Every finding on record at Wheatland Health Services LLC

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site Recertification and Complaint Survey (iQIES 4F555-H1, KS0071630) at the above-named Home Health Agency from 09/06/22 to 09/12/22 resulted in a finding of no deficiency citations respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.22.

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site Recertification and Complaint Survey (iQIES 4F555-H1, KS0071630) at the above-named Home Health Agency from 09/06/22 to 09/12/22 resulted in a finding of substantial compliance respective to applicable Condition of Participation (CoP) under 42 CFR 484, Subpart A through C with the following standard-level deficiencies cited.

Integrate all orders CFR(s): 484.60(d)(2) Integrate orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient. This ELEMENT is not met as evidenced by: Based on document review, policy review, and interview, the Home Health Agency (HHA) failed to ensure orders for wound care were integrated into the Plan of Care (POC) to assure the coordination of all interventions provided for one of ten records reviewed (Patient 2). Failure to ensure wound care orders were integrated in the POC has the potential to place all patients receiving wound care services at risk for receiving improper, inconsistent, or omitted patient care by agency staff. Findings Include: Review of a policy titled "Plan of Care HH5-2A.01” Effective July 1, 2018, Revised: February 2022 showed the agency would develop and implement an individualized Plan of Care (POC) for each patient admitted to the agency. The policy showed specific orders, including procedures, modalities, interventions, and treatments for each discipline were required including realistic measurable long and short-term goals, rehab potential and discharge plans. Review of Patient 2's medical record showed the patient resided at home and the patient’s daughter was the primary caregiver responsible for the patient’s wound care. Patient 2's "Home Health Certification and Plan of Care," POC for the Certification Dates of 07/13/22 through 09/10/22, showed a principal diagnosis of Fistula of Intestine with Type 2 Diabetes Mellitus and Colostomy status (Presence of a colostomy, an opening for the colon, through the abdomen). The POC showed that patient had a new colostomy due to a mass found in the colon, the surgical wound dehisced (separation or opening of previously closed wound edges, due to failure of proper wound healing) causing an intestinal fistula (abnormal passageway between the intestine and the skin) due to patient’s anatomy. Hospital staff had been applying a colostomy bag over the stoma (an opening on the abdomen which is used to remove body waste) and over the dehisced wound/fistula Due to patient’s anatomy, the colostomy bag over the fistula constantly leaked. Review of Client Coordination Note Report, dated 09/09/22, “Late Entry” for Start of Care (SOC)-admission 07/13/22, completed by Staff K, LPN showed call was placed to physician’s office in regard to using Eakins bags (fistula drainage bag) and “. . . they said that was fine and that hopefully we could find something that worked.” Review of the POC showed there were no orders for the performance of wound treatments (application of Eakins bags and other supplies) by staff or instruction to caregiver specific to the abdominal wall fistula. The POC did not contain measurable long and short-term goals, rehab potential and discharge plans for the treatment of the fistula. Review of physician’s orders titled “Resumption of Care” dated 08/03/22, for resumption of services by the home health agency following the patient’s hospitalization, did not include orders for the performance of wound treatments by staff or instruction to caregiver for the abdominal wall fistula. The POC did not contain measurable long and short-term goals, rehab potential and discharge plans for the treatment of the fistula. During an interview on 09/07/22 at 3:41 PM, the agency Administrator, Staff A, confirmed the nurses would make home visits to the patient and find that the caregiver had already changed the fistula dressing, prior to leaving for work, making assessment and education more difficult. The surveyor inquired about the lack of care coordination/treatments/education in the POC. The surveyor also questioned Administrator, Staff A about involvement of professional staff with the patient’s daughter/caregiver, disposition of supplies for the fistula care from admission, and the status of the patient’s discharge. The agency failed to ensure updated orders for wound care were integrated into the Plan of Care (POC) on admission and resumption of agency services, to assure the coordination of all interventions with the staff, patient, and caregiver.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review, policy review and staff interview, the Home Health Agency (HHA) failed to coordinate care delivery to meet the patient’s needs and to involve the caregiver in coordination of care activities for one of ten patients reviewed (Patient 2) who received wound care services from the agency. Failure to coordinate care delivery and activities with the patient and caregiver involved with the care has the potential to place patients at risk for unmet wound care expectations, needs and treatment goals. Findings Include: Review of a policy titled, "Care Coordination HH5-4A,” Effective July 1, 2018, Revised: February 2022, showed “All personnel providing services to a patient will maintain communication to ensure their efforts effectively complement one another and support the goals and objectives outlined in the patient’s plan of care (POC). Care coordination is conducted as needed to discuss patients that are newly admitted, recently discharged from the hospital, requiring an update to the POC, experiencing complex or changing needs or being considered for discharge.” Review of Patient 2's medical record showed the patient resided at home. The patient’s daughter assumed the primary caregiver role responsible for the patient’s wound care. Patient 2's "Home Health Certification and Plan of Care," (POC) for the Certification Dates of 07/13/22 through 09/10/22, showed a principal diagnosis of Fistula of Intestine with Type 2 Diabetes Mellitus and Colostomy status (Presence of a colostomy, an opening for the colon, through the abdomen). The POC showed that patient had a new colostomy due to a mass found in the colon, the surgical wound dehisced (separation or opening of previously closed wound edges, due to failure of proper wound healing) causing an intestinal fistula (abnormal passageway between the intestine and the skin) due to patient’s anatomy. Review of the Client Coordination Note Report showed a late entry note written by Staff K, LPN dated 09/09/22. The actual visit day was listed as “Prior to Start of Care.” Staff K, LPN wrote that she called the hospital case manager to verify what the hospital staff were doing with Patient 2’s fistula since no orders had been received. The case manager stated that they were trying different bags but were having difficulty finding one that would stay on due to the placement of the fistula. Review of Visit Note Report-RN OASIS Admission dated 07/13/22 completed by Staff C, RN on admission showed skilled nurses were “. . . required to evaluate and manage wound progression and perform wound care.” The assessment stated that Patient 2 had a colostomy and a dehisced wound/fistula to midline abdomen and was unable to reach the area. The assessment further stated that Patient 2’s daughter reported being uncomfortable managing her mother’s current wound condition. There was no documented coordination between the visiting professionals and the caregiver (daughter) regarding fistula care instruction and supplies management to ensure an adequate number of supplies were in the home for the management of the wound condition of both the fistula and colostomy. Review of Visit Note Report, dated 07/18/22, completed by Staff D, RN, showed wound was not assessed, (caregiver had already completed care) and wound care not provided, (caregiver had already completed care.) There was no documented coordination of care with the caregiver regarding the need for skilled assessment of the wound by the nurses during visits. There was no documented coordination of an opportunity to observe/demonstrate wound care technique with both the caregiver and the nurse present. In addition, there was no documentation of counts of wound care and colostomy supplies utilized by the caregiver during the time between nursing visits. Review of Visit Note Report, dated 07/22/22, completed by Staff E, LPN, showed wound care was not provided, because the caregiver had already completed care. There was no documentation to support the coordinated observation/demonstration of wound care technique with both the caregiver and the nurse present. There was no documented counts of wound care and colostomy supplies utilized by the caregiver during the time between nursing visits, resulting in inadequate supplies available for the patient. Review of Visit Note Report, dated 07/28/22, completed by Staff F, RN, showed patient was transferred to the hospital on 07/23/22. Review of Visit Note Report, RN Resumption of Care assessment, dated 08/03/22, completed by Staff G, RN, showed patient was admitted to the hospital with a diagnosis of Unspecified Protein-Calorie Malnutrition. The assessment noted the fistula was opened with red, irritated skin, with Eakins fistula drainage bag (a pouching system to control drainage from the fistula, protect skin from caustic drainage and control odor). The assessment showed wound care was not provided because the caregiver had already completed care. The assessment showed the caregiver was at work during the visit. There was no documented care coordination with the caregiver regarding the fistula wound condition or changes in care following hospitalization., There was no documented counts of wound care and colostomy supplies utilized between nursing visits by the caregiver, resulting in inadequate supplies available for the patient since hospitalization. Review of Visit Note Report, dated 08/8/22, completed by Staff H, LPN showed the patient’s caregiver is performing wound care as needed due to frequent leaking around the fistula to the abdomen area. It was noted that the caregiver has great difficulty trying to get bags to stay on without leaking. There was no documented education of wound care, nor counts of wound care and colostomy supplies utilized between nursing visits by the caregiver, to ensure adequate supplies were available for the patient. Review of Visit Note Report, dated 08/18/22, completed by Staff I, LPN showed the wound was not assessed and no wound care provided, because the caregiver had already completed care. There was no documented care coordination with the caregiver regarding the fistula wound condition. There was no documented counts of wound care and colostomy supplies utilized by the caregiver during the time between nursing visits, creating a failure to ensure adequate supplies were available for the patient since readmission. Review of PT (Physical Therapy) Therapy Progress Note, dated 08/22/22, completed by Staff J, Physical Therapy Assistant (PTA), showed patient now going for intravenous fluids (IV’s) three times a week. It was noted that the patient’s fluid intake was washing out through her colostomy region. Patient advises the PTA that she feels until her colostomy is reversed, there is not any need for physical therapy right now. Review of agency Event Report, dated 08/24/22, showed the daughter contacted the agency regarding needing supplies for fistula, stated she ran out of bags over the weekend. Review of Visit Note Report, dated 08/25/22, completed by Staff H, LPN showed the wound was not assessed and no wound care provided, because the caregiver had already completed care. There was no documented care coordination or follow-up with the caregiver regarding the need for fistula supplies requested the prior day by the nurse. There was no documentation of the fistula wound condition, nor documented counts of wound care and colostomy supplies utilized by the caregiver during the time between nursing visits, creating a failure to ensure adequate supplies were available for the patient over weekends. There was no documentation to support coordination of discharge planning for patient with physical therapy following the PTA visit from 08/22/22. Review of Client Coordination Note Report dated 08/29/22, Late Entry for 08/26/22, completed by Staff K, LPN showed daughter was notified that only 3 bags were delivered on 08/26/22 due to bags being on backorder. Daughter stated that should be fine as patient currently had one on and should be able to get through the weekend. Review of agency Event Report, dated 08/29/22 showed the daughter contacted the agency, stated she ran out of bags over the weekend. Review of a PT Therapy Progress Note dated 08/31/22, Completed by Staff J, PTA showed Supervising PT to see patient on the next visit. Patient was given 2 day written discharge notice. The note showed the PTA provided “specific exercise performance to not loosen the fistula bag, as patient expresses slight blood from irritation of changing it multiple times when draining increases.” The same document showed limited bags for fistula which drains constantly. There was no documented follow-up by the supervising P T for the pending 2 -day discharge. Review of Client Coordination Note Report, dated 09/01/22, completed by Staff K, LPN showed Patient’s daughter called and stated she would need supplies for the weekend. Review of Client Coordination Note Report dated 09/01/22, Missed Visit notification completed by Staff H, LPN showed that the patient stated she was being discharged and did not wish to be seen. The patient was given a 5 day notice of possible discharge, end of episode 09/10/22. Review of Client Coordination Note Report, dated 09/01/22, completed by Staff H, LPN showed the nurse spoke with the daughter about a possible discharge. The daughter stated she would have to contact Medicaid, that she had spoken with them before about obtaining patient’s supplies for the ostomy and that she would do that again. Review of Client Coordination Note Report, dated 09/06/22, completed by Staff K, LPN showed the patient refused for the nurse to complete in person discharge that day. During an interview on 09/07/22 at 3:41 PM, the agency Administrator, Staff A, confirmed the patient’s pending discharge. The surveyor inquired about care coordination/treatments/education from the POC and with the patient’s daughter/caregiver from professional staff. The surveyor also inquired about the disposition of supplies for the fistula care, from admission, and the status of the patient’s nursing and therapy discharge. During an interview on 09/08/22 at 1:45 PM, the Administrator, Staff A, confirmed follow- up contact to the patient regarding discharge had been completed and documented in the patient’s record. The administrator confirmed that the patient had been upset by the discharge process and a nursing visit was being scheduled with the caregiver and patient, in order to review wound management, availability of colostomy and fistula supplies and possible physical therapy reassessment. During an interview on 09/12/22 at 11:53 AM, the patient’s Daughter (caregiver) confirmed the patient required about 10-15 pouches (fistula drainage bags supply) per week and that the agency had not supplied enough for her mother. She stated she and her brother had incurred out of pocket expenses for fistula supplies that sometimes required traveling out of town to obtain. During the same interview she confirmed the nurses had not suggested a need to coordinate times to assess the fistula without the pouch in place, to observe her and instruct on fistula care and to discuss a management plan for needed supplies. She confirmed a discharge plan with the agency for obtaining supplies was not discussed at the time of the proposed discharge from the agency. She confirmed the agency had since contacted her about the discharge of her mother, sent a nurse to reevaluate and decided to keep her mother on service to develop a plan for the fistula management.