Every finding on record at Golden Age Home Health Agency Corp

An unannounced complaint survey for #2021008530 was conducted on 8/12/21 at Golden Age Home Health, a Home Health Agency in Fort Myers, Florida. Complaint #2021008530 was substantiated at G442 and G608. Golden Age Home Health is in compliance with Code of Federal Regulations (CFR) 42, Part 484, Conditions of Participation for Home Health Services. The following is a description of the element-level citations.

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on medical records reviewed and interviews the home health agency failed to ensure 3 (patients #1, #2, and #3) of the 3 patients sampled, received proper written notice, in advance of service reductions or the terminating services. Review of Patient #1 medical records revealed a start of care date of, 6/5/21, the Outcome and Assessment Information Set, the admission comprehensive assessment was completed. The noted Orders for Discipline and Treatments are the following: Physical Therapy effective week of 6-6, one visit one week and two visits a week for two weeks. Occupational Therapy effective week of 6/6 one day visit for evaluation, and Skill Nurse two visit for one week, noting patient has a right rotator cuff tear, and a history of diabetes. The following visits were document, Nurse visits 6/5/21 and 6/9/21, Physical Therapy visits 6/9/21 and 6/10/21, and Occupational Therapy visit on 6/7/21 an Evaluation. There was no further visits noted. The medical notes a discharge date of 6/9/21. The medical record did not provide evidence of further communication with the patient. The medical record did not provide an interdisciplinary conference regarding the patient’s need for further services. On 8/12/21, at 9:53am an interview with Patient #1. During the interview she said, “I needed therapy prior to a procedure I was scheduled to have. I needed Lymphedema therapy. I needed assistance with lifting my legs. The Nurse came out twice once for the initial Assessment, then a second visit which I signed some papers. I not sure what they were. Physical Therapy came out once I refused them, when they called, it was the Lymphedema therapy I needed. The Occupational Therapy came out wraps my legs and told me to leave the wraps on as long as I can. I was under the impression I would see her within 2 days. I did not hear from for 2 weeks. When I did the therapist said now, I have my schedule right. I called the office several times and never got an answer and not was able to leave a message. The doctor ordered the therapy before I was to have (Platelet-Rich Plasma) PRP treatment. The therapy was to be Lymphedema therapy, which I did not get. PT was to be after the PRP therapy. Review of Patient #2 medical records revealed a start of care date of, 6/3/21, the Outcome and Assessment Information Set, the admission comprehensive assessment was completed. The noted Orders for Disciplines and Treatments are the following: Skill Nurse visit one visit for two weeks, Physical Therapy visits one visit one week, and two visits for one week. It is noted the patient declined Occupational evaluation. It is noted additional orders, “Back Surgery Protocol, incision care.” Noted health history is not limit to neuropathy, lumbar spondylosis. The medical record revealed Physical Therapy visit dated 6/4/21, an Evaluation. The Physical Therapy visit on 6/9/21 is documented as a “Missed Visit”. There are no other visits noted. The Physical Therapy Discharge Summary dated 6/11/21, “Uneven surface to reach a vehicle". She is appropriate for discharge at this time. The patient has been difficult to schedule over her plan of care and is often not home when attempted.” There is one Missed Visit noted by the Physical Therapist. On 8/12/21 at 12:20pm during an interview with Patient #2 she said, “The nurse came out twice and the Therapist came out a couple of times. She stated, he told me the doctor said it was ok to discharge me.” The patient primary language is Spanish. Review of Patient #3 medical records revealed a start of care date of, 6/13/21, the Outcome and Assessment Information Set, the admission comprehensive assessment was completed. The noted Orders for Discipline and Treatments are the following: Skill Nurse visit two visits for one week, one visit for one week and one visit as needed for ostomy complications, Physical Therapy effective 6/15/21 one visit for one week, two visits for 2 weeks. Review of the medical records revealed Physical Therapist visits on 6/15/21 Evaluation, Physical Therapy Assistant visits on 6/23/21, 6/25/21, and 6/29/21. The medical record revealed an Outcome and Assessment Information Set - Discharge (Non-Billable)-PT dated 6/29/21. The Nursing visits are noted visits 6/13/21 Start of Care, Skill Nurse Visit 6/15/21 and Skill Nurse W/Discharge Summary 6/22/21. On 8/12/21, at 2:08pm during interview with Patient #3 she said, “I had surgery May 24, 2021, and the home health agency start 2 weeks after that, after the rehab facility. The nurse came out twice then no more she just dropped me. Physical Therapy came out 3 times than no more I never heard from them. I did have a second surgery because the wound got infected that was around the last week of July 2021. After the three visits from Physical Therapist, they did not come out. I never got a notice of being discharged. On 8/12/21, at 2:54pm during interview with the Office Manager, and the Director of Nursing. The Director of Nursing said, “There is no discharge plan or letter that went to the patient #1 in her file. We have the patients to sign the Notice of Medicare Non-Coverage form at the time of admission. This informs them of the possible of no services due to insurance denial of service.” The Home Health Agency did not provide evidence of interdisciplinary conferences, which would ensure all the patient services were coordinated, met the patients service needs, the patient’s safety, and the effectiveness of the treatments.