Every finding on record at Asa Home Care Inc

A complaint survey (complaint number #2023012187) was conducted on 09/22/2023 at ASA Home Care Inc. The home health agency was in non-compliance with 42 CFR 484 Subpart A-C, Requirements for Home Health Agencies.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on clinical record review and interview, the home health agency failed to have in the clinical record all physician orders for 1 out of 3 Sampled Patients (SP). SP#3 Findings include: Closed clinical record review for SP#3 showed a Start of Care date of 07/25/2023 and the Plan of Care (POC) for certification period of 07/25/23 to 09/22/23 revealed SP#3 received Skilled Nursing service daily for wound care. The POC reads for "SN (skilled nurse) 1 x day x 60 days. Perform wound treatment of wound posterior cervical incision: clean with normal saline, pat dry and cover with dry dressing, and secure with tape daily.” The skilled nurse was provided daily from 07/25/23 to 09/06/23. A prescription dated 07/27/23 reads “Skilled Nursing services to continue home health services for daily wound care changing the dressings twice daily, clean the area with hydrogen peroxide pat dry and secure with dry dressing.” There were no interdisciplinary communication notes, case conference and/or physician modify order in the clinical record reflecting the reason the skilled nursing service was provided daily and failed to be provided twice a day as of 07/27/23. Interview conducted with the Director of Nursing (DON) on 09/22/23 at 1:45 PM. The DON stated the order was received through the patient’s insurance, but the primary care physician signing the POC was notified and he agreed to continue with the same wound care and frequency. The DON confirmed the above findings that clinical record for SP#3 did not contain documentation regarding reporting of the patient’s condition and interdisciplinary communication with the patient’s primary care physician.