Jnb Home Health LLC

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure services ordered by the physician as indicated in the plan of care (POC) were provided for 1 of 3 active patients reviewed (Patient #3). Findings include: 1. The clinical record for Patient #3 was reviewed on 5/24/24. The plan of care for the certification period dated 4/21/24 to 6/19/24 revealed a start of care date of 8/5/22; diagnoses included multiple sclerosis and hypertension. Plan of care orders included; skilled nursing (SN) visits two times a day for 60 days with three PRN visits for condition, for medication review, reconciliation and medication administration; Ketorolac 30mg/ml, injectable solution 15 mg/0.5ml intramuscular (IM) for pain, and home health aid (HHA) visits one time a day, seven days a week for nine weeks for assistance with personal care and activities of daily living. a) The agency failed to ensure services ordered by the physician as indicated in the plan of care (POC) were provided. Specifically the agency failed to ensure the twice daily administration of Ketorolac 30mg/ml injectable solution at 15 mg/0.5ml IM for pain took place during the second ordered SN visit. Review of POC documentation showed on 4/20/24 the agency received orders electronically from Patient #3’s primary care physician (PCP) ordering SN for Patient #3 two times daily for assistance with IM injection of Ketorolac 30mg/ml, injectable solution at 15 mg/0.5ml for pain. Review of Patient #3’s a.m. visit narratives from 4/20/24 through 5/21/24 revealed narrative notes documenting the IM injection of Ketorolac 30mg/ml for each planned and ordered a.m. SN visit. Review of Patient #3’s p.m. visit narratives from 4/20/24 through 5/21/24 revealed no narrative notes or documentation of any IM injections of the ordered and planned Ketorolac 30mg/ml, injectable solution at 15 mg/0.5ml during any of the p.m. SN visits. During an interview on 5/28/24 at 11:16 a.m., the licensed practical nurse (LPN) providing the care for Patient #3 stated she was aware the care plan stated ketorolac injections were to occur twice daily. The LPN further stated she documented the ketorolac injection occurrence during the patient’s first shift but was not documenting the Ketorolac injection occurrence during the patient’s second visit of the day. During an interview on 5/29/24 at approximately 9:45 a.m., the chief executive officer (Employee #1) confirmed Patient #3’s chart was missing documentation regarding completion of the Ketorolac injection that was written on Patient #3’s care plan to occur twice daily, specifically during the p.m. SN visit. Employee #1 further stated she should have caught the missing Ketorolac injection documentation for p.m. visit notes in Patient #3’s record in her patient chart auditing process.”

“In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure services were provided in accordance with current clinical practice guidelines and accepted professional standards of practice to patients in 2 of 3 clinical records reviewed (Patients #1 and #2). Findings include: 1. The clinical record for Patient #1 was reviewed on 5/24/24. The Plan of Care for the period dated 2/22/21 to 4/22/21 revealed a start of care date of 2/20/21; diagnoses included type 2 diabetes mellitus without complications, peripheral vascular disease unspecified, chronic obstructive pulmonary disease, major depressive disorder, presence of right artificial hip joint, pain in unspecified foot, functional urinary incontinence, heredity and idiopathic neuropathy, gastro-esophagel reflux disease without esophagitis, abnormal finding in lung field, pleural effusion, hyperlipidemia, trochanteric bursitis in right hip, periodic limb movement disorder, chronic respiratory failure with hypoxia and personal history of nicotine dependence. Plan of care orders included skilled nursing (SN) visits two days a week for nine weeks. a) The agency failed to ensure services were provided in accordance with current clinical practice guidelines and accepted professional standards of practice to Patient #1. Review of verbal orders dated 2/22/21 signed by licensed practical nurse (LPN) #1 (not a registered nurse, RN who would be authorized to accept verbal orders), revealed orders to provide services for Patient #1. 2. The clinical record for Patient #2 was reviewed on 5/24/24. The Plan of Care for the period dated 4/21/24 to 6/19/24 revealed a start of care date of 8/5/22; diagnoses included multiple sclerosis, essential (primary) hypertension, neuromuscular dysfunction of bladder, generalized anxiety disorder, chronic pain syndrome, depression and migraine with aura. Plan of care orders included SN visits twice a day for sixty days as needed for condition and medication changes. a) The agency failed to ensure services were provided in accordance with current clinical practice guidelines and accepted professional standards of practice to Patient #2. Review of the HHA care plan dated 4/20/24 showed it was signed by LPN #1 (not a registered nurse). Review of an Outcome and Assessment Information Set (OASIS) dated 4/20/24 revealed LPN #1 had signed and completed the assessment, not a registered nurse as required by regulation. 3. During an interview on 5/28/24 at 12:19 a.m., LPN #1 confirmed she was a LPN and not a RN. During an interview on 5/29/24 at 9:10 a.m., the director of nursing (DON) confirmed she was the DON for the agency and LPN #1 should not have been accepting verbal orders without a co-signature or documenting on the HHA care plan or OASIS assessment.”