Every finding on record at Wayne Memorial Hospital Department of Home Health

Based on the findings of an unannounced, onsite Medicare recertification survey conducted March 7 through March 9, 2023, Wayne Memorial Hospital Department of Home Health Services was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.

Based on the findings of an unannounced, onsite Medicare recertification survey conducted March 7 through March 9, 2023, Wayne Memorial Hospital Department of Home Health Services was found to not to be in compliance with the following requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on review of agency policies/procedures, documentation and clinical records, and based on interview with the administrator, the agency failed to ensure written instructions regarding updated visit frequencies were provided to two (2) of two (2) patients for whom the admission folder/booklet was available for review during a home visit. (Patients #2 and #3) Findings include: On March 9, 2023 at approximately 4:12 PM, review of agency policy HH10022, titled "Care Planning-Home Health", revealed the following under "Policy": The patient and/or patient's legal representative...have the rights, and shall be encouraged, to participate in the development of the Plan of Care before care is started and when changes in the established Plan of Care are implemented... Patient #2: During home visit conducted on March 8, 2023 at approximately 9:00 AM, review of the agency admission folder revealed the physical therapy (PT) visit frequency documented on the "Visit Frequency and Treatment Plan" was for a PT evaluation visit only. Review of the clinical record between March 8, 2023 at approximately 12:30 PM and March 9, 2023 at approximately 9:43 AM revealed the PT visit frequency documented on the "Home Health Certification and Plan of Care" for the initial certification period of 02/21/2023 through 04/21/2023 was one (1) visit within 10 days (evaluation visit). Review of the physician order dated 02/13/2023 revealed the PT visit frequency was updated to two (2) times a week for four (4) weeks (2wk4). There was no documentation in the admission folder, nor the clinical record, which provided evidence that the updated PT frequency included on the 02/13/2023 physician order had been provided to the patient/responsible party in writing. Patient #3: During home visit conducted on March 8, 2023 at approximately 10:25 AM, review of the agency admission folder revealed the physical (PT) and occupational (OT) therapy visit frequency documented on the "Visit Frequency and Treatment Plan" was for a PT and OT evaluation visit only. Review of the clinical record between March 8, 2023 at approximately 1:44 PM and March 9, 2023 at approximately 9:50 AM revealed the following visit frequencies were documented on the "Home Health Certification and Plan of Care" for the initial certification period of 02/21/2023 through 04/21/2023. -PT: 1wk1 followed by 2wk6; and -OT: 1wk1 followed by 2wk4. There was no documentation in the admission folder, nor the clinical record, which provided evidence that the updated PT fand OT visit frequencies included on the initial "Home Health Certification and Plan of Care" had been provided to the patient/responsible party in writing. During interview conducted on March 9, 2023 at approximately 4:15 PM, the administrator confirmed that there was no documentation in the clinical record which provided evidence that written instructions regarding the updated PT and OT visit frequencies had been provided to above identified patients in writing.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on review of agency policies/procedures, professional wound assessment guidelines, observation, clinical records, and based on interview with the administrator, the agency failed to ensure the progress toward wound healing goals were assessed by the skilled nurse (SN) for three (3) of three (3) patients for whom wound care orders and goals were included on the "Home Health Certification and Plan of Care". (Patients #4, #5 and #7) On March 9, 2023 at approximately 4:10 PM, review of agency policy 8004, titled "Wound Assessment and Reassessment", revealed the following under "Procedure": Page 1: Wound Assessment shall be performed after the wound has been cleaned... Page 2-3: Wound Assessment shall include...Wound bed tissue (color, moist or dry, granulation tissue (new tissue), eschar (dry/dead tissue), slough (moist/dead tissue)...Presence and amount of necrotic tissue (dead tissue)...Presence of exudate (drainage) including amount color and consistency... Page 5: Review of additional wound reassessment guidelines revealed reassessment of the wound could be completed weekly which was in contrast to the wound assessment guidelines included on page 1 of the policy. On March 9, 2023 at approximately 5:20 PM, review of internet-based professional wound assessment guidance (https://wtcs.pressbooks.pub/nursingskills/chapter/20-3-assessing-wounds/) included the following under "20.3 ASSESSING WOUNDS…OPEN RESOURCES FOR NURSING (OPEN RN)" revealed the following: Wounds should be assessed and documented at every dressing change. Wound assessment should include the following components: Anatomic location Type of wound (if known) Degree of tissue damage Wound bed... Wound edges and periwound skin (skin surrounding the wound) Signs of infection.... Patient #4: During home visit conducted on March 8, 2023 at approximately 12:02 PM, observation of the right foot wound dressing revealed brown drainage was evident on the exterior portion of the dressing. Observation of the right great and second toe revealed an open wound was present on the inner aspect of each of the toes. Review of the clinical record on March 9, 2023 at approximately 10:31 AM revealed the secondary diagnosis included non-pressure chronic ulcer of part of the right foot, that skilled nursing (SN) was to provide wound care to the right great toe, that SN was to assess for infection and that wound healing goals included for the wound to show evidence of healing within two (2) weeks and that the wound would remain free of signs/symptoms of infection as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 01/11/2023 through 03/11/2023. Review of handwritten, interim physician order documentation dated 01/24/2023 revealed SN was to provide wound care to the right second toe wound. Review of SN visit note documentation revealed the licensed practical nurse (LPN-Employee #15) provided wound care to the right great and second toe on 01/27/2023, 02/01, 02/10 and 02/15/2023 and 03/01 and 03/03/2023. There was no documentation on the SN visit note which provided evidence that the LPN assessed the right great and second toe wound appearance and/or drainage on 01/27/2023, 02/01, 02/10 and 02/15/2023 and 03/01 and 03/03/2023. Review of SN visit note documentation revealed the RN (Employee #16) provided wound care to the right great and second toe on 01/30/2023. There was no documentation on the SN visit note which provided evidence that the RN assessed the right great and second toe wound drainage on 01/30/2023. Patient #5: During home visit conducted on March 8, 2023 at approximately 1:00 PM, observation revealed an open wound was present on the right lower back region and that drainage was present on the wound packing/gauze. Review of the clinical record on March 9, 2023 at approximately 11:46 AM revealed secondary diagnoses included encounter for change or removal of surgical wound dressing, that skilled SN was to provide wound care to the right lower back wound, that SN was to assess for infection and that wound healing goals included for the wound to show evidence of healing within two (2) weeks and that the wound would remain free of signs/symptoms of infection as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 01/08/2023 through 03/08/2023. Review of SN visit note documentation revealed the LPN (Employee #15) documented that green drainage was noted from the right lower back wound on 01/18/2023. Review of SN visit note documentation revealed the LPN (Employee #15) provided wound care to right lower back wound on 01/12, 01/20 and 01/23/2023 and 02/17, 02/22 and 02/24/2023. There was no documentation on the SN visit note which provided evidence that the LPN assessed the right lower back wound appearance and/or drainage on 01/12, 01/20 and 01/23/2023 and 02/17, 02/22 and 02/24/2023. Review of SN visit note documentation revealed the RN (Employee #16) provided wound care to right lower back wound on 01/25/2023. There was no documentation on the SN visit note which provided evidence that the RN assessed the right lower back wound appearance and drainage on 01/25/2023. Patient #7: Review of the clinical record on March 9, 2023 at approximately 1:42 PM revealed secondary diagnoses included encounter for change or removal of surgical wound dressing, that SN was to provide wound care to the left ankle wound, that SN was to assess for infection and that wound healing goals included for the wound to show evidence of healing within two (2) weeks and that the wound would remain free of signs/symptoms of infection as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 02/12/2023 through 04/12/2023. Review of SN visit note documentation revealed the RN (Employee #5) provided wound care to left ankle wound on 02/22, 02/24 and 02/28/2023. There was no documentation on the SN visit note which provided evidence that the RN assessed the left ankle wound appearance and drainage on 02/22, 02/24 and 02/28/2023. During interview conducted on March 9, 2023 at approximately 4:15 PM, the administrator confirmed there was documentation in the clinical record which provided evidence that wound appearance and/or drainage were assessed when wound care was provided by the above referenced SN's on the aforementioned dates for patients #4, #5, and #7)