Every finding on record at Wake Forest Baptist Health Care at Home, LLC

An onsite complaint investigation was conducted 4/18/22. The allegation was substantiated with deficiencies to the Medicare CoP.

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 agency policy review, clinical record review and staff interviews the agency failed to follow the physician's order to assess the patient for physical therapy and home health aide services within 48 hours for 1 of 3 records reviewed [#1]. The findings included: The policy, Initial and Comprehensive Assessments [1/22], was provided by the agency clinical manager on 4/18/22 at approximately 3:45 pm. The policy stated, “…All patients receiving skilled services must have an initial on-site professional assessment. The assessment must be completed on or before start of care and within 48 hours from the date of referral or facility discharge…” Patient # 1 had a Start of Care [SOC] date of 3/27/22 and admitting diagnoses of cutaneous abscess of left upper limb, laceration without foreign body, left knee and type 2 diabetes mellitus with hyperglycemia. A review of the Plan of Care [POC] for the certification period 3/27/22 to 5/25/22 revealed orders for SN [skilled nursing] 4 times a week for 1 week, 3 times a week for 4 weeks, 2 times a week for 3 weeks, 1 time a week for 1 week. A review of the clinical record revealed documents titled, Physical Therapy Prescription for Home Health and CNA [certified nursing assistant] Prescription for Home Health. The forms were dated 3/24/22. Further review of the clinical record revealed RN # 1 made a routine visit on 4/4/22. A review of the documentation revealed the following information, “…PT [patient] REQUESTING PT/OT FOR STRENGTHENING AND ASSISTANCE WITH NEW PROSTHETIC…” A review of the SN visit note by RN # 1 dated 4/11/22 revealed the following information, “…SPOKE WITH _____[name] AT ______[physician practice name] TO REQUEST PT/OT ORDERS. PT IS UPSET THAT THESE ORDERS HAVE NOT BEEN RECEIVED…” A review of the physician’s orders revealed the order for physical therapy and occupational therapy to evaluate for treatment was not written until 4/13/22. There is no evidence the patient received any home health aide services. An interview was conducted with the agency clinical manager on 4/18/22 at approximately 3:15 pm. During the interview the clinical manager stated, “We didn’t realize we had the order for PT at the time the patient was admitted. This was a case of multi systems failure. We simply overlooked the order. We have not sent a home health aide to see the patient since OT is managing the ADL’s [activities of daily living].”