Premier Health Care Services II

“Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This Element is not met as evidenced by: Based on record review and interview the agency failed to ensure the patient’s individualized plan of care was reviewed by the patient’s physician no less than once every 60 days, beginning with the start of care date in six (Clinical Records # 1, 3, 5, 6, 7 and 9) of 7 active clinical records and 2 (# 2 and 8) of 3 Discharged clinical records reviewed. The failure could place the patients at risk of not having physician oversight of care and treatment and not having an individualized plan of care developed in the required timeframe. Clinical Record #1: Record review of the clinical record for Patient # 1 contained a POC for the certification period of 08/20/2024 to 10/18/2024. The POC included a start of care date of 08/20/2024 with a primary diagnosis of essential hypertension (a condition identified by consistent high blood pressure without a known medical cause). The POC was signed by RN F and dated 08/20/2024. The POC contained an order for SN visits one time per week for nine weeks. The POC did not have a doctor’s signature or any documentation of the doctor reviewing the POC during the episode of care reviewed. On 12/18/2024 at 11:45 a.m. the surveyor asked the supervising nurse if the doctor reviewed and signed off on patient #1’s POC. The Supervising Nurse stated, “no, he didn’t sign it.” The surveyor asked the supervising nurse if the physician reviewed the plan of care. The supervising nurse stated, “no, I don’t think so.” Clinical Record #2: Record review of the clinical record for Patient #2 contained a POC for the certification period of 03/05/2024 to 05/03/2024. The POC included a start of care date of 03/05/2024 with a primary diagnosis of type 2 diabetes mellitus with hyperglycemia (a condition where the body does not use or produce enough insulin, leading to high blood sugar levels). The POC was signed by the Supervising Nurse and dated 03/05/2024. The POC contained an order for SN visits one time per week for 1 week and 3 times per week for eight weeks. The POC did not have a doctor’s signature or any documentation of the doctor reviewing the POC during the episode of care reviewed. On 12/18/2024 at 11:45 a.m. the surveyor asked the supervising nurse if the doctor reviewed and signed off on patient #2’s POC. The Supervising Nurse stated, “nope I don’t see it.” The surveyor asked the supervising nurse if the physician reviewed the plan of care. The supervising nurse stated, “I don’t know, probably not.” Clinical Record #3: Record review of the clinical record for Patient # 3 contained a POC for the certification period of 07/13/2024 to 09/10/2024. The POC included a start of care date of 05/17/2023 with a primary diagnosis of essential hypertension (a condition identified by consistent high blood pressure without a known medical cause). The POC was signed by the Supervising Nurse and dated 07/13/2024. The POC contained an order for SN visits one time per week for nine weeks. The POC did not have a doctor’s signature or any documentation of the doctor reviewing the POC during the episode of care reviewed. On 12/18/2024 at 11:45 a.m. the surveyor asked the supervising nurse if the doctor reviewed and signed off on patient #3’s POC. The Supervising Nurse stated, “no, that one isn’t signed either.” The surveyor asked the supervising nurse if the physician reviewed the plan of care. The supervising nurse stated, “I don’t know, probably not.” Clinical Record #5: Record review of the clinical record for Patient #5 contained a POC for the certification period of 08/17/2024 to 10/15/2024. The POC included a start of care date of 08/22/2023 with a primary diagnosis of spinal stenosis, lumbar region with neurogenic claudication (a condition that happens when the space inside the backbone is too small and caused numbness or weakness in the legs when walking). The POC was signed by the Supervising Nurse and dated 08/17/2024. The POC contained an order for SN visits three times per week. The POC did not have a doctor’s signature or any documentation of the doctor reviewing the POC during the episode of care reviewed. On 12/18/2024 at 11:45 a.m. the surveyor asked the supervising nurse if the doctor reviewed and signed off on patient #5’s POC. The Supervising Nurse stated, “no, that one isn’t signed either.” The surveyor asked the supervising nurse if the physician reviewed the plan of care. The supervising nurse stated, “I’m not sure.” Clinical Record #6: Record review of the clinical record for Patient #6 contained a POC for the certification period of 08/02/2024 to 09/30/2024. The POC included a start of care date of 03/22/2023 with a primary diagnosis of essential hypertension (a condition identified by consistent high blood pressure without a known medical cause). The POC was signed by RN K and dated 08/02/2024. The POC contained an order for SN visits one time per week for nine weeks. The POC did not have a doctor’s signature or any documentation of the doctor reviewing the POC during the episode of care reviewed. On 12/18/2024 at 11:45 a.m. the surveyor asked the supervising nurse if the doctor reviewed and signed off on patient #6’s POC. The Supervising Nurse stated, “no, it’s not.” The surveyor asked the supervising nurse if the physician reviewed the plan of care. The supervising nurse stated, “probably not.” Clinical Record #7: Record review of the clinical record for Patient #7 contained a POC for the certification period of 07/31/2024 to 09/28/2024. The POC included a start of care date of 07/31/2024 with a primary diagnosis of Atherosclerotic heart disease of native coronary artery w/o angina pectoris. The POC was signed by the Supervising Nurse and dated 07/31/2024. The POC contained an order for SN visits one time per week. The POC did not have a doctor’s signature or any documentation of the doctor reviewing the POC during the episode of care reviewed. On 12/18/2024 at 11:45 a.m. the surveyor asked the supervising nurse if the doctor reviewed and signed off on patient #7’s POC. The Supervising Nurse stated, “no.” The surveyor asked the supervising nurse if the physician reviewed the plan of care. The supervising nurse stated, “I don’t think so.” Clinical Record #8: Record review of the clinical record for Patient #8 contained a POC for the certification period of 02/14/2024 to 04/13/2024. The POC included a start of care date of 10/18/2023 with a primary diagnosis of Atherosclerotic heart disease of native coronary artery w/o angina pectoris (a condition when plaque builds up in the artery that supply blood to the heart which decreases the amount of blood that is supplied to the heart). The POC was signed by the Supervising Nurse and dated 02/14/2024. The POC contained an order for SN visits one time per week. The POC did not have a doctor’s signature or any documentation of the doctor reviewing the POC during the episode of care reviewed. On 12/18/2024 at 11:45 a.m. the surveyor asked the supervising nurse if the doctor reviewed and signed off on patient #8’s POC. The Supervising Nurse stated, “no.” The surveyor asked the supervising nurse if the physician reviewed the plan of care. The supervising nurse stated, “I don’t think so.” Clinical Record #9: Record review of the clinical record for Patient #9 contained a POC for the certification period of 10/07/2024 to 12/05/2024. The POC included a start of care date of 07/31/2024 with a primary diagnosis of cerebral infarct due to thombos [sic] of left middle cerebral artery (a type of stroke that occurs when blood flow to the brain is blocked due to blood that clots in an artery and does not allow blood around the blocked area). The POC was signed by RN K and dated 10/07/2024. The POC contained an order for SN visits three times per week for 9 weeks. The POC did not have a doctor’s signature or any documentation of the doctor reviewing the POC during the episode of care reviewed. On 12/18/2024 at 11:45 a.m. the surveyor asked the supervising nurse if the doctor reviewed and signed off on patient #9’s POC. The Supervising Nurse stated, “not that one either.” The surveyor asked the supervising nurse if the physician reviewed the plan of care. The supervising nurse stated, “no there’s nothing in there to show it was.” An interview was conducted with the Supervising Nurse (whom is also the Alternate Administrator) on 12/18/2024 at approximately 11:45 a.m. The surveyor asked who at the agency was responsible to make sure the plan of care is signed. The Supervising nurse stated, “I am. I sometimes have other people that will submit the plan of care to the system but I am the one who is responsible to make sure they are signed. The surveyor asked why patient # 1, 2, 3, 5, 6, 7, 8 and 9’s clinical records did not contain plan of cares that were reviewed by a physician no less than once every 60 days on the date the surveyor completed record reviews on 12/18/2024. The Supervising Nurse stated, “We upload them for the doctor to sign and we call to remind them but we can’t always get them to sign it. Some of the doctors are good but not all of them.” Review of agency policy titled “Orders for Care” no revision date read in part: “ ...Procedure... The plan of care must be reviewed and signed by the physician or allowed practitioner who established the plan of care… at least every 60 days. Each review of a patient’s plan of care must contain the signature of the physician or allowed practitioner and the date of review.””