Prohealth Home Care, Inc.

“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 that their patient received home health services in accordance with the written individualized plan of care (POC) when staff did not reschedule a therapy missed visit for one out of 17 sampled patients (Patient 1). This failure had the potential to prevent Patient 1 from receiving needed home health treatments and services. Findings: A review of Patient 1’s clinical records indicated Patient 1 had a start of care date with the Home Health Agency (HHA) on 5/8/26 and had diagnoses that included chronic kidney disease (a long-term condition where the kidneys gradually lose their ability to filter waste products and excess fluid from the blood) and diabetes mellitus (a chronic condition causing too much sugar in the blood). A review of Patient 1’s plan of care, dated 5/8/26, indicated, “PT [Physical therapy] ...: 2 x week for 2 weeks starting 05/17/2026...” A review of Patient 1’s schedule of PT visits for the week of 4/17/26, indicated Patient 1 had a PT missed visit on 5/20/26 and a PT visit on 5/21/26. A review of Patient 1’s “PHYSICAL THERAPY PATIENT MISSED VISIT”, dated 5/20/26, revealed that the PT missed visit on 5/20/26 was not rescheduled later in the week. During a concurrent interview and record review on 6/3/26 at 12:22 p.m. with the Director of Patient Care Services (DPCS), Patient 1’s clinical record was reviewed. The DPCS confirmed that Patient 1 only received 1 PT visit for the week of 4/17/26 instead of 2 PT visits. The DPCS also confirmed that the 5/20/26 PT missed visit note did not indicate that there was an attempt to reschedule the visit later in the week. The DPCS stated the 5/20/26 missed visit should have been rescheduled to follow the ordered PT visit frequency. A review of the agency’s policy and procedure titled, “MISSED VISITS”, revised 7/2025, indicated, “...A missed visit will be rescheduled the same week if possible...1. If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit.””

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to ensure clinical records were completed timely for one out of 17 sampled patients (Patient 4). This failure created the potential for inaccurate or incomplete communication of treatment needs, risking unmet care needs and possible adverse events. Findings: A review of Patient 4’s clinical records indicated Patient 4 had a start of care date on 4/20/26 and had diagnoses that included hemiplegia (partial or complete paralysis of one side of the body) following cerebral infarction (stroke) affecting left non dominating side. A review of Patient 4’s Plan of Care (POC) for the certification period 4/20/26-6/18/26 included PT (Physical Therapy) services. Review of Patient 4’s clinical record included a “Physical Therapy Patient Missed Visit” note dated 4/28/26, which was blank. The record did not include: • An explanation for the missed visit • Documentation of how Patient 4’s needs were addressed • Any assessment of the impact of the missed visit on the patient’s care. During a concurrent interview and record review on 6/2/26 at 9:26 AM, the Director of Patient Care Services (DPCS) confirmed that the 4/28/26 missed visit documentation had not been completed. The DPCS stated the missed visit form should be completed within 48 hours and that clinicians were expected to follow policy by communicating missed visits to the case manager and physician. A review of the agency’s policy and procedure (P&P) titled, “Contents of the Clinical Record,” revised 7/2025, indicated, “The clinical record will contain sufficient information to identify the patient, describe the patient’s problems and needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among organization and contract personnel.” A review of the agency’s P&P titled, “Missed Visits,” revised 7/2025, indicated, “To ensure that missed visits are documented and does not affect the quality of patient care…Missed visits will be communicated to the clinical supervisor and the patient’s physician.””

“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 interview and record review, the agency failed to ensure services and treatments were administered only as ordered by a physician or allowed practitioner for one out of 17 sampled patients (Patient 5). This failure resulted in the agency’s inability to ensure that the patients’ home health needs were coordinated and provided as ordered by a physician. Findings: A review of Patient 5’s clinical records indicated Patient 5 had a start of care date with the Home Health Agency (HHA) on 3/20/26 and had diagnoses that included neurocognitive disorder with Lewy bodies (a progressive brain disorder and is the second most common type of progressive dementia), and prostate cancer. A review of Patient 5’s physician orders titled, “HOME HEALTH PHYSICIAN ORDERS”, dated 4/20/26, indicated, “Extension of PT (Physical Therapy) visit frequency...1 x week for 3 weeks starting 04/20/2026...” During a concurrent interview and record review on 6/3/26 at 12:22 p.m. with the Director of Patient Care Services (DPCS), Patient 5’s clinical record was reviewed. The DPCS confirmed that Patient 5 received 1 PT visit for 4 weeks starting 4/20/26. The DPCS also confirmed that they only have an order for 1 PT visit for 3 weeks starting 4/20/26. The DPCS stated there should have been a physician’s order for the extra visit of Patient 5. A review of the agency’s policy and procedure titled, “PHYSICIAN PARTICIPATION IN PLAN OF CARE”, revised 7/2025, indicated, “A physician will direct the care of every home health patient admitted for service. The attending physician will certify that medical, skilled, rehabilitation, and social services provided by the organization are medically necessary...8. Orders will be reviewed and revised by the patient’s physician (or allowed practitioner) based on: A. Changes in the care or service being provided...””

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on interview and record review, the agency did not ensure home health aide supervisory visits were completed within the required 14‑day timeframe for two of 17 sampled patients (Patient 12 and Patient 16). This failure had the potential to result in Patient 12’s and Patient 16’s treatment and personal care needs not being met. Findings: A review of Patient 12’s clinical record showed an SOC (Start of Care) date of 1/7/26 with diagnoses that included a pressure ulcer (damage to skin and tissue caused by pressure) to the right buttock. A review of Patient 16’s clinical record showed an SOC date of 4/29/26 with diagnoses that included a malig (malignant – invading local tissue) neoplasm (abnormal growth of tissue) of the head, face, and neck. During a concurrent interview and record review on 6/3/26 at 10:45 p.m., the DPCS (Director of Patient Care Services) confirmed Patient 12 received weekly skilled nursing and home health aide visits. The DPCS confirmed Patient 12 had a home health aide supervisory visit on 2/2/26 and again on 3/25/26, and stated supervisory visits were required every 14 days. Patient 12 missed two supervisory visits between 2/2/26 and 3/25/26. During a concurrent interview and record review on 6/3/26 at 2:55 p.m., the DPCS confirmed Patient 16 received weekly skilled nursing and home health aide visits. The DPCS confirmed Patient 16 had not received any home health aide supervisory visit since the SOC. The DPCS stated supervisory visits were required every 14 days per agency policy. During a review of the agency’s policy and procedure (P&P) titled, “Home Health Aide Plan of Care,” revised 7/2025, the P&P indicated, “The registered nurse or other appropriate clinician who is familiar with the patient, the patient’s plan of care and the written patient care instructions will complete a supervisory assessment of the home health aide no less frequently than every fourteen (14) days to ensure care is provided according to plan. The home health aide does not need to be present during the supervisory assessment.””

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to ensure discharge summaries were sent to their primary care practitioner (PCP) within 5 business days of their discharge from the agency and clinical records were completed timely for three out of 17 sampled patients (Patient 7, Patient 5, and Patient 3). These failures had the potential for Patient 7 and Patient 5 not to receive continuous treatment and care after their discharge from the agency and for Patient 3 to have an incomplete clinical record. 3. Review of Patient 3’s clinical records indicated the patient had a start of care date of 4/10/26 and diagnoses included dysphagia (difficulty swallowing) and chronic kidney disease (a condition in which the kidneys are damaged and unable to filter blood efficiently). During a concurrent interview and record review of Patient 3’s clinical record on 6/3/26 at 1:39 p.m. with the Director of Patient Care Services (DPCS), it was confirmed that the Medical Social Worker (MSW) initial evaluation for Patient 3 was completed on 4/13/26 and the MSW documented a missed visit on 4/23/26. The DPCS confirmed the MSW had not conducted any further visits with Patient 3. During a follow-up interview with the DPCS on 6/3/26 at 2:26 p.m., the DPCS stated that after speaking with the MSW, the patient no longer wanted MSW services, and the MSW had completed a discharge summary as of 6/3/26. The DPCS stated she would expect MSW communication regarding the patient being discharged or not wanting any more services from MSW. A review of the agency’s P&P titled, “Discharge Summary,” revised 7/2025, indicated, “Each clinician who provides care will complete a discharge summary at the time his/her discipline is discharged…The discharge summary and other relevant clinical record documents will be completed and submitted within 72 hours of discharge from service.” 2. A review of Patient 5’s clinical records indicated Patient 5 had a start of care date with the HHA on 3/20/26 and had diagnoses that included neurocognitive disorder with Lewy bodies (a progressive brain disorder and is the second most common type of progressive dementia), and prostate cancer. A review of Patient 5’s discharge document titled, “OASIS PT [Physical Therapy] DISCHARGE”, dated 5/14/26, indicated, Patient 5 was discharged from the agency on 5/14/26. During a concurrent interview and record review on 6/3/26 at 12:22 p.m. with the Director of Patient Care Services (DPCS), Patient 5’s clinical record was reviewed. The DPCS confirmed that Patient 5 was discharged from their agency on 5/14/26. The DPCS also confirmed that Patient 5’s discharge document was faxed to Patient 5’s PCP on 5/22/26, which was more than 5 business days from Patient 5’s discharge date. The DPCS stated that their policy was that the patient’s discharge summary will be faxed to the PCP within 5 business days after their discharge from agency. A review of the agency’s policy and procedure titled, “DISCHARGE SUMMARY”, revised 7/2025, indicated, “Each patient discharged from a service and from the organization will have a written discharge summary filed in the clinical record...3. A copy of the discharge summary will be provided to the patient’s primary care practitioner, (or allowed practitioner) or other health care professional who will be responsible for providing care and services to the patient after discharge from the organization within five (5) business days of the patient’s discharge.” Findings: 1. A review of Patient 7’s clinical records indicated Patient 7 had a start of care date of 2/2/26 and had diagnoses that included fracture of vertebra T9 and T10 (a break in the ninth and tenth bones of the thoracic [mid-back] spine), Rhabdomyolysis (a medical condition involving the rapid breakdown of damaged skeletal muscle), Hypothyroidism (condition where the thyroid gland doesn’t produce enough thyroid hormones), Hypertension (HTN-high blood pressure). A review of Patient 7’s discharge document titled, “OASIS PT [Physical Therapy] DISCHARGE”, dated 3/27/26, indicated, Patient 7 was discharged from the agency on 3/27/26. During a concurrent interview and record review on 6/3/26 at 2:55 p.m. with the Director of Patient Care Services (DPCS), Patient 7’s clinical record was reviewed. The DPCS confirmed that Patient 7 was discharged from their agency on 3/27/26 and the discharge summary was never sent to the PCP. The DPCS stated the expectation was that the patient’s discharge summary be faxed to the PCP within 5 business days after their discharge from agency.”