Every finding on record at Diagnostic Medical Imaging Services, Inc

A Complaint Survey for complaint #2021000200, was conducted on February 15, 2021 at Leon At Home. The Home Health Agency was found to be in non-compliance with 42 CFR 484 Subpart A-C requirements for Home Health Agencies.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the Home Health Agency failed to have a completed individualized Plan of Care (POC) for 1 out of 3 Sampled Patients (SP). SP#3 Review of SP#3's record revealed a start of care dated 11/05/2020. Further review of SP#3's POC for the certification period of 01/04/2021 to 03/04/2021 revealed the section titled "Allergies" was blank. During an interview conducted on 02/15/2021 at 2:20 PM, the Director of Nursing and the Compliance Officer acknowledged that the section titled "Allergies" was blank on SP#3's POC.

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 record review and interview, the Home Health Agency failed to ensure an employee conformed to the physician's orders for 1 out of 3 Sampled Patients (SP). SP#1 Findings include: Record review revealed SP#1 was admitted on 12/06/2020. Further review of SP#1's record revealed a resumption of care order dated 01/09/2021 that contained the following order: "SN to administer Insulin Gargline (Lantus) 100 Units/Ml, 10 Units Subcutaneous twice a day." Further review SP#1's Skilled Nursing (SN) notes dated 01/23/2021, 01/28/2021 and 01/29/2021 revealed no documentation that the nurse administered the Insulin Gargline (Lantus) 100 units/ml, 10 units subcutaneous during the evening visits as ordered by the physician. During a telephone interview conducted on 02/16/2021 at 3:06 PM, the Director of Nursing (DON) acknowledged that the SN notes of 01/23/2021, 01/28/2021 and 01/29/2021 did not contain documentation that the nurse administered the Lantus 10 units subcutaneously to SP#1 during the evening visits.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview, the Home Health Agency failed to ensure that the nurse (s) documented the required information in the clinical notes of 1 out of 3 Sampled Patients (SP). SP#3 Findings include: Record review revealed SP#3 was admitted on 01/15/2020. Further review of SP#3's Plan of Care (POC) for the certification period of 01/04/2021 to 03/04/2021 revealed a section titled " Treatments Medications" that contained the following order: "Retacrit Injection 10000 Unit/Ml 2 ml (20, 000 units total) subcutaneous weekly if Hb 10 g/dl or less by SN." Further review of SP#3's Skilled Nursing (SN) notes revealed the nurse (s) did not document: 1) SP#3's Hb's result nor the administration of the Retacrit on 01/06/2021 and 01/13/22021; 2) SP#3's Hb's result on 01/16/21; 3) the administration of the Retacrit to SP#3 on 01/20/2021; 4) SP#3's Hb's result nor the administration of the Retacrit on 01/27/21; 5) SP#3's Hb's result nor the administration of the Retacrit on 02/03/21; 6) SP#3's Hb's result nor the administration of the Retacrit on 02/10/21. During an interview conducted on 02/15/2021 at 2:21 PM, the Director of Nursing and the Compliance Officer acknowledged the above findings.

Contents of clinical record CFR(s): 484.110(a) Standard: Contents of clinical record. The record must include: This STANDARD is not met as evidenced by: Based on record review and interview, the Home Health Agency failed to ensure one employee documented accurate information in 1 out of 3 Sampled Patients (SP)'s record. SP#3 Findings include: Review of SP#3's Skilled Nursing (SN) notes dated 02/07/2021 revealed the nurse documented two different blood glucose readings of 144 and 209 for the evening visit. Further review of the SN notes dated 02/22/2021 revealed the nurse documented two different blood glucose readings of 117 and 118 for the morning visit. During an interview conducted on 02/15/2021 at 2:15 PM, the Director of Nursing and the Compliance Officer acknowledged the above findings.