Every finding on record at Gulf Coast Home Health

During the partial extended recertification survey conducted on 10/19/2021 thru 10/21/2021 at Gulf Coast Home Health, Emergency Preparedness was reviewed. The home health agency is in compliance with Emergency Preparedness per Code of Federal Regulations (CFR) 42, Part 484.22, Condition of Participation for Home Health Agencies.

A partial extended recertification survey was conducted on 10/19/2021 thru 10/21/2021 at Gulf Coast Home Health. At the time of the survey, the home health agency is not in compliance with 42 CFR Part 484, Requirements for Home Health Agencies.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and staff interview the agency failed to send a completed discharge summary to the primary care physician responsible for provision of patient care within 5 business days of discharge from the home health agency for 3 of 3 discharged sample patients (#9, 10 and 11). The Findings are: Review of the clinical record for sample patient #9 revealed a start of care (SOC) date of 4/2/21 with primary diagnoses of multiple Pressure Ulcers. Services ordered in the plan of care (POC) were for skilled nursing (for wound care), physical therapy (for home exercise program/strengthening), and medical social services (to evaluate and assist with community resources). Coordination of care notes in the record revealed the patient was discharged from agency services on 4/7/21 per family request to transfer to Hospice services with another agency. Review of the patient's discharge summary revealed a completion date of 4/26/21 and a fax transmittal record of the summary to the physician on 4/27/21. Interview on 10/21/21 at 10:50 AM with the Administrator confirmed a discharge date of 4/7/21 for this patient, and confirmed that the discharge summary was not completed or sent to the physician within 5 business days of the discharge, as required by federal regulations. She confirmed the discharge summary was not sent to the physician until 14 business days following the patient's discharge from the agency. Review of the clinical record for sample patient #10 revealed a SOC of 7/7/21 with a primary diagnosis of Bone Graft Infection. Services ordered in the POC were for physical therapy (for home exercise program, gait training, balance training) and occupational therapy (to evaluate need for services). Coordination of care notes in the record revealed the patient was discharged from agency services on 7/22/21 due to non-compliance (not answering phone calls or knocks on door - unable to reach patient to continue services). The discharge was conducted via data collection only and was not based on a clinician visit since staff was unable to reach the patient. Review of the patient's discharge summary revealed a completion date of 7/22/21 and a fax transmittal record of the summary to the physician on 8/10/21. Interview on 10/21/21 at 10:50 AM with the Administrator confirmed a discharge date of 7/22/21, and confirmed that the discharge summary was not sent to the physician until 8/10/21 which was 13 business days after the patient's discharge from the agency. Review of the clinical record for sample patient #11 revealed a start of care (SOC) date of 5/6/21 with primary diagnoses of Aftercare following joint replacement. Services ordered in the plan of care (POC) were for skilled nursing (for incision care) and physical therapy (for home exercise program/strengthening). Coordination of care notes in the record revealed the patient was discharged from agency services on 5/20/21 with goals met. Review of the patient's discharge summary revealed a completion date of 5/23/21 and a fax transmittal record of the summary to the physician on 6/8/21. Interview on 10/21/21 at 10:50 AM with the Administrator confirmed a discharge date of 5/20/21 for this patient, and confirmed that the discharge summary was not completed or sent to the physician within 5 business days of the discharge, as required by federal regulations. She confirmed the discharge summary was not sent to the physician until 13 business days following the patient's discharge from the agency.