Every finding on record at Sta-Home Health Agency of Greenwood, Inc

COMPLAINT INVESTIGATION #MS-70848 The complaint investigation survey conducted 06/14-06/15/2022 revealed the allegations Falsification of Records/Reports; Nursing Services; Quality of Care/Treatment and Resident/Client/Patient Neglect was substantiated. Deficiency cited as follows….

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on staff interview, medical record review, policy/procedure review the facility failed ensure the Registered Nurse (RN) followed the facility policy when reporting a change in the wound status to the physician in one (1) of three (3) medical records reviewed, on two (2) of two (2) days of survey; Patient #1. Findings Include: Interview with Registered Nurse #1 (RN) on 6/15/2022 at 11:00 a.m. confirmed she failed to report to the physician a change in the wound status on Patient #1. Interview with Patient Care Manager on 6/15/2022 at 2:30 p.m. confirmed (RN) #1 did not report a change in patient’s wounds. Review of the medical record titled, “Visit Note Report”, dated 05/18/2022 for Patient #1, revealed no documented evidence RN #1 reported to the physician a change in the patient wound status or wound changes to the Patient Care Manager. Review of the facility policy number: HH 2.1.4 “Care Planning, Coordination and Assessment Process”, dated 02/15/2022 revealed: “…10. The comprehensive assessment includes the following components: s. Consultation with the physician or NPP on the assessment findings…19. Documentation of care coordination activities…Documentation will consist of the date and time of the communication, individuals involved with the communication, information discussed and the communication outcome…”. Review of the facility policy number: HH2.1.6 dated/revised 10/01/19 “Significant Change of Condition”, revealed: “It is the policy of this agency to establish the following guidelines for determining when a patient has experienced a significant change in condition…The clinician shall notify the patient’s prescribing physician…” Review of facility policy number: HH 2.1.5 dated/revised 4/1/22 “Physician Plan of Care” revealed: “This agency’s policy is to establish a written plan of treatment…In addition, the clinician responsible for any specific treatment or visit will notify the certifying physician…Notification is required when: …b. A significant change occurs in the patient’s condition…c. patient findings fall within physician – ordered reporting parameters…” During exit conference on 6/15/2022 at 5:00 p.m. with staff management, survey findings were discussed, and no further documentation was submitted for review.