Every finding on record at Central Florida Quality Care Services Inc

Complaint Investigation #2021008372 was conducted on 07/07/21 and 07/08/2021. Central Florida Quality Care Service Inc was not in compliance with 42 CR 484.60 requirements for Home Health Agencies.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure the patient rights for home health services included a discharge date and summary of the patient's progress meeting care plan goals for 2 (#1, #2) of 3 discharge records reviewed, out of a sample of 3. Review of patient #1's record revealed she was admitted to the HHA on 6/14/2021. Diagnosis included Aftercare following joint replacement surgery. A Plan of care was dated 6/14/21,documented skilled nursing 1w1(one time a week for one week) and physical therapy orders 3w2 (three times a week for two weeks) . Physical Therapy was ordered to provide education to patient regarding transfer, bed mobility, and gait training. An “Oasis Assessment Details” start of care assessment was completed and dated 6/14/21. Review of the discharged record revealed that a Medicare Non-Coverage form with no discharge date was signed by patient #1 on 6/21/21. The discharge summary was completed by the physical therapist B remotely on 6/23/21. The discharge record has no evidence a discharged Outcome and Assessment Information set (OASIS) assessment was completed. Review of patient #2’s record displayed he was admitted to the HHA on 6/2/2021. Diagnosis included aftercare following joint replacement surgery. A Plan of care was dated 6/2/2021, documented "skilled nursing 1w1 and physical therapy to evaluate and treat." Physical Therapy was ordered to include education to Patient #2 spouse regarding safe transfers to all surfaces, home exercise program (HEP), safe mobility and safe use of scooter. Review of the discharged records revealed that a Medicare Non-Coverage form with no discharge date was signed by patient #2 on 6/29/21. There is no evidence of discharge instructions, summary or discharge OASIS completed on patient #2. On 7/8/21 at 1:18PM Physical Therapist B stated that she completes a discharge summary based on information documented by the Physical Therapy Assistant during the last visit. She explained all discharge summaries were completed remotely and patients were never provided with copies of the written discharge instructions. On 7/8/21 at 2:16 PM, the Alternate Director of Nursing stated that the “Medicare Non-coverage” forms must include the patient’s discharge date. She acknowledges patient had a right to be informed of the discharge date and receive discharge instructions. The HHA’s “Patient Care Policies dated 2017 read, “Patient/Family will be informed of the discharge, orally and in writing, at least 5 days prior to discharge. The following will be discussed…. The date of the discharge…reason for the discharge… Oasis data sets are completed when a patient is transferred or discharged.”