Every finding on record at Caretenders Visiting Services of District 7, LLC

During the recertification survey conducted on 6/1/25 to 6/5/25 at Mederi Caretenders, a Home Health Agency, Emergency Preparedness was reviewed. Mederi Caretenders was 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 completed on 6/1/25 to 6/5/25 at Mederi Caretenders. The facility was not in compliance with Code of Federal Regulations (CFR) 42, Part 484.22, Requirements for Home Health Agencies.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to incorporate clinical notes from the triaging nurse after hours group into a patient's clinical record for 1 of 9 sampled active patients (#8). Review of patient #8's clinical record revealed a start of care date, 5/28/25. His diagnoses included aftercare following surgery for neoplasm, malignant neoplasm of the esophagus, unspecified, chronic obstructive pulmonary disease, unspecified, and paroxysmal atrial fibrillation. On patient #8's plan of care with the certification period of 5/28/25 to 7/26/25 it indicated in the orders of discipline and treatments section part of his post operative care included wound/Jackson Pratt (JP) drain care and JP drain monitoring. Review of patient #8's medical record revealed a clinical note electronically signed by a registered nurse (RN) and dated 6/1/25 6:09 AM, a Sunday not during the agency's office hours. This clinical note indicated patient #8 called the agency because he was concerned about the quantity and contents of the drainage in his JP bulb (collection piece attached to the JP drain which is internal). This note indicated that his concerns would be relayed to the care team and someone would follow up. There were no additional clinical notes in the record of what follow up occurred. On 6/3/25 at 3:57 PM the Administrator reviewed the call log kept in an electronic system, used by the afterhours triaging nurse service, and noted that after the 6/1/25 6:09 AM call from patient #8 there had been 2 calls made by the clinical triaging nurse team, RNs, to patient #8 on 6/1/25 to discuss his JP drainage concerns, at 6:35 AM and at 9:14 AM. The Administrator verified that the two additional clinical triage RN notes from 6:35 AM and 9:14 AM on 6/1/25 should also be in patient #8's clinical record, not just in the electronic system used by the afterhours triaging nurse service. She said to ensure timely coordination of care all communication with patient #8, including the triaging clinical nurse service, should be patient #8's medical record. On 6/4/25 at 2:42 PM via videoconferencing the agency's Corporate Director of the Clinical Triage team said, with the Administrator and the Vice President of Operations present, that for 1 month she has known that the electronic record system used by the after hours clinical triage nurse group only sends the first clinical nursing note of a triaging event into a patient's medical record. It is the agency's responsibility to copy notes from that system and paste any additional notes from the clinical nurse triage group's event into a patient's medical record. The Administrator said she did not know this copy and pasting between each system had to be done and that is why patient #8 did not have all the clinical coordination of care notes in his medical record. The agency's home care record policy with the most current revision date of 10/01/23 indicated documentation and communication with the patient should be kept in the patient's record.

During the Recertification survey from 8/30 to 9/2/21, the Home health agencies’ emergency preparedness plan was reviewed. The Home Health Agency was in compliance with 42 CFR 484, Requirements for Home Health Agencies.

A recertification and Focused infection control survey was conducted from 8/30 to 9/2/21. Mederi Caretenders was not in compliance with 42 CFR 484, Requirements for Home Health Agencies.

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 interview and record review, the agency failed to notify the physician for delay in service for 1 of 9 patients reviewed for start of care home care services of a total sample of 13 patients (#2). Findings: Patient #2 was admitted to the agency on 7/14/21 with diagnoses that included chronic obstructive pulmonary disease, disc degeneration, and history of falling. Review of the medical record revealed on 6/24/21 the agency received a referral from the physician with a written order for Physical Therapy (PT) and Occupational Therapy (OT) to evaluate and treat. Review of “Client Coordination Note Report” dated 6/24/21 showed a verbal order was obtained from the physician for Skilled Nursing (SN), PT, and OT services to start on 6/25/21. Review of subsequent “Client Coordination Note Report” dated 7/02/21 read, “Late entry for 6/24/21: Delay in start of care (SOC). Called patient to set up SOC for 6/25/21, and patient said that she’s not going to be home for a few days and will let us know when she returns home. Patient also stated that her husband passed away a few weeks ago and that’s the reason for her not being home.” Review of “Client Coordination Note Report” dated 7/12/21 read, “Patient is now back at her home after staying with her daughter for a while. Confirmed SOC with patient for 7/14/21…” No evidence of physician communication was found in the medical record for the delay in SOC. SOC was done 19 days after referral, on 7/14/21. On 8/31/21 at approximately 1:05 PM, the Executive Director (ED), confirmed notification to physician regarding SOC delay was not documented for patient #2. The ED indicated since it was not documented, it was not done, and she confirmed a new order was not obtained for new SOC. Review of the agency policy and procedure titled, ”Admission Process” revised on 1/1/21 read, “Admission/initial visits are made within 48 hours from referral unless there is a specific physician ordered start of care (SOC) date which would supersede the state established timeframes.”