Jessy Effective Home Health Care, Inc. — Every Inspection Finding on Record

E0000

G0000

• Purpose of visit: Recertification/Relicensure Survey • Entrance date: 4/30/2024 • Census: L&CHHS-2 LHHS-0 PAS-0 Abbreviations: Licensed Home Health Services (LHHS) Personal Assistance Services (PAS) Licensed and Certified Home Health Services (L&CHHS) Quality Assurance and Performance Improvement (QAPI) Plan of Care (POC) Start of Care (SOC) Director of Nursing (DON) Skilled Nurse (SN) Administrator (ADM) FNP (Family Nurse Practitioner) Review Course Clinical Update Live Advanced Practice Education Associates (APEA) Department of Aging and Disability Services (DADS)

G0606

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure documentation of coordination of services between the agency and an outpatient facility involved in the care of one (Patient #2) of one patient receiving outpatient dialysis, whose record was reviewed. The failure could place patients at a risk of harm, due to a lack of shared information regarding the ongoing care and service needs. FINDINGS INCLUDED: Clinical Record #2: Record review of the clinical record revealed a Plan of Care (POC) for the certification period of 02/12/2024 to 04/11/2024 with a Start of Care (SOC) date of 04/14/2023 and was dated 02/08/2024 and signed by the Director of Nursing (DON). The POC included a primary diagnosis of Type 2 Diabetes Mellitus with Other Circulatory Complications (Type 2 diabetes is a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel. That sugar also is called glucose. This long-term condition results in too much sugar circulating in the blood.) and other pertinent diagnosis of Dependence on Renal Dialysis (the process of removing water, solutes, and toxins from the blood of individuals with compromised kidney function). The POC contained an order for Skilled Nurse (SN) visits one time per week for nine weeks beginning week of 02/12/2024 and two as needed visits for exacerbation of disease processes. The POC contained an order for no blood pressure or venipuncture (medical procedure in which a puncture is made by inserting a needle into the vein to create access for venous blood sampling or administration of intravenous therapy) in left arm, Arteriovenous Shunt (An arteriovenous shunt is an abnormal connection or passageway between an artery and a vein. It may be congenital, surgically created for hemodialysis treatments, or acquired due to pathologic process, such as trauma or erosion of an arterial aneurysm.) shunt left arm, dialysis is on Monday, Wednesday and Fridays. Patient # 2's record did not include any documentation that indicated the agency had coordinated care with the outpatient dialysis facility. During an interview on 05/01/2024 at approximately 11:05 AM, with the Administrator (ADM)/ Director of Nursing (DON the surveyor presented the above findings. The surveyor requested documentation of coordination of services with patient #2's outpatient dialysis facility. The ADM/DON stated, “I talk to the dialysis, but I didn’t document the conversations or send the plan of care,” Review of agency policy titled "Monitoring Patient Care/Coordination of Care" undated, read in part "...Policy ...II ...Agency will also collaborate with a licensed facility, group home, foster home, or boarding home facility in which the patient/client resides. Other providers of health care services involved in care may include ...another agency ...an outpatient facility ..."

Every finding on record at Jessy Effective Home Health Care, Inc.

Survey of May 3, 2024