Every finding on record at Rehabtrust Inc

A recertification survey was initiated on 9/12/2022. The census was: LCHH-75 LHH-0 Total agency census: 75

A recertification survey was initiated on 9/12/2022. The census was: LCHH-75 LHH-0 Total agency census: 75 Abbreviations Freq-frequency LHH-Licensed Home Health LCHH-Licensed and Certified Home Health POC-Plan of Care SN-Skilled Nursing Services EMR-electronic medical record LVN-licensed vocational nurse PTA-physical therapy assistant PT-Physical Therapist POA-power of attorney ART-Advanced RehabTrust Home Health Eval-evaluation Kmail-Kinnser software based email Wk=week CG-caregiver Pt-patient

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to coordinate care with a patient’s representative and the LVN to meet the patient’s needs in 1 (Patient #9) of 3 discharged patient records reviewed. The failure placed the patients at risk for omission of care/visits or inappropriate care. Findings include: Patient #1: The record contained a plan of care for episode 4/18/2022 through 6/15/2022 with a start of care of 12/19/2021. The primary diagnosis was unspecified open wound right lower leg with hypertensive chronic kidney disease stage 4 and type 2 diabetes mellitus. The plan of care included orders for skilled nursing 2 times a week for 3 weeks and 1 time a week for 6 weeks. The record contained 2 missed visit forms for the first week of the episode on 4/20/2022 and 4/22/2022. The record contained an order dated 4/28/2022 for a physical therapy evaluation. The record contained the physical therapy evaluation dated 5/2/2022 signed by the PT. The evaluation included a frequency of 1 time a week for 7 weeks. The record contained a recertification verbal order dated 4/15/2022 for skilled nursing 2 times a week for 3 weeks and 1 time a week for 6 weeks starting the week of 4/18/2022. The record contained 3 missed visit forms. One missed visit was dated 4/20/2022 and one dated 4/22/2022 that read in part…Missed due to scheduling error-SN not notified to see patient.”… One was dated 3/30/2022 signed by the LVN that read in part…”CG reported she was taking pt out of town and would not be home or available for a visit again until next week.”…There was no evidence found in the record of coordinating with Client #1’s POA of any changes in frequency or care. On 9/12/2022 at approximately 1:05 p.m. the surveyor reviewed the complaint log. Patient #1’s POA complained 2 times on 4/27/2022 and 5/9/2022. Complaint #1: On 4/27/2022, Patient #1’s POA complained due to not being notified of changes related to the skilled nursing frequency change from 3 times a week to 2 times a week and no skilled nursing visits from 3/23/2022 until 4/15/2022. Patient #1’s POA had a copy of a physician’s order dated 4/15/2022 for skilled nursing 3 times a week. The agency complaint documentation on 4/27/2022 included 2 missed visit forms signed and dated by a LVN on 4/20/2022 and 4/22/2022 stating, “Missed due to scheduling error-SN not notified to see patient” The agency failed to coordinate the scheduled visits with the LVN. Complaint #2: On 5/9/0222 Patient #1’s POA complained due to not being notified of the change in the physical therapy frequency from 2 times a week for 3 weeks and 1 time a week for four weeks to 1 time a week for 7 weeks. Patient #1’s POA requested discharge from the agency on 5/9/2022. The agency complaint documentation on 5/9/2022 contained the following documentation: A kmail on 5/2/2022 that read in part…” Eval done today. Freq requested is 2wk3, 1wk4. Please schedule visits with PTA. Thanks PT.”… A kmail on 5/3/2022 from agency scheduler that read in part…: “I scheduled visits for 1 x weekly to PTA. New freq 1 wk7. I sent the eval back to PT to please change the freq. Scheduler.”… The physician signed PT evaluation dated 5/2/2022 that included orders for PT 1 time a week for 7 weeks. The agency failed to coordinate the changes with Patient #1’s POA, resulting in Patient #1’s POA complaining a second time and requesting discharge on 5/9/2022, causing a break in services ordered by the physician. On 9/12/2022 the surveyor interviewed the Administrator at 2:15 pm. The surveyor reviewed the 2 complaints made by Patient #1’s POA. Complaint 1: The Administrator was asked why the skilled nursing visits were missed on 4/20/2022 and 4/22/2022. The Administrator explained that LVN was a contract nurse and was not notified of the scheduled visits for Patient #1. Complaint 2: The Administrator was asked why Patient #1’s POA was not notified of the change in frequency from 2 times a week for 3 weeks and 1 time a week for 4 weeks to 1 time a week for 7 weeks. The Administrator said she didn’t know. An interview was conducted on 9/16/2022 at approximately 3:00 pm with the Administrator and the Supervising Nurse. The Administrator and Supervising Nurse were asked how not coordinating changes in a patient’s plan of care could impact the agency patients. The Administrator said that it could cause a decline in their health and missed visits. Agency policy: MONITORING PATIENT CARE/COORDINATION OF CARE PC.10 read in part…”PURPOSE To ensure coordination of patient/client care and treatment…PROCEDURE I. The Agency will: … C. Integrate services, whether services are provided directly or under arrangement, to ensure the identification of patient/client needs and factors that could affect patient/client safety and treatment effectiveness and the coordination of care provided by all disciplines. D. Coordinate care delivery to meet the patient/client needs, and involve the patient/client, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities…”

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record review and interviews, the agency failed to provide the patient and/or caregiver with written information outlining a visit schedule including frequency of visits by home health staff in 3 (Patients #1, #3 and #8) of 3 patients' home folders reviewed during home visits. This failure placed the patients at risk of missed visits by staff when visits were not scheduled and conflicted with other appointments and the availability of the patients. Findings included: Patient #1: Record review contained a plan of care for the period of 7/8/2022 through 9/5/2022 with a start of care of 7/8/2022. The frequency for the skilled nurse was ordered 1 time a week for 3 weeks, home health aide 1 time a week for 3 weeks and physical therapy to evaluate. During a home visit with Patient #1 on 9/16/2022 at 11:40 am, no documentation was found in the agency home folder provided to Patient #1 of written information outlining a visit schedule including frequency of visits to be made by the skilled nurse, home health aide or physical therapy. The surveyor asked if anything had been removed from the folder. Patient #1 said “No.” The surveyor asked if Patient #1 had been provided with a written schedule of visits to be made by the skilled nurse, home health aide and physical therapy. Patient #1 said, "No, I put it on my calendar." Patient #3: Record review contained a plan of care for the period of 6/15/2022 through 8/13/2022 with a start of care of 10/18/2021. The frequency for the occupational therapy was ordered 1 time a week for 4 week and 1 time every other week for 4 weeks. During a home visit with Patient #3 on 9/13/2022 at 11:00 am, no documentation was found in the agency home folder provided to Patient #3 of written information outlining a visit schedule including frequency of visits to be made by the occupational therapist. The surveyor asked if anything had been removed from the folder. Patient #3 said “No.” The surveyor asked if Patient #3 had been provided with a written schedule of visits. Patient #3 said, "No.” Patient #8: Record review contained a plan of care for the period of 732/2022 through 8/31/2022 with a start of care of 7/3/2022. The frequency for the skilled nurse was ordered 2 times a week for 1 week, 1 time a week for 4 weeks and 1 time every other week for 4 weeks. During a home visit with Patient #8 on 9/16/2022 at 12:40 pm, no documentation was found in the agency home folder provided to Patient #8 of written information outlining a visit schedule including frequency of visits to be made by the skilled nurse. The surveyor asked if anything had been removed from the folder. Patient #8 said, ”No.” The surveyor asked if Patient #8 had been provided with a written schedule of visits. Patient #8 said, "No, they text me." An interview was conducted on 9/12/2022 at 11:25 am with the Administrator. The Administrator was asked how the agency patients knew when the nurses, home health aides or therapists would be making home visits. The Administrator said, “We call or text them.” An interview was conducted on 9/16/2022 at 3:00 pm with the Administrator and Supervising Nurse. The Administrator and Supervising Nurse were asked if the patients are provided with a written schedule of visits. The Administrator said, “They are supposed to be.” The Administrator and Supervising Nurse were asked what the possible impact to the patients could be when not provided with a written schedule of visits including therapy. The Administrator said, “They (the patients) may have missed visits or not be available.”