Every finding on record at Soul Care Services, Inc.

Recertification survey completed. Standard Level deficiencies cited. Abbreviations: SN = Skilled Nurse

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 clinical records review and Staff interview, it was determined the Agency failed to ensure physician orders were followed. This was found in 3 of 7 records reviewed (Patients #1, 4 and 6). Findings include: 1. Patient #1 was admitted to the home health agency on 10/04/23 with diagnoses of Varicose Veins of Bilateral Lower Extremities with Pain and Type 2 Diabetes Mellitus without complications. The clinical record was reviewed on 10/10/23. The signed Physician orders dated, 10/04/23 included orders for the SN to notify the physician of pulse below 60. On 10/04/23 the SN documented a pulse of 47 and on 10/10/23 a decreased pulse of 45. The SN visit notes lacked notification to the physician of the heart rate below 60. 2. Patient #4 was admitted to the home health agency on 08/23/23 with a diagnosis of Type 2 Diabetic Mellitus with Diabetic Polyneuropathy. The clinical record was reviewed on 10/11/23. The signed Physician orders dated 08/23/23 included orders for the SN to notify the Physician of “...random blood sugar greater than 90 or less than 60..." The SN failed to assess the blood glucose during the weeks of: 09/10/23 (week #4), 09/17/23 (week #5), 09/24/23 (week #6) and 10/01/23 (week #7) as ordered by the Physician. 3. Patient #6 was admitted to the home health agency on 05/06/23 with diagnoses of Spinal Stenosis, Lumbar region without Neurogenic Claudication and Type 2 Diabetic Mellitus with Hyperglycemia. The clinical record was reviewed on 10/11/23. The signed Physician orders dated 05/06/23 included: “Assessment of the Type 2 diabetes mellitus hyperglycemia” and to notify the Physician of “random blood sugar greater than 250 or less than 60." The Agency Staff failed to include the assessment of the blood glucose results during the weeks of 05/07/23 (week #2), 05/14/23 (week #3), 05/21/23 (week #4), 06/04/23 (week #7) and 06/18/23 (week #8) as ordered by the Physician. 4. The above findings were confirmed during the interview with the Administrator and Agency Supervisor on 10/11/23, between 1:45 PM and 3:00 PM.