Age in Place Home Services LLC

“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 record review and interview, the home health agency failed to ensure the POC contained all required information for 4 of 5 patient records reviewed (Patient #1, 3, 4, 5). Findings include: 1. Review of the Plan of Care policy, dated 01/15/2019, indicated “… The Plan of Care shall be completed in full to include… Type, frequency, and duration of all visits/services… Medications… Any safety measures to protect against injury…” 2. Review of the Medication Orders policy, dated 01/15/2019, indicated “… Orders for PRN [as needed] Medications must include name, dose, reason for use and any specific time constraints for administration…” 3. Review of Patient #1’s clinical record included a POC for certification period 11/03/2025 to 01/01/2026. The POC failed to include the reason for use for the as needed medication Albuterol-Budesonide inhaler, a medication used to relax the muscles around the airway to make breathing easier. During an interview on 12/09/2025 at 1:12 PM, the CM relayed the indications for Patient #1’s as-needed medication Albuterol-Budesonide inhaler would not be found on the POC because it was on the Patient’s medication profile under PRN indications. 4. Review of Patient #3’s clinical record included a POC for certification period 11/30/2025 to 01/28/2025. The POC medication list included daily aspirin, a medication used to relieve pain and fever and as an antiplatelet to prevent blood clots. The POC failed to include antiplatelet or bleeding precautions. The POC also included SN orders for daily medication administration via gastric tube. The record failed to evidence daily SN visits for medication administration were provided. The POC also failed to include the duration for HHA visit orders. During an interview on 12/09/2025 at 1:18 pm, the CM relayed Patient #3 did not have anticoagulant or antiplatelet precautions in the POC. The CM also indicated the SN order to administer medications daily to the Patient via gastric tube was an entry error and relayed the Patient’s family member provided that care for the Patient. The CM also relayed Patient #3’s POC did not contain a duration for HHA services. 5. Review of Patient #4’s clinical record included a POC for certification period 11/06/2025 to 01/04/2026. The POC medication list included Pletal, an antiplatelet medication used to improve blood flow. The POC failed to include antiplatelet or bleeding precautions. During an interview on 12/08/2025 at 3:52 PM, the CM relayed Patient #4’s POC did not contain safety precautions related to bleeding or bruising. 6. Review of Patient #5’s clinical record included a POC for certification period 11/26/2025 to 01/24/2026. The POC failed to include the reason for use for the as needed medications Meclizine, a medication used to treat the symptoms of motion sickness, and Ubrogepant, a medication used to treat migraine headaches. During an interview on 12/08/2025 at 3:35 PM, the CM relayed the indications for Patient #5’s Meclizine were listed in the medication profile, but they weren’t put in the comments section, so they did not show up on the POC. The CM also relayed the Patient’s Ubrogepant was listed on the POC, but the POC did not include the indication of migraine. 7. During an interview on 12/09/2025, the CM relayed the patients’ medication profiles were not sent to the physician for signature.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to promptly notify the physician of changes to the patient’s needs that suggest the POC should be altered for 2 of 5 patient records reviewed (Patient #1, 2). Findings include: 1. Review of the Plan of Care policy, dated 01/15/2019, indicated “… Professional staff shall promptly alert the physician to any changes that suggest a need to alter the Plan of Care…” 2. Review of the Clinical Documentation policy, dated 01/15/2019, indicated “… Services not provided and the reason for the missed visits will be documented and reported to the physician…” 3. Review of Patient #1’s clinical record included a POC for certification period 11/03/2025 to 01/01/2026 which included orders for SN three times per week for physical assessment, International Normalized Ratio (INR, a test that measures how long it takes for blood to clot) monitoring, and medication management. SN interventions in the POC included but were not limited to SN to assess pain via pain scale with every visit, SN to assess for skin breakdown with each visit, SN to assess respiratory status and pulse oximetry every visit or as needed if dyspneic (suffering from shortness of breath or difficulty breathing), and SN to instruct patient/caregiver on medication dose, route, frequency, indications, and side effects. The POC orders were received from Patient #1’s primary care provider and included an order for SN to complete INR checks and manage Warfarin dose as directed by the anticoagulant therapy clinic. The record included scheduled visits not performed on 11/14/2025, 11/21/2025, 11/26/2025, 11/28/2025, 12/04/2025, and 12/05/2025 with the reason of Cancelled at the request of the Client and/or Client request visit canceled due to INR check not ordered by the clinic. The record failed to evidence Patient #1’s primary care provider was notified the Patient had cancelled six of the twelve scheduled SN visits in a four-week period. During an interview on 12/08/2025 at 3:17 PM, the CM relayed Patient #1 had only been receiving one to two of the three ordered SN visits per week because it was based on whether they had an INR check as that was their only skilled service. The CM further relayed SN could see the Patient a maximum of three times per week, but they take new orders each week based on the Patient’s INR. During an interview on 12/09/2025 at 1:12 PM, the CM relayed the provider who authorized the POC was not the same provider giving orders for INR checks. When asked how the primary care provider who ordered more than 12 interventions in addition to the intervention to receive INR check orders from the anticoagulant therapy clinic had been made aware Patient #1 had not been receiving those SN interventions three times per week as ordered, the CM indicated the agency was not missing visits the Patient was cancelling them. The CM further relayed the agency was not required to notify the physician if the Patient cancelled. 4. Review of Patient #2’s clinical record included a POC for certification period 10/28/2025 to 12/26/2025 with orders for SN one time biweekly for medication management and set up. The record failed to evidence any SN visits from 11/12/2025 through 12/05/2025. The record included a SN visit on the schedule for 11/25/25 checked Canceled but with no comments as to why it was canceled. The record included a SN visit note dated and signed by the Administrator on 11/11/25, which indicated the Patient was receiving pre-filled medication packets from the pharmacy and that the Patient self-dispensed the medications with reminders. The note indicated the Administrator called the physician to inform the Patient had taken their medication incorrectly and that the Patient reported feeling their antidepressant wasn’t effectively managing their depression. The clinical record, including but not limited to, the SN note dated 11/11/25 failed to evidence the Administrator informed the physician Patient #2 no longer needed medication set up due to receiving pre-filled medication packets from the pharmacy. During an interview on 12/09/2025 at 12:49 PM, the Administrator relayed Patient #2 had not received SN visits since 11/11/2025 because the Patient began receiving pre-filled prescription packets from the pharmacy. The Administrator further relayed she called the physician on 11/11/2025, but she did not document discussing Patient #2 no longer needing SN medication set up and did not have an order to discontinue SN medication set up.”