Every finding on record at Western Health Resources

An unannounced on-site investigation for complaint #71067 was completed on 8/23/2022. The agency was surveyed for compliance with 42 CFR Conditions of Participation for Home Health Agencies, Part 484. The deficiencies identified during the survey follow in this report. The investigation was initiated on-site on 8/17/2022 at 10:55 AM, an entrance conference was held with the agency's Administrative Director of Home Health and the Clinical Manager. The purpose of the survey and the survey needs were explained. An opportunity was provided for questions, answers, and comments. A sample of seven patient records, policies and procedures, log of grievances and complaints for the past 12 months, and patient admission packet were reviewed. Interviews were conducted with the agency Administrative Director of Home Health and the Director of Quality and Risk Education. Definitions and Acronyms: CFR - Code of Federal Regulations # - Number

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 interview and medical record review, it was determined the agency failed to ensure the registered nurse performed an initial assessment visit within 48 hours of referral for 3 of 7 patient records reviewed (Patients #1, #5, and #7). Findings: Patient #1: Review of the medical record revealed a referral date of 7/14/2022. The initial assessment visit was conducted on 7/18/2022, four days after the referral date. During an interview with Employee #1 and Employee #2 on 8/17/2022 at 12:00 PM, Employee #1 stated the late start of care "I am guessing it was because of the weekend." Patient #5: Review of the medical record revealed a referral date of 6/30/2022. The initial start of care date was on 7/19/2022, 19 days after the referral date. During an interview with Employee #1 and Employee #2 on 8/17/2022 at 12:15 PM, Employee #1 stated "I don't know why the delay." No additional documentation was received. Patient #7: Review of the medical record revealed a referral date of 7/19/2022. The initial start of care date was on 7/30/2022, 11 days after the referral date. During an interview with Employee #1 and Employee #2 on 8/17/2022 at 1:07 PM, Employee #1 stated "Don't know why the delay." No additional documentation was received.