Every finding on record at Assure Home Healthcare, Inc

Substantial allegation Survey conducted for complaint # 98658 Standard level deficiencies cited.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: A. Based on clinical record review, Agency policy review and staff interview it was determined that Agency failed to ensure that interdisciplinary assessment / communication is maintained to coordinate patient care. This was found in 1 of 4 clinical records reviewed. (Patient #1) Findings include: 1. Patient. #1 Start of Care 04/27/23 Diagnosis: Hypertensive Chronic Kidney Disease. The clinical record was reviewed on 06/06/23. The clinical record contained a physician order dated 05/01/23 for blood test CBC and CMP. Patient #1 clinical record also contained a patient communication note dated 05/10/23 that states " The patient did not answer the door for the lab to draw blood. Per Heritage Lab Service". (9 days after physician order). No other communication notes or physicians' orders were found in the clinical record. 2. The Agency policy titled “Care Planning” was reviewed. The policy required…N..9...Diagnostic testing must be ordered the day it is received...d... Results are faxed to the ordering provider the same day received and emailed to the care team for follow-up and/or additional orders….e…. A confirmation call is placed to the ordering provider to ensure results are acknowledged. Documentation is placed in the chart to confirm these actions.” 3. During an interview with the Director of Nursing (DON) on 06/06/23 at 1:30 PM, the DON stated that the Home Health Agency utilizes an outside lab service to perform all blood draws. The DON stated once a lab order is taken by the Home Health Agency the lab is contacted, the lab service performs the blood draw with-in 1-2 days. The lab faxes the results to the home health Agency the same day it is drawn. 4. On 06/06/2023 at 1:30 pm the DON confirmed that the usual overall timeframe from Agency lab order to receive results is 3 days.