Every finding on record at Nursecore of Ocala

An unannounced Recertification survey was conducted on 6/3/2022 at Nursecore of Ocala. Nursecore of Ocala was found not to be in compliance with requirements 42 CFR 484 Sub part A-C for this survey.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency failed to communicate with the physician involved in the patients’ plan of care of a missed skilled nurse visit for 1 of 7 sampled patients. Patient # 4. Findings: Patient # 4 was admitted with start of care on 11/22/2021 Diagnoses: Familial Hypogammaglobulinemia Period Reviewed: 1/21/2022 - 3/21/2022 Review of the plan of care , certification period starting on 1/21/2022 to 3/21/2022 revealed the following physicians' orders: Benadryl 50 mg. IV give 30 minutes prior to administration of Privigen. Privigen intravenous solution 20 grams 300 ml. 1 times every month (IVIG). Acetaminophen ER oral tablet 650 mg. 30 minutes prior to mediation. Solumedrol 12.5 mg. IV 30 minutes prior to infusion pre-medication administration. SN 2 hours monthly- IVIG IV Infusion every 4 weeks as ordered. Record review revealed the Patient # 4 had a missed skilled nurse visit for the month of February 1- 28, 2022. Interview with the Clinical Director (CD) on 6/3/2022 at 10:22 AM stated and confirmed the missed skilled nurse (SN) visit in February 2022. CD stated, "we did not have a nurse, the regular nurse was out, and patient did not want another nurse". When asked for documentation of the missed SN visit, CD replied, "we did not document it". Review of clinical notes dated 2/7/2022 reads: Patient complained of headache, fever, flu-like symptoms, scheduled IVIG infusion was cancelled due to patient testing positive for COVID-19. Patient stated physician is aware. No medications were ordered. Will follow up in a couple of weeks to reschedule infusion. CD interview on 6/3/2022 at 1:46 PM confirmed nurse failed to follow up to schedule the infusion. Unable to reach the primary nurse for interview. When asked whether the physician was notified of the missed visit, CD stated, "yes, but no documentation that physician was notified of the missed SN visit". Review of the Administrative Policy Manual for Monitoring Patient / Client Care / Coordination of Care with revision date of 1/2020. Page 1 of 1 of the policy reads: Purpose: To ensure coordination of patient / client care and treatment. Policy: I. Nurscore will monitor, evaluate, and report to the patient's / client's physician regarding the patients progress toward achieving goals established on the plan of care. Procedure: 1. Nursecore will A. Assure communication with all physicians involved in the plan of care. B. Integrate orders from all physicians involved in the plan of care to assure the coordination of all services and interventions provided to the patient / client.