Every finding on record at Coteau Des Prairies Hosp Home

A recertification survey for compliance with 42 CFR Part 484, Subpart G, Subsection 484.102 Emergency Preparedness Requirements for Home Health Agencies, was conducted from 6/25/24 through 6/26/24. Coteau Des Prairie Healthcare System was found in compliance.

A recertification health survey for compliance with 42 CFR Part 484, Subparts B-C, requirements for Home Health Agencies, was conducted from 6/25/24 through 6/26/24. Coteau Des Prairie Health Care System was found not in compliance with the following requirements: G0520 and G0574.

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on record review, interview, and policy review, the provider failed to ensure the physician-ordered occupational therapy (OT) evaluation was completed within five days of the start of care (SOC) and was included in the comprehensive assessment for two of seven sampled patients (2 and 3) records reviewed. Findings include: 1. Review of patient 2’s electronic medical record (EMR) revealed: *She was referred to the home health agency (HHA) on 6/6/24. *The referring physician ordered home health skilled nursing (SN), physical therapy (PT), and OT services. * The HHA registered nurse (RN) completed the initial assessment and SOC on 6/6/24. *OT completed their initial evaluation on 6/12/24, six days after the SOC. 2. Review of patient 3’s EMR revealed: *She was referred to the HHA on 3/21/24. *The referring physician ordered home health SN, PT & OT services. *The HHA RN completed the initial assessment and SOC on 3/21/24. *OT completed their initial evaluation on 4/2/24, twelve days after the SOC. 3. Interview on 6/26/24 at 12:25 p.m. with occupational therapist (OT) C revealed: *All therapy referrals were sent to the therapy agency by the HHA. *She completed initial OT evaluations. *She did not schedule the home health initial OT evaluations and visits; the therapy agency secretary scheduled the home health initial OT evaluations and visits. *She had thought at least one of the home health initial therapy evaluations was supposed to be completed within 48 hours of the referral to their agency. *She had not been aware all home health skilled services ordered at SOC were to be completed within five days and included in the comprehensive assessment. 4. Interview on 6/26/24 at 3:20 p.m. with clinical manager A revealed: *The HHA RN completed the SOC and comprehensive assessments for all HHA patients. *She had not managed or scheduled the home health therapy services. *The HHA had contracted with a therapy agency to provide PT, OT, and speech therapy (ST) services. *Therapy referrals were sent to the contracted agency when received by the HHA. 5. Interview on 6/26/24 at 3:40 p.m. with therapy clinic manager B revealed: *He had been the therapy clinic manager for eleven years. *Therapy staff completed home health training and competencies online annually. * Therapy staff and the HHA met weekly to discuss the patient caseload and upcoming referrals. *The HHA agency sent therapy referrals to the therapy agency and initial evaluations were scheduled by their department secretary. *He was aware all home health skilled services ordered at SOC were to be completed within five days and included in the comprehensive assessment. *They did their best to complete the initial OT therapy evaluations within five days of the SOC, but with one OT on staff, there were times when they were unable to meet the compliance. *They had not notified or obtained new orders from the referring physician regarding their inability to complete the initial OT evaluations within the required five days of SOC. 6. Review of the HHA Intake and Admission policy dated 7/8/21 revealed: *” Policy - Before accepting patient for services, the agency ensures that it can meet the patient’s identified medical, nursing, rehabilitative and psychosocial needs in the patient’s place of residence. The governing body establishes criteria for admission including: --the agency has adequate and suitable staff and resources to provide the needed services.” --“Coordinating timely service delivery, including communication to the appropriate staff members.” --“If the agency encounters difficulties with the time frames the admitting RN contacts the provider to discuss the situation. --Staff will perform the comprehensive assessment, including OASIS, within five calendar days of the start of care or patients subject to the requirement.” 7. Review of the [therapy agency] Home Health Therapy Order/Extension Order/Missed Visit Form policy dated 2/2/21 revealed: *”Purpose -1.1 To establish guidelines for completing a home health evaluation in a timely manner and adjustment of frequency and duration of established plan of care. *Policy -2.1 An Evaluation must be completed for each home health patient within agency timeline ([therapy agency] recommends within 48 hours for at least one discipline).” * “Procedure -3.1 Schedule evaluation within guidelines. -3.2 Complete Extension Order/Missed Visit Form when additional visits required and missed visits occur.”

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review, interview, and policy review, the provider failed to ensure the goals and interventions established from the initial occupational therapy (OT) evaluation were included in the patient's initial plan of care (POC) and sent to the physician for review and signature for two of seven sampled patients (2 and 3) records reviewed. Findings include: 1. Review of patient 2’s electronic medical record (EMR) revealed: *She was referred to the home health agency (HHA) on 6/6/24. *The referring physician ordered home health skilled nursing (SN), physical therapy (PT), and OT services. * The HHA registered nurse (RN) completed the initial assessment and SOC on 6/6/24. *OT completed their initial evaluation on 6/12/24, six days after the SOC. *The patient's OT goals and interventions established during the initial OT evaluation were listed on the care plan, but not included in the patient's initial POC or sent to the physician for review or signature. 2. Review of patient 3’s EMR revealed: *She was referred to the HHA on 3/21/24. *The referring physician ordered home health SN, PT & OT services. *The HHA RN completed the initial assessment and SOC on 3/21/24. *OT completed their initial evaluation on 4/2/24, twelve days after the SOC. *The patient's OT goals and interventions established during the initial OT evaluation were listed on the care plan, but not included in the patient's initial POC or sent to the physician for review or signature. 3. Interview on 6/26/24 at 12:25 p.m. with occupational therapist (OT) C revealed: *She completed home health initial OT evaluations and OT visits. *She had been trained to use the home health EMR system. *She documented the patient’s initial OT evaluation, entered goals and interventions into the patient care plan, and generated an order for OT visits into the patient’s home health EMR. *She was unsure if the computer system automatically sent her documentation to the physician for review and signature or how the physician received the OT plan of care or other orders for review and signature. *The other hospital computer systems used in the therapy department notified her when the physician had signed OT orders and POCs. 4. Interview on 6/26/24 at 3:20 p.m. with clinical manager A revealed: *The HHA RN completed the SOC, and comprehensive assessment, and generated the initial home health POC that was sent to the physician for review and signature for all HHA patients. *She had not managed or scheduled the home health therapy services. *The HHA had contracted with the therapy agency to provide PT, OT, and speech therapy (ST) services. *Therapy referrals were sent to the contracted therapy agency when received by the HHA. *She had not reviewed the OT POC to ensure it was sent to the provider for review and signature. *She agreed the home health initial POC for patients 2 and 3 did not include the OT POC established during the initial OT evaluation, and the OT goals and interventions for patients 2 and 3 had not been reviewed or signed by the physician. *She stated the RN did not check the appropriate box in the system that would have included the initial OT goals and interventions in the POC for the physician's review and signature. 5. Interview on 6/26/24 at 3:40 p.m. with therapy clinic manager B revealed: *He had been the therapy clinic manager for eleven years. *Therapy staff completed home health training and competencies online annually. *He had not reviewed the OT POC to ensure it was sent to the provider for review and signature. *He agreed the home health initial POC for patients 2 and 3 did not include the OT POC established during the initial OT evaluation, and the OT goals and interventions for patients 2 and 3 had not been reviewed or signed by the physician. 6. Review of the HHA “The Provider’s Role” policy dated 12/2/20 revealed: *” Purpose The purpose of this policy is to establish guidelines for interactions with the providers that promote appropriate care planning, delivery of care, orders and provider certification, and coordination of services; ensures that the providers who work with the agency provide orders for services practice within accepted standards of care; and ensure that the agency informs the providers who manage patient care of the policies and procedures regarding agency and provider responsibilities.” *” Policy The plan of care includes all pertinent diagnoses, mental status, types of services and equipment required, frequency of visits, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, medications, treatments, safety measures to protect against injury, instructions for timely discharge or referral any other appropriate items. The agency uses the Home Health Certification and Plan of Care (CMS 485) as the plan of care. The plan is individualized to the patient's needs, strengths, limitations, goals, and environment.” -“Care delivery follows the plan of care.” -” The agency ensures that staff providing services under arrangement or contract: --Participate in developing the plan of care. --Deliver services according to the plan of care. --Notifies the provider of changes in the patient’s condition and communicates and documents accordingly.”