Centerwell Home Health

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on patient medical record reviews, policy review, and staff interviews the Home Health Agency failed to ensure transfer summaries were completed for 1 (Patient #1) and failed to ensure a discharged summary was sent to the primary care practitioner for 1 (Patient #5) of 3 patients reviewed for discharge and transfer summaries. The findings include: Review of the facility Discharge or Transfer policy 03-25, Annual review and Revised 04/2023: Transfer/Discharge Summaries… 1) A copy of the Home Health agency transfer/discharge summary will be sent to the receiving healthcare provider responsible for ongoing patient care… 2) Transfer/discharge documents completed by the Home Health agency will be sent within Center for Medicare mandated timeframes outlined in this policy. · Patients discharged to their physician/allowed practitioner will be sent within five business days of the Home Health agency discharge date. · Patients transferred to a healthcare facility will be sent within two business days of the planned transfer or the date the Home Health agency became aware of the patient transfer to a facility if the patient is still receiving care in the health care facility. The physician/allowed practitioner must also be notified of the patient transfer and documented in the patient’s medical record. 1. Review of Patient #1’s medical record revealed Start of Care date of 4/27/23. Review of the second Certification period 6/26/23 to 8/24/23: Plan of care for Skill Nursing services effective 7/2/23 1 visit for 1 week, on 7/16/23 1 visit for 1 week, on 8/6/23 1 visit for 1 week and on 8/20/23 1 visit for 1 week. Skill nurse to insert/change/maintain indwelling foley catheter. Patient has a history of malignant neoplasm of bladder. Review of 8/24/23 Client Coordination Note Report: A skilled nurse visit for recertification and performed a urinary catheter change due to malfunction. Further medical record review revealed a 9/27/23 Client Coordination Note Report: Patient notified the home health agency of her transferring to another home health agency. The patient will need continuous care with the urinary catheter. The medical record failed to provide evidence of a completed Transfer Summary. The medical record failed to provide evidence of the home health agency communicating with the receiving home health agency or with the patient’s primary care practitioner. The Home Health Agency failed to follow their Discharge or Transfer policy. On 1/10/24 at 12:30 p.m. during an interview, the Clinical Manager said we did not complete or send a discharge/ transfer summary; we didn’t send anything to her doctors. 2. A review of Patient #5’s medical record failed to provide evidence of a Discharge Summary sent to the patient’s primary care practitioner. The Home Health Certification and Plan of Care noted a Start of Care date of 11/6/23 for skill services: Skill Nursing - 1 visit per week for 3 weeks, then 1 visit every 2 weeks for 6 weeks. Physical Therapy - 1 visit for 1 week, then 2 visits per week for 1 week, then 1 visit for 1 week, then 2 visits per week for 1 week, then 1 visit per week for 3 weeks, and then 1 visit every 2 weeks for 2 weeks. Patient #5’s primary diagnosis of spinal stenosis of lumbar region. Review of 12/10/23 Client Coordination Note Report documents Physical Therapy discharge, reason noted as goals met. The medical record failed to provide evidence of a discharge summary having been sent to the patient’s primary care practitioner who will be responsible for providing care and services, after home health discharge. On 1/10/24, at 1:45 p.m. in an interview, the Clinical Manager said presently we do not have a way to track the documents, transfer notifications or discharge summaries, that have to go to the Veteran Administration Centers.”