Every finding on record at Allstar Healthcare Inc

Purpose: Recertification Survey Entrance Date: 10/25/2022 Census: Licensed and Certified - 137 The agency was in compliance with 42 CFR Part 484.22, Emergency Preparedness Requirements for Home Health Agencies.

Purpose: Recertification Survey Entrance Date: 10/25/2022 Census: Licensed and Certified - 137

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 record review and interview, the agency failed to have all patient care orders recorded in the Plan of Care in 1 (#1) of 1 patient record reviewed where the patient had sutures and 1 (#2) of 1 patient record reviewed where the skilled nurses performed laboratory testing on a patient that was on anticoagulation therapy. The failure placed the patients at risk that procedures would not be performed or would be performed at the incorrect times. Patient #1: Record review of Patient #1's record revealed a Plan of Care dated 7/27/2022 to 9/24/2022. The Plan of Care indicated that Patient #1 started on the agency's services on 7/27/2022. The Plan of Care listed Chronic Pain Syndrome, Anxiety, and Abnormalities of Gait and Mobility as diagnoses. The Plan of Care contained an order for skilled nurse visits one time a week for nine weeks. Registered Nurse C conducted a skilled nurse visit on 9/6/2022. Registered Nurse C documented in the skilled nurse visit note that Patient #1 had a fall which required treatment at the emergency room. Registered Nurse C documented that Patient #1 had received 7 sutures to the forehead which were to be removed on September 19, 2022. Patient #1's record did not contain an order for the sutures to be removed on 9/19/2022. Licensed Vocational Nurse D conducted a skilled nurse visit on 9/14/2022. Licensed Vocational Nurse D documented that Licensed Vocational Nurse D removed the sutures with aseptic technique. Patient #1's record did not contain an order for suture removal. Patient #2: Record review of Patient #2's record revealed a Plan of Care dated 6/28/2022 to 8/26/2022. The Plan of Care indicated that Patient #2 started on the agency's services on 12/30/2021. The Plan of Care listed Chronic Atrial Fibrillation, Encounter for Therapeutic Drug Level Monitoring, and Long-term Use of Anticoagulants as diagnoses. The Plan of Care listed Warfarin (anticoagulant - blood thinner) as a medication. The Plan of Care contained an order for the skilled nurse to obtain a PT/INR (Prothrombin Time and International Normalized Ratio - test that measures how long it takes blood to clot) laboratory specimen on 7/5/2022 and as ordered. Licensed Vocational Nurse E conducted a skilled nurse visit on 8/17/2022. Licensed Vocational Nurse E documented that a PT/INR was obtained, and the results were PT 45.2 and INR 3.8. Patient #2's record did not contain an order for a PT/INR to be conducted on 8/17/2022. During an interview on 10/27/2022 at approximately 2:50 p.m. with the Supervising Nurse and the Alternate Supervising Nurse, the surveyor discussed that there was no order for suture removal in Patient #1's record and no order to obtain a PT/INR on 8/17/2022 in Patient #2's record. The Supervising Nurse informed the surveyor that the PT/INR had been obtained weekly. The Supervising Nurse would investigate the issues. During an interview on 10/28/2022 at approximately 2:30 p.m. with the Supervising Nurse, the surveyor was informed that Licensed Vocational Nurse D was at the assisted living facility and the nurse practitioner told Vocational Nurse D to remove the sutures. Licensed Vocational Nurse E had called the physician's office on 8/17/2022 to inquire whether the physician wanted a PT/INR done. Licensed Vocational Nurse E had received a verbal order to obtain a PT/INR. The Supervising Nurse stated, they "forgot to put in the orders." The Supervising Nurse did not dispute that there was no orders in Patient #1's record for the sutures to be removed or in Patient #2's record for the PT/INR to be obtained on 8/17/2022. The policy read in part; "Purpose To define Allstar Healthcare, Inc. policy regarding the patient's plan of care and physician/allowed practitioner orders. Policy: 1. The patient's plan of care is established and authorized in writing by the physician or allowed practitioner based on evaluation of the patient's immediate and long-term needs...." The agency had a policy titled "Verbal/Fax Orders" labeled 5.003.3 with a revision date of March 2021. The policy read in part; "Purpose To define the policy and procedure for management of physician/allowed practitioners orders from the time the order is accepted to the time the physician's signature is obtained and filed into the medical record. Policy: 1. Each verbal order is dated and identified by the names of the individuals who gave the orders. 2. The order shows clearly who gave the order, accepted order, authorized order. Verbal orders must be signed and dated by the registered nurse or qualified therapist who is furnishing or supervising the ordered service...4.Verbal orders are accepted/authorized and transmitted/transcribed by qualified staff who are identified by title..."