Jefferson Homecare

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on Clinical Record review and Agency staff interviews, the Skilled Nurse (SN) failed to ensure the patients Plan of Care (POC) included the required elements of all medication and treatments in 1 (#11) of 17 (#1- 17) patient records reviewed with orders for medications and 1 (#16) of 1 patient record reviewed with orders for enteral nutrition. This failed practice had the potential to result in harm for all patients on census by inhibiting the SN and Physician’s ability to make informed decisions regarding the patient’s medication regimen related to potential adverse effects, drug reactions, significant side effects or significant drug interactions. Additionally, the patient and family would not be instructed on specific enteral (artificial) nutrition which could cause harm to the patient. Findings follow: 1. Review of Clinical Record #11 with a Start of Care date of 05/29/25 revealed a patient with a diagnosis of Pressure Ulcer of sacral region, Stage 2. a. On 08/19/25 at 1:05 p.m., during a home visit, the patient’s medication at home included AZO Urinary Pain Relief. The family member stated, “I’ve been giving her those for a while.” b. The Home Health Certification and Plan of Care dated 07/28/25 – 09/25/25 did not include the AZO on the medication list. c. A Policy and Procedure provided by the Administrator on 8/21/25 documented, “….all clinicians will participate in medication review and reconciliation throughout the episode….Review all medications including over the counter (OTC) medications, vitamins, herbs and herbal products….” 2. Review of Clinical Record #16 with a Start of Care date of 08/02/25 revealed a patient with a diagnosis of Hypertension, Aphasia, Cerebral Infarction, and Gastrostomy (stomach) tube for enteral (artificial) nutrition. a. The Home Health Certification and Plan of Care dated 08/02/25 – 09/30/25 included orders which documented, “…Enteral Feedings Osmolite 1.5 250 ml [milliliters] via bolus…Flush with 180 ml of H20 [water] before and after each feeding…” The order did not include the frequency for this feeding. b. On 8/21/25, the Administrator stated they were able to locate the original orders in the hospital records and updated the orders on the Plan of Care accordingly.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on clinical record review and staff interviews, it was determined clinical staff did not follow Physician orders for visit frequency in 1 (5) of 17 (#1 – 1 7) records reviewed. This failed practice had the potential to affect the quality of care received by all patients currently on census, in that patients may not receive treatments as ordered by the Physician which could result in adverse outcomes. Findings follow: Review of clinical record #5 with a Start of Care (SOC) date of 03/06/2025 showed, a “Home Health Certification and Plan of Care dated 03/06/2025 through 05/04/2025 for “Skilled Nurse (SN) 3wK1 (three times a week for one week) to evaluate patient and develop plan of care.” The clinical record contained SN visit note for 03/06/2025 only. Review of a “client coordination miscellaneous note” dated 03/10/2025 showed SN1wk 8. During an interview on 08/19/2025 at 2:20 PM Agency Personnel #1 confirmed the Physician did not receive or sign an order to decrease SN frequency to SN 1Wk8.”

“Coordinate patient care CFR(s): 484.105(c)(2) Coordinating patient care, This Element is not met as evidenced by: Based on clinical record review and staff interview, the Agency failed to communicate with the laboratory, physician or patient to ensure coordination of patient care in 1 (#7) of 17 (#1 - #17) records reviewed. This failed practice had the potential to affect the quality of care received by all patients currently on census, in that patients may not receive treatments as ordered by the Physician which could result in adverse outcomes. Findings follow: Review of clinical record # 7 with a start of care date of 03/06/2025 showed, Patient #7 had diagnoses of Sepsis Unspecified Organism, Anemia in Neoplastic Disease, and Adult Failure to Thrive. On a document titled “Physician Order” dated 08/12/2025 the order description documented “SKILLED NURSE TO OBTAIN CBC (COMPLETE BLOOD COUNT) AND CMP (COMPREHENSIVE METABOLIC PANEL) VIA VENIPUNCTURE ON 08/13/2025.” Review of a “Clinical Note” dated 08/19/2025, the skilled nurse documented “Late entry for 08/13/2025, unable to obtain labs due to no blood return after 4 attempts.” Review of a “Physician Order note,” dated 08/19/2025 at 3:36 PM, documented discontinue lab draw from 08/12/2025 due to unable to stick due to dehydration. Will reassess on 08/22/25 for lab draw.” The CMP and CBC lab results or attempts to obtain ordered lab were not in the clinical record. There was no evidence of communication between Agency, or physician to ensure coordination of care until 08/19/2025. Review of a document titled, “Home Care Record, Information Management” showed, “Clinical notes for all services shall be: Turned in to the agency in person or by fax, at least within 2 days from visit. For Point of Care users, synchronization will occur within 24 hours from visit.” During an interview on 08/19/25 at 2:30 PM, Agency Personnel #1 confirmed there was no documentation in the clinical record of attempted venipunctures or communication with the Physician to follow up on ordered tests. Confirmed failure to coordinate patient care with Physician and Agency staff on 08/19/2025.”