Mercyhealth at Home

“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 Registered Nurse failed to conduct an initial assessment within 48 hours of referral order in 3 of 17 (#4, 6, and 11) patient records reviewed. Findings include: Review of agency policy/procedure titled, “Admission Assessment Process” last reviewed 06/20/2024 revealed in part ’’...Patients referred for skilled nursing services receive a skilled nursing visit by a licensed RN (Registered Nurse) within 48 hours of receiving referral...” Review of Patient #4’s record revealed a referral order dated, 01/05/2026. The initial RN assessment was documented on 01/08/2026, three days after referral order. No documented patient requests to start services at a later date, no physician orders to change/delay start of service, and no documented attempts to schedule the assessment prior was found within the record. Review of Patient #6’s record revealed a referral order dated, 05/21/2026. The initial RN assessment was documented on 05/26/2026, five days after referral order. No documented patient requests to start services at a later date, and no documented attempts to schedule the assessment prior was found within the record. Physician order dated, 05/21/2026 to approve delay of start of care revealed no explanation/reason for delay. Review of Patient #11’s record revealed a referral order dated, 04/10/2026. The initial RN assessment was documented on 04/15/2026, five days after referral order. No documented patient requests to start services at a later date, no physician orders to change/delay start of service, and no documented attempts to schedule the assessment prior was found within the record. During an interview with Director A on 06/09/2026 at 9:10 AM, Director A stated that the initial assessment is expected to be completed within 48 hours of receiving a referral.”

“Skilled professional performs assessment CFR(s): 484.55(a)(2) When rehabilitation therapy service (speech language pathology, physical therapy, or occupational therapy) is the only service ordered by the physician or allowed practitioner who is responsible for the home health plan of care, the initial assessment visit may be made by the appropriate rehabilitation skilled professional. For Medicare patients, an occupational therapist may complete the initial assessment when occupational therapy is ordered with another qualifying rehabilitation therapy service (speech-language pathology or physical therapy) that establishes program eligibility. This Element is not met as evidenced by: Based on record review and interview the agency Physical Therapist (PT) when therapy was the only service ordered failed to conduct an initial assessment within 48 hours of referral order in 3 of 17 (#2, 8, and 16) patient records reviewed. Findings include: Review of agency policy/procedure titled, “Admission Assessment Process” last reviewed 06/20/2024 revealed in part “...All patients admitted for home health services will receive a comprehensive assessment. This initial comprehensive assessment may be completed by a... physical therapist...” Review of Patient #2’s record revealed a referral order dated, 05/19/2026. The initial PT assessment was documented on 05/26/2026, seven days after referral order. Documented attempts to schedule the assessment on 05/21/2026 and 05/22/2026, no further documented attempts were found. No documented patient requests to start services at a later date, and no physician orders to change/delay start of service were found. Review of Patient #8’s record revealed a referral order dated, 05/28/2026. The initial PT assessment was documented on 06/02/2026, five days after referral order. No documented patient requests to start services at a later date, and no documented attempts to schedule the assessment prior was found within the record. Physician order dated, 06/09/2026 (seven days after initial assessment) to approve delay of start of care revealed no explanation/reason for delay. Review of Patient #16’s record revealed a referral order dated, 01/13/2026. The initial PT assessment was documented on 02/10/2026, thirty days after referral order. Documented attempts to schedule the assessment on 01/19/2026 (6 days), 01/29/2026 (10 days) and 02/03/2026 (23 days), no other documented attempts were found. A documented patient requests (on 02/03/2026) to start services on 02/10/2026 was found. No documented explanation for the delay in care was found. Physician order dated, 02/10/2026 to approve delay of start of care revealed no explanation/reason for delay. During an interview with Director A on 06/09/2026 at 9:10 AM, Director A stated that the initial assessment is expected to be completed within 48 hours of receiving a referral.”