Every finding on record at 1st Choice Home Health Care, Inc

At this Emergency Preparedness survey, 1st Choice Home Health Agency was found to be in compliance with 42 CFR 484.102, Emergency Preparedness Requirements for Medicare Participating Providers and Suppliers. State of Alaska DOH/HCS Health Facilities Licensing and Certification 4601 Business Park Blvd.,Bldg. K Anchorage, AK 99503

. The following deficiencies were noted during an unannounced Medicare/Medicaid complaint investigation survey conducted at 1st Choice Home Health Care Inc. This survey became fully extended on 7/13/23 and a recertification survey was conducted. The sample included 10 closed records, 8 active records, and 1 non-admit record (a referral only). Census: Unduplicated skilled admissions in previous 12 months: 145 patients It was determined that the facility was not in compliance with the Condition for Participation (CoP) requirements under 42 CRF §484.60 Care Planning, Coordination of Services and Quality of Care and in addition to the following Standard level citations. Complaint #98903 was found to be substantiated. Federal deficiencies were cited. Complaint #97801 was found to be substantiated. Federal deficiencies were cited. Complaint #97220 was found to be substantiated. Federal deficiencies were cited. State of Alaska DOH/ HCS Health Facilities Licensing & Certification 4601 Business Blvd., Bldg. K Anchorage, AK 99503 .

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Outcome Assessment and Information Set (OASIS) data were submitted within 30 days of collection for 2 of 18 clinical records, #2 and #4, reviewed for patients who qualified for OASIS data collection. Findings: Patient #2 Record review on 7/11-13/23 revealed Patient #2 was admitted to HHA with a diagnosis of encounter for attention to cystostomy (a surgical procedure that creates an opening in the urinary bladder). Review of Patient #2 “Recertification and Other Follow-up,” imported on 2/9/23, revealed: “Trns [transmitted] date: 4/18/23…accepted date: 4/18/23.” Review of the OASIS Agency Final Validation” report for Patient #2 recertification revealed “submission date 4/18/23…Completion date 4/18/23…Record Submitted Late: The submission date is more than 30 days…” Review of Patient #2 Plan of Care updates signed by the physician on 3/21/23, revealed: “…Discharge date: 3/3/23. Reason for discharge: Patient is being DC [discharge] from [the home health agency] to transfer to different HH (home health) due to PT [physical therapy availability] …” Review of the OASIS Agency Final Validation” report for Patient #2 discharge revealed “submission date 5/10/23…Completion date 5/10/23…Record Submitted Late: The submission date is more than 30 days…” During an interview on 7/13/23 at 8:42 AM, the Administrator confirmed the OASIS information submission was late. She explained the recertification assessment was rejected due to incorrect entries. The Administrator also stated she could not remember what happened. Patient #4 Record review on 7/11-13/23 revealed Patient #4 was admitted to HHA with a diagnosis of encounter for fitting and adjustment of urinary device. Review of Patient #4 “Transfer to Inpatient Facility,” revealed: “Trns [transmitted] date:1/25/23…accepted date: 1/25/23.” Further review revealed: “…2. (M0090) Date Assessment Completed: 11/24/22, 3 QM (M0100) This assessment is Currently Being Completed for the following Reason…Transferred to an inpatient facility -patient discharged from agency…Complete Discharge Summary…” Review of the OASIS Agency Final Validation” report for Patient #4 discharge revealed “submission date 1/25/23…Completion date 1/25/23…Record Submitted Late: The submission date is more than 30 days…” During an interview on 7/13/23 at 2:15 PM, the Administrator confirmed the OASIS information submission was late. She explained the discharge summary was not completed. Review of HHA (Home Health Agency)’s policy “Reporting of OASIS Information,” dated 2/2021, revealed: “The Agency will report required data collected for the…[OASIS] items…Agency will electronically transmit completed, encoded and locked OASIS data for each completed OASIS assessment at least monthly to the System…”

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure the patient or representative was informed of the discontinuation of Skilled Nursing (SN) visits and discharge for 1 patient (#7) out of 10 sampled closed patients. This failed practice placed the resident at risk of not receiving necessary nursing care and worsening of patient’s condition. Findings: Record review on 7/11-13/23 revealed Patient #7 was admitted to the Home Health Agency (HHA) with a diagnosis of Pressure Ulcer of Sacral Region, Stage 2. The Patient received 1 Skilled Nursing (SN) visit once a week for wound care. Review of the Plan of Care (POC), dated 1/11/23, revealed SOC: 12/22/22, certification period 12/22/22 to 2/19/23. During a joint interview on 7/11/23 at 2:13 PM, the Administrative Assistant (AA) stated Patient #7 discharged from the HHA on 12/22/22. The Administrator stated there was no other SN visit after the discharge. Review of SN visit notes revealed there were visits on 12/22/22, 12/27/22, 1/5/23, and 1/19/23. During an interview on 7/13/23 at 9:28 AM, when asked why there were SN visits after the discharge date of 12/22/22, the Administrator stated, “I don’t remember what happened.” The Administrator stated there was no documented family communication about the discontinuation of the SN visits and discharge. Review of the HHA’s “Patient Orientation for Home Health Care,” handbook, revised 4/22, revealed “Patient Rights and Responsibilities…you have the right to : Participate in, consent to or refuse care in advance and during treatment and be fully informed in advance about your care/service, where appropriate, including…completion of all assessments…any changes in the care to be provided…the reason for impending discharge or transfer to another agency…” .

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure that the patients' right to be advised of the State of Alaska Department of Health, Health Facility Licensing and Certification department's toll - free hotline number and its purpose had been communicated to the patients / patient representatives. This failed practice denied patients and / or representatives information needed to file a grievance / complaint with the State Agency. Findings: A review of the admission folder titled "Patient Orientation for Home Health Care" revised 4/22 failed to include the State of Alaska Department of Health, Health Facility Licensing and Certification's name in the Problem-Solving Procedure section of the folder. This section stated, "You may also make a confidential complaint, ask questions about local home health agencies or lodge complaints concerning the implementation of the advance directive requirements to Certification and Licensing. The toll - free hotline number is 1-888-387-9387. The alternate number during working hours [8:00 AM to 4:30 PM., Monday through Friday] is 907-334-2483. The hotline is 24 hours a day. After working hours, please leave a voicemail and calls will be returned as soon as possible." During an interview on 7/17/23 at 6:00 PM, Patient #19 stated no awareness on how to contact the state home health hotline number and would like to become knowledgeable about how to contact the state hotline number. During an interview on 7/18/23 at 9:00 AM, the Administrator / Clinical Manager stated that the state department of health's phone number was in the admission folder.

Standard: Initial assessment visit. CFR(s): 484.55(a) Standard: Initial assessment visit. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to complete the initial assessment within 48 hours of 1 referral from 18 referrals reviewed (#10). This failed practice had the potential to cause a delay in needed treatment and a possible delay in wound healing for this patient. Findings: Record review on 7/11-13/23 revealed Patient #10 was not admitted to the Home Health Agency (HHA) and did not have an initial assessment conducted within 48 hours of the referral dated 1/20/23. The guardian signed consent to start care and documents on 1/25/23. However, no initial assessment was conducted within 48 hours of the consents being signed. Further review of the clinical record on 7/13/23 revealed an Intake and Communication Sheet dated 1/20/23 with the Patient #10's name and contact information. The Start of Care was scheduled for 1/23/23 and services ordered were Skilled Nurse (SN). The referral was dated 1/20/23. Further review of the clinical record on 7/13/23 revealed the guardian for patient #10 completed signing consents for treatment on 1/25/23. A physician order dated 1/20/23 revealed, "Wound Care Left heel ulcer evaluate and treat." A second physician order dated 1/20/23 revealed, "CMP [Complete Metabolic Panel] and CBC [Complete Blood Count]" (These are two Laboratory or blood tests to measure parts of the blood). During an interview on 7/13/23 at 12:45 PM, the Assisted Living Administrator where Patient #10 resided revealed that the initial assessment and the start to the agency care was very delayed. The SN had to reschedule the initial assessment, and this delayed the wound assessment and wound care for this patient. A new home health agency was obtained. During an interview on 7/13/23 at 12:49 PM, Complainant #1 revealed that another home health agency started home health services with this patient on 2/2/23. During an interview on 7/13/23 at 1:05 PM, the Administrator / Clinical Manager agreed that an initial assessment was delayed. She revealed, "We had to reach out to the guardian, but it took time to get this together." During an interview on 7/13/23 at 1:42 PM, the Administrative Assistant agreed that the referral was received on 1/20/23 and the initial assessment was set up for 1/23/23. The guardian was slow to return consent forms which also delayed the start of care. The request was withdrawn by the Assisted Living Facility and the date of this withdrawal was not known. She revealed that the request for withdrawal may have occurred on 1/30/23. Review of the agency's policy titled "Initial Assessments / Comprehensive Assessments" dated 2/2022 stated, "Initial assessment and time frame ... A RN, PT or SLP must conduct the initial assessment visit within 48 hours of referral ..." .

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: This condition is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patients' medical and nursing needs were met for 2 patients who did not receive timely and adequate nursing care for wound care by licensed nursing staff (see G 570); failed to ensure the patient received the home health services written in the individualized plans of care (see G 572); and the agency failed to ensure discharge planning was completed for 1 patient out of 10 sampled discharged patients (see G 598). These failed practices had the potential to affect all patients of the agency to receive less than optimal care as ordered by the physician. The cumulative effect of these systemic problems resulted in the home health agency's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation 42 CFR 484.60 Care Planning, Coordination of Services and Quality of Care. Based on record review and interview, the agency failed to ensure the patients' medical and nursing needs were met for 2 patients (#6 and #10). This failed practice resulted in Patient #6 requiring a higher level of care, and Patient #10 to start care with another agency. Findings: Patient #6 Record review on 7/11/23 - 7/13/23 with a start of care dated 11/15/22 and a diagnosis of pressure ulcer of sacral region, stage 3, failed to evidence skilled nursing was provided as needed to keep the patient in the home. Record review revealed a Home Health Certification and Plan of Care with a certification period of 11/15/22 - 1/13/23 with Skilled nurse visits ordered for wound care 1 times a week for 9 weeks with 6 as needed visits also ordered for signs and symptoms of infections, falls, patient decline, medication management, wound development and / or care, and resumptions of care. The verbal order date for this plan of care was 11/16/22. Skilled nurse visit notes evidenced skilled nursing visits were completed on 11/15/22, 11/22/22, and 11/28/22. After the 11/28/22 visit note, there were no other skilled nurse visit notes found in the clinical record. Further review revealed an Office Visit note dated 12/2/22 with Patient #6's medical provider, a Nurse Practitioner. Documentation revealed on 11/10/22 the wound measured 8 centimeters (cm) X 3 cm and was noted to have surrounding cellulitis which was treated by antibiotics and on 12/2/23 measured 4 X 4.5 cm. This Nurse Practitioner note revealed, "Recent decubitus ulcer appears to be improving but still 4 X 4.5 cm with central slough and debridement needed. Would benefit from minimum of twice weekly wound care visits and also pressure reducing sleep surface and wheelchair pad to prevent progression." Further review evidenced a Home Health External Ambulatory referral dated 12/8/22. This order revealed, "Ulcer of coccyx needs to be cared for two times a week." An additional similar referral dated 12/8/22 stated, "Ulcer of coccyx needs to be cared for every week." There was no clarification found in the record during review. Further review evidenced a Patient Communication note dated 12/9/22 completed by the Intake Coordinator. This note revealed, "[Power of Attorney (POA)] called again, wondering when the nurse be by to see [Patient #6]. [POA] seems worried and is wondering why [Patient #6] hasn't been seen in so long. I informed [POA] [LN# 3] has been in jury duty. Wound care order is meant for patient to be ... twice a week instead of once a week. [Patient #6] is scheduled to be seen tomorrow 12/10/22." Further record review evidenced the patient entered the hospital on 12/14/22. This document titled "Death Summary" dated 12/22/22 stated, "[Patient #6] ... resides in ... Assisted Living with history of decubitus wound sacral region being managed by wound care and primary care provider presented to the ER [Emergency Room] as wound care has not been able to get to the nursing home the last couple of weeks and at this time was found to have a wound that is progressing and having some discharge." During an interview on 7/13/23 at 1:22 PM, the Administrator / Clinical Manager stated the nurse had missed a visit, when asked why visits were missed and if the patient's needs were met. She also stated, that the missing visit was discussed in case conference. She further stated that the skilled staff work together to ensure that visits were completed and not missed. Record #10 Record review on 7/11-13/23 revealed Patient #10 was not admitted to the Home Health Agency (HHA) and did not have an initial assessment conducted within 48 hours of the referral dated 1/20/23. The guardian signed consent to start care and documents on 1/25/23. However, no initial assessment was conducted within 48 hours of the consents being signed and the patient did not start care or receive care by the agency nurse. Further review of the clinical record on 7/13/23 revealed an Intake and Communication Sheet dated 1/20/23 with the Patient #10's name and contact information. The Start of Care was scheduled for 1/23/23 and services ordered were Skilled Nurse (SN). The referral was dated 1/20/23. Further review of the clinical record on 7/13/23 revealed the guardian for patient #10 completed signing consents for treatment on 1/25/23. A physician order dated 1/20/23 revealed, "Wound Care Left heel ulcer evaluate and treat." A second physician order dated 1/20/23 revealed, "CMP [Complete Metabolic Panel] and CBC [Complete Blood Count]" (These are two Laboratory or blood tests to measure parts of the blood). During an interview on 7/13/23 at 12:45 PM, the Assisted Living Administrator where Patient #10 resided revealed that the initial assessment and the start to the agency care was very delayed. The SN had to reschedule the initial assessment, and this delayed the wound assessment and wound care for this patient. A new home health agency was obtained. During an interview on 7/13/23 at 12:49 PM, Complainant #1 revealed that another home health agency started home health services with this patient on 2/2/23. During an interview on 7/13/23 at 1:05 PM, the Administrator / Clinical Manager agreed that an initial assessment was delayed. She revealed, "We had to reach out to the guardian, but it took time to get this together." During an interview on 7/13/23 at 1:42 PM, the Administrative Assistant agreed that the referral was received on 1/20/23 and the initial assessment was set up for 1/23/23. The guardian was slow to return consent forms which also delayed the start of care. The request was withdrawn by the Assisted Living Facility and the date of this withdrawal was not known. She revealed that the request for withdrawal may have occurred on 1/30/23. Review of the policy "Care Planning Process" dated 2/2021 revealed, "In order to assure that care is provided is appropriately planned to meet each patient's specific needs and problems, the agency will utilize data / information gathered during patient assessments in the care planning process." Review of the policy "Initial Assessments / Comprehensive Assessments" dated 2/2022 stated, "The Initial Assessment bridges the gap between when the first patient encounter occurs and when a plan of care can be implemented. 'Immediate care and support needs' are those items and services that will maintain the patient's health and safety through this interim period."

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review, interview and document review, the agency failed to ensure the patients (#6 and #15) received the home health services written in the individualized plans of care. This failed practice had the potential to affect all patients of the agency to receive less than optimal care as ordered by the physician. Findings: Record #6 Record review on 7/11 - 13/23 revealed Patient #6, Start of Care 11/15/22 was admitted to the facility with a diagnosis of Alzheimer's disease with late onset and Pressure ulcer of sacral region, stage 3. Review of the Home Health Certification and Plan of Care for the Certification Period of 11/15/22 - 1/13/23 revealed the Skilled Nurse was to visit for cognitive assessments, end of life care, nutrition monitoring and wound evaluation with 6 as needed visits for signs and symptoms of infection, falls, patient decline, medication management, Wound development and care and resumptions. On 11/23/22 a plan of care update revealed, "Autolytic debridement dressing over the wound as prescribed: Wound is located on the sacrum, remove old dressing, cleanse gently with normal saline solution, wound cleanser and gauze, apply dressing as follows: use calmoseptine, cover with mepilex dressing. At what frequency to do wound care: weekly and / or daily as needed for soiled dressings. Teach patient / caregiver to perform wound care - Caregiver aware of how to perform dressing changes. Immediately notify provider of any worsening / healed wounds. " Further review revealed Skilled nurse visit notes completed on 11/15/22, 11/22/22, and 11/28/22. After the 11/28/22 visit note, no other skilled nurse visit notes were found in the clinical record. Record #15 Record review on 7/11-13/23 revealed Patient #15, Start of Care 6/8/22 was admitted to the facility with a diagnosis of unspecified wound of left lower leg. Review of the patient's orders and Home Health Plan of care for the certification period of 6/2/23 - 7/31/23 failed to reveal an order for a wound treatment which was completed by the skilled nurse (SN) #1 on 7/11/23. A Visit Information note signed by SN #1 on 7/11/23 revealed, "Left leg from knee to foot is a scabbed rash on patient leg, healing, but pt [patient] continues to scratch. Cleaned leg with WC [wound cleanser] and gauze, covered leg with Cortisone 10 ointment. Clean technique used and Pt tolerated well." During an interview on 7/13/23 at 3:00 PM, the Administrator / Clinical Manager stated that there was no order for this over-the-counter treatment. Review of the policy "Professional Standards of Practice" dated 10/2017 stated, "Agency staff will provide care, treatment and services according to the plan of care."

Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure 1 patient record (#12) of 18 reviewed was accurate and adhered to clinical record documentation standard of practice. Findings: Patient #12 Record review on 7/13/23 at 11:43 AM revealed Patient #12 was admitted to HHA with a Start of Care (SOC) on 12/22/22, certification period 4/20/23 to 6/18/23 with a diagnosis of pressure ulcer of right buttocks, Stage 2. Missed Visit During an interview on 7/18/23 at 11:45 AM, the Administrative Assistant (AA) stated there was a missed Skilled Nursing (SN) visit for Patient #12 on 6/22/23 that was not documented. The AA stated that she called SN #1, who confirmed that missed visit. The AA further stated she would inform the physician of that missed visit. During an interview on 7/18/23 at 1:48 PM, the Administrator stated the SN should have reported the missed visit that same day. SN Visit Review of the “Lab[laboratory] Order,” dated 5/31/23, revealed: “…please perform the following” T-4, Free #866 [and TSH #899…” Review of Patient #12’s SN “Visit Information”, dated 6/12/23, revealed: “…attempted to a blood draw but unable to get at this time…” the notes further revealed: “…6/13/23: Attempted blood draw…but not draw out. Contacted [SN #2] who is scheduled to attempt [blood] draw… [on 6/14/23].” Review of Patient #12’s SN visits for the month of June 2023, no documentation of the SN visit for 6/14/23. During an interview on 7/18/23 at 2:49 PM, Administrator and SN #2 stated he/she went to Patient #12’s home to help SN #1 to perform a blood draw. When asked if that visit was documented in the patient’s chart, SN #2 stated SN #1 did not document the visit in the chart. SN #2 stated SN#1 should have documented the visit within 5 business days. SN #2 further stated he/she re-educated SN #1 on 7/18/23. Review of the Home Health Agency (HHA)’s policy “Timely Submission of Patient Documentation,” dated 2/2021, revealed: “The Agency will ensure the timely submission of patient documentation…, must be submitted the next scheduled workday, not exceeding three (3) business days…” Review of the HHA’s policy “Medical Record Content,” dated 2/2022, revealed: “…The Agency will initiate and maintain an individual and accurate medical record for each patient…”

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on record review and interview the facility failed to ensure all entries in the medical record are complete and appropriately authenticated for 1 clinical record(#16) out of 18 clinical records reviewed. This failed practice placed patients at risk of having inaccurate health information. Findings: Record review on 7/17/23 12:02 PM revealed Patient #16 was admitted to the HHA with a Start of Care (SOC) on 6/21/23, certification period 6/21/23 to 8/19/23 with a diagnosis of Epilepsy (a neurological disorder that causes seizures or unusual sensations and behaviors). Review of the Plan of Care on 7/17/23 at 12:05 PM revealed a Skilled Nursing (SN) evaluation and consult. Review of the SN visit “Nursing Intervention,” dated 6/22/23 by SN #2 revealed the primary service provided was skilled intervention that included vital signs, patient assessment, and medication reconciliation. Review of the SN visit “Nursing Intervention,” dated 6/29/23 by SN #2 revealed the primary service was skilled intervention that included vital signs, patient assessment, and medication reconciliation. Review of Patient #16 hard chart revealed SN visit “Start or Resumption of Care,” dated 6/29/23 by SN #1. The SN#1 filled-out the full form for Patient’s assessment. The form further revealed a handwritten note that read: “Wrong visit type to file.” During an interview on 7/18/23 at 3:00 PM, the Administrator stated during an audit she caught that SN #1 did a wrong visit type on 6/29/23, SN #1 had start or resumption of care visit instead of a regular SN visit because it was SN #1’s first visit to the Patient. The Administrator also explained the start of resumption of care visit was conducted already on 6/22/23. The Administrator explained that she corrected the visit information and entered her name instead of SN #1. The Administrator stated that she should have written SN #1’s name. Review of the Home Health Agency (HHA)’s policy “Medical Record Content,” dated 2/2022, revealed: “…The Agency will initiate and maintain an individual and accurate medical record for each patient…”

The following deficiency was identified during a Federal complaint investigation of a deemed facility. Complaint #70770: Substantiated. Facility #: 02 - 7020 HHA #: 004 Skilled Unduplicated Patients in last 12 months: 255 Total # of Active Patients: 76 Discharge # in past 6 months: 71 State of Alaska DHSS/HCS Health Facilities Licensing & Certification 4601 Business Park Blvd., Bldg K Anchorage, AK 99503

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure coordination of care was completed with the patient / patient representative as appropriate, in the coordination of care activities for 1 of 4 active records reviewed (# 1). This failure had the potential to affect the communication and knowledge of all those involved in the patient's care and needs. Review of Record #1 revealed Patient # 1's start of care was 3/7/22. The start of care document evidenced the patient was chairfast, unable to ambulate and was unable to propel self and had a manual wheelchair. The Home Health Certification and Plan of care received 3/29/22 for the certification period of 3/7/22 - 5/5/22 stated, "POC [Plan of care] update ordered 3/7/22 PT [Physical Therapy] evaluation and consult evaluation for WC [wheelchair] fit and supplies." Review of a Progress note dated 3/1/22 from Patient #1's physician revealed the physician had documented that the patient was in a borrowed wheelchair that was too small for the patient. A physician's order, dated 3/1/22, evidenced an order for a evaluation for wheelchair fit / supplies. A physical therapist evaluation dated 3/14/22 revealed Physical Therapist # 1 had completed a wheelchair assessment and had a second visit scheduled for a "Tilt N Space" Wheelchair fitting. A second physical therapist visit, dated 3/21/22, revealed Physical Therapist #1 had a completed a second visit for a "Tilt N Space" wheelchair. A durable medical equipment employee was present to obtain the patient's measurements for the wheelchair. On 6/14/22 at 4:35 PM, Patient #1's power of attorney stated dissatisfaction that the wheelchair had never occurred and dissatisfaction with that plan of care intervention. On 6/15/22 at 11:10 AM, when asked where the coordination of care was regarding the lack of a wheelchair for Patient # 1, Physical Therapist #1 stated that there was a lack of coordination of care documentation in the record. Physical Therapist #1 stated that she had discussed the wheelchair's delay with the power of attorney. Physical Therapist #1 stated that the arrival of the wheelchair might take months. On 6/15/22 at 11:10 AM, the Administrator agreed that the lack of coordination of care was due to a lack of documentation in the record. The Administrator stated, "If you don't document it, it is not done." Review of a policy titled "Coordination of Patient Care" revised February 2021 stated, "The agency must ... coordinate care delivery to meet the patient's needs, and involve the patient, representative [if any] and caregivers, as appropriate, in the coordination of care activities."