Every finding on record at Mederi Caretenders

A recertification survey was completed on 5/26/2021 to 5/27/2021 at Mederi Caretenders. The agency was not in compliance with the Code of Federal Regulations (CFR) 42, Part 484, Condition of Participation for Home Health Agencies.

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 interviews, record and policy reviews the agency failed to follow physician orders to provide nursing services for 1 (#15) patient out of 16 records sampled. Findings included: A review of the agency policy titled Plan of Care (PCOI)e with an effective date of 5/04/1999 with a revision date of 1/01/2021. “Purpose: to share an appropriate POC is developed and revised in a timely manner for each patient to ensure the physicians orders are followed. Policy: each patient has an individualized POC developed in consultation with the patient, physician, and staff that integrates comprehensive assessment findings to address patient problems, needs, and goals, as well as to address specific services being provided. 3. The qualified clinician develops and revises the POC under the direction of the physician. The POC is established prior to providing services. 6. 8. Alterations in the POC are made only with the physician’s approval. 13. Staff reviews the patients chart periodically to ensure compliance with physicians orders.” A review of the medical record for patient #15 revealed an admission date of 4/17/2020 with a certification period of 4/17/202 to 6/15/2020 with pertinent diagnoses of Radiculopathy Cervical Region, pain in right and left knee. The physician ordered POC listed for Frequency/Duration of Visits: SN (skilled nursing) Effective 4/19/2020 1wk1. A review of the medical record for patient #15 revealed there were no nursing visit notes or nursing assessments completed for patient #15. A review of the physician supplemental orders revealed there no documentation of communication to the physician or a physician order to change the patient plan of care to remove the orders for SN from the POC. A copy of the patient client visit report provided by the Business Office Manager reflected no nursing visit was scheduled or one verified as conducted. An interview was conducted on 5/27/2021 at 11:51 a.m., the Agency Administrator said, “I do not see that a visit by a nurse was made on 4/19/2020 or that the physician was notified. If something changed, we should have notified the physician.” TEST

Supervision of home health aides CFR(s): 484.80(h) Standard: Supervision of home health aides. This STANDARD is not met as evidenced by: Based on interviews and record reviews the agency failed to conduct on-site home health aide supervisory visits every 14 days for 2 ( #6, #7) patients out of 2 with aide services ordered out of 16 records sampled. Findings included: A review of the medical record for patient #6 reflected an admission date of 12/20/2020 and a current certification period of 4/19/2021 to 6/17/2021 with pertinent diagnoses of cellulitis of the right lower limb, Type 2 Diabetes, Other Acute Osteomyelitis right ankle and foot, dementia, and a history of falling. Documented on the physician-ordered plan of care (POC) for 4/19/2021 to 6/17/2021 under Frequency/Duration of Visits: HHA (home health aide) Effective 5/02/2021 1wk 7. Home health aide service for assistance with personal care and ADL’s (activities of daily living) secondary to functions limitations which prevent self-care with a goal that the patient will exhibit the optimum level of personal hygiene during illness / Patient ill have safe and effective personal hygiene this episode. A review of the visit notes reflected a visit a Registered Nurse (RN) aide supervisory was made on 4/08/2021. An aide home health visit was made on 4/09/2021. The next RN aide supervisory visit was made again on 5/05/2021. An interview was conducted on 5/27/2021 at 12:20 p.m., the Agency Administrator reviewed the home health aide and nursing visits in the medical record for patient #6 and confirmed that an RN nursing onsite supervisory visit should have been made before or on 4/22/2021. “Yes, I do not see another RN supervisor visit until 5/05/2021. We missed it.” A review of the medical record for patient #7 reflected an admission date of 4/03/3021 with a current physician ordered POC dated 4/03/2021 to 6/01/2021 with a pertinent diagnosis of Paraplegia. A physician supplemental order dated 4/13/2021 with orders to add the services of a home health aide for ADL assistance effective 4/11/2021 for 2 visits a week for 7 weeks. A review of the home health aide visit notes revealed the first home health aide visit was dated 4/14/2021. The first on-site Registered Nurse visit for supervision of the HHA was conducted on 5/17/2021. An interview was conducted on 5/27/2021 at 12:25 p.m., the Agency Administrator reviewed the home health aide and nursing visits in the medical record and confirmed that an RN nursing onsite supervisory visit should have been made before or on 4/28/2021. “It looks like the nursing visit frequency changed. We just missed it. I expect that we follow the regulations, and an onsite RN aide supervisory visit should be done every 14 days at a minimum.” A request for an agency policy for conducting on-site home health aide visits was requested. On 5/27/2021 at 12:30 p.m., the Agency Administrator said she could not find a policy for home health aide supervisor visits. “ Our policy would be to follow Medicare regulations.” TEST