Every finding on record at Home Call, LLC

A recertification survey of Home Call Westminster Home Health agency was conducted March 27-30, 2023. After the review of the agency's emergency preparedness program and plan for both locations, the agency was found to be in compliance with all Conditions of Participation and related standards found at 42 CFR (Code of Federal Regulations) Part 484.102.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on review of patient records and interview with agency staff, the agency staff did not complete the initial assessment within 48 hours of referral or the patient's return home for 5 out of 18 patient records reviewed. Also, the delays in care were not communicated placing the patients at risk for adverse or negative health care outcomes This did not occur, as evidenced by the review of patient records on 3/27/2023, 3/28/2023, and 3/29/2023. a) On 3/28/2023, during the review of Patient #7 medical record, it is documented that on 2/16/2023 the agency received and accepted a referral to provide physical therapy services for the patient. The start of care date is documented as 2/20/2023. There was no documentation explaining the delay in the start of care. No documentation communicating the four-day delay in the start of care to the referring physician was in the record. During the interview, the agency staff did not provide any further information or documentation for the delay in care. b) On 3/29/2023, during the review of Patient #12 medical record, the agency received and accepted a faxed referral on 12/7/2022 for physical therapy and occupational therapy to evaluate and treat the patient. The patient record notes the start of care began on 12/16/2022. No documentation was in the medical record explaining the nine-day delay in the start of care. The agency staff did not provide any further information or documentation for the delay in the start of care. c) On 3/29/2023, during the review of medical record, the agency obtained orders on 3/5/2023 to provide occupational therapy services to Patient #13. The occupational therapy evaluation was provided on 3/10/2023. No documentation explaining the 5-day delay in the start of occupational therapy services. d) On 3/30/2023, during the review of Patient #17 medical record, the agency received and accepted orders on 1/6/2023 to provide physical therapy services. The physical therapy services started 1/10/2023. There were no explanations why the start of care was delayed for 4 days. e) On 3/30/2023, during the review of medical record, the agency obtained orders on 3/12/2023 to provide occupational therapy services to Patient #18. The occupational therapy evaluation was provided on 3/16/2023. The agency staff did not provide any documentation explaining the 4-day delay in the start of occupational therapy services.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on the review of patient records and interview with agency staff, the skilled nurse (SN) did not follow physician orders for 1 out of 18 patients reviewed. Failure to follow all physician orders has the potential to cause negative health care outcomes. Patients: #1 Findings included: 1. The SN has an obligation to follow all physician’s orders. This did not occur, as evidenced by the record review on 3/29/2023. a) On 10/20/2022, the SN visit noted that Patient #1 was educated to keep the sacral (upper buttock) area dry and continue to apply “colmoseptine” (moisture barrier ointment) to the area. This over-the-counter medication was not listed on the patient’s medication list and there was no documentation of a physician order being obtained for this medication.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: All clinical staff members have the responsibility to communicate or refer patient care related issues to other professional disciplines to ensure the provision of optimal health care services and to prevent adverse outcomes. Communicate potential negative health care issues for 1 out of 18 patients reviewed a) Patient #3 was admitted to the agency on 11/25/2022 following left knee replacement. Visit note dated 11/30/2022, the PT indicated that the patient’s skin was “red and hot” under the bandage, then in the same note documented that there were no signs or symptoms of infection. Signs and symptoms of infection include but are not limited to the area feeling hot or warm to the touch, redness, swelling, discharge or pus, and or pain. When asked, the agency staff were unable to provide evidence of the Physical Therapist (PT) reporting these findings to the physician or the agency.

Aides are members of interdisciplinary team CFR(s): 484.80(g)(4) Home health aides must be members of the interdisciplinary team, must report changes in the patient's condition to a registered nurse or other appropriate skilled professional, and must complete appropriate records in compliance with the HHA's policies and procedures. This ELEMENT is not met as evidenced by: Home health aides must be members of the interdisciplinary team, must report changes in the patient's condition to a registered nurse or other appropriate skilled professional, and must complete appropriate records in compliance with the HHA's policies and procedures. Failure to comply with regulations places patients at risk for inadequate health care. When asked during interview on 3/27/2023, the ED stated that the Westminster office has not employed a home health aide since January 2022 and the Rosedale branch since December 2022. Furthermore, the ED stated that patients requiring home health aide services are “turned down or turned away” and or given a referral to area residential service agencies.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on a review of the agency's policies and procedures and interviews with the agency's staff, the agency's governing authority was unable to confirm compliance in offering home health aide services to patients when or if ordered during. Failure to demonstrate compliance with regulations and requirements prevented the provision of safe and effective patient care. Findings included: The governing body shall ensure that the home health agency is providing all condition of participation clinical services. 1) This does not occur as the Westminster agency has not employed a home health aide since January 2022 and the Rosedale branch since December 2022, according to the agency Executive Director (ED). When asked how home health aide services are provided the ED stated that patients requiring home health aide services are “turned down or turned away” and given a referral to area residential service agencies. When asked the ED was unable to produce the agency’s scope of services policy. The agency’s latest policy review was done on 5/9/2022 at the time of this survey.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: The correct patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders are to be include in the medical record. Based on the review of Patient #16 medical record the agency staff documented erroneously in the patient's record. On 3/30/2023 during the review of Patient #16 medical record, a skilled nursing note dated 2/27/2023 documented a nursing missed visit. The patient has orders for physical therapy services, there were no orders or documentation for skilled nursing services for this patient. When asked the agency staff stated that this patient was not receiving skilled nursing services and that the missed visit note was erroneously written in this patient’s medical record. Inaccurate documentation in a patient medical record places the patient at risk for negative health outcomes.

An on-site complaint investigation was conducted at Home Call Inc, Westminster location, on March 28, 2023. The agency provides home health care services. Complaint number: 62780 The complaint includes one allegation. Allegation: Admission, transfer, and discharge rights. The complaint was substantiated. The investigation included interviews with the agency’s Executive Director, a clinical record review, and a policies and procedures review. The findings in this report are based on an interview with the Executive Director and data present in the administrative records at the time of review. The Executive Director was informed of the investigative findings as the investigation progressed. The Executive Director was allowed to present information relative to the findings during the investigation.

Make complaints to the HHA CFR(s): 484.50(c)(3) Make complaints to the HHA regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the HHA; This ELEMENT is not met as evidenced by: Findings include: 1. On 3/28/2023, a review of the patient's clinical record revealed no documentary evidence to support the ongoing complaints by the patient related to visit frequencies was being addressed administratively. 2. On 3/28/2023, a request to the agency's executive director to see the investigative outcome of the patient's complaint he/she indicated the information would be provided. This surveyor received notes from the patient's clinical record, not including a documented formal investigation with a resolution or outcome. 3. On 3/28/2023, during an interview with the agency's Executive Director, he/she confirmed no additional documentation for the complaint outside of notes from the patient's clinical record. 4. On 3/28/2023, a review of the policies and procedures, there is a "Grievance Procedure, Patient Complaints," policy number 1.007, which describes the agency's complaint resolution process. There was no documentary evidence to support that this process was followed.

Before discharge for cause HHA must: CFR(s): 484.50(d)(5) The HHA determines, under a policy set by the HHA for the purpose of addressing discharge for cause that meets the requirements of paragraphs (d)(5)(i) through (d)(5)(iii) of this section, that the patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. The HHA must do the following before it discharges a patient for cause: This ELEMENT is not met as evidenced by: Based on a review of administrative documents and the patient’s clinical record, the agency failed to discharge the patient for cause from services appropriately. Failure to do so placed the patient at risk for poor health outcomes. Findings include: On 3/28/2023, a review of the patient’s clinical record revealed the patient was unsatisfied with the plan of care. There is no documentary evidence to indicate the patient’s complaints related to the plan of care are being investigated or addressed. The 3/21/2022 client coordination note revealed a “message left for a patient that she is discharged,” as reported by the patient receiving a voicemail message notifying him/her of discharge from the agency. On 3/28/2023, an interview with the agency’s executive director revealed the discharge was left, and he/she has not heard back from the patients. Home agencies must document attempts made to resolve patient care issues. If unable to resolve, at minimum, referral information should have been provided to the patient so he/she could consider obtaining services with other healthcare providers. The patient being discharged while in the middle of care could result in harm to the patient and unsafe delays in care.

Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This ELEMENT is not met as evidenced by: Based on a review of administrative documents and the patient’s clinical record, the patient was discharged from the agency’s services with no referral resources provided to continue care with another provider. Failure to do so placed the patient at risk for poor health outcomes. Findings include: On 3/28/2023, a review of the patient’s clinical record revealed no documentary evidence to support any referral resources were provided to the patient.

Document efforts to resolve problems CFR(s): 484.50(d)(5)(iv) (iv) Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records; This ELEMENT is not met as evidenced by: Based on a review of the agency’s administrative documents and the patient’s clinical record, the agency had no documented efforts to resolve the patient’s complaints related to the plan of care. Failure to make efforts to resolve issues or concerns placed the patient at risk for poor health outcomes. Findings include: On 3/28/2023, a review of the patient’s clinical record revealed no documentary evidence to support that a complaint investigation occurred by the agency’s administrative staff.

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on a review of the agency’s administrative documents and the patient’s clinical record, the agency had no documented efforts to resolve the patient’s complaints related to the plan of care. Failure to make efforts to resolve issues or concerns placed the patient at risk for poor health outcomes. Findings include: On 3/28/2023, a review of the patient’s clinical record revealed no documentary evidence to support that a complaint investigation occurred by the agency’s administrative staff.