Victory Home Health, LLC

“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 record review and interview, the agency failed to ensure weights were obtained as ordered for two (Patient #2 and 6) of 11 patients. Patient #2 A review of the plan of care dated 08/07/23 to 10/05/23 showed orders to obtain weights every skilled nurse visit and documented a skilled nurse frequency of one visit per week for one week and one visit per week for eight weeks. A review of the clinical records showed the following: A skilled nurse assessment dated 08/11/23 documented no weight. A skilled nurse assessment dated 08/31/23 documented no weight. A skilled nurse assessment dated 09/07/23 documented no weight. Patient #6 A review of the plan of care dated 08/23/23 to 10/21/23 showed orders to obtain weights every skilled nurse visit and documented a skilled nurse frequency of one visit per week for one week and one visit per week for eight weeks. A review of the clinical records showed the following: A skilled nurse assessment dated 08/30/23 documented no weight. A skilled nurse assessment dated 09/29/23 documented no weight. A skilled nurse assessment dated 09/13/23 documented no weight. On 12/06/23 at 12:50 pm., Staff C stated weights were not obtained as ordered for Patient #2 and 6.”

“Coordination of Care CFR(s): 484.60(d) Standard: Coordination of care. The HHA must: This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure coordination of care for the management of pain for one (Patient #2) of 11 patients. A review of the plan of care dated 08/07/23 to 10/05/23 showed a primary diagnosis of hypertensive heart and chronic kidney disease and documented a skilled nurse frequency of one visit per week for one week and one visit per week for eight weeks. A review of the clinical records showed the following: A skilled nurse assessment dated 08/11/23 documented a pain level of 10 our of 10 (on the classic pain scale) and the physician was notified. There was no documented follow up to the reported pain level. A skilled nurse assessment dated 08/18/23 documented a pain level of 10 out of 10 (on the classic pain scale) and the physician was notified. There was no documented follow up to the reported pain level. A skilled nurse assessment dated 08/25/23 documented a pain level of 10 out of 10 (on the classic pain scale) and the physician was notified. There was no documented follow up to the reported pain level. A skilled nurse assessment dated 08/31/23 documented a pain level of 8 out of 10 (on the classic pain scale) and the physician was notified. There was no documented follow up to the reported pain level. A skilled nurse assessment dated 09/21/23 documented a pain level of 10 out of 10 (on the classic pain scale) and the physician was notified. There was no documented follow up to the reported pain level. A skilled nurse assessment dated 09/29/23 documented a pain level of 10 out of 10 (on the classic pain scale) and the physician was notified. There was no documented follow up to the reported pain level. A skilled nurse assessment dated 10/05/23 documented a pain level of 10 out of 10 (on the classic pain scale) and the physician was notified. There was no documented follow up to the reported pain level. On 12/06/23 at 1:10 pm., Staff C stated there was no follow up regarding physician notification of the elevated pain level and the patient pain was not managed.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on record review and interview the agency failed to ensure the accuracy of the primary diagnosis documented on skilled nurse assessments for one (Patient #2) of 11 patients. Patient #2 A review of the plan of care dated 08/07/23 to 10/05/23 showed a primary diagnosis of hypertensive heart disease with chronic kidney disease and documented a skilled nurse frequency of one visit per week for one week and one visit per week for eight weeks. A review of the clinical record showed the following: A skilled nurse assessment dated 08/30/23 documented a primary diagnosis of spinal stenosis. A skilled nurse assessment dated 09/07/23 documented a primary diagnosis of spinal stenosis. A skilled nurse assessment dated 09/15/23 documented a primary diagnosis of spinal stenosis. A skilled nurse assessment dated 09/29/23 documented a primary diagnosis of spinal stenosis. A skilled nurse assessment dated 10/13/23 documented a primary diagnosis of spinal stenosis. On 12/06/23 at 12:50 pm, Staff C stated the primary diagnosis documented on the skilled nurse assessments for Patient #2 was incorrect.”

“Coordinate patient care CFR(s): 484.105(c)(2) Coordinating patient care, This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure coordination of care was provided for one (Patient #6) of 11 patients. Patients #6 A review of the plan of care dated 08/23/23 to 10/21/23 showed a primary diagnosis of hypertensive heart with chronic kidney disease and documented orders for a skilled nurse frequency of one visit per week for one week and one visit per week for eight weeks. A skilled nurse missed visit note dated 09/29/23 documented the reason for the missed visits was due to the patient being in the hospital related to chronic kidney disease. On 12/05/23 at 2:20 pm., assisted living staff A stated they had attempted to contact he agency regarding fluid coming from the patient ankles and the agency failed to return their call, so the patient was sent to the emergency room. On 12/06/23 at 1:10 pm., Staff C stated she was unaware of the incident.”