Star Home Health 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 record review and interview, the agency failed to ensure an initial assessment was conducted within 48 hours of referral or the practitioner ordered start of care dated in 2 of 4 active records reviewed (Patients: #2 and 5) and 2 of 4 focused active records reviewed (Patients: #9 and 11). Findings Include: A review of the clinical record for Patient #2, with a start of care date of 02/19/2025 evidenced a physician order for home health care services for nursing and therapy signed by Physician 4 and a Fax from Entity 5, a skilled nursing facility, dated 02/12/2025 reporting Patient #2 would be discharged to home on 02/14/2025. A review of the initial start of care comprehensive assessment visit was dated 02/19/2025 and signed by Alternate Administrator, RN. During an interview on 03/26/2025 at 2:51 PM, Patient #2 reported being discharged from Entity 5 on 02/14/2025 and was contacted by the Alternate Administrator, RN, on 02/19/2025 and a visit was made that day. During an interview on 03/26/2025 at 4:08 PM, Alternate Administrator, RN, indicated they had not completed an initial assessment on Patient #2 until 02/19/2025 because they were unable to contact them. When queried what the agency process for referrals and initial assessments were, they reported the process was to do the initial assessment within 48 hours of the referral and contact the physician if this was not completed. When asked if there was documentation of contact with the physician or attempts to contact the Patient, they reported writing a note related to contacting the Patient after they started care on 02/19/2024. The Alternate Administrator, RN failed to complete an initial assessment 48 hours after receiving an order for a referral to home health care. 410 IAC 17-14-1(a)(1)(A) 1. A review of undated Star Home Health policy titled “Initial Assessment” indicated but was not limited to “ … 1. The initial visit shall be made within 48 hours of referral from a physician or from discharge from an inpatient facility, or on the physician-ordered start of care date. If the initial visit is delayed for reasons such as and inability to contact the patient or at the patient’s request, the physician shall be notified, and documentation shall be completed reflecting the physician’s approval … ” 2. A review of the clinical record for Patient #5 start of care date 10/24/2024, contained a physician order dated 10/17/2024 for Patient #5 to receive PT, OT, HHA for bathing to eval and treat. A review of the initial start of care comprehensive assessment visit dated 10/24/2024, had been completed and signed by the CM. A review of the communication notes dated 10/17/2024 through 03/25/2025 evidenced a communication note dated 10/24/2024 electronically signed by the CM. The communication note indicated the CM had spoken to the caregiver for Patient #5 on 10/18/2024 and scheduled appointment to see the patient on 10/22/2024, due to Patient #5’s dialysis schedule. The note further confirmed the SOC was set up for 10/24/2024 due to a family emergency. The communication notes failed to evidence documentation of the physician being notified of the delay in the SOC. During an interview on 03/25/2025 at 2:45 PM, when requested the new order for the new start of care and documentation of the physician being notified of the delay in Patient #5’s SOC, the CM confirmed they did not obtain a new order for the SOC, nor did they notify the physician of the delay in the SOC. 3. A focused review of the clinical record for Patient #9 start of care date 02/24/2025, contained a physician order dated 02/20/2025 for Patient #9 to receive PT, OT, and Skilled Nursing. A review of the initial start of care comprehensive assessment visit dated 02/24/2025, had been completed and signed by the CM. A review of the communication notes dated 02/20/2025 through 03/25/2025 failed to evidence documentation of the physician being notified of the delay in the SOC. During an interview on 03/26/2025 at 2:00 PM, when requested the new order for the new start of care and documentation of the physician being notified of the delay in Patient #9’s SOC, the CM stated, “No. I did not call the physician to obtain a new order for the SOC or notify the physician of the delay in the SOC.” 4. A focused review of the clinical record for Patient #11 start of care date 02/24/2025, contained a physician order dated 11/14/2024 for Patient #11 to receive PT, OT, Skilled Nursing, and HHA. A review of the initial start of care comprehensive assessment visit dated 11/20/2024, had been completed and signed by RN 2. A review of the communication notes dated 11/20/2024 through 03/25/2025 failed to evidence documentation of the physician being notified of the delay in the SOC. During an interview on 03/26/2025 at 3:29 PM, when asked regarding the referral date for Patient #11 and the SOC date, RN 2 confirmed the SOC initial assessment should had been completed in 48 hours of the receipt of referral, and if unable to complete a communication note with the physician notification should had been completed. RN 2 further communicated they were unaware of the reason the SOC was delayed.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment included a review of all the medications, and allergies to include drug interactions in 1 of 1 active clinical record reviewed receiving in-center dialysis treatment. (Patient: #5) Findings Include: 1. A review of a Star Home Health policy titled “Drugs and Biologicals” indicated but was not limited to, “ … To maintain a standard for managing patient medications that serves to prevent errors and protect the patient from adverse reactions … At time of admission, the clinician shall document all current … and over the counter medications and allergies … The clinician shall assess, and document is a medication is long standing, new within the last 30 days, or changed with the last 60 days … The clinician shall document a drug regimen review … ” 2. A review of the clinical record for Patient #5 contained a recertification comprehensive assessment dated 02/20/2025, electronically signed by RN1. The recertification assessment indicated RN 1 completed medication review and assessed drug interactions. A review of a document from Entity 1, an ESRD provider [dialysis facility] for Patient #5, indicated Patient #5’s medications included: Venofer, Mircera, Cinacalcet, and listed an allergy to Lidocaine. During an interview on 03/25/2025 at 3:12 PM, RN 1 communicated they were unaware of the dialysis prescriptions and Patient #5’s allergy to Lidocaine. RN 1 further confirmed they had not coordinated care with Entity 1 to obtain a complete and accurate list of Patient #5’s medications and allergies to reconcile Patient #5’s medication to check for medication interactions. The POC for the recertification period 02/21/2025- 04/21/2025 included a list of Patient’s medications; the POC failed to evidence Venofer (treats anemia), Mircera (treats anemia), and Cinacalcet (treats increased amounts of calcium), and Patient’s allergy to Lidocaine. 410-IAC 17-14-1(a)(1)(B)”