Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 017016 (X3) Date Survey Completed 06/16/2022
Name of Provider or Supplier Southeast Alabama Homecare, Llc Street Address, City, State 804 Glover Avenue, Enterprise, AL
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
E0000 Based on the recertification survey conducted on 6/16/22, Southeast Alabama Homecare was found to be in substantial compliance with the standards for Emergency Preparedness.

G0000 A recertification survey was conducted on 6/14/22 to 6/16/22 and standard level deficiencies were cited.

G0536 A review of all current medications
CFR(s): 484.55(c)(5)

A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy.


This ELEMENT is not met as evidenced by:
Based on observations, review of medical records (MR), agency policy, and interviews, it was determined the agency failed to ensure staff reconciled medications in 3 of 5 Home Visits (HV) conducted, including HV # 4, HV # 2 and HV # 5, and had the potential to negatively affect all patients receiving services by this agency.



Findings include:



Agency Policy: Monitoring Medications



Policy Number: 10.008



Revised Date: 5/1/19



Purpose: To provide process to ensure continuous monitoring of medications in the patient's home.



Policy:

A drug regimen review will be performed on all patients in conjunction with all comprehensive assessments. Additionally, all clinicians will participate in medication review and reconciliation throughout the episode.



For patients receiving skilled nursing and therapy services, the skilled nurse is responsible for medication review and reconciliation throughout the episode. The therapist will participate by monitoring and reporting any identified medication issues...to the Patient Care Manager.


3. HV # 5 was admitted on 5/17/22 with diagnoses including Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1-4 Unspecified Chronic Kidney Disease; Heart Failure, Unspecified.




Review of the HHC and POC dated 5/17/22 revealed an order for SN 1wk9; Physical Therapist (PT) 1wk1, 2wk1,1wk1, 2wk2 1wk4; Occupational Therapist (OT) 1wk1,2wk2,1wk2; Home Health Aide (HHA) Effective 5/22/22 1wk4.




A HV was conducted on 6/15/22 at 9:15 AM with EI # 6, HHA (Home Health Aide) to observe shower assistance provided. EI # 1 Executive Director was also present.




During the HV, the CMR printed by the agency on 6/14/22 at 10:12 AM and the medications in the home were compared to the CMR and the following discrepancy was found and verified by the patient.




Benadryl 25 mg tablets one every six hours as needed was found in the home and not listed on the CMR. The patient stated," I only take that if I get into the car which is when I have a doctor's visit. I get car sick and I will vomit in my son's car if I don't take that."




An interview was conducted on 6/15/22 at 10:05 AM with EI # 1 who confirmed the staff failed to reconcile the medication per the agency policy.

1. HV # 4 was admitted to the agency on 5/11/22 with diagnoses including Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Hypertensive Heart Disease with Heart Failure and Acute Embolism and Thrombosis of Unspecified Deep Veins of Left Lower Extremity.



Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 5/11/22 to 7/9/22 revealed a Skilled Nurse (SN) frequency of once a week for 1 week (1wk1), twice a week for 1 week (2wk1) then once a week for 7 weeks (1wk7).



A HV was conducted on 6/14/22 at 8:45 AM with Employee Identifier (EI) # 4, Licensed Practical Nurse, to observe wound care provided.




During the HV the agency Client Medication Report (CMR), printed by the agency on 6/14/22 at 4:03 PM, and the medications in home were compared with the following discrepancies found and verified by the patient's caregiver.




Vitamin D3 125 mcg (micrograms) 1 tablet daily was found in the home. The caregiver verbalized the patient has taken the Vitamin D3 since discharge from the hospital on 5/10/22. There was no documentation of the Vitamin D3 on the agency CMR.




Magnesium 400 mg (milligrams) 1 tablet daily. The caregiver verbalized the patient has taken the Magnesium for "a month". There was no documentation of the Magnesium on the agency CMR.




Albuterol 90 mcg 1 inhalation every 6 hours as needed was found in the home with the prescription box dated 5/17/22. There was no documentation of the Albuterol on the agency CMR.




Hydrocodone 5 mg - Acetaminophen 325 mg 1 tablet every 6 hours as need for pain was found in the home with the prescription dated 5/17/22 and verified as current by the caregiver. Review of the agency CMR revealed documentation of Hydrocodone 5 mg - Acetaminophen 325 mg 1 tablet every 4 hours as needed for pain.




Hydrocodone 7.5 mg - Acetaminophen 325 mg 1 tablet every 4 hours as needed for pain was documented on the agency CMR. The caregiver verbalized the patient had not been on Hydrocodone 7.5 mg - Acetaminophen 325 mg since "before January..."




Ipratropium 0.5 mg - Albuterol 3 mg/ 3 ml (milliliter) nebulization 3 ml 4 times daily as needed for shortness of breath was documented on the agency CMR. The caregiver verbalized the patient had not been on Ipratropium-Albuterol since discharge from the hospital on 5/10/22.




Pregabalin 1000 mg 1 capsule twice a day was found in home with prescription dated 5/16/22 and verified as current by the caregiver. Review of the agency CMR revealed documentation of Pregabalin 50 mg 1 capsule twice a day.




Triamcinolone Acetonide 0.1 % Topical Cream 1 application to the left leg twice daily was on the agency CMR. The caregiver verbalized the Triamcinolone Acetonide had been discontinued "a couple weeks."




An interview was conducted on 6/16/22 at 2:17 PM with EI # 2, Patient Care Manager (PCM), who confirmed the SN failed to reconcile medications in home per the agency policy.




2. HV # 2 was admitted to the agency on 5/16/22 with diagnoses including Encounter for Surgical Aftercare Following Surgery on the Circulatory System, Atherosclerotic Heart Disease of Native Coronary Artery with Unspecified Angina Pectoris and Essential (Primary) Hypertension.




Review of the HHC and POC dated 5/16/22 to 7/14/22 revealed a SN frequency of 2wk1 then 1wk8 and a Occupational Therapy frequency of 1wk1, 2wk2 then 1wk2.



A HV was conducted on 6/14/22 at 1:00 PM with EI # 5, Occupational Therapist, to observe care provided.




During the HV the agency CMR, printed by the agency on 6/14/22 at 10:14 AM, and the medications in home were compared with the following discrepancies found and verified by the patient.




Lantus Solostar Insulin 100 Unit/ml 6 Units Subcutaneous at bedtime was found in the home and confirmed as the current dosage by the patient "since I've been home from the hospital" on 5/15/22. Review of the agency CMR revealed documentation of Lantus Solostar dosage as 10 Units at bedtime.




Janumet XR (extended release) 50 mg/ 1000 mg 1 tablet twice daily was found in the home with prescription dated 4/6/22 and verified as current by the patient. There was no documentation of Janumet on the agency CMR.




Metformin 500 mg 1 tablet twice daily was documented on the agency CMR. The patient verbalized Metformin was discontinued "at least 5 to 6 months ago."




Tramadol 50 mg 1 tablet every 6 hours as needed for pain was documented on the agency CMR. The patient verbalized Tramadol was "gone 2 weeks ago and not in the home."





An interview was conducted on 6/16/22 at 1:48 PM with EI # 1, Executive Director, who confirmed the SN failed to reconcile medications in home per the agency policy.




G0578 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 Medical Record (MR) review, and staff interview it was determined the agency failed to ensure the staff was in conformance with physician orders for:



1. Wound care




2. Daily Weights every visit




3. Administration of Midodrine twice daily and as needed for blood pressure less then 120 systolic.



This deficient practice did affect 3 of 13 MRs reviewed, including Home Visit (HV) # 4, MR # 7, HV # 1 and had the potential to negatively affect all patient's served by the agency.








3. HV # 1 was admitted to the agency on 4/28/22 with admitting diagnoses of Abscess of Lung Without Pneumonia and Paroxysmal Arterial Fibrillation.




Review of the HHC and POC dated 4/28/22 revealed an order to instruct patient/caregiver on importance of obtaining weight and keeping a weight log at same time every day. SN to assess weight log each SN visit. Report to MD a weight loss 5 lbs. or greater over one week.




Review of the HHC and POC dated 4/28/22 revealed the SN to visit 2 times a week for 2 weeks and then 1 time a week for 7 weeks. Physical Therapy (PT) to visit 1 time a week for 1 week then 2 times a week for 4 weeks beginning 5/1/22. Beginning 5/29/22 Physical Therapy to visit 2 times a week for 1 week then 1 time a week for 3 weeks.




Review of the physician order dated 4/29/22 revealed an order for Midodrine 10 mg (milligrams) 1 tablet 2 times daily as needed for hypotension. Only take if blood pressure is less than 120 systolic.




Review of the SN visit note dated 4/29/22 revealed no documentation of a daily weight. Further review revealed in the interventions under obtain weight this visit the SN documented weight obtained , see results in vital signs (VS). Review of the VS area revealed no documentation of a weight.




Review of the SN visit note dated 5/2/22 revealed no documentation of a daily weight. Further review revealed in the interventions under obtain weight this visit the SN documented weight obtained , see results in vital signs. Review of the VS area revealed no documentation of a weight.




Review of the physical therapy visit notes dated 5/17/22 to 6/8/22 revealed the following patient blood pressures:




5/17/22 - 98/60




5/19/22 - 98/60




5/25/22 - 78/50




6/3/22 - 98/62




6/8/22 - 92/52




Review of the PT and PTA (Physical Therapy Assistant) notes dated 5/17/22, 5/19/22, 5/25/22, 6/3/22 and 6/8/22 revealed the patient's blood pressure was below the parameters of 120 systolic and should have taken the Midodrine as ordered per the MD. Further review of the PT and PTA visit notes dated 5/17/22, 5/19/22, 6/3/22 and 6/8/22 revealed no documentation by the therapist the patient had taken the Midodrine as ordered by the physician and no documentation the SN or the physician was notified of the low blood pressure.




Review of the therapy note dated 5/25/22 revealed the therapist notified the SN by voice mail and no follow up documentation the nurse received the notification and the physician was notified.




An interview was conducted on 6/16/22 at 2:30 PM with EI # 2, PCM, who confirmed the nurse failed to document the daily weights per the MD orders and the therapists failed to document if the patient was instructed to take the Midodrine as ordered per the physician orders and failed to document follow up with the SN or notification of the MD.




1. HV # 4 was admitted to the agency on 5/11/22 with diagnoses including Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Hypertensive Heart Disease with Heart Failure and Acute Embolism and Thrombosis of Unspecified Deep Veins of Left Lower Extremity.



Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 5/11/22 to 7/9/22 revealed a Skilled Nurse (SN) frequency of once a week for 1 week (1wk1), twice a week for 1 week (2wk1) then once a week for 7 weeks (1wk7).




Review of the Physician Order dated 5/31/22 revealed an order for "SN to cleanse new open areas to left lower leg with NS (Normal Saline) and pat dry with clean dry gauze. Apply Xeroform to open areas and wrap with kerlix and secure with tape during SN visit on 5/31/22..." as ordered.



Review of the SN Visit Note Report (VNR) dated 5/31/22 revealed no documentation wound care was provided to "...3 new open areas...to left lower leg..."



An interview was conducted on 6/16/22 at 2:17 PM with Employee Identifier (EI) # 2, Patient Care Manager (PCM), who confirmed the SN failed to document wound care was provided to the left lower leg wounds on 5/31/22.




2. MR # 7 was admitted to the agency on 8/23/21 and recertified for continued care from 10/22/21 to 12/20/21 with diagnoses including Other Intervertebral Disc Degeneration, Lumbosacral Region, Atherosclerotic Heart Disease of Native Coronary Artery with Unspecified Angina Pectoris, Heart Failure, Unspecified and Chronic Obstructive Pulmonary Disease, Unspecified.




Review of the HHC and POC dated 10/22/21 to 12/20/21 revealed a SN frequency of once a week for 8 weeks and orders for the following:




a. SN to perform/instruct reinforce wound care to the # 1 Coccyx, Pressure Ulcer Stage III, # 2 upper buttock, pressure ulcer stage II, # 3 left lower buttock pressure ulcer stage II, # 4 Coccyx pressure ulcer stage II, # 5 right upper buttock pressure ulcer stage II and # 6 right lower buttock pressure ulcer stage II twice weekly by cleaning with vashe and sterile gauze, pat dry with sterile gauze, apply polymem to wound bed and secure with mefix tape.




b. SN to obtain weight every visit and notify the Registered Nurse/ Medical Doctor (MD) of weight gain or loss of 2 pounds (lbs) overnight or 5 lbs in one week.




Review of the SN VNR's dated 10/26/21, 11/1/21, and 11/9/21 revealed no documentation the SN obtained the patient's weight.




Review of the Physician Order dated 10/26/21 revealed documentation the "SN may use sacral foam border dressing until polymem in home...", which was not signed by the physician and was documented as not sent to the physician for signature.




Review of the SN VNR's dated 10/26/21 and 11/1/21 revealed documentation a sacral foam dressing was applied to wounds # 1, # 2, # 3, # 4, # 5 and # 6 instead of the ordered Polymem.




Review of the Supply Requisition Report dated 11/1/21 revealed documentation the Polymem was ordered for the patient's wound care.




Review of the Client Coordination Note Report dated 11/6/21 revealed documentation the Polymem was delivered to the patient's home "side door" on 11/4/21.




Review of the SN VNR's dated 11/16/21 and 11/27/21 revealed documentation a sacral foam dressing was applied to wounds # 1, # 2, # 3, # 4, # 5 and # 6 instead of the ordered and delivered Polymem.




Review of the SN VNR's dated 11/30/21 and 12/7/21 revealed documentation a sacral foam dressing was applied to wound # 1 instead of the ordered and delivered Polymem.




An interview was conducted on 6/16/22 at 1:55 PM with EI # 9, PCM, who confirmed there was no documentation the SN obtained the patient's weight on the above dates, the Polymem was reported as delivered on 11/6/21 per the agency documentation and the SN failed to use the ordered Polymem for the patient's wound care on the above dates.

G0580 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 Medical Record (MR) review, agency policy and procedure and staff interview it was determined the agency failed to ensure the Skilled Nurse performed wound care only as ordered by a signed physician order.



This deficient practice did affect 1 of 6 MRs reviewed with wounds, including MR # 7 and had the potential to negatively affect all patient's served by the agency with wounds.




Findings Include:




Agency Policy: Wound Assessment, Documentation and Photography




Policy Number: 2.2.001




Revised Date: 12/1/21




Procedure:




...3. Document the following in the medical record:




...i. Exact wound care performed, following physician orders.




4. Redress the wound using appropriate wound care dressing procedure following physician orders...








1. MR # 7 was admitted to the agency on 8/23/21 and recertified for continued care from 10/22/21 to 12/20/21 with diagnoses including Other Intervertebral Disc Degeneration, Lumbosacral Region, Atherosclerotic Heart Disease of Native Coronary Artery with Unspecified Angina Pectoris, Heart Failure, Unspecified and Chronic Obstructive Pulmonary Disease, Unspecified.




Review of the Home Health Certification and Plan Of Care dated 10/22/21 to 12/20/21 revealed orders for the Skilled Nurse (SN) to perform/instruct reinforce wound care to the # 1 Coccyx, Pressure Ulcer Stage III, # 2 upper buttock, pressure ulcer stage II, # 3 left lower buttock pressure ulcer stage II, # 4 Coccyx pressure ulcer stage II, # 5 right upper buttock pressure ulcer stage II and # 6 right lower buttock pressure ulcer stage II twice weekly by cleaning with vashe and sterile gauze, pat dry with sterile gauze, apply polymem to wound bed and secure with mefix tape.




Review of the Physician Order dated 10/26/21 revealed documentation the "...SN may use sacral foam border dressing until polymem in home...", which was not signed by the physician and documented as not sent to the physician for signature.




Review of 5 of 5 SN Visit Note Reports (VNR) dated from 10/26/21 to 11/27/21 revealed documentation the sacral foam dressing was applied to wounds # 1, # 2, # 3, # 4, # 5 and # 6 without a signed physician order.




Review of the SN VNR's dated 11/30/21 and 12/7/21 revealed documentation the sacral foam dressing was applied to wound # 1 without a signed physician order.




An interview was conducted on 6/16/22 at 1:55 PM with Employee Identifier # 9, Patient Care Manager, who confirmed there was no documentation the order dated10/26/21 was sent to the physician for signature.



G0590 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 review of Medical Records (MR), agency policy and procedure and interviews it was determined the agency staff failed to notify the physician with changes in:




1. Edema




2. Pain



3. Wound measurements




This deficient practice affected 2 of 5 Home Visits (HV) conducted, including HV # 4 and HV # 2, and had the potential to affect all patients served by the agency.



Findings include:



Agency Policy: Coordination of Care, From Admit through Discharge



Policy Number: 2.1.017



Revised Date: 8/1/19



Purpose: To establish processes and criteria so that the coordination of patient care will be optimal from admit through discharge.



Policy: The agency provides care and services within an integrated continuum of care system...



Procedure:



...4. Coordination of care with physician: At admission, throughout care...coordination of services is promoted through routine communication with the patient's physician:



a. When changes occur in the patient's condition or response to treatment...


1. HV # 4 was admitted to the agency on 5/11/22 with diagnoses including Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Hypertensive Heart Disease with Heart Failure and Acute Embolism and Thrombosis of Unspecified Deep Veins of Left Lower Extremity.



Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 5/11/22 to 7/9/22 revealed a Skilled Nurse (SN) frequency of once a week for 1 week (1wk1), twice a week for 1 week (2wk1) then once a week for 7 weeks (1wk7), Physical Therapy (PT) 1wk1, 2wk2, then 1wk2 and physician order for pain above a 6 on a 1-10 scale to be reported to the physician by the Licensed Professional.



Review of the PT Visit Note Report (VNR) dated 5/12/22 revealed documentation the patient reported pain in the right shoulder at a 9 on a 1-10 scale. There was no documentation the PT notified the physician of the patient's pain outside of ordered parameters.



Review of the SN VNR dated 5/16/22 revealed documentation the patient had 2 + pitting edema to the bilateral lower extremities.




Review of the SN VNR dated 5/25/22 revealed documentation the patient had 3 + pitting edema to the Lower Left Extremity, there was no documentation of the Right Lower Extremity. There was no documentation the SN notified the physician of the increased Left Lower Extremity edema from the previous SN visit on 5/16/22.



An interview was conducted on 6/16/22 at 2:17 PM with Employee Identifier (EI) # 2, Patient Care Manager (PCM), who confirmed the SN failed to document the physician was notified of the increased edema to the Left Lower Extremity on 5/25/22 and the PT failed to notify the physician of increase in pain.




2. HV # 2 was admitted to the agency on 5/16/22 with diagnoses including Encounter for Surgical Aftercare Following Surgery on the Circulatory System, Atherosclerotic Heart Disease of Native Coronary Artery with Unspecified Angina Pectoris and Essential (Primary) Hypertension.




Review of the HHC and POC dated 5/16/22 to 7/14/22 revealed a SN frequency of 2wk1 then 1wk8.




Review of the SN VNR dated 5/20/22 revealed a new wound to the right Thoracic area due to the chest tube being removed by the physician, which measured 0.5 cm (centimeters) in length, 1.5 cm in width and 0.1 cm in depth.




Review of the SN VNR dated 5/25/22 revealed wound measurement to the right Thoracic wound as 0.5 cm in length, 2.5 cm in width and 0.1 cm in depth, which was a 1.0 cm increase in the width of the wound. There was no documentation the physician was notified of the increased width of the wound.




An interview was conducted with EI # 1, Executive Director, who confirmed there was no documentation the physician was notified of the increased right Thoracic wound width on 5/25/22.
G0682 Infection Prevention
CFR(s): 484.70(a)

Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases.


This STANDARD is not met as evidenced by:
Based on review of agency policy and procedure, observation and interview, it was determined the agency failed to ensure staff followed infection control standards and discarded contaminated gloves, performed hand hygiene and donned clean gloves prior to continuing with clean procedures.




This deficient practice affected 1 of 5 home visits (HV) including HV # 5 and had the potential to affect all patients admitted to this agency.




Findings include:




Agency Policy: Hand Hygiene




Policy Number 8.004




Revised: 5/1/19




Purpose:




To help prevent the spread of micro-organisms and infection by cross-contamination and to provide practice guidelines.




Policy:




Staff are required to perform hand hygiene prior to, at specified time points during and following patient contact. Hand hygiene will be performed using soap and water or an alcohol based hand sanitizer.




Procedure:




1. Staff are required to perform hand hygiene by handwashing with soap and water or using an alcohol based hand sanitizer:




a. before direct contact with patients....




d. if moving from a contaminated body site to a clean body site during patient care...




8. c. Change gloves during patient care if moving from a contaminated body site to a clean body site.


1. HV # 5 was admitted on 5/17/22 with diagnoses including Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1 through 4 Unspecified Chronic Kidney disease; and Heart Failure, Unspecified.






Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 5/17/22 revealed an order for Home Health Aide (HHA) to visit once a week for 4 weeks for assistance with personal care and activities of daily living secondary to functional limitations which prevent self-care.






A HV was conducted on 6/15/22 at 9:15 AM to observe a shower and care provided by Employee Identifier (EI # 6) HHA. EI # 1, Executive Director was also present.




EI # 6 performed hand hygiene, donned gloves and apron to assist HV # 5 with a shower. EI # 6 washed buttocks and continued wearing contaminated gloves throughout the rest of the shower. EI # 6 helped the patient towel dry, get dressed, brush teeth, assisted with walker, and handed hearing aids to the patient in a dish wearing the contaminated gloves.




An interview was conducted with EI # 1 on 6/15/22 at 10:10 AM, who confirmed EI # 6 did not change gloves and perform hand hygiene per agency policy and procedure.
G0706 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 Medical Record (MR) review, agency policy and procedure and staff interview it was determined the agency staff failed to document wound assessments per agency policy.



This deficient practice did affect 1 of 6 MR's reviewed with a wound, including Home Visit (HV) # 4, and had the potential to affect all patient's with wounds served by the agency.



Findings Include:




Policy: Wound Assessment, Documentation and Photography




Policy Number: 2.2.001




Revised Date: 12/1/21




Purpose: To ensure the accurate and consistent assessment and documentation of wounds.




Policy: Upon initial visit and subsequently...all wounds will be assessed with appropriate documentation within the medical record.




Wound location and description documentation is completed on all patients with wounds at the time of admit or upon development of a wound...Wound assessment findings will be documented...




Unless otherwise ordered by the physician, the Registered Nurse (RN)…will assess wounds at least: …every other week for patients receiving wound care by the agency at a frequency less than daily...




Reassessments will be documented on the Wound Assessment Tool.




The assessment includes measurement of the length (L), width (W), and Depth (D), undermining and tunneling, wound bed description, wound edges, exposed tissue types, drainage and the condition of the peri wound.




At each dressing change, the clinician should record the wound bed description, wound edges, exposed tissue types, drainage and the condition of the peri wound.




…Procedure:




…3. Document the following in the medical record:




a. Wound type...




…c. Stage or Thickness:




…ii. For all other ulcers, document underlying etiology of the ulcer and skin involvement to include limited to breakdown of skin; fat layer exposed; necrosis of muscle; or necrosis of bone.




iii. All other wounds will be described as either Partial or Full Thickness.




c. (c is documented twice) Wound size: L, W and D are measured in centimeters (cm)…




d. Undermining and/or Tunneling...




e. Wound bed: percentage of eschar, slough, and granulation.




f. Wound edges: whether open or closed.




g. Drainage: odor, type (color) and amount.




h. Peri wound condition.


1. HV # 4 was admitted to the agency on 5/11/22 with diagnoses including Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Hypertensive Heart Disease with Heart Failure and Acute Embolism and Thrombosis of Unspecified Deep Veins of Left Lower Extremity.



Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 5/11/22 to 7/9/22 revealed a Skilled Nurse (SN) frequency of once a week for 1 week (1wk1), twice a week for 1 week (2wk1) then once a week for 7 weeks (1wk7).



Review of the Physician Order dated 5/31/22 revealed an order for "SN to cleanse new open areas to left lower leg with NS (Normal Saline) and pat dry with clean dry gauze. Apply Xeroform to open areas and wrap with kerlix and secure with tape during SN visit on 5/31/22..."



Review of the SN Visit Note Report (VNR) dated 5/31/22 revealed no documentation wound care was provided to "...3 new open areas noted to left lower leg and two blisters that have not opened..." There was no documentation of wound measurements, wound type for the new open areas, stage or thickness of the wounds, if undermining and/or tunneling were present, wound bed appearance, if the wound edges were open or closed, the type and amount of wound drainage and peri wound condition.




Review of the SN VNR's dated 6/2/22 (week of 5/29/22 - 6/4/22) and 6/7/22 (week of 6/5/22 - 6/11/22) revealed no documentation of wound measurements for the left lower leg wounds.



An interview was conducted on 6/16/22 at 2:17 PM with Employee Identifier (EI) # 2, Patient Care Manager (PCM), who confirmed the SN failed to document the wound assessments of the left lower leg wounds per agency policy on 5/31/22, 6/2/22 and 6/7/22.

G0714 Patient and caregiver education
CFR(s): 484.75(b)(5)

Patient and caregiver education;


This ELEMENT is not met as evidenced by:
Based on agency policy and procedure, medical record (MR) review and interviews it was determined the agency failed to ensure patients / caregivers were provided education and/or a return demonstration was obtained to ensure competency of wound care and disease processes per the physician order.




This affected 2 of 13 records including Home Visit (HV) # 2 and MR # 7 and had the potential to affect all patients served by the agency.




Findings include:

Agency Policy: Patient Education




Policy Number: 3.001




Revised Date: 11/01/17




Purpose: To describe patient and/or caregiver interactions designed to promote and maximize patient health and safety.




Policy: The agency plans, supports, and coordinates patient and caregiver education designed to promote optimal patient health and safety...




Procedure:




…3. The patient and caregiver receive ongoing information specific to the identified needs...




…b. Patient/caregiver plan of care responsibilities




…7. Using the progress/visit note, the clinician documents the level of patient/caregiver comprehension, patient/caregiver return demonstration of skill(s) taught, compliance and any follow-up with team members...


1. HV # 2 was admitted to the agency on 5/16/22 with diagnoses including Encounter for Surgical Aftercare Following Surgery on the Circulatory System, Atherosclerotic Heart Disease of Native Coronary Artery with Unspecified Angina Pectoris and Essential (Primary) Hypertension.


Review of the Home Health Certification (HHC) and Plan Of Care (POC) dated 5/16/22 to 7/14/22 revealed a Skilled Nurse (SN) frequency of 2wk1 (twice a week for one week) then 1wk8 (once a week for 8 weeks) and an order for "SN to instruct on Hypertension to include disease process, signs and symptoms, complications, and management."




Review of the SN VNR dated 5/25/22 revealed documentation the "SN instructed patient on role patient and caregiver has in the Hypertension POC..." There was no documentation of the specific education the SN provided the patient and caregiver on Hypertension.




An interview was conducted on 6/16/22 at 1:48 PM with Employee Identifier (EI) # 1, Executive Director, who confirmed there was no documentation of the specific education the SN provided the patient and caregiver on Hypertension.




2. MR # 7 was admitted to the agency on 8/23/21 and recertified for continued care from 10/22/21 to 12/20/21 with diagnoses including Other Intervertebral Disc Degeneration, Lumbosacral Region, Atherosclerotic Heart Disease of Native Coronary Artery with Unspecified Angina Pectoris, Heart Failure, Unspecified and Chronic Obstructive Pulmonary Disease, Unspecified.




Review of the HHC and POC dated 10/22/21 to 12/20/21 revealed orders for "SN to provide instructions on Chronic Obstructive Pulmonary Disease (COPD) to include disease process, signs and symptoms, complications, and management."




Review of the SN VNR dated 12/1/21 revealed documentation the SN "instructed patient/caregiver on signs/symptoms of acute exacerbation of COPD and when to call home health nurse/physician or emergency personnel." There was no documentation the SN instructed the patient and/or caregiver on the COPD disease process, complications and management of COPD and of the specific signs and symptoms of COPD the SN educated the patient and/or caregiver on at the visit.




Review of the SN VNR's from 12/1/21 to 12/20/21 revealed no documentation the SN instructed the patient and/or caregiver on the COPD disease process, complications and management of COPD.




An interview was conducted on 6/16/22 at 1:55 PM with EI # 9, PCM, who confirmed there was no documentation the SN instructed the patient and/or caregiver on the COPD disease process, complications and management of COPD and of the specific signs and symptoms of COPD the SN educated the patient and/or caregiver on at the visit on 12/1/21.