Every finding on record at All American Home Care, Inc

Recertification survey completed. Standard level deficiencies cited Abbreviaitions: x = Times wk = Week # = Number AM = Morning PRN = As needed SN = Skilled Nurse POC/PsOC = Plan of care/Plans of Care SOC = Start of care PM = Afternoon/evening Pt./ Pts. = Patient/Patients DON = Director of Nursing O2 = Oxygen S/S = Signs and Symptoms ABD = Abdominal

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 review of clinical records, patient and staff interviews, it was determined that Agency failed to ensure that staff provided care as ordered by the physician. This was found in 4 of 7 (Pt #2, 4, 5 and 7) clinical records reviewed. 3. Pt. #5 SOC 04/10/2020 Primary Diagnosis: Moderate Persistent Asthma. The clinical record was reviewed on 03/08/2022 at 1:00 PM. The clinical recorded included a POC for the certification period beginning 01/30/2022. The POC included, “…notify Physician of… O2 Saturation: Less Than () 5….” The SN visit note dated 02/01/2022 lacked documentation that any pain assessment was done. A home visit was conducted on 03/09/2022 at 2:00PM with visiting SN. Pt.# 2 was interviewed and it was stated that she is in pain all the time. 2. Pt. #4 SOC 09/14/2020 Primary Diagnosis: Venous Insufficiency. The clinical record was reviewed on 03/08/2022 at 1:00 PM. The POC for certification period of 01/07/2022 to 03/07/2022 which required SN Frequency 1 time a week for 9 weeks. The record contained 2 SN visits for week of 02/20/2022, dated 02/21/2022 (PRN) and 02/25/2022. The record lacked any documentation of modification of physician orders or communication for the PRN visit.