Avera @ Home

“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 agency policy review, clinical record review and agency staff interview, the agency failed to follow a Plan of Care or notify the physician of missed visits for 1 of 2 sampled patients with missed visits. (Patient #5) Failure to follow a Plan of Care established by a physician placed patients at risk of not receiving safe, individualized and consistent care designed to meet each patient’s health care needs. Findings include: According to the agency policy, titled Care/Service Coordination, dated 6/7/22, team members will communicate with the attending primary care physician in the case of a missed visit for any ordered discipline. During an interview on 1/14/25 at 10:10 AM, the Director of Patient Care Services reported the nurse notified the physician of home health aide missed visits but not the skilled nurse missed visit. Patient #5 had a start of care date of 4/14/25 and discharge date of 1/12/25. Clinical record review revealed: a. Plan of Care, dated 12/10/25 to 2/7/25, included a primary diagnosis of Type 2 Benign prostatic hyperplasia and physician orders for skilled nurse and home health aide services. b. Clinical record review lack documentation of a skilled nurse visit during the week of 12/21/25 to 12/27/25. Agency failed to notify the physician of missed skilled nurse visit. The above findings reviewed with the Administrator and Clinical manager.”

“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 observations, patient interviews, staff interview, clinical record reviews and agency policy review, the agency failed to complete an accurate drug regimen review with each comprehensive assessment for 1 of 3 sampled patients with home observation visits (Patient #3). Failure to ensure medications reviewed at the time of each drug regimen review are current and accurate placed the patients at risk for increased potential unidentified medication interactions, side effects and duplication of medications. Findings include: According to the agency policy titled Medication Profile, dated 11/9/23,a drug regimen review will be performed at the time of initial and comprehensive assessment, when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication. During an interview on 1/14/26 at 9420 AM the Clinical Manager stated the Registered Nurse (RN) responsible to complete the Drug Regimen Review (DRR) at admission, recertification and discharge. Patient #1 had a start of care date of 11/11/25. Clinical record review revealed the following: a. The Plans of Care (POC), dated 11/11/25 to 1/9/25 and 1/10/25 to 3/10/25, identified the patient had a diagnosis of Schizophrenia and included physician orders for medication and skilled nursing services. b. The comprehensive assessment at recertification, dated 1/6/25, completed by Staff C, RN, included documentation a DRR was completed. c. During a home observation visit on 1/6/26 at 7:30 AM with Staff E, RN, the patient interview revealed the following medication discrepancies orders and patient stated medication schedule: Fenofibrate 48 milligrams oral, 1 tablet daily with a fill date of 12/10/25. The agency medication list failed to include the medication. The DRR failed to include an accurate review of all medications taken by the patient. The above findings were reviewed with the Administrator and Clinical Manager.”

“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, agency policy review, home visit observation and agency staff interview, the agency failed to ensure skilled professional staff involved in the patient’s plan of care completed an ongoing interdisciplinary services as required by agency policy and expectation for 1 of 3 sampled patients (Patient #5), who received wound care. Failure to complete an ongoing interdisciplinary services placed patients at risk not receiving ongoing needs. Findings include: According to the agency policy, titled Documentation of Wounds, reviewed 7/26/24, initial documentation and reassessment documentation should include at minimal: wound type, odor, surrounding skin, wound measurements as indicated bby wound type, wound bed description, clinical evaluation of the wound progress and other basic wound assessment criteria as indicated by wound type. During Interview on 1/14/25 at 10:10 AM, the Director of Patient Services stated the nurse reported during her visit, the family identified the patient wound previously had a nonremovable dressing and when the skilled visit made, the wound had been resolved. Patient #5 had a start of care date of 4/14/25. Clinical record review revealed: a. The Plan of Care (POC), dated 12/26/24 to 2/23/25, identified the patient had a diagnosis of Benign prostatic hyperplasia. Orders included skilled 1 services. b. The skilled nurse visit note, dated 12/29/25, identified the patient had a left eye laceration over the holidays and sutures placed. The note lacked documentation of assessment of the laceration area or dressing in place. The agency nurses failed to provided complete skilled nurse services. The above findings were reviewed with the Administrator and Clinical Manager.”