Every finding on record at Synergy Medical Services Inc

An unannounced complaint survey for allegations contained within complaint numbers, 2021002255, 2021002262 and 2021002585 was conducted on 2/22/2021 through 2/25/2021 at Synergy Medical Services, LLC. At the time of the survey, the facility was not in compliance with 42 CFR Part 484, Requirements 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 interview and record review the home health agency failed to provide patient care services as indicated in the plan of care for skilled nursing care for 3 of 6 sampled patients, (#2, #4, #5) The findings include: Resident #2 A review of sampled patient #2's Home Health Certification and Plan of Care, for certification period from 1/7/2021 through 3/7/2021, was completed. The Home Health Certification and Plan of Care revealed a physician order for skilled nursing care for assessment of patient with cellulitis of the right upper limb, management of vascular access device, pain in right arm, essential hypertension, long term (current) use of antibiotics, for therapeutic drug level monitoring. The Skilled nurse services were ordered 1 time a week for one week, then 3 times per week for 1 week, then 2 times per week for 1 week then 1 time per week for 6 weeks. A review of the skilled nurse visits for patient #2 revealed the agency did not provide a skilled nurse visit for the two visits ordered for the week of 1/17/21 through 1/23/21. The record review revealed a pending discharge visit scheduled for 2/15/21. The record review failed to reveal documentation of a physician order to change the skilled nurse visit frequency. A review of the patient notes/messages section in Patient #2's medical record revealed a message dated 1/28/21 from staff L, clerk to staff M, authorization clerk, which revealed patient #2 had exceeded the insurance authorized visits but needed more skilled nursing. The note revealed the authorization expired on 1/21/21. A message dated 1/28/21 sent to staff L, revealed that staff M, asked staff N, the former director of nursing, to get the authorization needs and further stated that it was unclear when patient #2 was last seen since staff I, LPN "just got her charting caught up!" Resident #4 A review of sampled patient #4's Home Health Certification and Plan of Care, for certification period from 12/30/20 through 2/27/21, was completed. The Home Health Certification and Plan of Care revealed a physician order for skilled nursing care for assessment of patient with COVID-19, other nonspecific abnormal finding of lung field, localized enlarged lymph nodes, heart disease, type 2 diabetes, obesity. The skilled nurse services were ordered 1 time per week for one week, then 3 times a week for 3 weeks, then 1 time a week for 5 weeks. A review of the record revealed one skilled nurse visit was missing for the week of 1/3/21 through 1/9/21, two visits were missing for the week of 1/10/21 through 1/16/21, and two visits were missing for the week of 1/17/21 through 1/22/21. The record review failed to reveal documentation of a physician order to change the skilled nurse visit frequency. An interview with the Administrator was conducted on 2/24/2021 at approximately 11:20 AM. The Administrator confirmed patient #2 did not receive the ordered visits for the week of 1/17/21 through 1/23/21 and confirmed patient #2 was scheduled for discharge on 2/15/21 which was not completed. The Administrator confirmed patient #4 did not receive the ordered visits for the week of 1/3/21 through 1/9/21 the week of 1/10/21 through 1/16/21, and the week of 1/17/21 through 1/22/21. Resident #5 Record review for sampled patient #5 revealed physician ordered plan for care beginning 1/8/2021 for skilled nurse to change central line dressing every week using sterile technique. The skilled nurse performed dressing change on the central line on 1/12/2021 and no further dressing changes were documented. An interview was conducted with the administrator on 2/24/2021 at approximately 11:40 AM. The administrator confirmed there were no other central line dressing changes documented in the patient record.

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 interviews the home health agency failed to ensure home health services were provided only as ordered by the physician for 2 of 6 sampled patients (#1, #2). The findings include: A review of sampled patient #2's Home Health Certification and Plan of Care, for certification period from 1/7/2021 through 3/7/2021, was completed. The Home Health Certification and Plan of Care revealed a physician order for skilled nursing care for assessment of patient with cellulitis of the right upper limb, encounter for adjustment and management of vascular access device, pain in right arm, essential hypertension, long term (current) use of antibiotics, for therapeutic drug level monitoring. A review of the skilled nurse note dated 1/12/21, signed by staff C, Registered Nurse (RN) revealed the nurse drew labs for a Vancomycin trough through the single lumen Peripherally Inserted Central Catheter (PICC) line in patient #2 left upper arm. A review of the skilled nurse note dated 1/13/21, signed by staff I, Licensed Practical Nurse (LPN) revealed the nurse completed wound care on patient #2 right elbow. A review of the skilled nurse note dated 1/28/21, signed by staff N, RN revealed the nurse completed a PICC line dressing change on patient #2. A review of the record revealed a request for physician order clarification made by staff N, RN on 1/8/21. Staff N, RN requested order clarification for wound care, PICC line dressing change and labs for patient #2. A review of patient #2 medical record failed to reveal a physician order for wound care to the right elbow, for lab draws and for PICC line dressing change. Record review of sampled patient # 1's medical record revealed the skilled nurse performed a Foley catheter change on 2/5/2021. There was no physician order in the medical record for the nurse to change the Foley catheter. An interview with the Administrator on 2/25/2021 at approximately 11:05 AM revealed there were no documented orders in patient #2 medical record for the lab draw, wound care, or PICC line dressing. The interview also revealed that patients #1's record failed to have an physician order for Foley catheter changes.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to notify the physician of missed visits as ordered in the plan of care for 1 of 6 sampled patients (#2). The findings include: A review of sampled patient #2's Home Health Certification and Plan of Care, for certification period from 1/7/2021 through 3/7/2021, was completed. The Skilled nurse services were ordered 1 time a week for one week, then 3 times per week for 1 week, then 2 times per week for 1 week then 1 time per week for 6 weeks. A review of the skilled nurse visits for patient #2 revealed the agency did not provide a skilled nurse visit for the two visits ordered for the week of 1/17/21 through 1/23/21. The record review failed to reveal documentation of physician notification of the missed visits. An interview with the home health agency administrator on 2/24/2021 at approximately 11:20 AM, confirmed patient #2 did not have the ordered visits for the week of 1/17/21 and confirmed the physician was not notified of the missed visits.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interviews the home health agency failed to complete scheduled patient discharges and failed to ensure a discharge summary was sent to the physician within 5 days of discharge for 4 of 6 sampled patients, (#2, #3, #4, #5). The findings include: A review of sampled patient #2's Home Health Certification and Plan of Care, for certification period from 1/7/2021 through 3/7/2021 was completed which revealed the last skilled nurse visit was dated 2/8/2021. A discharge visit was scheduled for 2/15/2021. At the time of the survey, the discharge was not completed, and a discharge summary was not found in patient #2 medical record. A review of sampled patient # 3's Home Health Certification and Plan of Care for certification period from 12/30/20 through 2/27/21 reveled a start of care date of 12/29/20 with an admission assessment completed on 12/30/20. The nurse attempted a visit on 1/8/21, 1/15/21, 1/22/21 and 1/27/21, however patient #3 refused the visits. Record review revealed a discharge visit was scheduled for 1/27/21. The discharge was not completed at the time of the survey, and a discharge summary was not found in patient #3 medical record. A review of sampled patient # 4's Home Health Certification and Plan of Care for certification period from 12/30/20 through 2/27/21 reveled a start of care date of 12/30/20. A skilled visit note dated 1/22/21 by staff E, a Licensed Practical Nurse (LPN) revealed patient #4 was fully recovered and requested to discontinue services. A review of the patient notes/message section of patient #4 medical record revealed a note dated 2/3/21 from staff M, authorization clerk to staff N, Registered Nurse (RN) which stated a discharge should be scheduled no later than 1/30/21. No discharge was noted, and no discharge summary was found in patient #4 medical record. A review of sampled patient #5 medical record revealed an admission date of 1/8/2021. Resident #5 was discharged on 1/28/2021. The medical record of sampled patient #5 did not have a discharge summary. An interview was conducted with the administrator on 2/24/21 at approximately 11:20 AM, who confirmed the discharge was not completed for patient #2 and patient #3 and a discharge summary has not been completed. He confirmed patient #4 was discharged on 2/24/21 and confirmed patient #5 did not have a discharge summary.