Assisted Home Care

“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 interview and record review, the home health agency (HHA) failed to ensure patients’ plan of care (POC) for home visits were followed, and documented for three (3) active patients (Patient 6, 8 15) and one (1) discharged (Patient 11) patient and failed to follow the POC during the certified home health aide (CHHA) home visit for 1 patient (Patient 5) when: 1. Patient 6 had missed Speech Therapy (ST) visit on week of 3/2/26 to 3/8/26. 2. Patient 11 had missed Skilled Nursing (SN) visit on week of 3/9/26 to 3/15/26 and 3/16/26 – 3/22/26. 3. Patient 8 had missed SN visit the week of 3/30/26 to 4/5/26. 4. Patient 15 had missed SN visit during the week of 10/20/25 to 10/26/25. 5. CHHA failed to obtain Patient 5’s vital signs. These failures had the potential to affect patient’s goals not to be met timely and had the potential to compromise the quality of patient’s care. 3. During a review of Patient 8’s health records on 4/6/26 at 2:27 p.m., the Plan of Care indicated skilled nursing visit frequency of one visit per week for the certification period of 3/25/26 to 5/23/26. During the week of 3/30/26 to 4/5/26, no skilled nursing visit was documented. During an interview with the DPCS on 3/9/26 at 11:29 a.m., the DPCS acknowledged the visit frequency was not followed. During a review of the HHA policies and procedure (P&P) titled “Missed Visits or Shifts and Refusal of Services,” dated 9/22, the P&P indicated in part, “…If a visit, treatment, or service is missed that is required by the plan of care (visit frequency), then the agency must notify the responsible physician. Physician notification is documented in the clinical record. Documentation of missed visits/shifts will include: Reason visit/shift not made, Notification of the physician, any new orders for care or service – change to plan of care, if appropriate.” 4. During a review of Patient 15’s health records on 4/8/26 at 2:48 p.m., the Plan of Care indicated a skilled nursing visit frequency of two visits per weeks for four weeks for the certification period of 9/30/25 to 11/28/25. During the week of 10/13/25 to 10/19/25 there was only one skilled nursing visit recorded. No missed visit documented. During an interview with the DPCS on 3/9/26 at 11:29 a.m., the DPCS acknowledged the visit frequency was not followed. During a review of the HHA policies and procedure (P&P) titled “Missed Visits or Shifts and Refusal of Services,” dated 9/22, the P&P indicated in part, “…If a visit, treatment, or service is missed that is required by the plan of care (visit frequency), then the agency must notify the responsible physician. Physician notification is documented in the clinical record. Documentation of missed visits/shifts will include Reason visit/shift not made, Notification of the physician, any new orders for care or service – change to plan of care, if appropriate.” 5. During a home visit for Patient 5 with the Certified Home Health Aide (CHHA) on 4/7/26 at 9 a.m., the CHHA stated she would provide a patient a bath. The CHHA proceeded to give the patient a bath. The CHHA did not obtain the patient vital signs during the home visit. During a review of Patient 5’s CHHA care plan on 4/8/26 at 9:47 a.m., the care plan indicated for the CHHA was to obtain vital signs at every visit. During an interview with the DPCS on 4/9/26 at 11:29 a.m., the DPCS acknowledged the care plan was not followed. During a review of the HHA policy and procedure (P&P) titled “Plan of care” dated 9/22, the P&P indicated, “The individualized plan of care must specify the care and services necessary to meet the patient specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the Agency anticipates will occur as a result of implementing and coordinating the plan of care.” Findings: 1.During a review of Patient 6’s clinical record, Patient 6’s POC and ST physician’s order (PO) were reviewed. The POC and PO indicated that the ST was to provide two (2) visits per week from 2/23/26 to 3/15/26. Further review of the Patient 6’s clinical record, ST provided only one visit the week of 3/2/26 to 3/8/26. No documentation was found for the missed visit. 2. During a review of Patient 11’s clinical record, Patient 11’s POC and SN PO were reviewed. The POC and PO indicated that SN was to provide 2 visits per week from 3/2/26 – 3/22/26. Further review of Patient 11’s clinical record, Patient 11 received only 1 visit the week of 3/9/26 to 3/15/26 and 3/16/26 to 3/22/26. No documentation was found why the Patent 11’s POC was not followed. During a concurrent interview and record review on 4/9, at 11:44 a.m. with the Director of Patient Care Services (DPCS), Patient 6 and 11’s clinical records were reviewed. The DPCS acknowledged the missing ST visit for Patient 6 and SN visit for Patient 11 and further acknowledged the missing documentation for the missed visits. During a review of the HHA policies and procedure (P&P) titled “Missed Visits or Shifts and Refusal of Services,” dated 9/22, the P&P indicated in part, “…If a visit, treatment, or service is missed that is required by the plan of care (visit frequency), then the agency must notify the responsible physician. Physician notification is documented in the clinical record. Documentation of missed visits/shifts will include: Reason visit/shift not made, Notification of the physician, Any new orders for care or service – change to plan of care, if appropriate.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to ensure medications were reviewed and the current medication profile was updated to reflect the medications the patient was taking for one of 17 sampled patients (Patient 3). This facility failure had the potential for the patient to receive unnecessary medication. During a home visit for Patient 3 with Registered Nurse (RN2) on 4/7/26 at 11:24 a.m., the home health agency medication profile was compared with the home medication list. The medication Colace (a laxative) was listed on the home health agency medication profile but was not included on the home medication list. RN2 verified the Colace with the caregiver, RN2 acknowledged the home health agency medication profile needs to be updated. During an interview with the Director of Patient Care Services (DPCS) on 4/9/26 at 11:29 a.m., the DPCS acknowledged home health medication profile needs to be updated. During a review the facility policy and procedures (P&P) titled “Medication Management,” dated 9/22, the P&P indicated “All medication a patient is taking will be documented on the medication profile to identify possible ineffective drug therapy or adverse reactions, side effects, drug allergies, and contraindicated medications.””