Every finding on record at Ycsc Pen Management LLC

Emergency Preparedness During the recertification survey conducted on 1/11/2021 through 1/14/2021 at Superior In-Home Care, Inc. Emergency Preparedness was reviewed. The agency is in compliance with Emergency Preparedness per Code of Federal Regulations (CFR) 42, Part 484.22, Condition of Participation for Home Health Agencies.

An unannounced recertification survey was conducted on 1/11/2021 through 1/14/2021 at Superior In-Home Care, INC, in Pensacola, FL. At the time of the survey, the facility was not in compliance with 42 CFR Part 484, Requirements for Home Health Agencies.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician. This ELEMENT is not met as evidenced by: Based on record review and interview the home health agency failed to ensure wound care was provided as ordered by the physician for 1 of 4 sampled patients receiving wound care services (#1). The findings include: On 1/12/2021 at approximately 9:40 AM, a review of patient #1's Home Health Certification and Plan of Care (POC), for the certification period of 12/14/2020 through 2/11/2021 was completed. The POC revealed the skilled nurse would perform wound care to one wound "SN (skilled nurse) to perform wound vac dressing change to right knee 3 x (times) week and PRN (as needed) - continuous suction at 125 MMHG (millimeters of mercury)". A wound vac is a type of therapy that helps wounds heal by decreasing air pressure on a wound. No other wounds or wound care orders were found in the POC. On 1/12/2021 a review of the Skilled Nursing Notes for patient #1was completed. The Skilled Nursing Note dated 12/14/2020, signed by Staff A, a Registered Nurse (RN) revealed that staff A, had removed the old dressing from wound 1, covered the wound with two Abdominal Pad (ABD) dressings and secured the dressing with tape. Wound 2 was cleansed with alcohol and was covered with two ABD pads and wound 3 (on the patients right knee) was cleansed with a 4x4 (dressing sponge), dried and tape was applied to the dressing. The Skilled Nursing Note dated 12/16/2020, signed by Staff A, RN, revealed Staff A replaced the ABD pads on wound 1 and secured with tape. The note revealed staff A removed the saturated ABD pad from wound 2 and cleaned staples with alcohol, covered with an ABD pad and secured it with tape. Patient #1 refused wound care for wound 3. The Skilled Nursing Note dated 12/17/2020, signed by Staff A, RN, revealed Staff A replaced the ABD pads on wound 1 and secured with tape. The note revealed staff A removed a saturated ABD pad from wound 2 and covered with an ABD pad and secured it with tape. Patient #1 refused wound care for wound 3. The Skilled Nursing Note dated 12/21/20 signed by staff A, RN, revealed staff A removed the Xeroform dressing from wound 1, cleaned the wound with normal saline, dried the wound, then applied a light layer of polysporin (antibiotic ointment), then applied an ABD pad and a long leg brace. The note revealed staff A cleaned wound 2 with normal saline, applied skin prep and mepitel wound dressing to the wound bed. The wound vac was applied to wound 3. The Skilled Nursing Note dated 12/23/20 signed by staff A, RN, revealed staff A cleaned wound 1 with normal saline, dried the wound then applied a light layer of polysporin, then applied an ABD pad, and secured the dressing with tape. The note revealed staff A cleaned wound 2 with normal saline, dried the wound then applied a light layer of polysporin, and covered the wound with ABD pads and secured with tape. The note revealed the wound vac was off. The Skilled Nursing Note dated 12/28/2020 signed by Staff A, RN, revealed wound 1 was cleaned with normal saline and a light layer of polysporin was applied. The wound was covered with an ABD pad and secured with tape. The Skilled Nursing Note dated 12/30/2020 signed by staff A, RN, revealed wound 1 and wound 2 were cleaned with normal saline and a light layer of polysporin was applied. The wounds were covered with ABD pads and secured with soft wrap loosely applied. The Skilled Nursing Note dated 1/4/2021 signed by staff A, RN, revealed wound 1 and 2 were cleaned with normal saline and a light layer of polysporin was applied. The wounds were covered with ABD pads and secured with tape or soft wrap and leg brace for wound 1. On 1/14/21 at approximately 12:01 PM, received and reviewed a physician order dated 12/22/20 which revealed the wound vac was removed and the skilled nurse to perform wound care daily to the right knee. The wound care order stated: clean with saline or soap and water, pat dry, cover with dry dressing. The skilled nurse to clean the right thigh with saline or soap and water and leave open to air. On 1/14/2021 at approximately 12:05 PM, an interview was conducted with the Director of Nurses, (DON), who confirmed the agency received a verbal order to apply polysporin, and confirmed there is no written, signed physician order for the wound care that was provided.