Adoration Home Health

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on clinical record review and staff interview, it was determined the agency staff failed to follow out the plan of care for assessing patients with Congestive Heart Failure (CHF) in 3 (#5, #7, #9) of 18, (#1-#18) medical records reviewed. If left uncorrected, this failed practice has the potential to place all patients with CHF at risk for complications, exacerbation of condition, hospitalization and death. Clinical record #5 showed: A) Start of care on 04/10/2025 showed an order for “Heart failure; RN (Registered Nurse) to assess/teach LPN (Licensed Practical Nurse) to observe/teach cardiopulmonary system to identify signs of decompensation and intervene to minimize the severity of fluid overload. Observe patient ability to monitor and record daily weights and vital signs, including pulse and blood pressure; record patient reported weight or weigh patient as needed, report increased edema or weight gain of >2 LBS (greater than two pounds) in 1 day or >5 LBS in 1 week or more over target weight. B) A Vital Sign Report with visit entries for 4/10/25, 4/16/25, 4/16/25 (therapy visit), 4/22/25, 4/24/25, 4/24/25 (therapy visit), 4/29/25. c) Only one weight recorded on 4/10/25. Clinical record #7 showed: A) A Plan of Care with certification dates of 03/03/2025-05/01/2025 B) Practitioners order to “Report increased edema or weight gain on >2 LBS in 1 day or >5 LBS in 1 week or 5LBS or more over target weight. May measure abdominal girth if unable to weigh. Scales and BP (blood pressure) monitor to be provided if needed. C) Vital sign report showing patient visits for 03/03/25, 03/08/25,03/12/25,03/13/25,03/19/25, 03/19/25 (therapy), 03/26/25,03/31/25,04/01/25,04/08/25,04/09/25,04/16/25,04/23/25,04/24/25,04/29/25. D) Weights were recorded only for 03/03/25, 03/12/25, 04/01/25, 04/09/25, 04/24/25, 04/29/25 E) There was no abdominal girth recorded for any visit date in lieu of weight. Clinical Record #9 revealed: A) A Plan of Care Certification Period of 04/06/25-06/04/25 B) Practitioners orders PT (physical therapist)/ PTA (physical therapy assistant) to monitor for Heart Failure exacerbation and record patient reported weight and notify the physician and/or the RN (registered nurse) clinical manager for physician notification of HF (heart failure) exacerbation (2 LBS weight gain in 1 day, 5 LBS in a week or 5 LBS over baseline; increased SOB (shortness of breath), edema (swelling), needing more pillows at night, crackles in basis of the lungs or PMI shift) (a difference in where one can hear the heart beat on a persons chest the loudest) C) Visit Entries for vital signs on 04/11/2025, 04/11/2025 (therapy visit), 04/14/25,04/16/25, 04/22/25, 04/23/25 D) Weights for the patient were only recorded on 04/11/25, 04/11/25 (therapy), 04/14/25 & 4/16/25. On 05/01/2025 3:00 PM, the Agency Administrator was asked to provide any further information. None was forthcoming.”

“Goals in the patient’s plans of care CFR(s): 484.110(a)(3) Goals in the patient’s plans of care and the patient’s progress toward achieving them; This Element is not met as evidenced by: Based on clinical record review and personnel interview, it was determined the Agency failed to ensure there were assessments and measurements of wounds to demonstrate progress toward healing in3 (#4, #6, & #8) of 18, (#1-#18) clinical records reviewed that have wounds being treated by the agency. If left uncorrected, this has the potential to affect all patients on census with wounds in that frequent assessment of wounds is necessary to avoid prolonged presence of wound, possible infection, complications, increase in size of wound and rehospitalization. Findings follow: Clinical Record #4 revealed the following A) Plan of care with certification dates from 04/08/25-06/06/2025 B) Diagnosis of Pressure Ulcer of Sacral Region Stage 2 C) A Wound Record Report showing no wound measurement during the current certification period. Clinical Record #6 Showed: A) Plan of Care with certification dates from 03/28/25-05/26/25 B) Diagnosis of Encounter for orthopedic aftercare following surgical amputation. (of great toe) C) A wound record report without wound measurements for visits dates 04/02/25, 04/07/25, 04/09/25, 04/14/25, 04/16/25, 04/23/25, 04/28/25. Clinical Record #8 Revealed: A) Plan of Care Certification period from 04/12/25-06/10/25 B) A Diagnosis of Pressure Ulcer Sacrum, Stage 2, and DTI (deep Tissue Injury) on the left buttock, a wound to right hand, wound to right buttock and venous ulcers on both right and left leg. C) Wound Record Report did not have an assessment for the wounds on the right hand and the right buttock. D) The Wound Record Report did not have an updated and routine assessment, including measurement, for the remainder listed wound areas. On 05/01/2025 at 3:00 PM, the Administrator was asked to provide further information. None was forthcoming.”