Every finding on record at Amedisys New Hampshire, LLC

The facility was surveyed on 8/29/23 pursuant to the Emergency Preparedness Regulations as referenced in the Centers for Medicare and Medicaid State Operations Manual, 42 CFR 484.102 Appendix Z - Rev. 204, issued: 4/16/21 with no deficiencies cited.

A health recertification survey was conducted on 8/29/23 through 8/31/23 pursuant to 42 CFR Part 484 for Home Health Agencies with deficiencies cited.

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 interview and record review it was determined the Home Health Agency (HHA) failed to follow the written plan of care for the frequency of visits and failed to consult the physician of missed visits for 2 patients in a survey sample of 17 patients (Patient identifiers are #5 and #11). Findings include: Patient #5 Review on 8/30/23 of Patient #5's Home Health Certification and Plan of Care for the certification period of 8/11/23 to 10/9/23 revealed orders for physical therapy one time a week for 7 weeks. Review on 8/30/23 of Patient #5's visit calendar revealed that on 8/17/23 there was a missed physical therapy visit and no additional visits were made that week. Review on 8/30/23 of Patient #5's Client Coordination Note Report, dated 8/17/23, revealed that Patient #5 refused the visit. There was no documentation that the physician had been notified of the missed visit. Interview on 8/30/23 at 11:05 a.m. with Staff B (Clinical Supervisor) confirmed the missed visit and that the physician was not consulted. Patient #11 Review on 8/29/23 of Patient #11's Home Health Certification and Plan of Care for the certification period of 7/22/23 to 9/19/23 revealed orders for physical therapy one time a week for 8 weeks. Review on 8/29/23 of Patient #11's visit calendar revealed that there were missed physical therapy visits on 8/8/23 and 8/18/23, and no additional visits were made either week. Review on 8/30/23 of Patient #11's Client Coordination Note Reports, dated 8/8/23 and 8/18/23, revealed that Patient #11 refused the visit for both days. There was no documentation that the physician had been notified of the missed visits. Interview on 8/30/23 at 11:05 a.m. with Staff B confirmed the missed visits and that the physician was not consulted. Interview on 8/31/23 at 12:18 p.m. with Staff A (Director of Operations (DOO)) confirmed that the missed visits were not communicated to the physician. Review on 8/31/23 of the facility's policy "Coordination of Care" last reviewed on 5/4/23 revealed, "... 19. A missed visit communication note is completed when a home care visit is unable to be completed as scheduled and not able to be rescheduled within the patient's Medicare treatment week. a. The physician will be notified by: the clinician; by way of faxing/mailing the missed visit communication note to the physician's office; or by the DOO, Clinical Manager, or other clinical management representative. b. If the clinician or the Clinical Manager notifies the physician of the missed visit, this communication will be noted on the Missed Visit Communication Note. c. There are no exceptions, in which the physician does not have to be notified of a missed visit..."

Contents of clinical record CFR(s): 484.110(a) Standard: Contents of clinical record. The record must include: This STANDARD is not met as evidenced by: Based on interview and record review it was determined that the Home Health Agency (HHA) failed to keep complete and accurate medical records by omission of documentation when there was a delay of a Start of Care (SOC) and that the physician, referring agency, and patient were notified of this delay for 3 of 17 patient charts reviewed (Patient Identifiers are #9, #11, and #16). The HHA also failed to document why Social Worker visits were ordered but not conducted for 5 weeks for 1 of 17 patient charts reviewed (Patient Identifier is #7). Findings include: Patient #16 Review on 8/30/23 of Patient #16's medical record revealed a referral date of 2/22/23 and a start of care (SOC) date of 3/6/23. Further review revealed no delayed SOC note in the medical record specifying the reason for delay beyond 48 hours in admission assessment and physician/referral source notified. Interview on 8/30/23 at 1:30 p.m. with Staff B (Clinical Supervisor) stated the delay in care was due to hospitalization and confirmed the above finding. Patient #9 Review on 8/31/23 of Patient #9's medical record revealed a referral date of 8/11/22 and an SOC date of 8/15/22. Further review revealed no delayed SOC note in the medical record specifying the reason for delay beyond 48 hours in admission assessment and physician/referral source notified. Interview on 8/31/23 at 11:15 a.m. with Staff B confirmed the finding. Review of facility policy titled, Initial Referral/Admission Process, last revised 8/26/21, revealed: "As permitted by state regulation, the admitting discipline will perform the admission assessment within 48 hours of BOTH the facility discharge AND receipt of referral, unless specified otherwise by the Physician. If the evaluation visit cannot be performed within the time frame, the reason should be specified within the documentation of the clinical record and the Physician/referral source notified." Review of facility policy titled, Clinical Record, Contents, last revised 6/24/21, revealed: "A clinical record is initiated and maintained in a standardized written or electronic format for every patient admitted for homecare services. All documentation is timely, detailed, accurate, and reflects the care, treatment, and services provided by an employee or contracted individual." Patient #7 Review on 8/31/23 of Patient #7's Home Health Certification and Plan of care revealed that Patient #7 start of care to HHA was on 1/6/23 and last date of service was on 3/20/23. Review on 8/31/23 of Patient #7's physician's orders revealed the following; -On 2/8/23 an order for a Social Worker effective 2/5/23 for 1 visit. -On 2/10/23 an order to reschedule the Social Worker visit to the next Medicare week. -On 2/17/23 an order to reschedule the Social Worker visit to the next Medicare week. -On 3/10/23 an order to reschedule the Social Worker visit to the next Medicare week. -On 3/17/23 an order to reschedule the Social Worker visit to the next Medicare week. The above orders did not indicate what the visit was intended for or why the visit was needing to be rescheduled. Review on 8/31/23 of Patient #7's calendar from January 26, 2023 through March 20, 2023 revealed that there were no visits made by the Social Worker. Review on 8/31/23 of Patient #7's Client Coordination Notes revealed no documentation as to why the above ordered social worker visits had been ordered and not been attempted or completed during this above time period. Review on 8/31/23 of Patient #7's Client Coordination Note Report dated 2/9/23 and completed by a Registered Nurse revealed, "...Patient reported to me that [pronoun omitted] is feeling depressed isolated and hopeless. Patient is tearful and stated [pronoun omitted] has been crying a lot recently this week. Patient currently is taking med[ications] for diagnosis of depression... I am concerned that patient may not be taking her med[ication] appropriately. Patient is attempting to rely on [pronoun omitted] [spouse] for medication management but patient's [spouse] appears to have a cognitive impairment..." Review on 8/31/23 of Patient #7's Client Coordination Note dated 8/30/23 revealed "Patient and family continued to delay [Social Worker] eval[uation] and requested no further [Social Worker] needs upon discharge. This note was signed by Staff C (Director of Operations, Bedford) on 8/30/23. Review on 8/31/23 of Patient #7's physician's orders revealed an order entered into the electronic medical record on 8/30/23 (during the survey) by Staff C that was dated 3/18/23 and not signed by the physician. Interview on 8/31/23 at 1:25 p.m. with Staff C confirmed the above and that there was no documentation as to why Patient #7 was not seen by the Social Worker. Staff C stated that there should have been documentation as to why the visits did not happen. Staff C confirmed that he/she had written the above discharge order on 8/30/23 and had dated it 3/18/23. Review on 8/31/23 of the facility's policy "Coordination of Care" last reviewed on 5/4/23 revealed, "... 4. The Clinical Manager/designee is assigned to supervise and coordinate care for a patient... c. Manages and oversees coordination/integration of care and services by all disciplines to meet the patient's needs and identify factors that could affect patient safety and treatment... 11. Patient care will not be interrupted due to staff absences. Clinical manager or designee will ensure appropriate staff assignment and coverage... 13. Each discipline's role is clearly defined in the provisions of each patient's care... Case conferences and verbal coordination between or among disciplines are documented in the clinical record to establish effective interchange, reporting, and coordination of patient care... 19. A missed visit communication note is completed when a home care visit is unable to be completed as schedule and not able to be rescheduled within the patient's Medicare treatment week..." Review on 8/31/23 of the facility's policy "Clinical Record, Late Entry and Corrections" last reviewed on 6/26/23, revealed, "...1. Late or additional follow-up entries are made to the clinical record on a Coordination Note and are dated the date the "late entry" or "addition" is written... 3. Recordkeeping principles identified as required for record amendments include... Clearly and permanently identify any amendment, correction or delay entry as such... Clearly indicate the date and author of any amendment, correction or delayed entry... Late or additional entries may be made through the use of a coordination note/clinical note addendum. the entry will be entitled, "late entry" or "additions," and will be dated by documenting the date the "late entry" or "addition" is written...Electronic health record corrections or delayed entries must: Distinctly identify any amendment, correction or delayed entry..." Patient #11 Review on 8/29/23 of Patient #11's Skilled Nursing Facility discharge paperwork revealed that Patient #11 was discharged from the SNF on 5/19/23 and that a referral for home care was faxed to the Home Health Agency on 5/19/23 at 11:50 a.m. Review on 8/29/23 of Patient #11's Home Health Certification and Plan of Care revealed that Patient #11's SOC was on 5/23/23 (four days after discharge and above faxed referral). Review on 8/29/23 of Patient #11's medical record, including coordination notes revealed no delayed SOC note for the reason for the delay or documentation that the physician/referral source had been notified of the delay. Interview on 8/30/23 at 11:05 a.m. with Staff B confirmed the above timeline. Staff B revealed that he/she had called Patient #11's physician but did not document this. Interview on 8/31/23 with Staff A (Chief Operating Officer) revealed that the agency's liaison had spoken to and informed both Patient #11 and the SNF that the SOC would not start until 5/23/23. Staff A confirmed that this was not documented in Patient #11's medical record.