Every finding on record at Crossroads Home Care Services, LLC

An investigation was conducted on 5/4/2021 for Complaint #IL00132835/#211350. The Home Health Agency was not in compliance with standards for Home Health Agencies 42 CFR 484., as evidenced by: Abbreviations: #-number E-employee HHA-home health agency OT-occupational therapy PCP-primary care physician Pt-patient PT-physical therapy RN-registered nurse SOC-start of care SN-skilled nurse

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 documentation and staff interview it was determined for 1 of 10 (Pt #1) clinical records reviewed, the Home Health Agency (HHA) failed to conform with physician orders. This has the potential to affect all patients seeking home health services-current census-70. Findings include: 1. The HHA policy revised by the agency on 10/1/19, titled, "PATIENT ASSESSMENT, INITIAL AND REASSESSMENT" was reviewed on 5/4/21 at 2:00 PM. The policy under "PROCEDURE: 5. A qualified clinician performs a comprehensive assessment or reassessment in the following situations: a. Admission visit within 48 hours from referral or physician ordered start of care date". 2. The clinical record of Pt #1 was reviewed on 5/3/21-5/4/21. On 3/26/21, Pt #1 had an exploratory laparotomy and detorsion of small bowel volvulus. Pt #1 has history of intellectual disability. The hospitalist referred to home health services on 4/1/21 for skilled nursing (SN), physical therapy (PT) and occupational therapy (OT). On 4/2/21, the SN did an initial assessment home visit. Upon arrival, the SN was told Pt#1's sister had notified physician of pain and swelling in Pt #1's scrotal area. The SN was notified later in day by the sister that Pt #1 was being admitted to the hospital. The HHA did not admit Pt #1 at this time. On 4/6/21, a referral was received from the primary care physician (PCP) for home health SN services, with requested start of care (SOC) date of 4/7/21. Documentation on the "Non-Admissions Report" indicated the SN had spoken to Pt #1's sister. The sister verbalized Pt #1 was going back to the hospital and doesn't know if Pt #1 will be admitted. Pt #1's sister also verbalized Pt #1 had an appointment on Monday, (4/12/21) to see surgeon. Pt #1's sister requested to hold off on home health admission until after surgeon appointment on 4/12/21. There is no other documentation to indicate the PCP was notified of delay in the SOC. On 4/15/21 at 9:53 AM, a referral was received from the PCP for SN home health services. There was no documentation to indicate a SN visit was conducted or the PCP and patient was notified that the visit did not occur. 3. On 5/4/21 at 9:30 AM, an interview was conducted with the executive director (E#3). E#3 reviewed Pt #1's clinical record and documentation . E#3 confirmed there was no follow-up with the patient or physician after receiving the referral.