Every finding on record at Tar Heel Care Services, LLC

Complaint investigation conducted on 06/09/21 with substantiated findings--standard level deficiency cited. Intake #17452

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to conduct the initial assessment within 48 hours for 1 of 3 patients reviewed (Patient #1) with admissions that occurred greater than 48 hours after referral to the agency. Findings include: Review of the clinical record revealed that Patient #1 was referred to the agency for skilled nursing, home health aide, physical therapy evaluation, occupational therapy evaluation, and medical social worker evaluation services on 11/02/20 with a documented “start” (start of care/admission) date of 11/04/20. Diagnoses included in the referral were congestive heart failure (heart not pumping effectively), dehydration, acute kidney injury, hyponatremia (low sodium), and hypokalemia (low potassium). Review of agency coordination notes dated 11/04/20 revealed “…SOC (start of care) 11.23.2020…” An additional coordination note dated 11/05/20 revealed “SOC > 48 hours. Email from [clinical manager] ‘I told…central intake SOC would be on or before 11/23/20’. There is no evidence in the clinical record of communication with the physician, referral source or patient regarding the use of 11/23/20 for start of care. An interview with the Executive Director, Employee #1, on 06/09/21 at approximately 3:00 PM revealed, “We talk to the case manager at the hospital. When we give them a date, they are to follow up with the patient or the doctor. They would put that on there (the referral) and would let the patient know and make sure that they know that it (the admission date) is going to be that far out.” Employee #1 confirmed there was no evidence that the physician was notified regarding the start of care date being scheduled for 11/23/20.