| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 017027 | (X3) Date Survey Completed 09/26/2018 |
| Name of Provider or Supplier Hga Homecare, Llc | Street Address, City, State 2050 Beltline Rd Sw, Decatur, AL | |
| For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency. | ||
| (X4) ID Prefix Tag | Summary Statement of Deficiencies
(Each deficiency should be preceded by full regulatory or LSC identifying information) |
| G1014 | Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on review agency policy and procedure, medical records (MR), and interview it was determined the staff failed to prepare clinical note documentation that included all interventions and services provided to meet patient needs. This affected Home Visits (HV) # 1 and # 2, which was 2 of 7 HV's conducted and had the potential to affect all patients admitted to the agency. Findings include: Policy Number: 2.1.017 Subject: Coordination of care, From Admit thorough Discharge Revision Date: 01/01/18 Policy: ...provides care and services within an integrated continuum of care system...by: Identifying patient needs through assessment and communication with other health care providers Procedure: 3. During time of referral, transfer, or discharge... a. Patients are referred to alternative agencies when the patient requires services that unable to be met by the agency and/or for continuing care needs. ...b. When changes occur in caregiver support or the environment that affect patient treatment c. Appropriate, timely communication with the patient, caregivers...involved in the patient's care regarding patient needs. goals, and care... 6. Coordination of services with other organizations and community: When the patient receives services from other organizations and/or individuals care is coordinated to ensure that patient's needs are met...without duplication of services... 7. Coordination of care with patient and caregiver: Written information obtained from the plan of care will be provided to the patient and caregiver... d. Pertinent instructions related to the patient's care and treatments...specific to the patient's needs... **** 1. HV # 1 was admitted to the agency 8/18/18 with diagnoses including Dizziness and Giddiness, Other Pancytopenia, Personal History of Nicotine Dependency and History of Falling. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 8/18/18 to 10/16/18 included a physician's verbal order dated 8/28/18 for MSW to make a visit to assess community resources. Further review revealed another physician's order dated 8/31/18 to omit order for MSW Week of 8/26/18. MSW to EVAL (evaluation) week of 9/2/18. The add-on evaluation MSW visit dated 9/4/18 was completed 7 days after the initial MSW eval order obtained and revealed HV # 1 has no caregiver, lives alone in a cluttered soiled living area, cannot physically do laundry, housekeeping, prepare meals consistently, requested assistance in accessing provider/homemaker services, worries about having a heart attack and being at home alone and grieves for deceased spouse who passed away less than 3 months ago. The MSW documentation dated 9/4/18 revealed community services needed were meals on wheels and volunteer services. The MSW documented care coordination occurred with the patient for community resources and documented "instructed the patient regarding support networks available in the community, including meals on wheels and homemaker services. " There was no documentation the MSW notified or communicated with any outside community resources including meals on wheels, volunteer and homemaker services which were identified as patient needs. In an interview conducted on 9/26/18 at 9:35 AM, Employee Identifier (EI) # 3, Performance Improvement Coordinator confirmed the aforementioned findings. 2. HV # 2 was admitted to the agency 9/1/18 with diagnoses including Sepsis due to Escherichia Coli, Bacteremia and History of Falling. Record review of the HHC and POC dated 9/1/18 to 10/30/18 included a physician's verbal order dated 9/6/18 for MSW to eval for any services to assist patient with ADL (activities of daily living). On 9/18/18, which was 12 days after the initial MSW eval order dated 9/6/18, the MSW completed an add-on evaluation visit. The 9/18/18 MSW documentation revealed HV # 2 has no caregiver, lives alone in a cluttered soiled living area, no willing or able caregiver to access food, cannot physically do housekeeping, prepare meals. HV # 2 requested assistance in accessing provider/homemaker services and was interested in meals on wheels. The 9/18/18 MSW documentation revealed community services needed were meals on wheels, volunteer services and charitable organizations. The MSW documented care coordination occurred with the patient, discussed community resources, provided the community resource list and instructed the patient regarding support networks available in the community, including meals on wheels and homemaker services. The MSW documented in a Client Coordination Note Report dated 9/18/18 no follow-up needed at this time. There was no documentation the MSW notified or communicated with any outside community resources, meals on wheels, volunteer and charitable organizations for assistance in meeting the patient's identified needs. In an interview on 9/26/18 at 10:10 AM, EI # 1, Executive Director confirmed the above findings. |