Every finding on record at Eastern Rio Blanco Health Services District

A recertification survey was completed on 5/25/22. One deficiency was cited.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the 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) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure a discharge or a transfer summary was sent to the primary care practitioner within five business days of the patient's discharge or within two days of the patients transfer to another facility for 2 of 2 discharged patient records reviewed (Patients #6 and #7). This deficiency was cited previously during a federal certification survey on 6/27/19. Although the agency corrected the deficiency, based on the findings below, the agency had not maintained compliance with this regulatory requirement. Findings include: AGENCY POLICY: According to the agency's policy titled, "Discharge/Transfer of a Home Health Patient" dated 5/2021 in pertinent parts: "The physician(s) involved in the patient's plan of care, treatment and/or services shall be notified of the patient transfer or discharge, and appropriate orders obtained and documented in the medical record." 1. The clinical record for Patient #7 was reviewed on 5/25/22. The plan of care for the certification period dated 8/18/21 to 10/16/21, revealed a start of care date of 2/25/20; diagnoses included a stage three pressure injury to the right heel, senile dementia with delirium and behavioral disturbance, neuropathy, and hypertension. Plan of care orders included skilled nursing (SN) visits twice a month for two months and four as needed (PRN) visits for assessment of cardiovascular status, assessment of pain medication effectiveness, teaching of safety and fall prevention, and assessment for respiratory complications and physical therapy (PT) visits once a week for four weeks for PT intervention for shoulder, hip and knee pain. a) The agency failed to send a transfer summary to the physician within two days of transfer to a healthcare facility. Review of the clinical record for Patient #7 revealed an agency transfer summary dated 10/5/21. The transfer summary noted the patient was transferred to a hospital on 10/5/21. The document was unsigned and did not have the name of the person who completed it. Review of the clinical record revealed a transfer to an inpatient facility OASIS (outcome and assessment information set) form dated 10/5/21 and signed by the director of nursing (DON). The form revealed Patient #7 had been transferred to the hospital on 10/5/21 for an unscheduled hospitalization. However there was no documentation that either of these forms were sent to the physician on record for Patient #7. Clinical record review from 10/5/21 to 10/14/21 revealed no evidence the agency had informed Patient #7's physician of the transfer to the hospital on 10/5/21 by sending a transfer summary. b) The agency failed to send a discharge summary to the primary care practitioner within five business days of discharge. Review of the clinical record for Patient #7 revealed a discharge summary dated 10/14/21, signed by the DON, which stated Patient #7 had passed away at the hospital. There was no documentation that the discharge summary regarding the passing of Patient #7 was sent to the physician. Clinical record review from 10/14/21 to 5/25/22 revealed no evidence the agency had informed Patient #7's physician of his passing while at the hospital on 10/14/21 by sending the discharge summary. 2. The clinical record for Patient #6 was reviewed on 5/25/22. The plan of care for the certification period dated 11/21/21 to 1/10/21, revealed a start of care date of 1/12/20; diagnoses included right lower leg open wound, cellulitis, hypertension and hypothyroidism. Plan of Care orders included SN visits once a week for one week and three times per week for eight weeks for comprehensive assessment, peripherally inserted centralized catheter (PICC) line care, medication management, wound care, assessment of signs and symptoms of infection, and patient education. a) The agency failed to send a discharge summary to the primary care practitioner within five business days of discharge. Review of the clinical record for Patient #6 revealed a discharge from agency OASIS (outcome and assessment information set), dated 12/22/21, signed by the DON. The discharge OASIS noted Patient #6 was discharged home, and required no further care. The discharge OASIS also noted Patient #6 had met her goals. Further review of the record failed to reveal that a discharge summary was created for Patient #6, or that any information regarding the discharge had been sent to the primary care practitioner of Patient #6. Review of the clinical record from 12/22/21 to 5/25/22 revealed no revealed no evidence the agency had informed Patient #6's physician of her discharge on 12/22/21 by sending a discharge summary. 3. During an interview on 5/25/22 at 10:11 a.m., the DON stated she was unaware of the federal regulation regarding the need for a discharge summary to be sent to the primary care practitioner on record upon discharge. The DON confirmed no discharge summaries had been sent to the primary care practitioner for Patient #6 and Patient #7.