Every finding on record at Salus Home Health and Hospice Az, LLC

Observed in Record Review. In 1 of 1 patient records reviewed, Surveyor noted a Notice of Medicare Non-Coverage (NOMNC) had not been obtained at least 48 hours prior to the discontinuation of services. This was evident in RRDC #1. The patient had a planned discharge for extended prognosis in October 2023. They had not been provided with the NOMNC prior to this discharge. This was validated with the Director of Patient Care Services Designee

Observed in Record Review. In 1 of 5 patient records reviewed, the Surveyor noted the RN completing the patient care visits had not documented a comprehensive assessment of the patient. For example, in RRHV #2 the RN completed a 'short note' for the visit document which only included pain assessment and vital signs with a brief narrative. The documentation of the full plan of care assessment had not been present between the end of December and the end of February. This was validated with the DPCS.

Observed in Record Review. In 3 of 5 patient records reviewed, the Surveyor noted as needed duplicative medications without a clear and specific indication for use or a topical medication without a specific site of application. For example, RRHV #1, the patient had Tylenol and Morphine both ordered as needed for pain without specific pain indication for use. The same patient also had 2 medications for constipation without instructions other than constipation. In RRHV #2, the patient had DSS and Senakot both ordered as needed for constipation without clear indications for use. In RRDC #2, the patient had Nystatin written to apply to affected area without clear directions on site of application. This was validated with the DPCS.