F & F Devoted Home Health Services Inc.

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on record review, observation and interview, the agency failed to ensure documentation of coordination of services between the agency and other providers of health care services involved in the care of four (Patients #2, #3, #4, and #5) of four patients receiving services from other providers of health care services, whose records were reviewed, The failure could place patients at a risk of harm, due to a lack of shared information regarding the ongoing care and service needs. FINDINGS INCLUDED: Clinical Record #2: Record review of the clinical record for Patient # 2 contained a Plan of Care (POC) for the certification period of 04/30/2024 to 06/28/2024. The POC included a start of care date of 05/06/2023 with a principal diagnosis of Other specified anemias (Deficiency of healthy red blood cells in blood. Red blood cells (RBCs) are essential to carry oxygen to all parts of the body). The POC was signed by the Director of Nursing (DON) and dated 04/25/2024. The POC contained an order for Skilled Nurse (SN) visits one time per week for nine weeks and two as needed visits. The POC read in part, “…Community Resources Providing Assistance (Pt is receiving Attendant services from Identifier #100) …Orders For Discipline and Treatment…Attendant Care staff to assist with personal care, Activities of daily living (ADLs), light housekeeping, companionship, errands and assistance to therapeutic activities per Attendant Task...” During a home visit conducted on 07/19/2024 at approximately 9:00 a.m., the surveyor asked about the care and services Patient # 2 was receiving. The patient stated he was receiving personal assistance services from another agency. Patient # 2’s Attendant was present, and provided the name of the agency as, Identifier #200. Patient # 2’s record did not include any documentation that indicated the agency had coordinated care with Identifier #200. Clinical Record #3: Record review of the clinical record for Patient #3 revealed a POC for the certification period of 05/01/2024 to 06/29/2024 with a SOC date of 05/01/2024, signed and dated by the DON on 05/01/2024. The POC included a principal diagnosis of Type 2 diabetes w diabetic autonomic (poly) neuropathy (Diabetic autonomic neuropathy is a common complication of diabetes. It occurs when high levels of sugar and fat in the blood damage the nerves that control the internal organs) and other diagnosis of Dependence on renal dialysis (Dialysis is a treatment for individuals whose kidneys are no longer able to filter waste and excess fluids from the blood effectively). The POC contained an order for SN visits two times per week for one week, one time a week per week for eight weeks and as needed visits. The POC read in part, “…SN to assess dialysis access … site on left arm for possible signs and symptoms of infection or other abnormality…” Patient # 3’s record did not include any documentation that indicated the agency had coordinated care with the renal dialysis provider. Clinical Record #4: Record review of the clinical record for Patient #4 revealed a POC for the certification period of 03/31/2024 to 05/29/2024 with a SOC date of 02/09/2022 and was dated and signed by the DON on 03/26/2024. The POC included a principal diagnosis of Athscl (Arteriosclerosis) heart disease of native coronary artery without (w/o) ang pctrs (Arteriosclerosis occurs when the blood vessels that carry oxygen and nutrients from the heart to the rest of the body (arteries) become thick and stiff — sometimes restricting blood flow to the organs and tissues. Without chest pain). The POC read in part, “...Caregiver Status…Pt is receiving PHC/Attendant services from Identifier 300...Attendant Care Staff to assist with personal care, ADLs, light housekeeping, companionship, errands and assistance to therapeutic activities per Attendant Care Plan…” Patient # 4’s record did not include any documentation that indicated the agency had coordinated care with Identifier 300. Clinical Record #5: Record review of the clinical record for Patient #5 revealed a POC for the certification period of 03/30/2024 to 05/28/2024 with a SOC date of 10/03/2023 and was dated and signed by the DON on 03/26/2024. The POC included a principal diagnosis of Chronic diastolic (congestive) heart failure (Diastolic heart failure, also known as heart failure with preserved ejection fraction is a condition in which your heart’s main pumping chamber (left ventricle) becomes stiff and unable to fill properly. Diastolic heart failure is one of two kinds of left-sided heart failure). The POC read in part, “...Caregiver Status…Daily/Attendant services… Community Resources Providing Assistance (Pt is receiving attendant services from Identifier 300...Attendant Care Staff to assist with personal care, ADLs, light housekeeping, companionship, errands and assistance to therapeutic activities per Attendant Care Plan…” Patient # 5’s record did not include any documentation that indicated the agency had coordinated care with Identifier 300. During an interview on 07/18/2024 at approximately 11:19 AM, with The Adm and the DON, the surveyor discussed the above findings and requested documentation of coordination of services for Patients #2, #3, #4, and #5. The DON provided a blank form the agency used for coordination of services. The DON stated, “I did the coordination but could not find it.” The surveyor asked the DON for the name of the renal dialysis center. The DON stated, “I don’t the name of the dialysis center. I never thought about it because we never had a problem to report to the dialysis.” The surveyor asked the DON was he aware of why coordination of care was important. The DON stated, “I understand now why it is important that everyone know what services each provider is providing.” Review of agency policy titled “Monitoring Patient Care/Coordination of Care TX.8” revised 060106 read in part: “ ...Policy...Agency will collaborate with other organizations providing services…to ensure appropriate coordination of care for the patient...””