Every finding on record at Family Home Health LLC

A recertification survey in conjunction with a COVID-19 survey was completed on 9/23/21. Two deficiencies were cited.

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 interview and record review, the agency failed to ensure the Registered Nurse (RN) or applicable rehabilitation skilled professional conducted an initial assessment visit to determine the immediate care and support needs of the patient within 48 hours of referral, or on the physician ordered start of care (SOC) date, for 2 of 10 clinical records reviewed (Patient's #5 and #6). Findings include: AGENCY POLICY According to the policy, Acceptance Of Patient, Care Planning, Coordination Of Services, And Admission (sic), dated 2014, in part: "The admission process will be initiated within 24-48 hours of the referral date unless specific admission date is ordered." 1. The clinical record for Patient #5 was reviewed on 9/22/21. The Plan of Care for the certification period dated 9/10/21 to 11/8/21 revealed a SOC date of 5/13/21; primary diagnoses included acute pancreatitis with uninfected necrosis, nontraumatic compartment syndrome of abdomen, paroxysmal atrial fibrillation and personal history of sudden cardiac arrest. Plan of Care orders included skilled nurse (SN) two times weekly for eight weeks and three as needed (PRN) visits for peripherally inserted central catheter (PICC) line troubleshooting related to blockage, dressing removal or additional labs. a) The agency failed to start services for Patient #5 on a Physician's SOC date. Record review revealed a physician's order for home health to visit Patient #5 on the day of hospital discharge and the following day, dates 5/12/21 and 5/13/21. Review of the Outcome and Information Set (OASIS), completed by RN #13 on 5/13/21 revealed Patient #5 was discharged on 5/12/21. Review of the Start of Care (SOC) Assessment, dated 5/13/21, completed by RN #13 revealed the agency initiated services on 5/13/21. Record review revealed Patient #5 received the first SN visit on 5/13/21 and failed to reveal SN services provided on 5/12/21 in accordance with the physician's order. During an interview on 9/23/21 at 10:24 a.m., Patient #5 stated the agency SN provided services on 5/13/21, the day after he [Patient #5] was discharged from the hospital. During an interview on 9/23/21 at 10:31 a.m., RN #13 stated when the agency was unable to meet a SOC date within 48 hours, the RN called the physician for an order to delay the SOC and this was documented in communication notes in the Electronic Medical Record (EMR). RN #13 further stated Patient #5's physician order for SOC was dated 5/12/21 and RN #13 was to provide SN services this date according to order, however Patient #5 lived too far for RN #13 to provide services on 5/12/21 and the patient's discharge from the hospital was too late in the day to call the physician to obtain a delay order. RN #13 confirmed services were not provided on the physician ordered SOC date. 2. The clinical record for Patient #6 was reviewed on 9/21/21. The Plan of Care for the certification period dated 3/23/21 to 5/22/21 revealed a SOC date of 3/23/21; primary diagnoses included hemiplegia following cerebral infarction affecting left non-dominant side, dysarthria following cerebral infarction and chronic pain. Plan of Care orders included Physical Therapy (PT) services once weekly for nine weeks, Occupational Therapy (OT) once weekly for nine weeks, and Home Health Aid (HHA) twice weekly for eight weeks. a) The agency failed to start services for Patient #6 within 48 hours of referral. Review of the referral, received 3/16/21, revealed Patient #6 was planned to discharge home on 3/17/21 from a long term care facility. Record review revealed a physician order for PT, OT, and Certified Nursing Aide (CNA/HHA) dated 3/18/21. Record review further revealed a verbal order for SOC received by RN #10 on 3/22/21. Review of the Start of Care (SOC) Assessment, dated 3/23/21 and completed by PT #14, revealed the agency initiated services on 3/23/21, and not on 3/19/21 which was 48 hours after Patient #6 discharged home. Additionally, record review failed to review communication notes explaining delay in SOC. During an interview on 9/23/21 at 8:22 a.m., PT #14 stated he could not recall if he had completed SOC assessment for Patient #6 and therefore he could not speak to delay in SOC. During an interview on 9/23/21 at 10:00 a.m.,. RN #10 stated the intake coordinator and scheduler (Employee #12) assigned cases to available staff to complete SOC assessments within the 48 hour requirement per regulation. However, after further record review , RN #10 stated a PT was unable to complete a SOC assessment until 3/23/21 and that is why RN #10 called the physician for a verbal SOC order on 3/22/21. RN #10 confirmed this was four days after Patient #6 discharged home. During an interview on 9/23/21 at 9:06 a.m., Employee #12 states PT #14 was unable to complete a SOC assessment until 3/23/21 and confirmed this was four days after the patient was discharged home. 3. During an interview on 9/23/21 at 11:19 a.m., the The Administrator agreed the physician's orders were not followed by the agency for Patient's #5 and #6. The Administrator further stated the admission process agency-wide needed to be reviewed for process improvement.

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 interview and record review the agency failed to ensure services were provided in accordance with physician's orders for 3 of 7 active patients reviewed (Patients #1, #4, and #5). Findings include: 1. The clinical record for Patient #5 was reviewed on 9/22/21. The Plan of Care for the certification periods dated 7/12/21 to 9/9/21 and, revealed a start of care date of 5/13/21; diagnoses included acute pancreatitis with uninfected necrosis, nontraumatic compartment syndrome of abdomen, paroxysmal atrial fibrillation, personal history of sudden cardiac arrest, hypovolemic shock, acquired absence of pancreas. Plan of Care orders included skilled nurse (SN) visits once weekly for eight weeks then twice a week for one week for weekly peripherally inserted central catheter (PICC) line dressing changes and lab draw. The Plan of Care for the certification period dated 9/10/21 to 11/8/21 revealed orders for SN visits twice weekly for eight weeks then once for one week for assessment and PICC line dressing changes twice weekly and lab draw weekly. a) The registered nurse (RN) failed to complete PICC line dressing change as ordered. Clinical record review revealed Patient #5 had been receiving weekly PICC line dressing changes since 5/13/21. Then was hospitalized on 8/25/21 for sepsis from gram positive bacteremia (blood stream infection) Patient #5 was discharged from the hospital on 8/30/21 and the agency was ordered to resume home health. Review of the resumption of care (ROC)/recertification assessment dated 9/7/21 revealed RN #13 documented Patient #5 was discharged from the hospital and required twice weekly visits for PICC line dressing changes and lab draw. However, review of the visit notes revealed the only visit completed that week was the resumption of care visit completed on 9/7/21 and there was no documentation as to why there was not a second visit completed that week to change Patient #5's PICC line dressing. During an interview on 9/23/21 9:01 a.m. the Clinical Manager (CM #3) stated RN #13 completed the ROC and recertification assessment on 9/7/21 and she intentionally did not schedule another visit that week because Patient #5 had an appointment on 9/10/21 with his infectious disease physician. She further stated Patient #5 was ordered to have visits twice weekly for PICC line dressing changes by the infectious disease physician and there was no documentation of a missed visit or an order to not complete the second visit that week. 2. The clinical record for Patient #1 was reviewed on 9/21/21. The Plan of Care for the certification periods dated 8/10/21 to 10/8/21, revealed a start of care date of 8/10/21; diagnoses included unspecified open wound of left great toe, ingrown nail, type 2 diabetes mellitus with diabetic neuropathy, hypertensive heart disease with heart failure, acute on chronic systolic (congestive) heart failure and chronic obstructive pulmonary disease. Plan of Care orders included Skilled Nurse (SN) visits effective 8/10/21 twice for one week, three times a week for one week then twice weekly for seven weeks for assessment and to provide wound care and three as needed (PRN) visits for additional dressing changes; and physical therapy (PT) visit once for one week effective 8/29/21 to evaluate to determine condition, PT plans and rehabilitation potential; occupational therapy (OT) once weekly for nine weeks effective 8/10/21; and home health aide (HHA) visits for one hour once for one week then three times a week for eight weeks beginning 8/10/21 to assist with activities of daily living (ADL) tasks . a) The agency failed to ensure PT visits were completed as ordered. Review of a referral and order dated 8/3/21 revealed Patient #1 was ordered to receive home health for PT, OT, nursing and HHA. Review of physician face to face encounter form signed by the physician on 8/20/21, revealed Patient #1's physician documented the patient needed PT for "cardiac rehab" and the justification for home health was the patient needed to increase exercise to decrease cardiac mortality. Review of an initial assessment dated 8/10/21 revealed RN #4 documented Patient #1 was receiving home health services and was found on 7/15/21 by OT to be in a dangerous exacerbation of his cardiorespiratory problems and was hospitalized then sent to a rehabilitation facility to improve his overall cardiorespiratory and other health needs. RN #4 documented Patient #1's goal as he would like to work up to walking daily in the hallway without assistance, and have no falls or health exacerbations. However, clinical record review failed to show evidence of a PT visit until 9/1/21, three weeks after the start of care, and there was no documentation as to why the first visit was not completed within the five days after start of care. During an interview on 9/22/21 at 11:23 a.m. CM #10 stated the patient had a lot of physician appointments and he did not want PT to start until later. She further stated she called the physician and notified them but did not document a verbal order and only put an effective date on the plan of care. During an interview on 9/23/22 at 9:40 a.m. PT #15 stated she is a contract worker who provides PT services for the agency and tried to do an evaluation within five days after the start of care. She further stated if she could not go out within the five days she informs her manager who would call for a delay order. PT #15 stated there was no PT availability prior to 9/1/21 and so she saw him when she was available. She further stated she did not call to get an order or notify the physician there was going to be a delay but she informed her manager and thought she did. PT #15 stated she would ask her manager about a delay order and would send it to the surveyor if there was. 3. The clinical record for Patient #4 was reviewed on 9/22/21. The Plan of Care for the certification period dated 8/14/21 to 10/12/21 revealed a start of care date of 8/14/21; diagnoses included diabetes type 2, cardiomyopathy, hypertension, muscle weakness, hematuria, dysuria, shortness of breath, cerebral infarction, tinnitus, and frequency of micturition. Plan of Care orders included SN once every 60 days for recertification, reassessment, and supervision of HHA beginning 8/14/21; PT once weekly for one week beginning on 8/15/21; OT twice weekly for eight weeks beginning on 8/15/21 and once every other week for eight weeks for HHA supervision beginning on 8/22/21; and HHA for one hour in the morning, two hours in the afternoon, and two hours in the evening once weekly for one week, seven times weekly for eight weeks, and three times weekly for one week beginning on 8/14/21 for assistance with personal care, hygiene, and ADLs. a) The agency failed to ensure HHA visits were completed as ordered. Review of completed HHA visit notes from 8/14/21 through 9/20/21 failed to show HHA visits from 9/8/21 to 9/14/21 for any of the three scheduled daily visits, a total of 21 visits not conducted to Patient #4. Review of Coordination Notes failed to show any documentation as to the reason for the missed visits or how the needs for Patient #4 were met during that time. During an interview on 9/22/21 at 3:18 p.m., the Clinical Manager, RN #10, stated she had an email from HHA #11 stating she would be on vacation from 9/8/21 through 9/14/21. She stated she typically had the agency Scheduler, Employee #12, reach out to the patient to inquire if a replacement HHA was needed and then a coordination note was completed in the clinical record. RN #10 stated the coordination note for Patient #4 was never written and therefore there was no explanation in the record for the 21 missing visits. During an interview on 9/23/21 at 11:25 a.m., the Administrator stated the HHA should have documented missed visits for the days services were not provided so the agency could notify the physician. He further stated the HHA could have called the supervisor and alerted the supervisor about not being available to provide services and the supervisor could have written a coordination note or an order to hold HHA services. 4. During an interview on 9/23/21 at 11:25 a.m., the Administrator stated the agency expectation was that every communication "find its way into the chart [clinical record]" either documented in the visit note or, more preferably, documented as a coordination note.