Every finding on record at Redemption Home Health Services Inc

A recertification survey entrance was conducted on 5/25/21 at 10:40 am with the Administrator. Census: L&C-0 LHHS:0 PAS: 0 An exit conference was conducted on 5/27/21 at 3:15 pm with the Administrator. The preliminary findings were discussed. The agency was found to be in compliance with 484.22 Condition of Participation for Home Health Agencies, Appendix Z - Emergency Preparedness Requirements.

A recertification survey entrance was conducted on 5/25/21 at 10:40 am with the Administrator. Census: L&C-0 LHHS:0 PAS: 0 An exit conference was conducted on 5/27/21 at 3:15 pm with the Administrator. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. Acronyms used PT-Physical Therapy OT -Occupational Therapist PAS- Personal Assistance Service L & C - Licensed and Certified LHHS - Licensed Home Health Services SN- Skilled Nurse RN - Registered Nurse POC: Plan of Care

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 record review and interview, the agency failed to provide services and treatments as ordered by the physician for 2 of 7 discharged patients (Patient #4 and #6), whose records were reviewed in that: 1. Physical Therapy (PT) services were not provided to Patients #4 and #6 as ordered by the physician in the written plan of cares. 2. Occupational Therapy (OT) services were not provided to Patient #6 as ordered by the physician in the written plan of care. Failure of the agency to conform with physician orders, could potentially place the patients at risk of harm due to not receiving care as ordered. Findings Include: Patient #4: Record Review of the Plan of Care (POC) for certification period:4/13/19- 6/11/19 digitally signed by Identifier A on 4/18/19 revealed a Start of Care date of 2/12/19. Record review of the POC revealed in part, " ... Primary Diagnosis: Other Alzheimer disease. The orders for discipline and treatments included: SN: 2w1,1W8 (twice a week for 1 week and once a week for 8 weeks); and SN may perform 2 PRN Visits for HTN{Hypertension}, falls, skin breakdown Physical Therapy: PT to consult evaluate and treat SN to notify MD of systolic BP greater than (>) 160 and less than ( 90 or 100 or 95; pulse rate > 110 or 32 or 7 on 1 - 10 Scale, Fasting blood sugar>250 or 300 or ) 160 and less than ( 90 or 100 or 95; pulse rate > 110 or 32 or 7 on 1 - 10 Scale, Fasting blood sugar>250 or 300 or <60....." Record Review of the POC for certification period of 4/13/19 - 6/11/19 was signed by Identifier # 102 on 6/3/19. PT Goals: Patient will demonstrate ability to follow home exercise program by end of period. OT: Patient will demonstrate ability to follow home exercise program by end of certification period. The discharge assessment record was completed on 6/11//19 by Identifier A. Record review did not reveal that the agency provided the patient with PT or OT. Record review revealed that the agency only provided SN Visits to the patient during certification period of 4/13/19 - 6/11/19. Interview Re-- Patient #4 During an interview with the administrator, Identifier A on 5/26/21 at 1:21 pm, the surveyor presented the above findings of why the patient #4 did not receive PT services, the administrator stated, "Physical therapy company said they don't provide coverage for that area." When asked why the agency did not look for an alternate agency to provide therapy to the patient, the administrator stated, "We tried two other therapy companies, they still did not have coverage." The agency did not provide the surveyor with any supporting evidence to show that the agency attempted to find another therapy agency to provide the therapy ordered for the patient. During an interview with the administrator, Identifier A on 5/27/21 at 1:38 pm, the surveyor reviewed the communication note and the physician order with her. The administrator, Identifier A stated, "The doctor did not sign it that is why there is no signature." The surveyor also reviewed the POC for certification period of 4/13/19 - 6/11/19 signed by Identifier #103 on 6/3/19 and 6/4/19 with the order for PT. The administrator stated, "If Plan of Care signed that is an order." The administrator further stated, "Sorry I should have written discharge physical therapy." Interview re -- Patient #6 During an interview with the administrator, Identifier A on 5/27/21 at 1:51 pm, the surveyor presented the above findings and asked if the agency provided patient #6 with PT and OT services. The administrator stated, "No because could not get the client." When asked if the physician was notified of the inability to provide therapy as ordered, the administrator stated that the communication was in the client's chart. She stated, "I had a communication that physical therapy could not get to them to schedule the visit." The administrator reviewed the chart with the surveyor which did not reveal documentation regarding the inability to contact the patient to provide ordered therapies to the patient, or any physician order to discontinue the ordered therapies. When asked if there was a physician order to discontinue the therapies, the Administrator did not provide the surveyor with a physician's order to discharge therapy. Record review of agency's policy titled, 'Plan of Care and Physician Orders' reads in part; " ... 1. Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is establish, periodically reviewed, and sign by a doctor of medicine ..."

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to obtain physician order prior to providing skilled nursing care to 1 of 7 (#1) discharged patients in that: Patient #1 received 3 Skilled Nursing Visits without a physician's order. This failure placed the patient at risk of receiving inadequate and ineffective care. Findings include: Record Review of the POC for certification period 8/18/19 to 10/16/19 completed by Identifier A on 8/22/19 revealed a Start of Care date of 10/22/18. Record review of the POC revealed in part, " ... Primary Diagnosis: Type 2 Diabetes mellitus with Diabetic Polyneuropathy The orders for discipline and treatments included: SN: 2w1,1w8, and (twice a week for 1 week and once a week for 8 weeks);and SN may perform 1-3 PRN Visits for falls, high or low B/P,B/S{Blood Pressure, Blood Sugar}, SN to notify MD of systolic BP greater than (>) 160 and less than ( 90 or 100 or 94; pulse rate > 110 or 32 or 7 on 1 - 10 Scale, Fasting blood sugar>250 or 300 or <60....." The POC listed Identifier #100's name. Record Review of the POC for certification 8 /18/19 did not reveal the POC was signed by physician #100 and did not show evidence that it was reviewed by a physician. Record Review of the POC for certification period 6/19/19 to 8/17/19 completed by Identifier A on 6/24/19 was signed by the Identifier #100 on 7/15/19. Record review revealed that patient # 1 had received a total of 3 SN Visits on: 8/20/19, 8/23/19 and 8/26/19. The discharge assessment record was completed on 9/3/19. Review of patient #1's clinical record revealed the Skilled Nursing Clinical Notes and the discharge assessment record were completed by Identifier A. Review of the clinical record and the discharge patient list showed Patient #1 was discharged on 9/3/19. In an interview with the administrator, Identifier A on 5/27/21 at 12:55 pm, the surveyor presented the above findings to the Administrator/Director of Nursing and asked why the POC for Patient#1 was not signed by the physician, she stated, "This is one of the ones the doctor did not sign." When asked the reason, the administrator, Identifier A stated, "We called and called, even suggested taking it to the doctor's office. They did not pick up the phone. They did not answer the patient's call." When asked the date the agency first sent the POC to the physician, the administrator stated, "It was on 8/22/19." When the surveyor asked for the evidence that the agency sent the POC, the administrator stated, "It was not registered mail so will not have evidence." When asked what the agency did when the signed POC was not received from the doctor (after mailing the POC), the administrator stated, "Called doctor's office and they did not answer us. In further interview with the administrator on 5/27/21 at 1:04 pm when the surveyor asked, "So the agency provided care without a physician order?", the administrator stated, "He did not sign this period, he signed the other episode. He moved out of the service area." Record review of agency's policy titled, ' Plan of Care and Physician Orders' reads in part; " ...The individualized plan of care must be reviewed and revised by the physician who is responsible for the home health plan of care and the HHA as frequently as the patient's condition needs require, but no less frequently than one every 60 days ..."