Every finding on record at Healthview Home Health & Hospice-Caswell LLC

An unannounced complaint investigation was conducted on 01/11/23. The complaint allegation of quality of care and treatment of services was substantiated. A deficiency to the Medicare Condition of Participation was identified. ABH

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 policy and procedure, clinical record review and staff interview the agency failed to follow the physician’s order regarding skilled nursing and physical therapy visit frequency for 2 of 3 clinical records reviewed (#1 and #3). Findings included: Review of a policy “Plan of Care-CMS #485 and Physician Orders”, revised 3/2018 was received from the interim administrator on 01/11/23 at 2:54 p.m. The policy stated,” …each patient must receive the home health services that are written in an individualized plan of care…”. 1.Patient #1 was admitted on 10/11/22 with diagnoses of quadriplegia (paralysis of all 4 limbs), neuromuscular dysfunction of the bladder, chronic pain syndrome, and pressure ulcer of the buttock. The plan of care 12/10/22 to 02/07/23 had orders for physical therapy 1 time a week for 9 weeks. Review of the physical therapy visits for the dates of 12/16/22, 12/20/22, and 01/06/23 revealed a visit was not conducted the week of 12/26/22. Interview with the interim administrator on 1/11/23 at 2:27 p.m. revealed, “the visit was inadvertently missed and wasn’t documented”. 2. Patient #3 was admitted on 10/22/22 with diagnoses of hypertensive heart disease, heart failure, type 2 diabetes, chronic kidney disease, and copd (chronic obstructive pulmonary disease). The plan of care for 10/22/22 to 12/20/22 had orders for skilled nursing 1 time a week for 9 weeks with 3 as needed visits. Review of the skilling nursing visits for the dates of 10/22/22, 10/28/22, 11/2/22, 11/11/22, 11/22/22, 11/29/22, 12/9/22, and 12/15/22 revealed a visit was not conducted the week of 11/15/22. Interview with the interim administrator on 1/11/23 at 2:33 p.m. revealed, “the nurse thought she documented the missed visit, but didn’t”.