Icg Home Health Care Services

“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 and Staff interview, it was determined that in 3 of 7 (Pts # 1, 3 and 2) the Agency failed to ensure that the Plans of Care (PsOC) contained patient specific interventions orders. 3. Pt. #2 was admitted to Home Health Services on 12/30/24 with the diagnosis of Fabry (Anderson) Disease. The clinical record was reviewed 02/25/25. The POC effective 12/30/24 to 02/27/25 with intravenous infusion orders: “SN INFUSION THERAPY INTERVENTIONS:….Administer Fabrazyme 70 mg in 100 ml of 0.9 NS every 2 weeks via CADD Pump via peripheral IV….Insert peripheral access device to initiate infusion….” The POC lack the patient specific orders/ interventions on type/size of peripheral IV access device used. 4. During interviews with the Administrator, Clinical Director and Clinical Manager on 02/26/25 between 1:00 PM to 2:45 PM, the Clinical Director and Clinical Manager confirmed the above findings. Findings include: 1. Pt. # 1 was admitted to Home Health Services on 03/04/24 with diagnosis of Mucopolysaccharidoses. The clinical record was reviewed on 02/25/25. The clinical record contained a POC for certification period 12/29/24 to 02/26/25 with intravenous infusion orders “infusion to be via implanted port”. The POC lacked patient specific orders on type of implanted port, size and type of needle to be used. 2. Pt. # 3 was admitted to Home Health Services on 12/06/24 with diagnosis of Fabry (Anderson) Disease. The clinical record was reviewed on 02/25/25. The clinical record contained a POC for certification period 12/06/24 to 02/03/25 with orders for intravenous medication Fabrazyme 70 mg every 2 weeks. The POC lacked dilution solution amount, description of infusion (gravity or intravenous pump) and rate / length of time of infusion. Pt # 3 POC also contained orders to infuse intravenous medication via “peripheral access device”. The POC lacked description orders on the use of peripheral access device.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on clinical records review and Staff interview, it was determined that in 2 of 4 (Pt. #5 and 7) closed records reviewed, the Agency failed to ensure that a discharge summary was sent to the Physician within 5 days of discharge. Findings include: 1. Pt. # 5 was admitted to Home Health Services on 12/11/24 with the Diagnosis of Malignant Neoplasm of Unspecified Part of Right Bronchus or Lung. The clinical record was reviewed on 02/25/25. The last visit by the Physical Therapy was dated 02/06/25. The Physical Therapy Discharge/ Transfer summary, dated 02/10/25, indicated Pt. #5 passed away. The discharge summary was sent more than 5 days after discharge. 2. Pt. # 7 was admitted to Home Health Services on 01/0524 with the Diagnosis of Encounter for Antineoplastic Chemotherapy. The clinical record was reviewed on 02/26/25. The discharge orders dated 02/05/24, indicated: “….Patient done with chemo treatment, discharged from home services as of 02/2/24….” The Discharge/Transfer summary, dated 02/02/24, indicated Pt. #7 discharged from Chemo therapy. As of 02/26/25, the discharge summary was not sent to the Physician. 3. During an interview with the Administrator, Clinical Director and Clinical Manager on 02/26/25 at 1:00 PM, the Clinical Director confirmed the above findings.”