Nhc Homecare

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on review of the Home Health Agency (HHA)’s Policy and Procedure review, record review and interview, the HHA failed to ensure an accurate and complete record for 3 of 10 sampled patients, as evidenced by failure to ensure the physician was notified of missed visits for Patient #1, #7 and #10. The findings included: 1) Review of the HHA’s Policy and Procedure for “Missed Visits” revised date December 2022, reveals that missed are ordered visits that are not made and that cannot be “made up” by moving them to later in the Sunday-Saturday treatment week. This should occur only for patient need/requests, never for staff preference or convenience. Every effort should be made to reschedule the visit-even if it is to the weekend day. Missed visits break the physician-ordered frequency and may disrupt the schedules of other staff, impact the patient’s care, put us out of compliance with orders, and lead to scheduling/billing errors if not managed correctly. Missed visits must be reported to the physician via a call/fax documented on a communication note or client missed visit report. Review of the record reveals Patient #1 was admitted to the HHA ‘s services on 12/30/2023 for the provision of Skilled Nursing and Physical Therapy. Review of the Plan of Care (POC) for the Certification period of 12/30/2023 through 02/27/2024 documents Patient #1 was to receive Physical Therapy services as of 12/31/2023, for one time a week for one week, then, two times a week for eight weeks. Further review reveals for the week 02/11/2024 through 02/17/2024, there were no Physical Therapy visits conducted on these scheduled dates, 02/14/2024 and 02/15/2024; there was no documented evidence that these “missed visits” were rescheduled within the treatment week and there was no documented evidence that these “missed visits” were reported to the physician. On 02/29/24 at 10:36 AM, during a side-by-side review and interview, the Clinical Manager confirmed that there were “missed visits” on 02/14/2024 and 02/15/2024 and there was no documented evidence of notification to physician. 2) Review of the record reveals Patient #7 was admitted to the HHA’s services on 01/19/2024 for the provision of Skilled Nursing and Physical Therapy. Review of the Plan of Care (POC) for the Certification period of 01/19/2024 through 03/18/2024 documents Patient #7 was to receive Physical Therapy services as of 01/21/2024, for two times a week for one week, then, one time a week for one week and two times a week for four weeks. Further review reveals for week 02/18/2024 through 02/24/2024, there were no Physical Therapy visits conducted on the scheduled date, 02/23/2024; there was no documented evidence that the “missed visit” was rescheduled within the treatment week and there was no documented evidence that the “missed visit” was reported to the physician. On 02/29/24 at 10:53 AM, during a side-by-side review and interview, the Clinical Manager revealed that the Physical Therapy “missed visit” on 02/23/2024 was because the patient went to the dentist and there was no evidence of notification to the physician. 3) Review of the record reveals Patient #10 was readmitted to the HHA’s services on 01/10/2024 for the provision of Physical Therapy. Review of the Plan of Care (POC) for the Certification period of 01/10/2024 through 02/15/2024 documents Patient #10 was to receive Physical Therapy services, as of 01/14/2024 for two times a week for five weeks. Further review reveals that for the week of 01/21/2024 through 01/27/2024, there were no Physical Therapy visits conducted on the scheduled date, 01/27/2024 and there was no documented evidence that the “missed visit” was reported to the physician. On 02/29/24 at 1:14 PM, during a side-by-side review and interview, the Clinical Manager indicated that the patient declined the Physical Therapy service on 01/27/2024, however the Clinical Manager confirmed there was no documented evidence regarding notification to the physician.”