Every finding on record at Westbrook Visiting Nurses & Public Health

Unannounced visits were concluded at Westbrook Visiting Nurse and Public Health on 12/20/23 and 12/21/23 for the purpose of reviewing the Emergency Preparedness Code of Federal Regulations 484.102, Condition of Participation for Home Health Agencies. The agency was in compliance with the requirements at the time of the survey.

Unannounced visits were conducted at Westbook Visiting Nurse and Public Health on 12/20/23 and 12/21/23 for the purpose of recertification. Standard level deficiency was identified

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on Clinical Record Review and interviews with agency personnel, for one (1) of two (2) patients receiving wound care, the agency failed to authenticate the accuracy of the referral source documentation for the accurate completion of the Initial Home Health Certification and Plan of Care document, as it related to the referral source documentation, as it related to the location of the patient’s wound. The findings include. Patient # 2 had a home health start of care date of October 25, 2023, with diagnosis that included non-pressure chronic ulcer of leg wound, Lymphedema, Peripheral Vascular Disease, Hypertension and Atrial Fibrillation, history of a Cerebral Vascular Accident, and obesity. Review of the health provider certification period of 10-25-23 through 12-23-23 included skilled nursing services 3 times a week for 8 weeks for wound care to the left lower leg for non-pressure ulcer, generalized nursing assessments for medication management, and monitoring of the patient’s skin integrity and bilateral lower leg lymphedema, and physical therapy services for gait training, functional mobility, and safety. Review of the patient’s health care providers’ referral documentation dated 10/24/2023 with the Administrator/Supervisor of Clinical Services (SCS) on 12/21/23 at 10:30am, identified Patient #2 was referred for home health services for skilled nursing for wound care to the left lower leg for a non-pressure ulcer, Further review of the health care provider referral document with the Administrator/SCS, identified the wound referral location was reported in the Primary Diagnosis section as, leg ulcer, but the order questions" section, identified the wound was located to the right leg. Interview and review of patient # 2, the Home Health Agency start of care document and healthcare provider orders dated 10-25-23 with the Administrator/SCS, 12-21-23 at 10:30 am, identified that during the initial nursing assessment visit, ton 10-25-23 he Primary Diagnosis was identified as, non-pressure chronic ulcer unspecified part of left lower leg limited to breakdown skin. Further review of the nursing interventions section in the initial start of care documentation, identified the nurse would assess, perform, instruct patient/primary care giver to perform wound care to the right lower extremity stasis ulcerations three (3) times per week. The Administrator identified he/she did not authenticate the accurate location of the patient’s wound as documented within the referral document, and initial start of care documentation. The agency failed to authenticate the accurate location of the Patient’s wound as documented within the referral document, and initial start of care documentation and failed to contact the referring provider to verify the correct location of the patient’s wounds.