Every finding on record at Fort Hudson Certified Home Health Agency, Inc

The following statement of deficiencies represents the results of a standard re-certification survey of Fort Hudson Certified Home Health Agency conducted October 11, 2022, through October 13, 2022. The survey consisted of a review of ten clinical records, including three discharge records, four observational home visits, and six personal records. The survey included a review of pertinent policies and procedures, Quality Improvement Meeting minutes for the past twelve months, the agency's admission packet, the Emergency Preparedness Plan and complaint log. A focused COVID-19 survey was conducted in conjunction with the re-certification survey and the vaccination records of 6 personnel were reviewed. The census of the agency at the time of the survey was one hundred and seventeen. Pre-survey activities consisted of a review on October 6, 2022, of the agency's Health Commerce System account, the Home Care Registry, Criminal History Record Check, and Certification and Survey Provider Enhanced Reports (CASPER) for the period June 01, 2021, through May 31, 2022. The agency's Administrator, Director of Patient Services and Director of Operations, CHHA (Certified Home Health Agency) were interviewed. The following deficiencies were identified as a result of the survey: Federal: G0572 Plan of Care G0590 Promptly alert relevant physician of changes State: L 0002 Acceptable Infection Ctl Procedure

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on clinical record review and staff interview the agency failed to ensure services are provided in accordance with the physician's Plan of Care (POC) in one of ten patient records (Patient # 3). Failure to follow the POC has the potential for patients to receive care that is inconsistent with the physician's orders resulting in unmet patient needs and possible negative patient outcomes. Patient # 3 (start of care 06/05/2021 and discharged on 07/16/2021) has diagnoses of Encounter for Orthopedic Aftercare following Surgical Amputation (Exacerbation 06/07/2021) and Type II Diabetic Chronic Kidney Disease. The POC for certification period 06/07/2021 through 08/05/2021 contains an order for: Skilled Nurse 2 times a week for 8 weeks (06/13/2021 through 08/05/2021). The record lacks documented evidence of two skilled nurse visits being conducted the week of 07/04/2021 through 07/10/2021. The finding was confirmed on 10/12/2022 at 4:00 PM with the Administrator, Director of Patient Services, and Director of Operations; no additional evidence was provided.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview evidence is lacking in one of ten records (Patient # 3) the physician was contacted regarding changes that alter or suggest the need to alter the Plan of Care (POC). Failure to consult with the physician when changes occur in the patient's condition has the potential for unmet patient needs and/or negative patient outcomes. Patient # 3 (start of care 06/05/2021 and discharged on 07/16/2021) has diagnoses of Encounter for Orthopedic Aftercare following Surgical Amputation (Exacerbation 06/07/2021) and Type II Diabetic Chronic Kidney Disease. The POC for certification period 06/07/2021 through 08/05/2021 contains an order for Skilled Nurse (SN) visits 2 times a week for 8 weeks (06/13/2021 through 08/05/2021). The record contains documentation of one SN visit being conducted the week of 07/04/2021 through 07/10/2021. The record lacks documented evidence the physician was notified of the missed visit. The finding was confirmed on 10/12/2022 at 4:00 PM with the Administrator, Director of Patient Services, and Director of Operations; no additional evidence was provided.