Every finding on record at Avera at Home

A recertification survey for compliance with 42 CFR Part 484 Subpart G, Subsection 483.102, Emergency Preparedness Requirements for Home Health Agencies, was conducted from 1/17/23 through 1/19/23. Avera At Home was found in compliance.

A recertification health survey for compliance with 42 CFR Part 484, Subparts B-C, requirements for home health agencies, was conducted from 1/17/23 through 1/19/23. Avera At Home was found not in compliance with the following requirement: G514. Avera At Home's vaccination program was reviewed for compliance with the Centers of Medicare and Medicaid (CMS) Quality, Safety and Oversight (QSO) memorandum QSO-23-2-ALL, dated October 26, 2022, on 1/19/23. Avera At Home was found in compliance.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review, interview, and policy review, the provider failed to ensure Start of Care (SOC) initial assessment visits were completed within forty-eight hours of referral, or within forty-eight hours of the patient's return home, or on the physicians' ordered start of care date for seven of thirteen (1, 3, 5, 7, 10, 11, and 13) reviewed charts. Findings include: 1. Review of patient 1’s medical chart revealed: *A referral date for home health was 1/9/23. *She was discharged from the hospital on 1/9/23. *Her admission SOC date was listed as 1/12/23. *A request to the physician on 1/13/23 from registered nurse (RN) clinical coordinator B for a SOC of 1/12/23 per patient request. *Patient 1’s medical record had not contained documentation to indicate: -The reason the patient’s SOC needed to move past the forty-eight-hour referral date. 2. Review of patient 3’s medical record revealed: *A referral date of 1/4/23. *A discharge date from the hospital of 1/9/23. *A SOC date of 1/12/23. *Her medical record had not contained: -Documentation to indicate the reason the patient’s SOC was past the forty-eight hours of her returning home. -A physician’s order to start the SOC beyond the forty-eight hours of returning home. 3. Review of patient 5’s medical record revealed: *A referral date of 12/21/22. *A discharge from the hospital of 12/24/22. *A SOC date of 12/29/22. *Her medical record had not contained: -Documentation to indicate the reason the patient’s SOC was past the forty-eight hours of her returning home. -A physician’s order to start the SOC beyond the forty-eight hours of returning home. 4. Review of patient 7’s medical record revealed: *A referral date of 12/26/22. *A SOC date of 12/29/22. *A request to the physician on 12/29/22 from RN clinical coordinator B for a SOC of 12/29/22 per patient request. *Her medical record had not contained documentation to indicate: -The reason the patient’s SOC was moved past the forty-eight-hour referral date. -The physician had been notified the SOC had not occurred until after the forty-eight-hours had passed. 5. Review of patient 10’s medical record revealed: *Her referral date to the home health of 3/12/22. *A discharge from the hospital of 3/12/22. *Her admission SOC date was listed as 3/15/22. *A request to the physician on 3/15/22 from RN clinical coordinator B for a SOC of 3/15/22 per patient request. -The order was received on 3/17/23. *Her medical record had not contained documentation to indicate: -The reason the patient’s SOC was past the forty-eight-hour referral date. -The physician had been notified the SOC change had occurred until after the forty-eight-hours had passed. 6. Review of patient 11’s medical record revealed: *A referral date of 6/9/22. *His SOC date was listed as 6/13/22. *A request to the physician on 6/13/22 from RN clinical coordinator B for a SOC of 6/13/22 per patient request. *His medical record had not contained documentation to indicate: -The reason the patient’s SOC was past the forty-eight-hour referral date. -The physician had been notified the SOC change had occurred until after the forty-eight-hours had passed. 7. Review of patient 13’s medical chart revealed: *A referral date of 6/24/22. *A discharge from the hospital of 6/24/22. *Her SOC date was listed as 6/29/22. *A request to the physician on 6/29/22 from RN clinical coordinator B for a SOC of 6/29/22 per patient request. *Her medical record had not contained documentation to indicate: -The reason the patient’s SOC was past the forty-eight-hour referral date. -The physician had been notified the SOC change had occurred until after the forty-eight-hours had passed. 8. Interview on 1/19/23 at 3:30 p.m. with agency manager A regarding the above patients’ SOC dates beyond forty-eight-hour regulation revealed: *Some admission SOC’s had not occurred due to inclement weather or employee illnesses. *Patients sometimes ask for a later date to begin home health. *She confirmed the above patients' charts did not have documentation to indicate a member of the home health team had discussed the patient’s current health status and care needs with the patient or physician and would be safe to extend the SOC beyond the forty-eight-hour regulation. *If the SOC could not be done within the forty-eight hours their physician should have been notified and an order received to get a SOC at a later date. *The home health employees do communicate with the patients, but they do not document the communication. -The home health agency did not have access to the charts until the day before or the day of the admissions. -Agency manager A stated the employees should have documented somewhere to identify the communication had occurred when the patient did not have a SOC within forty-eight hours after a referral, or returning home, or on the physician-ordered SOC date. *Notification to the physician and request for a later SOC should have occurred prior to before setting the date. 9. Review of the provider’s revised October 2022 Home Health Admission Criteria and Process policy revealed: *The manager/clinical coordinator would assign clinical organization personnel to conduct initial assessments of eligibility for services within forty-eight hours of the patients return home, or on the start of care date ordered by the primary care provider. * ”The patient’s most critical needs for home care services must be identified during the initial assessment and must be met in a timely fashion.” * ”In the event that the time frame for assessment cannot be met, the patient’s primary care provider, the referral source, and the patient, will be notified for approval of the delay.” a. Such notification and approval will be documented. b. If approval is not obtained for the delay, the patient will be referred to another organization for services. * ”A nurse or therapist will attempt to make an initial contact prior to the patient’s hospital discharge if possible or appropriate. The initial home visit will be made within 48 hours after the patients discharge from a facility or as ordered by the primary care provider."