Every finding on record at Encompass Home Heath of Dfw LLC

A recertification inspection and complaint investigation survey were conducted for Intake 487261, on 07/01/2024. Licensed and certified home health services census was 230. The Agency was in compliance with 42 CFR Part 484.102, Emergency Preparedness Requirements for Home Health Agencies.

A recertification inspection and complaint investigation survey were conducted for Intake 487261, on 07/01/2024. Licensed and certified home health services census was 230. Acronyms/Abbreviations: Adm-Administrator Alt Adm-Alternate Administrator Sup Nurse- (Supervising Nurse) Alt Sup Nurse- (Alternate Supervising Nurse) EHR- Electronic Health Record Registered Nurse (RN) Licensed Vocational Nurse (LVN) Physical Therapist (PT) Occupational Therapist (OT) POC- Plan of Care SOC- Start of Care MSW-Master of Social Work SN- Skilled Nursing HCSSA-Home and Community Support Service Agencies QAPI-Quality Assessment Performance Improvement

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review, observation, and interview the clinical manager failed to ensure coordination of care delivery to meet the patients’ needs for four (Patient # 6, 7, 9, and 10) of six patients who received home visits, in that: Patient # 6: The agency failed to coordinate and document why a MSW consult was delayed 26 days after the order was written. Patient # 7: The agency failed to coordinate and document why a PT evaluation and MSW consult was delayed at least eight days after the order was written. Patient # 9: The agency failed to coordinate and document why a PT and OT evaluation was delayed eight days after the order was written. Patient # 10: The agency failed to coordinate and timely document the client’s request for no information to a family member. The failure placed the clients at risk of delay in their functional recovery and wound healing, or rehospitalization. The failure caused a breach in the client’s rights to privacy. Findings included: Patient # 6: Review of Patient # 6’s record on 07/03/2024, revealed a POC with a SOC date of 06/05/2024 for the treatment period of 06/05/2024 to 08/03/2024. The POC was dated 06/05/2024 and signed by the Alt Sup Nurse and RN A. Review of the POC revealed diagnoses of Acute and chronic respiratory failure (when the blood has too much carbon dioxide or not enough oxygen) with hypoxia (low levels of oxygen in the tissues of the body); and pressure ulcers (wounds) of left ankle, hip, other site, and right hip; and quadriplegia (paralysis of the arms, legs, chest, abdomen, pelvis, and back). Continued review of the POC revealed an order for SN visits one time per week for one week and three times per week for eight weeks. Further review of the record revealed a verbal physician’s order (from physician Identifier 100) dated 06/07/2024 and signed by the Alt Sup Nurse. Review of the order revealed that it read in part: “…received verbal order from [Nurse Practitioner, Identifier 200] for MSW consult for a sand bed (a medical bed with covered sand, instead of a mattress, which helps with wound healing and prevention) ...” The order was signed by physician, Identifier 100 on 06/13/2024. Continued review of the record did not reveal any records or documentation that showed the MSW consult that was ordered on 06/07/2024 had been conducted on 07/03/2024 (26 days after the order). During a home visit with Patient # 6 on 07/08/2024 at approximately 09:10 a.m., the surveyor observed that the Patient was not lying on a sand bed. The surveyor asked if the MSW had visited and ordered the sand bed. Patient # 6 and the client’s caregiver stated that they were “waiting.” Patient # 6: During an interview on 07/11/2024 at 1:33 p.m. with the Adm and Sup Nursing the surveyor reviewed the findings and asked who at the agency was responsible for coordinating the services. The Sup Nurse (Branch Manager) stated that the branch manager or alternate was responsible. The surveyor also asked, why the delay in the MSW consult and the sand bed ordered for Patient # 6. The Sup Nurse replied, “Getting the doctor to order it (the order was signed by physician, Identifier 100 on 06/13/2024).” While reviewing the patient record the Adm stated, “I don’t see anything in the record that explains that (the delay).” The surveyor requested the MSW consult visit. The Adm printed the MSW visit, which was dated 07/05/2024 (28 days after the order was written on 06/07/2024). Patient # 7: Review of Patient # 7’s record on 07/03/2024, revealed a POC with a SOC date of 06/30/2024 for the treatment period of 06/30/2024 to 08/28/2024. The POC was dated 06/30/2024 and signed by RN B and RN C. Review of the POC revealed diagnoses of Cerebral Infarction (stroke); Left side hemiplegia (paralysis of left side); and aphasia (difficulty communicating due to damage to the part of the brain that controls language). Continued review of the POC revealed an order for SN visits two times per week for one week and one time per week for eight weeks; PT one time per week for one week for evaluation; and MSW one time per week for one week for evaluation. Continued review of the record did not reveal any records or documentation that showed PT or MSW evaluations ordered on 06/30/2024 had been conducted as of 07/03/2024. During a home visit with Patient # 7 on 07/08/2024 at approximately 10:00 a.m., the surveyor observed PT A conducting the PT evaluation (eight days after the order on 06/30/2024). During an interview with the client’s family member the family member stated that the social worker had not visited. Patient # 7: During an interview on 07/11/2024 at 1:33 p.m. with the Adm and Sup Nursing (Clinical manager/Branch Director), the surveyor reviewed the findings and asked why the delay in the evaluations. The Adm stated, “That is certainly unusual. I’m checking the notes. I don’t see anything in the record that tells me why.” The surveyor asked who at the agency was responsible for coordinating the services. The Adm stated that the Sup Nurse was responsible. The Sup nurse stated, “I don’t know why the delay. We try to get out there within two to three days to do the evaluation.” The surveyor asked how not coordinating Patient services in accordance with the agencies processes, policies and procedures could adversely affect the patients. The Sup nurse stated that the Patient could “wind up back in the hospital.” The Adm stated that it would delay their functional recovery. Patient # 9: Review of Patient # 9’s record on 07/03/2024, revealed a POC with a SOC date of 06/19/2024 for the treatment period of 06/19/2024 to 08/17/2024. The POC was dated 06/19/2024 and signed by RN B and RN C. Review of the POC revealed diagnoses of Atrial fibrillation (fast irregular heartbeat), shortness of breath, and chest pain. Continued review of the POC revealed a verbal order for SN visits one time per week for one week, two times per week for three weeks, and one time per week for five weeks. Further review of the POC revealed a verbal order for PT and OT to evaluate and develop a plan of care. Continued review of the record revealed a coordination note report dated 06/25/2024 and entry by LVN A that read in part: “…[Patient] stated I really don’t feel like I need home health and no OT…PT has even called to schedule[.] SN sent email to office to [Sup Nurse and Alt Sup Nurse] regarding PT and OT awaiting response…” Continued review of the record revealed an order dated 06/25/2024 entered by the Alt Sup Nurse that read in part: “…Patient is requesting physical therapy and occupational therapy…Please send orders for PT and/or OT…” During a home visit with Patient # 9 on 07/09/2024 at approximately 11:30 a.m., the surveyor observed the Patient sitting at a dining table in a wheelchair. The surveyor asked what services the Patient received from the agency. Patient # 9 stated that an agency nurse (RN B) came out to do an evaluation one time (on 06/19/2024). The Patient stated that RN B stated that Patient # 9 would receive PT and OT and that PT and OT would come out to evaluate Patient # 9. The Patient stated that PT or OT never came or called but another nurse (LVN A) came once (on 06/25/2024). Patient # 9 stated that [Patient # 9] talked to LVN A about not receiving PT or OT and that [Patient # 9] did not think [Patient # 9] needed the services any longer. Patient # 9 and a family member stated that [Patient # 9] had used the agency’s services before. The family member stated, “I don’t know where the disconnect came in this time.” Patient # 9 stated that an anonymous agency staff said the agency was over two weeks behind on everything. The Patient stated that [Patient # 9] and a family member requested to be discharged from the agency on 06/27/2024. Patient # 9: During an interview on 07/11/2024 at approximately 1:33 p.m. with the Adm and the Sup Nurse, the surveyor reviewed the findings. The surveyor asked who at the agency was responsible for coordinating the services. The Adm stated that the Sup Nurse was responsible. The surveyor asked why the delay (8 days after the order on 06/19/2024) in the PT and OT evaluation The Sup nurse stated, “I don’t know why the delay. We try to get out there within two to three days to do the evaluation. The surveyor asked how not coordinating patient services in accordance with the agencies processes, policies, and procedures could adversely affect the clients. The Sup nurse stated that the patient could “wind up back in the hospital.” The Adm stated that it would delay their functional recovery. Patient # 10: Review of Patient # 10’s record revealed a POC with a SOC date of 11/16/2023 for the treatment period of 01/15/2024 to 03/14/2024. The POC was dated 01/10/2024 and signed by RN D and RN A. Review of the POC revealed diagnoses of Dementia, moderate and peripheral vascular disease (a narrowing of the blood vessels (example, veins and arteries) that are away from the brain and heart). Continued review of the POC revealed an order for SN visits one time per week for two weeks, one time every two weeks for six weeks, and one time per week for one week. Review of agency’s complaint records revealed a complaint report dated 02/21/2024 that read in part: “…[LVN A] accidentally called [Patient # 6’s family member] to report confusion due to not understanding the request for no information to the [family member]…Contact for [family member] removed from medical record and numbers for community help place in chart for paid [caregiver…and MSW…]” The complaint report was processed by the Adm and followed up by the Sup Nurse. During a home visit with Patient # 10 on 07/09/2024 at approximately 10:40 a.m., the surveyor observed the Patient walk from front door of home to living area with the assistance of a cane. The surveyor asked what services the patient received from the agency. Patient # 10 stated that a nurse came to visit and did an assessment of vital signs (blood pressure, heart rate, breathing, and temperature). The surveyor asked if Patient # 10 had any concerns. Patient # 10 stated that [Patient # 10] was not comfortable with other people coming into her home. The surveyor asked who the other people were. Patient # 10 stated that caregivers were coming to help with household tasks. The surveyor asked if Patient # 10 had family members who could assist with household tasks. Patient # 10 stated that [Patient # 10] had a [family member], but “Keep [family member] away from me! I don’t know why they keep calling [family member].” Patient # 10: During an interview on 07/11/2024 at 8:43 a.m. with LVN A by phone, the surveyor asked how the agency coordinated care and services with the field staff for the clients. LVN A stated that they have a weekly meeting, were able to email, speak directly to the office, and call the agency. The surveyor asked if LVN A had been told directly by any of those avenues that there was a no information request by Patient # 10 for her [family member]. LVN A stated that [LVN A] did not know the [family member] was not supposed to be called. LVN A stated that the [family member’s] number was listed as a personal contact in the record [on the patient information page]. LVN A stated, “They later took it out. If you don’t know. It was listed in the system.” Patient # 10: During an interview on 07/11/2024 at 1:57 p.m. with the Adm and the Sup Nurse, the surveyor reviewed the findings and asked if the agency had a process for ensuring coordination when there was a request for no information. The Adm replied, “What should have happened is that we should have taken the [family member’s number out of the record.” The Adm also stated that [the Adm] was not aware of the no information request until LVN A called the [family member]. Review of agency’s service delivery policy titled, “Coordination of Services S05” revised on 10/18/2023 read in part: “…Purpose…Establish guidelines for communication for liaison between care providers that…confirm continuity, consistency, efficiency and appropriateness of service delivery…Confirm that documentation in the clinical records shows coordination of services…Policy…3.3.1 Staff implement actions which reflect coordination, including…interdisciplinary communication, reporting…3.3.1.7 Development and implementation of nursing, therapy…medical social services…Staff document actions which reflect coordination according to established procedures…” Review of agency’s service delivery policy titled, “Admission process and patient assessment S02” revised 10/20/2023 read in part: “… Policy…3.4 Evaluations for additional Licensed Professional services will be conducted as ordered by the physician, and based on the patient needs and/or request, or no later than I week post referral…”