Every finding on record at Kinesis Home Health Care LLC

An Entrance Conference was conducted on 5/11/2023 at 9:40 a.m. with the Administrator/ Supervising Nurse and the Office Manager. The agency representatives were informed that the purpose of the visit was a recertification survey. The agency census was: Round Rock (Parent): Licensed &Certified Home Health Services- 23 Licensed Home Health Services-0 Personal Assistance Services-0 An Exit conference was conducted on 5/16/2023 at 12:25. p.m. with the Administrator, Alternate Administrator and Office Manager. The agency representatives were informed the agency was in substantial compliance with no deficiencies cited.

An Entrance Conference was conducted on 5/11/2023 at 9:40 a.m. with the Administrator/ Supervising Nurse and the Office Manager. The agency representatives were informed that the purpose of the visit was a recertification survey. The agency census was: Round Rock (Parent): Licensed &Certified Home Health Services- 23 Licensed Home Health Services-0 Personal Assistance Services-0 An Exit conference was conducted on 5/16/2023 at 12:25. p.m. with the Administrator, Alternate Administrator and Office Manager. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of receiving the Statement of Deficiencies. Abbreviations: SN- Skilled Nursing PT- Physical Therapy OT- Occupational Therapy COTA- Certified Occupational Therapy Assistant ST or SLP- Speech Therapy SW- Social Worker Adm- Administrator Alt Adm- Alternate Administrator SVN- Supervising Nurse EMR- Electronic Medical Record QOW- Every other week w- week QAPI- Quality Assessment and Performance Improvement

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on record review, observation and interview the agency failed to ensure that all patient care orders, including verbal orders, were recorded in the plan of care/ client record in 2 of 8 records reviewed (Patient #2 and #3). This failure has the potential that the clinical record would not have the most recent orders received from the physician and had the potential to result in an interruption of care or confusion as to what services should be provided. Findings: 1. Review of the agency Policy and Procedure Manual revealed a policy entitled “2.25 Physician Responsibilities. The policy read in part: “5. The agency will send to the physician written orders and request their prompt return so that they are signed and dated by the physician and in the patient/ client’s chart within thirty days…Verbal/ Telephone Orders: Procedure: 1. Directly after receiving a verbal/ telephone order from an attending physician, the licensed staff person will complete a Physician Order form stating the order as received, this form must include the time, date and signature of qualified person receiving the order.” 2. Review of the clinical record for patient #2 for the period of 3/3/2023 to 5/1/2023 revealed the following orders which read in part: Plan of Care dated 3/3/2023 to 5/1/2023, “Orders for Service: SN (Skilled Nursing) 1w1 (one time a week for one week), 3w1 (three times a week for one week), 2w3 (two times a week for three weeks), 1w4 (one time a week for four weeks).” Physician Order dated 3/17/2023, “late entry from 3/3/2023. SN to perform wound care 1w1 (one time a week for one week), 3w1 (three times a week for one week), 2w3 (two times a week for 3 weeks) then re-eval.” Physician Order dated 3/28/2023, “SN to perform wound care 3w2 (three times a week for two weeks) then re-eval.” Review of the clinical record revealed services were provided by SN on 4/19/2023 and 4/26/2023 with no order for skilled nursing services. During an interview with the Adm/SVN on 5/11/2023 at 1:53 p.m., this surveyor informed the Adm/ SVN that I did not see an order that continued care for the weeks of 4/16/2023 and 4/23/2023. The Adm/ SVN stated “we are still seeing her, I am behind on my orders.” Adm/ SVN stated she received a verbal order to continue care but had not yet written the order. On 5/15/2023 this surveyor was provided a copy of a Physician Order dated 5/11/2023 which read in part: “Late entry from 3/28/2023…it should read 3/27/2023: 2w5 (two times a week for 5 weeks).” The order was signed by the physician on 5/15/2023. 3. Review of the clinical record of patient #3 for the period of 3/12/2023 to 5/10/2023 revealed a Plan of Care which read in part: “SN effective w of 3/8/2023 1w1 (one time a week for one week), then QOW 8 (every other week for 8 weeks). PT effective w of 3/12/2023: 1w8 (one time a week for eight weeks).” During a home visit with patient #3 on 5/15/2023 at 11:30 a.m. the home chart was reviewed. The home chart contained documentation for visits from Occupational Therapy on 3/25/2023, 4/5/2023, 4/7/2023, 4/12/2023, 4/14/2023, 4/27/2023, 4/29/2023, 5/1/2023 and 5/3/2023. Review of the clinical record for patient #3 revealed OT evaluations on 3/25/2023, 4/18/2023 and 5/10/2023 and COTA visits on 3/31/2023, 4/5/2023, 4/7/2023, 4/12/2023, 4/14/2023 4/27/2023, 4/29/2023, 5/1/2023 and 5/3/2023. The clinical record did not contain an order for an initial OT evaluation. During an interview with the Alternate Administrator on 5/15/2023 at 3:35 p.m., the Alt Adm was questioned if the agency had received an order for an evaluation by OT that had not yet been uploaded. The Alt Adm stated he had received a verbal order from the physician for the initial OT evaluation but forgot to write the order. On 5/16/2023, the Alt Adm provided this surveyor a physician’s order dated 5/15/2023 which read in part: “Late entry 3/19/2023, OT to eval and treat the week of 3/19/2023. Orders were given by Dr.”