Interim Healthcare of the Twin Cities

“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 interview and record review, the facility failed to ensure the initial start of care (SOC) visit was held within 48 hours of referral for 2 of 7 patients (P4, P7) currently receiving home care services. P7’s POC for certification period 1/10/24-3/9/24, indicated P7 had diagnoses which included a fractured radius, type II diabetes, chronic kidney disease, and a history of falling. P7’s POC further indicated, P7 received in home skilled nursing, physical therapy, occupational therapy, and home health aide services. P7’s home care referral (dated 1/4/24), lacked any indication a SOC date was scheduled. P7’s verbal physicians order received 1/9/24, indicated a SOC date of 1/10/24. The order lacked any indication of why the SOC visit was delayed. P7’s medical record lacked any indication P7 requested a delayed SOC date. During interview on 1/25/24 at 1:02 p.m., the director of therapy stated when a referral was received for a patient, it was best practice to complete the initial assessment within 48 hours. If the agency was unable to complete the initial assessment within the required time frame, he would expect the clinician to notify the physician stating the reason for the delay, which would ideally be driven by the patient. The clinician would also be responsible for communicating with the patient in order to see if they want to continue with the agency or go somewhere else and then documenting it in a communication note in the chart. The documentation should also include the reason for the delay of the SOC. During an interview on 1/25/24 at 1:10 p.m. the director of nursing (DON) stated when a referral was received, it was best practice to complete the initial assessment within 48 hours. If the agency was unable to complete the initial assessment, then the provider would need to be notified indicating the reason for the delay and documented in the patient’s chart. During an interview on 1/24/24 at 2:46 p.m., the administrator stated the initial assessment of the patient should be completed within 48 hours of the referral. If the agency was unable to complete the assessment within the timeframe, the clinician was responsible for notifying the physician to get a new SOC order and the reason for the delay of care. The DON also stated the delay of services and the reason for the delay should be documented in the patients’ medical record and verified P4 and P7 did not have a documented reason for why the SOC was delayed. The facility’s policy titled initial comprehensive assessment dated 4/2/2021, indicated an initial comprehensive assessment of an individual was conducted within 48 hours of a referral for home care services, an individual’s return home, or on the physician’s ordered SOC date. P4’s plan of care (POC) for certification period dated 12/11/23-2/8/24, indicated P4 had diagnoses a leg laceration, peripheral vascular disease, and history of falling. P4’s POC further indicated P4 required in home skilled nursing, physical therapy, and occupational therapy services. P4’s home care referral dated 12/6/23, lacked indication a SOC date was scheduled. P4’s physician order dated 12/8/23, indicated P4’s SOC date was “ok” to be completed on 12/11/23. The order lacked indication of why the SOC visit was delayed. P4’s medical record lacked indication P4’s requested a delayed SOC date. When interviewed on 1/23/24 at 3:30 p.m., the Administrator stated it was best practice was to initiate SOC within 48 hours of the referral. If staff were unable to complete the SOC within the 48-hour time timeframe a provider order was obtained. An interview on 1/23/24 at 11:29 a.m., registered nurse (RN)-A stated SOC should be completed within 48 hours after a referral. If it cannot be done, the patient and provider were contacted, and an order obtained for an extension. If the delay was the patient’s wish, a provider order would still be obtained.”