Every finding on record at Bwb Sunbelt Home Health Services LLC

An Entrance Conference was conducted on 11/16/2022 with the Administrator, the Alternate Administrator/Supervising Nurse, the Alternate Supervising Nurse, the Medical Records Clerk and the Licensed Vocational Nurse/Intake Coordinator at 9:45 AM. The Agency representatives were informed that the purpose of the survey was a Recertification survey. Written information regarding “What to Expect During Your Agency’s Survey” was provided. The Agency census was: L&CHHS - 77 LHHS - 25 An Exit Conference was conducted on 11/18/2022 with the Administrator, the Alternate Administrator/Supervising Nurse, the Alternate Supervising Nurse and virtually with the Director of Clinical Operations, the Area Director of Operations, the Area Director of Rehabilitation Services at 5:00 PM. The preliminary findings of the survey were discussed. The Agency was afforded the opportunity to ask questions regarding the survey and given the opportunity to provide additional information. Additional information was received on 11/22/2022 at 5:15 PM. Written instructions were provided for submitting a plan of correction within 10 days of receipt of the Statement of Deficiencies. The Agency was determined to be in compliance with the Centers for Medicare and Medicaid Services Conditions of Participation for Emergency Preparedness.

An Entrance Conference was conducted on 11/16/2022 with the Administrator, the Alternate Administrator/Supervising Nurse, the Alternate Supervising Nurse, the Medical Records Clerk and the Licensed Vocational Nurse/Intake Coordinator at 9:45 AM. The Agency representatives were informed that the purpose of the survey was a Recertification survey. Written information regarding “What to Expect During Your Agency’s Survey” was provided. The Agency census was: L&CHHS - 77 LHHS - 25 An Exit Conference was conducted on 11/18/2022 with the Administrator, the Alternate Administrator/Supervising Nurse, the Alternate Supervising Nurse and virtually with the Director of Clinical Operations, the Area Director of Operations, the Area Director of Rehabilitation Services at 5:00 PM. The preliminary findings of the survey were discussed. The Agency was afforded the opportunity to ask questions regarding the survey and given the opportunity to provide additional information. Additional information was received on 11/22/2022 at 5:15 PM. Written instructions were provided for submitting a plan of correction within 10 days of receipt of the Statement of Deficiencies.

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure the patient's plans of care were reviewed by the patient's physician no less than once every 60 days, beginning with the start of care date for 4 of 10 patients (Patients #3, #5, #7, #10) for which the records were reviewed. This failure has the potential to cause harm to agency patients in that the physician may not be aware of changes in the patient's condition or the need for additional care and services. Findings Included: Review of the clinical record for Patient #3 revealed a start of care date of 06/27/2022. Review of the record revealed the POC for the certification period of 08/26/2022 to 10/24/2022. Further review of the POC revealed no documentation that the physician approved or signed the POC. During an interview conducted with the Administrator on 11/17/2022 at 2:15 PM, this Surveyor requested the signed POC for Patient #3 for the certification period of 08/26/2022 to 10/24/2022. The Administrator stated that she would locate it. During an interview with the Administrator on 11/18/2022 at approximately 3:00 PM, the Administrator stated the Agency had not received the signed POC for Patient #3 for the certification period of 08/26/2022 to 10/24/2022. On 11/22/2022 at approximately 5:15 PM , this Surveyor received additional information from the Agency. The additional information included the POC for Patient #3 for the certification period of 08/26/2022 to 10/24/2022. The Plan of Care was signed by the physician, dated 11/22/2022. Review of the clinical record for Patient #5 revealed a start of care date of 08/31/2022. Review of the record revealed the plan of care for the certification period of 08/31/2022 to 10/29/2022. Further review of the POC revealed no documentation that the physician approved or signed the POC. During an interview on 11/17/2022 with the Administrator at 2:00 PM. This Surveyor requested the signed POC for Patient #5 for the certification period of 08/31/2022 to 10/29/2022. The Administrator stated she would locate it. During an interview with the Administrator on 11/18/2022 at approximately 3:00 PM, the Administrator stated the Agency had not received the signed POC for Patient #5 for the certification period of 08/31/2022 to 10/29/2022. Review of the clinical record of Patient #7 revealed a start of care date of 08/04/2022. Review of the record revealed the plan of care for the certification period of 08/04/2022 to 10/02/2022. Further review of the POC revealed no documentation that the physician approved or signed the POC. During an interview on 11/17/2022 with the Administrator at 2:15 PM. This Surveyor requested the signed POC for Patient #7 for the time-period of 08/04/2022 to 10/02/2022. The Administrator stated she would locate it. During an interview with the Administrator on 11/18/2022 at approximately 3:00 PM, the Administrator stated the Agency had not received the signed POC for Patient #7 for the certification period of 08/04/2022 to 10/02/2022. Review of the clinical record of Patient #10 revealed a start of care date of 08/31/2022. Review of the record revealed the plan of care for the certification period of 08/31/2022 to 10/29/2022. Further review of the POC revealed no documentation that the physician approved or signed the POC. During an interview on 11/17/2022 with the Administrator at 2:15 PM. This Surveyor requested the signed POC for Patient #10 for the certification period of 08/31/2022 to 10/29/2022. The Administrator stated she would locate it. During an interview with the Administrator on 11/18/2022 at approximately 3:00 PM, the Administrator stated the Agency had not received the signed POC for Patient #10 for the certification period of 08/31/2022 to 10/29/2022. During an interview on 11/18/2022 with the Administrator at 3:00 PM, the surveyor reviewed the findings regarding the lack of physician signatures on the POC for Patients #3, #5, #7, and #10. The Administrator stated the Agency had identified lack of physician signatures on orders in June 2022. The Administrator stated she was tracking the number of unsigned orders and had noted improvement. The Administrator provided a spreadsheet which revealed the number of unsigned orders the Agency had. Review of the Agency’s QAPI plan and meeting minutes for 2020, 2021, and 2022 did not contain documentation of an identified issue or improvement plan related to unsigned physician orders. Review of additional documentation received from the Agency on 11/22/2022 at approximately 5:15 PM revealed a form which read in part, “Outstanding Orders > 30 days 06/08/2022 metrics report shows 314 > (greater than) 30 days orders not received. Action: 1. Medical Records Clerk will go out into community 2-3 days per week to drop off and pick up orders. 2. Medical Records Clerk and I (Administrator) will review the metrics weekly to measure effectiveness….4. All faxed orders not received will be refaxed after telephone confirmation that faxed orders are accepted. Completion: Goal of 50 % decrease in orders outstanding by February 1, 2023. Evaluation: We will re-evaluate in 4 months and make changes as needed to include: Increased days in the community to take and pick up orders, increase number of visits that marketers take out.” The documentation was signed by the Administrator, dated 06/20/2022. Further review of the additional documentation received by the Agency on 11/22/2022 at approximately 5:15 PM revealed no documentation of the re-evaluation of this action. Review of the Agency’s policy and procedure manual revealed a policy entitled “Physician/Provider Orders,” with a revision date of 01/2022, which read in part, “The POC must be reviewed and signed by the Physician/allowed practitioner every 60 days.”