Every finding on record at Delta Home Health Care

A Recertification Survey was initiated on 10/11/2022. Census: Licensed and Certified- 0 Licensed Home Health- 0 Personal Assistance Services- 9 The agency was in substantial compliance with 42 CFR Part 484.22, Emergency Preparedness Requirements for Home Health Agencies.

A Recertification Survey was initiated on 10/11/2022. Census: Licensed and Certified- 0 Licensed Home Health- 0 Personal Assistance Services- 9 Acronyms used: POC- Plan of Care SOC- Start of Care RN- Registered Nurse SN- Skilled Nurse PT- Physical Therapy PRN- as needed

Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient's discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner's issuing orders for the HHA plan of care, and the patient's 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). This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patients’ discharge was communicated to the physicians for 7 (Patients #1, 2, 3, 4, 5, 6 and 7) of 7 patients' whose discharge records were reviewed. The agency did not notify the physician of the patient’s discharge from the agency and discontinuance of clinical services. This failure could place patients at a risk of harm, due to a lack of shared information regarding the ongoing care and service needs. FINDINGS INCLUDE: On 10/11/2022 at approximately 2:00 PM, the surveyor was provided a list of discharged patients for the past three years. The list included the following discharge dates: Patient #1- 04/09/2021 Patient #2- 05/21/2021 Patient #3- 06/30/2021 Patient #4- 07/16/2021 Patient #5- 07/05/2021 Patient #6- 01/11/2021 Patient #7- 05/15/2021 In an interview with the Office Manager on 10/19/2022 at approximately 10:40 AM, the surveyor asked if the agency had any documentation of discharge for Patient #5. The Office Manager stated, “that is the wrong date on the discharge list, the patient was actually discharged at the end of the episode that ended 05/04/2021.” CLINICAL RECORDS: Patient #1: Record review of the clinical record included a POC with a SOC date of 06/24/2020 and a certification period 02/19/2021-04/19/2021. The POC included the following diagnoses: Essential hypertension and other schizophrenia. Physician orders included SN visits once a week for eight weeks and one RN visit for recertification/discharge. Further review of the record failed to reveal any documentation of communication or coordination of care with the physician that included a request or notification the patient was to be discharged from the agency. Patient #2: Record review of the clinical record included a POC with a SOC date of 10/27/2020 and a certification period 04/25/2021-06/23/2021. The POC included the following diagnoses: Heart disease with failure and Type 2 diabetes mellitus with diabetic neuropathy. Physician orders included SN visits once a week for nine weeks and one PRN visit for recertification. Further review of the record failed to reveal any documentation of communication or coordination of care with the physician that included a request or notification the patient was to be discharged from the agency. Patient #3: Record review of the clinical record included a POC with a SOC date of 05/31/2021 and a certification period 05/31/2021-07/29/2021. The POC included the following diagnoses: Peripheral vascular disease; Type 2 diabetes mellitus with hyperglycemia; Chronic obstructive pulmonary disease and Heart disease with failure. Physician orders included SN visits once a week for nine weeks. A PT Evaluation was signed by the physician 07/12/2021 and included physician orders for PT frequency once a week for one week, twice a week for four weeks and once a week for three weeks. Further review of the record failed to reveal any documentation of communication or coordination of care with the physician that included a request or notification the patient was to be discharged from the agency. Patient #4: Record review of the clinical record included a POC with a SOC date of 06/05/2021 and a certification period 06/05/2021-08/03/2021. The POC included the following diagnoses: Follicular lymphoma grade 1, intra-abdominal lymph nodes; Malignant neoplasm (cancer); Heart disease and Essential hypertension. Physician orders included SN visits one time a month, for three months and PT once a week for one week and twice a week for six weeks. Further review of the record failed to reveal any documentation of communication or coordination of care with the physician that included a request or notification the patient was to be discharged from the agency. Patient #5: Record review of the clinical record included a POC with a SOC date of 01/05/2021 and a certification period 03/06/2021-05/04/2021. The POC included the following diagnoses: Pneumonia; Chronic obstructive pulmonary disease and Heart failure. Physician orders included SN visits once a week for nine weeks and one PRN visit for RN recertification/discharge. Further review of the record failed to reveal any documentation of communication or coordination of care with the physician that included a request or notification the patient was to be discharged from the agency. Patient #6: Record review of the clinical record included a POC with a SOC date of 01/11/2021 and a certification period 01/11/2021-03/11/2021. The POC included the following diagnoses: Bilateral primary osteoarthritis of knee; other abnormalities of gait and mobility; chronic pain and Hypertension. Physician orders included SN visits once a week for nine weeks. Further review of the record failed to reveal any documentation of communication or coordination of care with the physician that included a request or notification the patient was to be discharged from the agency. Patient #7: Record review of the clinical record included a POC with a SOC date of 04/12/2021 and a certification period 04/12/2021-06/10/2021. The POC included the following diagnoses: Type 2 diabetes mellitus with diabetic neuropathy; Hypertension and Osteoarthritis. Physician orders included SN visits once a week for four weeks and every other week for 4 weeks. Further review of the record failed to reveal any documentation of communication or coordination of care with the physician that included a request or notification the patient was to be discharged from the agency. During an interview with the Administrator and Office Manager on 10/19/2022 at approximately 3:15 PM, the surveyor reviewed the findings of the agency's failure to coordinate care with physicians to notify of Patient’s #1-7’s discharges and asked why the agency did not coordinate care with the physician’s regarding the patient’s discharges. The Administrator stated, “we talked to them and let them know.” The surveyor asked how the lack of documented coordination could impact the patients. The Administrator stated, “we just didn’t document it, but we know if it isn’t documented, it isn’t done.” Agency policy, dated 2014, quoted in part, “Discharge Criteria, Policy: Patients are discharged by Agency based on specifically defined criteria…. Procedure: … 3. Physician and other care providers will be informed and knowledgeable of discharge….”