Every finding on record at Princewill Healthcare Services Inc

A re-licensure, re-certification survey was conducted on 2/17/2023. The census was 6. The agency was in substantial compliance with 42 CFR Part 484.102, Emergency Preparedness Requirements for Home Health Agencies.

A re-certification survey was conducted on 2/17/2023. The census was 6. The agency is in substantial compliance with Conditions of Participation for Home Health Agencies.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to assure communication with all physicians involved in the plan of care in 1 of 9 patient records reviewed. Citing Patient #5 in that Patient #5's electronic medical record did not contain documentation that the patient's physician had been notified of the patient's admission to the hospital or to rehab. This failure could place the patient at risk of poor outcomes in that the patient's doctor would not have accurate information as to the condition of the patient. The Findings Include: Review of the electronic medical record of Patient #5 revealed three documents titled "Communication Note." Review of the electronic medical record of Patient #5 revealed three documents titled "Communication Note." The first Communication Note was dated 1/9/2023 and read, in part, [Patient #5’s Family Member], called the office to let us know that [Patient #5] would be hospitalized today and part of tomorrow..." The second Communication Note was dated 1/11/2023 and read, in part, "... [Client #5’s Family Member], informed the office that [Patient #5} is still hospitalized due to seizures. She will contact the office when [Patient #5] is discharged." The third Communication Note was dated 2/3/2023 and read, in part,"... [Patient #’s Family Member] contacted the office today to let us know that [Patient #5] was discharged from the rehab facility on 02/01/2023." Further review of Patient #5's electronic medical record revealed a completed Physician Order dated 1/18/2023. This order read, in part, "...Summary: Recertification Order...Recertify patient for 01/20/2023 to 03/20/2023..." This order was electronically signed by the Administrator/Director of Nursing on1/18/2023. This order was electronically signed by Patient #5's physician on 1/31/2023. There was no documentation regarding Patient #5's admission to hospital or to rehab in the order. Nowhere in Patient #5's electronic medical record was there any documentation that the Patient's physician had been notified of the admission to the hospital or to rehab. An interview with the agency's Administrator/Director of Nursing was conducted on 2/15/2023 at approximately 11:00 a.m. The surveyor reviewed the above findings and inquired as to why the physician had not been notified of the Patient's condition. The Administrator/Director of Nursing stated, "...I got behind. We always fax to the doctor...I don't know why it wasn't done..." The agency's policy titled "Monitoring Patient Care/Coordination Care-Addendum PC.45-TX page 1 of 1 Last Reviewed 030122" read, in part, "...Procedure A. The Agency will ensure the effective exchange of information, reporting, and coordination of patient/client services among: 1. All agency personnel providing care and services...2. The agency and other providers of health care services involved in the care of a patient/client...B Other providers of health care services involved in the care of a patient/client may include a physician..."