Every finding on record at Compassionate Home Health Care LLC

A recertification survey was completed on 10/25/23. 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 agency staff only as ordered by a physician for 1 of 1 active patients reviewed who received physical therapy (PT) and occupational therapy (OT) (Patient #8). Findings include: 1. The clinical record for Patient #8 was reviewed on 10/24/23. The plan of care for the certification period dated 7/6/23 to 9/3/23 revealed a start of care date of 7/6/23; diagnosis included Parkinson's disease, extrapyramidal and movement disorder, senile degeneration of the brain, osteoarthritis, intervertebral disc degeneration, spondylolisthesis, spinal stenosis, bipolar disorder, pulmonary hypertension, asthma, hyperlipidemia, gastro-esophageal reflux, history of urinary tract infections, presence of a right artificial hip joint, presence of left artificial knee joint, arthrodesis and history of falling. The plan of care orders included: PT one time a week for two weeks, two times a week for one week and one time a week of two weeks for balance training, functional mobility training, gait training, therapeutic exercise, education on home exercise program, muscle re-education, and education on safety precautions; OT to evaluate and treat for activities of daily living (ADL) and decreased assistance; speech therapy (ST) one time a week for one week for speech evaluation for cognitive/communication abilities; and medical social worker (MSW) one time a month for one month for psychosocial assessment of social, economic environmental and emotional factors. Further review of Patient #8's plan of care for the certification period dated 7/6/23 to 9/3/23 failed to reveal verbal orders for the plan of care had been received from Patient #8's physician. Review of this plan of care showed it was signed by Patient #8's physician on 7/21/23. The plan of care for the certification period dated 9/4/23 to 11/2/23 revealed a start of care date of 7/6/23; diagnosis included Parkinson's disease, extrapyramidal and movement disorder, senile degeneration of the brain, osteoarthritis, intervertebral disc degeneration, spondylolisthesis, spinal stenosis, bipolar disorder, pulmonary hypertension, asthma, hyperlipidemia, gastro-esophageal reflux, history of urinary tract infections, presence of a right artificial hip joint, presence of left artificial knee joint, arthrodesis and history of falling. The plan of care orders included PT two times a week for four weeks for balance training, functional mobility training, gait training, therapeutic exercise, education on home exercise program, muscle re-education, and education on safety precautions and OT evaluation and treatment for the new certification period. Further review of Patient #8's plan of care for the certification period dated 9/4/23 to 11/2/23 revealed a verbal order for continued PT services was obtained from Patient #8's physician on 9/1/23 at 4:30 p.m. which ordered PT two times a week for four weeks (effective 9/4/23). No further verbal orders were documented on this plan of care. The plan of care was signed by Patient #8's physician on 9/9/23. a) The agency failed to ensure PT services were provided only as ordered by the physician. Review of a start of care outcome and assessment information set (OASIS) completed by the alternate administrator/PT, on 7/6/23, revealed the alternate administrator obtained a verbal order from Patient #8's physician on 7/7/23 at 2:05 p.m. for Patient #8's plan of care which included orders for OT, ST and MSW evaluation and treatment and for PT one time a week for two weeks (effective 7/6/23), two times a week for one week (effective 7/16/23) and one time a week for two weeks (effective 7/23/23) for balance training, functional mobility training, gait training, therapeutic exercise, education on home exercise program, muscle re-education, and education on safety precautions. Review of a PT reassessment for Patient #8 completed on 8/1/23 and signed by Patient #8's physician on 8/23/23, revealed PT #9 wrote PT clarification orders as follows: two times a week for one week (effective 7/24/23); one time a week for one week (effective 8/5/23); two times a week for three weeks (effective 8/6/23); and one time a week for one week (effective 8/27/23). Review of this PT reassessment failed to show a verbal order was obtained for these PT clarification of orders. Review of a verbal order obtained on 9/1/23 at 4:30 p.m. from Patient #8's physician by PT #9, revealed Patient #8 was to receive PT two times a week for one week (effective 8/27/23) to allow for Patient #8's recertification visit and Patient #8 was to receive PT two times a week for four weeks (effective 9/4/23). This verbal order was signed by Patient #8's physician on 9/8/23. Review of a PT reassessment for Patient #8 completed on 9/28/23 and signed by Patient #8's physician on 9/29/23, revealed PT #9 wrote PT clarification orders as follows: two times a week for one week (effective 10/1/23) and one time a week for two weeks (effective 10/8/23). Review of this PT reassessment failed to show a verbal order was obtained for these PT clarification of orders. Review of Patient #8's clinical record showed Patient #8 received PT visits on the following dates: 7/6/23, 7/12/23, 7/19/23, 7/21/23, 7/24/23, 7/26/23, 8/1/23, 8/5/23, 8/7/23, 8/10/23, 8/14/23, 8/17/23, 8/20/23, 8/23/23, 8/30/23, 9/1/23, 9/5/23, 9/8/23, 9/11/23, 9/15/23, 9/18/23, 9/20/23, 9/25/23, 9/28/23, 10/2/23, 10/5/23, and a discharge visit on 10/9/23. Further review of Patient #8's clinical record failed to show a verbal order was received for PT care provided to Patient #8 at her eight PT visits (7/26/23, 8/1/23, 8/5/23, 8/7/23, 8/10/23, 8/14/23, 8/17/23 and 8/20/23) completed prior to Patient #8's physician signing Patient #8's PT reassessment on 8/23/23. During an interview on 10/25/23 at 10:40 a.m., PT #9 stated when he completed start of care evaluations and recertification evaluations for a patient, including for Patient #8, he would complete his evaluation and then call the patient's physician to receive verbal orders to proceed with his planned PT visits and POC. PT #9 stated when he completed PT reassessments, which he typically completed 30 days into a 60 day certification period, he would write his PT clarification orders on his PT reassessment and fax this reassessment to a patient's physician for approval. PT #9 stated he did not call a patient's physician, including Patient #8's physician, for a verbal order when he completed the PT reassessments. PT #9 stated he assumed patients' physicians reviewed and signed the PT reassessments in a timely manner, thus, there was no need to obtain a verbal order for visits requested on a PT reassessment. PT #9 stated if the PT reassessment was not signed in a timely manner, he understood he would be providing PT treatment without orders and he would start calling for verbal orders when he completed PT reassessments. b) The agency failed to ensure OT services were provided only as ordered by the physician. Review of an OT evaluation completed on 7/12/23 and signed by Patient #8's physician on 7/21/23, revealed OT #10 obtained a verbal order from Patient #8's physician at 4:00 p.m. for OT visits one time a week for four weeks (effective 7/12/23). Review of an OT reassessment completed by OT #10 on 8/2/23 and signed by Patient #8's physician on 8/11/23, revealed OT #10 wrote OT clarification orders for OT one time a week for four weeks (effective 8/6/23). Review of this OT reassessment failed to show a verbal order was obtained for these OT clarification of orders. Review on an OT evaluation completed on 9/6/23 and signed by Patient #8's physician on 9/14/23, revealed OT #10 obtained a verbal order from Patient #8's physician at 2:00 p.m. for OT visits one time a week for four weeks (effective 9/6/23). Review of an OT reassessment completed by OT #10 and signed by Patient #8's physician on 10/16/23, revealed OT #10 wrote OT clarification orders for OT one time a week for four weeks (effective 10/4/23). Review of this OT reassessment failed to show a verbal order was obtained for these OT clarification of orders. Review of Patient #8's clinical record showed Patient #8 received OT visits on the following dates: 7/12/23, 7/20/23, 7/25/23, 8/2/23, 8/9/23, 8/16/23, 8/23/23, 9/6/23, 9/13/23, 9/20/23, 9/29/23, 10/4/23, 10/12/23, and 10/19/23. Further review of Patient #8's clinical record failed to show a verbal order was received for OT care provided to Patient #8 at her 8/8/23 visit completed prior to Patient #8's physician signing Patient #8's OT reassessment on 8/11/23. Additional clinical record review failed to show a verbal order was received for OT care provided to Patient #8 at her 10/4/23 and 10/12/23 visits completed prior to Patient #8's physician signing Patient #8's OT reassessment on 10/16/23. During an interview on 10/25/23 at 10:58 a.m., OT #10 stated after he completed an OT evaluation (both start of care and recertification evaluations) he would call a patient's doctor to receive verbal orders for the OT POC including visit frequency. OT #10 stated when he completed OT reassessments (typically done 30 days after he completed an evaluation or reevaluation with a patient) he would write clarification orders for continued visits on the OT reassessment and fax the OT reassessment to the patient's physician for review and approval. OT #10 stated he did not call the patient's physician to receive verbal orders for continued OT visits. OT #10 stated he assumed the patient's physician reviewed and signed the OT reassessment and returned the OT assessment back to the agency in a timely manner, thus he did not need to call the patient's physician for verbal orders for continued visits requested at the OT reassessment. 2. During an interview on 10/25/23 at 11:41 a.m., the alternate administrator stated the agency expectation was after a clinician completed an evaluation/assessment if a patient required clarification orders for continued visits, the clinician was to call the patient's physician to obtain a verbal order for those visits to ensure the clinician had orders for the visits completed prior to the agency receiving the signed evaluation/assessment. The alternate agency manager stated she was surprised PT #9 and OT #10 were not calling patient's physicians after they completed reassessments and she would re-educate all staff on the need for obtaining verbal orders. During an interview on 10/25/23 at 11:41 a.m., the administrator stated the reassessment forms created by the agency's electronic medical record (EMR) system for PT and OT did not have a section to remind the therapist to document the verbal order he/she received after completion of the reassessment similar to the section on the OT and PT evaluation forms. The administrator stated most clinicians would find another section on the form to document the verbal order they received. The administrator stated in addition to the re-education to all staff on the need for obtaining verbal orders to ensure all care was provided as ordered by a physician, the administrator planned to contact the agency's EMR to see if a section could be added to the reassessment forms to provide a visual reminder to the clinician to call the physician for verbal orders.