Every finding on record at M A R G Home Health Care Inc

A Complaint Survey for complaint #2020003634 was conducted on April 14, 2021 at M A R G Home Health Care Llc. The Home Health Agency was not in compliance with 42 CFR 484 Subpart A-C requirements for Home Health Agencies.

Information to patient CFR(s): 484.50(a)(1) Provide the patient and the patient's legal representative (if any), the following information during the initial evaluation visit, in advance of furnishing care to the patient: This ELEMENT is not met as evidenced by: Based on record review and interview, the Home Health Agency failed to establish a written agreement with the patient or the patient's legal representative specifying the home health services to be provided, the frequency of the services, the rates or charges for services, and the sources of payment for 1 out of 3 Sampled Patients (SP) prior to providing care. SP#3 Findings include: Review of SP#3's record revealed he was admitted on 03/13/2021. Further review of SP#3's record revealed the agency started providing Home Health Aide (HHA) services to the patient on 03/09/2021. Additional review of SP#3's record revealed the agency established a service agreement/consent form with the patient on 03/13/2021 which is four days after the first day of service. During an interview conducted on 04/14/2021 at 2:42 PM, the Director of Nursing acknowledged that the agency did not establish a service agreement/consent form with SP#3 on 03/09/2021 prior to providing the HHA services.

Standard: Initial assessment visit. CFR(s): 484.55(a) Standard: Initial assessment visit. This STANDARD is not met as evidenced by: Based on record review and interview, the Home Health Agency failed to conduct an initial assessment of 1 out of 3 Sampled Patients (SP) within 48 hours of receiving the authorization to conduct the visit from the patient's insurance. SP#1 Findings include: Review of SP#1's record revealed the patient was discharged from the hospital on 02/19/2020 with the following diagnoses: glioblastoma multiforme, numbness and tingling of the left side of face, left arm numbness, glioblastoma of temporal lobe, brain compression, brain edema, status post craniotomy and cerebral edema. Further review of SP#1's record revealed the agency received the authorization to conduct a Registered Nurse (RN) clinical assessment on 02/21/2020 from the patient's insurance. Further review of SP#1's record revealed the agency completed the RN initial assessment on 02/24/2020, 72 hours after the facility received the authorization. During an interview conducted on 04/14/2021 at 2:48 PM, the Director of Nursing acknowledged that the agency did not conduct SP#1's RN initial assessment within 48 hours of receiving the authorization from the patient's insurance.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on record review and interview, the Home Health Agency failed to complete a discharge summary for 1 out of 3 Sampled Patients (SP). SP#1 Findings include: Review of SP#1's record revealed she was admitted on 02/24/2020. Further review of SP#1's record revealed she received Physical Therapy (PT) on 02/28/2020. Additional review of SP#1's record revealed no documentation that she received any additional services from the agency after 02/28/2020. Further review of SP#1's record revealed no documentation that the agency completed a discharge summary for the patient. During an interview conducted on 04/14/2021 at 2:55 PM, the Director of Nursing acknowledged that SP#1's record contained no documentation to demonstrate that a discharge summary of the patient's progress in meeting the care plan goals was completed.

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 record review and interview, the Home Health Agency failed to develop an individualized plan of care (POC) that identifies patient-specific measurable outcomes and goals for 1 out of 3 Sampled Patients (SP). SP#3 Findings include: Review of SP#3's record revealed he was admitted on 03/13/2021. Further review of SP#3's record revealed no documentation that the Director of Nursing (DON) developed a Plan of Care (POC) for the certification period of 03/13/2021 to 05/11/2021. During an interview conducted on 04/14/2021 at 2:42 PM, the DON stated the POC has not been developed because the Physical Therapist (PT) has not submitted his notes yet.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the Home Health Agency failed to : 1) ensure the Physical Therapy (PT) goals documented in 1 out of 3 Sampled Patients (SP) Plan of Care (POC) were accurate. SP#1; 2) document the frequency and duration of the HHA visits to be made and the goals on SP#2's POC. Findings include: Review of SP#1's record revealed the patient was evaluated by the Physical Therapist (PT) on 02/24/2020. Further review of SP#1's record revealed the PT established the long-term outcomes goals to be completed in 6 weeks. Additional review of SP#1's POC revealed the agency documented the PT goals to be completed in 7 weeks which differed from the goals which were established by the PT on 02/24/2020. During an interview conducted on 04/14/2021 at 2:40 PM, the Director of Nursing reviewed SP#1's record and acknowledged that the long-term care goals on the patient's POC differed from the ones which were established by the PT on 02/24/2020. Review of SP#2's record revealed she was admitted on 03/13/2021. Further record review revealed the patient received Skilled Nursing, Physical Therapy, and Home Health Aide (HHA) services from the agency. Additional review of SP#2's record for the certification period of 03/13/2021 to 05/11/2021 revealed the agency did not document the frequency and duration of the HHA visits to be made nor the goals of the HHA services on SP#2's POC. During an interview conducted on 04/14/2021 at 2:41 PM, the Director of Nursing acknowledged the above findings.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review and interview, the Home Health Agency failed to conform with the physician or allowed practitioner orders for 1 out of 3 Sampled Patients (SP). SP#1 Findings include: Review of SP#1's record revealed the patient was discharged from the hospital on 02/19/2020 with the following diagnoses: glioblastoma multiforme, numbness and tingling of the left side of face, left arm numbness, glioblastoma of temporal lobe, brain compression, brain edema, status post craniotomy and cerebral edema. Further record review revealed the physician ordered SP#1 to be evaluated by the following disciplines: skilled nursing, physical therapy, occupational therapy, and speech therapy. Additional review of SP#1's record revealed the insurance authorized three (3) units of speech therapy on 02/22/2020. Further record review revealed no documentation that the agency provided the speech therapy services to SP#1. During an interview conducted on 04/14/2021 at 2:48 PM, the Director of Nursing acknowledged the agency did not provide the speech therapy services to the patient.

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: Based on record review and interview, the Home Health Agency failed to ensure 1 out 3 Sampled Patients (SP)'s record contained all clinical notes for the services provided by the agency's personnel. SP#3 Findings include: Review of SP#3's record revealed he was admitted on 03/13/2021. Further review of SP#3's record revealed the physician ordered Skilled Nursing (SN) and Physical Therapy (PT) services for the patient. Additional review of SP#3's record revealed it contained only the SN notes of 03/13/2021. Additional record review revealed no clinical documentation that the agency provided any additional SN services and PT evaluation/treatments to SP#3. During an interview conducted on 04/14/2021 at 2:42 PM, the Director of Nursing acknowledged that SP#3's record contained no clinical documentation to demonstrate that the agency provided additional SN services after 03/13/2021 and PT evaluation/treatments to SP#3.