Every finding on record at HME Hlth Dept Willis Knighton

Complaint Survey # LA116847

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record reviews and interview the provider failed to ensure the doctor was notified the patient was no longer receiving services for 1 (Patient #1) of 3 patients (Patient#1, Patient #2, and Patient #3) reviewed. Findings: Review of the facility Clinical Record policy dated 03/2025 revealed in part: 3. Admission Policy c. Acceptance of Referrals 9) If patient does not meet admission criteria, the physician will be informed as to non- eligibility and non-admit reason will be filed in the Homecare Documentation system. Review of Patient #1’s medical record revealed referral from a nursing home rehab on 06/25/2025 for nursing and physical therapy services. Further review of Patient #1’s medical record revealed documentation services were refused by Patient #1’s family upon their refusal to complete admission paperwork. Patient #1’s record failed to reveal Patient #1’s physician was notified of the non-admission to services due to refusal to complete admission paperwork. During an interview on 7/14/25 at 11:42 a.m. S1 Registered Nurse/Compliance Officer confirmed Patient #1’s physician was not notified of non-admission to home health services due to refusal to complete admission paperwork and should have been.

Home Health Department of Willis Knighton is in compliance with federal emergency preparedness requirements.

Recertification Survey

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 provider failed to ensure a patient’s plan of care was reviewed and signed by a physician according to the provider’s policy for 1 (#1) of 17 patients reviewed. Findings: Review of the provider’s Clinical Record policy with a revision date of 06/2022 revealed the following: a. Plan of Care (485) must be completed, signed, dated, and counter-signed by the physician and placed in the medical record within 30 days of admission and recertification. Review of patient #1’s Plan of Care (485) revealed patient #1 had an admission/start of care date of 02/08/2024 for the certification period of 02/08/2024 to 04/07/2024 with a primary diagnosis of urinary tract infection and an encounter for fitting and adjustment of urinary device. Further review of patient #1’s Plan of Care (485) revealed it was not signed by the physician until 04/15/2024. During an interview on 04/17/2024 at 10:42 a.m. S1 RN, Regulatory Coordinator confirmed patient #1’s Plan of Care (485) was not signed by a physician within 30 days of admission and should have been.