Every finding on record at The Palace at Home

A complaint survey for complaint number 2021005568 was conducted on April 27, 2021 at The Palace At Home. The Home Health Agency was not in compliance with Code of Federal Regulations (CFR) 42, Part 484, Requirements for Home Health Agencies.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on record review and interview, the Home Health Agency failed to document: the frequencies of the visits to be conducted for 4 out of 4 Sampled Patients (SP). SP#1, SP#2, SP#3, and SP#4; all the disciplines that will furnish the care for 2 out 4 Sampled Patients (SP). SP#2 and SP#4 Clinical record review conducted on 04/27/21 revealed SP#3 was admitted to service on 04/08/21 revealed titled documentation "Consent/Authorization & Release Form" under section "Client Liability for Payment" omitted the frequency of visits from the disciplines Skilled Nurse, Physical Therapy and Home Health Aide providing care to SP#3. Clinical record review conducted on 04/27/21 revealed SP#4 was admitted to service on 02/20/21 revealed titled documentation "Consent/Authorization & Release Form" under section "Client Liability for Payment" omitted the documentation of the disciplines that will furnish the care and the frequency of the visits for SP#4. Interview conducted with Administrator and Director of Nursing on 04/27/21 at 1:23 pm. The Administrator and Director of Nursing reviewed documentation for SP#3 and SP#4. The Director of Nursing acknowledged that the consent form for SP#3 and SP#4 have incomplete documentation to demonstrate the provider advised the patient of the disciplines and frequencies at the time of the the admission. The Administrator added that they provide an additional form for the documentation of the disciplines and their frequencies that is left at the patient's home. The Administrator stated that they do not have a copy of the form in the patient's clinical record. Review of SP#1's record revealed he was admitted on 11/16/2020. Further record review revealed a form titled "Consent/Authorization & Release Form." Additional review of the section "Client Liability for Payment" revealed it did not contain the frequencies of the Skilled Nursing (SN) and Home Health Aide (HHA) services to be provided to the patient. Review of SP#2's record revealed she was admitted on 03/15/2021. Further record review revealed the patient is receiving Skilled Nursing (SN), Physical Therapy (PT) and Home Health Aide (HHA) services. Additional record review revealed a form titled "Consent/Authorization & Release Form." Further review of the section titled "Client Liability for Payment" revealed the agency did not list HHA as one of the disciplines and it did not include the frequencies of the SN and PT services to be provided. During an interview conducted on 04/27/2021 at 1:37 PM, the Director of Nursing and the Administrator reviewed SP#1 and SP#2's records and acknowledged the above findings. The Administrator stated that the agency leaves a form which contain the disciplines and the frequencies of the services at the patients' residences, but it is not kept in the patients' files.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the Home Health Agency failed to include in 3 out of 4 Sampled Patients (SP)' Plans of Care (POC) the interventions and the goals for the Home Health Aide (HHA). SP#1, SP#2 and SP#3 Clinical record review conducted on 04/27/21 revealed SP#3 was admitted to service on 04/08/21. The Plan of Care for certification period 04/08/21 to 06/06/21 revealed the patient is receiving Skilled Nurse, Physical Therapy and Home Health Aide. Further review of the Plan of Care revealed it omitted the interventions and goals for the service of Home Health Aide. Interview conducted with Administrator and Director of Nursing on 04/27/21 at 1:23 pm. The Administrator and Director of Nursing reviewed documentation for SP#3. The Director of Nursing acknowledged that the Plan of Care did not contain the documentation of the Home Health Aide's intervention and goals. Review of SP#1's record revealed he was admitted on 11/16/2020 to receive Skilled Nursing (SN) and Home Health Aide (HHA) services. Further review of SP#1's POC for the certification period of 11/16/2020 to 01/14/2021 revealed it did not contain the interventions and goals for the HHA services. Review of SP#2's record revealed she was admitted on 03/15/2021 to receive SN, Physical Therapy (PT) and HHA. Further review of SP#2's POC for the certification period of 03/15/2021 to 05/13/2021 revealed it did not contain the interventions and goals for the HHA services. During an interview conducted on 04/27/2021 at 1:24 PM, the Administrator and the Director of Nursing acknowledged that SP#1 and SP#2's POCs did not contain interventions and goals for the HHA services.