Every finding on record at Martins Florida Elder Care Inc

A Complaint Survey for complaint #2021004449 was conducted on April 06, 2021 at All-Dade Home Health Care. The Home Health Agency was not in non-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). SP#1 Findings include: On 04/06/2021 at 11:02 AM, SP#1's record including the admission paperwork/consent forms and the clinical notes were requested for review from the President/CEO. Review of SP#1's record revealed he was admitted on 06/01/2020. Further review of SP#1's record revealed no documentation that the agency completed the initial admission paperwork/consent forms with the patient on 06/01/2020. During an interview conducted on 04/06/2021 at 1:00 PM, the President/CEO acknowledged that SP#1's record contained no documentation showing that the agency completed the admission paperwork/consent forms with the patient on 06/01/2020. On 04/06/2021 at 1:05 PM, the President/CEO stated, "The consent forms are stored at a warehouse and it would take at least a couple of hours to locate them."

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on record review and interview, the Home Health Agency failed to provide proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care for 1 out of 3 Sampled Patients (SP). SP#3 Findings include: Review of SP#3's record revealed he was admitted on 01/23/2021 and discharged on 02/06/2021. Further record review revealed no documentation showing that SP#3 was notified in writing of the planned date of termination by the agency and the reason for termination. During an interview conducted on 04/06/2021 at 2:55 PM, the President/CEO acknowledged that the agency did not provide an advance notice of discharge to SP#3 prior to his discharge on 02/06/2021.

Treatment or care CFR(s): 484.50(e)(1)(i)(A) (i)(A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; and This ELEMENT is not met as evidenced by: Based on record review and interview, the Home Health Agency failed to honor 1 out of 3 Sampled Patients' (SP) rights by not providing the Home Health Aide (HHA) services. SP#1 Findings include Review of SP#1's record revealed he was admitted on 06/01/2020. Further review of SP#1's record revealed he is receiving ten hours of HHA services from the agency daily. Additional review of SP#1's record revealed the agency did not provide the HHA services on 03/22/2021 and 03/23/2021. During an interview conducted on 04/06/2021 at 2:36 PM, the President/CEO acknowledged that the agency did not provide the HHA services on 03/22/2021 and 03/23/2021; he stated, "The staff canceled, and we were not able to restaff the case."

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 include in the Plans of Care (POCs) information related to the description of the patients' risks for emergency department visits and hospital re-admissions, and all necessary interventions to address the underlying risk factors and information related to any advanced directives for 2 out of 3 Sampled Patients (SP) reviewed. SP#2 and SP#3 Findings include: Review of SP#2 and SP#3's records revealed that the agency did not include in the patients' POCs information related to the description of the patients' risks for emergency department visits and hospital re-admission and information related to any advanced directives. During an interview conducted on 04/06/2021 at 1:53 PM, the President/CEO acknowledged that the agency did not include in SP#2 and SP#3's POCs information related to the description of the patients' risks for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors and information related to any advanced directives.

Coordination of Care CFR(s): 484.60(d) Standard: Coordination of care. The HHA must: This STANDARD is not met as evidenced by: Based on record review and interview, the Home Health Agency failed to coordinate care for 1 out of 3 Sampled Patients (SP). SP#1 Findings include: Review of SP#1's record revealed he was admitted on 06/01/2020. Further review of SP#1's record revealed he is receiving ten hours of HHA services from the agency daily. Additional review of SP#1's record revealed the agency did not provide the HHA services on 03/22/2021 and 03/23/2021. During an interview conducted on 04/06/2021 at 2:36 PM, the President/CEO acknowledged that the agency did not provide the HHA services on 03/22/2021 and 03/23/2021; he stated, "The staff canceled, and we were not able to restaff the case."

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 that 1 out 3 Sampled Patients (SP)'s record contained the admission documents and consent forms for the most recent home health admission. SP#1 Findings include: On 04/06/2021 at 11:02 AM, SP#1's record including the admission paperwork/consent forms and the clinical notes were requested for review from the President/CEO. Review of SP#1's record revealed he was admitted on 06/01/2020. Further review of SP#1's record revealed no documentation that the agency completed the initial admission paperwork/consent forms with the patient on 06/01/2020. During an interview conducted on 04/06/2021 at 1:00 PM, the President/CEO acknowledged that SP#1's record contained no documentation showing that the agency completed the admission paperwork/consent forms with the patient on 06/01/2020. On 04/06/2021 at 1:05 PM, the President/CEO stated, "The consent forms are stored at a warehouse and it would take at least a couple of hours to locate them."