Deficiency Index

Every finding on record at Gentiva Certified Healthcare Corp.

Lancaster, Pennsylvania · CCN 397237

3 findings across 1 survey, in the inspector's own words.

The inspector’s own words from form CMS-2567, unedited, including CMS’s own spacing. Names and some dates are redacted by CMS.

Survey of February 26, 2021

3 findings
E0000

Based upon the findings of an unannounced onsite Medicare recertification survey completed February 26, 2021, Kindred at Home was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.

G0000

Based on the findings of an unannounced onsite Medicare recertification survey completed February 26, 2021, Kindred at Home was found not to be in compliance with the following requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

G0588

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on a review of agency policy, review of clinical records (CRs), and an interview with the agency Administrator, agency failed to have the total plan of care reviewed by the attending physician at least once every 60 days for four (4) out of ten (10) clinical records with recertifications reviewed (CR#2, CR#10, CR#15, CR#16). Findings Include: Agency policy reviewed February 25, 2021 at approximately 10:00 a.m. Policy 'PA3-12 Physician Orders' section (3) states "The Total Plan of Treatment will be reviewed by the attending physician and location personnel as often as the severity of the patients condition requires, but at least every 60 days ....". A review of CRs was conducted on February 25, 2021 between approximately 9:00 a.m. and 1:30 p.m. The patients start of care (SOC) is listed below: CR#2 SOC 10/10/2020: Patient's initial certification period was 10/10/2020-12/08/2020. A recertification of the Plan of Care for the period of 12/09/2020-02/06/2021 (signed by physician on 12/10/2020). A recertification of the Plan of Care for the period of 02/07/2021-04/07/2021 (signed by physician on 02/10/2021). (63 days). CR#10 SOC 07/27/2020: Patient's initial certification period was 07/27/2020-09/24/2020. A recertification of the Plan of Care for the period of 09/25/2020-11/23/2020 (signed by physician on 09/24/2020). A recertification of the Plan of Care for the period of 11/24/2020-01/22/2021 (signed by physician on 12/03/2020). (70 days). CR#15 SOC 07/07/2020: Patient's initial certification period was 07/07/2020-09/04/2020 (signed by physician on 07/28/2020). A recertification of the Plan of Care for the period of 09/05/2020-11/03/2020 (signed by physician on 10/01/2020). (66 days). CR#16 SOC 04/30/2020: Patient's initial certification period was 04/30/2020-06/28/2020 (signed by physician on 05/06/2020). A recertification of the Plan of Care for the period of 06/29/2020-08/27/2020 (signed by physician on 07/08/2020). (64 days). An interview conducted with agency Administrator on February 25, 2021 at approximately 1:45 p.m. confirmed the above findings.

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Federal survey findings only. State licensure findings for home health agencies are not shown.

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