Every finding on record at Iron County Home Health Agency

Based on a recertification survey conducted 11/4/2024 through 11/6/2024, it was determined that Iron County Home Health was found in compliance with the Conditions of Participation for Emergency Preparedness; 42 CFR (Code of Federal Regulations) 484.22 and 484.102.

Based on a recertification survey conducted on 11/4/2024 to 11/6/2024. It was determined that Iron County Home Health was not in compliance with all Conditions of Participation for home health 42 CFR (Code of Federal Regulations). Deficient practice was identified in the following area: 484.75 preparing of clinical notes.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency did not assume the responsibility of preparing clinical notes. Specifically, visit notes for skilled nursing (SN) and home health aides (HHA) were not being completed in a timely manner and according to agency policy. (Patient identifier: 6) Findings include: Patient 6 was admitted to the agency on 7/5/2024, with diagnoses that included rheumatoid arthritis, intervertebral disc degeneration, and migraines. Patient 6 had SN orders for a visit once per week for 8 weeks starting on 7/5/2024, and once per week for 8 weeks starting 9/8/2024. HHA orders, dated 7/5/2024, were for once per week for 1 week, then twice per week for 8 weeks. All visits ordered were documented in the medical record with a time in and time out, but surveyors were unable to open the documentation for the following visits in the electronic medical record (EMR): For SN: 7/19/2024, 7/22/2024, 7/25/2024, 7/29/2024, 08/14/2024, 8/22/2024, 8/26/2024, 9/16/2024, 9/19/2024, 10/17/2024, 10/25/2024, and 11/1/2024. For HHA visits: 7/23/2024, 8/2/2024, 8/22/2024 and 8/26/2024. On 11/5/2024 at 3:03 PM, an interview was conducted with the administrator. The administrator stated, I am just going to be honest. Patient 6 was a challenging patient, and the documentation is simply not done. The agency’s policy for documentation and client records stated that notation should be made before the completion of each shift, after an event or more frequently, if required. The agency’s nursing documentation policy states that charting is to be completed the day the visit occurred. For the outcome and assessment information set (OASIS) documents, they should be completed no later than three days after the initial visit.