Every finding on record at Able Home Healthcare Inc

An entrance conference was conducted for a Relicensure and Recertification Survey with the Administrator/ Owner on 7/10/2023 at 12:37 p.m. Census: 45 Licensed and Certified Home Health: 45 Licensed Home Health: 0 Personal Assistant Services: 0 Hospice:0 Exit conference was conducted on 7/13/2023 at 3:36 p.m. with the Administrator and Assistant Administrator. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. No deficiencies were cited. The agency was in substantial compliance with 42 CFR Part 484.102 Emergency Preparedness Requirements for Home Health.

An entrance conference was conducted for a Relicensure and Recertification Survey with the Administrator/ Owner on 7/10/2023 at 12:37 p.m. Census: 45 Licensed and Certified Home Health: 45 Licensed Home Health: 0 Personal Assistant Services: 0 Hospice:0 Exit conference was conducted on 7/13/2023 at 3:36 p.m. with the Administrator and Assistant Administrator. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure that the documentation of services provided was current and accurate for one of ten active patients (Patient #3) whose records were reviewed, in that: 1. Patient’s #3's Plan of Care was inaccurate. This deficient practice places the agency's patients at risk for receiving inadequate service delivery and could lead to miscommunication among all care providers. The findings included: 1. Review of Patient’s #3's clinical record revealed a SOC date of 7/10/2023 for a POC certification period from 6/15/2023 through 8/13/2023 with a diagnosis of a wound of the buttock and a Skilled Nurse visit frequency of one Skilled nurse visit twice per week for one week then one visit per week for five weeks. Review of the 485 (Plan of Care orders), dated 7/10/2023, revealed “Skilled nursing to administer 1 can of Glucerna via g tube (tube inserted externally through the skin to bypass traditional eating) every four hours.” Further review of the Plan of Care revealed that caregiver is independent on g tube management. During a home visit with Client #3 at 10:00 am on 7/11/2023, Client #3’s caregiver stated that she feeds the patient via g tube “for years” every 4 hours and verbalized independence. During an interview with the Administrator on 7/13/2023 at 11:45 a.m., the Administrator was informed of the above findings. The Administrator acknowledged the discrepancy on the order and stated, “We don’t provide continuous nursing services to place perform a feeding every four hours. Her daughter is independent in tube feeding management. The electronic medical record entry is an error and an issue. I will revise the order for accuracy. The electronic documentation system auto populates some sentences, and it must be edited to each patient.” During an interview with the Alt. Administrator on 7/13/2023 at 11:50 a.m., the Alt. Administrator was informed of the above findings. The Administrator acknowledged the discrepancy on the order and stated, “Yes, this is an internal systems issue.” Review of the agency’s policy titled, “Care Planning,” dated 9/2022, revealed “Each patient must receive an individualized written Plan of Care …related to patient findings…must specify: Care and services to meet patient -specific needs as identified in the comprehensive assessment provided…must include…Frequency and duration of visits to be made…”