Mission Home Health of Redding

“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 agency failed to ensure the physician was notified of the need to modify the Plan of Care (POC - a personalized doctor approved plan of care that includes medical services, goals, and treatments) for one of six sampled patients (Patient 2) when Medical Social Worker services were not provided in a timely manner. This had the potential for Patient 2’s related care needs to go unaddressed including counseling, resource connection, and patient advocacy. The facility policy titled “Missed Visits,” dated March 2024, indicated “Missed visits will be communicated to the… patient’s physician… Missed visits will be documented in the clinical record… If a visit is missed and not rescheduled the clinician will… Notify the physician... The physician will decide if a visit may be skipped or additional intervention is required.” Patient 2’s Clinical Health Record was reviewed. Patient 2 was admitted to home health services on 4/30/26 for diagnoses that included chronic obstructive pulmonary disease (A restrictive lung disease that causes fatigue and makes breathing difficult), chronic heart failure, and muscle weakness. During a concurrent interview and record review on 5/21/26 at 10:15 am with Patient Care Coordinator (PC) the POC for Patient 2 was reviewed. PC confirmed that a physician’s order, dated 5/3/26 indicated the patient should have Medical Social Worker (MSW) assessed Patient 2 one time within 1 week. PC confirmed that Patient 2 had not yet been assessed by MSW, nor had the physician been notified that at MSW visit had not been conducted as ordered. PC confirmed the physician should have been notified within 1 week and the POC revised.”

“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 interview and record review, the agency failed to ensure the Plan of Care (POC - a personalized doctor approved plan of care that includes medical services, goals, and treatments) was followed for one of six sampled patients when Patient 2 did not receive an assessment from a Medical Social Worker as order by the physician. This failure had the potential to cause a delay in needed services, which could lead to negative clinical outcomes. The facility policy titled “Missed Visits,” dated March 2024, indicated “Missed visits will be communicated to the… patient’s physician… Missed visits will be documented in the clinical record… If a visit is missed and not rescheduled the clinician will… Notify the physician... The physician will decide if a visit may be skipped or additional intervention is required.” Patient 2’s Clinical Health Record was reviewed. Patient 2 was admitted to home health services on 4/30/26 for diagnoses that included chronic obstructive pulmonary disease (A restrictive lung disease causes fatigue and makes breathing difficult), chronic heart failure, and muscle weakness. During a concurrent interview and record review on 5/21/26 at 10:15 am with Patient Care Coordinator (PC) the POC for Patient 2 was reviewed. PC confirmed that a physician’s order, dated 5/3/26 indicated the patient should have Medical Social Worker (MSW) assessed Patient 2 one time within 1 week. PC confirmed that Patient 2 had not yet been assessed by MSW, nor had the physician been notified that a MSW visit had not been conducted as ordered for a total of 18 days since the time it was ordered up to present. During an interview on 5/21/26 at 11:08 am with PC, she confirmed that the physician should have been notified the first week that MSW services had been ordered but not performed.”