Every finding on record at Royal Majesty Home Health, Inc

This Statement of Deficiencies was generated as a result of an Emergency Preparedness survey conducted in conjunction with a Medicare recertification survey conducted at your facility on 08/30/2022 and finalized on 09/02/2022, in accordance with 42 Code of Federal Regulations (CFR) and the State Operations Manual (SOM), Appendix Z- Emergency Preparedness for All Provider and Certified Supplier Types. The findings and conclusions of any investigation by the Division of Public and Behavioral Health shall not be construed as prohibiting any criminal or civil investigations, actions or other claims for relief that may be available to any party under applicable federal, state, or local laws. The agency was found to be in substantial compliance with the requirements for Emergency Preparedness. No further action necessary.

This Statement of Deficiencies was generated as a result of a Medicare Recertification Survey conducted at your agency from August 30, 2022 through September 1, 2022, in accordance with 42 CFR (Code of Federal Regulations) Part 484 - Home Health Services. The active census on the first day of the survey was 51 patients. The patient sample was seven patients. Three home visits were conducted. The investigation of regulatory compliance for COVID-19 Vaccination of Facility Staff included: The investigation of regulatory compliance for COVID-19 Vaccination of Facility Staff included: - Review of Infection Control Surveillance plans. - Review of Vaccination policies including staff members vaccination status, exemptions, (medical and non-medical), temporary delays for vaccinations, additional precautions for unvaccinated staff, contingency plans for unvaccinated staff and additional precautions to prevent the spread of Covid -19. Review of the facility's Healthcare Worker Vaccination policies and facility documentation revealed the facility was at 100% compliance with Healthcare Worker vaccination requirements. The findings and conclusions of any investigation by the Division of Public and Behavioral Health shall not be construed as prohibiting any criminal or civil investigation, actions or other claims for relief that may be available to any party under applicable federal, state, or local laws. The following regulatory deficiencies were identified:

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 ensure the agency followed a physician order for skilled nursing visits for 1 of 7 patients (Patient 1) and failed to acquire a walker and notify a physician according to pain level parameters ordered in the plan of care for 1 of 7 patients (Patient 5). Findings include: 1) Patient 1 was admitted on 3/22/2022, with open wound of right upper arm. The agency continuously recertified the patient through the current care episode from 7/20/2022 through 9/17/2022. On 7/20/2022, the plan of care documented a physician ordered weekly skilled nursing visits. On 9/1/2022, the clinical record lacked documented evidence of skilled nursing visits after 8/10/2022. The clinical record lacked documented evidence of a change, discontinuation, modification of ordered visits or missed visits. On 9/1/2022 at 11:00 AM, the Director of Nursing confirmed the visits were missed without documentation. 2) Patient 5 was admitted on 7/18/2022, with a right femur neck fracture. On 7/18/2022, the plan of care documented a physician ordered a physical therapy evaluation. On 7/18/2022, a Physical Therapist (PT) documented the patient had a 4 wheeled walker, but it was broke. The PT further documented the patient would benefit from a walker with a seat. On 7/18/2022, a physician documented an order for a four wheeled walker from the durable medical equipment company (DME). On 7/21/2022, the agency faxed the order to the DME company. The agency lacked documented evidence of any further correspondence regarding the four wheeled walker until 8/17/2022. On 8/17/2022, the agency faxed an updated physical therapy evaluation and order for a walker with a seat, as originally documented in the initial evaluation. On 8/17/2022, communication from the DME company showed the beginning of a communication chain about what the patient was eligible for to assist with ambulation. Communication went back and forth through 8/31/2022. On 8/31/2022, a home visit was conducted with a registered nurse. At the time of the home visit, the patient verbalized a pain level of 8 with no assistive device to get around in the home dwelling and inquired about when the walker would arrive. The registered nurse documented the patient was still waiting for a physician's approval. On 7/18/2022, the plan of care documented a physician ordered skilled nurses to notify a physician for severe pain greater than 7 on a scale of 0-10, unrelieved by medication. On 9/1/2022, the clinical record lacked documented evidence the registered nurse contacted a physician for a pain level greater than 7 and lacked documented evidence when and whether or not the patient took pain medication and whether or not there was relief. On 9/1/2022, the Director of Nursing confirmed the findings.

Coordination of Care CFR(s): 484.60(d) Standard: Coordination of care. The HHA must: This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure it resolved issues regarding obtaining an assistive device and notified a physician regarding a pain level that exceeded parameters for 1 of 7 patients (Patient 5). Findings include: Patient 5 was admitted on 7/18/2022, with a right femur neck fracture. On 7/18/2022, the plan of care documented a physician ordered a physical therapy evaluation. On 7/18/2022, a Physical Therapist (PT) documented the patient had a 4 wheeled walker, but it was broke. The PT further documented the patient would benefit from a walker with a seat. On 7/18/2022, a physician documented an order for a four wheeled walker from the durable medical equipment company (DME). On 7/21/2022, the agency faxed the order to the DME company. The agency lacked documented evidence of any further correspondence regarding the four wheeled walker until 8/17/2022. On 8/17/2022, the agency faxed an updated physical therapy evaluation and order for a walker with a seat, as originally documented in the initial evaluation. On 8/17/2022, communication from the DME company showed the beginning of a communication chain about what the patient was eligible for to assist with ambulation. Communication went back and forth through 8/31/2022. On 8/31/2022, a home visit was conducted with a registered nurse. At the time of the visit, the patient verbalized a pain level of 8 with no assistive device to get around in the home dwelling and inquired as to when the walker would arrive. The registered nurse documented the medical supplier (DME) was still waiting for a physician's approval. On 7/18/2022, the plan of care documented a physician ordered skilled nurses to notify a physician for severe pain greater than 7 on a scale of 0-10, unrelieved by medication. On 9/1/2022, the clinical record lacked documented evidence the registered nurse contacted a physician for a pain level greater than 7 and lacked documented evidence when and whether or not the patient took pain medication and whether or not there was relief. On 9/1/2022, the Director of Nursing confirmed the findings.

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 record review and interview, the agency failed to ensure a registered nurse authenticated clinical assessments for 1 of 7 patients (Patient 4). Findings include: Patient 4 was admitted on 12/29/2021, with urinary incontinence and polyarthritis. The agency continuously recertified Patient 4 up through the current care episode from 6/27/2022 through 8/25/2022. On 8/17/2022, a registered nurse conducted a resumption of care assessment after a week's stay in an acute care facility. As of 9/1/2022, the resumption of care assessment lacked documented evidence of the registered nurse's clinical authentication. On 8/22/2022, a registered nurse conducted a recertification assessment for the next care episode. As of 9/1/2022, the recertification assessment lacked documented evidence of the registered nurse's clinical authentication. On 9/1/2022, the Director of Nursing confirmed the findings.

Social Worker CFR(s): 484.115(m) Standard: Social worker. A person who has a master's or doctoral degree from a school of social work accredited by the Council on Social Work Education, and has 1 year of social work experience in a health care setting. This STANDARD is not met as evidenced by: Based on interview, record review and document review, the facility failed to confirm if their social worker was qualified for their positions for one of one Social Workers (Social Worker 1). Findings include: The State of Nevada Board of Examiners for Social Workers revealed Social Worker 1 was a Licensed Certified Social Worker. There was no verified documented evidence Social Worker 1 had a master’s degree from a school accredited or approved by the council on Social Work Education. On 08/31/2022 in the afternoon, the Administrator indicated the agency did not verify if the social worker had a master’s degree from a school accredited or approved by the council on Social Work Education. The Administrator indicated the agency had only one social worker and was unable to contact the social worker to verify if they were a master’s degree social worker from a school accredited or approved by the council on Social Work Education.