Every finding on record at Inswan Home Health Agency, Ltd

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 09/21/23. The Agency was in compliance with the Condition, 42 CFR 484.22, Establishment of the Emergency Program for this survey.

Recertification survey completed. Standard Level deficiencies cited. Abbreviations: # = number AM = morning PM = afternoon MD = Medical Doctor PT = Physical Therapy/Therapist OT = Occupational Therapy/ Therapist mg/dl = milligrams per deciliter OASIS = Outcome and Assessment Information Set

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 record reviews and interviews it was determined the Agency failed to ensure that Physician’s orders were followed for 3 of 7 (Patients #1, 3 and 7) clinical records reviewed. 2. Patient #3, was admitted to the home health agency on 07/24/23. Diagnosis: Malignant Neoplasm of Mouth, Unspecified. The clinical record was reviewed on 09/19/23. The Physician orders dated 07/24/23 included orders for the PT to provide care for the Patient, 1 time a week for 1 week, 2 times week for 2 weeks and 1 time a week for 6 weeks. The PT failed to provide the care 2 times a week during the week of 07/30/23 (week #2) as ordered by the Physician. The PT also failed to provide the care 1 time a week during the week of 09/03/23 (week #7) as ordered by the Physician. The Physician orders dated 07/24/23 also included orders for the OT to provide care for the Patient 1 time a week for 1 week, 2 times week for 2 weeks and 1 time a week for 1 week. The OT failed to provide the care 2 times a week during the week of 08/06/23 (week #3) as ordered by the Physician. The OT also failed to provide the care 1 time a week during the week of 08/20/23 (week #5) as ordered by the Physician. 3. Patient #7, was admitted to the home health agency on 07/25/23. Diagnosis: Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 09/19/23. The Physician orders dated 07/25/23 included orders for the PT to provide care for the Patient 2 times week for 2 weeks and 1 time a week for 3 weeks. The PT provided care 1 time a week for the week of 07/30/23 (week #2). The PT failed to provide the care 2 times a week during week #2 as ordered by the Physician. The Physician orders dated 07/24/23 also included orders for the OT to provide care for the Patient 1 time a week for 5 weeks. The OT failed to provide the care 1 time a week during week #3 and week #5 as ordered by the Physician. 4. The findings were confirmed with the Administrator and Director of Nursing, on 09/20/23 between 9:30 AM and 11:30 AM. Findings include: 1. Patient #1 was admitted for skilled home health services on 09/01/23 with the Principal Diagnosis of Type 1 Diabetes Mellitus with Diabetic Kidney Disease. The clinical record was reviewed on 09/19/23. The clinical record included a Plan of Care for the period of 09/01/23 to 10/30/23 requiring: “Interventions: Skilled Nurse to monitor vital signs and notify MD if…Fasting blood sugar greater than 250 mg/dl or less than 60 mg/dl. Random blood sugar greater than 300 mg/dl or less than 60 mg/dl.” Patient #1’s Skilled Nursing Visit Note dated 09/07/23 included a documentation of a blood sugar result of 354 mg/dl. The clinical record lacked documentation of MD notification or the reason why the physician was not notified of the blood sugar result which was not within the normal range.

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 a review of clinical records, home visit and staff interviews, policy review, and therapy contract review, it was determined the Agency failed to ensure that clinical records included all clinical assessments. This was found in 2 of 7 (Patients #1 and 7) clinical records reviewed. 2. Patient #7, was admitted to the home health agency on 07/25/23. Diagnosis: Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 09/19/23. The record included a discharge OASIS dated 08/29/23 that lacked the summary of care. On 09/20/23, during the interview with the Director of Nursing, it was stated the PT note dated 09/08/23 (10 days after the discharge) titled “Physical Therapy Discharge Summary” was with the contracted Agency, instead of the clinical records. 3. The Agency’s policy titled “Timely Submission of Patient Documentation” was reviewed on 09/20/23 at 11:20 AM. The policy included “…PROCEDURE: …All visit notes must be entered inside EMR within 7 business days. All patient visit reports from contracted personnel must be submitted within seven (7) business days from the date of the visit…” 4. The findings were confirmed with the Administrator and Director of Nursing, on 09/20/23 between 9:30 AM and 11:30 AM. Findings include: 1. Patient #1 was admitted for skilled home health services on 09/01/23 with the Principal Diagnosis of Type 1 Diabetes Mellitus with Diabetic Kidney Disease. During a home visit conducted with the Registered Nurse on 09/18/23, Patient #1 stated the OT conducted a skilled home visit. The OT visit was conducted on 09/15/23. As of 09/20/23, the clinical record reviewed lacked documentation of the OT assessment.