Every finding on record at Stat Home Health North, LLC

The entity is in compliance with the federal emergency preparedness requirements.

Recertification Survey

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 the agency failed to ensure the patient's wriitten individualized plan of care was followed as evidenced by failure to have been evaluated by the Physical Therapist as ordered by the plan of care for 1 (#4) of 7(#2,#3,#4,#6,#7,#8,#12) patients reviewed with orders for therapy. Findings: Review of the medical record for patient #4 revealed a start of care date of 04/02/2024 with a diagnosis of heart and kidney failure. Further review of the plan of care revealed an order for a Physical Therapy evaluation to be completed the week of 04/07/2024. Review of the medical record on 04/24/2024 revealed the paient had not been seen by the physical therapist for the evaluation. During a home visit with patient #4 on 04/25/2024 at 10:00 a.m confirmed the physical therapist has not been to see the patient to do an evaluation and he would like to recieve therapy. Interview on 04/25/2024 at 9:30 a.m. with S1Administrator confirmed patient #4 has not been evaluated for physical therapy and should have been evaluated the week of 04/07/2024.

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on personnel record review and interview the provider failed to ensure the Licensed Practical Nurse(LPN) was supervised by the Registered Nurse (RN) in the care that was provided to the patients for 2 of 2 (#2,#3) LPNs that work for the provider. Findings: Review of the personel record for S2LPN revealed a hire date of 06/09/21. Further review revealed S2LPN had not had a supervisory visit made by the Registered Nurse since 6/28/2023. Interview on 04/25/2024 at 1:25 p.m.with S1Administrator/Director of Nurses confirmed S2LPN had not had a supervisory visit made since 06/28/2023 and should have had one completed by a Registered Nurse while provideing care to the patients in January 2024. Review of the personal record for S3LPN revealed a hire date of 06/09/2023. Further review revealed S3LPN had no documentation a supervisory visit was made by the Registered Nurse since she had been hired. Interview on 4/25/2024 at 1:25 p.m. with S1Administrator/Director of Nurses confirmed S3LPN had not had a supervisory visit made since she had been hired and should have had one completed by a Registered Nurse while provideing care to the patients in January 2024.

Recertification Survey

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 reviews and interviews, the Home Health agency failed to ensure the Consumer's individualized POC (Plan of Care) was followed as evidence by, 1. The agency failed to provide recorded evidence of a MSW (Medical Social Worker) visit for Consumers #6 and #12 and 2. The agency failed to provide recorded evidence of a PT (Physical Therapy) visit for Consumers #10 and #14. Findings: 1. Consumer #6 Review of the electronic health records for Consumer #6 revealed she was admitted to the home health agency on 05/13/2021 with diagnoses including hypertensive emergency, hypertensive heart disease with heart failure, acute on chronic systolic (congestive) heart failure, arteriosclerosis heart disease of native coronary artery with unspecified, angina pectoris, unspecified anxiety disorder, dehydration, unspecified atrial fibrillation, dilated cardiomyopathy, low back pain, other chronic pain, periodontosis, morbid (severe) obesity due to excess calories, generalized abdominal pain, presence of aortocoronary bypass graft, long term (current) use of anticoagulants, and long term (current) use of antithrombotics/anti-platelets. Review of the Consumer #6's POC revealed a start of care date of 05/13/2021. Review of the certification period dated 05/13/2021 to 07/11/2021 revealed the following physician order: MSW effective 05/30/2021; 1 time a week for 1 week. Further review revealed Medical Social Services for evaluation to assess social and emotional factors related to the patient's illness, need for care, response to treatment and adjustment to care; to be followed by collaboration with the physician and nurse to develop a plan of care. Review of the electronic health records for Consumer #6 revealed there was no recorded evidence of a MSW visit being conducted by the effective date of 05/30/2021 as ordered. On 06/16/2021 at 10:37AM an interview with S2DON (Director of Nursing) was conducted and she was notified of the findings. After reviewing electronic health records with S2DON, she reported that Consumer #6 did have a physician order for a MSW visit with an effective date of 05/30/2021. She further reviewed the electronic health records calendar for any scheduling of a MSW visit. She reported she noted a MSW visit in green which indicated that the visit was scheduled, but not completed and she would have to further investigate as to why the visit had not been completed. On 06/16/2021 at 11:07AM, further interview was conducted with S2DON. She reported that the MSW visit was scheduled for the date of 05/30/2021, but the MSW was locked out her tablet on 06/01/2021 due to the employee's Relias training not being completed and did not receive the physician's order for the visit. She further reported the MSW would be locked out of the tablet until the training courses were completed. On 06/16/2021 at 1:18PM after S2DON had completed her investigation, she confirmed the MSW visit was a missed visit, the physician had not been notified of the missed visit, and there was no recorded evidence of Consumer #6 refusing a MSW visit. She confirmed the MSW visit had not been conducted in accordance with Consumer #6's written plan of care. On 06/16/2021 at 3:00PM S1Administrator was notified of the findings. Consumer #12 Review of the electronic health records for Consumer #12 revealed the consumer was admitted to the home health agency on 05/05/2021 with diagnoses including type 2 diabetes mellitus with hyperglycemia, essential (primary) hypertension, unspecified protein-calorie malnutrition, hyperlipidemia, unspecified, other specified disorders of brain, other nonspecific abnormal finding of lung field, cystocele, encounter for fitting and adjustment of other devices, unspecified osteoarthritis, unspecified site, localized swelling, mass and lump, unspecified, long term (current) use of oral hypoglycemic drugs, and long term (current) use of oral hypoglycemic drugs. Review of Consumer #12's POC revealed a start of care date of 05/05/2021. Review of the certification period dated 05/05/2021 to 07/03/2021 revealed the following physician order: MSW effective 05/09/2021; 1 time a week for 1 week. Further review revealed Medical Social Services for evaluation to assess social and emotional factors related to the patient's illness, need for care, response to treatment and adjustment to care; to be followed by collaboration with the physician and nurse to develop a plan of care. Review of the electronic health records for Consumer #12 revealed there was no recorded evidence of a MSW visit being conducted by the effective date of 05/09/2021 as ordered. On 06/16/2021 at 10:37AM an interview with S2DON was conducted and she was notified of the findings. After reviewing electronic health records with S2DON, she reported that Consumer #12 did have a physician order for a MSW visit with an effective date of 05/09/2021. She further reviewed the electronic health records calendar for any scheduling a MSW visit. After reviewing the electronic health records with S2DON, she confirmed the MSW visit was a missed visit. S2DON reported that she would have to further investigate as to why the visit had been missed. On 06/16/2021 at 3:00PM after S2DON had completed her investigation, an interview with the DON was conducted and reported the MSW visit was scheduled for the date of 05/09/2021, but the MSW was locked out her computer tablet due to the employee's Relias training not being completed and did not receive the physician's order for the visit. She further reported the MSW would be locked out of the tablet until the training courses were completed. S2DON confirmed the MSW visit was a missed visit, the physician had not been notified of the missed visit, and there was not recorded evidence of Consumer #12 refusing a MSW visit. She further confirmed the MSW visit had not been conducted in accordance with Consumer #12's written plan of care. S1Administrator was present and he was notified of the findings. 2. Consumer #10 Review of the electronic health records for Consumer #10 revealed she was admitted to the home health agency on 04/26/2021 with diagnoses including Parkinson's disease, repeated falls, and other long term (current) drug therapy. Review of the Consumer #10's POC revealed a start of care date of 04/26/2021. Review of the certification period dated 04/26/2021 to 06/24/2021 revealed the following physician order: PT (Physical Therapy) 2 times a week for 8 weeks, then 1 time a week for 1 week. Further review revealed Consumer #10 had an encounter with the physician on 04/21/2021. The consumer was seen in the clinic for falls with diagnoses including Parkinson. Documentation revealed Consumer #10 had a knowledge deficits related to self-care, medications, and diagnoses. Documentation revealed therapy for strengthening and to improve mobility. Further review revealed Consumer #10 was home bound related to shortness of breath, difficulty transferring, ambulation difficulties, and frequent falls. Review of the electronic health records for Consumer #10 revealed documentation of a missed PT visit on the date of 04/28/2021. Further review revealed there was no other PT visit recorded during the week of 04/23/2021 through 04/29/2021. On 06/16/2021 at 10:20AM an interview with S2DON was conducted and she was notified of the findings. After reviewing the electronic health record with S2DON she confirmed there was no recorded PT visit during the week of 04/23/2021 through 04/29/2021 except for the missed visit on 04/28/2021. She reported there had not been a recorded frequency change for the missed visit and no recorded evidence of Consumer #10 refusing a PT visit. S2DON further reported that she would have to further investigate. On 06/6/2021 at 11:11AM an interview with S2DON was conducted and she reported that the PT that was originally scheduled to see Consumer #10 was on vacation during the week of 04/23/2020 through 04/29/2021 and the PT visit had been reassigned to another therapist, but there was no recorded evidence of the visit being conducted. S2DON confirmed that Consumer #10 had not received her physical therapy visits in accordance with the consumer's written plan of care. On 06/16/2021 at 3:00PM S1Administrator was notified of the findings. Consumer #14 Review of the electronic health records for Consumer #14 revealed she was admitted to the home health agency on 03/03/2021 with diagnoses including dislocation of right ankle joint, subsequent encounter, dislocation of left ankle joint, subsequent encounter, long term (current) use of anticoagulants, and person injured in unspecified motor-vehicle accident, non-traffic, subsequent. Review of the Consumer #14's POC revealed a start of care date of 03/03/2021. Review of the certification period dated 03/03/2021 to 05/01/2021 revealed the following physician order: PT (Physical Therapy) 2 times a week for 1week, then 3 times a week for 5 weeks. Review of the electronic health records for Consumer #14 revealed documentation of a missed PT visit on the date of 04/28/2021. Review of the week of 03/28/2021 through 04/03/2021 revealed therapy visits were recorded for the dates of 03/29/2021 and 04/02/2021. There was no recorded evidence of Consumer #14 receiving a total of three therapy visits for the week as per the consumer's plan of care. On 06/16/2021 at 10:31AM an interview with S2DON was conducted and she was notified of the findings. After reviewing Consumers #14's electronic health record with S2DON, she confirmed there was no order change for PT frequency, no recorded evidence of a missed visit and physician notification of the missed visit. S2DON reported that sometimes the PT staff would record the visits on paper and she would have to further investigate. On 06/16/2021 at 11:09AM an interview with S2DON was conducted and she confirmed there was no paper visits for the week of 03/28/2021 through 04/03/2021. She further confirmed there was a missed visit, there was no recorded evidence of physician notification of the missed visit, and there was no recorded evidence of Consumer #14 refusing a PT visit. S2DON confirmed Consumer #14 had not received PT visits in accordance with the consumer's written plan of care. On 06/16/2021 at 3:00PM S1Administrator was notified of the findings.