Every finding on record at Vicki Roy Home Health Care Inc

Purpose of visit: Recertification survey and Follow-up to 10/16/19. Entrance date: 10/10/22 at 8:27 a.m. Census: L&C – 0 The agency was in substantial compliance with 42 CFR Part 484.22, Emergency Preparedness Requirements for Home Health Agencies.

Purpose of visit: Recertification survey and a Follow-up to 10/16/19. Entrance date: 10/10/22 at 8:27 a.m. Census: L&C – 0 An exit conference was conducted on 10/14/22 at 8:40 a.m. with the administrator/supervising nurse and staff. Preliminary findings were discussed. The agency was informed the previously cited deficiencies from the survey conducted on 10/16/19 were cleared. Written instructions were provided for submitting a plan of correction within 10 days of receipt of the statement of deficiencies. Abbreviations: MD – Medical Doctor OASIS – Outcome and Assessment Information Set

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 interview and record review, the agency failed to enforce its written policy to ensure verbal orders were documented, signed, dated, and authenticated by the physician for 1 of 1 (Patient #1) discharged patient whose record was reviewed. This failure could potentially affect the patients in that the agency staff may not be aware of active patients requiring services versus patient’s that are discharged from services. Findings include: Patient #1-Review of the discharge skilled nursing visit note dated 11/29/21 indicated the patient was discharged from services per MD/family request on 11/29/21 due to being transferred to hospice. The clinical record included a Discharge OASIS form dated 11/29/21 and a discharge summary dated 11/29/21. Review of the physician orders did not include a physician’s order to discharge Patient #1 from home health services. During an interview conducted on 10/10/22 at 2:23 p.m., when asked where the physician order to discharge Patient #1 was located, the administrator/supervising nurse said the patient’s family went to see the physician and the physician suggested the patient transfer to hospice care and the family contacted home health and requested the patient be discharged from home health, and she (the administrator/supervising nurse) received a verbal order to discharged Patient #1. When asked where the verbal order was located, the administrator/supervising nurse said she did not get it written and that she did a discharge visit and a discharge summary to the doctor and called and notified the doctor. When asked what the usual procedure was when receiving a verbal physician order, the administrator/supervising nurse said she writes the order but just missed this one. Review of the agency policy titled, “Physician Orders and Supplemental Orders” with a revision date of 10/22/02 included, “Physician and Supplemental orders are those that are written between the 60-day review of the physician plan of care (485-7) in order to address problems or needed treatment of the patient… Orders are to be given by physicians only. If given verbally, they are to be immediately transcribed. 2.Verbal orders are put in writing and signed and dated with the date the order was taken by the qualified individual… 4. When verbal orders are received, they are to be written on the Physician Order Form. The original (top sheet) is mailed to the physician for his signature, while the duplicate copy is retained in the patient’s clinical record…”