Every finding on record at Eastern Carolina Home Health Agency LLC

An unannounced, onsite complaint investigation was conducted 12/06/21. The allegation that the agency delayed the start of care is substantiated. Standard level deficiencies to the Medicare Conditions of Participation were identified. -MHB

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the agency delayed the start of care for 1 of 3 patients (Patient #2). Findings included: Patient #2 was admitted to the agency on 10/11/21 with diagnoses including chronic kidney disease, obesity, urinary tract infection, diabetes, and protein calorie malnutrition. Order home health for services dated 10/04/21 revealed, “Home health PT eval + treat (home health physical therapy evaluate and treat), Home health OT eval + treat (home health physical therapy evaluate and treat), Nurse for med management (nurse for medication management)” Client Coordination Note Report of 10/18/21 revealed a clinical comment intake note from Employee #2, an intake department licensed practical nurse (LPN), “LATE ENTRY...VERBAL ORDER SOC (start of care) 10/11/21…(name of social worker who sent referral to agency) FOR-OKAY FOR [sic] SOC 10/11/2021” There is no evidence in the clinical record that the physician ordering home health services was made aware of a delayed start of care. Plan of Care from 10/11/21 to 12/09/21 revealed orders for skilled nursing 1 time per week for 3 weeks, physical therapy 1 time per week for 1 week effective 10/17/21, and occupational therapy 1 time per week for 1 week effective 10/17/21. Supporting documentation for home health eligibility revealed, “PRIMARY NEED IN THE HOME IS THERAPY. PATIENT’S STATED GOAL IS ‘WALKING WITHOUT FALLING’…” In an interview on 12/08/21 at 3:55 PM, Employee #1, the agency director, stated, “I know that we were having PT capacity issues and we make our referral sources aware, but I don’t know why this PT eval would have been delayed until the following week…we make sure our referral sources know when the start of care will be.” At approximately 4:10 PM, Employee #1 stated that the order for physical and occupational therapy services to start the week of 10/17/21 was added to the plan of care by the clinical manager and was related to staffing.