Every finding on record at Care-Med Home Health Services, Inc

Recertification survey completed. Standard level deficiencies cited. Abbreviations: x = times wk = week # = number AM = morning SN = Skilled Nurse POC = Plan of care SOC = Start of care PsOC = Plans of Care RN = Registered Nurse PM = afternoon/evening Pt./ Pts. = Patient/Patients

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: A. Based on clinical record reviews and staff interviews it was determined that the Agency failed to ensure physicians orders were followed as stated in the PsOC. This was found in 3 of 7 clinical records reviewed. (Pts. # 4, 2 and 7) 2. Pt. #2 SOC 9/10/2021 Diagnoses: Type 2 Diabetes mellitus with Diabetic Neuropathy, Muscle Weakness. The clinical record was reviewed on 11/09/2021 at 3:30 PM. The POC for certification period of 9/11/2021 to 11/08/2021 required Home health aide services for 2 times a week for 9 weeks. The record lacked documentation for any home health aide visits for week 1 (9/10/2021- 9/11/2021) as ordered by the physician. No modification orders were found in the record. 3. Pt. # 7 SOC 7/13/2021 Diagnoses: Type 2 Diabetes mellitus, Hypertensive Heart and Chronic Kidney Disease. The clinical record was reviewed on 11/10/2021 at 12:30 PM. The POC for certification period of 7/13/21 to 9/10/21 and 9/11/21 to 11/09/21 required “SN to assess and monitor patient’s vital signs to include….blood sugar.” The recertification assessment dated 9/07/2021 and discharge assessment dated 10/23/2021 lacked an assessment for blood sugar as ordered by the physician. No modification orders were found in the record. 4. On 11/10/2021 from 12:00 PM to 2:00 PM, interviews were conducted with the Administrator and Agency Supervisor, both confirmed the above findings. Findings include: 1. Pt. # 4 SOC 09/18/2021 Diagnoses: Spinal Stenosis Lumbar Region, Type 2 Diabetes Mellitus with Hyperglycemia. The clinical record was reviewed on11/10/2021 at 9:30 AM. The clinical record contained a POC for certification period 09/18/2021 to 11/16/2021 that included orders "SN to notify MD (Medical Doctor) of: Fasting blood glucose greater than (>) 200 or less than () 250 or less than (<) 70". The clinical record contained a SN visit note dated 10/08/2021 with a blood glucose level of 286 and a SN visit note dated 10/12/2021 with a blood glucose level of 302. The clinical record lacked documentation that the Physician was notified about the blood glucose levels on neither of the SN visit notes.