Every finding on record at Richland County Home Health Agency

A recertification survey conducted on February 14-16, 2022 found Richland County Home Health in compliance with the requirements of 42 CFR § 484.102, Home Health Agency (HHA) Emergency Preparedness.

For the standard Medicare/Medicaid recertification survey started on 02/14/22 and completed on 02/16/22, the sampled included 4 records reviewed with no home visits and 3 records reviewed with home visits.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on observation, record review, review of facility policy, and staff interview, the Home Health Agency (HHA) failed to include all orders on the patient's current plan of care for 1 of 7 sampled patients (Patient #1). Failure to include all orders on the plan of care may result in inconsistent care delivery. Findings include: Review of the facility policy titled "Physician Orders" occurred on 02/16/22. This policy, revised 01/08/18, stated, ". . . Verbal orders shall reflect new orders, changes in orders, and/or discontinuance of any order(s). . . . Verbal order will be completed/transcribed as follows in the order section of the computer . . ." The facility policy titled "Admission and Recertification for Non-Medicare or Non-Medicaid Third Party Payer Home Health Services (VA [Veteran's Administration] or private insurance)," revised 08/26/21, stated, ". . . the plan of care will be developed which will include but is not limited to the following: . . . Types and frequency of services to be provided, including medication, diet, treatment procedures, equipment, and devices . . ." Observation at a home visit on 02/14/22 at 11:30 a.m. showed a nurse (#1) filled Patient #1's medi-planner. Medications included Gabapentin (an anticonvulsant sometimes used to treat nerve pain). The nurse also identified a bottle of as needed (prn) Lasix (a diuretic) kept in the home for Patient #1 to take if his weight exceeded 259 pounds. Review of Patient #1's medical record occurred on all days of survey. Diagnoses included heart failure and a coagulation defect. The patient's current plan of care, dated 01/11/22, failed to identify the medications Lasix and Gabapentin. A verbal order, dated 01/27/22, identified an INR (international normalized ratio, a type of lab test used to check the clotting time of blood) recheck on 02/14/22. Observations during the home visit on 02/14/22 failed to show an INR recheck. During an interview on the morning of 02/16/22, a nurse (#2) identified Nurse #1 spoke to the anticoagulation clinic on 02/08/22, and the clinic staff discontinued the order for an INR draw on 02/14/22. The medical record lacked evidence of this verbal order. The nurse (#2) stated the new orders for Gabapentin and Lasix, as well as the verbal order for discontinuing the INR, should be part of Patient #1's plan of care/medical record.