Every finding on record at Pacific Home Care Associates, Inc

An unannounced Federal recertification survey was completed at this agency on 8/22/2023. The agency was surveyed for compliance with 42 CFR Conditions of Participation for Home Health Agencies, Part 484.102 Emergency Preparedness. An entrance conference was held with the Director of Patient Care on 8/15/2023 at 10:15 AM. The purpose of the survey and the survey needs were explained. An opportunity was provided for questions, answers and comments. Definitions and abbreviations: CFR - Code of Federal Regulations

An unannounced Federal recertification survey was completed at this agency on 8/22/2023. The agency was surveyed for compliance with 42 CFR Conditions of Participation for Home Health Agencies, Part 484. An entrance conference was held with the Director of Patient Care on 8/15/2023 at 10:15 AM. The purpose of the survey and the survey needs were explained. An opportunity was provided for questions, answers and comments. Definitions and abbreviations: CFR - Code of Federal Regulations CMS - Centers for Medicare and Medicaid Services DPC - Director of Patient Care HHA - Home Health Aide MSW - Medical Social Worker PT - Physical Therapist SN - Skilled Nurse

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 interview and medical record review, it was determined the agency failed to ensure the services ordered by the physician were provided for 1 of 7 patient records reviewed (Patient #4). Findings: Review of the medical record for Patient #4 with a start of care date of 05/09/2023 revealed a document titled, "Home Health Certification and Plan of Care" for the certification period from: 05/09/2023 to 07/07/2023. A section in this document listed "Orders and treatments: SN ... PT ... MSW ... HHA ... " It was determined that documentation failed to reflect services were provided to the patient by the MSW as ordered by the physician. During an interview with the Director of Patient Care (DPC) on 08/21/2023 at 3:30 PM, the above finding was presented. The DPC was given an opportunity to provide information regarding the lack of documentation of a MSW providing service. The DPC was unable to provide documentation and acknowledged the finding with, "I am sorry, but it looks like it wasn't done."