Every finding on record at Capital Care Resources LLC

An unannounced, onsite complaint investigation was conducted 2/17/25. The allegation related to patient rights was substantiated.

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on agency policy review, review of the incident/complaint tacking log, clinical record review, and staff interviews the agency failed to document a complaint/concern for 1 of 1 records reviewed voicing a concern/complaint [#1]. The findings included: The policy, 03-23 Patient Complaint Managment [07/2024], was provided by the branch director on 2/17/25 at 11 am. The policy stated, "...All verbal and written complaints/grievances the Home Health agency receives from patients or authorized representatives will be documented in the patient's medical record as an occurance. All complaints/grievances will be logged with ongoing/acconmpany documentation until resolved..." Patient # 1 had a Start of Care date of 12/30/24 with admitting diagnosis of atherosclerotic heart disease [build-up of fats, cholesterol and other substances in and on the artery walls]. Review of the Plan of Care for the certification period 12/30/24-2/27/25 included: SN [skilled nurse] 1 time a week for 3 weeks, 1 time every 2 weeks for 6 weeks; PT [physical therapy] 1 time a week for 7 weeks; OT [occupational therapy] 1 time a week for 1 week. Review of the clinical record revealed PTA # 1 documented the following information on , “...Patient’s son and daughter in law had multiple complaints regarding cancelled visits and no shows.” Review of the coordination notes revealed RN # 2 documented the following information on 1/24/25, “Attempted to call PT’s [patients] family at ___________ [telephone number] and left vm [voice mail] to discuss POC [plan of care] and complaint [sic] concern that was shared by the clinician on 1/22 at 4 pm, 1/23 at 10 am and 12 pm, and 1/24 at 8:10 am with no return call from the family.” Review of the agency complaint/concern log did not include any documentation related to patient # 1. During an interview with the branch director on 2/17/25 at approximately 3 pm, the director confirmed the agency failed to log the concern/complaint. “We were kinda waiting on a call back before we logged anything.”

2/8/21-2/9/21 Unannounced onsite complaint investigation was conducted. Deficiencies to the Medicare CoP were identified.-MHB NC00172795

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 review and staff interviews the agency failed to conduct an initial assessment visit within 48 hours of accepting a referral for 2 of 3 charts [#1 and 3]. The findings included: 1. Patient # 1 had a Start of Care date of 12/24/20 and diagnoses of Pneumonia and Hypertension. A review of the clinical record revealed Patient # 1 was admitted to _____[name of hospital] on 12/9/20 with a diagnosis of Acute Respiratory Failure secondary to Pneumonia. Further review of the record revealed the agency communicated with the hospital via naviHealth and accepted the referral on 12/14/20. The patient was not admitted to the agency until 12/24/20 and the physician was notified there would be a delay in admission. The director was not available for interview. On 2/9/21 at approximately 12 pm an interview was conducted with Employee # 4 [director from another branch which was assisting with complaint investigation]. During the interview employee # 4 confirmed the agency failed to admit the patient during the 48-hour time frame. "I am not sure what happened, except we failed to get out there." 2. Patient 3 had a Start of Care [SOC] date of 9/8/20 and an admitting diagnosis of Type 1 Diabetes Mellitus with Diabetic Chronic Kidney Disease. A review of the clinical record revealed Patient # 3 was admitted to ______[name of hospital] on 8/27/20 with a diagnosis of DKA [Diabetic Ketoacidosis]. Further review of the clinical record revealed the agency responded to ____[name of system] Online Referral on 8/30/20 and accepted the referral. The discharging agency had requested a start of care date of 8/31/20. Patient # 3 was discharged from the hospital on 8/30/20. Patient # 3 was not admitted to the agency until 9/8/20. The physician was not notified for an order to delay the start of care. The director was unavailable for an interview. On 2/9/21 at approximately 12:15 pm an interview was conducted with Employee # 4[director from another branch which was assisting with complaint investigation]. During the interview employee # 4 confirmed the agency failed to admit the patient during the 48-hour time frame. "As I said before, I will not offer an excuse. We did not admit the patient within the regulated time frame".