Every finding on record at Ecs Health Care Agency and Home Health Services

Recertification survey completed. Standard level deficiencies cited.

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 clinical records review, policy review and staff interview, it was determined the Agency failed to include all clinical notes in the clinical record. This was found in 4 of 7 (Pt. # 2, 5, 3 and 4) clinical records reviewed. Findings include: 1. Patient (Pt.) #2 was admitted to home health services on 08/03/2023 with a diagnosis of Pressure Ulcer of Sacral Region Stage 2. The clinical record included a plan of care dated 08/03/2023 that ordered occupational therapy (OT) evaluation and a medical social worker (MSW) evaluation. As of 08/23/2023 at 10:00 AM, the clinical record lacked OT and MSW evaluation notes. During an interview with the Agency Supervisor on 08/23/2023 at 12:30 PM, she stated the MSW submits notes late and she has to pull the OT notes and put them in the clinical record. 2. Pt. #5 was admitted to home health services on 07/10/2023 with a diagnosis of Hypertensive Heart Disease and Chronic Kidney Disease. The clinical record included a plan of care dated 07/10/2023 with a Skilled Nurse (SN) frequency order of one week nine. The clinical record also included a Physical Therapy (PT) evaluation dated 07/12/2021 and an OT evaluation dated 07/14/2023 with frequency orders of one week six. The clinical record lacked SN visit notes for the weeks of 07/30/2023, 08/06/2023 and 08/13/2023. The clinical record also lacked PT visit notes for the weeks of 07/23/2023, 07/30/2023 and 08/06/2023 and OT visit notes for the weeks of 07/30/2023 and 08/06/2023. 3. Pt. #3 was admitted to Home Health Services on 07/19/2023 with a diagnosis of Essential (primary) Hypertension. The clinical record was reviewed on 08/22/2023. The clinical record included a plan of care dated 07/19/2023 with a SN frequency order of one week nine. The clinical record lacked SN visit notes for the weeks of 07/30/2023 and 08/06/2023. 4. Pt. #4 was admitted to Home Health Services on 05/11/2023 with a diagnosis of Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 08/22/2023. The clinical record included a plan of care dated 07/10/2023 with a SN frequency order of one week nine. The clinical record lacked SN visit notes for the weeks of 07/23/2023, 07/30/2023 and 08/06/2023. 5. The Agency policy titled, "Clinical Records" was reviewed on 08/24/2023. The policy included..."The clinical records shall contain...7. Signed and dated clinical notes for each contact which are written the day of service and incorporated into the patient's clinical record at least weekly... Standards of Clinical Documentation... All skilled notes including notes from PT, OT, ST, Medical Social Worker and CNAs must be completed and submitted on a weekly basis." 6. During interviews with the Agency supervisor on 08/22/2023 at 2:30 PM and 08/23/2023 at 12:30 PM, she confirmed all services were provided per physicians' order, however the documentation was not entered into the clinical records weekly as per policy.