Quality Care Home Health, Inc.

“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: 1. SN frequencies were followed as ordered for two (Patients #1 and 3) of nine patients; 2. PT and OT evaluations were conducted as ordered for one (Patient #2) of nine patients; 3. SN provided oxygen treatment as ordered for one (Patient #4) of nine patients; 4. SN notified the physician of systolic and diastolic blood pressure levels outside the ordered parameters for one (Patient #6) of nine patients; and 5. SN notified the physician of pain levels outside the ordered parameters for one (Patient #7) of nine patients. 1. Patient #1 A review of the POC dated 01/17/24 to 03/16/24 showed a SN frequency of once a week for eight weeks. A review of clinical records showed the following: A SN missed visit note dated 01/25/24 documented the reason for the missed visit as client refused, and no other visits documented for the week of 01/21/24 to 01/27/24. 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. A SN missed visit note dated 02/01/24 documented the reason for the missed visit as physician appointment, and no other visits documented for the week of 01/28/24 to 02/03/24. 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. A SN missed visit note dated 02/15/24 documented the reason for the missed visit as client refused, and no other visits documented for the week of 02/11/24 to 02/17/24. 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 #3 A review of the POC dated 12/29/23 to 02/26/24 showed a SN frequency of once a week for nine weeks. A review of a SN missed visit note dated 02/21/24 documented the reason for the missed visit as client refused, and no other visits documented for the week of 02/18/24 to 02/24/24. 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 #2 A review of a physician’s order dated 01/16/24 showed an order for PT and OT to evaluate and treat. Documentation showed no PT or OT evaluations were conducted, no patient/caregiver refusal of the evaluations, no physician notifications, and no changes in orders. 3. Patient #4 A review of the POC dated 01/01/24 to 02/29/24 showed an order for oxygen at 2 liters nasal cannula as needed. A review of clinical records showed the following: A SN visit dated 01/11/24 showed the patient’s oxygen at 2.5 liters per minute continuous. Documents showed no order for oxygen to be increased or a change in treatment by the physician. A SN visit dated 01/27/24 showed the patient’s oxygen at 2.5 liters per minute continuous. Documents showed no order for oxygen to be increased or a change in treatment by the physician. A SN visit dated 02/01/24 showed the patient’s oxygen at 2.5 liters per minute continuous. Documents showed no order for oxygen to be increased or a change in treatment by the physician. 4. Patient #6 A review of the POC dated 10/09/23 to 12/07/23 showed an order for the physician to be notified of systolic blood pressure greater than 180 and diastolic blood pressure less than 50. A review of clinical records showed the following: A SN visit dated 10/26/23 showed a systolic blood pressure reading of 188. Documents showed no physician notification for the systolic blood pressure reading greater than 180. A SN visit dated 11/09/23 showed a diastolic blood pressure reading of 42. Documents showed no physician notification for the diastolic blood pressure reading less than 50. 5. Patient #7 A review of the POC dated 09/18/23 to 11/16/23 showed an order for the physician to be notified of pain greater than six out of ten. A review of clinical records showed the following: A SN note dated 09/19/23 showed the patient’s reported pain as seven out of ten. Documents showed no physician notification for the reported pain greater than six. A SN note dated 10/05/23 showed the patient’s reported pain as eight out of ten. Documents showed no physician notification for the reported pain greater than six. A SN note dated 10/12/23 showed the patient’s reported pain as seven out of ten. Documents showed no physician notification for the reported pain greater than six. On 04/25/24 at 1:15 p.m., Staff A stated: 1. the SN frequencies for Patients #1 and 3 were not met as ordered by the physician; 2. PT and OT evaluations were not conducted for Patient #2 and there was no documentation of visits; 3. there was no order to increase the oxygen level or a change in treatment by the physician for Patient #4; 4. there was no documentation of physician notification of the systolic and diastolic blood pressure readings being out of parameter for Patient #6; and 5. there was no documentation of physician notification of the pain levels being out of parameter for Patient #7.”