American Advantage Home Care

“Coordinate patient care CFR(s): 484.105(c)(2) Coordinating patient care, This Element is not met as evidenced by: Based on record review and interview, the Agency failed to ensure patient care was coordinated to receive Skilled Nursing and Physical Therapy services for 3 (P-1, P-2, P-3) of 3 patients who required the ordered services, from a total of 3 sampled records reviewed, resulting in patients not receiving care based on their individualized plan of care and the potential for physiological decline and unmet care needs. Findings include: P-2: The Start of Care (SOC) was dated 3/13/23. The Plan of Care (POC) identified diagnoses of Urinary Tract Infection, Chronic Kidney Disease and Hypertension. During record review on 6/3/24, it was noted that the RN (Registered Nurse) completed a recertification on 7/6/23 and 9/7/23 with visit frequencies of 1w8 (One visit a week for eight weeks) for both certification periods. The RN had missed visits without documentation on 8/17/23, 8/24/23, 9/21/23, 10/12/23 and 10/19/23. The RN did document a missed visit on 10/26/23 with the reason being “Patient refused visit.” Additionally, the RN completed an OASIS Non-Visit DC on 11/3/23 which is not reviewable. The agency failed to provide oversight and coordinate patient visits accordingly. P-3: The Start of Care (SOC) was dated 7/3/23. The Plan of Care (POC) identified diagnoses of Diabetes Type 2, Unsteadiness on Feet and Hypertension. During record review on 6/3/24, it was noted that the POT (Physical Therapist) completed a comprehensive assessment on 7/3/23 with visit frequencies of 2w2, 1w3. An order was written on 8/24/23 stating, “Order to continue with Physical Therapy int recertification period (No frequency was documented).” The PT completed a recertification on 8/29/23 with frequencies of 1w6. The RN completed an evaluation on 7/19/23 with a frequency of 2m2. The RN had missed visits without documentation on 8/3/23, 8/8/23 and 8/22/23 (RN DC). Additionally, the PT documented missed visits on 7/28/23 due to “Patient refused visit due to not feeling well”, 9/8/23 due to “I received a call from patient’s sone requesting to reschedule PT appointment today due to patient is not feeling well” and 9/22/23 due to “I received a call from patient’s son requesting to reschedule patient PT appointment for next week due to not feeling well.” The agency failed to provide oversight and coordinate patient visits accordingly. P-1: The patient’s start of care (SOC) was 9/13/24 with diagnoses that included Heart Failure and Atrial Fibrillation. The Plan of Care (POC) ordered Skilled Nursing (SN) 1w7, and Physical Therapy (PT) 1w6 services to be provided. On 6/3/24 at 3:08 p.m., during the clinical record review, the following was noted: there were only 3 visits in total, made to the patient’s home. The SN saw the patient on 9/13/23 for the SOC visit. There was a SN missed visit (MV) on 9/21/23, 10/18/23 and 10/25/23. There was no MV note documenting the rationale for the missed SN visits. Further, PT saw the patient on 9/25/23 for the initial evaluation. There was a PT MV on 10/9/23, 10/16/23 and 10/23/23. There was no documented rationale for the MV on 10/9/23 or 10/23/23. The patient was subsequently discharged from the agency’s services on 10/25/23. Additionally, the SN and PT discharge summary and discharge oasis had not been completed at the time of this review. There was no documented evidence to support the agency’s coordination of care to ensure the patient received the proper care and ordered services. These findings were reviewed with and acknowledged by the Administrator/Owner who responded, “The missed visits either slipped through QA or the staff forgot to submit the note. I’ll have to check the queue.” After searching through the electronic medical record system, the Administrator acknowledged that there were no additional documents available for review. The Administrator further reported, “Essentially, if it’s not documented, it’s not done.”