Shanadoa Home Health, Inc.

“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: 1. SN frequencies were followed as ordered for two (Patient #3 and 4) of thirteen patients; 2. PT frequencies were followed as ordered for two (Patient #3 and 6) of thirteen patients; 3. OT frequencies were followed as ordered for one (Patient #6) of thirteen patients; and 4. a medical procedure were completed as ordered for one (Patient #10) of thirteen patients. 1. Patient #3 A review of the plan of care dated 09/14/23 to 11/12/23 showed a SN frequency of two visits per week for two weeks and one visit per week for seven weeks. A review of the medical record showed one SN visit dated 09/19/23 and no other visits documented for the week of 09/17/23 to 09/23/23. A review of a SN missed visit note dated 10/31/23 documented the patient went to her primary care physician, and no other visits documented for the week of 10/29/23 to 11/04/23. Documentation showed no refusal of visits or services from the patient or caregiver and no contact made with the patient or caregiver and no physician order for a change in services. Patient # 4 A review of the plan of care dated 08/24/23 to 10/22/23 showed a SN frequency of one visit per week for one week and two visits per week for two weeks and one visit per week for six weeks. A review of a SN missed visit note dated 09/05/23 documented the reason for the missed visit as attempt details duplicate, and no other visits documented for the week of 09/03/23 to 09/09/23. A review of the medical record showed no SN visits for the week of 09/24/23 to 09/30/23. Documentation showed no refusal of visits or services from the patient or caregiver and no contact made with the patient or caregiver and no physician order for a change in services. 2. Patient #3 A review of the plan of care dated 09/14/23 to 11/12/23 showed a PT frequency of one visit per week for one week, two visits per week for six weeks. A physician’s order dated 10/05/23 showed a PT frequency of two visits per week for eight weeks, effective 10/03/23. A review of the medical record showed one PT visit dated 10/31/23 and no other visits documented for the week of 10/29/23 to 11/04/23. Documentation showed no refusal of visits or services from the patient or caregiver and no contact made with the patient or caregiver and no physician order for a change in services. Patient # 6 A review of the plan of care dated 09/10/23 to 11/08/23 showed a PT frequency of one visit per week for eight weeks. A physician’s order dated 10/04/23 showed a PT frequency of one visit every two weeks for two weeks, effective 10/01/23. A review of the medical record showed no PT visits for the week of 10/01/23 to 10/07/23. A physician’s order dated 10/17/23 showed a PT frequency of two visits per week for three weeks and one visit per week for one week, effective 10/15/23. A review of the medical record showed one PT visit dated 10/17/23 and no other visits documented for the week of 10/15/23 to 10/21/23. Documentation showed no refusal of visits or services from the patient or caregiver and no contact made with the patient or caregiver and no physician order for a change in services. 3. Patient #6 A review of a physician’s order dated 10/05/23 showed an OT frequency of two visits per week for five weeks, effective 10/01/23. A review of the medical record showed one OT visit on 10/05/23 and no other visits documented for the week of 10/01/23 to 10/07/23. Documentation showed no refusal of visits or services from the patient or caregiver and no contact made with the patient or caregiver and no physician order for a change in services. 4. Patient #10 A review of a physician’s order dated 08/16/23 showed an order for an Xray of the left ribs and chest. A review of clinical records showed no evidence the procedure were carried out or completed. Documentation showed no change in the order. On 12/08/23 at 12:16 p.m., Staff B stated: 1. the SN frequencies for Patient’s #3 and #4 were not met as ordered by the physician; 2. the PT frequencies for Patient’s #3 and #6 were not met as ordered by the physician; 3. the OT frequencies for Patient #6 were not met as ordered by the physician; and 4. the Xray order for Patient #10 were not done and the order should have been clarified with the physician.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure a physician’s medication order were followed for one (Patient #2) of thirteen patients. A POC dated 09/11/23 to 11/09/23 showed a medication order for Oxycodone-Acetaminophen (brand name Percocet) 10 MG-325 MG tablet, with one tablet to administered daily for pain. A physician order dated 10/30/23 showed an order for Percocet 10 MG 1 tablet PO (by mouth) QID (four times a day) for pain. A review of a medication report showed both pain medication orders were current and scheduled to be given five times a day. Documentation showed no order clarification, no discontinuation of a pain medication order, and no changes in physician orders. On 12/08/23 at 12:11 p.m., Staff B confirmed both orders were current and stated the medication should have been checked for duplication and should have been clarified with the physician.”

“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 record review and interview, the agency failed to ensure OT evaluation was conducted for one (Patient #1) of thirteen patients. A POC dated 09/19/23 to 11/17/23 showed an OT frequency of one visit per week for one week, effective 09/24/23. Documentation showed no OT evaluation was conducted, no patient/caregiver refusal of the evaluation, no physician notifications and no changes in orders. On 12/08/23 at 12:07 p.m., Staff B stated there was no documentation of OT visits and stated it was missed and should have been conducted.”