Yale New Haven Health - Health at Home

“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 interview with agency personnel, for three of five patients (Patient’s #1, #10 and #15) requiring blood glucose monitoring for a diagnosis of type II diabetes mellitus and/or weight monitoring for a diagnosis of congestive heart failure, the agency nurses failed to ensure the plan of care addressed the patient’s individual needs and failed to follow the physician’s orders. The findings include: Patient #1 had a start of care date of 2/12/25 and diagnoses that included lacerations to the right hand, elbow, scalp, congestive heart failure, Alzheimer’s disease and dementia. The physician’s orders dated 2/12/25 included nursing services for assessments, measuring and documenting the degree of edema and wound care to the left venous stasis wound one to two times a week, physical therapy and occupational therapy services. Patient #1 resided in an Assisted Living Facility/ALF. i. Interview and review of physician’s orders and initial nursing assessment with the Director of Quality on 3/18/25 at 1:20 PM identified the presence of 3+ bilateral pitting leg and foot edema but failed to clarify with the physician the need for weight monitoring and parameters for reporting abnormal results. ii. Interview and review of the nursing notes from 2/12/25 to 3/17/25 (13 visits) with the Director of Quality on 3/18/25 at 1:25 PM failed to identify measurements of the degree of edema in the patient’s legs and feet in accordance with physician’s orders. Patient #10 had a start of care date of 3/01/25 and diagnoses that included hypertensive heart and chronic kidney disease with heart failure, acute on chronic congestive heart failure and type II diabetes mellitus. The physician’s orders dated 3/01/25 included nursing services two to three times a week for blood glucose monitoring, measuring and documenting the degree of edema, instructing on daily weight monitoring, physical therapy and occupational therapy services. iii. Interview and review of nursing notes from 3/01/25 to 3/17/25 (6 visits) with the Director of Quality on 3/18/25 at 1:40 PM identified an initial weight measurement of 114 pounds but failed to identify further weight monitoring documented in accordance with physician’s orders. iv. Interview and review of nursing notes from 3/01/25 to 3/17/25 (6 visits) with the Director of Quality on 3/18/25 at 1:45 PM identified the presence of trace edema in the bilateral lower extremities but failed to identify measurements of the degree of edema in the patient’s legs and feet in accordance with physician’s orders. a. Patient #15 had a start of care date of 10/03/2024 with diagnoses that included acute respiratory failure, chronic kidney disease with heart failure, type two diabetes mellitus, high cholesterol, morbid obesity and anxiety. The physician’s orders for the certification period of 10/03/2024 to 12/01/2024 included nursing services for assessments, diabetic management teaching, measuring and documenting the degree of edema for one to two times per week, physical therapy and medical social work. i. Interview and review of physician’s orders and the initial nursing assessment with the Director of Quality on 03/19/2025 at 11:30 AM, identified Patient #15 was not testing his/her blood glucose but had a glucometer (glucose monitor) in the home and had the presence of 2+ bilateral lower extremity edema but failed to clarify with the physician the need for weight and blood glucose monitoring and parameters for reporting abnormal results. ii. Interview and review of the nursing notes dated 10/03/2025, 10/11/2025 and 10/16/2025 with the Director of Quality on 03/19/2025 at 11:40 AM, failed to identify diabetic monitoring and measurements of the degree of edema in the Patient’s lower extremities occurred in accordance with physician’s orders.”

“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 review of the clinical record, review of agency policies and interview with agency personnel, for two of five patients (Patient’s #10 & 15) requiring blood glucose and weight monitoring, the agency licensed nurses failed to provide the necessary assessments. The findings include. Patient #10 had a start of care date of 3/01/25 and diagnoses that included hypertensive heart and chronic kidney disease with heart failure, acute on chronic congestive heart failure and type II diabetes mellitus. The physician’s orders dated 3/01/25 included nursing services two to three times a week for blood glucose monitoring, measuring and documenting the degree of edema, instructing on daily weight monitoring, physical therapy and occupational therapy services. i. Interview and review of nursing notes dated 3/03/25, 3/07/25 and 3/17/25 with the Director of Quality on 3/18/25 at 1:45 PM failed to identify an evaluation of the blood glucose levels in accordance with physician’s orders. ii. Interview and review of nursing notes from 3/03/25 to 3/17/25 (5 visits) with the Director of Quality on 3/18/25 at 1:47 PM failed to identify an assessment of the patient’s weight in accordance with physician’s orders. a. Patient #15 had a start of care date of 10/03/2024 with diagnoses that included acute respiratory failure, chronic kidney disease with heart failure, type two diabetes mellitus, high cholesterol, morbid obesity and anxiety. The physician’s orders for the certification period of 10/03/2024 to 12/01/2024 included nursing services for assessments, diabetic management teaching, measuring and documenting the degree of edema for one to two times per week, physical therapy and medical social work. i. Interview and review of the nursing notes dated 10/03/2025, 10/11/2025 and 10/16/2025 with the Director of Quality on 03/19/2025 at 11:40 AM, failed to identify diabetic management teaching and measurements of the degree of edema in the Patient’s lower extremities occurred in accordance with physician’s orders. a. Patient #10 had a start of care date of 3/01/25 and diagnoses that included hypertensive heart and chronic kidney disease with heart failure, acute on chronic congestive heart failure and type II diabetes mellitus. The physician’s orders dated 3/01/25 included nursing services two to three times a week for blood glucose monitoring, measuring and documenting the degree of edema, instructing on daily weight monitoring, physical therapy and occupational therapy services. i. Interview and review of nursing notes dated 3/03/25, 3/07/25 and 3/17/25 with the Director of Quality on 3/18/25 at 1:45 PM failed to identify an evaluation of the blood glucose levels in accordance with physician’s orders. ii. Interview and review of nursing notes from 3/03/25 to 3/17/25 (5 visits) with the Director of Quality on 3/18/25 at 1:47 PM failed to identify an assessment of the patient’s weight and measurements of the degree of edema in accordance with physician’s orders. b. Patient #15 had a start of care date of 10/03/2024 with diagnoses that included acute respiratory failure, chronic kidney disease with heart failure, type two diabetes mellitus, high cholesterol, morbid obesity and anxiety. The physician’s orders for the certification period of 10/03/2024 to 12/01/2024 included nursing services one to two times per week for assessments, diabetic management teaching, measuring and documenting for the degree of edema, physical therapy and medical social work. Interview and review of the nursing notes dated 10/03/2025, 10/11/2025 and 10/16/2025 with the Director of Quality on 03/19/2025 at 11:40 AM, failed to identify diabetic management teaching and the measurement of the degree of edema in the Patient’s lower extremities occurred in accordance with physician’s orders.”

“Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This Element is not met as evidenced by: Based on review of clinical records and interview with agency personnel, for one of one patients (Patient #10) who received home healthcare services, the agency’s nurses failed to provide patients and caregivers with education related to the patients’ care and individualized treatments. The findings include: Patient #10 had a start of care date of 3/01/25 and diagnoses that included hypertensive heart and chronic kidney disease with heart failure, acute on chronic congestive heart failure and type II diabetes mellitus. The physician’s orders dated 3/01/25 included nursing services two to three times a week for blood glucose monitoring, measuring and documenting of the degree of edema, instructing on daily weight monitoring, physical therapy and occupational therapy services. Interview and review of nursing notes dated 3/03/25, 3/07/25 and 3/17/25 with the Director of Quality on 3/18/25 at 1:45 PM failed to identify diabetic management education was provided to Patient #10 and the Patient’s responsible person.”

“Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This Element is not met as evidenced by: Based on clinical record reviews and interviews with agency personnel, for two of seventeen patients (Patient #10 and #16) in the survey sample, the agency nurses failed to communicate with the physician involved in the care plan. The findings include: Patient #10 had a start of care date of 3/01/25 and diagnoses that included hypertensive heart and chronic kidney disease with heart failure, acute on chronic congestive heart failure and type II diabetes mellitus. The physician’s orders dated 3/01/25 included nursing services two to three times a week for blood glucose monitoring, measuring and documenting the degree of edema, instructing on daily weight monitoring, physical therapy and occupational therapy services. Interview and review of LPN #1’s nursing note dated 3/05/25 with the Director of Quality on 3/18/25 at 1:50 PM indicated that the patient was unable to safely stand for a weight assessment but failed to identify physician notification of an alteration in the plan of care. a. Patient #16 had a start of care date of 0417/2024 with diagnoses that included adjustment disorder and oppositional defiant disorder. The physician’s orders for the certification period of 12/13/2024 to 02/10/2025 included nursing services once daily for sixty-days for nursing assessments and medication administration. i. Interview and review of Patient #16’s clinical record with the Director of Quality on 03/19/2025 at 1:00 PM, identified the Patient did not have a nursing visit on 12/25/2024, 01/12/2025, 01/25/2025 and 01/26/2025 but failed to identify documentation to reflect why the nursing visit did not occur and failed to identify the physician was notified of an alteration in the plan of care. Review of the agency’s Delivery of Services in the Home Health Setting policy, identified the home health agency, would provide service seven days per week and case management to patients with acute, chronic or terminal illnesses when there is a reasonable expectation that home health services can safely and adequately meet a patient’s care needs. Service would be coordinated to ensure continuity of care. There would be coordination of agency services with all other facilities or agencies actively involved in patient care.”