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 017027 (X3) Date Survey Completed 09/26/2018
Name of Provider or Supplier Hga Homecare, Llc Street Address, City, State 2050 Beltline Rd Sw, Decatur, 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)
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 review of agency policy, medical records (MR), and interviews, it was determined the agency failed to ensure:



1. Wound reassessments were conducted at least weekly and included measurements.



2. Documentation of the wound vac (Negative Pressure Wound Therapy, NPWT) dressing change to included the number of foam pieces removed and applied to wound.



This affected 4 of 12 records reviewed with wounds including MR # 10, # 5, # 1 and # 4 and had the potential to affect all patients admitted to the agency with wounds.



Findings include:



Policy: Wound Assessment, Documentation, and Photography

Policy Number: 2.2.0001

Revised: 9/1/17



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



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



...Unless otherwise ordered by the physician, the Registered Nurse (RN) will assess wounds at least: Weekly for patient receiving negative pressure wound therapy, receiving daily wound care performed by the agency, have an infected wound, or have stage IV (4) pressure injury...



...The assessment includes measurement of the length, width and depth, undermining and tunneling, wound bed description, wound edges, exposed tissue types, drainage and the condition of the periwound.



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



*****



Policy: Negative Pressure Wound Therapy (NPWT)

Policy Number: 2.2.007

Revised Date: 9/1/17



Purpose:



To promote wound healing and establish competency assessment guidelines when utilizing negative pressure wound therapy.



Procedure:



2. Perform procedure utilizing LHC adopted clinical guidelines.



3. The dressing will be labeled with the date and time of application, clinician's initials, and number of foam/sponge pieces placed in the wound.



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 bed.



****



1. MR # 10 was admitted to the agency 9/7/18 with diagnoses including Hemiplegia Following Cerebral Infarct Affecting Left Nondominant Side and History of Falling.



Record review revealed a physician order dated 9/12/18 for a Registered Nurse (RN) visit for followup up after a fall with injury and daily wound care to wound # 1 left great (Toe) superficial trauma and wound # 2 left patellar superficial trauma, clean with soap and water, dry and apply triple antibiotic ointment, leave open to air.



The 9/12/18 RN Visit documentation revealed wound # 1 measured 1.5 cm (centimeters) length (L) x (by) 1 cm width (W) x 0.1 cm depth (D) and wound # 2 measured 2 cm L x 1.5 cm W x 0.1 cm D.



Review of the weekly nurse visit dated 9/19/18 revealed wound assessments were completed but the nurse failed to document wound measurements for wounds # 1 and wound # 2.



In an interview conducted on 9/26/18 at 11:30 AM, Employee Identifier (EI) # 2, Clinical Director confirmed there were no wound measurements documented the week of 9/12/18.



2. MR # 5 was admitted to the agency on 5/25/18 and recertified for continued care on 7/24/18 to 9/21/18 and with diagnoses of Type II Diabetes Mellitus With Other Specified Complications and Other Acute Osteomyelitis, Right Ankle and Foot.



Review of the physician order dated 7/30/18 the patient was receiving wound care to the right ankle and foot using the wound vac as ordered: Remove old dressing with number of pieces of foam removed, cleanse wound with Saf Clens or Normal Saline and gauze, using window pane technique, apply black foam to wound bed noting number of foam applied, apply wound vac at negative 125 mmHg (millimeters of mercury) continuous setting 3 times per week.



Review of the skilled nurse visits (SN) for the week of 8/12/18 to 8/18/18 and the week of 8/26/18 to 9/1/18 revealed no wound measurements documentation.



Review of the SN visit note dated 8/15/18 revealed the nurse failed to document the number of foam pieces removed, the color foam removed and how many pieces of foam were applied.



An interview was conducted on 9/26/18 at 9:50 AM with EI # 2, Clinical Director, who confirmed the above mentioned findings.



3. MR # 1 was admitted to the agency 5/9/18 with diagnoses including Encounter for Surgical Aftercare Following Surgery on the Circulatory System and Encounter for Orthopedic Aftercare Following Surgical Amputation.



Review of the Physician Order form dated 5/16/18 revealed the following order "clean R (right) heel with NS (normal saline) and gauze, pat dry with gauze, apply wet to dry dressing. cover with rolled gauze, secure with tape. Dressing to be changed daily."



Review of the Visit Note Report dated 5/16/18 revealed narrative documentation of "Patient has a new wound to back of R Heel. Measurement not done..."



Review of the Visit Note Report dated 5/18/18 revealed narrative documentation of "Patient has wound on R Heel 3 x 3 x 0 applying wet to dry dressing, wrapping with rolled gauze secured with tape."



The Visit Note Reports(s) dated 5/16/18 and 5/18/18 revealed no wound assessment documentation for the R Heel wound bed description, presence or absence of undermining and tunneling, wound edges, exposed tissue types, drainage or condition of the periwound tissue.



An interview was conducted on 9/26/18 at 10:35 AM, with EI # 1, Executive Director who confirmed the previous findings.



4. MR # 4 was admitted to the agency on 3/9/18 with diagnoses including Type 2 Diabetes Mellitus with Foot Ulcer and Non-Pressure Chronic Ulcer of Right Heel and Midfoot with Unspecified Severity.



Review of the Client Coordination Note Report dated 3/18/18 revealed documentation of "...Caregiver called. Patient has been off of Aricept for 1 week due to interaction... She/He is weak and shaking and keeps sliding out of wheelchair. There is no one in the home capable of taking care of patient..."



Review of the Physician Order form dated 3/21/18 revealed an order to "Cleanse Stage I PU (pressure ulcer) to left buttock with soap and water, pat dry, apply Calazime Daily and prn (as needed) with each incontinent episode."



Review of the Visit Note Report dated 3/21/18 revealed narrative documentation of "Patient has new stage I PU to buttock..."



Further review of the Visit Note Report dated 3/21/18 revealed no documentation of the left buttock wound bed description, measurements of the wound, if undermining and tunneling were present, wound edges, exposed tissue types, drainage of wound, condition of the periwound, or if wound care was provided.



Review of the Visit Note Report dated 3/23/18 revealed narrative documentation of "CG (caregiver) did wound care and demonstrated correctly."



Further review of the Visit Note Report dated 3/23/18 revealed no documentation of the left buttock wound bed description, measurements of the wound, if undermining and tunneling were present, wound edges, exposed tissue types, drainage of wound, condition of the periwound, or what wound care was provided by the caregiver.



An interview was conducted on 9/26/18 at 11:34 AM with EI # 1, who confirmed the previous findings.