Every finding on record at Central Healthcare, Inc

Recertification survey completed. Standard level deficiencies cited. Abbreviations: Pt/Pts = Patient/Patients PT = Physical Therapy/Therapist SN = Skilled Nurse

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: Based on the clinical record review and Staff interview, it was determined the Agency Staff did not conform to the Physician’s orders. This was found in 2 of 7 (Pts. # 7 and 6) records reviewed. Findings include: 1. Patient #7, was admitted to the home health services on 11/01/22. Diagnosis: Type 2 Diabetes Mellitus without Complications. The clinical record was reviewed on 08/30/23. The Physician orders dated 12/31/22 included orders for the SN to assess the Patient 1 time a week for 9 weeks. The SN did not assess the patient the weeks of 01/08/23 (week #2) and the week of 02/12/23 (week #7). The Physician orders dated 12/31/22 also included orders for the Aide to provide skincare for the Patient 2 times week for 8 weeks. The Aide provided care 3 times a week for the week of 01/15/23 (week #3) and 1 time a week for the week of 01/29/23 (week #5). The Physician orders dated 12/31/22 also included orders for the PT to provide care for the Patient 2 times week for 5 weeks. The PT provided care 1 time a week for the week of 01/22/23 (week #4) and the week of 02/12/23 (week #7). 2. Patient # 6 was admitted to home health services on 04/06/23. Diagnosis: Emphysema. The closed clinical record was reviewed on 08/30/23. The Plan of care effective 04/06/23 included Home Health Aide frequency of 2 times a week for 8 weeks (to start on 04/10/23). The record included a home health aide visit dated 04/14/23. The record lacked another visit for the week of 04/09/23. During the interview with the Administrator, Agency Supervisor and Office Manager on 08/30/23 at 1:30 PM, the Office Manager confirmed that there was a missed visit from the Home Health Aide on 04/10/23 and there was no attempt to reschedule another visit within the week. 3. During the interviews with the Administrator, Agency Supervisor and Office Manager on 08/30/23 from 11:45 AM to 2:15 PM, the above findings were confirmed by the Agency Supervisor.

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 the clinical record review and Staff interviews, it was determined the Agency’s clinical records were incomplete. This was found in 2 of 7 (Pts. #7 and 6 ) records reviewed. 2. Patient #6 was admitted for home health services on 04/06/23. Diagnosis: Emphysema. The closed clinical record was reviewed on 08/30/23. The record included a signed order dated 04/20/23, for certification period 04/06/23 to 06/04/23, indicating transfer to hospital for evaluation and management and for home health services to resume once patient is discharged from hospital. The record included a transfer assessment dated 04/20/23, indicating “transferred to an inpatient - patient not discharged from agency. As of 08/30/23, the record lacked documentation of the patient’s status. 3. During interviews with the Administrator, Agency Supervisor and Office Manager on 08/30/23 from 11:45 AM to 2:15 PM, the above findings were confirmed. Findings include: 1. Patient #7, was admitted to the home health services on 11/01/23. Diagnosis: Type 2 Diabetes Mellitus without Complications. The clinical record was reviewed on 08/30/23. The clinical record included an SN visit note dated 02/28/23 that lacked the date the discharge summary was sent to the physician.