Every finding on record at Health Facilities Incorporated

A complaint investigation survey was conducted at Homeplus from 09/25/23 through 09/26/23. At the time of the survey, the active patient census was one hundred and sixteen (116). A total of ten (10) medical records were reviewed and four (4) employee records were reviewed. It was determined the agency was not in compliance with the requirements of 42 CFR, Part 484 – The Medicare Conditions of Participation for Home Health Agencies.

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on medical record review, document review and staff interview, it was determined the agency failed to ensure that the comprehensive assessments were completed within the five (5) day time frame from the referral date in three (3) out of ten (10) medical records reviewed (patients #5, 7, and 10). This failure has the potential to affect all patients with the delay in the start of care services from the agency. Findings include: A medical record review conducted for patient #5 revealed the patient had a referral order dated 01/19/23. The comprehensive assessment and the start of care did not occur until 01/30/23. The medical record revealed no evidence of a physician ordering to delay the start of care. A medical record review conducted for patient #7 revealed the patient had a referral order dated 01/20/23. The comprehensive assessment and the start of care did not occur until 02/02/23. The medical record revealed no evidence of a physician ordering to delay the start of care. A medical record review conducted for patient #10 revealed the patient had a referral order dated 01/17/23. The comprehensive assessment and the start of care did not occur until 02/03/23. The medical record revealed no evidence of a physician ordering to delay the start of care. Review of a policy, titled “Plan of Care Documentation”, revised 10/29/14, stated in pertinent part: “Every patient/client admitted for service to the company shall receive a complete assessment by a qualified individual. A qualified individual will initial and complete the assessment on all patients. The assessment will include a review of functional limitations, activities permitted, safety issues and the initiation of the patient’s plan of care … Procedure:1. The patient care staff member will initiate contact with the patient by phone/visit within forty-eight (48) hours. 2. Qualified personnel will initiate the assessment tool on the initial visit." Review of a policy, titled “Comprehensive Oasis Assessment'', reviewed 5/1/09, stated in pertinent part “ … The comprehensive assessment must be conducted by a qualified clinician in conjunction with a home visit … the date assessment completed should match the date of the visit during which the assessment was performed … review of data for completeness and consistency, and resolution of any data problem prior to locking the data record in transmission to the State. HomePlus will at a minimum, transmit locked OASIS assessments monthly, however at the agencies discretion OASIS assessment may be transmitted weekly or every other week to ensure that no assessments are outside of the specified timeframes … Procedure: … 2. Start of Care (SOC): Upon admission the HomePlus, the SOC comprehensive assessment shall be completed within five (5) days." An interview was conducted on 09/26/23 at 8:35 a.m. with Employee #1 and they concurred there was no documentation showing why the start of care was delayed from 01/19/23 until 01/30/23 for patient #5. An interview was conducted on 09/26/23 at 11:41 a.m. with Employee #1 and they concurred there were no additional physician orders written for the delay in care for patient #7. The referral date was 01/20/23 and the start of care did not occur until 02/23/23. An interview was conducted on 09/26/23 at 11:45 a.m. with Employee # 1 and they concurred there were no additional physician orders written for the delay in care for patient #10. The referral date was 01/17/23 and the start of care did not occur until 02/03/23.