CARING NURSES, INC.
SOC HHRG
Patient: PACIELLO, VIRGINIA- MR# 900003020
Chart: 8 Episode: 1
Patient Care Assistant: son is assisting with care.
Visit Date: 08/27/2024
Problems:
Dysphagia, AFIB, COPD, CHF, Chronic pain syndrome, Thrombocytopenia, O2 dependence, Right lower leg trauma

Tests
CLOX:
fail

08/27/2024
OASIS-D
Joan Leyderos
Assessor
(M0030) Start of Care Date:
08/27/2024

(M1030) Therapies the patient receives at home: (Mark all that apply.)

(M1033) Therapies the patient receives at home: (Mark all that apply.).
1 - History of falls (2 or more falls - or any fall with an injury - in the past 12 months)
2 - Unintentional weight loss of a total of 10 pounds or more in the past 12 months
4 - Multiple emergency department visits (2 or more) in the past 6 months
5 - Decline in mental, emotional, or behavioral status in the past 3 months
6 - Reported or observed history of difficulty complying with any medical instructions (for example, medications, diet, exercise) in the past 3 months
7 - Currently taking 5 or more medications
8 - Currently reports exhaustion

(M1200) Vision (with corrective lenses if the patient usually wears them):

(M1242) Frequency of Pain Interfering with patient's activity or movement:

(M1400) When is the patient dyspneic or noticeably Short of Breath?
3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation

(M1610) Urinary Incontinence or Urinary Catheter Presence:
1 - Patient is incontinent

(M1620) Bowel Incontinence Frequency:
3 - Four to six times weekly

(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, or b) necessitated a change in medical or treatment regimen?
0 - Patient does not have an ostomy for bowel elimination.
(M1800). Grooming: Current ability to tend safely to personal hygiene needs (specifically: washing face and hands, hair care, shaving or make up, teeth or denture care, or fingernail care).
2 - Someone must assist the patient to groom self.

(M1810) Current Ability to Dress Upper Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:
2 - Someone must help the patient put on upper body clothing.

(M1820) Current Ability to Dress Lower Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:
2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.

(M1830) Bathing: Current ability to wash entire body safely. Excludes grooming (washing face, washing hands, and shampooing hair).
3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.

(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.
2 - Unable to get to and from the toilet but is able to use a bedside commode (with or without assistance).

(M1850) Transferring: Current ability to move safely from bed to chair, or ability to turn and position self in bed if patient is bedfast.
2 - Able to bear weight and pivot during the transfer process but unable to transfer self.

(M1860) Ambulation/Locomotion: Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces.
3 - Able to walk only with the supervision or assistance of another person at all times.

(M2030) Management of Injectable Medications: Patient's current ability to prepare and take all prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals. Excludes IV medications.
NA - No injectable medications prescribed.

Home Health Certification and Plan of Care
08/27/2024
Skilled Nursing Joan Leyderos
Added by: Ron 08/28/24 03:16 PM
1Week9
08/27/24 - 10/25/24
9
PRN
08/27/24 - 10/25/24
2
Primary Care Physician DR. DONIELLE FREEDMAN
PECOS Enrolled
Physician Scheduled Visit 11/03/2018: DR. ELIZABETH BROWN
08/30/2020: DR. RANA ADEEL
08/28/2020: DR. RANA ADEEL
09/29/2020: DR. KRISTINA JONES
10/06/2020: DR. KRISTINA JONES
10/13/2020: DR. KRISTINA JONES
10/27/2020: DR. KRISTINA JONES
11/03/2020: DR. KRISTINA JONES
11/10/2020: DR. KRISTINA JONES
11/05/2020: DR. KATHLEEN WAIRIMU
11/17/2020: DR. KRISTINA JONES
11/24/2020: DR. KRISTINA JONES
12/01/2020: DR. KRISTINA JONES
12/08/2020: DR. KRISTINA JONES
12/15/2020: DR. KRISTINA JONES
12/22/2020: DR. KRISTINA JONES
12/29/2020: DR. KRISTINA JONES
05/11/2021: DR. KRISTINA JONES
05/18/2021: DR. KRISTINA JONES
05/25/2021: DR. KRISTINA JONES
06/08/2021: DR. KRISTINA JONES
06/15/2021: DR. KRISTINA JONES
09/15/2021: DR. KRISTINA JONES
09/22/2021: DR. KRISTINA JONES
10/13/2021: DR. KRISTINA JONES
10/20/2021: DR. KRISTINA JONES
10/27/2021: DR. KRISTINA JONES
11/03/2021: DR. KRISTINA JONES
11/10/2021: DR. KRISTINA JONES
11/17/2021: DR. KRISTINA JONES
11/24/2021: DR. KRISTINA JONES
01/05/2022: DR. KRISTINA JONES
01/12/2022: DR. KRISTINA JONES
01/19/2022: DR. KRISTINA JONES
01/26/2022: DR. KRISTINA JONES
02/28/2022: DR. ADAM LUCKETTE
08/30/2023: DR. JESSICA COOKS
Reported to: Ron 08/28/2024 03:16 PM
Printed By/Date/Time: 09/19/2024 02:19 AM