Every finding on record at The Prudent Healthcare Agency Inc

Purpose: Recertification and Complaint survey Entrance: 10/9/2023 Census: Licensed and Certified - 17 Exit Date: 10/13/2023 Intake 454445 The Agency was in compliance with 42 CFR Part 484.102, Emergency Preparedness Requirements for Home Health Agencies.

Purpose: Recertification and Complaint survey Entrance: 10/9/2023 Census: Licensed and Certified - 17 Exit Date: 10/13/2023 Intake 454445

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to enforce its policy that the physician authenticated and date the individual Plans of Care for 6 (#1, #2, #3, #4, #5, #7) of 7 of skilled patient records reviewed. The failure placed the patients at risk of receiving services that had not been reviewed and approved by their physicians. The agency had a policy titled "Timeline" that was labeled IM.10 and dated 4/1/2010. The policy read in part; "Purpose to establish timely parameters for all medical record information. Policy Agency will ensure timely provision of care and services to meet the patient's needs in compliance with all federal and state laws and regulations. Procedure...1.8 Physician signatures are obtained on CMS (Centers for Medicare and Medicaid Services) 485 and supplemental verbal orders within 60 days..." Patient #1: Record review of Patient #1's record revealed a Plan of Care dated 2/8/2023 to 4/8/2023. The Plan of Care indicated that Patient #1 started on the agency's services on 2/8/2023. The Plan of Care listed Essential Hypertension as the primary diagnosis. Registered Nurse A signed the Plan of Care with a verbal start of care order that was dated 2/8/2023. The Plan of Care was not authenticated and dated by the physician throughout the 60-day certification period. Patient #2: Record review of Patient #2's record revealed a Plan of Care dated 1/18/2023 to 3/18/2023. The Plan of Care indicated that Patient #2 started on the agency's services on 1/18/2023. The Plan of Care listed Essential Hypertension as the primary diagnosis. Registered Nurse A signed the Plan of Care with a verbal start of care order that was dated 1/18/2023. The Plan of Care was not authenticated and dated by the physician throughout the 60-day certification period. Patient #3: Record review of Patient #3's record revealed a Plan of Care dated 3/3/2023 to 5/1/2023. The Plan of Care indicated that Patient #3 started on the agency's services on 3/3/2023. The Plan of Care listed Essential Hypertension as the primary diagnosis. Registered Nurse A signed the Plan of Care with a verbal start of care order that was dated 3/3/2023. The Plan of Care was not authenticated and dated by the physician throughout the 60-day certification period. Patient #4: Record review of Patient #4's record revealed a Plan of Care dated 6/3/2023 to 8/1/2023. The Plan of Care indicated that Patient #4 started on the agency's services on 6/3/2023. The Plan of Care listed Essential Hypertension as the primary diagnosis. Registered Nurse A signed the Plan of Care with the verbal start of care order that was dated 6/3/2023. The Plan of Care was not authenticated and dated by the physician throughout the 60-day certification period. Patient #5: Record review of Patient #5's record revealed a Plan of Care dated 6/20/2023 to 8/18/2023. The Plan of Care indicated that Patient #5 started on the agency's services on 6/20/2023. The Plan of care listed Other Seizures as the primary diagnosis. Registered Nurse A signed the Plan of Care with a verbal start of care order that was dated 6/20/2023. The Plan of Care was not authenticated and dated by the physician throughout the 60-day certification period. Patient #7: Record review of Patient #7's record revealed a Plan of Care dated 4/25/2023 to 6/23/2023. The Plan of Care indicated that Patient #7 started on the agency's services on 4/25/2023. The Plan of Care listed Essential Hypertension as the primary diagnosis. Registered Nurse A signed the Plan of Care with a verbal start of care order that was dated 4/25/2023. The Plan of Care was not authenticated and dated by the physician throughout the 60-day certification period. During an interview on 10/12/2023 at approximately 2:00 p.m. with the Administrator/Supervising Nurse and the Office Manager, the surveyor discussed the Plans of Care were not signed by the physician within the agency's policy of 60 days. The Administrator informed the surveyor that the Plans of Care were generated and then uploaded into a portal to go to the physician for signature. The Plans of Care were not returned to the agency. The Administrator informed the surveyor that Patient #4's Plan of Care had to be sent through secure sign. "We did not know that we had to send through secured sign. It has been better since we learned that was how we were to send them."