Family Care Solutions LLC

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on clinical record review and agency staff interview, the agency failed to update the Plan of Care with all new physician orders for 2 of 2 sampled patients with interim orders. (Patients #4 and #6). Failure to update the Plan of Care increased the potential for medication errors in administration or inaccurate provision of care. Findings include: During an interview on 1/28/25 at 9:55 AM, Clinical Manager reported the updated plans of care are found under the communication tab in the electronic medical record for each patient. 1.Patient #4 had a start of care date of 5/20/2020. Clinical record review revealed: a. Plan of Care, dated 12/25/24 to 2/22/25, included the diagnoses of severe intellectual disabilities and cerebral palsy and orders for skilled nursing services 1-2 days/week for 8 weeks. b. Interim physician order, dated 12/26/24, to increase skilled nurse shift frequency for the weeks of 12/29/24 and 1/5/25, from 1-2 days per week to 2-3 days per week. c. Interim physician order, dated 1/13/25, to increase skilled nurse shift frequency for the week of 1/12/25, from 1-2 days per week to 2-3 days per week. During an interview on 1/29/25 at 3:55 PM, Clinical Manager reported she would review electronic medical record for updated plan of care but thinks it may not have been completed. The clinical record failed to include an updated plan of care that included the frequency changes from the interim physician orders dated 12/26/24 and 1/13/25. 2. Patient #6 had a start of care date of 8/16/19 and a discharge date of 7/19/24. Clinical record review revealed: a. Plan of Care, dated 1/22/24 to 3/21/24, included the diagnoses of noncompliance with medication regimen and major depressive disorder and orders for skilled nursing services. b. Interim physician order, dated 3/21/24, to update medication profile: discontinue Quetiapine 200 milligram (mg) tabs, add Quetiapine 400 mg tab 1 at bedtime for 7 days, then Quetiapine 400 mg tabs 1.5 tabs for 7 days, then continue at 600 mg nightly. Increase Prazosin from 1 mg at bedtime to 2 mg at bedtime. Taper off Mirtazepine 30 mg by taking 1/2 tab for 7 days then stop. Effective today 3/21/24. Increase Duloxetine from 60 mg to 90 mg daily every morning, effective tomorrow morning 3/22/24. During an interview on 2/4/25 at 11:48 AM, Clinical Manager reported she reviewed electronic medical record and the updated plan of care was missed. The clinical record failed to include an updated plan of care that included the medication changes from the interim physician order dated 3/21/24. The findings were reviewed with the Clinical Manager.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on staff interviews and clinical record reviews, the agency failed to ensure the clinical record included the patient’s admission consent forms and/or annual service agreement forms for 7 of 7 sampled patients (Patients #1, #2, #3, #4, #5, #6 and #7). Failure of the agency to ensure the clinical record included all consent forms placed agency patients at risk to receive care or not receive care meeting the needs of the patient. Findings include: During an interview on 1/28/25 at 2:56 PM, Clinical Manager reported the admission consent forms and annual service agreement forms signed by patient or caregiver are not kept in the electronic medical record (EMR) system. The signed forms are uploaded into a different computer program and can be printed out for the surveyor to review. During an interview on 1/29/25 at 3:46 PM, Clinical Manager reported the admission consent forms and annual service agreement forms are easier to access in the other computer program and makes annual chart audits easier to complete. There is not a good place in the EMR to store the files that would allow the consents to be sorted by date, If a patient is on services for a long time, there are multiple forms and it can be hard to find what you are looking for. 1.Patient #1 had a start of care date of 7/14/24. Clinical record review revealed no admission consent forms in the electronic medical record. The surveyor was emailed (electronic mail) copies of the admission consent and service agreement forms, dated 7/14/24. The clinical record lacked documentation of the admission consent and service agreement forms. 2. Patient #2 had a start of care date of 7/10/23. Clinical record review revealed no admission consent or annual service agreement forms in the electronic medical record. The surveyor was emailed copies of the admission consent and service agreement forms, dated 7/10/24. The clinical record lacked documentation of the admission consent and service agreement forms. 3. Patient #3 had a start of care date of 11/15/21. Clinical record review revealed no annual service agreement forms in the electronic medical record. The surveyor was emailed copies of the service agreement forms, dated 2/1/24. The clinical record lacked documentation of the service agreement forms. 4. Patient #4 had a start of care date of 5/20/2020. Clinical record review revealed no annual service agreement forms in the electronic medical record. The surveyor was emailed copies of the service agreement forms, dated 4/25/24. The clinical record lacked documentation of the service agreement forms. 5. Patient #5 had a start of care date of 6/5/24. Clinical record review revealed no admission consent or annual service agreement forms in the electronic medical record. The surveyor was emailed copies of the admission consent and service agreement forms, dated 6/5/24. The clinical record lacked documentation of the admission consent and service agreement forms. 6. Patient #6 had a start of care date of 8/16/19 and a discharge date of 7/19/24. Clinical record review revealed no annual service agreement forms in the electronic medical record. The surveyor was emailed copies of the service agreement forms, dated 7/24/23. The clinical record lacked documentation of the service agreement forms. 7. Patient #7 had a start of care date of 10/3/23 and a discharge date of 11/11/24. Clinical record review revealed no admission consent or annual service agreement forms in the electronic medical record. The surveyor was emailed copies of the service agreement forms, dated 9/24/24. The clinical record lacked documentation of the admission consent and service agreement forms. The clinical records lacked documentation of admission consent forms and annual service agreement forms. The findings were reviewed with the Clinical Manager.”