Angels Care Home Health

“Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on record review and interviews, the Administrator failed to involve relevant physicians in the development and implementation of the POC to ensure correct supplies were ordered and delivered timely to meet the patient’s needs for 1 of 3 patients reviewed (Patient #1). Findings Include: Record review of Patient #1, with a start of care date of 09/22/2025, showed no documentation of communication with the urologist responsible for determining the correct catheter type and quantity required for the patient’s daily self‑catheterization needs. The clinical record contained no orders or coordination with the specialist to ensure adequate supply management. During an interview on 03/18/2026 at 10:54 AM, the Administrator stated the agency had not received catheter supply orders from the patient’s urologist. The Administrator acknowledged that communication should have occurred between agency staff and the specialist physician to ensure all patient needs were met.”

“Integrate all orders CFR(s): 484.60(d)(2) Integrate orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient. This Element is not met as evidenced by: Based on record review and interviews, the Regional Clinical Director failed to ensure orders from the physician responsible for the patient’s genitourinary care were obtained and integrated into the plan of care to coordinate the services and supplies needed for ongoing bladder management for 1 of 3 patients reviewed (Patient #1). Findings include: The clinical record for Patient #1 evidenced supply orders were submitted, without a physician’s order, on 10/22/2025, 11/07/2025, 11/17/2025, 11/25/2025, 12/04/2025, 12/16/2025, 12/29/2025, 01/05/2026, 01/14/2026, 02/24/2026, 03/10/2026, and 03/16/2026. The record failed to evidence a physician order indicating the type and quantity of genitourinary needed to meet the patient’s needs. During an interview on 03/18/2026 at 10:54 AM, the Administrator explained that non‑formulary or high‑cost supply requests required approval by the Regional Clinical Director. However, the record did not demonstrate appropriate coordination or communication necessary to ensure timely delivery of supplies required for the patient’s ongoing bladder management needs.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on record review and interviews, the Administrator failed to ensure the coordination of care necessary to meet the patient’s needs for 1 of 3 patient records reviewed (Patient #1). Findings included: A review of the clinical record for Patient #1 evidenced the following: A case conference note dated 01/12/2026 identified the need for recertification related to quadriplegia but failed to identify the patient’s urologist or indicate the need to coordinate catheter‑related care with the specialist. The comprehensive assessment dated 01/15/2026 listed only the referring physician and failed to include the physician responsible for the patient’s genitourinary needs. The assessment documented urinary tract education but failed to reflect coordination with the physician overseeing the patient’s catheter management or the need for catheter-related supply management. The current plan of care (01/20/2026–03/20/2026) listed DME, urological supplies, and catheter‑related functional limitations but failed to identify the urologist or need to order supplies related to ongoing bladder management. A case conference note dated 03/11/2026 again indicated the need for recertification due to catheter management needs but did not identify or include the urologist in care coordination. During an interview on 03/18/2026 at 10:54 AM, the Administrator stated the urologist did not refer the patient to home health, was not involved with therapy services, and only provided needed input when a Foley catheter was required due to lack of proper supplies. The Administrator acknowledged that communication should occur between agency staff and physicians who may need to be involved to ensure all patient needs are met.”