Every finding on record at Super Health Care Incorporated

A complaint survey prompted by #CO27960 was completed on 10/20/21. Two deficiencies were cited.

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 interview and record review the agency failed to ensure services and treatments were provided in accordance with physician's orders for 2 of 2 pediatric patients reviewed (Patients #5 and #6). 2. The clinical record for Patient #5 was reviewed on 10/14/21. The Plan of Care for the certification period dated 5/2/21 to 6/30/21 and 7/1/21 to 8/29/21 revealed a start of care date of 3/3/21; diagnoses included dysphagia, nontraumatic intracranial hemorrhage, other seizures and autistic disorder. Plan of Care orders included PDN visits 24 hours a day for seven days a week for skilled assessment, vital sign monitoring, seizure assessment, and feedings and medication administration via G-tube ; and CNA visits up to five hours per 24 hour period for personal care assistance. a) The agency failed to ensure CNA visits were being provided as ordered by the physician. Review of the CNA plan of care revealed five different plans of care. The plans of care were labeled bedtime, AM 1, AM, Noon and PM. Services on these plan of cares included assistance with toileting, partial bed bath, oral care, skin care, hair care, check pressure areas, peri care including changing diapers, assist with dressing and undressing, doing laundry and checking for soiled bed linens, changing bed linens, assist with ambulation, reposition patient if he is in bed, assist with transfer to chairs and to the wheelchair, passive range of motion, equipment maintenance, nail care, and assistance with ambulation. Record review of the CNA visit notes revealed that the Patient #5 did not receive any of the five visits per day from 6/7/21 to 6/12/21. Patient #5 did not receive 30 CNA shifts to provide him personal care. According to a communication note dated 6/5/21 the MOC called the agency with a request to hold CNA services from 6/7/21 to 6/12/21. The note also stated the family will be providing the services. The final part of the communication noted that the agency had notified the physician and left a voicemail. The agency never received orders from the physician for Patient #5 to put the CNA services on hold. Record review revealed a fax transmission dated 8/19/21. The transmission had the comment "missed visits" on it. The transmission included all the CNA patient missed visit notes for the 30 shifts between 6/7/21 and 6/12/21. During interview on 10/18/21 at 3:25 p.m., the Staffing Coordinator stated she would send missed visit information to the physician when she found out about it. She stated that she would be told by the employees if a visit was missed. When asked why the missed visits notes for 6/7/21 to 6/12/21 were not sent until August, the Staffing Coordinator could not give an answer. During an interview on 10/19/21 at 11:50 a.m., the DON and consultant stated that the communication that was sent to the physician regarding the request to hold CNA visits from 6/7/21 to 6/12/21 was not an order but a communication note. Findings include: AGENCY POLICY According to the agency's policy titled “Physician Orders/Plan of Care”, not dated, in pertinent part; "The physician establishes and reviews a plan of treatment for the patient. The plan is updated and is maintained as part of the agency’s clinical record." 1. The clinical record for Patient #6 was reviewed on 10/14/21. The Plans of Care for the certification periods dated 9/7/20 to 11/5/20 and 11/6/20 to 1/4/21 revealed a start of care date of 11/12/19; diagnoses included hypoxic ischemic encephalopathy, spastic quadriplegic, cerebral palsy, and epilepsy, unspecified. Plan of Care orders included private duty nursing (PDN) services up to 24 hours daily for 60 days for skilled assessment, vital signs monitoring, respiratory assessments, oxygen administration, G-tube feeding, G-tube care, medication administration, seizure precautions and monitoring, and nutrition assessment and monitoring; and certified nurse aide (CNA) visits four times daily to assist with personal care for activities of daily living (ADL) and light housekeeping. a) The agency failed to ensure CNA services were provided according to physician's orders. Review of the home health aide care plan within the Plan of Care for the certification periods dated 9/7/20 to 11/5/20 and 11/6/20 to 1/4/21 showed the CNA was to provide care four times daily to Patient #6. Specifically, the care included toileting, showers, oral care, hair care, peri-care, dressing, repositioning, transfers, bed bath and range of motion. However, clinical record review revealed there were no CNA visits provided to Patient #6 between 11/19/20 and 11/25/20 and again between 12/16/20 and 12/24/20. Clinical record review revealed a documentation titled “Physician’s telephone/Verbal order dated 11/18/20, completed by an unknown author and not signed. The author wrote she was writing on behalf of another agency clinician who had reported the mother of the child (MOC) was requesting to hold CNA visits in the morning and noon from 11/19/20 to 11/25/20. Further review showed the unsigned physician request by the agency staff was then faxed out and was signed by the physician on 11/24/20, 5 days after the agency had put the patient’s services on hold at the MOC’s request. Additionally, there was no documentation found for the remaining 2 visits of the day not requested to be held and no documentation found care was provided. Record review failed to show how the patient’s needs were met and failed to reveal an explanation why the visits were not completed as ordered by the physician. Patient #6’s CNA services were again put on hold between 12/16/20 and 12/24/20. Clinical record review revealed a documentation titled “Physician’s telephone/Verbal order dated 12/15/20, completed by an unknown author and without a signature. The author wrote she was writing on behalf of another agency clinician who had reported the MOC was requesting to hold CNA visits in the morning and noon from 12/16/20 to 12/24/20. Further review showed the unsigned request by the agency staff was then faxed out and was signed by the physician on 12/22/20, 7 days after the agency had put the patient’s services on hold. Additionally, there was no documentation found to account for the remaining 2 visits (evenings) of the day, how the patient’s needs were met and there was no explanation why the visits were not completed as ordered by the physician. Clinical record review failed to show evidence orders were obtained from the physician to put the patient’s services on hold. During an interview on 10/19/21beginning at 9:48 a.m., licensed practical nurse (LPN #5) confirmed she authored the physician’s requests. She stated she wrote them for a field RN and confirmed she did not speak with the physician. LPN #5 stated “It is a mistake because I do not have my name and time on the order and did not speak with the physician. I wrote it for someone else.” During interview on 10/19/21begining at 3:44 p.m., the director of nursing (DON) and the agency consultant were shown the request written by LPN #5 and agreed the request did not contain the information required of an order and this was not a verbal order. It was a notification.They both then stated they already started a plan to correct the issue related to documentation of orders.

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure each patient's total plan of care was reviewed by the physician at least every 60 days in 1of 2 pediatric patient records reviewed who received services from the agency for at least 60 days (Patient #5). Findings include: AGENCY POLICY According to the agency's policy titled Physician Orders/Plan of Care, not dated, in pertinent part; "The physician and appropriate professional staff will review and recertify the written plan of care at least once per episode and as warranted by the patient’s condition. 1. The clinical record for Patient #6 was reviewed on 10/14/21. The Plans of Care for the certification periods dated 9/7/20 to 11/5/20 and 11/6/20 to 1/4/21 revealed a start of care date of 11/12/19; diagnoses included hypoxic ischemic encephalopathy, spastic quadriplegic, cerebral palsy, and epilepsy, unspecified. Plan of Care orders included private duty nursing (PDN) services up to 24 hours daily for 60 days for skilled assessment, vital signs monitoring, respiratory assessments, oxygen administration, G-tube feeding, G-tube care, medication administration, seizure precautions and monitoring, and nutrition assessment and monitoring; and certified nurse aide (CNA) visits four times daily to assist with personal care for activities of daily living (ADL) and light housekeeping. a) Record review showed the total plan of care was not reviewed and approved by the physician at least every 60 days beginning with the start of care date as required. Review of the plan of care for the certification period from 9/7/20 to 11/5/20, showed the plan of care was reviewed and signed by Patient #5's physician on 10/5/20. However review of Patient #5's subsequent plan of care for the certification period dated 11/6/20 to 1/4/21, revealed the physician did not review and sign the plan of care for the entire 60 day service period. Specifically, review showed the plan of care had been reviewed and signed by the physician on 1/29/21, 25 days after the end of the certification period, and 116 days since the prior plan of care was reviewed and signed. During an interview on 10/19/21 beginning at 3:44 p.m. the clinical manager confirmed the plans of care were to be reviewed and signed by the physician during each episode. She stated she did not know Patient #5’s plan of care was not signed timely, but will ensure all plans of care were monitored for physicians’ review and signature moving forward.