Every finding on record at Hospice & Home Care of Juneau

A Recertification Emergency Preparedness Survey was conducted by Healthcare Management Solutions, LLC on behalf of Hospice & Home Care of Juneau. An unannounced on-site Recertification Emergency Preparedness Survey at the above named Home Health Agency (HHA) from 11/8/21 through 11/10/21 resulted in no deficiency citations respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.22. State of Alaska Department of Health and Social Services Division of Health Care Services Health Facilities Licensing and Certification 4601 Business Park Blvd, Building K Anchorage, Alaska 99503

The following deficiency was noted during an unannounced Medicare/Medicaid recertification survey conducted 11/8/21 to 11/10/21 at Hospice and Home Care of Juneau. Sample Size: 9 Sampled Patients: 9 Non-sampled Patients: 0 Closed records: 2 State of Alaska Department of Health and Social Services Health Facilities Licensing and Certification 4601 Business Park Blvd. Building K Anchorage, AK 99503

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 medical record review, policy review, and interview, the home health agency failed to complete an initial assessment within 48 hours of the referral, or within 48 hours of the patient's return home from an inpatient stay, or on a physician ordered start of care date for five of nine patients (Patient #1, Patient #3, Patient #4, Patient #5, and Patient #7). This failure to complete the initial assessment in a timely manner had the potential to result in the patient's immediate care needs not being addressed and puts all patients admitted for care at risk. Findings: 1.Review of a paper copy of a "Hospice & [and] Home Care of Juneau Referral Form" for Patient #1 indicated a signed physician order for home health services for skilled nursing, physical therapy, and occupational therapy dated 3/31/21. Review of a paper copy of the plan of care (POC) for Patient #1 indicated a start of care (SOC) dated 4/5/21 which is greater than 48 hours after the signed physician referral. 2.Review of a paper copy of a "Hospice & Home Care of Juneau Referral Form" for Patient #3 indicated a signed physician order for home health services for physical therapy and occupational therapy dated 1/29/21. Review of a paper copy of an inpatient rehabilitation discharge report indicated a discharge date of 1/26/21. Review of a paper copy of the POC for Patient #3 indicated a SOC date of 2/1/21 which is greater than 48 hours after the signed physician referral and the discharge date from inpatient care. 3.Review of the "Hospice & Home Care of Juneau Referral Form" for Patient #4 located in the "Misc" (Miscellaneous) tab of the electronic medical record (EMR) indicated a physician signed referral date of 10/21/21. Review of the POC for Patient #4 located in the "Orders" tab of the EMR indicated a SOC date of 10/26/21 which is greater than 48 hours after the signed physician referral. 4.Review of the "Hospice & Home Care of Juneau Referral Form" for Patient #5 located in the "Misc" (Miscellaneous) tab of the electronic medical record (EMR) indicated a physician signed referral date of 10/14/21. Review of the POC for Patient #5 located in the "Orders" tab of the EMR indicated a SOC date of 10/21/21 which is greater than 48 hours after the signed physician referral. 5.Review of the "Hospice & Home Care of Juneau Referral Form" for Patient #7 located in the "Misc" (Miscellaneous) tab of the electronic medical record (EMR) indicated a physician signed referral date of 9/28/21. Review of the POC for Patient #7 located in the "Orders" tab of the EMR indicated a SOC date of 10/13/21 which is greater than 48 hours after the signed physician referral. Review of the agency policy titled, "Home health Initial and Comprehensive Assessment," dated 4/9/18, indicated, "The admission visit, and initial assessment must be completed within 48 hours of referral to home health services, or within 48 ours of the patient's return home, or on the physician ordered start of care date or on another date if ordered by the physician." During an interview on 11/12/21 at 10:30 AM, the Clinical Director confirmed the patient's listed above were admitted greater than 48 hours after the physician referral and/or return home from an inpatient stay. The Clinical Director also confirmed that the agency policy is for patients to be admitted within 48 hours.