Every finding on record at Jar, Inc

A recertification survey of Americare In Home Nursing Home Health agency was conducted April 19, 20, and 27, 2023. After the review of the agency's emergency preparedness program and plan, 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.

A standard home health agency re-certification survey at Americare In Home Nursing was conducted on April 19, 20, and 27, 2023. The survey included the following: a review of clinical records; a review of the complaint/incident reports; a review of on-call documentation; a review of admission documentation including patient bill of rights; a review of personnel files including professional licenses and expiration dates; a review of Quality Assurance Project Plan and Reports (QAPI) & Potentially Avoidable Event Report; a review of the organizational chart; a review of the CLIA waiver, and interviews with the agency's administrative. A total of seventeen randomly selected patient records were reviewed during the survey. The scope of services included the following: Skilled Nursing Services - 15 Physical Therapy Services - 12 Occupational Therapy Services - 6 Medical Social Worker - 0 Home Health Aide Services - 5 Speech-Language Services - 0 No home visit observations were conducted during the survey. Findings in this report were based on data present in the clinical record at the time of the reviews. The agency's administrative and clinical staff were kept informed of the survey findings as the survey progressed. The agency's staff were given the opportunity to present information relative to the findings during the course of the survey. The exit conference was conducted with agency personnel on April 27, 2023. The findings of the Medicare re-certification survey were reviewed; a patient identification key code and a signed plan of correction verification form were provided to the agency's administrator.

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 a review of patient records and interviews with agency staff, the agency staff did not complete the initial assessment within 48 hours of referral or the patient's return home for 11 out of 17 patient records reviewed. Delays in care were not communicated to the referring provider or patient's physician, 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 4/20/2023 and 4/27/2023. Patients: #1, #2, #6, #7, #8, #9, #12, #13, #14, #15 and #17 Findings include: a) On 4/20/2023, during the review of patient #1 medical record, it was documented that 1/28/2023, the agency received and accepted a referral to provide services for the patient. The start of care date is documented as 2/01/2023. There was no documentation explaining the delay in the start of care. Also, there was no documentation communicating the delay in the start of care to the referring provider or patient's physician in the medical record. b) On 4/20/2023, during the review of patient #2 medical record, it was documented that on 1/6/2023, the agency received and accepted a referral to provide services for the patient. The start of care date is documented as 1/9/2023. There was no documentation explaining the delay in the start of care. Also, there was no documentation communicating the delay in the start of care to the referring provider or patient's physician in the medical record. c) On 4/20/2023, during the review of patient #6 medical record, it is documented that on 3/17/2023 the agency received and accepted a referral to provide services for the patient. The start of care date is documented as 3/24/2023. There was no documentation explaining the delay in the start of care. Also, there was no documentation communicating the delay in the start of care to the referring provider or patient's physician in the medical record. d) On 4/20/2023, during the review of patient #7 medical record, it was documented that on 10/29/2022, the agency received and accepted a referral to provide services for the patient. The start of care date is documented as 11/4/2022. There was no documentation explaining the delay in the start of care. Also, there was no documentation communicating the delay in the start of care to the referring provider or patient's physician in the medical record. e) On 4/20/2023, during the review of patient #8 medical record, it was documented that on 12/30/2022, the agency received and accepted a referral to provide services for the patient. The start of care date is documented as 1/26/2023. There was no documentation explaining the delay in the start of care. Also, there was no documentation communicating the delay in the start of care to the referring provider or patient's physician in the medical record. f) On 4/20/2023, during the review of patient #9 medical record, it is documented that on 1/24/2023 the agency received and accepted a referral to provide services for the patient. The start of care date is documented as 2/6/2023. There was no documentation explaining the delay in the start of care. Also, there was no documentation communicating the delay in the start of care to the referring provider or patient's physician in the medical record. g) On 4/20/2023, during the review of patient #12 medical record, it was documented that on 10/14/2022, the agency received and accepted a referral to provide services for the patient. The start of care date is documented as 10/18/2022. There was no documentation explaining the delay in the start of care. Also, there was no documentation communicating the delay in the start of care to the referring provider or patient's physician in the medical record. h) On 4/27/2023, during the review of patient #13 medical record, it was documented that on 10/19/2022, the agency received and accepted a referral to provide services for the patient. The start of care date is documented as 11/2/2022. There was no documentation explaining the delay in the start of care. Also, there was no documentation communicating the delay in the start of care to the referring provider or patient's physician in the medical record. i) On 4/27/2023, during the review of patient #14 medical record, it is documented that on 5/25/2022, the agency received and accepted a referral to provide services for the patient. The start of care date is documented as 6/13/2022. There was no documentation explaining the delay in the start of care. Also, there was no documentation communicating the delay in the start of care to the referring provider or patient's physician in the medical record. j) On 4/27/2023, during the review of patient #15 medical record, it is documented that on 9/15/2022, the agency received and accepted a referral to provide services for the patient. The start of care date is documented as 9/27/2022. There was no documentation explaining the delay in the start of care. Also, there was no documentation communicating the delay in the start of care to the referring provider or patient's physician in the medical record. k) On 4/27/2023, during the review of patient #17 medical record, it is documented that on 8/23/2022, the agency received and accepted a referral to provide services for the patient. The start of care date is documented as 8/31/2022. There was no documentation explaining the delay in the start of care. Also, there was no documentation communicating the delay in the start of care to the referring provider or patient's physician in the medical record.

Completion of the comprehensive assessment CFR(s): 484.55(b) Standard: Completion of the comprehensive assessment. This STANDARD is not met as evidenced by: Based on a review of patient clinical records and an interview with the agency’s clinical staff, the agency’s staff failed to ensure the completion of the in-person discharge comprehensive assessment. Failure to complete this clinical assessment placed patients at risk for inadequate continuity of care and poor health outcomes. Non-visit discharge comprehensive assessment was completed for 2 out of 17 records reviewed. Patient #2, #3 Finding includes: a) On 4/20/2023, a review of patient #2 clinical record revealed on 4/7/2023, a missed visit note indicates the agency’s staff received a call from the patient’s family member to request the visit for this day to be rescheduled to 4/11/2023 due to the patient having conflicting appointments. On 04/07/2023, the skilled professional (SP) completed a discharge summary without visiting the patient. b) On 4/20/2023, a review of patient #3 clinical record revealed the patient had physical therapy assistant (PTA) visits on 3/7, 3/9, 3/14, and 3/16/2023. On 03/22/2023, the physical therapist (PT) completed a discharge summary for the patient. There is no documentary evidence to support that the PT performed a visit with the patient on this day. There is no regulatory guidance that allows a non-visit discharge comprehensive assessment.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on clinical record reviews, the agency’s staff failed to complete the patient visit frequencies as ordered in the plan of care (POC). The missed visits were both documented and undocumented in the patient’s clinical record but did not always include notification to the patient’s physician. This occurred for 3 out of 17 clinical records reviewed. Missed visits placed the patients at risk for delays in treatments and services. Patients: #3, #5, #6 Findings include: a) On 4/20/2023, a clinical review for patient #3 revealed the skilled nurse (SN) had a missed visit during week 3/26/2023. There was no documentary evidence the patient’s physician was notified of the missed visit. b) On 4/27/2023, a clinical review for patient #5 revealed that the home health aide (HHA) missed a visit during week 3/19/2023. The documented missed visit note indicates the physician was not notified. c) On 4/27/2023, a clinical review for patient #6 revealed the SN had missed visits to the patients on 3/29/2023, 3/31/23, and 4/3/2023. During the 4/3/2023 visit, the patient’s physician was not notified. Missed visits can impact patient outcomes; therefore, the physician should be notified when they occur. This patient was subsequently admitted to the hospital on 4/15/2023.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on a review of the patient's clinical record, documentation related to services the patient should be receiving from the agency. Failure to ensure an accurate plan of care to include all orders timely placed the patient at risk for delays in care and negative health outcomes. Patient #1 Finding includes: a) On 04/20/2023 review of the patient's medical record revealed a plan of care for the certification period 04/02/2023 – 5/31/2023, with occupational therapy (OT) interventions and OT goals for the patient. There a no OT orders in the record for the certification timeframe to support the included interventions and goals. b) On 4/20/2023, a review of the patient's medical record also revealed an OT memo in the record from 04/13/2023 stating awaiting an order. On 04/20/2023, inquiry to the agency's Administrator, the surveyor was presented with an email dated 04/04/2023 that indicated the agency was seeking authorization for visits; there was no documentary evidence that follow-up occurred.

Laboratory services/CLIA waivers CFR(s): 484.100(c)(1) Laboratory services. If the HHA engages in laboratory testing outside of the context of assisting an individual in self-administering a test with an appliance that has been cleared for that purpose by the Food and Drug Administration, the testing must be in compliance with all applicable requirements of part 493 of this chapter. The HHA may not substitute its equipment for a patient's equipment when assisting with self-administered tests. This STANDARD is not met as evidenced by: The agency's administrative staff was requested to provide a copy of their Clinical Laboratory Improvement Amendments (CLIA) waiver and the letter of permit exception. The agency's administrator failed to provide a copy of the CLIA waiver for review. Finding includes: a) On 4/20/2023, during the entrance interview, this surveyor requested the agency's CLIA with a letter of permit exception from the agency's administrator. The administrator did not have the CLIA license for review. b) On 4/20/2023 and 4/27/2023, clinical record reviews revealed that the skilled nursing staff was performing lab draws for patients. The home health agency must abide by all local, state, and federal regulations.

Contents of clinical record CFR(s): 484.110(a) Standard: Contents of clinical record. The record must include: This STANDARD is not met as evidenced by: The contents of the patient's clinical record are to include all the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders in a timely manner. The agency's staff's failure to document visit notes timely placed patients at risk for negative health outcomes. This occurred for 2 out of the 17 clinical records reviewed. Patients: #3 and #9 Findings include: a) On 4/27/2023, during the review of patient #3 medical record, visit notes for 4/21/2023 and 4/22/2023 were undocumented. b) On 4/20/2023, during the review of patient #9 medical record, visit notes for 4/12/2023 and 4/17/2023 were undocumented. c) A review of the agency's "Late Documentation Policy" revealed, in part: All documentation related to patient visits of any type must be submitted for review within 48 hours of the visit occurrence." Complete and timely medical record documentation ensures continuity of care and that patients get the right care at the right time.