Every finding on record at Concentric Homecare LLC

An unannounced complaint survey for complaint #2023015286 was conducted on 10/17/23, at Concierge Home Care, a home health agency in Sarasota Florida. Complaint #2023015286 was substantiated at G728 and G1010. Concierge Home Care is not in compliance with the Code of Federal Regulations (CFR) 42, Part 484, Conditions of Participation for Home Health Services. The following is a description of the Standard-level deficiencies.

Rehab services supervised by PT, OT CFR(s): 484.75(c)(2) Rehabilitative therapy services are provided under the supervision of an occupational therapist or physical therapist that meets the requirements of §484.115(f) or (h), respectively. This ELEMENT is not met as evidenced by: Based on interview and record review the agency failed to ensure physical therapy services were provided under the supervision of a physical therapist for one patient (Patient #1) of three patients surveyed Findings included: Review of a “PT Evaluation” dated 9/18/23 shows The Director of Professional Services, who is a registered nurse signed the evaluation. On 10/17/23 at 12:30 p.m. the Director of Professional Services said she had signed the PT evaluation because the physical therapist who was over Patient #1 had been terminated on 9/20/23. Review of the electronic record showed no additional evaluation had been completed by a physical therapist. The electronic record showed a Physical Therapy Assistant (PTA) had conducted therapy visits on 9/22/23, 9/25/23, 9/27/23, and 10/2/23. On 10/17/23 at 2:15 p.m., the Administrator said the owner of the contracted company providing physical therapy services to the home health agency provided the contact information for Physical Therapist Staff A and stated he was the physical therapist supervising the PTA who was visiting Patient #1. On 10/17/23 at 2:30 p.m. Staff A said he had never seen Patient #1. He said he had attempted to contact the patient and was unsuccessful. He said he could not provide supervision for Patient #1 if he had never seen the patient. Restated he would need to complete a PT evaluation in order to provide supervision for services.

Contents of clinical record CFR(s): 484.110(a) Standard: Contents of clinical record. The record must include: This STANDARD is not met as evidenced by: Based on interview and record review the facility failed to ensure an accurate electronic record was maintained for one patient (Patient #1) of three patients surveyed by failing to ensure a Physical Therapy evaluation signed and dated by the physical therapist was a part of the patient’s electronic record. Findings included: On 10/17/23 at 10:00 a.m., Physical Therapist Staff B said she had completed a PT evaluation on 9/18/23 for Patient #1. Staff B said the Director of Professional Services (DOPS) sent her a PT evaluation form in which the frequency of visits had been changed from two visits weekly for three weeks to two visits weekly for two weeks then one visit weekly for seven weeks. Staff B said she had refused to sign the form because of the changed frequencies. She stated that later, she had seen where the DOPS had changed the frequencies and signed the form. Staff B said she did not believe this action was legal. Review of Patient #1’s electronic medical record found one PT evaluation dated 9/18/23 and signed by the DOPS. There were no other PT evaluations noted in Patient #1’s electronic medical record. A Care Plan dated 9/15/23 and signed by Staff C shows frequency of PT visits ordered were two times weekly for two weeks and then one time weekly for 7 weeks. A communication note dated 9/18/23 shows Staff B had contacted the physician on 9/18/23. The documentation shows on 9/18/23 the physician wanted Patient #1 to have physical therapy two times weekly for three weeks. The form reads, “MD [medical doctor] contacted with POC [plan of care] and freq. 2x3” On 10/17/23 at 12:30 a.m., the DOPS verified she had signed the PT evaluation and stated she had signed the form after consulting with the corporation. The DOPS stated she had signed the evaluation because Staff B had been terminated form the agency. The DOPS verified she had not completed the PT evaluation on 9/18/23. The DPOS said she had changed the frequency of visits after she had spoken with the owner of the company providing therapy services for whom Staff B had worked. The Owner of the company was an Occupational Therapist (Staff D). The DPOS said she had not received a verbal order from the physician to change the physical therapy frequency for Patient #1. She stated The Occupational Therapist, Staff D had gotten a verbal order to change the frequency. Review of the electronic medical record finds no documentation after 9/18/23 for any changes to the frequency of physical therapy services for Patient #1. On 10/17/23 at 12:56 p.m., Staff D verified he had not obtained a verbal order from Patient #1’s physician to change the frequency of physical therapy visits. Staff E said he had not instructed the DOPS to change the frequency of physical therapy visits. Staff E said he had no authority to tell the DPOS to change physical therapy services.