Professional Care Home Health Services

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on record review, and interview, the agency failed to ensure the comprehensive assessment was completed within 5 days of the start of care for 1 of 1 patient with occupational therapy. (Patient # 3). Findings include: 1. An undated policy, titled, “Initial and Comprehensive Assessment,” indicated the comprehensive assessment would be completed no later than 5 calendars days after the start of care. 2. A referral, dated 07/02/2025, indicated Patient #3 was to be evaluated for occupational therapy. A Plan of Care, for certification period 07/02/2025 to 08/30/2025, indicated a start of care date of 07/02/2025. An Occupational Therapy Initial Evaluation, dated 07/08/2025, failed to evidence Patient’s comprehensive assessment was completed within 5 calendar days from the start of care. During an interview, on 07/10/2025, beginning at 3:00 PM, the Administrator, Administrative Staff 1, indicated there was a delay for the occupational therapist to evaluate Patient due to difficulty contacting the occupational therapist and the comprehensive assessment was not completed within the 5 days allowed.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: (1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on record review, and interview, the agency failed to ensure the comprehensive assessment included patient’s current health status in 1 of 1 Patient’s with a gastrostomy tube (a tube into the stomach for nutrition) (Patient #4). Findings include: 1. An undated policy, titled, “Patient Assessment Guidelines,” indicated a comprehensive assessment would be utilized to identify the patients’ needs for home care and would include but not limited to physical assessment and review of systems. 2. A Plan of Care, for certification period 05/25/2025 to 07/23/2025, for Patient #4 indicated Patient had a gastrostomy tube. A Comprehensive Assessment, dated 05/23/2025, indicated under gastrointestinal abdomen soft no further details and failed to evidence documentation and assessment of the gastrostomy tube site. During an interview, on 07/10/2025, beginning at 3:00 PM, the Administrator, Administrative Staff 1, indicated the gastrostomy tube documentation and evaluation should have been and was not documented on the comprehensive assessment. 410 IAC 17-14-1(a)(1)(A)”

“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 observation, record review, and interview, the agency failed to ensure the plan of care included all treatments, nutritional/fluid requirements or restrictions in 3 of 4 active clinical records reviewed with a diagnosis of diabetes mellitus (high blood sugar that affects how the body processes glucose) (Patient #1, Patient #3, Patient #4). Findings include: 1. An undated policy, titled, “Patient Plan of Care,” indicated the plan of care should meet the individual needs of each patient based on patient assessments. The policy indicated the plan of care would consist of problems or needs identified, actions or interventions to be taken and services to be provided. 2. A Start of Care Comprehensive Assessment, for Patient #1, dated 06/18/2025, indicated a diagnosis of diabetes mellitus type 2 that was controlled with oral diabetic medications and blood sugar testing frequency was before each meal. A Plan of Care, for certification period 06/18/2025 to 08/16/2025, indicated Patient was to be assessed for diabetes management and appropriate interventions, Patient’s blood glucose levels would remain within prescribed parameters, and Patient/caregiver would demonstrate knowledge of diabetes management and appropriate interventions. During an observation of a home visit, on 07/08/2025, beginning at 3:00 PM, RN 1 obtained Patient’s blood sugar with a level of 244. The Plan of Care failed to include the frequency of blood sugar testing and prescribed parameters. During an observation of a home visit, on 07/08/2025, beginning at 3:00 PM, Patient’s spouse indicated Patient’s blood sugars are checked three times per day. During an interview, on 07/09/2025, beginning at 3:30 PM, the Administrator, Administrative Staff 1, indicated the plan of care should include the frequency of blood sugar testing and blood sugar parameters should have been and were not included in the plan of care. 3. A Start of Care Comprehensive Assessment, for Patient #3, dated 07/02/2025, indicated a diagnosis of type 2 diabetes mellitus, was on oral diabetic medication, blood sugar testing frequency was before each meal and had a continuous glucose monitor free style libre 2. A Plan of Care, for certification period 07/02/2025 to 08/30/2025, indicated to notify the physician of blood sugars greater than 300 or less than 50 and indicated Patient would be instructed on frequency of glucose monitoring. During an observation of a home visit, on 07/09/2025, beginning at 12:00 PM, Patient was observed with a continuous glucose monitor libre 2 on her/his arm. Patient indicated the continuous glucose monitor results went to a monitor and he/she checked the monitor 2 times per day, and her/his physician changed the continuous glucose monitor sensor every week. The Plan of Care failed to include the frequency of the blood sugar monitoring, the use of the continuous glucose monitor, and the frequency of the continuous blood sugar sensor change. During an interview, on 07/10/2025, beginning at 3:00 PM, the Administrator indicated the continuous glucose monitor use and the frequency of blood sugar checks should have been and were not included in the plan of care. 4. A Comprehensive Assessment, dated 05/23/2025, for Patient #4, indicated a diagnosis of diabetes with a random blood sugar of 110. A Plan of Care, for certification period 05/25/2025 to 07/23/2025, indicated Patient/caregiver would demonstrate diabetes management and appropriate interventions, and blood glucose levels would remain within prescribed parameters. The Plan of Care failed to include blood glucose monitoring frequency and blood glucose parameters. The Comprehensive Assessment indicated Patient had a gastrostomy tube (tube into the stomach for nutrition) and was to have 100 milliliters of hydration after each feeding. The Plan of Care failed to include hydration after each feeding. During an interview, 07/09/2025, beginning at 3:36 PM, the Administrator indicated the gastrostomy tube flushes, and the blood sugar frequency and parameters should have been and were not included in the plan of care. 410 IAC 17-13-1(a)(1)(D)(viii, ix)”