Every finding on record at Charter Healthcare of Northern Colorado LLC

A recertification survey was completed on 3/19/21. Three deficiencies were cited.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on interview and record review the agency failed to ensure services and treatments were provided in accordance with physician's orders for 1 of 7 patients who received Physical Therapy (PT) services (Patient #9). Findings include: 1. The clinical record for Patient #9 was reviewed on 3/17/21. The Plan of Care for the certification period 1/24/21 to 3/4/21, revealed a start of care date of 11/25/20; diagnosis included COVID 19, pneumonia, fatigue, DM2, hyperlipidemia and hypertension. Plan of Care orders included PT for fall prevention, balance and strengthening. PT visits were ordered once weekly for one week then two times weekly for five weeks starting 1/25/21. a) Record review revealed the agency failed to ensure PT services were provided as ordered by the physician on the Plan of Care. Review of PT visit notes for the time period 1/25/21 through 3/4/21 revealed one PT visit on 2/18/21 for a total of eleven missed PT visits without explanation as to why the visits had not been conducted as ordered in the Plan of Care. Clinical record review failed to show Missed Visit notes for services cancelled; it was unknown if the agency or the patient cancelled the services. There was no documentation in the clinical record explaining why the services had not been provided as ordered and no documentation how the patient's needs were met. During an interview on 3/18/21 at approximately 11:30 a.m. the Director Patient Care Services (DPCS) acknowledged only one visit was completed by the PT during the six week period of therapy ordered by the physician on the plan of care. The DPCS was not sure why the visits were not completed. During an interview on 3/18/21 at approximately 4:00 p.m. the Administrator reported the PT was a contract employee and no longer provided services at the agency.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure services and treatments were administered by agency staff only as ordered by a physician for 1 of 4 patients who received Occupational Therapy (OT) services (Patient #5). Findings include: 1. The clinical record for Patient #5 was reviewed on 3/17/21. The Plan of Care for the certification period dated 2/11/21 to 4/11/21, revealed a start of care date of 2/11/21; diagnosis included colon cancer, colostomy, necrotizing soft tissue infection, atrial fibrillation. The Plan of Care included OT visits three times a week for one week then 2 times a week for 1 week starting 2/14/21 for improved self care. a) Record review revealed the agency failed to ensure the OT provided services only as ordered by the physician. Review of the visit notes for the time period 2/12/21 through 3/15/21 revealed OT visits were completed as ordered for weeks one and two. Record review showed the OT made two additional visits to Patient #5 on 3/1/21 and 3/3/21 without a physician's order. There was no evidence of communication with the physician or verbal orders for the additional OT services provided. During an interview on 3/18/21 at approximately 11:30 a.m. the Director Patient Care Services (DPCS) acknowledged there was no evidence of physician orders for additional OT services. The DPCS explained a new electronic medical record (EMR) was implemented January 2021 and the OT may not have been aware of how to accurately process or document orders. She stated that she would establish an education plan regarding physician orders for additional services going forward

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure a completed discharge summary was sent to the primary care practitioner within five business days of the patient's discharge for 1 of 3 discharged patient records reviewed (Patient #9). Findings include: AGENCY POLICY According to the policy, Summary of Care Provided, revised 11/2019: (in pertinent part) "The agency should send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care and treatment preferences to the receiving health care practitioner to ensure the safe and effective transition of care." 1. The clinical record for Patient #9 was reviewed on 3/17/21. The Plan of Care for the certification period 1/24/21 to 3/4/21, revealed a start of care date of 11/25/20; diagnosis included COVID 19, pneumonia, fatigue, DM2, hyperlipidemia and hypertension. Plan of Care orders included Physical Therapy (PT) for fall prevention, balance and strengthening. PT visits were ordered once weekly for one week then two times weekly for five weeks starting 1/25/21. PT Missed Visit note dated 3/4/21 stated the "patient will be discharged due to non-compliance throughout care." Review of Patient #9's record failed to show evidence a discharge summary was sent to the physician required by regulation. During an interview 3/18/21 at 11:30 a.m., the Director Patient Care Services (DPCS) stated the discharge summary had not been completed by the PT. She acknowledged the discharge summary was not sent to the physician. During an interview on 3/18/21 at approximately 4:00 p.m. the Administrator reported the PT was a contract employee and no longer provided services at the agency.