Every finding on record at Preferred Mobile Nurses Inc

A recertification and COVID-19 infection control survey were conducted on 1/6/21. One deficiency was cited.

Contents of clinical record CFR(s): 484.110(a) Standard: Contents of clinical record. The record must include: This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure clinical records contained accurate and complete documentation of pertinent past and current findings in accordance with accepted professional standards for 2 of 5 active patient records reviewed (Patients #1 and #5). Findings include: AGENCY POLICY According to the policy, Content of the Clinical Record, revised on 3/4/20, "[Agency Name] will ensure that a completed clinical record will be kept on each client receiving care/service and will contain pertinent past and current findings in accordance with accepted professional standards and State of Colorado Home Care Agency Regulations Section 6.20 and shall be maintained for every client receiving home health agency services. This record will demonstrate what [Agency Name] actually provides to the client as well as the outcomes of the care/service. 1. During an interview on 1/4/21 at approximately 10:15 a.m., the Administrator stated she reviewed all Outcome and Assessment Information Set (OASIS) documentation submitted by clinicians and Employee #2, who is both the Alternate Administrator and the Assistant Director of Clinical Services (ADCS) reviewed all plan of care documentation submitted by the clinicians. She further stated the ADCS clarified the plans of care with the clinicians prior to sending the plan of care to the physician for review and approval. 2. The clinical record for Patient #5 was reviewed on 1/5/21. The Plan of Care for the certification period dated 10/29/20 to 12/27/20 revealed a start of care date of 10/29/20; diagnoses included hypertension, asthma, hearing loss, aphasia, hypo-osmality and hyponatremia, abdominal aortic aneurysm, sleep apnea, cataracts, osteoarthritis, benign neoplasm of the prostate, hypercholesterolemia, and weakness. Plan of Care orders included skilled nurse (SN) visits once once weekly for nine weeks and two times as needed (PRN) for skilled assessment and medication management; Physical Therapy (PT) visits once weekly for one week and twice weekly for nine weeks; Occupational Therapy (OT) visits once weekly for one week and twice weekly for nine weeks; Speech Therapy (ST) visits once weekly for nine weeks; and (certified nurse aide) CNA visits once weekly for for one week twice weekly for seven weeks for assistance with bathing and personal care. a) The agency failed to ensure the plan of care reflected accurate frequencies and durations for services provided. Review of the plan of care for the certification period dated 10/29/20 to 12/27/20 showed Patient #1 was to receive PT and OT visits once weekly for one week and twice weekly for nine weeks beginning on 10/30/20, a total of 10 weeks; ST visits once weekly for nine weeks, beginning on 11/4/20; and CNA visits once weekly for one week and twice weekly for seven weeks, a total of eight weeks, beginning on 11/9/20. However, clinical record review revealed between 10/29/20 and 12/27/20, Patient #1 received PT and OT visits for nine weeks, ST visits for eight weeks, and CNA visits for seven weeks. Additionally, review of the frequency calendar between 10/30/20 and 12/27/20 showed only nine weeks were available for PT and OT services, rather than the 10 weeks documented on the plan of care. Continued review of the frequency calendar between 11/4/20 and 12/27/20 showed only eight weeks were available for ST services, rather than the nine weeks documented on the plan of care. Further review of the frequency calendar between 11/9/20 and 12/27/20 showed only seven weeks were available for CNA services, rather than the eight weeks documented on the plan of care. During an interview on 1/6/20 at 10:16 a.m., the Administrator stated the electronic medical record (EMR) system was responsible for calculating the appropriate duration for the individual disciplines after the clinicians inputted their desired frequency. She stated she was unsure why the plans of care had one additional week per discipline listed on them and she would need to research the issue further. 3. The clinical record for Patient #1 was reviewed on 1/4/21. The Plan of Care for the certification period dated 10/1/20 to 11/29/20 revealed a start of care date of 10/1/20; diagnoses included venous insufficiency, lymphedema, localized edema, history of falling, chronic pain syndrome, restless leg syndrome, polyosteoarthritis, cerebral palsy, epilepsy and muscle weakness. Plan of Care orders included SN visits once every 60 days and three times PRN for signs and symptoms of complications and to complete supervision of the CNA every 60 days and as needed and CNA visits twice weekly for two weeks and five times weekly for nine weeks for assistance with ambulation, bathing, and personal care. a) The agency failed to ensure the plan of care reflected accurate frequencies and durations for services provided. Review of the plan of care for the certification period 10/1/20 to 11/29/20 showed Patient #1 was to receive CNA visits twice weekly for two weeks and five times weekly for 9 weeks, a total of 11 weeks. However, clinical record review of the completed CNA Revisit Notes from 10/1/20 to 11/29/20 revealed Patient #1 received CNA services for nine weeks. Additionally, review of the frequency calendar between 10/1/20 and 11/29/20 showed only nine weeks were available for CNA services, rather than the 11 weeks documented on the plan of care. 4. During an interview on 1/6/20 at approximately 11:30 a.m., the Administrator stated following discussion with the surveyor regarding the incorrect duration on the plans of care, she looked into the frequency and duration issue in the EMR and stated she had discovered some issues within the EMR that would need to be addressed. During an interview on 1/6/20 at 11:39 a.m., the ADCS confirmed she reviewed all plans of care for completion prior to sending them to the physician for approval. She stated she reviewed areas including risk of hospitalization, advanced directives, medications, diagnoses, written clinician summaries, goals, and services ordered. She stated she did not check to ensure frequencies and durations were accurate as she relied on the EMR to indicate if a requested frequency could not be satisfied within the available duration in the certification period. She continued to state she had spoken with the Administrator and they were unsure why the EMR was allowing the duration to include an additional week that could not be completed during the time frame of the certification period. She further stated going forward, she would manually review the frequency and duration of all services to ensure they were documented appropriately on the plans of care.