Every finding on record at Acadian Homecare, LLC

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Recertification Survey

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient's written individualized POC (plan of care) was followed as evidenced by the SN (skilled nurse) failing to perform and record blood sugar readings and failing to obtain and record weights as ordered per the POC for patient #8 and OT (Occupational Therapy) failing to report pain to the physician as ordered per the POC for patient #7 for 2 (#8, #7) out of a total sample of 17 patients. 1. Patient #8. Review of the patient’s electronic clinical records revealed the start of care date was 9/18/2021. The patient’s diagnoses included Infection of Amputation Stump Right Lower Extremity, Diabetes, and Hypertensive Heart Disease with Heart Failure. The certification period reviewed was 3/17/2022 to 5/15/2022. Review of the patient’s POC for certification period 3/17/2022 to 5/15/2022 revealed an order for “SN effective 3/20/2022 1wk8 (skilled nurse visit effective 3/20/2022 one time a week for eight weeks).” Further review of the patient’s POC revealed an order for “…Skilled nurse to obtain weight every SNV (skilled nurse visit)… SN to assess/obtain CBG (Capillary Blood Glucose) every SNV…” Review of the patient’s skilled nurse visit notes dated 3/28/2022 and 4/4/2022 revealed that there was no evidence that the patient’s CBG reading was obtained. Review of the patient’s skilled nurse visit notes dated 4/4/2022 and 4/11/2022 revealed that there was no evidence that the patient’s weight was obtained. On 4/19/2022 at 2:12 pm, an interview was conducted with S3RN (Registered Nurse). S3RN reviewed the patient’s clinical record and confirmed that there was no evidence that the patient’s CBG reading and the patient’s weight were obtained as ordered per the POC on those dates. 2. Patient #7. Review of the patient’s electronic clinical records revealed the start of care date was 3/16/2022. The patient’s diagnosis included Encounter for Orthopedic Aftercare Following Amputation. The certification period reviewed was 3/16/2022 to 5/14/2022. Review of the patient’s POC for certification period 3/16/2022 to 5/14/2022 revealed an order for “OT 1wk5 (Occupational Therapy visit one time a week for five weeks).” Further review of the patient’s POC revealed orders for parameters on when to report when falling outside the parameters which included reporting pain greater than 6. Review of the patient’s OT visit note dated 3/25/2022 revealed that the patient was assessed as having pain rated 8 based on an assessment tool on a pain scale of 0-10 The note revealed that there was an alert that the patient was above pain of 6. Further review of the note revealed that the physician was not contacted concerning the patient’s pain. Review of the note under emergent care revealed, “Yes patient had a fall…” On 4/19/2022 at 12:13 pm, an interview was conducted with S2CN (Corporate Nurse). S2CN reviewed the patient’s clinical record and confirmed that there was no evidence that S4OT (Occupational Therapy) reported the patient’s pain to the physician. On 4/19/2022 at 12:15 pm, a telephone interview was conducted with S4OT. S4OT confirmed that she did not report the patient’s pain to the physician.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure staff promptly documented a physician’s verbal order in the patient’s record for 1 (#11) out of 17 sampled patients. Review of Patient #11’s electronic clinical record revealed a start of care date of 8/18/2019. The patient’s diagnoses included Type 2 Diabetes Mellitus with Other Skin Ulcer and Chronic Venous Hypertension with Ulcer and Inflammation of Bilateral Lower Extremities. Review of the patient’s POC (Plan of Care) for certification period from 3/25/22 to 5/23/22 revealed an order for SN (skilled nurse) to perform wound care with home health to see the patient on Fridays and Mondays. Review of the patient’s SN visit notes for the week of 4/17/2022 revealed that a SN visit was conducted on Thursday, 4/14/22. There was no SN visit conducted on Friday, 4/15/22 as per the plan of care. Further review of the patient’s electronic clinical record failed to reveal an order or other clinical note that explained why a visit was not conducted on Friday, 4/15/22. On 4/19/22 at 3:40 pm, an interview was conducted with S1CD. S1CD was asked for clarification as to why a SN visit was not conducted on Friday, 4/15/22 as ordered for Patient #11. On 4/20/22 at 9:05 am, S1CD stated that the S5RN had received a verbal order to conduct the SN visit Thursday but failed to write the order at the time it was received and presented a copy of a physician’s order to perform the visit on Thursday that was dated and timed 4/19/22 at 5:26 pm. S1CD confirmed that the verbal order should have been written on the day it was received. S1CD was asked to provide the agency's policy regarding verbal orders. Review of physician order for Patient #11 dated 4/19/22 at 5:26 pm revealed the following: Verbal date 4/14/22 at 9:43 AM…HH (home health) to perform wound care on Thursday and Monday…VO (verbal order) S5RN 4/14/22. Review of Physician Orders policy presented by S1CD revealed the following: …verbal or telephone orders are entered into the software system when received and included the time and date the verbal order was received…

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 record review and interview, the agency failed to ensure Patient #14's physician was promptly alerted of a three pound weight gain in one day that was noted by the skilled nurse during the skilled nurse visit made on 11/30/2021 for 1 (#7) out of 17 sampled patients. Patient #14. Review of the patient's electronic clinical record revealed the start of care date was 11/23/2021. The patient's diagnoses included Ischemic Cardiomyopathy and Hypertensive Heart Disease with Heart Failure. The certification period reviewed was 11/23/2021 to 1/21/2022. Review of the patient's POC (Plan of Care) for certification period 11/23/2022 to 1/21/2022 revealed the following order, SN 1wk9 (skilled nurse visit one time a week for nine weeks). Further review of the POC revealed, “…Skilled nurse to obtain weight every visit and notify RN/MD of weight gain … of 3 lbs (pounds) per day….” Review of the patient's SN Visit Note dated 11/29/2021 revealed that the patient’s weight was 153.8 pounds. Review of the patient’s SN Visit Note dated 11/30/2021 revealed that the patient’s weight was 156.8 pounds, which was a three pound weight gain in one day. There was no evidence that the SN notified the physician of the patient’s 3 pound weight gain in one day. On 4/20/2022 at 10:25 am, an interview was conducted with S1CD (Clinical Director) and after a review of the patient's clinical record, S1CD verified that there was no evidence that the physician was notified of the patient’s three pound weight gain in one day. Also, S1CD stated that the three pound weight gain in one day should have been reported to the physician.