Every finding on record at Medi Home Health Agency

During the recertification survey conducted on 4/22/2021 at Medi Home Health, a Home Health Agency, Emergency Preparedness was reviewed. Medi Home Heath is in compliance with Emergency Preparedness per Code of Federal Regulations (CFR) 42, Part 484.22, Condition of Participation for Home Health Agencies.

A recertification survey was completed on 4/19/2021 to 4/22/2021 at Medi Home Health Agency. The facility was not in compliance with Code of Federal Regulations (CFR) 42, Part 484.22, Condition of Participation for Home Health Agencies.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on patient record review and staff interview the home health agency failed to update the plan of care with current assessment data reflecting the patient's progress toward measurable outcomes obtained from the comprehensive assessment for 2 of 5 active patient records reviewed from the home health agency branch, (#5 and #8). The findings include: Patient #5 On 4/21/2021 an electronic medical record review was conducted for patient #5, a 65-year-old admitted to the home health agency on 4/8/2020 for physical therapy services at home. The admission Home Health Certification and Plan of Care for certification period 4/8/2020 to 6/6/2020 revealed patient #5 would receive physical therapy for stroke at home program for right-side weakness. The physical therapy goals included: improve balance as evidenced by the Tinetti balance and gait score (a test that measures a resident's ability to perform specific tasks) from 17/28 to 26/28 with a short-term goal target date of 4/30/2020; improve Time up and Go (TUG) score of 18 seconds using cane, with a short-term goal target date of 4/30/2020 and improve strength of right lower leg musculature from 3-3+/5 to 4+/5 with a short-term goal target date of 4/30/2020. The document revealed the patient would be discharged when goals were met, or maximum potential reached. A review of the Outcome and Assessment Information Set (OASIS), dated 6/5/2020 revealed under the heading, "Physical Assessment" right knee and ankle strength as 3+/5, a Tinetti balance and gait score of 18/28 and a TUG score of 24 seconds. A review of the Home Health Certification and Plan of Care for certification period 2/2/2021 to 4/2/2021 revealed physical therapy goals which included: improve balance as evidenced by the Tinetti balance and gait score from 17/28 to 26/28, with a long-term goal target date of 4/2/2021; improve strength of right lower leg musculature from 3-3+/5 to 4+/5, with a long-term goal target date of 4/2/2021, and improve mobility as evidenced by a TUG score of 18 seconds with a long-term goal target date of 4/2/2021. A review of a physical therapy re-evaluation note dated 3/24/2021 revealed patient #5 right knee and ankle strength as 3+/5, a Tinetti balance and gait score of 22/28, and a TUG score of 26 seconds with cane. A review of the OASIS dated 3/31/2021 revealed under the heading, "Physical Assessment" right knee and ankle strength as 3+/5, a Tinetti gait and balance score of 20/28 and a TUG score of 24 seconds. The Home Health Certification and Plan of Care for certification period 4/3/2021 to 6/1/2021 revealed physical therapy goals which included: improve balance as evidenced by the Tinetti balance and gait score from 17/28 to 26/28, with a long-term goal target date of 6/1/2021, improve strength of right lower leg musculature from 3-3+/5 to 4+/5, with a long-term goal target date of 6/1/2021, and improve mobility as evidenced by a TUG score of 18 seconds, with a long-term goal target date of 6/1/2021. Patient #8 An electronic medical record review was conducted on 4/21/2021 for sampled patient #8, an 82-year-old admitted to the home health agency on 5/2/2020. The admission Home Health Certification and Plan of Care for certification period 5/2/2020 to 6/3/2020 revealed patient #8 would receive physical therapy services with the goals to include the following: improve mobility as evidenced by a TUG score of 18-20 seconds using rolling walker or rollator, improve balance as evidenced by the Tinetti balance and gait score from 0/28 to 26/28, improve strength of bilateral lower leg musculature from 3-3+/5 to 4+/5. A review of the Home Health Certification and Plan of Care for certification period 12/28/2020 to 2/25/2021 revealed physical therapy goals to include the following: improve balance as evidenced by the Tinetti balance and gait score from 0/28 to 26/28; improve mobility as evidenced by a TUG score of 18-20 seconds using rolling walker or rollator; improve strength of bilateral lower leg musculature from 3-3+/5 to 4+/5. A review of a Physical Therapy Evaluation dated 1/19/21 revealed lower extremity strength as 3+/5, a Tinetti balance and gait score of 20/28 and a TUG of 24 seconds. A review of a Physical Therapy Evaluation dated 2/9/2021 revealed lower extremity strength as 4-/5, a Tinetti balance and gait score of 20/28 and a TUG of 24 seconds. A review of the OASIS dated 2/23/2021 under the physical assessment heading, revealed patient #8 continued with bilateral lower leg weakness and coordination deficits with 3+/5 strength noted in both lower extremities, a Tinetti balance and gait score of 20/28 and a TUG score of 24 seconds. A review of the Home Health Certification and Plan of Care for certification period 2/26/2021 to 4/26/2021 revealed physical therapy goals to include the following: improve strength of bilateral lower leg musculature from 3+/5 to 4+/5, improved balance as evidenced by the Tinetti balance and gait score from 0/28 to 26/28; improve mobility as evidenced by a TUG score of 18-20 seconds using rolling walker or rollator. An interview was completed on 4/22/2021 at approximately 12:05 PM, with the Administrator who reviewed the medical records for patient #5 and #8 and confirmed the documentation on the plan of care for the two patients did not reflect the Oasis assessment of the patients, and did not show the patient had improvement through the certification periods. An interview with the Director of Nurses on 4/22/2021 at approximately 12:15 PM, who revealed the typical length of stay for physical therapy services is less than 30 days. She revealed some go into the second certification period, but usually no more than 2 certification periods, if the patient is showing improvement.