Every finding on record at Access Life Care, Ltd

Recertification survey completed. Standard level deficiencies cited. Abbreviations: ER = Emergency Room lbs. = Pounds MD = Medical Doctor Pt./Pts. = Patient/Patients SN = Skilled Nurse

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 clinical record review, home visit observation and Staff interview, it was determined that the Agency failed to conform with Physician orders. This was found in 2 of 7 (Pts. # 1 and #5) records reviewed. Findings include: 1. Patient #1 was admitted to Home Health Services on 09/28/23 with a diagnosis of Alzheimer’s Disease with late onset. The clinical record was reviewed on 11/07/23. The signed Physician order effective 09/28/23, included orders for Discipline and Treatment to notify physician if pulse is less than 60 beats per minute. The following Physical therapy notes documented on 10/17/23 a pulse of 58, 10/26/23 a pulse of 52, 10/31/23 a pulse of 54 and 11/07/23 a pulse of 59. The record lacked documentation the physician was notified. A home visit was conducted on 11/07/23 at 1:00 PM, with Employee #1 (Physical Therapist). It was observed that Patient #1 had a pulse reading of 59, there was no notification of physician. 2. Patient #5, was admitted to Home Health Services on 08/14/23 with diagnoses of Hypertensive Heart Disease with Heart Failure and Type 2 Diabetes Mellitus without Complications. The clinical record was reviewed on 11/07/23. The Physician orders dated 08/14/23 included orders for the SN to notify the physician immediately of any potential problems…” The SN visit notes dated 08/14/23 included a weight of 160 lbs and on 08/23/23 a weight of 175 lbs. The MD was not notified and on 08/26/23, the patient was transferred to ER, with shortness of breath. 3. The above findings were confirmed during the interview with the Administrator, Agency Supervisor and Quality Assurance Nurse on 11/08/23 between 10:15 AM and 2:00 PM.