Every finding on record at Fairfield Memorial Hospital Association

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey on 3/16/2023. The Agency was in compliance with the Condition, 42 CFR 484.102, Establishment of the Emergency Program (EP), for this survey.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 3/16/23. The Agency was not in compliance with the Standards for Home Health Agencies, 42 CFR 484, as evidenced by: Abbreviations: E employee Pt patient PT physical therapy SOC start of care

Skilled professional performs assessment CFR(s): 484.55(a)(2) When rehabilitation therapy service (speech language pathology, physical therapy, or occupational therapy) is the only service ordered by the physician or allowed practitioner, who is responsible for the home health plan of care, and if the need for that service establishes program eligibility, the initial assessment visit may be made by the appropriate rehabilitation skilled professional. This ELEMENT is not met as evidenced by: Based on document review and staff interview, it was determined in 1 of 7 (Pt #6) clinical records reviewed, the Home Health Agency (HHA), failed to ensure the initial assessment visit was conducted within 48 hours of referral. This failure has the potential to affect all patients accepted for home health services. Findings include: 1. The clinical record of Pt #6 was reviewed on 03/15/23. Pt #6's record indicated Pt #6 was referred for Physical Therapy (PT) on 12/06/2022. The initial assessment was not completed until 12/16/23, 8 days past the 48-hour requirement. 2. An interview was conducted with the Director of Home Health (E #1) on 03/16/23 at 10:00 AM. E #1 reviewed Pt #6's record and confirmed the assessments were not completed within the 48-hour time frames as required. E #1 stated, "The initial order was for physical therapy only. PT was booked out a week at that time, so we scheduled it for the first available time which was the 16th. There is no documentation or order to indicate the physician was okay with the delayed start of care. We should document that information."