Every finding on record at Access Home Health of Florida, LLC

During the Recertification survey conducted from 3/14/23 to 3/16/23 at Centerwell Home Health, a Home Health agency, Emergency Preparedness was reviewed. Kindred At Home was in compliance with Emergency Preparedness 42 CFR 484.102, Requirements for Home Health Agencies.

A recertification survey was conducted from 3/14/23 to 3/16/23. Centerwell Home Health was not in compliance with 42 CFR 484, Requirements for Home Health Agencies.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency failed to send the discharge summary report to the primary care practitioner for 2 of 5 patients reviewed for discharges out of a total sample of 17 patients, (#14 and #16). Findings: 1. Patient #14 was admitted to the agency on 2/15/23 with diagnoses that included aftercare following joint replacement surgery, presence of right artificial knee joint, hypertension, and obstructive sleep apnea. Review of the medical record revealed patient #14 was discharged from the agency on 3/3/23. No evidence of a discharge summary sent to the physician was found in the medical record. On 3/16/23 at 1:25 PM, the Administrator stated she looked in patient #14’s medical record and did not find any documentation showing a discharge summary was sent to the physician. She explained the discharge process included a workflow task created after the Discharge “Outcome and Assessment Information Set” was processed in the office and assigned to the Medical Records Specialist. She noted the Medical Records Specialist was responsible for faxing the “Discharge-Transfer Summary Report” to the physician. She stated she did not know what happened this time and validated this was a requirement at discharge. On 3/16/23 at 2:20 PM, the Medical Records Specialist stated she was responsible for handling the patients’ medical records including sending out the “Discharge-Transfer Summary Report” to the physicians. She explained she received a task in her workflow which prompted her to fax them out but did not know the timeframe she had to complete this task. She indicated during her training she was told discharge summaries were required to be sent to the physicians. She stated she did not know why patient #14’s “Discharge-Transfer Summary Report” was not sent to the physician. 2. Patient #16 was admitted to the agency on 2/01/23 with diagnoses that included congestive heart failure, pleural effusion, pneumonia, and type 2 diabetes. Review of the medical record revealed patient #16 was discharged from the agency on 2/20/23. A “Discharge-Transfer Summary Report” was faxed to the physician on 2/22/23 but the “Fax Status Report” showed the fax did not go through. Patient #16’s medical record did not show evidence the discharge summary was resent to the physician. On 3/16/23 at 1:24 PM, the Administrator explained the “Discharge-Transfer Summary Report” was faxed to the physician on 2/22/23, however, the fax failed. She stated the Medical Records Specialist was supposed to refax it, but she could not find documentation or evidence this was completed. On 3/16/23 at 2:20 PM, the Medical Records Specialist stated the office manager checked the “Fax Status Report” every day to ensure faxes sent the previous business day went through. She explained if a fax failed to send, she tried again through the computer software or via regular fax. She indicated she did not know if the discharge summary for patient #16 was resent to the physician. Review of the Medical Records Specialist job description not dated revealed “Essential Functions” which read, “Fax the discharge / transfer summary / episode detail summary and case conference / 60 Day summary to the physician as task appears on the action screen.” It included, “Must possess knowledge of Medicare guidelines governing home health and hospice agencies.” Review of the agency policy and procedure titled, "Discharge or Transfer” last revised on January 2023 read, “Transfer/discharge documents completed by the Home Health agency will be sent within CMS (Centers for Medicare & Medicaid Services) mandated timeframes outlined below. . . . Patients discharged to their physician/allowed practitioner will be sent within five business days of the Home Health agency discharge date.”