Every finding on record at St. Charles Home Health Services

An unannounced Federal recertification survey was completed at this agency on 9/13/2024. The agency was surveyed for compliance with 42 CFR Conditions of Participation for Home Health Agencies, Part 484.102 Emergency Preparedness. An entrance conference was held on 8/13/2024 at 2:20 PM with the Director of Home Based Care, Quality Improvement Coordinator, Clinical Educator, Home Health Therapy Manager, Home Health Nurse Manager, Regulatory Manager, Hospice Nurse Manager, IT Epic Trainer, Human Resource Business Partner, Clinical Division Medical Director, Service Line Administrator, and Admin. The purpose of the survey and the survey needs were explained. An opportunity was provided for questions, answers, and comments. Definitions and abbreviations: CFR - Code of Federal Regulations

An unannounced Federal recertification survey was completed at this agency on 9/13/2024. The agency was surveyed for compliance with 42 CFR Conditions of Participation for Home Health Agencies, Part 484. An entrance conference was held with the Director of Home Based Care, Quality Improvement Coordinator, Clinical Educator, Home Health Therapy Manager, Home Health Nurse Manager, Regulatory Manager, Hospice Nurse Manager, Information Technology Epic Trainer, Human Resource Business Partner, Clinical Division Medical Director, Service Line Administrator, and Administrative Assistant on 8/13/2024 at 2:20 PM. The purpose of the survey and the survey needs were explained. An opportunity was provided for questions, answers, and comments. Definitions and abbreviations: CFR - Code of Federal Regulations IDT - Interdisciplinary Team

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 record review and interview, it was determined the agency failed to document the reasons and make efforts to resolve multiple missed Home Health Aide visits for 3 of 17 patient records reviewed (Patients #1, #2, and #3). Findings: Patient #1: Review of a document titled "07/24/2024 - Home Health Admission in [Name of the agency]" revealed, "Home Health Aide visits: 1 visit every week for 6 weeks [from] 8/11/2024 to 9/21/2024." Review of a document titled with "List of Aide Visits & Missed Visits" revealed Home Health Aide missed visits on 8/22/2024, 8/29/2024, and 9/05/2024. The agency failed to provide documentation of the reason for the missed visits and an effort made by clinicians to resolve missed visits or discussion in IDT meetings. Patient #2: Review of a document titled "07/01/2024 - Home Health Admission in [Name of the agency]" revealed, "Home Health Aide visits: 1 visit every week for 8 weeks [from] 7/21/2024 to 9/10/2024." Review of a document titled with "List of Aide Visits & Missed Visits" revealed a Home Health Aide missed visit on 7/23/2024. The agency failed to provide documentation of the reason for the missed visit and an effort made by clinicians to resolve the missed visit. Patient #3: Review of a document titled "05/25/2024 - Home Health Admission in [Name of the agency]" revealed, "Home Health Aide visits: 1 visit every week for 7 weeks [from] 6/16/2024 to 8/2/2024 and 1 visit every week for 9 weeks [from] 8/4/2024 to 10/1/2024." Review of a document titled with "List of Aide Visits & Missed Visits" revealed a Home Health Aide missed visit on 6/21/2024. The agency failed to provide documentation of the reason for the missed visit and an effort made by clinicians to resolve the missed visit. During an interview on 9/11/2024 at 11:30 AM with Employee #10 and Employee #11, the finding was discussed. No additional documentation was provided.

An unannounced Federal recertification survey was completed at this agency on 8/4/2021. The agency was surveyed for compliance with 42 CFR Conditions of Participation for Home Health Agencies, Part 484. An entrance conference was held on 7/26/2021 at 2:06 PM with the Administrator, the Business & Regulatory Manager, the Director of Home Health, the Clinical Manager of Home Health, the Rehab Manager of Home Health, and the Quality Accreditation & Licensing Specialist. The Manager of Regulatory Affairs & Accreditation, and the Hospice Nurse Manager attended via phone. The purpose of the survey and the survey needs were explained. An opportunity was provided for questions, answers, and comments. Definitions and abbreviations: CFR - Code of Federal Regulations

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based interview and record review, it was determined the agency was unable to provide evidence that ongoing interdiscplinary assessment of the patient which included all skilled professional staff involved in a patient's plan of care took place by failing to document attendance at interdisciplinary team meetings. Findings: During the entrance conference on 7/26/2021, the agency was asked to provide interdisciplinary team meeting attendance for the prior three months. Documentation of attendance was not provided. During an interview with Employee #2 and Employee #5 on 7/28/2021 beginning at approximately 12:30 PM, Employee #2 stated that interdisciplinary team meetings were being held via remote technology and confirmed the agency was unable to provide documentation of attendance. Employee #2 stated "We can't show you who attended. I can show you the invites, but that doesn't mean they attended."