Every finding on record at Reliant Home Health of Fort Worth, LLC

Purpose: Recertification Entrance Date: 7/11/2022 Census: Licensed and Certified - 13 No deficiency cited. The agency was in compliance with 42 CFR Part 484.22, Emergency Preparedness Requirements for Home Health Agencies.

Purpose: Recertification Entrance Date: 7/11/2022 Census: Licensed and Certified - 13

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency's skilled professional (physical therapist) failed to prepare the discharge clinical note for 1 (#4) of 1 discharged patient records reviewed where the patient received physical therapy services only. The failure resulted in discontinuity of care and placed all the agency's patients at risk for discontinuity with health care needs after the agency would no longer provide services. The surveyor was provided a list of the agency's current patients on 7/11/2022. Client #4 was listed on the current patient list. The agency had a policy titled "Timelines" that was labeled IM.7 with a revision date of 8/1/2020. The policy read in part: "Purpose To establish timely parameters for all medical record information. Policy The agency will ensure timely provision of care and services to meet the patient's/client's needs in compliance with all federal and state laws and regulations. Procedure...H. The Discharge Comprehensive Assessment is completed within forty-eight hours of the discharge..." Patient #4: The record review of Patient #4's clinical record was conducted on 7/12/2022. The clinical record was an electronic medical record. Record review of Patient #4's clinical record revealed a Plan of Care dated 5/18/2022 to 7/16/2022. The Plan of Care indicated that Patient #4 started on the agency's services on 5/18/2022. The Plan of Care listed Aftercare following Joint Replacement Surgery and Presence of Left Artificial Knee Joint as diagnoses. The Plan of Care contained an order for physical therapy skilled visits twice a week for one week, then three times a week for two weeks. The clinical record contained documentation of skilled therapy visits on 5/18/2022, 5/19/2022, 5/23/2022, 5/25/2022, and 5/27/2022. The last skilled physical therapy visit was conducted on 5/27/2022. The visit conducted on 5/27/2022 was not a discharge visit. Patient #4 informed the surveyor during an interview on 7/13/2022 at approximately 11:30 a.m., that the insurance had approved 4-5 visits. Patient #4 informed the surveyor that the physical therapist was going to request more visits. Patient #4 stated, "I never heard from them (agency) after." Patient #4 did not know if (Patient #4) was discharged from the agency. The record was reviewed with the Administrator/Director of Nursing and with the Alternate Administrator/Alternate Director of Nursing on 7/14/2022 at approximately 9:36 a.m. The surveyor discussed and asked questions regarding Patient #4 status with the agency. The record contained a non-billable discharge clinical note that was not in the clinical record when it was reviewed by the surveyor on 7/12/2022. The electronic schedule indicated that the visit was conducted on 6/9/2022 but the date of Physical Therapist D's signature on the clinical note was 5/30/2022. The clinical record did not contain evidence that a discharge summary had been sent to the health care professional that would be providing services after discharge. During an interview with the Administrator/Director of Nursing on 7/14/2022 at approximately 9:36 a.m., the Administrator informed the surveyor that Physical Therapist D was a contracted physical therapist with Therapy Agency D. The Administrator informed the surveyor that the agency had issues with therapy clinical notes being late from contracted staff with Therapy Agency D. The agency had auditors that ran reports each week to track clinical notes that were late. The agency would notify Therapy Agency D regarding late clinical notes. Therapy Agency D would notify the contract staff. The agency would then would give staff 48 hours to complete notes. The agency had a contract with Therapy Agency D titled "Home Healthcare Staffing Agreement." The contract read in part; "...2.3 Audit, Inspection and Review of Patient Notes. Subject to the availability of information, (Therapy Agency D) will instruct the Providers to provide the Patient notes in a manner that complies with all specified Agency policies, procedures, standards and requirements..."