Amberwell Health 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 record review and staff interview, the Home Health Agency (HHA) failed to ensure that when receiving a general referral for home health services that the physician was contacted for orders based off of assessment finding when developing patient plans of care for 8 of 10 sample patients (Patients 1,2,3,4,6,7,8,10). This deficient practice placed all patients at risk for unmet care needs, and adverse outcomes related to the lack of care coordination with the physician regarding the plan of care. Findings Include: Patient 1 Review of Patient 1’s clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 09/12/25 was based off of a general referral verbal order. Review of the Start of Care Comprehensive Assessment note showed that the Registered Nurse developed the plan of care but failed to contact the physician for approval of the orders and treatments listed on the plan of care. The Occupational Therapist completed their evaluation on 09/12/25 and developed the OT plan of care but failed to contact the physician for approval of the ordered frequency and treatments listed. There was no documented evidence of any communication with the physician who would sign/approve the plans of care at the time of their development. Patient 2 Review of Patient 2’s clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 09/19/25 was based off of a general referral verbal order. Review of the Start of Care Comprehensive Assessment note showed that the Registered Nurse developed the plan of care but failed to contact the physician for approval of the orders and treatments listed on the plan of care. The Occupational Therapist completed their evaluation on 09/19/25 and developed the OT plan of care but failed to contact the physician for approval of the ordered frequency and treatments listed. There was no documented evidence of any communication with the physician who would sign/approve the plans of care at the time of their development. Patient 3 Review of Patient 3’s clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 09/27/25 was based off of a general referral verbal order. Review of the Start of Care Comprehensive Assessment note showed that the Registered Nurse developed the plan of care but failed to contact the physician for approval of the orders and treatments listed on the plan of care. The Occupational Therapist completed their evaluation on 09/29/25 and developed the OT plan of care but failed to contact the physician for approval of the ordered frequency and treatments listed. There was no documented evidence of any communication with the physician who would sign/approve the plans of care at the time of their development. Patient 4 Review of Patient 4’s clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 09/04/25 was based off of a general referral verbal order. Review of the Start of Care Comprehensive Assessment note showed that the Registered Nurse developed the plan of care but failed to contact the physician for approval of the orders and treatments listed on the plan of care. The Occupational Therapist completed their evaluation on 09/04/25 and developed the OT plan of care but failed to contact the physician for approval of the ordered frequency and treatments listed. There was no documented evidence of any communication with the physician who would sign/approve the plans of care at the time of their development. Patient 6 Review of Patient 6’s clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 09/18/25 was based off of a general referral verbal order. Review of the Start of Care Comprehensive Assessment note showed that the Registered Nurse developed the plan of care but failed to contact the physician for approval of the orders and treatments listed on the plan of care. The Occupational Therapist completed their evaluation on 09/18/25 and developed the OT plan of care but failed to contact the physician for approval of the ordered frequency and treatments listed. There was no documented evidence of any communication with the physician who would sign/approve the plans of care at the time of their development. Patient 7 Review of Patient 7’s clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 09/06/25 was based off of a general referral verbal order. Review of the Start of Care Comprehensive Assessment not showed that the Registered Nurse developed the plan of care but failed to contact the physician for approval of the orders and treatment listed on the plan of care. The Occupational Therapist completed their evaluation on 09/08/25 and developed the OT plan of care but failed to contact the physician for approval of the ordered frequency and treatments listed. There was no documented evidence of any communication with the physician who would sign/approve the plans of care at the time of their development. Patient 8 Review of Patient 8’s clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 07/14/25 was based off of a general referral verbal order. Review of the Start of Care Comprehensive Assessment showed that the Registered Nurse developed the plan of care but failed to contact the physician for approval of the orders and treatment listed on the plan of care. There was no documented evidence of any communication with the physician who would sign/approve the plans of care at the time of their development. Patient 10 Review of Patient 10’s clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 06/11/25 was based off of a general referral verbal order. Review of the Start of Care Comprehensive Assessment showed that the Registered Nurse developed the plan of care but failed to contact the physician for approval of the orders and treatment listed on the plan of care. The Occupational Therapist completed their evaluation on 06/11/25 and developed the OT plan of care but failed to contact the physician for approval of the ordered frequency and treatments listed. There was no documented evidence of any communication with the physician who would sign/approve the plans of care at the time of their development. During an interview on 10/02/25 at 9:15 AM, Staff A, Agency Director confirmed the above finding of lack of care coordination with the physician regarding the plan of care.”

“HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator’s name, business address, and business phone number in order to receive complaints. This Element is not met as evidenced by: Based on record review and document review, the Home Health Agency (HHA) failed to ensure the patient’s right to receive the contact information for the HHA’s administrator, including the administrator’s name, business address, and business phone number in order to receive complaints for 10 of 10 sample patients (Patients 1-10). The agency’s failure to ensure the patient’s right to receive the contact information for the administrator, placed all patients currently on service, at risk for unmet needs due to not being able to contact the home health agency’s administrator. Findings Include: Review of all admission documents for Patients 1 through 10, showed the agency failed to document any evidence the Agency’s Administrator contact information was provided to the patients during the admission process or thereafter. Review of Agency Admission packet and all admission documents provided, showed the agency failed to provide any written information regarding the Agency’s Administrator contact information, such as name, address or business phone number, being giving during the admission process or thereafter.”

“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 staff interview, the Home Health Agency (HHA) failed to ensure all patients plans of care included all required elements, such as all safety measures for all medications they were taking for 4 of 10 sample patients (Patients 5, 6, 9, 10). This deficient practice placed all patients at risk for unmet care needs, and adverse outcomes. Findings Include: Patient 5 Review of Patient 5’s clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 08/22/25. The Principle Diagnosis showed; Metabolic Encephalopathy. The listed medications showed; Aspirin 81 mg oral tab once daily. Review of the safety measures listed on the plan of care lacked evidence of bleeding precautions for the patient. Patient 6 Review of Patient 6’s clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 09/18/25. The Principle Diagnosis showed; Acute Cystitis with Hematuria. The listed medications showed; Plavix 75 mg oral tab once daily. Review of the safety measures listed on the plan of care lacked evidence of bleeding precautions for the patient. Patient 9 Review of Patient 9’s clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 06/24/25. The Principle Diagnosis showed; Displaced Fracture of Femur. The listed medications showed; Aspirin 81 mg oral tab once daily. Review of the safety measures listed on the plan of care lacked evidence of bleeding precautions for the patient. Patient 10 Review of Patient 10’s clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 06/11/25. The Principle Diagnosis showed; Compression Fracture of T11 and T12 Vertebra. The listed medications showed; Aspirin 81 mg oral tab once daily. Review of the safety measures listed on the plan of care lacked evidence of bleeding precautions for the patient. During an interview on 10/02/25 at 9:50 AM, Staff A, Agency Director confirmed the above findings of not having all the specific requirements, treatments, and safety measures included as a part of the patient’s plans of care.”

“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 record review, and staff interview, it was determined the Home Health Agency (HHA) failed to send a transfer summary to the facility where the patient was receiving in-patient health care services for 1 of 10 sample patients (Patient 10). The HHA also failed to send a discharge summary to the primary care physician responsible for patient’s health care services, within 5 business days from the date of discharge for 1 of 10 sample patients (Patient 8). This deficient practice had the potential to affect patient safety and to place the patients at risk for adverse outcomes related to the lack of care coordination with other health care services. Findings Include: Patient 10 Review of Patient 10’s clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 06/11/25. Review of visit notes for the current certification period showed a transfer to the hospital on 07/03/25. The HHA completed an OASIS/Transfer to In-Patient Facility (TIF) on 07/03/25 however, there was no evidence of a Transfer Summary being completed with the TIF. There was no evidence of a Transfer Summary being sent to the receiving facility. Patient 8 Review of Patient 8’s clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 07/14/25. Review of the visit notes for the current certification period showed the patient was discharged on 07/28/25 and a discharge summary was completed at that time. However, the summary was not sent to the physician until 08/11/25 which was greater than 5 business days from the discharge date of 07/28/25. During an interview on 10/02/25 at 10:05 AM, Staff A, Agency Director, confirmed the above findings of the agency not providing Transfer/Discharge Summaries in a timely manner to the receiving health care providers.”