American Home Health

“Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This Element is not met as evidenced by: Based on clinical records review, Agency policy review and Staff interviews, it was determined in 3 of 7 (Pts. #5, 4 and 1) clinical records reviewed, the Agency failed to ensure staff complete a Pt. assessment within the last 5 days of every 60 day certification period, wherein service was provided after the initial certification period. 2. Pt. #4 was admitted to Home Health Services on 04/27/22 with the primary diagnosis of Hereditary Hemolytic-Uremia Syndrone. The clinical record was reviewed on 04/30/24. The record contained the PsOC for the certification periods of 02/16/24 to 04/15/24 and 04/16/24 to 06/14/24. The recertification comprehensive assessment completed by the RN was dated 03/29/24. The record lacked documentation that the recertification comprehensive assessment was conducted within the last 5 days of the certification period that ended on 04/15/24. 3. Pt. #1 was admitted to Home Health Services on 08/01/14 with primary diagnosis of Alpha 1 Antitrypsin deficiency. The clinical record was reviewed on 04/30/24. The record contained PsOC for certification period of 02/10/24 to 04/09/24 and 04/10/24 to 06/08/24, The recertification comprehensive assessment completed by the RN was dated 03/19/24. The record lacked documentation that the recertification comprehensive assessment was conducted within the last 5 days of the certification period that ended on 04/09/24. 4. Agency Policy titled “Further Functional Assessment/Comprehensive Assessment” was reviewed on 05/02/24 and indicated: “….Purpose….2. To comply with Medicare conditions of participation for home health agencies….Policy:….2. Recertification assessments can be done no more infrequently than every 60 days. ….assessments completed with in the 5 day window prior to the expiration of their current plan of care….” 5. During interviews with the Administrator on 05/01/24 at 2:31 PM to 3:00PM and on 05/02/24 at 9:00 AM, the Administrator confirmed the comprehensive assessment was not done within the last 5 days of the 60 day certification period. 1. Pt. #5 was admitted to Home Health Services on 12/16/13 with the primary diagnosis of Hemiplegia, unspecified affecting unspecified side. The clinical record was reviewed on 05/01/24. The record contained a POC for the certification period of 02/22/24 to 04/21/24, wherein the Physician ordered “SN every 6months and PRN for labs and assessment x60days”. The record lacked documentation that the recertification comprehensive assessment was conducted within the 60 day certification period.”

“At discharge CFR(s): 484.55(d)(3) At discharge. This Element is not met as evidenced by: Based on clinical record reviews, Agency policy review and Staff interview, it was determined that in 2 of 2 (Pts. #6 and 7) discharged records reviewed, the Agency failed to ensure that a comprehensive assessment was updated at discharge. Findings include: 1. Pt. #6 was admitted to Home Health Services on 10/13/20 with primary diagnosis of Hereditary Deficiency of Other Clotting Factors. The clinical record was reviewed on 04/30/24. The record documented that the last visit by the RN was on 12/18/23. The Physician order dated 01/24/24 indicated discharge from SN and Home Health Services. The clinical record lacked documentation that a comprehensive assessment was updated at discharge. 2. Pt. #7 was admitted to Home Health Services on 02/29/24 with primary diagnosis of Cystic Fibrosis with Pulmonary Manifestations. The clinical record was reviewed on 05/01/24. The record documented that the last visit by the RN was on 03/14/24. The Physician order dated 03/15/24 indicated discharge from SN and Home Health Services. The clinical record lacked documentation that a comprehensive assessment was updated at discharge. 3. The Agency policy titled “Discharge Assessment” was reviewed on 05/02/24 at 8:45 AM and indicated “….1. Upon discharge from home health services, the client will receive an assessment….” 4. During an interview with the Administrator on 05/02/24 at 9:00 AM, the Administrator confirmed that the comprehensive assessments were not updated at discharge.”

“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 clinical record reviews, Agency policy review and Staff interview, it was determined that in 2 of 2 (Pts. #6 and 7) discharged records reviewed, the Agency failed to ensure a discharge summary was completed and sent to the Physician. Findings include: 1. Pt. #6 was admitted to Home Health Services on 10/13/20 with primary diagnosis of Hereditary Deficiency of Other Clotting Factors. The clinical record was reviewed on 04/30/24. The record documented that the last visit by the RN was on 12/18/23. The Physician order dated 01/24/24 indicated discharge from SN and Home Health Services. The clinical record lacked documentation of a discharge summary. 2. Pt. #7 was admitted to Home Health Services on 02/29/24 with primary diagnosis of Cystic Fibrosis with Pulmonary Manifestations. The clinical record was reviewed on 05/01/24. The record documented that the last visit by the RN was on 03/14/24. The Physician order dated 03/15/23 indicated discharge from SN and Home Health Services. The clinical record lacked documentation of a discharge summary. 3. The Agency policy titled “Discharge Assessment” was reviewed on 05/02/24 at 8:45 AM and indicated “….1. Upon discharge from home health services, the client will receive….a summary of services including the client’s current condition….3. The discharge summary will be sent to the physician within 5 days of the discharge.” 4. During an interview with the Administrator on 05/02/24 at 9:00 AM, the Administrator confirmed that the Agency failed to complete a discharge summary and send it to the Physician.”