Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 017037 (X3) Date Survey Completed 10/10/2018
Name of Provider or Supplier Alabama Homecare Of Montgomery, Llc Street Address, City, State 400 South Union Street Suite 285, Montgomery, 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)
G0456 Patient/payer will no longer pay for services
CFR(s): 484.50(d)(2)

The patient or payer will no longer pay for the services provided by the HHA;


This ELEMENT is not met as evidenced by:
Based on the review of the medical records, agency policy and procedure and interview, it was determined the agency failed



a. To notify the patient of discharge from the agency and the reason for the discharge.



b. To direct the patient to appropriate community resources to continue wound care with a negative pressure wound therapy.



c. To provide discharge instructions including a complete and reconciled list of medications to the patient.



This affected Medical Record (MR) # 2, 1 of 1 records reviewed with no insurance coverage and had the potential to affect all patients admitted with private insurance.



Findings include:



Policy: 2.1.004

Subject: Patient Discharge/Transfer Process

Revised: 3/1/2018



"Purpose: To ensure continuity of care when a patient is discharged, transferred, or referred.



Policy:



1. Any of the following reason may be criteria for patient discharge or transfer:

...b. Patient or payer will no longer pay for services provided by the agency...



Procedure:



...3. Revisions to plan for patient's discharge will be communicated to:

i. Patient...



8. Patients are notified of discharge as soon as possible prior to discharge as outlined in Notice of Non-Coverage, Expedited Determination and Reconsideration for discharge policy. The agency will also provide patient and legal representative (if any) with contact information and numbers for other community resources or providers and evidence will be documented in the medical record...



10. ...When transferred and/or discharged, the patient is provided the reason for transfer or discharge. Ongoing psychosocial or physical care needs are identified and appropriate referrals made....



19. Patients received discharge instructions from the clinician at the time of discharge, to include anticipated needs for continued care, treatment and services. A complete and reconciled list of medications is provided directly to the patient and, as needed, the family, and the list is explained to patient and/or family.





1. MR # 2 was admitted to the agency on 7/25/18 with diagnoses including Type 2 Diabetes Mellitus with Diabetic Polyneuropathy and Non-Pressure Chronic Ulcer of Left Heel and Midfoot with Fat Layer Exposure.



Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 7/25/18 through 9/22/18 revealed patient was receiving SN (skilled nurse) services for wound care to left foot.



Review of the Physician Order dated 8/6/18 revealed SN was to provide Negative Pressure Wound Therapy to left foot wound three times a week for 7 weeks.



Review of the Client Coordination Note Report dated 9/11/18 by Employee Identifier (EI) # 2, Patient Care Manager, revealed the following documentation, "SN called to notify (physician identified) that Blue Cross has denied HH (home health) services for patient and that they will need to set her/him up in office for wound care, spoke to (Registered Nurse (RN) identified by name). She/He stated that they may have to DC (discharge or discontinue) wound vac because they will not be able to complete vac changes 3 days a week in clinic, she/he also stated that she/he thought they received a quick referral form from (another agency identified) per patient request and that she will send DC order for BHH (Baptist Home Health)... She/He (RN at physician's office) would let (physician identified) know about insurance denial and he/she can contact them if needed, but she/he will send DC order today."



Further review of the Client Coordination Note Report dated 9/11/18 by EI # 2, revealed the following documentation "SN called patient to let her know that BHH will be discharging her as of today per his/her request. Voicemail full, will have SN that is scheduled to see her/him today inform her/him or have patient call our office if she/he prefers."



Review of the Visit Note Report dated 9/11/18 at 1:25 PM by EI # 3, Licensed Practical Nurse (LPN), revealed documentation the wound care to the left foot was provided by the SN using the Negative Pressure Wound Therapy.



Further review of the Visit Note Report dated 9/11/18 at 1:25 PM by EI # 3, revealed documentation of care coordination communication occurred with agency EI # 2 about "visit detail" at the visit.



Further review of the Visit Note Report dated 9/11/18 at 1:25 PM by EI # 3, revealed documentation under "Has the Patient/Caregiver been included in changes/modifications to the plan of care?" and "Not applicable, the plan of care has not changed." was entered by EI # 3.



Further review of the Visit Note Report dated 9/11/18 at 1:25 PM by EI # 3, revealed documentation under plans for next visit "Assessment and teaching and wound care."



Further review of the Visit Note Report dated 9/11/18 at 1:25 PM by EI # 3, revealed no documentation there was a revision to the discharge plan, the revision to the discharge plan was communicated to the patient, the reason for the revision to the discharge plan was communicated to the patient, the patient was provided contact information of appropriate community resources to continue wound care with a negative pressure wound vacuum, or discharge instructions including a complete and reconciled list of medications were given to the patient.



Review of the written physician's order dated 9/11/18 at 5:00 PM revealed the following: "Please discharge patient from Home Health..." this was received by the agency on 9/11/18 at 5:59 PM.



Review of the Client Coordination Note dated 9/12/18 revealed documentation that agency "received call from (physician office RN identified), stated that (name of another Home Health agency) does not except her/his insurance, SN informed her/him that patient was dc'd (discharged) from BHH per their order 9/11/18, she/he (physician office RN) also stated that she/he spoke to BCBS (blue cross blue shield) regarding denial and wanted to know if there was anything else HH could do to help with that, SN informed that patient's MD (medical doctor) will need to file an appeal with BCBS. Stated that wound care center will have to DC wound vac (Negative Pressure Wound Therapy) and arrange wound care as outpatient if necessary."



Review of the Client Coordination Note dated 9/14/18 revealed a Team Case conference note with documentation of "The team reviewed the episode detail report and discussed the following: Insurance is denying coverage."



Further review of the Client Coordination Note dated 9/14/18 revealed documentation of "Based on discussion the recommendation of the team is discharge."



Review of the Visit Note Report dated 9/14/18 at 3:19 PM revealed an "RN discharge - Data Collection Only" note with documentation of "discharging based on last skilled visit" which occurred on "9/11/18".



Further review of the Visit Note Report dated 9/14/18 at 3:19 PM revealed "Patient remained in the community (without formal assistive services)" documentation.



Further review of the Visit Note Report dated 9/14/18 at 3:19 PM revealed documentation under discharge teaching provided as "N/A - Not Applicable".



Review of the entire MR from 9/11/18 through 9/14/18 revealed no documentation of communication with patient about discharge plan.



The agency staff failed to ensure patient was directed to an appropriate community resource for continued wound care with a negative pressure wound therapy.



The agency also failed to document the revision to the discharge plan was communicated to the patient, the reason for the revision to the discharge plan was communicated to the patient, the patient was provided contact information of appropriate community resources to continue wound care with a negative pressure wound care, or discharge instructions including a complete and reconciled list of medications were given to the patient.



An interview was conducted on 10/10/18 at 1:44 PM with EI # 1, Executive Director, who confirmed there was no additional documentation in the MR for the discharge of MR # 2.