Every finding on record at Pinnacle Home Care of the Villages Inc

An unannounced complaint survey, complaint number 2025005585, was conducted on May 29, 2025, at Pinnacle Home Care of The Villages, Inc. The facility was not in compliance with Code of Federal Regulations (CFR) 42 Part 484, Requirements for Home Health Agencies.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to communicate and follow up with the physician of the patient's laboratory results according to professional standards of practice for 1 of 3 patients, Patient #1. Findings include: Review of Patient #1's medical record documented the patient had a urine analysis results reported on 12/03/2024, via fax. The results were not forwarded or communicated to the physician. During the review of the home visit note dated 12/09/2024 an attempt was made to contact the physician without success. This attempt was not followed through by the nurse or escalated to a Case Manager as per the agency policy. During an interview on 5/29/25 at 11:30 AM the Clinical Director stated, “I would expect a prudent nurse to follow up with these results.” Review of the policy and procedure titled, "MONITORING PATIENT’S RESPONSE/REPORTING TO PHYSICIAN. Policy No. 4-012.1." read, "PURPOSE To provide guidelines for monitoring the patient’s response to care, and for reporting to the patient’s physician. POLICY: Clinicians will monitor, document, and report the patient’s response to care and treatment provided on each home visit. Progress of goals will be measured at regular intervals. Clinicians will monitor and maintain ongoing communication with the physician to ensure safe and appropriate care for the patient. 3. The patient's physician will be contacted on the same day when any of the following occur: G. When results are received for relevant laboratory test ordered. 5. When unable to contact the patient's physician for medical consultation warranted by change in patient's condition, the following procedures will be followed: A. The nurse or therapist will immediately notify the Clinical Manager or designee regarding the need for medical consultation and problems encountered.