New Haven Home Health Care, Inc.

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure the initial assessment visit was done within 48 hours of the referral date. This was found in 2 of 7 (Pts. #5 and 7) clinical records reviewed. Findings include: 1. Pt. #5 was admitted for skilled home health on 2/13/23 with a primary diagnosis of Alzheimer’s Disease. The clinical record was reviewed on 1/17/24. The record contained a “Face to Face” document sent from the physician’s office dated 2/9/23. The SOC initial assessment was conducted by the RN on 2/13/23. The record lacked a Physician ordered SOC date. The record lacked documentation the Agency started care/services within 48 hours of the referral date. 2. Pt. #7 was admitted for skilled home health on 12/8/23 with a primary diagnosis of Bilateral osteoarthritis of knee. The clinical record was reviewed on 1/17/24. The record contained a “Face to Face” document sent from the physician’s office dated 12/1/22. The SOC initial assessment was conducted by the RN on 12/8/23. The record lacked a Physician ordered SOC date. The record lacked documentation the Agency started care/services within 48 hours of the referral date. 3. During an interview with the Administrator and Director of Nursing on 1/17/24 at 2:00 PM it was stated that the initial assessment should be conducted within 48 hours of the referral date, the date documented on the Face-to-Face physician form or on a specified physician ordered date. During the same interview, the above findings were confirmed.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on clinical record and staff interviews, it was determined the Agency failed to obtain a physician order for a wound treatment. This was found in 1 of 7 (Pt. #6) clinical records reviewed. Findings include: 1. Pt. #6 was admitted to Home Health Services on 4/6/23 with primary diagnosis of Alzheimer’s disease, unspecified. The clinical record was reviewed on 1/17/24. The record contained “Skilled Nurse Visit” notes dated 5/11/23, 5/18/23 and 5/25/23. The notes included the documentation: “Wound 1 – Location: Right hip pressure ulcer…Treatment: …cleansed wound with normal saline solution…covered with hydrocolloid dressing…” The record lacked documentation of a physician order for the wound treatment. 2. On 1/17/24 at 1:45 PM, during an interview conducted with the Administrator and Director of Nursing, it was stated that a physician order is needed for wound treatment. During the same interview, the above finding was confirmed.”

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on clinical record review and staff interviews, it was determined the Agency failed to ensure that Pt. changes in condition, assessment or concerns were communicated to the healthcare team, and with the physician to ensure Pt. needs were identified and addressed. This was found in 2 of 7 (Pts. #1 and 5) clinical records reviewed. Findings include: 1. Pt. #1 was admitted for skilled home health services on 10/11/23 with the primary diagnosis of Other postherpetic nervous system involvement. The clinical record was reviewed on 1/17/24. The record contained “Skilled Nurse Visit” notes which include documentation for the following dates: 11/15/23, blood pressure = 110/56 and 12/4/23, blood pressure = 120/56. The record also contained “HHA Visit” notes which include documentation for the following dates: 12/11/23, blood pressure = 111/56; 12/18/23, blood pressure = 111/58; 12/18/23, blood pressure = 119/52; 12/22/23, blood pressure = 117/52. The above-mentioned notes also included documentation of the Home Health Aide, “Noted with low diastolic (blood pressure). Nurse and office notified.” The clinical record lacked documentation that Pt. #1’s diastolic blood pressure, which was not within the parameters specified in the plan of care, was communicated to the physician. 2. Pt. #5 was admitted for skilled home health services on 4/6/23 with the primary diagnosis of Alzheimer’s Disease, unspecified. The clinical record was reviewed on 1/17/24. The clinical record included a “Skilled Nurse Visit” note which included documentation by the Licensed Practical Nurse that on 5/11/23, “Noted pressure related alteration of intact skin on the right hip which is warm to touch with firm tissue consistency. The pressure ulcer appears with persistent red skin which is categorized as stage 1. SN performed wound care…” The “Skilled Nurse Visit” notes dated 5/18/23 and 5/25/23 also included documentation and measurements of Pt. #5’s pressure ulcer on the right hip. The clinical record contained “HHA Visit” notes for the dates 5/15/23, 5/17/23, 5/23/23, 5/24/23, 5/29/23 and 5/31/23; and the above-mentioned HHA notes included documentation that Pt. #5’s “Skin is intact.” The clinical record lacked documentation that the onset of the pressure ulcer was communicated to the physician, RN and the HHA. 3. During an interview conducted with the Administrator and Director of Nursing on 1/17/24 at 1:30 PM, it was stated as of the time of the interview that any changes in condition/assessment of the Pt. should be communicated and coordinated with the physician, the RN and the HHA. During the same interview, the above finding was confirmed.”

“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 review of clinical records and staff interview, it was determined the Agency failed to ensure the Physician was sent a copy of the Discharge Summary. This was found in 2 of 2 (Pts. #6 and 7) closed/discharged clinical records reviewed. Findings include: 1. Pt. #6 was admitted to Home Health Services on 4/6/23 with a primary diagnosis of Alzheimer’s disease, unspecified. The record contained Physician Order dated 6/1/23, indicating that Pt. #6 was discharged from the Agency. As of the date of the clinical record review on 1/17/24, the record lacked documentation that a copy of the Pt. #6’s discharge summary was sent to the Physician. 2. Pt. #7 was admitted to Home Health Services on 4/7/23 with a primary diagnosis of Hemiplegia following cerebral infarction affecting left non-dominant side. The record contained Physician Order dated 6/5/23, indicating that Pt. #7 was discharged from the Agency. As of the date of the clinical record review on 1/17/24, the record lacked documentation that a copy of the Pt. #7’s discharge summary was sent to the Physician. 3. During an interview with the Administrator and the Director of Nursing on 1/19/24 at 1:45 PM, the above findings were confirmed.”