Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 017037	(X3) Date Survey Completed 10/10/2018
Name of Provider or Supplier Alabama Homecare Of Montgomery, Llc	Street Address, City, State 400 South Union Street Suite 285, Montgomery, 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)
G0000	An abbreviated survey was conducted on 10/9/18 to 10/10/18 to investigate complaint # AL 00035884. The complaint was substantiated with a standard level deficiencies.
G0456	Patient/payer will no longer pay for services CFR(s): 484.50(d)(2) The patient or payer will no longer pay for the services provided by the HHA; This ELEMENT is not met as evidenced by: Based on the review of the medical records, agency policy and procedure and interview, it was determined the agency failed a. To notify the patient of discharge from the agency and the reason for the discharge. b. To direct the patient to appropriate community resources to continue wound care with a negative pressure wound therapy. c. To provide discharge instructions including a complete and reconciled list of medications to the patient. This affected Medical Record (MR) # 2, 1 of 1 records reviewed with no insurance coverage and had the potential to affect all patients admitted with private insurance. Findings include: Policy: 2.1.004 Subject: Patient Discharge/Transfer Process Revised: 3/1/2018 "Purpose: To ensure continuity of care when a patient is discharged, transferred, or referred. Policy: 1. Any of the following reason may be criteria for patient discharge or transfer: ...b. Patient or payer will no longer pay for services provided by the agency... Procedure: ...3. Revisions to plan for patient's discharge will be communicated to: i. Patient... 8. Patients are notified of discharge as soon as possible prior to discharge as outlined in Notice of Non-Coverage, Expedited Determination and Reconsideration for discharge policy. The agency will also provide patient and legal representative (if any) with contact information and numbers for other community resources or providers and evidence will be documented in the medical record... 10. ...When transferred and/or discharged, the patient is provided the reason for transfer or discharge. Ongoing psychosocial or physical care needs are identified and appropriate referrals made.... 19. Patients received discharge instructions from the clinician at the time of discharge, to include anticipated needs for continued care, treatment and services. A complete and reconciled list of medications is provided directly to the patient and, as needed, the family, and the list is explained to patient and/or family. 1. MR # 2 was admitted to the agency on 7/25/18 with diagnoses including Type 2 Diabetes Mellitus with Diabetic Polyneuropathy and Non-Pressure Chronic Ulcer of Left Heel and Midfoot with Fat Layer Exposure. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 7/25/18 through 9/22/18 revealed patient was receiving SN (skilled nurse) services for wound care to left foot. Review of the Physician Order dated 8/6/18 revealed SN was to provide Negative Pressure Wound Therapy to left foot wound three times a week for 7 weeks. Review of the Client Coordination Note Report dated 9/11/18 by Employee Identifier (EI) # 2, Patient Care Manager, revealed the following documentation, "SN called to notify (physician identified) that Blue Cross has denied HH (home health) services for patient and that they will need to set her/him up in office for wound care, spoke to (Registered Nurse (RN) identified by name). She/He stated that they may have to DC (discharge or discontinue) wound vac because they will not be able to complete vac changes 3 days a week in clinic, she/he also stated that she/he thought they received a quick referral form from (another agency identified) per patient request and that she will send DC order for BHH (Baptist Home Health)... She/He (RN at physician's office) would let (physician identified) know about insurance denial and he/she can contact them if needed, but she/he will send DC order today." Further review of the Client Coordination Note Report dated 9/11/18 by EI # 2, revealed the following documentation "SN called patient to let her know that BHH will be discharging her as of today per his/her request. Voicemail full, will have SN that is scheduled to see her/him today inform her/him or have patient call our office if she/he prefers." Review of the Visit Note Report dated 9/11/18 at 1:25 PM by EI # 3, Licensed Practical Nurse (LPN), revealed documentation the wound care to the left foot was provided by the SN using the Negative Pressure Wound Therapy. Further review of the Visit Note Report dated 9/11/18 at 1:25 PM by EI # 3, revealed documentation of care coordination communication occurred with agency EI # 2 about "visit detail" at the visit. Further review of the Visit Note Report dated 9/11/18 at 1:25 PM by EI # 3, revealed documentation under "Has the Patient/Caregiver been included in changes/modifications to the plan of care?" and "Not applicable, the plan of care has not changed." was entered by EI # 3. Further review of the Visit Note Report dated 9/11/18 at 1:25 PM by EI # 3, revealed documentation under plans for next visit "Assessment and teaching and wound care." Further review of the Visit Note Report dated 9/11/18 at 1:25 PM by EI # 3, revealed no documentation there was a revision to the discharge plan, the revision to the discharge plan was communicated to the patient, the reason for the revision to the discharge plan was communicated to the patient, the patient was provided contact information of appropriate community resources to continue wound care with a negative pressure wound vacuum, or discharge instructions including a complete and reconciled list of medications were given to the patient. Review of the written physician's order dated 9/11/18 at 5:00 PM revealed the following: "Please discharge patient from Home Health..." this was received by the agency on 9/11/18 at 5:59 PM. Review of the Client Coordination Note dated 9/12/18 revealed documentation that agency "received call from (physician office RN identified), stated that (name of another Home Health agency) does not except her/his insurance, SN informed her/him that patient was dc'd (discharged) from BHH per their order 9/11/18, she/he (physician office RN) also stated that she/he spoke to BCBS (blue cross blue shield) regarding denial and wanted to know if there was anything else HH could do to help with that, SN informed that patient's MD (medical doctor) will need to file an appeal with BCBS. Stated that wound care center will have to DC wound vac (Negative Pressure Wound Therapy) and arrange wound care as outpatient if necessary." Review of the Client Coordination Note dated 9/14/18 revealed a Team Case conference note with documentation of "The team reviewed the episode detail report and discussed the following: Insurance is denying coverage." Further review of the Client Coordination Note dated 9/14/18 revealed documentation of "Based on discussion the recommendation of the team is discharge." Review of the Visit Note Report dated 9/14/18 at 3:19 PM revealed an "RN discharge - Data Collection Only" note with documentation of "discharging based on last skilled visit" which occurred on "9/11/18". Further review of the Visit Note Report dated 9/14/18 at 3:19 PM revealed "Patient remained in the community (without formal assistive services)" documentation. Further review of the Visit Note Report dated 9/14/18 at 3:19 PM revealed documentation under discharge teaching provided as "N/A - Not Applicable". Review of the entire MR from 9/11/18 through 9/14/18 revealed no documentation of communication with patient about discharge plan. The agency staff failed to ensure patient was directed to an appropriate community resource for continued wound care with a negative pressure wound therapy. The agency also failed to document the revision to the discharge plan was communicated to the patient, the reason for the revision to the discharge plan was communicated to the patient, the patient was provided contact information of appropriate community resources to continue wound care with a negative pressure wound care, or discharge instructions including a complete and reconciled list of medications were given to the patient. An interview was conducted on 10/10/18 at 1:44 PM with EI # 1, Executive Director, who confirmed there was no additional documentation in the MR for the discharge of MR # 2.
G0578	Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician orders. This STANDARD is not met as evidenced by: Based on review of medical records (MR), agency policy and procedures, and interviews with agency staff, it was determined the agency failed to ensure wound care was provided according to physician orders This affected 3 of 6 records reviewed with wounds including, Home Visit (HV) # 1, MR # 2, and MR # 1 and the potential to negatively affect all patients served by the agency Findings include: Policy: 2.2.001 Subject: Wound Assessment, Documentation, and Photography Revised: 9/1/2017 Purpose: To ensure the accurate and consistent assessment and documentation of wounds Procedure: ...2. Perform wound care according to LHC adopted clinical skills guidelines and physician orders... ...4. Redress the wound using appropriate wound care dressing procedure following physician orders... Policy: 2.2.007 Subject: Negative Pressure Wound Therapy (NPWT) Revised: 9/1/17 Purpose: To promote wound healing and establish competency assessment guidelines when utilizing negative pressure wound therapy. Policy: The RN (Registered Nurse) performs a wound assessment at least once a week during therapy... Procedure: 2. Perform procedure utilizing LHC adopted clinical guidelines... 4. The clinician will document the number of foam/sponge pieces placed in the wound bed and the number of foam/sponge pieces removed from the wound... 1. HV # 1 was admitted to the agency on 8/27/18 with diagnoses including, Encounter for Orthopedic Aftercare Following Surgical Amputation. Review of the Physician Order dated 8/29/18 revealed the following physician's order: "SN (skilled nurse) to perform wound care with KCI (company that supplies the Negative Pressure Device) Negative Pressure Device to # 2 Right Transmetatarsal Surgical Amputation site 3X (3 times) weekly as follows: Cleanse wound with wound cleanser and gauze. Gently pat dry with gauze. Prepare periwound area with skin protectant. Cover wound with contact layer then fill entire cavity with black foam. In tunneled/undermined areas apply white foam. Cover with transparent drape and apply tubing. Apply negative pressure device at 125 mmHg (Millimeters of Mercury) continuous..." Review of the Visit Note Report(s) dated 9/14/18, 9/17/18, 9/19/18, and 9/21/18 revealed no documentation of what wound care was provided by the SN at the visit. Review of the Physician Order dated 9/25/18 revealed the following physician's order: "SN to perform/instruct/reinforce wound care to # 2 (Diabetic) Distal Dorsum Right Foot Transmetatarsal Surgical Amputation site 3 x week (3 times a week) as follows: Cleanse with wound cleanser and gauze. Gently pat dry. Apply Lotion to affected Extremity. Apply Prisma to wound. Cover with Xeroform. Cover with gauze and ABD (abdominal) pad. Wrap with cotton followed by Kerlix and secure with paper tape..." Review of the of the Visit Note Report(s) dated 9/26/18 and 9/28/18 revealed no documentation of what wound care was provided by the SN at the visit. An interview was conducted on 10/10/18 at 1:19 PM with Employee Identifier (EI) # 1, Executive Director, who confirmed the previous findings. 2. MR # 2 was admitted to the agency on 7/25/18 with diagnoses including Type 2 Diabetes Mellitus with Diabetic Polyneuropathy and Non-Pressure Chronic Ulcer of Left Heel and Midfoot with Fat Layer Exposure. Review of the Physician Order dated 8/6/18 revealed order for "SN to provide negative pressure wound therapy to Left Foot wound: Using Aseptic technique, cleanse wound with wound cleanser. Apply skin prep to peri wound area and windowpane wound edges with transparent drape. Apply adaptic to wound bed, cover with black foam. Bridge to top of foot and apply trac pad. initiate vacuum at 125 continuous. Secure with kerlix and tape..." Review of the Visit Note Report(s) dated 8/6/18, 8/8/18, 8/10/18, 8/13/18, 8/15/18, 8/17/18, 8/20/18, and 8/22/18 revealed documentation of wound care to wound # 1 Lt (left)-Mid Plantar, Diabetic Ulcer provided as, "SN performed negative pressure wound therapy to left foot using aseptic technique. applied skin prep and drape to wound edges and applied adaptic to wound bed. Covered with black foam and bridged to top of foot and applied trac pad. Suction at 125 continuous. Secured with kerlix and tape..." Further review of the Visit Note Report(s) dated 8/6/18, 8/8/18, 8/10/18, 8/13/18, 8/15/18, 8/17/18, 8/20/18, and 8/22/18 revealed no documentation of what was used to cleanse wound # 1. An interview was conducted on 10/10/18 at 1:44 PM with EI # 1, who confirmed the previous findings. 3. MR # 1 was admitted to the agency on 8/1/18 with admitting diagnoses of Abcess of The Breast and Nipple and Cellulitis of Other Sites. Review of the Home Health Certification and Plan of Care dated 8/1/18 revealed the following Physican order: Skilled Nurse to cleanse wound with wound cleanser and pat dry. Prepare periwound area with skin prep and window pane wound edges with transparent drape. Apply white foam in tunneled/undermined areas, then cover with black foam. Cover with transparent drape and apply trac pad/tubing. Initiate negative pressure device at 125 mm/Hg (millimeters of mercury) continuous. Dressing to be changed twice a week... Review of the SN visit note dated 8/3/18 revealed the documentation in the wound assessment section of the note stated patient had wound # 1 to left upper inner quad of breast,Abcess. Review of the documentation in the wound assessment section of the note dated 8/3/18 revealed the SN documented wound assessed: no, wound care provided: wound care not provided: not ordered this visit and no wound measurements were documented. Further review revealed in the narrative section of the note the SN documented wound care provided and completed. Review of the wound care assessment and the narrative section of the note revealed no documentation of how the wound care was provided and how many pieces of white and black foam was removed or applied. Review of the SN visit note dated 8/7/18 revealed the documentation in the wound assessment section of the note stated wound assessed: No, awaiting orders, wound care provided: wound care not provided awaiting orders and no documentation of wound measurements. Review of the narrative section of the note revealed the SN attempted to do wound care, SN could not find 2nd white foam. RN notified and team leader will come to the patient's house. Review of the Client Coordination Note Report dated 8/7/18 revealed the SN documented the white foam was removed and wound care completed per orders and wound vac placed at 125 mm/Hg. Review of the documentation revealed the SN failed to document the actual wound care provided and the number of white and black foam pieces removed or applied to the wound. Review of the SN visit note dated 8/9/18 revealed in the wound assessment section of the note the SN documented applied white foam in tunneled/undermined areas, then covered with black foam. The SN failed to document the actual wound care provided and the number of white and black foam pieces removed or applied. Review of the SN visit note dated 8/13/18 revealed in the wound assessment section of the note the nurse documented applied white foam in tunneled/undermined areas, then covered with black foam. Further review revealed no documentation as to how many pieces of white foam and black foam were removed or applied. Review of the SN visit note dated 8/14/18 revealed the nurse documented applied white foam in tunneled/undermined areas, then covered with black foam. Further review revealed no documentation as to how many pieces of white and black foam were removed or applied. Review of the SN visit note dated 8/16/18 revealed the nurse documented in the wound assessment section the patient had developed a second wound to the left breast. Wound assessment was complete with measurements of wound # 2. Review of the wound assessment section of the note revealed the nurse documented applied white foam in tunneled/undermined areas, then covered with black foam. Further review revealed no documentation as to how many pieces of white and black foam were removed or applied and no documentation of wound measurements for wound # 1. Review of the SN visit note dated 8/24/18 revealed the nurse documented in the wound assessment section applied white foam in tunneled/undermined areas, then covered with black foam. Further review revealed no documentation as to how many pieces of white and black foam were removed or applied. Review of the SN visit note dated 8/29/18 revealed the nurse documented in the wound assessment section applied white foam in tunneled/undermined areas, then covered with black foam. Further review revealed no documentation as to how many pieces of white and black foam were removed or applied and no documentation the nurse measured wound # 2 and stated under measurements taken: No and Reason for measurements not taken: documented unable. Review of the SN visit note dated 8/31/18 revealed no documentation of wound measurements for wound # 2. An interview was conducted on 10/10/18 at 1:30 PM with EI # 1 who confirmed the above mentioned findings.
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. This ELEMENT is not met as evidenced by: Based on review of medical records (MR), agency procedure, and interviews with agency staff, it was determined the agency failed to ensure Physician orders were obtained for all wound treatments provided. This affected 1 of 6 records reviewed with wounds and did affect Home Visit (HV) # 1 , and had the potential to negatively affect all patients served by the agency Findings include: Policy: 2.2.001 Subject: Wound Assessment, Documentation, and Photography Revised: 9/1/2017 Purpose: To ensure the accurate and consistent assessment and documentation of wounds Procedure: ...2. Perform wound care according to LHC adopted clinical skills guidelines and physician orders... ...4. Redress the wound using appropriate wound care dressing procedure following physician orders... 1. HV # 1 was admitted to the agency on 8/27/18 with diagnoses including, Encounter for Orthopedic Aftercare Following Surgical Amputation. Review of the Physician Order dated 8/29/18 revealed the following physician's order: "Skilled Nurse (SN) to provide/instruct/reinforce to client/caregiver wound care to # 3, # 4, and # 5 Right Leg Closed Surgical Incisions daily as follows: Cleanse with wound cleanser and gauze. Gently pat dry with gauze. Cover with dry dressing..." Review of the Visit Note Report(s) dated 9/3/18, 9/5/18, 9/7/18, and 9/10/18 revealed a wound # 6 Mid Thigh, Medial, Rt (Right), Surgical Incision with the following wound care performed, "...Cleansed with wound cleanser and patted dry with gauze. Covered with dry dressing. Patient tolerated well." Review of the MR physician order(s) from 8/27/18 through 9/10/18 revealed no documentation of a physician's order for wound care to wound # 6. The agency staff provided wound care to wound # 6 without a physician's order. Further review of the Visit Note Report dated 9/10/18 revealed documentation of "Inactivate Wound - Completely Epthelialized" under change in status of wounds # 3, # 4, # 5, and # 6 Further review of the Visit Note Report dated 9/10/18 revealed no documentation that the physician was notified and order obtained to inactivate wound # 3, # 4, # 5, and # 6. Review of the Visit Note Report dated 9/12/18 revealed the following documentation under wound care provided to wounds # 3, # 4, # 5, and # 6: "Wound care not provided: Healed" Further review of the Visit Note Report dated 9/12/18 revealed no documentation that the physician was notified of wound # 3, # 4, # 5, and # 6 being healed and order obtained to discontinue wound care. An interview was conducted on 10/10/18 at 1:19 PM with Employee Identifier # 1, Executive Director, who confirmed the previous findings.
G0590	Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(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 medical records (MR) review, agency policy and procedure, and staff interviews, it was determined staff failed to notify the physician for change in the patient's condition which included deterioration in wound status. This affected 3 of 6 records reviewed with wounds and did affect MR # 5, Home Visit (HV) # 1, MR # 2, and had the potential to negatively affect all patients served by the agency. Findings include: Policy: 2.1.017 Subject: Coordination of Care, From Admit Through Discharge Revised: 01/01/2018 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. This is accomplished by...coordinating patient care among various disciplines to ensure that services are continuous and coordinated from admission through discharge. Procedure: ...4. Coordination of care with physician: At admission, throughout care, and at discharge, 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. MR # 5 was admitted to the agency on 3/9/18 and recertified for continued care for the dates of 9/5/18 through 11/3/18 with diagnoses including Type 2 Diabetes Mellitus with Foot Ulcer. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 9/5/18 through 11/3/18 revealed a physician's order for skilled nurse (SN) to instruct/perform/reinforce wound care with negative pressure device to left diabetic ulcer... Review of the Visit Note Report dated 9/11/18 revealed documentation of wound # 3 Left Distal Dorsum Diabetic Ulcer exudate (drainage) as a moderate amount of serosanguineous exudate. Review of the Visit Note Report dated 9/14/18 revealed documentation of wound # 3 exudate as a moderate amount of purulent exudate. Review of the Visit Note Report dated 9/17/18 revealed documentation of wound # 3 exudate as a moderate amount of purulent exudate. Further review of the Visit Note Report dated 9/14/18 and 9/17/18 revealed no documentation the physician was notified of the change of the wound exudate. An interview was conducted on 10/10/18 at 1:22 PM with EI (Employee Identifier) # 1, Executive Director, who confirmed the previous findings. 2. HV # 1 was admitted to the agency on 8/27/18 with diagnoses including, Encounter for Orthopedic Aftercare Following Surgical Amputation. Review of the Physician Order dated 8/29/18 revealed the following physician's order: "SN (skilled nurse) to perform wound care with KCI (company that supplies the Negative Pressure Device) Negative Pressure Device to # 2 Right Transmetatarsal Surgical Amputation site..." Review of the Visit Note Report dated 9/10/18 revealed wound # 2 measurements as "11 x 6 x 0.1" (length x (by) width x depth) in cm (centimeters). Review of the Visit Note Report dated 9/12/18 revealed wound # 2 measurements as "13.5 x 7.5 x 0.2" in cm, which was an increase in length by 2.5 cm, width by 7.5 cm, and depth by 0.1 cm. Further review of the Visit Note Report dated 9/12/18 revealed no documentation the physician was notified of the increased length, width, or depth of wound # 2. Review of the Visit Note Report dated 9/26/18 revealed documentation of wound # 2 measured width as 7 cm. Review of the Visit Note Report dated 10/1/18 revealed documentation of wound # 2 measured width as 14 cm, which was an increase of 7 cm. Further review of the Visit Note Report dated 10/1/18 revealed no documentation the physician was notified of the increased width of wound # 2. An interview was conducted on 10/10/18 at 1:19 PM with EI # 1, who confirmed the previous findings. 3. MR # 2 was admitted to the agency on 7/25/18 with diagnoses including Type 2 Diabetes Mellitus with Diabetic Polyneuropathy and Non-Pressure Chronic Ulcer of Left Heel and Midfoot with Fat Layer Exposure. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 7/25/18 through 9/22/18 revealed a physician's order for "Skilled Nurse (SN) to Perform / Instruct / Reinforce patient/caregiver procedure of wound care to left foot..." Review of the Visit Note Report dated 7/25/18 revealed wound # 1 Lt (left)-Mid Plantar, Diabetic Ulcer length measurement as "7" cm. Review of the Visit Note Report dated 7/30/18 revealed wound # 1 length measurement as "7.5" cm, which was an increase in length by 0.5 cm. Further review of the Visit Note Report dated 7/30/18 revealed no documentation the physician was notified of the increased length of wound # 1. Further review of the Visit Note Report dated 7/30/18 revealed wound # 1 depth measurement as "0.2" cm. Review of the Visit Note Report dated 8/6/18 revealed wound # 1 depth measurement as "1" cm, which was an increase in depth by 0.8 cm. Further review of the Visit Note Report dated 8/6/18 revealed no documentation the physician was notified of the increased depth of wound # 1. Review of the Visit Note Report dated 8/20/18 revealed wound # 1 width measurement as "3" cm. Review of the Visit Note Report dated 8/27/18 revealed wound # 1 width measurement as "3.4" cm, which was an increase in width by 0.4 cm. Further review of the Visit Note Report dated 8/27/18 revealed no documentation the physician was notified of the increased width of wound # 1. An interview was conducted on 10/10/18 at 1:44 PM with EI # 1, who confirmed the previous findings.
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 review of medical records (MR), agency policy and procedure, Fundamentals of Nursing by Potter-Perry, and interview with agency staff, it was determined the agency failed to ensure the following: 1. The patient or caregiver was provided instruction on how to perform wound care. 2. The patient or caregiver performed a return demonstration to ensure competency for wound care. This affected 1 of 6 records reviewed with wounds including MR # 2. This had the potential to negatively affect all patients served by the agency. Findings include: Policy: 3.001 Subject: Patient Education Revised: 11/1/2017 "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. Patients receive oral and/or written information for this purpose on an ongoing basis while being cared for by the agency. Procedure: ...3. The patient and caregiver receive ongoing information specific to the identified needs, at a level appropriate to their learning abilities, including: ...b. Patient/caregiver plan of care responsibilities... Fundamentals of Nursing by Potter-Perry 6th Edition Chapter 24 Client Education Page 473 Key Concepts-....A nurse evaluates a client's learning by observing performance of expected learning behaviors under desired conditions.... 1. MR # 2 was admitted to the agency on 7/25/18 with diagnoses including Type 2 Diabetes Mellitus with Diabetic Polyneuropathy and Non-Pressure Chronic Ulcer of Left Heel and Midfoot with Fat Layer Exposure. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 7/25/18 through 9/22/18 revealed a physician's order for "Skilled Nurse (SN) to Perform / Instruct / Reinforce patient/caregiver procedure of wound care to left foot. Using clean technique, cleanse with wound cleanser and pat dry. Apply Santyl to wound bed. Cover with Xeroform and ABD (abdominal) pad. Wrap with Kerlix. Secure with tape. Wound care to be performed daily... Caregiver to perform wound care in absence of SN..." Review of the Visit Note Report dated 7/25/18 revealed documentation of wound care at the visit was provided by the SN. Further review of the Visit Note Report dated 7/25/18 revealed the following documentation, "Patient lives alone but has a friend to come by to assist with wpund (wound) care. Verbalized good understanding of wound care and written step by step instructions left..." Further review of the Visit Note Report dated 7/25/18 revealed no documentation the "friend" that assists patient with the wound care was present at visit or that the "friend" was instructed and/or knowledgeable about the wound care to be performed. Review of the Visit Note Report(s) dated 7/27/18 and 7/30/18 revealed documentation of wound care was provided by the SN Further review of the Visit Note Report(s) dated 7/27/18 and 7/30/18 revealed no documentation the caregiver was provided instruction on wound care or that a return demonstration was obtained to ensure caregiver competency with wound care. Review of the Physician order dated 8/1/18 revealed order for "SN to Perform / Instruct / Reinforce patient/caregiver procedure of wound care to left foot: using clean technique, cleanse with wound cleanser and pat dry. Apply Prisma or equivalent to wound bed. Cover with Xeroform, dry gauze and ABD pad. Wrap with cotton and kerlix. Secure with paper tape. Wound care to be performed 3 times a week...Caregiver to perform wound care in absence of SN..." Review of the Visit Note Report dated 8/3/18 revealed documentation of wound care was provided by the SN. Further review of the Visit Note Report dated 8/3/18 revealed no documentation the caregiver was provided instruction on wound care or that a return demonstration was obtained to ensure caregiver competency with wound care. Review of the Physician Order dated 8/6/18 revealed order for "SN to provide negative pressure wound therapy to Left Foot wound...Cg (Caregiver) may apply normal saline wet to dry dressing if vac malfunctions..." Review of the Visit Note Report dated 8/6/18 revealed documentation of the following, "Patient educated on wet to dry dressing, patching leaks and changing canister, verbalized understanding." Further review of the Visit Note Report dated 8/6/18 revealed no documentation that the caregiver was provided instruction on the normal saline wet to dry wound dressing for vac malfunctions or that a return demonstration was obtained to ensure caregiver competency with normal saline wet to dry wound dressing. Review of the Visit Note Reports dated 8/8/18 through 9/11/18 revealed no documentation the caregiver was provided instruction on the normal saline wet to dry wound dressing for vac malfunctions or that a return demonstration was obtained to ensure caregiver competency with normal saline wet to dry wound dressing. An interview was conducted on 10/10/18 at 1:44 PM with Employee Identifier # 1, Executive Director, who confirmed the previous findings.