Greater Manchester Homecare, LLC

“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, review of agency policies and interview with agency personnel, for one of five patients (Patient #12) requiring weight monitoring for diuretic therapy and/or a diagnosis of congestive heart failure, the agency nurses failed to ensure a comprehensive care plan. The findings include: Patient #12 had a start of care date of 1/23/24 and diagnoses that included paroxysmal atrial fibrillation, atherosclerotic heart disease, acute respiratory failure with hypoxia and chronic obstructive pulmonary disease. The physician’s orders for the certification period of 1/23/24 through 3/22/24 included nursing services once weekly for assessments and weight monitoring, with notification to the physician of a greater than three-pound weight gain in a day or a five-pound weight gain in a week. On 2/27/24, the patient was transferred to the hospital for a low sodium level, weakness and bilateral edema and returned on 3/04/24 with a diagnosis of hyponatremia and congestive heart failure. i. Interview and review of the physician’s orders dated 3/23/24 with the Administrator and Quality Manager on 4/03/24 at 11:10 AM identified skilled nursing services for weight monitoring with notification to the physician of a greater than three-pound weight gain in a day or a five-pound weight gain in a week, although, review of the nursing summary indicated that the patient was unable to ambulate and stand on a scale and failed to ensure a comprehensive care plan for alternate methods to monitor edema and weight gain. Review of agency policies for Delivery of Service directed a written care plan is developed for each client admitted to service. The care plan is comprehensive and reflects collaborative planning by the client/family/staff involved in the care to the client.”

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on clinical record review and interview with agency personnel, for one of five patients (Patient #12) requiring weight monitoring for diuretic therapy and/or a diagnosis of congestive heart failure, the agency nurses failed to provide the necessary assessments. The findings include: Patient #12 had a start of care date of 1/23/24 and diagnoses that included paroxysmal atrial fibrillation, atherosclerotic heart disease, acute respiratory failure with hypoxia and chronic obstructive pulmonary disease. The physician’s orders for the certification period of 1/23/24 through 3/22/24 included nursing services once weekly for four weeks for assessments and weight monitoring with notification to the physician of a greater than three-pound weight gain in a day or a five-pound weight gain in a week. i. Interview and review of the nursing notes dated 1/26/24, 2/01/24, 2/06/24, 2/08/24, 2/11/24, 2/16/24 and 2/18/24 with the Administrator and Quality Manager on 4/03/24 at 11 AM failed to identify weight monitoring during the nursing visits and failed to follow physician’s orders.”