Every finding on record at Southeast Homecare Corporation

An unannounced Complaint #2020002986 and Focused Infection Control survey was conducted on 04/01/2021 at Southeast Homecare, Home Health Agency provider. The provider is not in compliance with 42 CFR Part 484, Subpart A-C, Conditions of Participation for Home Health Agencies.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on review of the Home Health Agency (HHA)'s Policies and Procedures, record review and interview, the HHA failed to establish an individualized Plan of Care for 1 of 3 sampled patients as evidenced by the lack of documentation of the physician's ordered Plan of Care in the patient's record (Patient #3). The findings included: Review of the HHA's Policy titled, "Submission of Clinical Record Visits Documentation" with no revision date noted, documents, "all initial assessments must be submitted within 48 hours ..." Review of the HHA's "Memorandum to the field staff," dated 11/04/19 documents "...all initial assessments must be submitted within 48 hours..." On 04/01/21 at 1:45 PM, during an interview with Staff A, Quality Assurance Nurse, a side-by-side review of Patient #3's record was conducted that reveals a "referral" for Physical Therapy (PT), Occupational Therapy (OT), Home Health Aide and Social Worker (SW) evaluation; during the review, Staff A, was asked for Patient #3's "Physician's Plan of Care" and Staff A stated that the Skilled Nurse (SN) has not submitted the patient's "Start of Care Assessment," that was done on 03/03/21; further stated that the submission of the "Start of Care (Assessment)" generates the "Physician's Plan of Care" that the HHA had not received Patient #3's "SN Assessment" documentation, done on 03/03/21 therefore, they did not have a "Physician's Plan of Care; she stated that the "Start of Care Assessment" documentation has to be submitted (to the HHA) within 48 hours and Staff A was not able to submit Patient #3's "Physician's Plan of Care." On 04/02/21 at 4:06 PM, an interview was conducted with Staff C, a Licensed Practical Nurse/Case Manager who stated that once a "Start of Care (Assessment) is completed, the SN calls the Case Manager within 24 hours with an initial report; Staff C was asked why there was no "Physician's Plan of Care" for Patient #3; she stated that was a question for the Director of Nursing (DON) and Staff C did not know that there was no Physician's Plan of Care" for Patient #3. On 04/01/21 at 4:43 PM, an interview was conducted with the DON and she stated that once the patients' "Start of Care (Assessment) is completed, it's expected to be submitted within 48 hours; the DON was apprised that Patient #3's "Start of Care Assessment" had not been submitted and that there was no "Physician's Plan of Care" for Patient #3.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview, the Home Health Agency (HHA) failed to provide Home Health Aide services to 1 of 3 sampled patients (Patient #1). The findings included: Review of Patient #1's record documents a Home Health Certification and Plan of Care, dated 02/13/20, completed by the Home Health Agency's Skilled Nurse (SN) with the SN frequency to be twice a week for two weeks and then once a week for one week. On 04/01/21 at 3:47 PM, an interview was conducted with Staff C, a Licensed Practical Nurse/Case Manager who stated that she was the Case Manager for Patient #1; further stated that after a patient's "Start of Care Assessment" is completed, the SN calls the Case Manager, provides an initial report and a request for visits. During a continued interview, with Staff C, on 04/01/21 at approximately 3:47 PM, a side -by-side review of Patient #1's SN"s "initial report," dated 02/13/20, was conducted to reveal evidence of documentation, "requesting MSW (Medical Social Worker) as early as possible, Physical Therapy (PT) and Home Health Aide services ...;" Staff C stated that the request for more services was faxed to the referring physician on (Friday) 02/14/20 and a review of the HHA's fax to the patient's physician, dated 02/14/20 requesting more services, was conducted. During the continued interview, with Staff C, on 04/01/21 at approximately 3:47 PM, Staff C stated that once they fax a report to the physician, they will "follow up" the following week; Staff C was asked to submit documentation of communication with Patient #1's physician related to the fax requesting PT, Home Health Aide and MSW services sent on 02/14/20; Staff C stated that there was no documentation related to a "follow up" on the fax sent to the physician on 02/14/20; Staff C stated that they received a fax from the patient's physician on 02/20/20 for PT, Home Health Aide and MSW evaluation; Staff C was asked about Home Health Aide "visit notes;" a side-by-side review of Patient #1 record for "Home Health Aide Notes" or "Home Health Aide Missed Visit Notes" for 02/21/20 was conducted with Staff C who stated that she did not know why the Home Health Aide visits were not done and Staff C stated that there was no evidence of documentation related to the Home Health Aide services not being provided. On 04/01/21 at 4:17 PM, an interview was conducted with the HHA Director of Nursing (DON) who stated that the Case Managers should be calling the physician's office every two to three days to follow on the faxes sent to them; the DON was apprised there was no evidence of documentation on the patient's record related to a follow up with the physician to a request for PT, Home Health Aide and MSW services; the DON was apprised that the Home Health Aide services were not provided as the physician ordered on 02/20/20 and the DON stated it was Staff C's "oversight."

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 review of the Home Health Agency (HHA)'s Policies and Procedures, record review and interview, the HHA's Director Of Nursing (DON) failed to oversee the coordination of services to assure the provision of care ordered by the patients' physician for 2 of 3 sampled patients (Patient #1 and #3). The findings included: 1) Review of the HHA policy titled "Coordination of Services" no revision date noted documented " ...all personnel involved in the patient's care are responsible for coordinating care effectively ...the agency coordinates care by ...coordinating care delivery to meet the patients' needs ..." Review of Patient #1'a record documents a "Home Health Certification and Plan of Care," dated 02/13/20, completed by the HHA's Skilled Nurse (SN). On 04/01/21 at 3:47 PM, an interview was conducted with Staff C, a Licensed Practical Nurse/Case Manager and "Case Manager" for Patient #1 who stated that after a patient's "Start of Care Assessment" is completed, the Skilled Nurse (SN) calls the Case Manager, provides an "initial report" and "request for visits;" during a side-by-side review of Patient #1's SN initial report, dated 02/13/20, on 04/01/21 at approximately 3:47 PM, documentation reveals, "requesting MSW (Medical Social Worker) as early as possible, Physical Therapy (PT) and Home Health Aide services ...". Staff C further stated that the request for more services was faxed to the referring physician on (Friday) 02/14/20 and a review of the HHA's fax to the patient's physician, dated 02/14/20 requesting more services, was conducted. During the continued interview, with Staff C, on 04/01/21 at approximately 3:47 PM, Staff C stated that once they fax a report to the physician, they will "follow up" the following week; Staff C was asked to submit documentation of communication with Patient #1's physician related to the fax requesting PT, Home Health Aide and MSW services sent on 02/14/20; Staff C stated that there was no documentation related to a "follow up" on the fax sent to the physician on 02/14/20; Staff C stated that they received a fax from the patient's physician on 02/20/20 for PT, Home Health Aide and MSW evaluation; Staff C was asked about Home Health Aide "visit notes;" a side-by-side review of Patient #1 record for "Home Health Aide Notes" or "Home Health Aide Missed Visit Notes" for 02/21/20 was conducted with Staff C who stated that she did not know why the Home Health Aide visits were not done and Staff C stated that there was no evidence of documentation related to the Home Health Aide services not being provided. On 04/01/21 at 4:17 PM, an interview was conducted with the HHA's DON who stated that the Case Managers should be calling the physician's office every two to three days to follow on the faxes sent to them; the DON was apprised there was no evidence of documentation on the patient's record related to a follow up with the physician to a request for PT, Home Health Aide and MSW services; the DON was apprised that the Home Health Aide services were not provided as the physician ordered on 02/20/20 and the DON stated it was Staff C's "oversight." 2) On 04/01/21 at 1:45 PM, during an interview with Staff A, Quality Assurance Nurse, a side-by-side review of Patient #3's record was conducted that reveals a "referral" for Physical Therapy (PT), Occupational Therapy (OT), Home Health Aide and Medical Social Worker (MSW) evaluation; during the review, Staff A, was asked for Patient #3's "Physician's Plan of Care" and Staff A stated that the Skilled Nurse (SN) has not submitted the patient's "Start of Care Assessment," done on 03/03/21; further stated that the submission of the "Start of Care (Assessment)" generates the "Physician's Plan of Care" that the HHA has not received Patient #3's "SN Assessment" documentation, done on 03/03/21 therefore, they did not have a "Physician's Plan of Care; she stated that the "Start of Care Assessment" documentation has to be submitted (to the HHA) within 48 hours. On 04/01/21 at 1:45 PM, during a further interview, Staff A was asked for the MSW's "evaluation/visit note;" Staff A stated that the MSW visit was scheduled for 03/05/21 and as of 04/01/21, the MSW has not submitted her documentation. Staff A was not able to provide the MSW evaluation/visit note, Physician's Plan of Care or the "Start of Care Assessment." On 04/02/21 at 4:06 PM, an interview was conducted with Staff C, a Licensed Practical Nurse/Case Manager who stated that once a "Start of Care (Assessment) is completed, the SN calls the Case Manager within 24 hours with an initial report; Staff C was asked why there was no "Physician's Plan of Care" for Patient #3; she stated that was a question for the Director of Nursing (DON) and Staff C did not know there was no Physician's Plan of Care" for Patient #3. On 04/02/21 at 4:06 PM, during a further interview, Staff C stated that they were following the "referral physician orders" for Patient #3; Staff C was asked if she was aware of the MSW visit delay and stated that she was not; Staff C confirmed that there was "no coordination of care written documentation," related to the MSW communication with the patient or family member. On 04/01/21 at 4:38 PM, a joint interview via telephone with the HHA's DON and Staff D, a MSW, was conducted; Staff D stated that Patient #3's evaluation was conducted on 03/09/21; Staff D was asked why the visit was not completed as scheduled on 03/05/21 and Staff D stated that the family kept postponing the visit; Staff D stated that she had no written documentation related to the delay of the visit and that she did not coordinate or communicate the information to the HHA's Case Manager. On 04/01/21 at 4:43 PM, an interview was conducted with the DON who stated that the MSW should have communicated with the HHA's Case Manager and documented her communication with the family related to the evaluation that was postponed.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on review of the Home Health Agency (HHA)'s Policies and Procedures, interview and record review, the HHA failed to ensure the accuracy of the patient's records for 1 of 3 sampled patients as evidenced by the lack of documentation/evidence of the "Physician Plan of Care, lack of documentation/evidence of the Skilled Nurse (SN)'s "Start of Care Assessment; lack of documentation the MSW (Medical Social Worker) "evaluation/visit notes" and lack of evidence of communication with the patient or the HHA (Patient #3). The findings included: Review of the HHA policy titled "Submission of Clinical Record Visits Documentation" no revision date noted, documented "all initial assessments must be submitted within 48 hours ...all medical social workers evaluation must be submitted within 7 days of visit ..." Review of the HHA memorandum to the field staff dated 11/04/19 documented " ...all initial assessments must be submitted within 48 hours ...all medical social workers evaluation must be submitted within 7 days of visit ..." On 04/01/21 at 1:45 PM, during an interview with Staff A, Quality Assurance Nurse, a side-by-side review of Patient #3's record was conducted that reveals a "referral" for Physical Therapy (PT), Occupational Therapy (OT), Home Health Aide and Medical Social Worker (MSW) evaluation; during the review, Staff A, was asked for Patient #3's "Physician's Plan of Care" and Staff A stated that the Skilled Nurse (SN) has not submitted the patient's "Start of Care Assessment," done on 03/03/21; further stated that the submission of the "Start of Care (Assessment)" generates the "Physician's Plan of Care" that the HHA has not received Patient #3's "SN Assessment" documentation, done on 03/03/21 therefore, they did not have a "Physician's Plan of Care; she stated that the "Start of Care Assessment" documentation has to be submitted (to the HHA) within 48 hours. On 04/01/21 at 1:45 PM, during the interview, Staff A was asked for the submission of the "MSW Evaluation/Visit note" and Staff A stated that the MSW visit was scheduled for 03/05/21 and as of 04/01/21, the MSW has not submitted her documentation. On 04/02/21 at 4:06 PM, an interview was conducted with Staff C, a Licensed Practical Nurse/Case Manager who stated that once a "Start of Care (Assessment) is completed, the SN calls the Case Manager within 24 hours with an "initial report;" Staff C was asked why there was no "Physician's Plan of Care for Patient #3 and she stated that was a question for the Director of Nursing (DON); she stated that they were following the "referral physician orders" for Patient #3; Staff C stated that there was no written documentation related to the MSW communication with the patient or the family member; Staff C confirmed that there was no evidence of documentation of the MSW evaluation/visit note. On 04/01/21 at 4:38 PM, a joint interview, via telephone with the HHA's DON and Staff D, a Medical Social Worker, was conducted; Staff D stated that Patient #3's evaluation was conducted on 03/09/21; Staff D was asked why the visit was not completed as scheduled on 03/05/21 and stated that the family kept postponing the visit; Staff D stated that she had no written documentation related to the delay of the visit and that she did not communicate the information to the HHA's office (staff) and Staff D stated that she has not submitted the evaluation/visit completed on 03/09/21 as of 04/01/21. On 04/01/21 at 4:43 PM, an interview was conducted with the DON who stated that once the patients' "Start of Care" is completed, it's expected to be submitted within 48 hours and stated that the MSW evaluation/visit note should have been in the patient's record as of 04/01/21.