Kina Healthcare Services 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 that initial assessment visits were conducted within 48 hours of the referral for 2 of 6 patients (Patients #2 and #3) whose records were reviewed. Failure of the agency to initiate care within 48 hours of receiving the referrals resulted in the care and treatment of Patients #2 and #3 being delayed, placing patients at risk for negative outcomes. Findings include: Review of Patient #2’s clinical record showed a referral date of 11/08/24. The initial assessment was completed on 11/21/24, 13 days after the referral. There was no documentation of the reason for the delay in SOC found in the clinical record. Review of Patient #3’s clinical record showed a referral date of 11/22/24. The initial assessment was completed on 11/25/24, 3 days after the referral. There was no documentation of the reason for the delay in SOC found in the clinical record. An interview with AA/DON was held on 02/12/2026 at 3:13PM. The AA/DON was asked who was responsible for overseeing clinical services and she said, “I am.” The AA/DON was asked the process of admitting patients on services after a referral was received. The AA/DON stated that patients are admitted within 48 hours. The AA/DON was asked the process if the agency does not admit the patient within 48 hours. The AA/DON stated that she informs the physician and documents this in the communication note. The AA/DON was informed that the SOC for Patient #2 and Patient #3 was not completed within 48 hours and there were not any communication notes in the clinical record. The AA/DON was asked why the initial assessments for Patient #2 and Patient #3 were not done within 48 hours of receiving the referral. The AA/DON said she was not sure why it was not done for Patient #2 but she thinks Patient #3 had dialysis on the weekend. When the AA/DON was asked, what harm could come to the patient if the initial assessment was not done within 48 hours of the referral, the AA/DON said she was the nurse that did the SOC for Patient #3 and thinks Patient #3 had dialysis, so there was no possible harm… AA/DON stated “I thought there was a note in the clinical record.” A phone call was placed to Patient #2 on 02/12/26 at 3:20pm and there was no answer. A phone call was placed to Patient # 3 on 02/12/26 at 3:21pm and there was no answer. An interview with the Administrator was held on 02/12/2026 at 3:37pm to ask who was responsible for accepting referrals and he said, “I do.” The Administrator was asked how he receives referrals, and he said, “I receive referrals through email.” The Administrator was asked the date he received the referrals for Patient #2 and Patient #3. The Administrator stated that he received the referral on 11/22/24 for patient #3. The Administrator was asked when the SOC was completed and he said it was completed on the 11/25/24. The Administrator was asked what the timeframe was that a SOC must be completed after accepting a referral. The Administrator stated that a SOC must be completed within 48 hours. The Administrator stated that the SOC was not done within 48 hours because the patient was in the hospital. The surveyor requested documentation of the attempts made to contact the patient within 48 hours. The Administrator stated that he needed time to find the documentation. At 3:53pm the Administrator stated that the patient did not want a visit on the weekend. The Administrator was asked to provide documentation of this. No documentation was provided. During a continued interview with Administrator on 02/12/2026 at 3:44pm regarding Patient #2, the Administrator was asked what was the date of the referral, and he said it was 11/08/24. The Administer was asked when was the SOC completed and he replied, “it was completed on 11/21/24.” The Administrator stated that he needed to look in his email for the date of when he first received the referral. The Administrator stated that the patient was not admitted within 48 hours of receiving the referral because he was waiting for authorization. The Administrator stated that he received authorization from the insurance on 11/19/24, then the client was admitted two days later. The Administrator was asked to provide documentation that he notified the provider. No documentation was provided. The Adm was asked what harm could come to the patient if the initial assessment was not done within 48 hours of the referral, and he said there was no risk for harm because Patient #2 was in the hospital and Patient #3 had dialysis. Review of the HHA’s policy titled, “Initial Comprehensive Assessment,” dated March 1, 2020, read in part, “The initial assessment visit must be held either within 48 hours of referral, within 48 hours of the patient’s return home, or on the physician/allowed practitioner-ordered start of care.””