Every finding on record at Basis Home Health LLC

On 07/25/2023 at 02:30PM, an entrance conference was conducted with Agency Representatives. The Agency Representatives were informed the purpose of the visit was to conduct a Medicare recertification survey. On 11/05/2023 at 01:15 PM, an exit conference was conducted with Agency Representatives. The findings of the survey were discussed and Agency Representatives were given an opportunity to ask questions. .

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on Clinical Record review and staff interview, the Agency did not ensure the Clinical Record included all documentation in the Electronic Medical Record (EMR) in 2 (# 1 and #2) of 7 (#1 - #7) Clinical Records reviewed. This lack of documentation had the potential to impact coordination and continuity of care for the patient and family and resulted in an inaccurate Clinical Record. Findings follow: 1. Review of Clinical Record #1 revealed orders for the Skilled Nurse (SN) to do wound dressings and to change collar pads daily. On 07/03/2023, the SN noted "Green Drainage to collar pad." On 07/12/23 the SN noted having to reuse collar pads. The SN made visits on 07/03/23, 07/12/23, and 0719/23 and noted the patient did not have collar pads and the patient was not doing daily dressing changes. There was no evidence the patient's physician was contacted regarding the change in the patients wound, lack of collar pads, and patient not doing daily dressing changes. 2. Review of Clinical Record #2 revealed orders for the Occupational Therapist (OT) to perform visits one time a week for three weeks. The OT conducted a visit on the first week of care, 06/16/23, but there were no other visits made by the OT. 3. During an interview on 07/28/23 at 12:40 PM, Agency Personnel #2 reported clinical staff had contacted the physician regarding the changes in the patient's condition, lack of collar pads, and patient not doing daily dressing changes as ordered, but the SN failed to document those calls. Agency Personnel #2 reported the Occupational Therapist had discharged the patient and had notified the physician but had not synched their computer which would have updated the EMR.