Every finding on record at Redlands Community Hosp H C

The following reflects the findings of the California Department of Public Health during the investigation of a complaint. Complaint Number: CA00745809 Representing the California Department of Public Health: Surveyor: 35183 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued as a result of the investigation for complaint number CA00745809

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the comprehensive assessment was completed within 5 calendar days of the Start of Care (SOC) for three of three sampled patients (Patients 1, 2, and 3) when: 1. For Patient 1, the Physical Therapy's (PT) evaluation was completed six days after the start of care date, the Medical Social Worker's (MSW) evaluation was completed fourteen days after the start of care date and the Occupational Therapy's (OT) evaluation was completed ten days after the start of care date. 2. For Patient 2, the Occupational Therapy's (OT) evaluation was completed seven days after the start of care date. 3. For Patient 3, the Physical Therapy's (PT) evaluation was completed seven days after the start of care date and the Occupational Therapy's (OT) evaluation was completed seven days after the start of care date. This failure caused the patients to suffer a delay in identifying needed therapy and psychosocial services. Findings: 1. A review of Patient 1's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of July 12, 2021, with a certification period of July 12, 2021 to September 9, 2021. Patient 1 had diagnoses that included atrial fibrillation (an irregular and rapid heart rate that causes poor blood flow). A review of Patient 1's initial assessment dated July 12, 2021 indicated a Start of Care (SOC) date of July 12, 2021. A review of Patient 1's Physical Therapy (PT) Evaluation indicated a date of July 18, 2021, six days after the SOC. A review of Patient 1's Medical Social Worker (MSW) Evaluation indicated a date of July 27, 2021, fourteen days after the SOC. A review of Patient 1's Occupational Therapy (OT) Evaluation indicated a date of July 22, 2021, ten days after the SOC. During an interview with the Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) in the presence of the Home Health/Hospice Manager (HHM) and Quality Assurance (QA) on August 2, 2021 at 12:52 PM, the AD/DPCSD stated the PT/MSW/OT evaluations were not done within 5 days of the SOC or on a physician's ordered start date. 2. A review of Patient 2's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of July 6, 2021, with a certification period of July 6, 2021 to September 3, 2021. Patient 2 had diagnoses that included encounter for surgical aftercare following surgery on the circulatory system. A review of Patient 2's initial assessment dated July 6, 2021 indicated a Start of Care (SOC) date of July 6, 2021. A review of Patient 2's Occupational Therapy (OT) Evaluation indicated a date of July 13, 2021, seven days after the SOC. During an interview with the Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) in the presence of the Home Health/Hospice Manager (HHM) and Quality Assurance (QA) on August 2, 2021 at 1:21 PM, the AD/DPCSD stated the OT evaluation was not done within 5 days of the SOC or on a physician's ordered start date. 3. A review of Patient 3's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of July 7, 2021, with a certification period of July 7, 2021 to September 4, 2021. Patient 3 had diagnoses that included inflammatory liver disease (inflammation in the liver). A review of Patient 3's initial assessment dated July 7, 2021 indicated a Start of Care (SOC) date of July 7, 2021. A review of Patient 3's Physical Therapy (PT) Evaluation indicated a date of July 14, 2021, seven days after the SOC. A review of Patient 3's Occupational Therapy (OT) Evaluation indicated a date of July 14, 2021, seven days after the SOC. During an interview with the Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) in the presence of the Home Health/Hospice Manager (HHM) and Quality Assurance (QA) on August 2, 2021 at 2 PM, the AD/DPCSD stated the PT and OT evaluations were not done within 5 days of the SOC or on a physician's ordered start date. A review of the agency's policy and procedure titled, "Patient Assessments," dated February 2, 1998 indicated, "The Start of Care (SOC) comprehensive assessment should be completed in a timely manner consistent with the patient's immediate needs but no later than 5 calendar days after the SOC."