Every finding on record at Bayront Home Health Care, LLC

During the recertification survey conducted on 3/22/22 to 3/23/22 at Bayfront Home Health Services, a home health agency, Emergency Preparedness was reviewed. Bayfront Home Health Services is in compliance with Emergency Preparedness per Code of Federal Regulations (CFR) 42, Part 484.22, Condition of Participation for Home Health Agencies.

A recertification survey was conducted on 3/22/22 to 3/23/22 at Bayfront Home Health Services, located at 603 7th Street. There are no branches. The home health agency was not in compliance with 42 CFR Part 484, requirements for Home Health Agencies.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview the Home Health Agency failed to provide needed services as ordered by the physician for 7 of 17 (#8, #9, #10, #12, #14, #15, #17) sampled patients. Findings included: 1. Review of Patient #8's record revealed that this patient had a physician/referral to home care on 8/19/21, with a start date of 8/19/21 for Physical Therapy (PT) and Occupational Therapy (OT) with a diagnosis of Adult Failure to Thrive. Review of the plan of care (POC) for the certification period 10/23/2021 to 12/21/2021 revealed orders for the following: -“SN effective 10/24/2021 2WK2 -PT effective 10/31/2021 1WK1 orders and goals to follow” Continued review of the record revealed that there was only 1 of 2 skilled nursing (SN) was conducted the week of 10/31/21 and no documentation in the record that would indicate that a Physical Therapy (PT) visit was conducted the week of 10/31/21. The record did not have any documentation present as to why the SN and PT was missed. Interview with the Patient Care Manager on 3/23/22 at 12:24 PM revealed that documentation should be in the file or the clinician should have ensured that they obtained new orders for any changes. She reported that her expectation is that clinicians discuss with patient all new orders, and that the recertifying clinician should be calling the physican and complete any documentation under coordination notes. 2. Review of Patient #9's record revealed that this patient had a physician/referral to home care on 11/26/21, with a start date of 11/26/21 for PT with a diagnosis of that included Congestive Heart Failure. Review of the (POC) revealed a start of care (SOC) dated 12/8/2021 for the certification period 12/8/2021 to 2/5/2022. Continued review of the record revealed that visits were authorized on 12/3/21. There was no documentation that would indicate why there was a 5-day lapse in the SOC. Interview with the Patient Care Manager on 3/23/22 at 11:18 AM revealed that notes should be documented in coordination notes. reviewed record, not present. 3. Review of Patient #10's record revealed that this patient had a physician order/referral to home care on 10/13/21, with a start date of 10/13/21 for SN, PT, and Skilled Assessment for Tube Feeding, with a diagnosis of Oral Cancer. Review of the POC revealed a SOC dated 10/19/2021 for the certification period 10/19/2021 to 12/17/2021. Continued review of the record revealed that there was no documentation that would indicate why there was a 6-day lapse in the SOC. 4. Review of Patient #12's record revealed that this patient had a physician order for home care on 10/13/21. Review of the record revealed a referral which indicated that the home health agency accepted the patient on 10/14/21 with a diagnosis of Stage IV carcinoma. Review of the POC revealed a SOC dated 10/18/2021 for the certification period 10/18/2021 to 12/16/2021. Continued review of the record revealed that there was no documentation that would indicate why there was a 5-day lapse in the SOC. 5. Review of Patient #14's record revealed that this patient had a physician order for a “D/C home 2/7/22 with home health pt/ot and nursing” on 2/4/22. Review of the POC revealed a SOC dated 2/15/2022 for the certification period 2/15/2022 to 4/15/2022 which indicated the following: -“SN 1WK1 Orders and goals to follow -PT 2WK7 -OT 1WK1, 2WK4”. Continued review of the record revealed that there was no documentation that would indicate why there was an 8-day lapse in the SOC. Review of the visit notes for patient #14 revealed that there was no documentation that would indicate that the patient received any SN visits as ordered. Interview with the Patient Care Manager on 3/23/22 at 2:38 PM revealed that when they recive a referral and/or physician order service should start within 48 hours. She reported that in some cases a referral/order is made and then the Patient for whaterever reason does not get released from the hspital. She reported that this information should be documented in the coordination notes. She reviewed the Patient records #10, #12, and #14 and confirmed that she is unaware as to why there is a lapse in care. 6. Review of Patient #15's record revealed that this patient had a physician order/referral for home health on 2/16/22 for SN, PT, and Home Health Aide, with a diagnosis that includes Dementia with Behavioral Disturbance. Review of the POC revealed a SOC dated 2/25/2022 for the certification period 2/25/2022 to 4/25/2022 which indicated the following: -“SN 1WK2, 1Every2W2 -PT effective 02/27/2022 1WK1, 2WK1, 1WK2”. Continued review of the record revealed that there was no documentation that would indicate why there was a 9-day lapse in the SOC. Review of the visit notes for Patient #15 revealed that there was no documentation that would indicate that the patient received any Home Health visits as ordered. Interview with the Patient Care Manager on 3/23/22 at 3:09 PM revealed that the Home Health Agency shares a Home Health Aide with 2 other sister Home Health Agencies. She reported that the Home Health Aide was not available to provide the services when they accepted the case. The Patient Care Manager reported that they did not contact the physician to inform them that they were unable to provide Home Health Aide services. 7. Review of Patient #17's record revealed that this patient had a physician order/referral for home health on 2/11/22 for Home Health, with a diagnosis that included Fall from ground level. Review of the POC revealed a SOC dated 2/17/2022 for the certification period 2/17/2022 to 4/17/2022 which indicated the following: -“SN Effective 02/27/2022 1WK1 orders and goals to follow -PT 1WK1, 2WK6, 1WK1”. Continued review of the record revealed notes indicating that the patient deferred the start of care on 2/12/22, 2/16/22. On 2/17/22 an Oasis assessment was completed by the PT. Continued review of the record revealed an order dated 2/18/22 indicating that “Effective week of 2/20/22 RN per patient request”. On 2/21/22 there was another order indicating that per the Patient request RN eval on 2/22/22. Additional review of the record revealed an order indicating “Effective 3/15/22 ST to evaluate. Patient has Dysphagia”. Review of the visit notes for Patient #17revealed that there was no documentation that would indicate that the patient received any SN or Speech Therapy (ST) visits as ordered. Interview with the Patient Care Manager on 3/23/22 at 3:40 PM revealed that this must have been an oversight and that the Patient should have received SN and ST visits. She reported that if the visit could not be made a call should have been made to the physician for clarification. Review of the Home Health Agency policy titled "Physician Orders" with an effective date of 12/08/03 and a revised date of 11/01/21 revealed that "3. The agency accepts patient referrals from a physician/authorized practitioner or physician designee to collect information regarding the patient and services required. The referral intake serves as a verbal order to begin services."