ARNP described the wound as a Stage 2 wound (shallow broken skin or blister) before and debridement. The wound measured the same after debridement and reidentified the wound's location as the right posterior upper leg. The ARNP noted the patient also had a suspected deep tissue injury on the left leg. The ARNP ordered a mixture of Calmoseptine and Silvadene to the wound bed, cover with gauze and tape in place for the wound on the right. g. The wound clinic visit (documented in the agency's electronic medical record), dated 4/4/23, included documentation the ARNP assessed the right poster leg wound measured 3.0 cm in length, 2.5 cm in width and 0.1 cm in depth. The wound had a small amount of purulent drainage, a large amount of red granulation tissue and small amount of necrotic tissue. The left gluteus wound measured 1.1 cm in length, 1 cm in width and 0.1 cm in depth. The wound had a small amount of drainage, no granulation tissue and a large amount of necrotic tissue. The ARNP ordered the same wound treatment for the left gluteal wound as previously ordered for the right posterior leg wound. h. The wound clinic visit (documented in the agency's electronic medical record), dated 4/25/23, included documentation the ARNP assessed the right posterior upper leg to be a stage 4 wound measuring 2.3 cm in length, 2.2 cm in width and 2 cm in depth with a small amount of purulent drainage and a large amount of necrotic tissue. The left gluteal wound was unstageable and measured 0.6 cm in length, 0.4 cm in width and 0.2 cm in depth with small amount of drainage and large amount of necrotic tissue. The treatment for both wound included applying Santyl to the wound bed, covering with woven gauze and securing with tape. On 5/10/23 at 10:55 AM, during an interview, the Wound Clinic ARNP, reported they had been seeing the patient for wounds to the right and left buttocks. The ARNP reported they first saw the patient on 3/28/23 for an open wound on the right buttock. The patient had deep tissue wounds with dark purple bruising on the right and left buttocks. The ARNP reported the patient appeared to have a hematoma to the deep tissue injury. The wounds worsened over the next couple weeks. The ARNP reported the wounds were consistent with trauma to the area. The ARNP confirmed deep tissue wounds can take 5 to 10 days to visibly appear. i. The POC, dated 5/1/23 to 6/29/23, included orders for the skilled nurse to provide wound care treatment 3 times per week to the right buttock. The right buttock wound treatment included application of wound vacuum. The left buttock included orders for the home health aide to apply Santyl, gauze and secure the wound with a Tegaderm dressing. Review of the agency's complaint investigation log revealed the following documentation: 1) On 3/29/23, Staff G, RN, made the initial report to agency supervisory staff. Staff G, RN, reported the patient informed her the home health aide was getting the patient up from the bed into the wheelchair with the Hoyer lift. Per the patient, the home health aide had connected the straps for the sling wrong on the Hoyer resulting in the patient being almost bent in half with the patient's head below the seat of the wheelchair and almost touching the ground. The sling was caught under the wheelchair. The patient used the emergency response system to contact the paramedics. The paramedics came and assisted the patient back into the bed. The patient believed his/her buttocks hit the foot rest causing the injuries to the right and left buttocks. 2) Agency management staff documented talking with Staff E, HHA, on 3/30/23. When agency management staff asked Staff E, HHA, "what happened at the home visit" (the complaint log investigation did not specify agency management staff asked Staff H, HHA, about a specific date. At this point in their investigation, agency management staff were not aware Staff E, HHA, had problems with completing Patient #1's Hoyer transfer on more than one occasion), at first Staff E could not remember that far back and then thought the last time they had worked with the patient was on 3/18/23. Staff E, HHA, told agency management staff the patient was in a mood that day; the patient was more silent rather than directing care and made rude comments. Staff E, HHA, explained the patient usually directs the home health aide when to release the Hoyer lift after positioning the patient over the chair, but that day the patient would not say anything. Staff E, HHA, reported she released the patient from the Hoyer lift into the chair where she felt she usually released the patient. Staff E, HHA, reported when she tried to open the legs of the Hoyer lift, the Hoyer lift legs usually stick and she has to really pull to get it to work. Staff E, HHA, reported she hooked up the color straps for the Hoyer sling in a different order resulting the in the patient's bottom hanging lower than normal. Staff E, HHA, explained that due to the patient being in a mood and not directing Staff E, she hooked the straps the best she could remember. When Staff E, HHA, went to transfer the patient to the wheelchair from the Hoyer lift, the legs stuck and the patient's buttocks did skid over the Roho cushion. Staff E, HHA, reported the patient told Staff E that she did not have to report this and Patient #1 did not get hurt. Agency management staff documented providing education to Staff E, HHA, on reporting any occurrences that differ from the patient's plan of care and to reach out if there are any questions. 3) On 3/31/23, agency management staff talked with Staff G, RN, and reported the patient's version of the story differed from Staff E, HHA. 4) On 4/3/23, agency management staff documented being unable to connect with Staff E, HHA, until 4/3/23. Agency management staff questioned Staff E, HHA, if there was anything else that occurred that Staff E forgot to mention and educated Staff E that the visit in question was potentially on 3/19/23. Staff E, HHA, reported not being sure, as it was so long ago and Staff E had worked both 3/18/23 and 3/19/23. Agency management staff asked Staff E, HHA, if the patient's family members were present. Staff E, HHA, confirmed the family members presence. Agency management staff asked something about an ambulance arriving, Staff E, HHA, responded that one of the family members came into the room while Staff E was providing care and the other family member was not responding. Staff E, HHA, reported the patient and family member in the room decided to call the ambulance for the unresponsive family member. Staff E, HHA, explained there was a lot of commotion between Staff E trying to transfer the patient into the wheelchair, the family member worrying about the unresponsive family member and the ambulance crew coming in. 5) The complaint investigation included documentation of the patient's visit to the emergency room and hospitalization on 4/10/23 due to issues with the patient's urinary catheter. During the course of the hospital visit, the patient reported the home health aide having difficulty transferring the patient with the Hoyer lift on 2 different occasions resulting in the patient being dropped. The patient reported on the first occasion, the home health aide had to call another home health aide to help get the patient off the floor. The patient reported the second occasion, the paramedics had to come assist. 6) On 4/13/23, agency management staff had a conference call with Staff E, HHA, to follow up on concerns the patient reported at the hospital. 7) On 4/14/23, agency management staff spoke with Staff C, HHA, on assisting Staff E, HHA, on their day off and provided education to Staff C on reporting events and safety. 8) On 4/18/23, agency management staff determined Staff C, HHA, provided additional training and coaching. On 5/10/23 at 8:30 AM, during an interview, the Administrator reported that the complaint log and investigation documentation included documentation of the education provided to both Staff E, HHA, and Staff C, HHA. They educated both home health aides on reporting any variances/concerns to their supervisor. The Administrator did not become aware of the incident on 3/10/23 and 3/19/23 until after Staff G, RN, notified the office of the concern. On 5/10/23 at 11:20 AM, during an interview, the Administrator provided a copy of the education provided to both Staff E, HHA, and Staff C, HHA, in regards to the incidents on 3/10/23 and 3/19/23. Staff E was removed from providing cares to Patient #1. The home health aide failed to provide cares consistent with the home health training for the patient's Hoyer lift. As result of the home health aide's improper actions, the patient suffered wounds still affecting the patient. The Administrator received the above findings and agency staff provided no further information prior to the end of the survey.

Aides are members of interdisciplinary team CFR(s): 484.80(g)(4) Home health aides must be members of the interdisciplinary team, must report changes in the patient's condition to a registered nurse or other appropriate skilled professional, and must complete appropriate records in compliance with the HHA's policies and procedures. This ELEMENT is not met as evidenced by: Based on clinical record review, policy review, agency complaint log review, patient interview, family member interview, health practitioner interview and staff interview, the agency failed to ensure home health aides reported patient concerns to a registered nurse or supervisor for 1 of 5 sampled patients receiving home health aide services (Patient #1). Failure to ensure that home health aides reported condition changes to a registered nurse (RN) or supervisor increased the risk of agency staff not meeting the personal care needs of the patients. Review of the agency policy, titled Home Care Aide Coordination and Documentation, dated 3/2015, revealed agency home health aides are responsible for informing the team leader or (RN) case manager regarding any concerns about the patient's care. See G0800 The home health aides failed to report difficulties in transferring the patient with the Hoyer lift on 3/10/23 and 3/19/23, and failed to report the paramedics responded to the patient's home to assist with getting the patient transferred out of the Hoyer lift. The Administrator received the above findings and agency staff provided no further information prior to the end of the survey.

Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This CONDITION is not met as evidenced by: Based on clinical record review, agency policy review, patient, family and agency staff interview, the agency failed to ensure ensure entries in the clinical record related to interventions provided by staff were accurate and complete and failed to ensure the accuracy and completeness of orders on the plan of care. The effect of these practices resulted in the failure of the agency to assure the safe delivery of patient care and for other disciplines providing services to have unclear or inaccurate information regarding the patient's condition.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on clinical record review, policy review, agency complaint log review, patient interview, family member interview, health practitioner interview and staff interview, the agency failed to ensure the patient's clinical record included accurate and specific documentation of interventions in the patient record and accurate and complete orders for patient care on the plan of care for 2 of 7 sampled patients (Patients #1 and #6) . Failure to ensure the patient's clinical record included accurate and complete documentation of orders on the plan of care and interventions provided by staff placed agency patient's at risk for not receiving the correct interventions, and for other disciplines providing services to have unclear or inaccurate information regarding the patient's condition. Review of the agency policy, titled Home Care Aide Coordination and Documentation, dated 3/2015, revealed home health aide staff are responsible for entering documentation into the agency's electronic health record. Review of the agency policy, titled Contents of Clinical Notes, dated 3/2017, revealed the clinical record will contain notes for each service provided for each visit. The clinical note will include what service/care the agency staff provided, treatment or procedures performed and the patient response to treatment/procedures performed. 1. Patient #6 had a start of care date of 3/25/23 and discharged from agency services per the patient's request on 3/31/23. See G0580 Agency nursing staff failed to ensure the clarification of conflicting physician orders relating to the patient's chest tube care and dressing change on the patient's Plan of Care, dated 3/25/23 to 6/23/23, and failed to ensure the timely documentation of physician orders to ensure agency nursing staff provided care in accordance with physician orders. 2. Patient #1 See G0800 The home health aide failed to document difficulties in transferring the patient via the Hoyer lift on 3/10/23 and 3/19/23, and failed to document the patient's inability to get out of the Hoyer lift sling safely both days. The Administrator received the above findings and agency staff provided no further information prior to the end of the survey.