Complete Home Health of Stigler

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on record review and interview, the Agency failed to provide an individualized POC to include patient specific vital sign parameters based on the assessed needs of each patient for five (#2, #4 - #7) of seven (#1- #7) records reviewed. A review of the POCs for Patients #2, #4, #5, #6 and #7 each revealed Vital Sign Parameters with orders to contact physician if the following is outside of parameters: Weight: low value 125 to high value 250; Pain: low value 0.0 and high value 10.0; Fasting Blood sugar: low value 70.0 to high value 200.0; Random Blood sugar: low value 70.0 to high value 300.0; PT Result low value 11.0 to high value 13.0; INR result: low value 2.0 to high value 3.0 Further review of records #2, #4, #5, #6 and #7 failed to provide evidence of patient specific assessed needs to support the vital sign parameters for weight, pain, CBG results, PT or INR results. On 02/14/24 at 12:15 PM, the Administrator stated the Agency failed to revise default parameters provided within the Electronic Medical Record and failed to include patient specific vital sign parameters for Pts #2, #4, #5, #6 and #7.”

“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 observations, record review and interview, the Skilled Nurse failed to monitor weights and CBG results as ordered on the POC for two (#4 and #6) of seven (#1 - #7) records reviewed. Patient #4 A review of the POC for Patient #4 for the re-certification period 01/11/24 to 03/10/24 revealed a primary diagnosis of Chronic Obstructive Pulmonary Disease and a secondary diagnosis Congestive Heart Failure. Review of the POC revealed orders for SN visits 1 time a week for eight weeks and vital sign parameters of “weight: low value 125 and high value 250” to be reported to the Physician. During a home observation visit conducted on 02/14/24 at 09:30 AM, the Caregiver demonstrated the home monitoring equipment and vital sign log which included daily weights and maintained by Pt. #4 to share with the physician as needed. Further review of SN Visit documentation indicated a weight of 155 pounds was obtained on 12/13/23 but failed to provide evidence weights were obtained or monitored for the following 8 weekly SN visits. Patient #6 A review of the POC for Patient #6 for the re-certification period 11/07/23 to 01/05/24 revealed a primary diagnosis of Type II Diabetes Mellitus and orders for SN visits every 14 days for the episode. Review of the POC revealed orders for “SN to assess diabetic status ...report significant changes to physician. SN may perform ... fingerstick blood glucose. SN instruct patient ... blood sugar monitoring...”. Further review of SN Visit documentation failed to provide evidence blood glucose results were obtained or assessed as ordered for SN visits conducted 01/07/24, 01/10/24 or 11/24/24. On 02/14/24 at 12:15 PM, the Administrator stated the SN failed to monitor weights and CBGs results as ordered on the POC for Patient #4 and #6.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on record review and interview, the Skilled Nurse failed to prepare and submit timely the clinical visit notes for two (#1 and #4) of seven (#1 - #7) records reviewed. Patient #1 A review of the POC for Patient #1 for the re-certification period 01/24/24 to 03/23/24 revealed a primary diagnosis of Hemiplegia and secondary diagnosis of Dysphagia. Review of the POC revealed orders for SN visits 1 time a week for 9 weeks. Further review of SN Visit documentation revealed a SN visit note for 01/19/24 but failed to provide evidence of a SN Visit or clinical record documentation tor the following 3 weeks of 01/21/24, 01/28/24 and 02/04/24. Patient #4 A review of the POC for Patient #4 for the re-certification period 01/11/24 to 03/10/24 revealed a primary diagnosis of COPD and secondary diagnosis of Heart Failure. Review of the POC revealed orders for SN visits 1 time a week for 8 weeks. Further review of SN Visit documentation revealed a SN visit was conducted on 02/01/24 but failed to provide evidence of a SN Visit or clinical record documentation tor the following week of 02/04//24. On 02/14/24 at 12:15 PM, the Administrator stated the SN failed to complete and submit clinical note documentation timely for Patients #4 and #6.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient’s home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This Element is not met as evidenced by: Based on record review and interview, the RN failed to conduct onsite supervisory visits to the patient’s home no less frequently than every 14 days for one (#2) of two (#2 and #5) records reviewed with orders for Home Health Aide services. Patient #2 Review of the POC for recertification periods 01/19/24 - 03/18/24 revealed a Primary Diagnosis of Paranoid Schizophrenia with orders for Home Health Aide services 2 times a week for 9 weeks. Further review of RN documentation for Supervisory Aide Visits indicated onsite visits were conducted on 01/17/24 and 02/29/24 (3 days late). On 02/14/24 at 12:15 PM, the Administrator stated the RN failed to conduct Supervisory Aide Visits at least every 14 days as required for Pt#2.”