Every finding on record at F.C. of Alabama, Inc.

A recertification survey was conducted from 5/31/22 to 6/2/22 at Intrepid USA Healthcare Services and a standard level deficiency was cited.

HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This STANDARD is not met as evidenced by: Based on review of the Emergency Preparedness Plan and interview, it was determined the agency failed to include procedures to follow up with on-duty staff and patients with notification of officials for any staff/patients unable to contact after an emergency. This had the potential to negatively affect all patients served by this agency. Findings include: 1. Review of the Emergency Preparedness Program on 5/31/22 at 1:33 PM revealed there was no documentation of procedures for the agency to follow up with on-duty staff and patients with notification of officials for staff/patient unable to contact. An interview was conducted on 6/2/22 at 12:03 PM with Employee Identifier # 1, Registered Nurse Administrator, who confirmed there was no procedure to follow up with on duty staff and patients with notification of officials for staff/patients unable to contact after an emergency.

A recertification survey was conducted on 5/31/22 to 6/2/22 at Intrepid USA Healthcare Services and standard level deficiencies were cited.

Have a confidential clinical record CFR(s): 484.50(c)(6) Have a confidential clinical record. Access to or release of patient information and clinical records is permitted in accordance with 45 CFR parts 160 and 164. This ELEMENT is not met as evidenced by: Based on observation, review of agency policy and procedure, and interviews, it was determined the agency failed to ensure the HIPPA (Health Insurance Portability and Accountability Act) regulations for patient privacy and security could be upheld in the Home Health Agency (HHA). This had the potential to negatively affect all patients served by this agency. Findings Include: Agency Policy: HIPPA Privacy and Security Compliance Master Program Policy Number: 1.058 Effective Date: October 2015 Policy Statement: This policy establishes a Privacy and Security Compliance Program, including a reporting and accountability structure, in order to facilitate compliance with federal and state privacy laws and security regulations. Guideline / Procedure The Privacy Officer is responsible for providing direction and oversight of the processes that impact confidentiality and related safeguards of patient data, as well as, rights afforded under HIPAA. The Security Officer shall be accountable for Intrepid USA"s electronic personal Health Information compliance, ensuring data... security. Together, these responsible person (s) will develop, implement, monitor, and maintain Intrepid USA's program of compliance concerning the privacy of access to patient health information as designated by HIPPA. The HIPPA Privacy and Security Officer's duties include: ... Ensure that future initiatives are structured in such a way as to ensure patient privacy. ...2. Each agencies Admin (Administrator) will concurrently serve as the designated HIPPA "Agency Privacy Lead". Responsibilities of the Agency Privacy Lead include ensuring that the companies HIPPA policies are followed at the agency level... The Agency Privacy Lead duties include: a, Ensure HIPPA policy and procedure is followed and enforced at the agency. 1. During an observation conducted in the home health agency office on 5/31/22 at 3:20 PM the surveyor observed four (4) tabletop desk with a two (2) door filing cabinet beside each desk. Further observation revealed one (1) of the desk had a name plaque on top of the desk labeled ... (person's name). The surveyor asked Employee Identifier (EI) # 1, Registered Nurse Administrator, "Who is ... (person's name on name plaque)?". EI # 1, stated, "I only have 1 desk that I occupy for Home Health. They rest (other 3 desk) are other businesses." The surveyor then asked EI # 1, "How do you maintain confidentiality of MR's (such as information on computer screen, paperwork, phone conversations with referral sources and patients)?" EI # 1 stated, "I am very seldom here, I have never seen that person here, but I guess I couldn't". The agency failed to ensure that HIPPA regulations for patient privacy and security could be upheld in the home health agency. An interview was conducted on 6/2/22 at 2:30 PM with EI # 1 who confirmed the agency failed to ensure that HIPPA regulations for patient privacy and security could be upheld in the home health agency.

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on review of medical records (MR), agency Patient Information Handbook document "State and Federal Funded Agencies Alabama", and interview, it was determined the agency failed to ensure the staff provided the name, address and telephone number of the Federally-funded and state-funded entities in all counties in which they served. This did affect 1 of 1 current record reviewed, including MR # 7, and had the potential to negatively affect all patients in all counties in which they served. Findings Include: 1. On 5/31/22 at 2:26 PM the surveyor reviewed the Patient Information Booklet document "State and Federal Funded Agencies Alabama". MR # 7 was admitted to the agency on 4/27/22 with diagnoses including Urinary Tract Infection, Site Note Specified and Encounter for Fitting and Adjustment of Urinary Device. Review of MR # 7's Home Health Certification and Plan of Care revealed an address of ... (Tallapoosa County). Further review of the document "State and Federal Funded Agencies" revealed the agency failed to include the name, address and telephone numbers of entities in the county which MR # 7 resided in. There was no documentation MR # 7 was educated on the State and Federal Funded agencies in which he/she resided in. An interview was conducted on 6/1/22 at 3:24 PM at Employee Identifier (EI) # 1, Registered Nurse Administrator who confirmed the agency failed to include all counties in which they provided services and there was no documentation MR # 7 had been provided the name, address and telephone number of the State and Federally-funded entities in the county in which he/she resided.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on review of medical records (MR), agency policy and procedure, and staff interview, it was determined the agency failed to document discharge instructions when discharging patient as directed per the agency policy. This affected 1 of 6 discharge records reviewed, including MR # 5, and had the potential to negatively affect all patients discharged from the agency. Findings include: Agency Policy: Discharge Policy Number: 2.011 Revision Date: March 2020 Policy Statement: Discharge planning is provided for each patient to assure continuity of care that is efficient, safe, effective and individualized to patient need... Guidelines / Procedures: 9. Agency personnel will prepare the patient and family for discharge by providing instructions, serving as referral source for the patient and/or family in obtaining subsequent support services and assisting with arrangements to ensure continuity of care following discharge. 1. MR # 5 was admitted to the agency on 5/14/2020 to 5/16/2020 with diagnoses including Aftercare Following Joint Replacement Surgery and Presence of Right Artificial Knee Joint. Review of the 5/14/2020 to 5/16/2020 Home Health Certification and Plan of Care included the Skilled Nurse (SN) 2 week 2, 1 week 7... Review of the record revealed the SN completed a discharge (non-billable) visit on 5/16/2020 which read, "Discharge Instructions". There were no discharge instructions documented as directed per the agency policy. An interview was conducted on 6/2/22 at 1:56 PM with Employee Identifier # 1, Registered Nurse Administrator, who confirmed the staff failed to document discharge instructions as directed per the agency policy.

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based on medical record (MR) review, agency policy and procedure, and staff interview, it was determined a discharge summary was not completed within 5 days of discharge from the agency. This affected 1 of 6 discharge records reviewed and included MR # 5, and had the potential to affect all patients discharged from the agency. Findings include: Agency Policy: Discharge Policy Number: 2.011 Revision Date: March 2020 Policy Statement: Discharge planning is provided for each patient to assure continuity of care that is efficient, safe, effective and individualized to patient need... Guidelines / Procedures: 6. A completed discharge summary is required to be 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 (Home Health Agency) within 5 business days of the patient's discharge. 1. MR # 5 was admitted to the agency on 5/14/2020 to 5/16/2020 with diagnoses including Aftercare Following Joint Replacement Surgery and Presence of Right Artificial Knee Joint. Review of the 5/14/2020 to 5/16/2020 Home Health Certification and Plan of Care included the Skilled Nurse (SN) 2 week 2, 1 week 7... Review of the record revealed the SN completed a discharge (non-billable) visit on 5/16/2020 which read, " Reason for discharge: Per patient/family request". There was no discharge summary documented as directed per the agency policy and there was no documentation the physician was notified of the MR # 5’s discharge from the agency. In an interview conducted on 6/2/22 at 1:56 PM, Employee Identifier # 1, Registered Nurse Administrator, confirmed the staff had failed to complete a discharge summary.

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 review of medical records (MR), agency policy and staff interview, it was determined the agency failed to ensure: 1. The Skilled Nurse (SN) educated the patient/caregiver (pt/cg) on proper care of Percutaneous Endoscopic Gastrostomy (PEG) tube as ordered by the physician. 2. The SN instructed the patient on daily weight self-monitoring program as ordered by the physician. 3. The SN assessed the patient’s weight log every visit as directed the Plan of Care (POC). This affected 1 of 6 discharge records reviewed, including MR # 5, and had the potential to negatively affect all patients served by this agency. Findings include: Agency Policy: Plan of Care Policy Number: 2.022 Revision Date: September 2019 Policy Statement: The agency will develop and implement an Individualized POC for each patient admitted to the agency. Clinical Services are implement in accordance with a POC established by a physician's written orders... 1. MR # 5 was admitted to the agency on 5/14/2020 to 5/16/2020 with diagnoses including Aftercare Following Joint Replacement Surgery and Presence of Right Artificial Knee Joint. Review of the 5/14/2020 to 5/16/2020 Home Health Certification and Plan of Care included the Skilled Nurse (SN) 2 week 2, 1 week 7... SN to instruct pt on daily weight self-monitoring program... SN to assess patient's weight log every visit... SN to instruct the pt/cg on proper care of PEG. Review of the SN Start of Care Visit Note dated 5/14/2020 revealed there was no documentation the SN educated the pt/cg on the proper care of the PEG tube as ordered by the physician. Review of the SN Visit Note's dated 5/14/2020 and 5/15/2020 revealed there was no documentation the SN instructed the pt on daily weight self-monitoring program as directed the physician's orders. Further review of the SN Visit Note dated 5/15/2020 revealed there was no documentation the SN assessed the patient's weight log every visit as ordered per the physician's orders. An interview was conducted on 6/2/22 at 1:56 PM with Employee Identifier # 1, Registered Nurse Administrator, who confirmed the staff failed to follow the physician's orders for PEG tube care and daily weight monitoring and assessment for MR # 5.

Skilled services furnished CFR(s): 484.105(f) Standard: Services furnished. Skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis, in a place of residence used as a patient's home. An HHA must provide at least one of the services described in this subsection directly, but may provide the second service and additional services under arrangement with another agency or organization. This STANDARD is not met as evidenced by: Based on review of agency policy, Active Employees list, and interviews, it was determined the agency failed to ensure at least one additional therapeutic service was available on a visiting basis to provide home health services to patients as needed. This had the potential to negatively affect all patients served by this agency. Findings include: Agency Policy: Scope of Services Policy Number: 2.007 Revision Date: May 2021 Policy Statement: ... Services are provided either directly or through contractual arrangements. All services listed may not be available at all locations. Basic medical services (skilled and non-skilled) may include, but not limited to the following: a. Skilled Nursing (SN) b. Physical Therapy (PT) c. Occupational Therapy (OT) d. Speech-Language Pathology (ST) e. Medical Social Services (MSW) ...g. Home Health Aide (HHA) 1. During the entrance conference on 5/31/22 at 1:23 PM the surveyor asked Employee Identifier (EI) # 1, Registered Nurse Administrator, "What services does the agency provide?" EI # 1 replied, "Only provide Nursing". The surveyor then asked, "Does the agency provide PT, OT, ST, MSW, HHA or any other services as needed?" EI # 1 stated, "No". Review of the Active Employees list on 6/2/22 at 10:35 AM revealed one (1) employee, EI # 1, Registered Nurse. The agency failed to ensure at least one additional therapeutic service was available on a visiting basis to provide home health services to patients as needed. An interview was conducted on 6/2/22 at 10:39 AM with EI # 1, who confirmed the agency failed to provide at least one additional therapeutic service to patients as needed.