Every finding on record at Citywide Home Health Care Inc.

A recertification survey was completed on 10/31/24. One deficiency was cited.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure services and treatments were administered by staff only as ordered by a physician in 2 of 5 active patient records reviewed (Patients #3 and #4). Findings include: 1. The clinical record for Patient #4 was reviewed on 10/29/24. The plan of care (POC) for the certification period 9/15/24 to 11/13/24 revealed a start of care date of 9/20/23; diagnoses included delayed milestones in childhood and unspecified visual loss. POC orders included skilled nursing once every 60 days for recertification, assessment, and certified nursing aide (CNA) supervision; and CNA visits 84 times per week for eight weeks, and 48 times per week for one week for assistance with activities of daily living (ADLs) including showers, hair care, mouth care, assistance with dressing, nail care, perineal care, lotion, assistance with mobility, meal preparation, feeding, changing bed linens, making bed, laundry, shopping, and incontinence care. a) The agency failed to have a physician order for all services provided to Patient #4 from 9/15/24 to 10/17/24. Review of Patient #4's clinical record revealed the POC for the certification period of 9/15/24 to 11/13/24 was not signed by the physician until 10/17/24. Further review of Patient #4's record failed to reveal the agency had received verbal orders from the physician to provide services to the patient. Furthermore there was no documentation the agency had received orders for services until 10/17/24. During an interview on 10/31/24 at 11:33 a.m., the director of nursing (DON), office manager, and alternate DON stated the agency did not receive verbal orders and had not received written orders to continue the care for Patient #4. The agency stated they would work to fix this issue. 2. Similar findings were found for Patient #3.