Elite Home Health

“Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) (i) Investigate complaints made by a patient, the patient’s representative (if any), and the patient’s caregivers and family, including, but not limited to, the following topics: This Element is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to thoroughly investigate complaints in a timely manner for 1 (#10) of 10 (#1-#10) clinical records reviewed This deficit had the potential to affect all patients currently on census. Findings include: 1. Review of clinical record #10 with a start of care date of 10/05/23 revealed a patient with a diagnosis of Sepsis Unspecified Organism. A document titled “Complaint Report” and dated 12/06/23 revealed the agency received a complaint from the patient’s son. States the patient requested the urinalysis on 11/16/23 because she was known to become septic from urinary tract infection. Reports they called the agency 2 days later about the urinalysis results. Reports the results were not sent to the patient or her Primary Care Physician. Reports patient had urinalysis done at physician’s office and prescribed oral antibiotics. Informed agency he would be filing complaint with state and patient’s insurance. Agency documented interventions “LISTENED TO CARE GIVERS CONCERNS”. Agency staff documented update 12/08/23 “ATTEMPTED TO CALL WITH NO ASNSWER”. Complaint processed 12/08/2023. There was no evidence the agency conducted an investigation, did a clinical record review or complaint log documentation. 2. During an interview on 12/21/23 at 2:30 PM, Agency Personnel #1 confirmed complaint processed but not investigated prior to patient’s discharge from the agency. Reports complaint currently being investigated and additional information to be added to the complaint report.”

“Coordinate patient care CFR(s): 484.105(c)(2) Coordinating patient care, This Element is not met as evidenced by: Based on clinical record review and staff interview, the Agency failed to communicate with the laboratory, physician or patient to ensure coordination of patient care in 1 (#10) of 3 (#5, #8, & #10) clinical records reviewed with orders for laboratory testing. This deficit had the potential to affect all patients currently on census. Findings include: 1. Review of clinical record #10 with a start of care date of 10/05/23 revealed a patient with a diagnosis of Sepsis Unspecified Organism. On a document titled “VISIT NOTE REPORT” and dated 11/17/2023 the skilled nurse documented “OBTAINED UA (urinalysis) AS ORDERED. SPECIMEN DROPPED OFF AT ELITE HOME HEALTH JONESBORO OFFICE”. On a document titled “VISIT NOTE REPORT” and dated 11/24/2023 the skilled nurse documented “NO PROBLEMS IDENTIFIED” and patient discharged from skilled nurse services. Urinalysis results not in clinical record. No evidence of communication between Agency, laboratory or physician to ensure coordination of care. 2. Review of a document titled “COORDINATION OF CARE, FROM ADMIT THROUGH DISCHARGE” reveals policy includes “Coordinating patient care among various disciplines to ensure that services are continuous and coordinated from admission through discharge. 3. During an interview on 12/21/23 at 2:30 PM, Agency Personnel #1 confirmed there was no documentation in the clinical record of communication with laboratory to follow up on ordered tests. Confirmed failure to coordinate patient care with laboratory.”

“Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This Element is not met as evidenced by: Based on clinical record review and staff interview, the Agency failed to maintain a liaison with the laboratory, physician or patient to ensure communication of laboratory results in 1 (#10) of 3 (#5, #8, & #10) clinical records reviewed with orders for laboratory testing. This deficit had the potential to affect all patients currently on census. Findings include: 1. Review of clinical record #10 with a start of care date of 10/05/23 revealed a patient with a diagnosis of Sepsis Unspecified Organism. On a document titled “VISIT NOTE REPORT” and dated 11/17/2023 the skilled nurse documented “OBTAINED UA (urinalysis) AS ORDERED. SPECIMEN DROPPED OFF AT ELITE HOME HEALTH JONESBORO OFFICE”. On a document titled “VISIT NOTE REPORT” and dated 11/24/2023 the skilled nurse documented “NO PROBLEMS IDENTIFIED” and patient discharged from skilled nurse services. Urinalysis results not in clinical record. No evidence of communication between Agency and laboratory to request laboratory results. 2. During an interview on 12/21/23 at 2:30 PM, Agency Personnel #1 confirmed the clinical record did not contain the urinalysis results. Confirmed there was no documentation in the clinical record of communication with laboratory to see if they had completed the ordered tests.”