Mercyhealth at 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 clinical records review and staff interviews, it was determined that in 3 of 17 (Pts. #9, 4 and 10) clinical records reviewed, the Agency failed to ensure that staff provided services ordered in the POC. 2. Pt. #4 was admitted to the Home Health Services on 11/05/24 with the diagnoses of Non-Pressure Chronic Ulcer Left lower leg and Type 2 Diabetes Mellitus. The clinical record was reviewed on 03/11/25. The clinical record contained recertification POC dated 03/05/25, that required the SN to assess the patient’s wound healing. The SN failed to document the wound size for 03/11/25. 4. The findings were confirmed, during the interviews with the Administrator and Home Health Manager, on 03/12/25 between 11:00 AM and 11:30 AM and on 03/13/25 between 9:30 AM and 11:30 AM. Findings include: 1. Pt. #9 was admitted to Home Health Services on 02/25/25 with the diagnoses of Pressure ulcer of sacral region, stage 2, Type 2 diabetes mellitus with hyperglycemia and Hypertensive heart disease with heart failure. The clinical record was reviewed on 03/12/25. The POC for the certification period of 02/25/25 to 04/25/25, required: “….Wound Care Interventions:….Obtain weekly wound measurements….” The SOC assessment dated 02/25/25 and SN assessment note dated 02/28/25, lack wound measurements as ordered.”

“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 review of clinical records and staff interviews, it was determined that in 5 of 17 (Pts. #7, 8, 5, 16, and 17) clinical records reviewed, the Agency failed to ensure that documentation entered into the clinical record was complete. 3. Pt. #5 was admitted to the Home Health Services on 02/08/25 with the diagnoses of Lumbago with Sciatica and Type 2 Diabetes Mellitus with Diabetic Neuropathy. The clinical record was reviewed on 03/11/25. The clinical record contained a POC dated 02/08/25, that required the PT to assess the patient. The PT failed to document the patient’s temperature, on 02/25/25. 4. Pt. #16 was admitted to the Home Health Services on 12/10/24 with the diagnosis of Hypertensive Chronic Kidney Disease with Stage 1-4. The clinical record was reviewed on 03/11/25. The clinical record included the form titled, “Illinois Consent for Treatment/Agreement to Pay/Receipt of Joint Privacy Notice” signed by the Pt. and not dated. 5. Pt. #17 was admitted to the Home Health Services on 07/01/24 with the diagnosis of Parkinson Disease without Dyskinesia without mention of Fluctuations. The clinical record was reviewed on 03/11/25. The clinical record contained a POC dated 07/01/24, that required the PT to assess the patient. The PT failed to document the patient’s temperature, on 07/18/24 and 07/31/24. 6. The above findings were confirmed, during the interviews with the Administrator and Home Health Manager, on 03/12/25 between 11:00 AM and 1:30 PM. 1. Pt. #7 was admitted for Home Health Services on 02/03/25 with diagnosis of Supraventricular Tachycardia Unspecified. The clinical record was reviewed on 03/11/25. The clinical record included the form titled, “Illinois Consent for Treatment/Agreement to Pay/Receipt of Joint Privacy Notice” signed by the Pt. and not dated. 2. Pt. #8 was admitted for Home Health Services on 07/26/24 with the diagnosis of Pressure Ulcer of other site, Stage 2. The clinical record was reviewed on 03/12/25. The clinical record included the form titled, “Illinois Consent for Treatment/Agreement to Pay/Receipt of Joint Privacy Notice” signed by the Pt. and not dated. Findings Include:”

“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 records review, Pt. interview, and staff interviews, it was determined that in 6 of 17 (Pts. #1, 12, 9, 4, 5 and 16) clinical records reviewed, the Agency failed to ensure the PsOC included patient-specific interventions, education and measurable outcomes. 4. Pt. #4 was admitted to the Home Health Services on 11/05/24 with the diagnoses of Non-Pressure Chronic Ulcer Left lower leg and Type 2 Diabetes Mellitus. The clinical record was reviewed on 03/11/25. The clinical record contained PsOC dated 01/03/25 and 03/05/25, that required the SN instruct patient of glucose monitoring, tracking and reporting of readings as appropriate. The POC lacked the specifics for reporting the glucose readings. 5. Pt. #5 was admitted to the Home Health Services on 02/08/25 with the diagnoses of Lumbago with Sciatica and Type 2 Diabetes Mellitus with Diabetic Neuropathy. The clinical record was reviewed on 03/11/25. A home visit was conducted on 03/11/25 with the PT. During the interview with the patient, she stated using Tylenol for pain relief. The POC dated 02/08/25, lacked the Tylenol orders. 6. Pt. #16 was admitted to the Home Health Services on 12/10/24 with the diagnosis of Hypertensive Chronic Kidney Disease with Stage 1-4. The clinical record was reviewed on 03/11/25. The clinical record contained POC dated 12/10/24, that required the SN to instruct patient of glucose monitoring, tracking and reporting of readings as appropriate. The POC lacked the specifics for reporting the glucose readings. 7. The findings were confirmed, during the interviews with the Administrator and Home Health Manager, on 03/12/25 between 11:00 AM and 11:30 AM and on 03/13/25 between 9:30 AM and 11:30 AM. 3. Pt. #9 was admitted to Home Health Services on 02/25/25 with the diagnoses of Pressure Ulcer of Sacral Region, Stage 2, Type 2 Diabetes Mellitus with Hyperglycemia, Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 03/12/25. The clinical record contained a POC for certification period of 02/25/25 to 04/25/25 that required SN to instruct patient/caregiver on blood glucose monitoring and weight measurements to report. The POC lacked Pt. specific interventions related to blood glucose parameters and weight parameters/changes to report. Findings include: 1. Pt. #1 was admitted to Home Health Services on 02/18/25 with diagnoses of Pressure Ulcer of Right Buttock, Stage 2 and Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. The clinical record was reviewed on 03/11/25. The clinical record contained a POC for certification period 02/18/25 to 02/18/25 that lacked patient specific Diabetes management interventions. 2. Pt. #12 was admitted to Home Health Services on 02/10/25 with diagnosis of Type 2 Diabetes Mellitus with foot ulcer. The clinical record was reviewed on 03/11/25. The clinical record contained a POC for certification period 02/10/25 to 04/10/25 that lacked patient specific Diabetes management interventions.”