Every finding on record at Bridges Home Health, Inc

An unannounced complaint survey for complaint #2022016722 was conducted on 11/21/22 through 12/13/22 at Trilogy Home Healthcare, a Home Health Agency in Fort Myers, Florida. Complaint #2022016722 was substantiated at G478 with citation. Trilogy Home Healthcare is in compliance with Code of Federal Regulations (CFR) 42, Part 484, Conditions of Participation for Home Health Services. The following is a description of the Standard level noncompliance.

Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) (i) Investigate complaints made by a patient, the patient's representative (if any), and the patient's caregivers and family, including, but not limited to, the following topics: This ELEMENT is not met as evidenced by: Based on clinical record review, and interviews, the home health agency failed to honor patient's rights for 1 (Patient #1) of 3 patients sampled. Patient #1 clinical record review revealed a Start of Care dated 10/9/22, diagnosis of Orthopedic Aftercare post-surgery. Physician ordered services include Skill Nursing 3 times a week for one week, 2 visits for 2 weeks, 1 visit for 3 week, and 2 visits as need for soiled or dislodged dressing changes. Physical Therapy visit ordered for 1 visit for 1 week and Occupational Therapy 1 visit ordered for 1 week. During interview on 11/21/22 at 11:55 a.m., Patient #1 said, she had sent the home health agency’s administrator several e-mails expressing her concerns regarding her services. Her concerns were never addressed. The e-mail included a letter outlining her concerns and requested medical records. During an interview on 11/21/22 at 2:00 p.m., the Interim Administrator said all requests for medical records are sent to the corporate compliance officer and they follow- up with the patient or the patient’s representative. She continued to say she was not aware of a medical record request from Patient #1. The Interim Administrator said she had just got the position a week ago. She communicated with the Compliance Officer and said they were unable to locate a request from Patient #1. She provided an e-mail from the Compliance Officer confirming there was no notification request from Patient #1 for medical records. During an interview on 11/21/22 at 3:45 .p.m., the Interim Administrator said she requested Information Technology, (IT) to check the previous Administrator’s e-mail and they found 2 e-mails, from Patient #1 that were deleted. IT was able to retrieve the content of the e-mail which was forward to the Compliance Officer. During an interview on 11/21/22, at 4:00 p.m., the Compliance Nurse said now that I am aware of the situation, I will be working to get the patient her medical record. I was not aware of the request. We will pull the records together, review and send them out to the patient within a couple of days.

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 clinical record reviews, and interviews, the Home Health Agency failed perform a start of care comprehensive assessment, initial visit, as ordered by the physician for 1 (Patient #1) or 3 patients sampled. Patient #1 record review revealed a hospital referral with physician’s orders for visits and treatment. The referral notes a post-surgery referral for Home Health Services. The referral requested a start of care date of 10/8/22 for Skill Nursing, Physical Therapy, and Occupational Therapy. The services requested: strengthening/exercise. The medical record revealed the home health agency’s initial visit was completed on 10/9/22 by the Skilled Nurse. The home health agency’s Certification period start of care is documented as 10/9/22 – 12/7/22. The home health agency did not start the care assessment; on the physician’s ordered date, of 10/8/22. On 12/2/22 at 1:55 p.m.. a call was received from the patient’s physician's office. The physician’s office Registered Nurse said he is assigned the task of referring patients for home health services. He said it is our expectation for a nurse to make her visit the day after surgery. Patient #1 had her surgery on 10/7/22 the nurse should have gone out on 10/8/22. The nurse is to open the case. The nurse is to make the visit the day after surgery. Therapy is to go to the patient’s home sometime within the week of the start of care.

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 clinical record review, and interviews, the home health agency failed to notify the physician of the delay in providing services to 1 (Patient #1) of 3 patients sampled. A delay in the start of care effects the development of a plan of care, the start of treatments and achieving goals. Patient #1 record review revealed a hospital referral revealed physician’s orders for visits and treatment. The referral notes a is post-surgery referral for Home Health Services. The requested start of care date 10/8/22 for skill nursing, Physical Therapy, and Occupational Therapy. The services requested: strengthening/exercise. The medical record revealed the home health agency’s initial visit 10/9/22 by the Skill Nurse. The home health agency’s Certification period start of care is documented as 10/9/22 – 12/7/22. The home health agency did not start the care assessment; on the physician’s ordered date, of 10/8/22. On 12/2/22 at 1:55 p.m., a call was received from the patient’s physician's office. The physician’s office Registered Nurse said he is assigned the task of referring patients for home health services. It is our expectation for a nurse to make her visit the day after surgery. Patient #1 had her surgery on 10/7/22 the nurse should have gone out on 10/8/22. The nurse is to open the case. The nurse is to make the visit the day after surgery. Therapy is to go to the patient’s home sometime within the week of the start of care.

Retrieval of records CFR(s): 484.110(e) Standard: Retrieval of clinical records. A patient's clinical record (whether hard copy or electronic form) must be made available to a patient, free of charge, upon request at the next home visit, or within 4 business days (whichever comes first). This STANDARD is not met as evidenced by: Based on clinical record review, and interviews, the home health agency failed to honor 1 (Patient #1) of 1 patient sampled request for clinical records. Patient #1 record review revealed a hospital referral revealed physician’s orders for visits and treatment. The referral notes a is post-surgery referral for Home Health Services. The requested start of care date 10/8/22 for skill nursing, Physical Therapy, and Occupational Therapy. The services requested: strengthening/exercise. The medical record revealed the home health agency’s initial visit 10/9/22 by the Skill Nurse. The home health agency’s Certification period start of care is documented as 10/9/22 – 12/7/22. The home health agency did not start the care assessment; on the physician’s ordered date, of 10/8/22. During an interview on 11/21/22 at 11:55 a.m., Patient #1 said, "I requested medical records and have not received them." During an interview on 11/21/22 at 3:45 p.m., the Interim Administrator said she requested Information Technology, (IT) to check the previous Administrator’s e-mail and they found 2 e-mails, from Patient #1 that were deleted. IT was able to retrieve the content of the e-mail which I forward to the Compliance Officer. During an interview on 11/21/22 at 4:00 p.m., the Compliance Nurse said, "Now I am aware of the situation, I will be working to get the patient her medical record. I was not aware of the request. We will pull the records together, review and send them out to the patient within a couple of days."

An unannounced complaint survey for #2021009486 was conducted 8/9/21 at Trilogy Home Healthcare, a Home Health Agency in Estero, Florida. Complaint #2021009486 was substantiated at G442 and G608. Trilogy Home Healthcare is not in compliance with Code of Federal Regulations (CFR) 42, Part 484, Conditions of Participation for Home Health Services.

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure 1 (Patient #1) of 3 patients sampled received proper written notice in advance of service reduction or service termination. The “Transfer or Discharge from Services/Agency” policy with a revision date of 3/18 read, “… Discharge planning begins at time of admission and will be reflected in the documentation. . . The patient’s continuing care needs, if any, are assessed at discharge and arrangement are made with appropriate resource. . . Patients will receive verbal or written discharge instructions. . .” Review of the Home Health Certification and Plan of Care revealed Patient #1 had a start of care date of 6/9/21 with a certification period of 6/9/21 to 6/7/21. The diagnoses included strain of the rotator cuff of the right shoulder and the presence of a right artificial shoulder joint. The physician’s orders of discipline and treatments included for the Physical Therapist to evaluate, assess, and develop physical therapy plan of care to be signed by the physician. The discharge plans included to discharge to care of family under physician’s supervision when goals are met. Review of the evaluation visits document revealed the Physical Therapist requested date of evaluation was 6/23/21. Review of the Comprehensive Admission Assessment completed on 6/9/21 by the Registered Nurse (RN) noted Patient #1 had “increased pain to right shoulder”. Review of the visit notes report revealed the RN visited Patient #1 on 6/10/21and 6/14/21. On 6/17/21 the RN documented Patient #1 remained with a pain level of 4 to the right shoulder and upper arm. The assessment noted Patient #1 had limited range of motion, pain, stiffness and decrease strength to the upper right extremity. In a communication note dated 6/17/21 the RN documented “PT (Physical Therapy) to start next week. SN (Skilled Nursing) to discharge. . . calm, alert and oriented, motivated to get better.” The medical record fail to provide documentation of a Physical Therapy assessment or evaluation as per the physician’s order. On 7/1/21 the RN wrote in a client coordination note “Late entry for Tuesday, June 29th. Patient called to say she was receiving workers comp [sic] therapy for her leg and they will be done on July 2nd so she wants to know if we will still be coming for her shoulder therapy? . . . Our nurse and therapist said they couldn’t come if she had workers comp. They would get back to her. I told her the same thing . . .” On 8/9/21, at 9:15 a.m., in a telephone interview Patient #1 said, “They made 3 visits. The nurse came out twice and therapy came out one time. Therapy did not do anything. They came and told me they would not be able to do therapies. I told them I was getting therapy through my job from Workman Comp [Compensation]. My workplace was providing therapy to my knee, I hurt when I fell at the job. The shoulder therapy orders were post-surgery, I had it done while I was out with the knee, and I used Medicare. They said they did not know how that was to work. They did not assist with finding another agency. They did not provide therapy. I did not get Physical Therapy services through this agency.” On 8/9/21 at 2:40 p.m., in an interview the Reginal Operations Support Nurse said, “The patient requested discharge on 7/2/21. We did not have documentation of notifying the MD (Physician) nor documentation the Physical Therapist a visit.” On 8/9/21 at 2:45 p.m., in an interview the Director of Clinical Services said the Physical Therapy visit was scheduled for 6/23/21. The Physical Therapist made a call to the patient on 6/25/21 but “We don’t have documentation of that communication”. Complete clinical record review failed to show documentation the Home Health Agency provided physical therapy services as ordered. The Home Health agency failed to have documentation of discharge orientation, assessment and arrangement made with appropriate resources to meet the patient’s continuing care needs.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review, patient and staff interview the Home Health Agency failed to have evidence of effective coordination to meet the needs for therapy for 1 (Patient #1) of 3 sampled patients with physical therapy orders. The “Transfer or Discharge from Services/Agency” policy with a revision date of 3/18 read, “… Discharge planning begins at time of admission and will be reflected in the documentation. . . The patient’s continuing care needs, if any, are assessed at discharge and arrangement are made with appropriate resource. . . “ Review of the Home Health Certification and Plan of Care revealed Patient #1 had a start of care date of 6/9/21 with a certification period of 6/9/21 to 6/7/21. The diagnoses included strain of the rotator cuff of the right shoulder and the presence of a right artificial shoulder joint. The physician’s orders of discipline and treatments included for the Physical Therapist to evaluate, assess, and develop physical therapy plan of care to be signed by the physician. On 8/9/21, at 9:15 a.m., in a telephone interview Patient #1 said, “They made 3 visits. The nurse came out twice and therapy came out one time. Therapy did not do anything. They came and told me they would not be able to do therapies. I told them I was getting therapy through my job from Workman Comp [Compensation]. My workplace was providing therapy to my knee, I hurt when I fell at the job. The shoulder therapy orders were post-surgery, I had it done while I was out with the knee, and I used Medicare. They said they did not know how that was to work. They did not assist with finding another agency. They did not provide therapy. I did not get Physical Therapy services through this agency.” Review of the visit notes report revealed the RN visited Patient #1 on 6/10/21and 6/14/21. On 6/17/21 the RN documented Patient #1 remained with a pain level of 4 to the right shoulder and upper arm. The assessment noted Patient #1 had limited range of motion, pain, stiffness and decrease strength to the upper right extremity. In a communication note dated 6/17/21 the RN documented “PT (Physical Therapy) to start next week. SN (Skilled Nursing) to discharge. . . calm, alert and oriented, motivated to get better.” The medical record fail to provide documentation of a Physical Therapy visit or an Evaluation. In a client coordination note dated 7/1/21 the RN wrote,” Late entry for Tuesday, June 29th. Patient called to say she was receiving workers comp [sic] therapy for her leg and they will be done on July 2nd so she wants to know if we will still be coming for her shoulder therapy. I asked her to explain about the worker comp therapy because we are not aware she had any other payor sources. She said workers comp denied her shoulder surgery and therapy. . . We are here to see her shoulder and our nurse and therapist said they couldn’t come if she had workers comp. They would get back to her. I told her the same thing and asked intake to ask corp [sic] about workers come and if they could determine what insurance we would be billing for our care. Patient was not happy that the information had to come from someone else as she was just telling me how it was and if we couldn’t come she would just get another agency. I suggested she wait on making any changes and if she was going to go outpatient for additional therapy for her workers comp injury, we would not be able to see her anyway. She was again irritated by that information so I assured her I would look into it and get back with her asap (as soon as possible).” On 7/14/21 a client coordination note read “Received call from patient. Upset that we have not discharged her yet. Stated she attempted to go for outpatient therapy but could not receive services because we have not discharged. Confirmed that she wanted no further services. She again stated that she does want discharged [sic]” On 8/9/21 at 1:35 p.m., in an interview the Director of Clinical Services stated she got involved with this case around 7/1/21. She said, “There was a lot of confusion with this case and here having Workman Comp in the home providing services on another joint. The patient called to tell us she wanted to be discharged because she was going to outpatient therapy and was having trouble because we were involved with her Medicare.” On 8/9/21 at 2:45 p.m., in an interview the Director of Clinical Services said the Physical Therapy visit was scheduled for 6/23/21. The Physical Therapist made a call to the patient on 6/25/21 but “We don’t have documentation of that communication.” The Director of Clinical Services verified the home health agency did not provide physical therapy services as ordered and did not make arrangement with appropriate resources to ensure Patient #1 received physical therapy services as ordered by the physician.

An unannounced focused infection control and complaint survey for #2020005994 was conducted on 1/13/21 at Trilogy Home Healthcare, a home healthcare agency in Estero, Florida. Complaint #2020005994 was substantiated. Trilogy Home Healthcare is in compliance with Code of Federal Regulations (CFR) 42, Part 484, Conditions of Participation for Home Health Services. The following is a description of the Standard level deficiency.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on medical record review, and interview, the home health agency failed to ensure patients medical records contained all interventions, treatments and services for 1 (Patient #2) of the 3 patients' medical records sampled. The findings included: Record review of Patient #2's medical record revealed a start of care date of 11/24/20. The Home Health Certification and Plan of Care Orders for Discipline and Treatment revealed a skilled nurse was to make 1 visit for 5 weeks, then 1 visit for 1 week, to provide foley catheter care. The skilled nurse was to remove the catheter on the next visit and perform bladder scan 6 to 8 hours later. The medical record revealed, a skilled nurse visit on 11/24/20 preformed an admission assessment. The nurse visit on 11/25/20 notes the foley catheter was removed and patient was informed the nurse would return towards the end of the day to perform a Bladder Scan. That was the last visit noted in the patient's medical record. During an interview on 1/13/21 at 12:45 p.m., the Administrator and the Regional Operations Support Nurse verified, the nurse who was to perform the Bladder Scan no longer with for the agency. They were going to try to go into her tablet to see if there are additional notes. During an interview on 1/13/21 at 1:30 p.m., the Administrator and the Regional Operations Support Nurse verified they were not able to retrieve the nurse's notes, documenting her return to perform a Bladder Scan. They were not able to provide physician orders changing the nurses visit frequencies, nor a discharge summary for this patient.