Every finding on record at Well Care Home Health of the Triad Inc

An onsite complaint investigation was conducted 5/16/24. The allegation was unsubstantiated, but standard level deficiencies to the Medicare CoP were identified.

Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This STANDARD is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews, the skilled nurse failed to assess a new wound/do wound care for 1 of 1 discharged patient with a wound [#1]. The findings included: The policy, Plan of Care [2/22] was provided by RN # 2 on 5/16/24 at approximately 4:30 pm. The policy stated, “Based on the assessment and conclusions, the individualized plan of care will include, but not be limited to...All patient care orders from all physicians involved in the individualized plan of care...Specific services and treatments to be provided...” Patient # 1 had a Start of Care [SOC] date of 3/3/23 and admitting diagnoses of venous insufficiency [a condition that occurs when the valves in veins do not work properly, making it harder for veins to move blood back to the heart], non-pressure chronic ulcer other part of left lower leg with fat layer exposed, and chronic kidney disease. Review of the Plan of Care [POC] for the certification period 7/1/23-8/29/23 included orders for SN [skilled nursing] 2 times a week for 8 weeks, 1 time a week for 1 week, 2 as needed visits for change in condition and “lower leg wound-left lateral- clean with soap and water, 2 times per week, clean with gauze with soap and water, wipe wound and peri wound using clean gauze...apply zinc oxide ointment to wound edges, spray antibiotic solution and set for 5 minutes...moisten Prisma cover wound bed then cover with hydrofera blue...” Review of the clinical record revealed the patient was seen at _______ [name of wound center] on 8/18/23. Review of the wound center’s notes revealed the wound center had identified a new wound noted on the right gluteus [buttock area]. The wound center had given the following order, “Gluteus; Right-clean wound with anasept and wound cleanser 1 time per day. Apply aquacel ag rope to wound bed; cover with abd pad and secure with tape. Review of the clinical record revealed the patient received a SN visit on 8/28/23. Further review of the clinical record revealed no evidence the wound on the right gluteus was assessed or the wound care was completed on 8/28/23. The patient had a return visit to the wound center on 8/31/23. The wound center provided new orders related to the area on the right gluteus which was identified on 8/18/23. The new order was, “...Location-Right gluteus-clean with sound cleanser...pack with packing strips moistened in Dakin's solution, cover with abd pad. Change dressing 2 times per day...” The patient received SN visits on 9/8/23 and 9/10/23. The clinical record revealed no evidence the new wound care was completed or the area to the right gluteus was assessed. During an interview with the branch director on 5/16/24 at approximately 3:30 pm, the director confirmed the wound was not assessed or the wound care completed

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews the skilled nurse failed to change an indwelling catheter as ordered by the physician in the plan of care for 1 of 1 discharged patient with an indwelling catheter [#1]. The findings included: The policy, Plan of Care [2/22] was provided by RN # 2 on 5/16/24 at approximately 4:30 pm. The policy stated, “Based on the assessment and conclusions, the individualized plan of care will include, but not be limited to...All patient care orders from all physicians involved in the individualized plan of care...Specific services and treatments to be provided...” Patient # 1 had a Start of Care [SOC] date of 3/3/23 and admitting diagnoses of venous insufficiency [a condition that occurs when the valves in veins do not work properly, making it harder for veins to move blood back to the heart], non-pressure chronic ulcer other part of left lower leg with fat layer exposed, and chronic kidney disease. Review of Plan of Care [POC] for the certification period 3/3/23-5/1/23 included orders for SN [skilled nursing] 1 time a week for 4 weeks, and 3 PRN [as needed for change in condition/catheter issues/signs of UTI [urinary tract infection] and “Skilled nurse for insertion of foley catheter maintenance with catheter # 18 with 10 cc balloon, change every month around the 13th and PRN dislodgement or stoppage...” Review of the clinical record revealed the foley catheter was changed on 3/24/23. There was no documented evidence of the foley catheter being changed in April 2023. Review of the Plan of Care for the certification period 7/1/23-8/29/23 included orders for “skilled nurse for insertion of foley catheter; maintenance with catheter size of 18 French with 5-10 cc balloon. Change foley every month and as needed...” The next foley catheter change was documented completed on 8/7/23. There was no evidence the foley catheter was changed during the month of July 2023. During an interview with the agency director on 5/16/24 at approximately 3 pm, the director confirmed the foley catheter was not changed in accordance with the POC.

An unannounced and onsite complaint investigation was conducted 11/8/21-11/9/21. The allegation was substantiated and standard level 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 clinical record review and staff interviews the agency failed to follow the physician's order for wound care for 1 of 3 charts [#1]. The findings included: 1. Patient # 1 had a Start of Care [SOC] date of 6/28/20. A review of the Plan of Care for the certification period 8/22/21 to 10/20/21 revealed the following diagnoses: Pressure Ulcer of Right Buttock [stage 4], Pressure Ulcer of other site [stage 2], Down’s Syndrome and Dementia. A review of the Plan of Care [POC] revealed orders for SN [skilled nursing] 2 times a week for 1 week; 3 times a week for 1 week; 2 times a week for 1 week; 3 times a week for 1 week; 2 times a week for 1 week; 3 times a week for 1 week; 2 times a week for 1 week; 3 times a week for 1 week; 2 times a week for 1 week and 1 PRN [as needed] for health complications and “Clinician to remove old dressing and dispose of in waste container…Teach caregiver wound care to right iliac crest. Clean well. Apply skin prep to peri wound area. Apply saline moistened collagen. Cover with abd pad. Secure with tape…Caregiver to change every day on non-SN days and as needed…” A supplemental order was written on 9/27/21 for “SN to perform wound care to right iliac crest. Clean well. Apply saline moistened Callogen [sic] then apply Aquacel Ag…Dressing to be changed daily and PRN. SN to change twice a week…” A review of the clinical record revealed the following information, Patient # 1 received visits 2 times per week from 9/27/21 through 10/14/21. During those routine visits the SN applied collagen without the Aquacel Ag. An interview was conducted with employee # 8 on 11/9/21 at approximately 9:30 am. During the interview employee # 8 confirmed the physician’s orders were not followed related to wound care.

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 and staff interviews the agency failed to provide wound care based on a physician's order for 1 of 3 charts [#1]. The findings included: 1A. Patient # 3 had a Start of Care [SOC] date of 9/27/21 and admitting diagnoses of Venous Insufficiency [Chronic] [Peripheral], Non-Prs Chronic Ulcer of Right Calf and Non-Prs Chronic Ulcer Unspecified part of Left Lower Leg. A review of the Plan of Care for the certification period 9/27/21 to 11/25/21 revealed orders for SN [skilled nursing] 1 time a week for 1 week; 2 times a week for 8 weeks; 2 PRN [as needed] for decline in wound or health status and “…clean left anterior mid-pretib [pretibial] venous ulcer with wound cleanser, pat dry, apply calcium alginate, abd pad, wrap with conform dressing and secure with medipore tape…” Further review of the Plan of Care revealed other treatment orders. A review of the Start of Care OASIS [The Outcome and Assessment Information Set] revealed RN # 6 documented 2 areas of skin breakdown. Wound 1 – Left mid tibial venous ulcer and Wound 2-Distal right calf. Further review of the clinical record revealed the following treatment was completed on wound 2 without an order from 9/27/21 to 11/8/21 “Applied skin prep to peri wound, covered with band aid and wrapped with a conforming dressing.” An interview was conducted with employee # 8 on 11/9/21 at approximately 9:30 am. During the interview employee # 8 confirmed the clinical record did not include a treatment order for wound 2. 1B. Patient # 3 had a Start of Care [SOC] date of 9/27/21 and admitting diagnoses of Venous Insufficiency [Chronic] [Peripheral], Non-Prs Chronic Ulcer of Right Calf and Non-Prs Chronic Ulcer Unspecified part of Left Lower Leg. A review of the Plan of Care for the certification period 9/27/21 to 11/25/21 revealed orders for SN [skilled nursing] 1 time a week for 1 week; 2 times a week for 8 weeks; 2 PRN [as needed] for decline in wound or health status and “…clean left anterior mid-pretib [pretibial] venous ulcer with wound cleanser, pat dry, apply calcium alginate, abd pad, wrap with conform dressing and secure with medipore tape…” A review of the Start of Care OASIS [The Outcome and Assessment Information Set] revealed RN # 6 documented 2 areas of skin breakdown. Wound 1 – Left mid tibial venous ulcer and Wound 2-Distal right calf. A review of the clinical record revealed on 11/1/21 LPN # 10 identified a third wound. The wound was described as Right mid pretibial wound-stage II. The wound measurements were 3x3x.1. A review of the wound assessment revealed LPN # 10 documented the following treatment, “…cleansed with wound cleanser, applied calcium alginate to wound bed, covered with abd pad and conforming dressing…” Further review of the clinical record revealed no physician’s order for the treatment. An interview was conducted with employee # 8 on 11/9/21 at approximately 9:30 am. During the interview employee # 8 confirmed the clinical record did not reveal a physician’s order for the treatment to the right mid pretibial wound.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review and staff interviews the agency failed to communicate changes in a wound/onset of a new wound to the physician for 1 of 3 charts [#1]. The findings included: The policy, Coordination of Care [1/3/13], was provided by employee # 8 on 11/9/21. The policy stated, "...Timely and ongoing communication is the responsibility of each team member of the interdisciplinary group...The clinicians will be responsible for facilitating communications about changes in the patient's status..." 1A. Patient # 3 had a Start of Care [SOC] date of 9/27/21 and admitting diagnoses of Venous Insufficiency [Chronic] [Peripheral], Non-Prs Chronic Ulcer of Right Calf and Non-Prs Chronic Ulcer Unspecified part of Left Lower Leg. A review of the Plan of Care for the certification period 9/27/21 to 11/25/21 revealed orders for SN [skilled nursing] 1 time a week for 1 week; 2 times a week for 8 weeks; 2 PRN [as needed] for decline in wound or health status and “…clean left anterior mid-pretib [pretibial] venous ulcer with wound cleanser, pat dry, apply calcium alginate, abd pad, wrap with conform dressing and secure with medipore tape…” A review of the clinical record revealed the following documentation- 10/12/21 LPN # 7 documented, “…redness observed to the right lower leg…” 10/14/21 LPN # 10 documented, “…Purulent drainage to right calf with strong odor…”10/18/21- LPN # 7 documented, “…Wound to back of right calf has stronger odor than last week…may have more drainage…” Further review of the clinical record revealed the physician was not contacted until 10/21/21 when the patient had to be started on an antibiotic. An interview was conducted with employee # 8 on 11/9/21 at approximately 9:30 am. During the interview employee # 8 confirmed the physician should have been contacted with the earliest signs of infection. 1B. Patient # 3 had a Start of Care [SOC] date of 9/27/21 and admitting diagnoses of Venous Insufficiency [Chronic] [Peripheral], Non-Prs Chronic Ulcer of Right Calf and Non-Prs Chronic Ulcer Unspecified part of Left Lower Leg. A review of the Plan of Care for the certification period 9/27/21 to 11/25/21 revealed orders for SN [skilled nursing] 1 time a week for 1 week; 2 times a week for 8 weeks; 2 PRN [as needed] for decline in wound or health status. A review of the Start of Care OASIS [ The Outcome and Assessment Information Set ] revealed RN # 6 documented 2 areas of skin breakdown. Wound 1 – Left mid tibial venous ulcer and Wound 2-Distal right calf. A review of the clinical record revealed on 11/1/21 LPN # 10 identified a third wound. The wound was described as Right mid pretibial wound-stage II. The wound measurements were 3x3x.1. Further review of the clinical record revealed no evidenced the physician was notified of the new wound. . An interview was conducted with employee # 8 on 11/9/21 at approximately 9:30 am. During the interview employee # 8 confirmed there was no evidence the physician was notified of the new open area.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review and staff interviews the agency failed to document/record wound measurements weekly in accordance with agency policy for 3 of 3 charts [#1, 2 and 3]. The findings included: The policy, Wound Addendum [last revision date 7/18], was provided by employee # 8 on 11/9/21. The policy stated, "Wounds will be documented in the electronic medical record using wound addendum. All disciplines will be responsible for the accurate and complete assessment of all wounds at every home health visit...Measurements should occur weekly on all wounds..." 1. Patient # 1 had a Start of Care [SOC] date of 6/28/20. A review of the certification period 8/22/21 to 10/20/21 revealed the following diagnoses: Pressure Ulcer of Right Buttock [stage 4], Pressure Ulcer of other site [stage 2], Down’s Syndrome and Dementia. A review of the Plan of Care [POC] revealed orders for SN [skilled nursing] 2 times a week for 1 week; 3 times a week for 1 week; 2 times a week for 1 week; 3 times a week for 1 week; 2 times a week for 1 week; 3 times a week for 1 week; 2 times a week for 1 week; 3 times a week for 1 week; 2 times a week for 1 week and 1 PRN [as needed] for health complications and “Clinician to remove old dressing and dispose of in waste container…Teach caregiver wound care to right iliac crest. Clean well. Apply skin prep to peri wound area. Apply saline moistened collagen. Cover with abd pad. Secure with tape…Caregiver to change every day on non-SN days and as needed…” A supplemental order was written on 9/27/21 for “SN to perform wound care to right iliac crest. Clean well. Apply saline moistened Callogen [sic] then apply Aquacel Ag…Dressing to be changed daily and PRN. SN to change twice a week…” Further review of the clinical record revealed no wound measurements were documented for the week of 10/4/21. An interview was conducted with employee # 8 on 11/9/21 at approximately 9:30 am. During the interview employee # 8 confirmed no wound measurements were documented for the week of 10/4/21. 2. Patient # 2 had a Start of Care [SOC] date of 10/8/21 and admitting diagnoses of Type 2 Diabetes Mellitus with Diabetic Neuropathy and Acquired Absence of Right Great Toe. A review of the Plan of Care for the certification period 10/8/21 to 12/6/21 included orders for SN [skilled nursing] 1 time a week for 8 weeks; 3 times a week for 1 week and “SN/CG [caregiver] to perform wound care to incision/suture site located at right great toe amputation-cleanse with wound cleanser apply Aquacell [sic]. Cover with gauze, wrap with kerlix and secure with medipore tape…” A review of the clinical record revealed Patient # 2 received 7 visits from 10/8/21 – 11/8/21. Further review of the clinical record revealed no documented wound assessment/measurements during that time. An interview was conducted with employee # 8 on 11/9/21 at approximately 9:30 am. During the interview employee # 8 confirmed the wound should have been measured/assessed during the weekly visits. 3. Patient # 3 had a Start of Care [SOC] date of 9/27/21 and admitting diagnoses of Venous Insufficiency [Chronic] [Peripheral], Non-Prs Chronic Ulcer of Right Calf and Non-Prs Chronic Ulcer Unspecified part of Left Lower Leg. A review of the Plan of Care for the certification period 9/27/21 to 11/25/21 revealed orders for SN [skilled nursing] 1 time a week for 1 week; 2 times a week for 8 weeks; 2 PRN [as needed] for decline in wound or health status and “…clean left anterior mid-pretib [pretibial] venous ulcer with wound cleanser, pat dry, apply calcium alginate, abd pad, wrap with conform dressing and secure with medipore tape…” A review of the clinical record revealed no documented wound measurements for the week of 10/4/21. An interview was conducted with employee # 8 on 11/9/21 at approximately 9:30 am. During the interview employee # 8 confirmed no wound measurements were documented for the week of 10/4/21.

An onsite complaint investigation was conducted 9/13/21-9/14/21. Deficiencies to the Medicare CoP were identified.

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on clinical record review and staff interviews the agency failed to document the existence and/or resolution of a complaint for 1 of 3 charts [#1]. The findings included: Patient # 1 had a Start of Care [SOC] date of 5/14/21 and an admitting diagnosis of Pressure-induced deep tissue damage of right heel. A review of the Plan of Care for the certification period 5/14/21 to 7/12/21 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; and Physical therapy [PT] effective the week of 5/16/21 2 times a week for 3 weeks; 1 time a week for 3 weeks. A review of PTA # 1’s narrative note for 6/17/21 revealed the following information, “…Pnt’s [patient] son arrived in room and immediately was agitated. Pnt’s [sic] stated that home health agency has done nothing for his mother and that he will be contacting the state to report agency. PTA attempted to discuss scenario with noted increased agitation from son and pnt…” A review of the agency’s complaint log did not include any information related to this incident. An interview was conducted with employee # 2 on 9/14/21. During the interview employee # 2 confirmed the PTA should have documented the incident as a complaint.

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 clinical record review and staff interviews the agency failed to follow the plan of care [POC] related to notifying the physician when vital signs were outside the given parameters for 1 of 3 patients [#1]. The findings included: Patient # 1 had a Start of Care [SOC] date of 5/14/21 and an admitting diagnosis of Pressure-induced deep tissue damage of right heel. A review of the Plan of Care for the certification period 5/14/21 to 7/12/21 revealed orders for Physical therapy [PT] effective the week of 5/16/21 2 times a week for 3 weeks; 1 time a week for 3 weeks and “Licensed professional to report vital signs falling outside the following established parameters…systolic bp [blood pressure] less than 80 or greater than 160; diastolic bp less than 45 or greater than 110…” A review of the clinical record dated 6/8/21 revealed PTA # 1 documented a blood pressure of 164/104 with the following documentation, “Was physician notified-no. Patient denied symptoms and daughter states she refused to take meds…” On 6/17/21 PTA # 1 documented a blood pressure of 174/100 with the following documentation, “…pnt [patient] denied any symptoms…” An interview was conducted with employee # 2 on 9/14/21. During the interview, employee # 2 stated, “_____ [PTA # 1] attempted to contact the MD, but when he did he was advised that the patient had not been seen by that particular physician for 2 years and the physician would not be following the patient any longer. So, he really had no one to report the blood pressure to. “A review of the POC for the certification period 7/13/21 to 9/10/21 revealed orders for SN [Skilled nursing] effective the week of 7/25/21 1 time a week for 1 week; 3 times a week for 6 weeks and “Licensed professional to report vital signs falling outside the following established parameters…systolic bp [blood pressure] less than 80 or greater than 160; diastolic bp less than 45 or greater than 110…” On 8/2/21 RN # 3 documented a blood pressure of 170/85. A review of the clinical record revealed the following documentation, “…BP [blood pressure] elevated today as the patient is agitated…Patients [sic] daughter states she will recheck BP and advise this clinician if it is greater than 160/90…” There is no evidence the physician was notified of the blood pressure reading. On 8/6/21 a supplemental order for Physical Therapy was written with the visit frequency as 1 time a week for 1 week; 2 times a week for 3 weeks; 1 time a week for 2 weeks. PTA # 1 made a routine visit on 8/26/21 and documented a blood pressure reading of 162/84 with the following documentation, “Was physician contacted-No. Pnt [patient] reports her daughter made her blood pressure up [sic] today. No other symptoms or complications reported.” An interview was conducted with employee # 2 on 9/14/21. During the interview employee # 2 confirmed the physician was not notified of the blood pressure readings in accordance with the POC.