Every finding on record at Royal Home Health Care, Incorporated

A recertification survey was initiated on 8/14/23. The census was: LCHH-15 LHH-0 PAS-0 Total agency census: 15 Abbreviations LCHH-Licensed and Certified Home Health LHH-Licensed Home Health PAS-Personal Assistance Services

A recertification survey was initiated on 8/14/23. The census was: LCHH-15 LHH-0 PAS-0 Total agency census: 15 Abbreviations LCHH-Licensed and Certified Home Health LHH-Licensed Home Health PAS-Personal Assistance Services RN-registered nurse LVN-licensed vocational nurse OASIS-Outcome and Assessment Information Set

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure that all entries were legible, clear, complete and appropriately authenticated, dated and timed. Authentication of a signature and title (occupation) failed to be included for 8 (Patient’s #1, 3, 4, 5, 7, 8, 9, and 10) of 10 Patient records reviewed. The failure placed the patient at risk of receiving inadequate service delivery and to have needs unmet because a primary author had not authenticated the entries to the clinical record, as true and accurate. Findings include: Agency policy 8.9 titled, “Authorization and Authentication of Patient Records” read in part… “All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation)…” Patient #1 record review included a plan of care for the episode 5/19/23 through 7/17/23 with a start of care date of 9/26/21. The primary diagnosis was listed as hypertensive chronic kidney disease stage 4. The orders included skilled nursing 1 time a week for 9 weeks. The record contained skilled nursing notes signed and dated by RN 1 on 5/24/23, 5/29/23, 6/8/23, 6/14/23, 6/21/23, 6/28/23, 7/2/23 and 7/14/23. The digital signatures for RN 1 did not include the nurse’s designation as a registered nurse. Patient #3 record review included a plan of care for the episode 5/6/23 through 7/4/23 with a start of care date of 1/6/23. The primary diagnosis was listed as primary osteoarthritis of the right knee. The orders included skilled nursing 1 time a week for 9 weeks and home health aide 3 times a week for 9 weeks. The record contained skilled nursing notes signed and dated by RN 1 on 5/10/23, 5/20/23, 5/27/23, 5/29/23, 6/10/23 and 6/17/23. The digital signatures for RN 1 did not include the nurse’s designation as a registered nurse. The record contained a skilled nursing note signed and dated by RN 2 on 6/24/23 and an OASIS assessment on 7/1/23. The digital signatures for RN 2 did not include the nurse’s designation as a registered nurse. Patient # 4 record review included a plan of care for the episode 5/29/23 through 7/27/23 with a start of care date of 3/30/23. The primary diagnosis was listed as diabetes mellitus type 2. The orders included skilled nursing 2 times a week for 1 week and 3 times a week for 8 weeks, physician therapy and occupational therapy to evaluate and treat. The record contained skilled nursing notes signed and dated by RN 1 on 7/1/23. The digital signature for RN 1 did not include the nurse’s designation as a registered nurse. The record contained skilled nursing notes signed and dated by LVN 1 on 5/31/23, 6/3/23, 6/6/23, 6/9/23, 6/20/23, and 6/23/23. The digital signatures for LVN 1 did not include the nurse’s designation as a licensed vocational nurse. Patient #5 record review included a plan of care for the episode 5/22/23 through 7/20/23 with a start of care date of 6/6/20. The primary diagnosis was listed as unilateral primary osteoarthritis of right hip. The orders included skilled nursing 1 time a week for 9 weeks. The record contained skilled nursing notes signed and dated by RN 1 on 5/22/23, 5/30/23, 6/8/23, 6/14/23, 6/22/23, 6/29/23, 7/4/23, 7/11/23 and an OASIS assessment on 7/19/23. The digital signatures for RN 1 did not include the nurse’s designation as a registered nurse. Patient #7 record review included a plan of care for the episode 4/28/23 through 6/26/23 with a start of care date of 4/28/23. The primary diagnosis was listed as trigeminal neuraligia (a chronic pain condition affecting the trigeminal nerve in the face). The orders included skilled nursing 1 time a week for 9 weeks and occupational therapy to evaluate and treat. The record contained skilled nursing notes signed and dated by LVN 3 on 5/11/23, 5/16/23, 5/27/23, 6/2/23, 6/6/23, and 6/17/23. The digital signature for LVN 3 did not include the nurse’s designation as a licensed vocational nurse. Patient #8 record review included a plan of care for the episode 6/4/23 through 8/2/23 with a start of care date of 12/11/21. The primary diagnosis was listed as hypertensive chronic kidney disease stage 3. The orders included skilled nursing 1 time a week for 9 weeks and home health aide 1 time a week for 9 weeks. The record contained skilled nursing notes signed and dated by RN 1 on 6/10/23 and 6/17/23. The digital signatures for RN 1 did not include the nurse’s designation as a registered nurse. The record contained skilled nursing notes signed and dated by RN 2 on 6/24/23, 7/1/23, 7/8/23, 7/15/23, 7/22/23, 7/28/23 and an OASIS assessment on 8/2/23. The digital signatures for RN 2 did not include the nurse’s designation as a registered nurse. Patient #9 record review included a plan of care for the episode 4/22/23 through 6/20/23 with a start of care date of 1/6/23. The primary diagnosis was listed as essential primary hypertension. The orders included skilled nursing 1 time a week for 9 weeks and occupational therapy 2 times a week for 5 weeks. The record contained an OASIS assessment signed and dated by RN 1 on 6/16/23. The digital signature for RN 1 did not include the nurse’s designation as a registered nurse. The record contained skilled nursing notes signed and dated by LVN 2 on 4/28/23, 5/6/23, 5/12/23, 5/19/23, 5/23/23, 5/31/23 and 6/10/23. The digital signature for LVN 2 did not include the nurse’s designation as a licensed vocational nurse. Patient #10 record review included a plan of care for the episode 4/28/23 through 6/26/23 with a start of care date of 4/28/23. The primary diagnosis was listed as primary osteoarthritis of the right hand. The orders included skilled nursing 1 time a week for 9 weeks. The record contained skilled nursing notes signed and dated by LVN 3 on 5/11/23, 5/16/23, 5/27/23, 6/2/23, 6/6/23, and 6/17/23. The digital signature for LVN 3 did not include the nurse’s designation as a licensed vocational nurse. An interview was conducted on 8/17/23 at 1:17 pm with RN 1. The surveyor reviewed the chart findings for Patient’s 1, 3, 4, 5, 8, and 9 in that RN 1’s signature did not include her discipline authenticating her as a registered nurse. RN 1 said, “I don’t know exactly why it is not showing up.” An interview was conducted on 8/18/23 at 4:49 pm with RN 2. The surveyor reviewed the chart finding for Patient’s 3 and 8 with RN 2 that her signature did not include her discipline authenticating her as a registered nurse. RN 2 said, “I’m not sure why, I never noticed.” An interview was conducted on 8/21/23 at 1:05 pm with LVN 1. The surveyor reviewed the chart findings for Patient #4 with LVN 1 in that her signature did not include her discipline authenticating her as a licensed vocational nurse. LVN 1 said, “It never does, I don’t know why.” An interview was conducted on 8/21/23 at 1:33 pm with LVN 3. The surveyor reviewed the chart findings for Patients’ 7 and 10 in that his signature did not include his discipline authenticating him as a licensed vocational nurse. LVN 3 said, “I’m not sure why, I didn’t know I had to do that.” An interview was conducted on 8/21/23 at 1:36 pm with LVN 2. The surveyor reviewed the chart findings for Patient 9 in that her signature did not include her discipline authenticating her as a licensed vocational nurse. LVN 2 said, “I always put it, so I don’t know why, unless it’s a glitch.” An interview was conducted on 8/16/23 with Alternate Administrator/Supervising Nurse. The surveyor reviewed that RN 1, RN 2, LVN 1, LVN 2, and LVN 3’s signatures did not include their disciplines, authenticating them as registered nurses and licensed vocational nurses. The Alternate Administrator/Supervising Nurse said, “It is probably a technical issue, I will call our software vendor and find out why this is happening.” An interview was conducted on 8/16/23 with Alternate Administrator/Supervising Nurse. The Alternate Administrator explained to the surveyor that a box for suffix was not checked so the LVN or RN was not showing up in the nurse’s signature. The Alternate Administrator/Supervising Nurse said the problem of the nurse’s designation was now corrected.