Every finding on record at Willamette Community Health Solutions

An unannounced Federal recertification survey was completed at this agency on 11/1/2022. The agency was surveyed for compliance with 42 CFR Conditions of Participation for Home Health Agencies, Part 484. An entrance conference was held with the Home Health Manager and the Director of Clinical Services on 10/24/2022 at 1:08 PM. The purpose of the survey and the survey needs were explained. An opportunity was provided for questions, answers and comments. Definitions and abbreviations: CFR - Code of Federal Regulations

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 interview and medical record review, it was determined the agency failed to ensure the plan of care included a description of the patient's risk for emergency department visits and hospital re-admission for 11 of 12 active patient records reviewed (Patients #1-3 and 5-12). During the entrance conference, the most recent plan of care was requested for each patient in the active patient sample for review. A plan of care for each patient, from the most recent certification period, was presented by Employee #1. Review of the "PLAN OF CARE" for Patients #7, 10 and 12 revealed the box titled "Risk for Hospitalization and Emergency Department Visits" contained only the "Most Recent Hospitalization Date:" for each patient. The information lacked a description of the patient's risk for emergency department visits and hospital re-admission. Review of the "PLAN OF CARE" for Patients #1, 2, 3, 5, 6, 8, 9, and 11 revealed the care plan did not contain any information regarding the patient's risk for emergency department visits and hospital re-admission. The box titled "Risk for Hospitalization and Emergency Department Visits" was absent. During an interview with Employee #1 on 11/1/2022 beginning at 11:00 AM the above findings were presented. Employee #1 acknowledged the findings and stated "I will have to look into that. It used to be that that section was pink in our medical record system, which meant that the clinician had to fill it in. I wonder if an update to our medical record system changed that. I don't know why it fell off there."