Every finding on record at Completecare Home Health LLC

Based on record review and interview, the Agency failed to ensure each patient record included clinical notes for 3 of 14 patients (Patients #3, #4, and #9) for which the clinical records were reviewed. This failure has the potential that patients may not receive care according to their Plan of Care and may result in client needs not being met. --- Findings included: Review of the electronic clinical record of Patient #3 revealed a start of care date of 11/09/2022 for a terminal diagnosis of Alcoholic Cirrhosis of Liver without Ascites (Liver disease). Further review of the electronic clinical record of Patient #3 revealed a Skilled Nursing visit was assigned to the LVN with a target date of 05/03/2023. The status of the Skilled Nursing visit read, ";Not started." Review of the electronic clinical record of Patient #4 revealed a start of care date of 01/10/2022 for a terminal diagnosis of Unspecified Sequelae of Unspecified Cerebrovascular Disease (Unspecified symptoms of unspecified circulatory disease). Further review of the electronic clinical record of Patient #4 revealed a Skilled Nursing visit was assigned to the LVN with a target date of 04/27/2023. The status of the Skilled Nursing visit read, ";Not started." Review of the clinical record of Patient #9 revealed a start of care date of 05/01/2023 for a terminal diagnosis of Carcinoma in situ of rectum (Cancer of the rectum). Review of the electronic clinical record of Patient #9 revealed a Skilled Nursing visit was assigned to the LVN with a target date of 05/02/2023. The status of the Skilled Nursing visit read, ";Not started." Further review of the electronic clinical record of Patient #9 revealed a Skilled Nursing visit was assigned to the LVN with a target date of 05/17/2023. The status of the Skilled Nursing visit read, ";Not started." Review of the clinical record of Patient #9 revealed Patient #9 expired on 05/26/2023. Review of the Agencys QAPI manual revealed a QAPI Action Plan, dated 04/20/2023. The QAPI Action Plan read in part, ";Late submission of notes (priority are the nurses notes)....Describe the action taken to improve the process: Multiple notifications sent to involved clinicians through text messages. Clinician involved text back ";ok" but still awaiting for the notes up to current...Frequency of continued monitoring: Bi-weekly." Review of the QAPI Action Plan did not include documentation of continued monitoring. The following page of the QAPI Action Plan read in part, ";Plan of Action: 1. Will hire new full time skilled nurse/clinician. Hospice will budget to improve compliance on notes submission and patient care. 2. Will perform more education/in-service to clinicians on the time frame on the notes submission. 3. To monitor notes weekly. 4. Disciplinary action for continued non-compliance." Further review of the Agencys QAPI manual did not contain documentation of continued monitoring. During an interview conducted with the Administrator/Supervising Nurse on 06/07/2023 at 4:40 PM, Surveyor reviewed the visits listed as ";Not started" for Patient #3 on 05/03/2023 and Patient #4 on 04/27/2023 with the Administrator/Supervising Nurse. The Administrator/Supervising Nurse stated the Alternate Administrator had been following up with the LVN via text message regarding visit notes not completed. The Administrator/Supervising Nurse stated the LVN informed the Alternate Administrator via text message that the LVN had fallen behind on documentation. The Administrator/Supervising Nurse stated that as of last week the LVN had stopped responding to attempts to contact the LVN. The Administrator/Supervising Nurse stated the Agency removed the LVN from further visiting patients effective the week of 05/30/2023. The Administrator/Supervising Nurse was asked if she could provide surveyor with documentation of monitoring of visit notes that were not completed by the LVN. The Administrator/Supervising Nurse stated that she did not have documentation of this. During an interview conducted with the Administrator/Supervising Nurse on 06/09/2023 at 9:20 AM, Surveyor reviewed the visits listed as ";Not started" for Patient #9 on 05/02/2023 and 05/17/2023 with the Administrator/Supervising Nurse. The Administrator/Supervising Nurse stated there was no indication visits that were not documented for Patients #3, #4, and #9 were not conducted as the Agency had not received any phone call or notification from clients questioning on why a nurse had not conducted a visit. The Administrator/Supervising Nurse stated that the RN also conducted visits with these clients and no concerns were reported. Review of the Agencys policy and procedure manual revealed a policy titled ";Timelines," with a revision date of 08/01/2015 which read in part, ";F. All clinical and progress notes will be written the day service is rendered....III. All medical record information will be incorporated into the patients medical record within fourteen (14) business days of providing service." By the time of exit on 06/09/2023 at 11:15 AM, no additional documentation was provided.