Every finding on record at Good Living Homecare LLC

Purpose: Recertification Survey Entrance Date: 10/11/2022 Census: Licensed and Certified - 1 The agency was in compliance with 42 CFR Part 484.22, Emergency Preparedness Requirements for Home Health Agencies.

Purpose: Recertification Survey Entrance Date: 10/11/2022 Census: Licensed and Certified - 1

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure authentication of verbal orders received by the agency's nurses from the physician in 2 (Patient #2, Patient #3) of 3 discharged clinical records reviewed. The failure placed patients at risk that provided care would not be appropriate and result in negative outcomes. Patient #2: Record review of Patient #2's clinical record revealed a Plan of Care that was dated 3/20/2021 to 5/18/2021. The Plan of Care indicated Patient #2 started on the agency's services on 1/19/2021. The Director of Nursing electronically signed that the Plan of Care. The Director of Nursing documented on the Plan of Care that the verbal start of care was received from the physician on 3/19/2021. The physician had not signed the Plan of Care as of 10/11/2022, 19 months after the Director of Nurses received the verbal order from the physician. Patient #3: Record review of Patient #3's clinical record revealed a Plan of Care dated 2/14/2021 to 4/14/2021. The Plan of Care indicated that Patient #3 started on the agency's services on 12/16/2020. The Director of Nursing electronically signed the Plan of Care. The Director of Nursing documented on the Plan of Care that the verbal start of care was received from the physician on 2/10/2021. The physician had not signed the Plan of Care as of 10/11/2022, 20 months after the Director of Nurses received the verbal order from the physician. The agency had been given an opportunity to present signed physician orders for Client #2 and Client #3. The agency was unable to provide the signed physician orders. During an interview on 10/12/2022 at approximately 10:31 a.m. with the Director of Nurses, the surveyor discussed and asked questions that Patient #2 and Patient #3's Plans of Care were not signed by their physicians. The surveyor asked whether the agency had found signed physician orders. The Director of Nursing responded, "No." The Director of Nursing did not dispute that the Plans of Care had not been signed by the physicians. The Director of Nursing informed the surveyor that the agency had not billed for the services provided to Patients #2 and #3. The Director of Nursing stated that Patient #3 was a Veterans Administration patient and the physician "did not have a payor code." The agency had a policy titled, "5.6 Orders for Care" with a revision date of 11/13/2017. The policy read in part; "The agency will obtain orders and provide care in accordance with physician's orders which are established prior to initiating care and reviewed/revised by the physician every 60 days and as needed...The original order is sent/faxed to the physician for signature, and a copy is retained in the patient's medical record and/or file. Agency may utilize faxed physician orders (POC [Plan of Care] and Verbal as originals...Physician signatures are obtained on 485s and supplemental verbal orders within 30 days..." The agency had a policy titled, "8.10 Timelines" with a revision date of 11/13/2017. The policy read in part; "The Agency will ensure timely provision of care and services to meet the patient's needs in compliance with all federal and state laws and regulations. Agency will also establish timely parameters for all medical record information....Supplemental Verbal Orders may be obtained before care is provided and written within 24 hours of receiving the orders. The Plan of Care may be used as the verbal start of care when signed and dated by the RN [Registered Nurse]…"