Every finding on record at Interim Healthcare of Northwestern Ohio, Inc

Substantial Allegation Survey Substantial Allegation 71633 An entrance conference was completed on 09/28/22 at 9:15 AM with the Regional Administrator. An exit conference was conducted on 09/28/22 at 5:15 PM with various staff. Interim Healthcare of Lima is not in compliance with the requirements at 42 CFR Part 484, Subpart B, C for Home Health Agencies in regards to allegations contained in 71633.

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, review of communication notes, policy review, and staff interview, the facility failed to conduct an initial assessment by the registered nurse on the physician ordered start of care date. This affected one patient (#2) with the potential to affect all patients cared for by this agency. The medical record for Patient #2 was reviewed on 09/28/22. A physician referral listed a start of care date of 08/19/22 with a note requesting care to be completed in three days to include physical therapy, occupational therapy and skilled nursing. This referral document was placed in this record by the intake nurse. A case note from the intake nurse (Staff C) on 08/19/22 at 4:50 PM listing a pending hospital discharge for 08/20/22 or 08/21/22 for Patient #2. Discharge instructions revealed Patient #2 went home on 08/21/22. The instructions listed to complete wound care every 72 hours with Mepilex Ag to the incision along with instructions on how to empty the Jackson-Pratt drain. No documentation was located in this medical record of a start of care or that an assessment by the registered nurse was completed on the physician ordered start of care date. Review of a communication note dated 08/23/22 at 11:06 AM from Staff C revealed the registered nurse was notified by Patient #2’s mother the patient was home and needing care that day. No documentation was found in this medical record that anyone checked if this patient was home over the weekend. Interview on 09/28/22, Staff A stated the intake nurse would communicate with weekend staff regarding all pending discharges. Staff A further stated no idea why this patient's discharge date from the hospital was not followed up with by the intake department and no documentation was found the hospital notified the agency of this discharge. Interview with Staff B on 09/28/22 at 3:45 PM revealed they went to do a start of care on 08/23/22 instead of the requested 08/22/22. Staff B stated the Jackson-Pratt drains were filled with frank blood, the patient was looking pale, and had an elevated heart rate. Staff B stated he/she thought Patient #2's blood pressure was low. Patient #2 then went to the emergency room with his mother. Staff B stated the agency recceived notification from the hospital Patient #2 was going home and Staff B told them the agency would not be taking him on assignment. Review of the facility policy titled "Start of Care," dated 04/21, revealed an initial comprehensive assessment should be completed by 48 hours from referal or on the physician's ordered start of care date. The registered nurse will document this assessment in the medical record. Interview on 9/28/22 at 4:00 PM with Staff A verified the findings of not completing an initial assessment on the day ordered by a physician.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on medical record review, policy review, and staff interview, the facility failed to document assessments and vital signs in the medical record. This affected one patient (#2) with the potential to affect all patients cared for by this agency. The facility census was 193. The medical record for Patient #2 was reviewed on 09/28/22. A physician referral listed a start of care date of 08/19/22 with a note requesting care to be completed in three days to include physical therapy, occupational therapy and skilled nursing. Discharge instructions revealed Patient #2 went home on 08/21/22. Interview with Staff B on 09/28/22 at 3:45 PM revealed Staff B went to do a start of care on 08/23/22. This patient had two Jackson-Pratt (JP) drains which were both filled with frank blood. Staff B could see them filling up as he/she was standing there. The patient was pale, had an elevated heart rate, and Staff B stated the blood pressure was low. The patients mother reported the patient had filled up two pints of blood since discharge from the hospital so Staff B was concerned with the blood loss. Staff B expressed concern to Patient #2's mother about his elevated heart rate, low blood pressure and he mentioned he was hallucinating at times. Staff B told them Patient #2 needed to go to the emergency room (ER). Patient #2 then became agitated and his mother was not happy about going to the ER. Staff B offered an emergency squad a couple times but they refused. Staff B then called the hospital to let them know the patient was on his way. Additional review of Patient #2's medical record on 09/28/22 at 3:00 PM revealed no documentation of the JP drains, blood loss, assessment, or vital signs in the record as Staff B stated. Interview at this time with Staff A verified there was no documentation. Review of the facility policy titled "Start of Care," 04/21, revealed an initial comprehensive assessment should be completed by 48 hours from referral or on the physicians ordered start of care date. Listed under Assessment of Adult Patients requiring Skilled care lists the registered nurse (RN) will document the comprehensive assessment in the medical record. Interview on 09/28/22 at 4:45 PM, Staff A verified the findings of not documenting the vital signs and assessments in the medical record that were completed during the initial assessment for start of care.