Every finding on record at Family Home Health Care Inc

A recertification survey was completed on 10/24/24. 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 1 of 5 active patients reviewed (Patients #7). Findings include: 1. The clinical record for Patient #7 was reviewed on 10/22/24. The plan of care (POC) for the certification period dated 8/21/24 to 10/19/24 revealed a start of care date of 3/26/18; diagnoses included anoxic brain damage, and schizoaffective disorder. POC orders included skilled nursing (SN) visits three times a day for assessment and evaluation of gastrointestinal and depression and medication administration; and Certified nursing aide (CNA) visits two times a day for assistance with activities of daily living (ADL), bathing, hair care, mouth care, dressing, nail filing, perineal care, applying lotion, ambulation, and repositioning. a) The agency failed to have physician orders for all services provided to Patient #7 from 8/21/24 to 8/26/24. Review of Patient #7's clinical record revealed physician order form dated 8/9/24. The order requested that all current orders be continued for the upcoming certification period of 8/21/24 to 10/19/24. The request form also stated the physician would be sent a copy of the POC for review and signature. RN #6 signed the form on 8/9/24. There was no signature from the physician of Patient #7. During an interview on 10/23/24 at 2:21 p.m., the director of nursing (DON) and alternate administrator stated the agency sends out continuation of care orders before the start of the certification period to have orders to continue care until the physician signs the POC. The DON and alternate administrator reviewed the unsigned physician order form and agreed the physician had not signed the order. The DON also stated the agency did not receive verbal orders for this certification period. Review of the POC for the certification period 8/21/24 to 10/19/24 revealed the physician did not sign it until 8/26/24. Since the agency failed to receive written orders to continue care until the POC was signed and failed to receive verbal orders, all SN and CNA services provided for the period between 8/21/24 and 8/26/24 were done without physician orders.

A Re-certification survey was completed on 11/10/21. One deficiency was 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 interview and record review, the agency failed to ensure clinical records contained accurate documentation of patient's clinical notes for 1 of 5 active patient records reviewed (Patient #4). Findings include: AGENCY POLICY According to agency policy titled, "Nursing services", dated 2/21 (in pertinent parts); "Professional nursing services will be provided by a registered nurse and include: -Preparing clinical and progress notes -Evaluating the effectiveness and outcomes of care" According to agency policy titled, "Skilled Professional services", dated 2/21 (in pertinent parts); "Skilled professionals must assume responsibility for, but not restricted to the following: -Providing services that are ordered by the physician/practitioner as indicated in the plan of care. - Preparing clinical notes. According to agency policy titled, " Medical Record entries and Authentication", dated 3/18 (in pertinent parts); "All entries in the medical records will be authenticated by staff signature and title. By authenticating entries in the patient's record, staff is validating the correctness of the information." 1. The clinical record for Patient #4 was reviewed on 11/9/21. The Plan of Care for the certification periods dated 8/11/21 to 10/9/21 and 10/10/21 to 12/8/21 revealed a start of care date of 12/20/19; diagnoses included multiple sclerosis, essential hypertension, hypovolemia, and pain in right and left shoulders. The plan of care orders included skilled nursing (SN) visits once a week for nine weeks, for cardiovascular assessment, disease process education, medication management and oxygen saturation monitoring. a) The agency failed to ensure the SN documented Patient #4's medical necessity accurately in the clinical notes. Review of the SN visit note dated 8/20/21 showed the registered nurse (RN #9) documented under the section titled Medical Necessity of Care "skilled intervention of physical therapy for exercises to increase strength and endurance, implementation of safety measure and evaluation of assistive devices due to impaired function or declining functional ability as demonstrated by increased weakness and skilled intervention of occupational therapy for exercises to increase strength and endurance, implementation of safety measures and evaluation for assistive devices due to impaired function or declining functional ability to perform ADL/IADLs." Further review of the SN visit notes dated, 8/27/21, 9/4/21, 9/10/21, 9/17/21, 9/24/21, 10/1/21, 10/15/21, 10/22/21, 10/29/21 and 11/5/21 also completed by RN #9 revealed that the same medical necessity of care statements had been copied over without being reviewed or changed, a lapse of approximately two months since the start of the certification period on 8/11/21. Review of the visit calendar for Patient #4 for certification periods 8/11/21 to 10/9/21 and 10/10/21 to 12/8/21 revealed Patient #4 had not received Physical therapy (PT) or Occupational therapy (OT) services from 8/7/21 to 11/6/21. Review of the plan of care dated 8/11/21 and signed by the physician 8/12/21 failed to reveal orders for PT or OT services. Further review of the clinical record failed to reveal any documentation of PT or OT services. During an interview on 11/9/21 at 1:51 p.m., RN #9 stated he was not aware of what he had documented. He stated he must have just clicked some buttons. During an interview on 11/9/21 at 1:59 p.m., RN #4 stated, the medical necessity section carried over automatically to all visit notes. However, RN #4 confirmed the nurse was able to make a change. RN #4 stated this was taught to all clinicians during their orientation.