Every finding on record at Presbyterian Seniorcare at Home, Inc

Based on the findings of an on site unannounced state relicensure and Medicare recertification survey completed on September 2, 2022, Presbyterian Seniorcare at Home, Inc. was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.

Based on the findings of an on site unannounced state relicensure and Medicare recertification survey completed on September 2, 2022, Presbyterian Seniorcare at Home, Inc. was found not to be in compliance with the following requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on review of clinical records (CR), agency policies, home visit observation (OBS), and staff interview, the agency failed to ensure the Plan of Care (POC) contained patient-specific interventions related to measurable outcomes identified by the agency for three (3) of thirteen (13) clinical records reviewed (CR1, CR8, CR9); and failed to ensure the plan of care contained all medications for two (2) of thirteen (13) clinical records reviewed (CR1, CR2). Findings included: Review of agency policies on 9/2/22 at approximately 1:00 PM revealed the following: “…Policy # C-6.0 Administration of Medications and Therapies…2. A. All prescription medication, over-the-counter medications…are to be reviewed each visit…E. Medications are accurately and completely reconciled across the continuum of care…v. The written list of reconciled medications is reviewed every visit and updated with changes…” During Observations of an Occupational Therapist home visit to residence of CR1 on 8/30/22 at approximately 9:40 AM, the patient's (CR1) home "Medication Profile" list was reviewed and compared to agency's most recent medication list for CR1. CR1 home "Medication Profile" contained the following medications that were not listed on the agency Plan of Care medication list for patient CR1: “Metformin ER 500 mg (milligram) tablet, Aspirin 81 mg tablet, and Alendronate 70 mg tablet.” During Observations of a Physical Therapist home visit to residence of CR2 on 8/30/22 at approximately 11:50 AM, the patient's (CR2) home "Medication Profile" list was reviewed and compared to agency's most recent medication list for CR2. CR2 home "Medication Profile" contained the following medication that was not listed on the agency Plan of Care medication list for patient CR2: “Pravastatin 20 mg tablet.” Review of agency policies on 9/2/22 at approximately 1:00 PM revealed the following: “…Policy # C-2.0 Acceptance of patients, Plan of Care, and medical Supervision…2. Plan of Care…care follows a written plan of care established and periodically reviewed…A. The plan of care is established by the appropriate agency staff after consultation with the physician…B. the plan of care includes:. All patient care orders…all…treatments…4. Case Management, Review of Patient Care Plans…Plan of Care shall include…Patient-specific interventions and education…” CR1, Start of Care (SOC): 8/19/22, certification period: 8/19/22 – 10/17/22. Plan of Care (POC) physician orders: “…Orders and Treatments…Notify Physician of:. Fasting blood sugar greater than (>) 200 or less than () 250 or less than () 200 or less than () 250 or less than () 200 or less than () 250 or less than (<) 70…” There were no documented interventions/assessments established in the POC for the monitoring of the patient blood sugar parameters as noted above. An exit conference was conducted 9/2/22 at approximately 2:15 PM with the agency administrator (EMP1) and Clinical manager (EMP2). The above findings were reviewed.

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 review of clinical records (CR), agency policies, and staff interview, the agency failed to follow the physician's ordered plan of care for one (1) of thirteen (13) clinical records reviewed (CR10). Findings included: Review of agency policies on 9/2/22 at approximately 1:00 PM revealed the following: “…Policy # C-2.0 Acceptance of patients, Plan of Care, and medical Supervision…2. Plan of Care…care follows a written plan of care established and periodically reviewed…A. The plan of care is established by the appropriate agency staff after consultation with the physician…B. the plan of care includes:. All patient care orders…all…treatments…3. Conformance with Physician Orders…C. Drugs and treatments are administered by agency staff only as directed by the physician…4. Case Management, Review of Patient Care Plans…Plan of Care shall include…treatments required…” CR10, Start of Care (SOC): 8/17/22, certification period: 8/17/22 – 10/15/22. Plan of Care (POC) physician orders: “…Orders and Treatments… SN (skilled nurse) 2W7 (visits two times a week, effective 8/30/22)…Clinicians to assess/monitor weights and edema QV (every visit) or Q week…Report to MD or clinician weight gain of 3 lbs (pounds) in 1 day, or gain 5 lbs in 1 week…” There were no patient weights documented for the SN visits during the treatment week of 8/28/22 for the SN visits conducted on 8/30/22 and 9/2/22. An exit conference was conducted 9/2/22 at approximately 2:15 PM with the agency administrator (EMP1) and Clinical manager (EMP2). The above findings were reviewed.