Every finding on record at Yuma District Hospital Home Health Care

A recertification survey was completed on 1/18/24. One deficiency was cited.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure services and treatments were provided only as ordered by the physician in 1 of 2 discharged patient records reviewed (Patient #7). Findings include: 1. The clinical record for Patient #7 was reviewed on 1/17/24. The plan of care (POC) for the certification period dated 9/11/23 to 11/9/23 revealed a start of care (SOC) date of 9/11/23; diagnosis included chronic combined systolic and diastolic heart failure. The POC orders included skilled nursing (SN) one time in week one for assessment and patient education and physical therapy (PT) for evaluation and treatment. a) The agency failed to ensure care was provided only as ordered by the physician. Review of Patient #7's record revealed a physician order on 9/11/23 for SN to evaluate and treat Patient #7. On 9/11/23, SN #1 completed an evaluation with Patient #7 and created a plan of care which included a PT frequency of one time per week for one week for evaluation and treatment. Further review of the SN plan of care revealed SN needs were no longer required after week one. No further supplemental or verbal orders were presented in the record. Review of Patient #7's service documentation completed by SN #4 revealed SN #4 had provided services without an order on the following two dates: 10/3/23, 10/12/23. During an interview on 1/18/24 at approximately 11:40 a.m., RN #4 stated she thought she had received a verbal order for the visit dates of 10/3/23 and 10/12/23. Following request from the State Auditor (SA), SN #4 reviewed the electronic medical record (EMR) documentation specific to Patient #7's physician orders on the following two dates: 10/3/23 and 10/12/23. SN #4 stated she was unable to locate or recall any verbal orders. SN #4 acknowledged the agency had not received an order for SN services to be provided on 10/3/23 and 10/12/23. SN #4 reported she had provided services to Patient #7 and those visits had been completed without a physician order on record. During an interview on 11/27/23 at approximately 12:00 p.m., the administrator and State Auditor (SA) reviewed the record for Patient #7. Following review the administrator acknowledged the agency had not maintained an order for the SN plan of care after the initial SN evaluation. The administrator further stated SN #4 had completed two visits to Patient #7 without an order in the record. The administrator stated the expectation at the agency was for the clinician to ensure they had received an order and verified the frequencies for all services provided to patients prior to providing the services. Further, the administrator stated that she thought there was a verbal order for the two service dates but again was unable to locate any verbal orders in the record.