Bayada Home Health Care, Inc.

“Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on medical record review, staff interviews, and review of facility policies, it was determined that the facility failed to ensure communication with the physician was documented when a missed visit occurred in four (4) out of five (5) medical records reviewed (Patient (P) 6, P10, P13 and P14). Findings include: Facility policy titled “Missed Visits/Hours”, last reviewed on 3/24/24, states “… Our Procedure: 1.0 Communicating Missed Visits/Hours. … 1.1.1.2: Missed Visit Process Flow. The field clinician is responsible for documenting the missed visit in the “Missed Visit Coordination Note” found in the medical record. 1.1.1.2.1: The Missed Visit Coordination Note will include the following: a. Date missed visit occurred; b. Reason for missed visit; and c. Method of notification to physician (verbal or fax).” On 10/17/24 at 11:00 AM, a review of P10’s medical record was conducted and revealed the following: record shows Staff (S) 14, Occupational Therapist (OT), entered a Coordination of Care Note on 10/4/2024 stating “This is a notification of delay in services. The RD [Registered Dietician] evaluation has been delayed until next week due to staffing”. There was no documented method of notification to physician (verbal or fax) for the missed RD visit on 10/4/24 in the medical record. Findings were confirmed by S3 at 10/18/24 at 2:30 PM. On 10/17/24 at 1:37 PM, an interview was conducted with S3, Director. When questioned about the Missed Visit/Hours policy, S3 stated “I would think it is for everyone” when asked if the policy applied to all staff or nursing staff only. On 10/18/24 at 9:50 AM, P13’s medical record was reviewed. P13 was receiving home care services for congestive heart failure and a history of falling. P14 had the following orders: “OT Effective 09/22/2024 - 2wk2, 1wk3...” - Occupational Therapy (OT): 2 visits a week for 2 weeks, 1 visit a week for three weeks. P13’s medical record revealed a missed OT visit the week of 9/29/24. There was no documented method of notification to the physician (verbal or fax) for the missed OT visit on 10/2/24 in accordance with facility’s policy, in the medical record. Findings were confirmed by S1, Division Director, on 10/18/24 at 10:02 AM. On 10/18/24 at 10:14 AM, P14’s medical record was reviewed. P14 was receiving home care services for chronic kidney disease and a history of falling. P14 had the following orders: Effective 8/9/24 - “PT 1WK1, 2WK2, 1WK1,...” - Physical Therapy (PT): 1 visit a week for 1 week; 2 visits a week for 2 weeks; 1 visit a week for 1 week. P14’s medical record revealed a missed PT visit the week of 8/25/24. There was no documented method of notification to the physician (verbal or fax) for the missed PT visit on 8/29/24 in accordance with the facility’s policy, in the medical record. Findings were confirmed by S1 on 10/18/24 at 10:35 AM. Facility policy titled “Missed Visits/Hours”, last reviewed on 3/24/24, states, “…Our Procedure: 1.0 Communicating Missed Visits/Hours. … 1.1.1.2. Missed Visit Process Flow. The field clinician is responsible for documenting the missed visit in the “Missed Visit Coordination Note” found in the electronic record. 1.1.1.2.1 The Missed Visit Coordination Note will include the following: a. Dated missed visit occurred; b. Reason for missed visit; and c. Method of notification to physician (verbal or fax)….” On 10/17/2024 at 11:00 AM, P10’s medical record was reviewed and revealed the following: P10 had the following order: “Registered Dietician [effective ___ ] _WK_, _WK_, etc.” – Review of P10’s medical record revealed a missed RD visit the week of 10/4/2024. “Care Coordination Note” written on 10/4/2024 lacked documentation of notification to the provider for the missed RD visit as per facility policy. On 10/17/2024 at 1:37 PM an interview was conducted with S3 (Director). When questioned about the Missed Visit/Hours policy, S3 stated “I would think it is for everyone” when asked if policy applied to all staff or nursing staff only. These findings were confirmed by S3 on 10/18/2024 at 2:30 PM. On 10/18/24 at 9:50 AM, P13’s medical record was reviewed. P13 had the following orders: “OT Effective 09/22/2024 - 2wk2, 1wk3...” - Occupational Therapy (OT): 2 visits a week for 2 weeks, 1 visit a week for three weeks. P13’s medical record revealed a missed OT visit the week of 9/29/24. There was no documented method of notification to the physician (verbal or fax) for the missed OT visit in accordance with facility’s policy, in the medical record. Findings were confirmed by S1, Division Director, on 10/18/24 at 10:02 AM. On 10/18/24 at 10:14 AM, P14’s medical record was reviewed. P14 had the following orders: Effective 8/9/24 - “PT 1WK1, 2WK2, 1WK1,...” - Physical Therapy (PT): 1 visit a week for 1 week; 2 visits a week for 2 weeks; 1 visit a week for 1 week. P14’s medical record revealed a missed PT visit the week of 8/25/24. There was no documented method of notification to the physician (verbal or fax) for the missed PT visit in accordance with the facility’s policy, in the medical record. Findings were confirmed by S1 on 10/18/24 at 10:35 AM. Facility policy titled “Missed Visits/Hours”, last reviewed on 3/24/24, states “… Our Procedure: 1.0 Communicating Missed Visits/Hours. … 1.1.1.2: Missed Visit Process Flow. The field clinician is responsible for documenting the missed visit in the “Missed Visit Coordination Note” found in the medical record. 1.1.1.2.1: The Missed Visit Coordination Note will include the following: a. Date missed visit occurred; b. Reason for missed visit; and c. Method of notification to physician (verbal or fax).” On 10/18/24 at 10:00 AM, P6’s medical record was reviewed. P6’s Plan of Care (“Home Health Certification and Plan of Care”), for Start of Care 9/12/2024, contained the following order: · “SN 1WK2, 2WK1, 1WK1, 1Q3WK3…” – Skilled nurse (SN): 1 visit a week for 2 weeks; 2 visits a week for 1 week; 1 visit a week for 1 week; 1 visit every 3 weeks times 3. P6’s medical record revealed a missed nursing visit the week of 9/22/24 and a second missed nursing visit the week of 9/29/24. The medical record did not have evidence of communication to the provider regarding the missed nursing visits as per facility policy. On 10/18/24 at 11:00 AM, Staff (S), 3, Director, confirmed that P6 had 2 missing nursing visits and the medical record lacked documentation of communication to the physician regarding these visits.”