Every finding on record at Wvuhs Home Care, LLC

A complaint survey was conducted at West Virginia University Health System Home Health from May 19, 2025 to May 21, 2025. It was determined that the facility was not in compliance with the requirements of 42 CFR, Part 482- The Medicare Conditions of Participation for Home Health.

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 medical record reviews, documentation review, policy review and staff interviews the agency failed to ensure that plans of care and physicians’ orders were obtained with physician signatures for forty-six (46) patients out of seventy-nine (79) patients (Patient 1, 3, 5, 13-55). This failure has the potential to affect all patients’ appropriateness and accuracy of delivered services through the agency. Findings: A medical record review was completed for patient #1. Patient #1’s start of care was 3/28/25. The certification period is from 3/28/25 to 5/26/25. The patient receives skilled nursing services at a frequency of one (1) time a week for one (1) week, one (1) time a week for three (3) weeks, physical therapy one (1) time a week for eight (8) weeks, two (2) times a week for eight (8) weeks and occupational therapy one (1) time a week for one (1) week and one (1) time a week for eight (8) weeks. Review of the medical record revealed no physician signed plan of care for services or physician’s order. A medical record review was completed for patient # 3. Patient # 3’s start of care was 2/13/25. The certification period is from 4/14/25 to 6/12/25. The patient receives occupational therapy one (1) time a week for eight (8) weeks. Review of the medical record revealed no physician signed plan of care for services or physician's order. A medical record review was completed for patient #5. Patient #5’s start of care was 5/8/25. The certification period is from 5/8/25 to 7/6/25. The patient receives skilled nursing services at a frequency of two (2) times a week for one (1) week, one (1) time a week for eight (8) weeks and two (2) times a week for eight (8) weeks. Review of the medical record revealed no physician signed plan of care for services or physician's order. A medical record review was completed for patient #13. Patient #13’s start of care was 5/6/25. The certification period is from 5/8/25 to 7/6/25. The patient receives skilled nursing services, physical therapy and occupational therapy with physician ordered frequencies not provided. Review of the medical record revealed no physician signed plan of care for services or physician’s order. A medical record review was completed for patient #14. Patient #14’s start of care was 3/25/25. The certification period is from 3/25/25 to 5/24/25. The patient receives skilled nursing services and physical therapy with physician ordered frequencies not provided. Review of the medical record revealed no physician signed plan of care for services or physician’s order. A medical record review was completed for patient #15. Patient #15’s start of care was 3/05/25. The certification period is from 3/05/25 to 5/05/25. The patient receives skilled nursing services and physical therapy with physician ordered frequencies not provided. Review of the medical record revealed no physician signed plan of care for services or physician’s order. A medical record review was completed for patient #16. Patient #16’s start of care was 5/12/25. The certification period is from 5/12/25 to 7/13/25. The patient receives skilled nursing, occupational therapy and physical therapy with physician ordered frequencies not provided. Review of the medical record revealed no physician signed plan of care for services or physician’s order. A medical record review was completed for patient #17. Patient #17’s start of care was 5/19/25. The certification period is from 5/19/25 to 7/24/25. The patient receives skilled nursing services and physical therapy with physician ordered frequencies not provided. Review of the medical record revealed no physician signed plan of care for services or physician’s order. A medical record review was completed for patient #18. Patient #18’s start of care was 4/17/25. The certification period is from 4/17/25 to 5/21/25. The patient receives skilled nursing services with physician ordered frequencies not provided. Review of the medical record revealed no physician signed plan of care for services or physician’s order. A medical record review was completed for patient #19. Patient #19’s start of care was 1/29/25. The certification period is from 3/29/25 to 5/24/25. The patient receives skilled nursing services with physician ordered frequencies not provided. Review of the medical record revealed no physician signed plan of care for services or physician’s order. A medical record review was completed for patient #20. Patient #20’s start of care was 4/15/25. The certification period is from 4/15/25 to 5/24/25. The patient receives skilled nursing services with physician ordered frequencies not provided. Review of the medical record revealed no physician signed plan of care for services or physician’s orders. A medical record review was completed for patient #21. Patient #21’s start of care was 3/10/25. The certification period is from 3/10/25 to 5/09/25. The patient receives physical therapy and occupational therapy with physician ordered frequencies not provided. Review of the medical record revealed no physician signed plan of care for services or physician’s order. A medical record review was completed for patient #22. Patient #22’s start of care was 4/04/25. The certification period is from 4/04/25 to 6/05/25. The patient receives skilled nursing services and physical therapy with physician ordered frequencies not provided. Review of the medical record revealed no physician signed plan of care for services or physician’s order. A medical record review was completed for patient #23. Patient #23’s start of care was 5/19/25. The certification period is from 5/19/25 to 7/18/25. The patient receives skilled nursing services and physical therapy with physician ordered frequencies not provided. Review of the medical record revealed no physician signed plan of care for services or physician’s order. A medical record review was completed for patient #24. Patient #24’s start of care was 12/05/24. The certification period is from 3/24/25 to 5/24/25. The patient receives skilled nursing services and physical therapy with physician ordered frequencies not provided. Review of the medical record revealed no physician signed plan of care for services or physician’s order. A medical record review was completed for patient #25. Patient #25’s start of care was 4/04/25. The certification period is from 4/04/25 to 6/03/25. The patient receives physical therapy and occupational therapy with physician ordered frequencies not provided. Review of the medical record revealed no physician signed plan of care for services or physician’s order. A medical record review was completed for patient #26. Patient #26’s start of care was 3/24/25. The certification period is from 5/7/25 to 7/6/25. The patient receives skilled nursing services and physical therapy with physician ordered frequencies not provided. Review of the medical record revealed no physician signed plan of care for services or physician’s order. A medical record review was completed for patient #27. Patient #27’s start of care was 4/07/25. The certification period is from 4/07/25 to 6/8/25. The patient receives skilled nursing services with physician ordered frequencies not provided. Review of the medical record revealed no physician signed plan of care for services or physician’s order. A medical record review was completed for patient #28. Patient #28’s start of care was 5/13/25. The certification period is from 5/13/25 to 7/13/25. The patient receives skilled nursing services and physical therapy with physician ordered frequencies not provided. Review of the medical record revealed no physician signed plan of care for services or physician’s order. A medical record review was completed for patient #29. Patient #29’s start of care was 4/09/25. The certification period is from 4/09/25 to 6/10/25. The patient receives skilled nursing services and physical therapy with physician ordered frequencies not provided. Review of the medical record revealed no physician signed plan of care for services or physician’s order. A medical record review was completed for patient #30 Patient #30’s start of care was 4/08/25. The certification period is from 4/08/25 to 6/09/25. The patient receives skilled nursing services, occupational therapy and physical therapy with physician ordered frequencies not provided. Review of the medical record revealed no physician signed plan of care for services or physician’s order. A medical record review was completed for patient #31 Patient #31’s start of care was 4/09/25. The certification period is from 4/09/25 to 6/10/25. The patient receives skilled nursing services and physical therapy with physician ordered frequencies not provided. Review of the medical record revealed no physician signed plan of care for services or physician’s order. A medical record review was completed for patient #32. Patient #32’s start of care was 3/05/25. The certification period is from 3/05/25 to 5/05/25. The patient receives skilled nursing services with physician ordered frequencies not provided. Review of the medical record revealed no physician signed plan of care for services or physician’s order. A medical record review was completed for patient #33. Patient #33’s start of care was 1/31/25. The certification period is from 4/01/25 to 6/30/25. The patient receives skilled nursing services and physical therapy with physician ordered frequencies not provided. Review of the medical record revealed no physician signed plan of care for services or physician’s order. A medical record review was completed for patient #34. Patient #34’s start of care was 4/07/25. The certification period is from 4/0725 to 6/08/25. The patient receives skilled nursing services and physical therapy with physician ordered frequencies not provided. Review of the medical record revealed no physician signed plan of care for services or physician’s order. A medical record review was completed for patient #35. Patient #35’s start of care was 4/28/25. The certification period is from 4/28/25 to 6/28/25. The patient receives skilled nursing services, occupational therapy and physical therapy with physician ordered frequencies not provided. Review of the medical record revealed no physician signed plan of care for services or physician’s order. A medical record review was completed for patient #36. Patient #36’s start of care was 4/07/25. The certification period is from 4/07/25 to 6/07/25. The patient receives skilled nursing services and physical therapy with physician ordered frequencies not provided. Review of the medical record revealed no physician signed plan of care for services or physician’s order. A medical record review was completed for patient #37. Patient #37’s start of care was 4/08/25. The certification period is from 4/08/25 to 6/08/25. The patient receives skilled nursing services, occupational therapy and physical therapy with physician ordered frequencies not provided. Review of the medical record revealed no physician signed plan of care for services or physician’s order. A medical record review was completed for patient #38. Patient #38’s start of care was 3/04/25. The certification period is from 3/04/25 to 5/04/25. The patient receives skilled nursing services with physician ordered frequencies not provided. Review of the medical record revealed no physician signed plan of care for services or physician’s order. A medical record review was completed for patient #39. Patient #39’s start of care was 5/16/25. The certification period is from 5/16/25 to 7/16/25. The patient receives skilled nursing services and physical therapy with physician ordered frequencies not provided. Review of the medical record revealed no physician signed plan of care for services or physician’s order. A medical record review was completed for patient #40. Patient #40’s start of care was 3/11/25. The certification period is from 3/11/25 to 5/16/25. The patient receives skilled nursing services, occupational therapy and physical therapy with physician ordered frequencies not provided. Review of the medical record revealed no physician signed plan of care for services or physician’s order. A medical record review was completed for patient #41. Patient #41’s start of care was 1/27/25. The certification period is from 3/27/25 to 5/27/25. The patient receives skilled nursing services with physician ordered frequencies not provided. Review of the medical record revealed no physician signed plan of care for services or physician’s order. A medical record review was completed for patient #42. Patient #42’s start of care was 2/26/25. The certification period is from 2/26/25 to 5/24/25. The patient receives skilled nursing services and physical therapy with physician ordered frequencies not provided. Review of the medical record revealed no physician signed plan of care for services or physician’s order. A medical record review was completed for patient #43. Patient #43’s start of care was 4/01/25. The certification period is from 4/03/25 to 6/04/25. The patient receives skilled nursing services and physical therapy with physician ordered frequencies not provided. Review of the medical record revealed no physician signed plan of care for services or physician’s order. A medical record review was completed for patient #44. Patient #44’s start of care was 4/08/25. The certification period is from 4/08/25 to 6/09/25. The patient receives skilled nursing services and physical therapy with physician ordered frequencies not provided. Review of the medical record revealed no physician signed plan of care for services or physician’s order. A medical record review was completed for patient #45. Patient #45’s start of care was 1/29/25. The certification period is from 3/30/25 to 5/29/25. The patient receives skilled nursing services, occupational therapy and physical therapy with physician ordered frequencies not provided. Review of the medical record revealed no physician signed plan of care for services or physician’s order. A medical record review was completed for patient #46. Patient #46’s start of care was 3/31/25. The certification period is from 4/01/25 to 6/30/25. The patient receives skilled nursing services, occupational therapy and physical therapy with physician ordered frequencies not provided. Review of the medical record revealed no physician signed plan of care for services or physician’s order. A medical record review was completed for patient #47. Patient #47’s start of care was 3/11/25. The certification period is from 3/11/25 to 5/11/25. The patient receives skilled nursing services and physical therapy with physician ordered frequencies not provided. Review of the medical record revealed no physician signed plan of care for services or physician’s order. A medical record review was completed for patient #48. Patient #48’s start of care was 3/31/25. The certification period is from 4/0125 to 6/30/25. The patient receives skilled nursing services with physician ordered frequencies not provided. Review of the medical record revealed no physician signed plan of care for services or physician’s order. A medical record review was completed for patient #49. Patient #49’s start of care was 4/09/25. The certification period is from 4/09/25 to 6/10/25. The patient receives skilled nursing services, occupational therapy and physical therapy with physician ordered frequencies not provided. Review of the medical record revealed no physician signed plan of care for services or physician’s order. A medical record review was completed for patient #50. Patient #50’s start of care was 3/25/25. The certification period is from 3/25/25 to 5/24/25. The patient receives skilled nursing services, occupational therapy and physical therapy with physician ordered frequencies not provided. Review of the medical record revealed no physician signed plan of care for services or physician’s order. A medical record review was completed for patient #51. Patient #51’s start of care was 4/10/25. The certification period is from 4/10/25 to 6/10/25. The patient receives skilled nursing services, occupational therapy and physical therapy with physician ordered frequencies not provided. Review of the medical record revealed no physician signed plan of care for services or physician’s order. A medical record review was completed for patient #52. Patient #52’s start of care was 3/24/25. The certification period is from 3/24/25 to 5/24/25. The patient receives occupational therapy and physical therapy with physician ordered frequencies not provided. Review of the medical record revealed no physician signed plan of care for services or physician’s order. A medical record review was completed for patient #53. Patient #53’s start of care was 4/03/25. The certification period is from 4/03/25 to 6/04/25. The patient receives occupational therapy and physical therapy with physician ordered frequencies not provided. Review of the medical record revealed no physician signed plan of care for services or physician’s order. A medical record review was completed for patient #54. Patient #54’s start of care was 3/26/25. The certification period is from 3/26/25 to 5/26/25. The patient receives occupational therapy and physical therapy with physician ordered frequencies not provided. Review of the medical record revealed no physician signed plan of care for services or physician’s order. A medical record review was completed for patient #55. Patient #55’s start of care was 3/26/25. The certification period is from 3/26/25 to 5/26/25. The patient receives occupational therapy and physical therapy with physician ordered frequencies not provided. Review of the medical record revealed no physician signed plan of care for services or physician’s order. A review of a document and attached plans of care provided by the agency revealed that there were thirty-three (33) signed plans of care and physicians’ orders for patients. A review of seventy-nine referrals was completed. A review of all patients plans of care was completed and revealed that there was no evidence of signed plans of care or physicians’ orders for forty-six (46) patients. There was no form of verification that the forty-six (46) patients without signed plans of care were receiving appropriate and accurate services. A policy titled, “PLAN OF TREATMENT/CARE PLAN 485,” last reviewed 3/26/24 was reviewed. The policy states in part, “POLICY: A written, comprehensive, individualized plan of care is established for each patient under home health care. The plan of care will be reviewed and revised as required by the needs of the patient and in compliance with law and regulations, at least every 60 days. The responsibility for revision of the plan of care is assigned to the interdisciplinary team with input from the patient and physicians or allowed. Practitioners involved in the patient care. PURPOSE: To develop a written, individualized plan of care for each home health patient. PROCEDURE: The individual last plan of care is developed within 48 hours upon admission by the clinician, under orders of the attending physician or allowed practitioner and may include, but is not limited to, the following information…. Physician or allowed practitioner name, signature, and certification of home health…” A policy titled, “ASSURING TIMELY SIGNATURES ON CHART DOCUMENTS,” last revised 4/11/23 was reviewed. The policy states in part, “Policy: All orders requiring signature will be obtained timely, within 30 (thirty) days or less. PURPOSE: To provide a standardized process to send and receive signed orders timely. A. Order Procedure: 1. When orders are created, they are automatically sent to EPIC providers. For non EPIC providers, the employee who is responsible will send the orders via the provider’s preferred method, i.e. fax or mail. 2. The employee who is responsible for obtaining signed orders, will monitor the work queue to determine any orders that have not been received as signed. 3. When an order is received (faxed or mailed back) it is checked for appropriate signature and date and scanned into the patient's EMR [electronic medical record]. 4. If the order is signed and dated within 30 days or less, it is marked as received in EPIC. 5. Daily, the record report is checked. 6. For orders that are not signed by 15 days, the employee who is responsible for obtaining signed orders will reach out to the physician or allowed practitioners office to determine the issue. If having barriers with receiving receive signatures, the orders need to note that it is the second or third attempt. 7. For orders that have been faxed twice and still remain out, the physician or allowed practitioners office is called to confirm receipt of the order and that a good fax number has been used. A note of the communication is written on the confirmation sheet for reference to the status of the order. Plan of Care Procedure: 1. The Plan of Care [POC]goes through all approved paths prior to distribution for signature. 2. For EPIC providers, the POC is automatically sent to the provider when signed off. 3. For non-EPIC providers, the POC is sent via the provider’s preferred means, i.e. by fax or mail. 4. When received POC is noted in EPIC report system as received and the POC is scanned into the patient’s EMR. 5. For POC's that are not signed by 15 days, the employee who is responsible for obtaining signed orders will reach out to the physician or allowed practitioner’s office to determine the issue. C. A summary report is provided to the manager no less than weekly to review regulatory compliance. 1. The report contains any POC's and orders that are 30 days out or older still needing signature along with comments as to what has been tried to get orders returned. D. Each working day the routine labs are faxed to the non EPIC physician or allowed practitioner of record. Critical results are given to the employee responsible for documentation of how the labs were handled by the call nurse prior to faxing. A policy titled, “Board of Managers” dated 1/1/24 and revised 11/21/2024 was reviewed. The policy states in part, “Purpose: To provide for governance and authority in the management of WVUHS [West Virginia United Health System] Home Care. Policy: The business of WVUHS Home Care is managed by its Board of Managers which has ultimate responsibility and legal authority of WVUHS Home Care. WVUHS Home Care must be administered in a manner that enables it to use its resources effectively and efficiently. Duties of the Governing Body include the following:…7. Monitor Agency organizational effects to identify and address patient concerns. 8. Adopt, approve and at least review annually and as necessary, new or revised operating agreement, mission statement, personnel policies, and patient care policies and procedures consistent with organizational philosophy and mission/purpose. 9. Develop and approve the Strategic Plan. 10. Oversee the management and fiscal affairs of the WVUHS Home Care. 11. Assume full legal authority, responsibility, and countability for WVUHS Home Care Operations…” An interview was conducted on May 20, 2025, at 10:30 a.m. with staff #3. Staff #3 stated, “The Joint Commission had been in and not having signed orders was a big part of the plan of correction. We were not aware that it was a huge problem. We have come up with a plan of correction and we have already started correcting it. We have started making sure we have signed orders and plan of care for the patients that have come into service since it was brought to our attention. I’m not sure who is ultimately responsible for ensuring this type of thing doesn’t happen. It started with managers, but I was looking at the governing body. All we want to do is correct issues and do better. I was looking at having a medical director so this type of thing can’t happen.” An interview was conducted on May 20, 2025, at 11:07 a.m. with staff #1. Staff #1 stated, “We send out the care plans and orders for signatures just like were supposed to. But what are we supposed to do when they don’t get returned? We have faxed, called and even resent care plans. The doctors don’t get back to us. We are all aware that there is a problem with the system, but no one has come up with a solution. I don’t know how it got this bad, but we do have some of them back now. Yes, there was a problem with coding and getting the care plan orders signed but they have been working on it. We provide care to our patients. Well, we do what they tell us, no I guess we don’t have verification, but the patients are taken care of. It was also a part of the corrections we have to do. The previous manager was aware of the issue. I don’t know what [he/she] did about it. Cert periods are for sixty [60] days unless otherwise specified. We have some information but no we don’t have orders from the doctor. I don’t know how we can make the doctors sign them and get them back to us.” An interview was conducted on May 21,2025, at 9:45 a.m. with staff #2. Staff #2 stated, “We have started to correct the issues with the care plans and getting signed physician’s orders. I can show you a chart I started and that there have been corrections made. I do concur that there are forty-six [46] patients that don’t have signed plans of care or physicians’ orders.”

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on medical record review, document review, policy and staff interviews, the governing body failed to provide appropriate oversight and ensure proper compliance with the conditions of participation. This failure has the potential to affect all patients receiving services. A total of ten (10) medical records, eighty (80) referrals and thirty-three (33) plans of care were reviewed. It was determined that forty-six (46) out of seventy-nine (79) patients did not have signed physician orders or a physician signed plan of care. A policy titled, “Governance Policy,” dated 11/06/03 and last revised on 11/19/17 was reviewed. The policy states in part, “… Policy. The Directors’ Role. The Board of Directors is responsible for the operation of WVUHS [West Virginia United Health System]; all corporate authority and affairs are to be managed by or under the direction of the Board of Directors. The directors are not obligated to manage the day-to-day affairs of WVUHS and may delegate the function to others, but must exercise reasonable and prudent oversight with respect to corporate officers, agents, employees to whom such affairs are delegated. In the performance of its duties, members of the Board of Directors may act in reliance on information and reports received from senior management as well as professional advisors and consultants whom the Board of Directors regard as reliable and competent with respect to the subject matter at issue. Manner of Governing. The Board of Directors will exercise its governance obligations in a manner that emphasizes: external vision rather than an internal preoccupation; encouragement of diversity in viewpoints; strategic leadership as well as administrative detail; clear distinction of Board and (management) roles; collective and not individual decisions; future rather than past; and proactivity rather than reactivity. More specifically, the board will: a. Operate in all ways mindful of its legal obligation to administer and govern WVUHS solely in the interest of the persons intended to benefit from the purposes expressed in the Articles of the Incorporation. It will allow no officer, individual or committee of the Board to hinder or be an excuse for not fulfilling this commitment. b. Enforcement upon itself whatever discipline is needed to govern with excellence. Discipline will apply to matters such as attendance, policymaking principles, respect of roles, preparedness, and ensuring the continuity of governance capability…” A review of annual meeting minutes for the Board of Directors was reviewed. There is no mention of issues with not getting signatures on plans of care or physician orders. An interview was conducted on May 20, 2025, with staff #3. Staff #3 stated, “I’m not sure who is ultimately responsible for ensuring this type of thing doesn’t happen. It started with managers, but I was looking at the governing body. All we want to do is correct issues and do better. I was looking at having a medical director so this type of thing can’t happen.” The Chief Executive Officer (CEO) was not available for interview.

A complaint investigation survey was conducted at WVUHS Home Care (Kearneysville Branch) from 06/21/21 through 06/22/21. The active census at the time of survey was one hundred sixty (160) with an unduplicated census for the past twelve (12) months of six hundred twenty-one (621). Thirteen (13) open and closed medical records were reviewed. The complaint was substantiated with one (1) Condition cited at G 510 and two (2) standard level deficiencies cited G 512 and G 514. As a result of the Condition level deficiency, this agency will not be permitted to complete home health aide training or competency evaluations for two (2) years as per regulation 42 CFR 484.80(f)(3).

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: Based on record review, document review, and staff interview it was determined the facility failed to ensure the initial assessment was conducted within forty-eight (48) hours of the referral to the agency in four (4) out of thirteen (13) records reviewed (patients #1, 2, 6, and 7). This failure has the potential to result in harm to any patient referred to the agency for care (See Tags G 512 and G 514).

Standard: Initial assessment visit. CFR(s): 484.55(a) Standard: Initial assessment visit. This STANDARD is not met as evidenced by: Based on record review, document review, and staff interview it was determined the facility failed to ensure the initial assessment was conducted within forty-eight (48) hours of the referral to the agency in four (4) out of thirteen (13) patients (patients #1, 2, 6, and 7). This failure has the potential to negatively affect all patients receiving services from the agency. Findings include: 1. A review was conducted of the medical record of patient #1. A referral was received by the agency on 01/05/21. The initial assessment was conducted on 01/10/21. There is no documentation of why there was a delay, a discussion with the physician about the delay, or if the patient was in agreement with the delay. 2. A review was conducted of the medical record of patient #2. A referral was received by the agency on 01/05/21. The initial assessment was conducted on 01/08/21. There is no documentation of why there was a delay, a discussion with the physician about the delay, or if the patient was in agreement with the delay. 3. A review was conducted of the medical record of patient #6. A referral was received by the agency on 01/15/21. The initial assessment was conducted on 01/18/21. There is no documentation of why there was a delay, a discussion with the physician about the delay, or if the patient was in agreement with the delay. 4. A review was conducted of the medical record of patient #7. A referral was received by the agency on 05/29/21. The initial assessment was conducted on 06/03/21. There is no documentation of why there was a delay, a discussion with the physician about the delay, or if the patient was in agreement with the delay. 5. A policy titled "Home Health Admission Policy," effective date 01/01/21, was reviewed. The policy states in part: "B. Admissions Process: ...2. The admitting clinician will respond to referral within 2 (two) days of request for services unless stated otherwise by MD (Medical Doctor)/family ... During times of unpredictable weather or high census, the physician is made aware of care delivery delay and patients may still be admitted to service based on physician and patient decision to do so." 6. An interview was conducted with the Case Manager on 06/22/21 at 8:50 a.m. She concurred for patient #1 there was no documentation of why there was a delay, a discussion with the physician about the delay, or if the patient was in agreement with the delay. 7. An interview was conducted with the Case Manager on 06/22/21 at 11:50 a.m. She concurred for patient #7 there was no documentation of why there was a delay, a discussion with the physician about the delay, or if the patient was in agreement with the delay. 8. An interview was conducted with the Case Manager on 06/22/21 at 2:00 p.m. She concurred for patients #2 and 6 there was no documentation of why there was a delay, a discussion with the physician about the delay, or if the patients were in agreement with the delay.

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 record review, document review, and staff interview it was determined the facility failed to ensure a registered nurse conducted an initial assessment within forty-eight (48) hours of the referral to the agency in four (4) out of thirteen (13) patients (patients #1, 2, 6, and 7). This failure has the potential to negatively affect all patients receiving services from the agency. Findings include: 1. A review was conducted of the medical record of patient #1. A referral was received by the agency on 01/05/21. The initial assessment was conducted on 01/10/21. There is no documentation of why there was a delay, a discussion with the physician about the delay, or if the patient was in agreement with the delay. 2. A review was conducted of the medical record of patient #2. A referral was received by the agency on 01/05/21. The initial assessment was conducted on 01/08/21. There is no documentation of why there was a delay, a discussion with the physician about the delay, or if the patient was in agreement with the delay. 3. A review was conducted of the medical record of patient #6. A referral was received by the agency on 01/15/21. The initial assessment was conducted on 01/18/21. There is no documentation of why there was a delay, a discussion with the physician about the delay, or if the patient was in agreement with the delay. 4. A review was conducted of the medical record of patient #7. A referral was received by the agency on 05/29/21. The initial assessment was conducted on 06/03/21. There is no documentation of why there was a delay, a discussion with the physician about the delay, or if the patient was in agreement with the delay. 5. A policy titled "Home Health Admission Policy," effective date 01/01/21, was reviewed. The policy states in part: "B. Admissions Process: ...2. The admitting clinician will respond to referral within 2 (two) days of request for services unless stated otherwise by MD (Medical Doctor)/family ... During times of unpredictable weather or high census, the physician is made aware of care delivery delay and patients may still be admitted to service based on physician and patient decision to do so." 6. An interview was conducted with the Case Manager on 06/22/21 at 8:50 a.m. She concurred for patient #1 there was no documentation of why there was a delay, a discussion with the physician about the delay, or if the patient was in agreement with the delay. 7. An interview was conducted with the Case Manager on 06/22/21 at 11:50 a.m. She concurred for patient #7 there was no documentation of why there was a delay, a discussion with the physician about the delay, or if the patient was in agreement with the delay. 8. An interview was conducted with the Case Manager on 06/22/21 at 2:00 p.m. She concurred for patients #2 and 6 there was no documentation of why there was a delay, a discussion with the physician about the delay, or if the patients were in agreement with the delay.