Every finding on record at Blc Homehealth Inc

The following reflects the findings of the California Department of Public Health during the investigation of a complaint. Complaint number: 97661 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for complaint number: 97661. See Tag G1024

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on interview and record review, for one of three sampled patients (Patient 1), the agency failed to ensure clinical record entries were appropriately authenticated, dated, and timed when MSW scribbled Patient 1’s signature on the visit notes. Review of the Referral Form indicated Patient 1 was referred to the agency for services that included physical therapy, occupational therapy, and social work. During a concurrent interview and review of clinical records with Registered Nurse Case Manager (RNCM) on 5/19/23 at 10:38 a.m., Patient 1’s Medical Social Services Evaluation and Care Plan dated 2/22/23 completed by MSW was reviewed. RNCM stated the care plan indicated Patient 1 was seen by MSW on 2/22/23 during a face-to-face home visit but the clinical notes appeared to be signed by Patient 1 on 3/7/23 at 9:32 p.m. RNCM stated Patient 1’s signature on the care plan did not appear similar to the previous signatures obtained by other clinicians from Patient 1. RNCM also stated, if the face-to-face visit was on 2/22/23, there was no way the signature could have been obtained from Patient 1 on 3/7/23 at 9:32 p.m. During a telephone interview on 926/23 at 5:08 p.m., MSW stated she scribbled Patient 1’s signature on the clinical notes to be able to turn in MSW's report to the agency. MSW stated the agency did not provide MSW any means to have Patient 1 attach electronic signature on the clinical notes during the visit. MSW stated ‘signing” Patient 1’s signature on the clinical notes later because she did not complete the notes during the actual home visit. During an interview on 10/11/23 at 11:30 a.m. with Director of Patient Care Services Designee (DPCS-D), DPCS-D stated there was no written policy on patient signatures in the clinical record but clinicians should ask the patient to sign on a piece of paper during the home visit if the electronic record could not be accessed. DPCS-D stated, once the electronic record can be accessed, the clinician will draw a straight line across the patient’s signature field and attach the paper copy of the patient’s signature as proof of the visit.