Elite Home Health

“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 2 (#14 and #18) of 18 (#1 - #18) Clinical Records reviewed. 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 clinical treatment regimen related to potential infection and safety due to use of a dialysis port (access line). Findings follow: Review of Clinical Record #14 with a start of care (SOC) date of 10/30/25 revealed a patient with a diagnosis of Osteomyelitis of vertebrae, unstageable pressure ulcers left and right buttock, and Paraplegia. The visit notes and the supplies list on the Plan of Care (POC) indicated the patient had an indwelling catheter. The Home Health Certification and Plan of Care with a certification period of 10/30/25 - 12/28/25 did not include orders for an indwelling catheter. Review of Clinical Record #18 with a SOC date of 10/31/25 revealed a patient with a diagnosis of chronic ulcer right lower leg and Acute Kidney Injury. The visit notes indicated the patient had a routine treatment for dialysis for Acute Kidney Failure. The Home Health Certification and Plan of Care with a certification period of 10/31/25 - 12/29/25 did not include orders for the care and prevention of injury in relation to the dialysis port. On 12/04/25, the Agency Representatives were asked to provide any further documentation regarding the orders and plan of care for these two identified issues, and none was provided.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on Clinical Record review and staff interview, it was determined the Agency staff did not provide care in accordance with the written Plan of Care (POC) in 3 (#11, #13 and #18) of 18 (#1 - #18) Clinical Records reviewed. This failed practice had the potential to affect the quality of care received by all patients currently on census, in that, there was a risk of adverse outcomes, potential to affect the attainment of the patients’ individual goals and a risk of hospitalizations due to unrecognized signs/symptoms of disease exacerbation. Findings follow: Review of Clinical Record #11 with a start of care of 10/21/24 revealed a patient with diagnoses of post-surgical wound dressing and Type 2 Diabetes Mellitus. The Home Health Certification and Plan of care dated 10/18/25- 12/14/25 noted an order for skilled nursing visits 1 time a week for 1 week, 2 times a week for 8 weeks. 2 visits were ordered for the week of 11/10/25 but only one visit was made. Review of Clinical Record #13 with a start of care of 10/18/25 revealed a patient with diagnosis of Sequalae of Cerebral Infarction, Hypertension, and kidney disease. The Home Health Certification and Plan of care dated 10/18/25 - 12/16/25 noted an order for skilled nursing visits 1 time a week for 2 weeks, every 2 weeks for 2 weeks, 1 every 4 weeks times 4 weeks, and 1 time a week for 1 week. There was no skilled nursing visit in the week of 11/16/25 as ordered. Review of Clinical Record #18 with a start of care of 10/31/25 revealed a patient with diagnosis of Chronic Ulcer of right lower leg, Acute Kidney Failure requiring Dialysis and Hypertension. The Home Health Certification and Plan of Care dated 10/31/25 - 12/29/25 noted an order, “...Skilled nurse may perform up to 2 PRN [as needed] visits for cardiac complications such as ...Increase in weight of 5 # in 1 week...” There was no documentation of continued weight monitoring. The admission weight was documented in the vital signs report and none other since 10/31/25. On 12/04/25, the Agency Representatives stated the standing orders for those patients with a cardiac diagnosis include weight monitoring and ankle circumference monitoring which are to be completed on skilled nursing visits.”