Every finding on record at 5 Star Home Health Services LLC

An unannounced Complaint, Number 2021009200, survey was conducted on 07/20/2021 at Doctors Choice Home Care, Inc Home Home Health Agency. The Home Health Agency was not in compliance with 42 CFR 484 Subpart A-C, Requirements for Home Health Agencies.

Property and person treated with respect CFR(s): 484.50(c)(1) Have his or her property and person treated with respect; This ELEMENT is not met as evidenced by: Based upon interview and clinical record review the agency failed to treat a patient with respect, related to addressing a person in derogatory manner for one ( Patient # 1) of three patient records reviewed. Findings: During an interview on 07/20/21 at 1:38 PM with Registered Nurse (RN) Supervisor Staff B she stated, the RN that was involved in the initial assessment stated (during interview with the clinical staff,) she asked the patient how she identified her race and if she identified herself (Race) as a negro. The Nurse completing the assessment admitted that the word Negro was not on the admission assessment form related to race. The Oasis nor the initial assessment had Negro identified in relation to race identification. Attempts were made to contact the nurse directly involved. No return call. A review of the Oasis form does not show to address race as negro or nigger. A review of the nursing assessment dated 03/11/2021 read (M0140) Race/Ethnicity: (mark all that apply 1. American Indian or Alaska native, 2 Asian, 3 Black or African American (Checked) 4. Hispanic or Latino. 5. Native/Hawaiian or Pacific Islander. 6. White. There is no designation on the form to indicated Negro or nigger. A review of the patient complaint form dated 03/11/21 and resolved 03/15/21 at 1:15 PM read, Patient #1 had called to report admitting Registered Nurse (RN Staff C offended her during visit. Patient reported RN asked her if she was a nigger or negro. Patient spoke to Staff D, Clinical Supervisor. Patient stated she would call corporate office also to file complaint. Staff D gave her Staff E name to follow up. Policy and procedure requested from Staff B Nursing Supervisor on 07/20/21 and no Policy and procedure provided.

Transfer and discharge CFR(s): 484.50(d) Standard: Transfer and discharge. The patient and representative (if any), have a right to be informed of the HHA's policies for transfer and discharge. The HHA may only transfer or discharge the patient from the HHA if: This STANDARD is not met as evidenced by: Based on record reviews and interviews the Home Health Agency failed to appropriately discharge a patient from services. To document in the patient's clinical record the behaviors and circumstances that warranted patient discharge for cause as well as the Home Health Agency (HHA's) efforts to resolve the problems for one of three patients records reviewed. Patient #2 Findings: A review of Patient #2 clinical record discharge summary showed documentation that the patient was discharged from the Home health agency for inappropriate comments with nursing staff. Specific discharge instructions given, patient will need more bloodwork done and PICC line dressing changed and eventually removed. During an interview on 07/20/21 at 1:38 PM with the Registered Nurse Supervisor Staff B she stated, there is no documentation in the patient’s chart to show the patient had exhibited inappropriate behavior towards the health care workers. The patient still required care after he was discharged. This agency did not attempt to place the patient with another agency. Policy and procedure requested from Staff B Nursing Supervisor on 07/20/21 and no Policy and procedure provided.

Treatments and therapy services CFR(s): 484.60(e)(3) Any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services. This ELEMENT is not met as evidenced by: Based on interview and record review the facility failed to Provide physical therapy services based upon a physician’s order for one of three residents charts reviewed. Resident #3. During an interview on 07/20/21 at 1:13 PM with patient #3 she stated, I was told by the doctor that I was going to be seen by both the nurse and physical therapy beginning at the same time. The PT did not come out at all last week (07/13/21) after the PTA told me he would be seeing me during his last visit (07/06/21). During an interview on 07/20/21 at 1:38 PM with Staff B RN supervisor she stated, I am not sure why the patients physical therapy was not started with the physician order. During an interview on 07/20/21 at 2:57 PM with Staff F Scheduler stated, Physical Therapy (PT) to put in communication note to the scheduler or the clinical manager. During a referral for services once the clinician (RN) has determined the services required she will call the clinical manager or the nurse supervisor with report to notify them of the care that is required. I do not see the physician orders or the referral. I Rely on clinician report for scheduling. This patient was not scheduled to be seen by PT initially. A review of the start of care ordered from the physician dated 06/17/21 for the certification period 06/17/21 to 08/15/21 read, Physical Therapy (PT) 1 week 5. The patient was not seen by PT for initial assessment until 06/29/21. There was no documentation to show why the patient was not seen and evaluated by PT in a timely manner. Policy and procedure requested from Staff B Nursing Supervisor on 07/20/21 and no Policy and procedure provided.