Spoon River Home Health Services

“Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This Standard is not met as evidenced by: Based on document review and interview, it was determined for 1 of 5 (Pt #12) patients, reviewed for discharge summaries, the agency failed to ensure there was a completed discharge summary. Findings include: 1. The policy titled “Discharge Criteria and Process Policy No. 4-045.1 (revised April 2018)” was reviewed on 9/25/24 at approximately 2:00 PM. The policy noted “...9. All discharge paperwork will be due in office within 72 hours of the discharge date. This will include...discharge summary...” 2. Pt #12 (Start of Care): 08/17/24 Diagnosis: Cellulitis of Right Foot. The record was reviewed on 09/25/24 at approximately 10:00 AM. The record noted a physician order dated 9/6/24 that included for discharge to be 09/08/24. The record lacked a discharge summary. 3. During an interview with the Director of Nursing (E#1) on 9/25/24 at approximately 2:00 PM, E#1 verbally confirmed the patient is discharged and a there had not been a discharge summary completed.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on document review and interview, it was determined in 3 of 17 (Pt #2, Pt #7, Pt#8) patients’ records reviewed, the Agency failed to ensure documentation was appropriately authenticated, dated, timed. Findings include: 1. Pt #2, SOC: 8/20/23 Diagnosis: Hemiplegia following cerebral infarct. Pt #2’s record for dates 7/28/24 through 9/24/24, was reviewed on 9/24/2024 at approximately 3:00 PM. a. The physician’s order (dated 8/19/24), noted Skilled Nursing one time monthly for catheter care for 2 months. The Skilled Nursing visit on 9/9/24 lacked the associated date and time of the staff’s signature, as to when the documentation was signed. b. The physician’s order (dated 8/19/24),noted Physical Therapy one time per week for 5 weeks, subsequently extended for 4 weeks. Of the Physical Therapy notes, the visit note dated 9/24/24, lacked the associated date and time of the staff’s signature; four visit notes (dated 8/6/24, 8/12/24, 9/10/24, 9/18/24), lacked the staff’s associated title and signature date and time; and two visit notes (dated 8/26/24, 9/3/24)lacked the staff’s signature and associated title and date and time of signature. 2. Pt #7, SOC: 10/12/22 Diagnosis: Type 2 Diabetes Mellitus with foot ulcer. Pt #7’s record for dates 7/28/24 through 9/25/24, was reviewed on 9/25/2024 at approximately 1:00 PM. The physician’s order (dated8/13/24), noted Skilled Nursing visits twice weekly for wound care for 9 weeks. The sixteen Skilled Nursing notes lacked the associated date and time of the staff’s signature, as to when the documentation was signed. 3. Pt#8, SOC: 5/12/24 Diagnosis: Encounter for change or removal of nonsurgical wound dressing. Pt #8’s record for dates 7/11/24 through 9/8/24 was reviewed on 9/24/24 at approximately 10:00 AM. a. The physician’s order (dated 7/30/24), noted Skilled Nursing visits three times per week for eight weeks. Of the Skilled Nursing visit notes, eleven notes (dated 7/31/24, 8/5/24, 8/7/24, 8/12/24, 8/16/24, 8/19/24, 8/23/24, 8/26/24, 8/28/24, 8/30/24, 9/11/24) lacked the associated date and time of the staff’s signature, as to when the documentation was signed; seven notes (dated 8/9/24, 8/14/24, 8/21/24, 9/16/24, 9/13/24, 9/9/24, 9/4/24), lacked the staff’s associated title and date and time of signature. b. The physician’s order (dated 7/30/24), noted Occupational Therapy visits once per week for 5 weeks. The Occupational Therapy visit notes (dated 7/23/24, 8/14/24), two signatures were illegible and lacking the associated date and time of the staff’s signature. 4. An interview with the Director of Nursing (E #1) was conducted on 9/26/24 at approximately 11:15 AM. E #1 verbally confirmed the lack of authentication related to missing staff signatures and associated titles, dates and times of the signature.”