Every finding on record at Stat Home Health -West, LLC

This entity is in compliance with federal emergency preparedness requirements.

Recertification Survey Unduplicated Admissions: 4 Total Census: 2

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 written individualized PoC (plan of care) was followed as evidenced by the SN (skilled nurse) failing to provide nurse visits as ordered per the PoC for 1 (#4) out of 4 (#1-4) sampled patients. Patient #4 was admitted to the agency on 12/5/2020 and had diagnoses including Pneumonia, Critical Illness Myopathy, Left Femur Fracture, Hypertension, Diabetes Mellitus, Anemia, History of Falling, Breast Neoplasm, Gastroesophageal Reflux Disease, and History of Urinary Tract Infections. The certification period reviewed was from 2/3/2021 to 4/3/2021. A review of Patient #4’s PoC (Plan of Care) revealed an order for skilled nurse effective 2/7/2021 -1wk1 (skilled nurse visits one time weekly for one week), and 1Q2WK2 (skilled nurse visits every other week for 2 weeks). A review of a skilled nurse visits conducted for Patient #1 during that certification period failed to reveal that a skilled nurse visit had been conducted during the week of 2/7/2021 to 2/13/2021. A review of the electronic medical record, including coordination notes, communication to Patient #4’s physician, and orders failed to reveal that a skilled nurse visit should not have been conducted as ordered starting 2/7/2021. On 1/20/2022 at 12:50PM, an interview was conducted with S1DON. He confirmed that Patient #4’s orders included that a skilled nurse visit was to be conducted once during the week of 2/7/2021. He reviewed the patient’s record and confirmed that no skilled nurse visit had been conducted as ordered and that agency had failed to follow Patient #4’s Plan of Care.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on record and policy and procedure review, and interview, the agency failed to ensure that services were integrated to assure the identification of patient needs and factors that could affect patient treatment and the coordination of care provided by all disciplines for 1 patient when the agency failed to follow up with a MSW (Medical Social Worker) to assess the needs for 1 (#2) out of 4 sampled patients. Patient #2. Review of the patient's electronic clinical records revealed the start of care date was 4/8/2021. The patient's diagnosis included Chronic Obstructive Pulmonary Disease. The certification period reviewed was 12/4/2021 to 2/1/2022. Review of the patient's POC (Plan of Care) for certification period 12/4/2021 to 2/1/2022 revealed an order for "SN effective 12/5/2021 1wk3, 1q2wk6 (skilled nurse visits effective the week of 12/5/2021 one visit one time a week for three weeks, one visit every two weeks for six weeks)." Review of the patient’s Client Coordination Notes Report dated 12/29/2021 revealed, “I lost my daughter. She was suffering. I don’t know what to do now…Patient noted with sad expression…” Review of the patient's skilled nurse visit notes dated 1/6/2022 revealed, "I could really use some help with my daughter passing…” Review of the patient’s skilled nurse visit notes dated 1/18/2022 revealed, “I’m missing my daughter. I thought she was ok. The doctors always did bloodwork. I don’t know how they didn’t find it sooner…” On 1/20/2022 at 11:50 am, an interview was conducted with S2LPN (Licensed Practical Nurse). S2LPN stated that the patient was sad after her daughter died. S2LPN stated that she requested the social worker to assess the patient for further needs. S2LPN stated that she found out that the patient did not see the social worker because the agency did not have a social worker to provide the services. On 1/20/2022 at 12:11 pm, S1DON (Director of Nurses) confirmed that the agency did not have a MSW (Medical Social Worker) and confirmed that the patient did not receive those services. Review of the agency policy and procedure for Coordination of Patient Care revealed, “(Home health agency) must: …Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines….Ensuring that patient needs are continually assessed…”