Every finding on record at In Home Health, LLC

Upon patient record review, 1 of 11 (Patient #9) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. Patient #9 - POC dated 09/01/2021 with MSW frequency 5 PRN, SC 3 PRN and MA 9 PRN - only frequency were PRN visits.

Upon patient record review, 2 of 11 (Patient #4, 10) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #4 - Order for INR not complete on 01/02/2022, 01/27/2022/02/01/2022 and 02/08/2022 . The order read "repeat INR next visit". Patient #10 - POC dated 12/21/2021 order for Port-a-cath did not include dressing changes frequency or procedure, Huber needle changes or gauge/length.

Upon client record review, 3 of 11 (Patient #4,6,10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #4 - POC dated 12/15/2021 with SN frequency 2wk1, 1 wk 12 effective 12/16/2021. SN only made 1 visit first week. Patient #6 - POC dated 12/30/2021 with SC order written 01/01/2022 for 1 within every 30 days, however, 2 visits were made 01/01/2022 and 01/27/2022. Patient #10 - POC dated 12/21/2021with SC visit frequency 1 within every 30 days effective 12/24/2021, however, visits made 12/24/2021 and 01/17/2022.

Upon patient client record review, 3 of 11 (Patient #4, 7, 10) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Patient #4 - SN visit note on 01/02/2022, 01/27/2022, 02/01/2022 and 02/08/2022 - nurse documented INR results only did not document how the sample was obtained. Patient #7 - SN visit note on 11/29/2021 - nurse documented INR results only did not document how the sample was obtained. Patient #10 - Huber needle changed on 01/15/2022 nurse documented "port-a-cath changed using aseptic technique". The documentation did not describe the procedure.