Star Care Home Health, LLC

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on record review and interview the agency failed to enforce a written policy that addressed applicable state laws or established the time frame for the countersignature of a physician’s verbal order for 2 of 5 active clients (Client #1 and #3) reviewed receiving skilled care. This failure had the potential to result in the agency failing to provide care in accordance with physician’s orders. Review of Client #1’s clinical record indicated a plan of care, certification period 12/08/2024 to 02/05/2025, signed by the physician on 02/18/2025 and the agency received the signed order of 02/18/2025 on 03/06/2025. Review of Client #3’s clinical record indicated a plan of care, certification period 02/08/2025 to 04/08/2025, signed by the physician on 05/01/2025 and the agency received the signed order of 05/01/2025 on 05/07/2025. During an interview, with RN, Alternate Administrator, on 05.14.205 @ 8:50am when asked about the policy for the time frame for obtaining doctor signatures, she said, “usually three days but it the just depends.” During an interview on 05.14.2025 @ 9:00am, with administrative staff H, said once we get the list of orders from the alternate administrator, usually it takes about 3 days and then sent to the physician’s office and usually returned signed within a week or two. When asked about the policy time frame for obtaining the signatures, she said, “I do not know about a week or two.” During an interview on 05.14.2025 @ 10:05am, with LVN C when asked about the agency’s policy & procedures for obtaining the doctors signature for verbal orders and sending it for countersignatures, she said, “I believe it is seven days, but not for sure. When I receive one, I give it to the DON, and she cosigns and sends it to the doctor.” When asked the time frame for obtaining the signature the policy states, she said, “I do not know.” During an interview on 05.14.2025 @ 10:40am, with Administrator , when asked the agency’s policy for obtaining doctor signatures for verbal order, she said, “when the order is obtained its dated and signed, if by a LVN then it is cosigned by an RN then sent to QA for processing and then to the doctor.: When asked the time frame for obtaining the signature, she said, “thirty days, I am pretty sure that’s what the policy states.” During an interview on 05.15.2025 @ 8:50am, with RN, Alternate Administrator, when asked, why orders were not being signed per HHA policy, she said, “that it was difficult because the physicians at the clinic were leaving, and patients were being assigned new physicians. We would send the orders to be signed and when we go get them, we were told they were not received and would have to resend them.” Review of an agency policy titled “Orders for Care”, ), dated 050124, “The Agency will obtain orders and provide care in accordance with physician’s and/or non-physician practitioner’s orders which are established prior to initiating patient/client care and reviewed by the physician and/or non-physician practitioner every 60 days and as needed. XIV. Verbal orders must be authenticated and dated by the physician and/or non-physician practitioner. Physician and/or non-physician practitioner signatures are obtained on Plan of Care and supplemental verbal orders within sixty (60) days or prior to billing for the services provided, or as required by payor.””