Phoenix Home Care

“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 failed to ensure each patient’s Plan of Care was individualized, to include all required safety measures and complete medication orders for 5 of 17 sample patients (Patient 4,6,7,11 and 17). This deficient practice had the potential to affect patient safety and to place the patients at risk for adverse outcomes and unmet needs. Findings Include: Patient 4 Review of Patient 4’s clinical record with a Start of Care date of 08/20/25 showed Aspirin 81 mg oral daily in the medication section of the Plan of Care. However, there were no risk of bleeding precautions listed under the safety measures section of the Plan of Care. Patient 6 Review of Patient 6’s clinical record with a Start of Care date of 08/08/25 showed Aspirin 81 mg oral daily in the medication section of the Plan of Care. However, there were no risk of bleeding precautions listed under the safety measures section of the Plan of Care. Patient 7 Review of Patient 7’s clinical record with a Start of Care date of 08/30/25 showed Aspirin 81 mg oral daily in the medication section of the Plan of Care. However, there were no risk of bleeding precautions listed under the safety measures section of the Plan of Care. Patient 11 Review of Patient 11’s clinical record with a Start of Care date of 07/30/25 showed Aspirin 325 mg oral daily in the medication section of the Plan of Care. However, there were no risk of bleeding precautions listed under the safety measures section of the Plan of Care. Patient 17 Review of Patient 17’s clinical record with a Start of Care date of 08/05/25 showed orders for Oxygen 2 L (liters) at night, on the Plan of Care. However, this order was incomplete, in that there was no route of delivery. During an interview on 09/04/25 at 2:30 PM, Staff A, Administrator, confirmed the above findings of the agency’s failure to ensure an individualized Plan of Care for the above patients.”

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on observation, record review, and staff interview, the Home Health Agency (HHA) failed to provide the patient and caregiver a copy of written instructions outlining visit schedule including frequency of visits by HHA personnel for 2 of 17 sample patients (Patient 1 and 6). The Home Health Agency’s failure to ensure the patients received written instructions regarding planned visits placed all patients, currently on services at risk for unmet needs, care and services. Findings Include: Patient 1 Observation during home visit with Patient 1 on 09/03/25 at 8:00 AM, there were no written instructions regarding visit frequency or a calendar indicating when the agency personnel would visit. Review of Patient 1’s clinical record lacked documented evidence by agency professional staff regarding giving or delivering written instructions outlining visit frequencies to the patient or caregiver. Patient 6 Observation during home visit with Patient 6 on 09/03/25 at 11:15 AM, there were no written instructions regarding visit frequency or a calendar indicating when the agency personnel would visit. Review of Patient 6’s clinical record lacked documented evidence by agency professional staff regarding giving or delivering written instructions outlining visit frequencies to the patient or caregiver. During an interview on 09/04/25 at 10:45 AM, Staff A, Administrator stated that, the agency does not give the patients a copy of the plan of care but does have a copy of a calendar in the admission packet for use by the professional staff. Staff A also confirmed the above findings of not providing written information regarding the frequency of visits to patients.”

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on observation, record review and interview, the Home Health Agency (HHA) failed to provide the patient and caregiver a copy of written instructions outlining medication schedule/instructions, including medication name, dosage, frequency, and which medications would be administered by HHA personnel for 1 of 17 sample patients (Patient #5). The home health agency’s failure to ensure the patients received written instructions regarding medication administration placed all patients, currently on service at risk for adverse medication outcomes, and unmet needs. Findings Include: Observation during home visit with Patient 5 on 09/03/25 at 10:15 AM, there were no written instructions regarding patient medications found in the home. The patient was asked how he managed his medications or if he had been provided a written list of his medications by the agency, he stated that he wasn’t aware of a list being provided. He also stated, “I just take them all together mixed with agave”. Review of Patient 5’s clinical record lacked documented evidence by agency professional staff regarding giving or delivering written instructions outlining medication to the patients or caregivers. During an interview on 09/04/25 at 10:45 AM, Staff A, Administrator stated that, the medication profile should have been delivered to the patient. Staff A confirmed the above findings of not providing the patient a written medication list.”

“Treatments and therapy services CFR(s): 484.60(e)(3) Any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services. This Element is not met as evidenced by: Based on observation, record review, and staff interview, the Home Health Agency (HHA) failed to provide the patient and caregiver a copy of written instructions outlining wound care treatments for 2 of 17 sample patients (Patients #1 & #3). The home health agency’s failure to ensure the patients received written instructions regarding treatments to be provided, placed all patients currently on services at risk for adverse outcomes and unmet needs. Findings Include: Patient 1 Observation during home visit with Patient 1 on 09/03/25 at 8:00 AM, there were no written instructions regarding how the wound care was to be performed, found in the home. Review of Plan of Care for Patient 1, with episode dates of 07/22/25 - 09/19/25 showed orders for Skilled Nursing to perform wound care using Collagen, Hydrafera Blue and a foam dressing. Review of Patient 1’s clinical record lacked documented evidence by agency professional staff regarding giving or delivering written instructions to the patient or caregiver, outlining how the wound care was to be preformed. Patient 3 Observation during home visit with Patient 3 on 09/03/25 at 9:15 AM, there were no written instructions regarding how the wound care was to be performed, found in the home. Review of Plan of Care for Patient 3 with a Start of Care dated 07/29/25 showed orders for Skilled Nursing to perform wound care to the left leg per orders from the wound clinic. Review of Patient 3’s clinical record lacked documented evidence by agency professional staff regarding giving or delivering written instructions to the patient or caregiver, outlining how the wound care was to be performed. During an interview on 09/04/25 at 11:00 AM with agency Staff A, Administrator confirmed that, the agency had not given patients written instructions regarding how wound care treatments were to be performed.”

“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 were the patient was receiving in-patient health care services for 1 (Patient #12) of 17 and a discharge summary to the physician following the patient’s care for 2 (Patient #15 & #16). 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 12 Review of Patient 12’s clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 08/28/23 and a Certification Period from: 06/18/25 to 08/16/25. Review of visit notes showed a transfer to the hospital on 06/24/25 with a “Transfer to In-Patient Facility” (TIF) OASIS/Comprehensive Assessment and a Transfer Summary both being performed. However, the transfer summary was faxed to the physician on 07/07/25 which was after the required timeframe. Patient 15 Review of Patient 15’s clinician record showed the Home Health Certification and Plan of Care with a Start of Care date of 03/28/25 and a Certification Period from : 05/27/25 to 07/25/25. Review of visit notes showed the patient was discharged on 06/09/25 however, there was no evidence the discharge summary was sent to the physician. Patient 16 Review of Patient 16’s clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 08/14/25 and a Certification Period from: 08/14/25 to 10/12/25. Review of visit notes showed the patient was discharged on 08/25/25 however, there was no evidence the discharge summary was sent to the physician. During an interview on 09/04/25 at 2:30 PM, Staff A, Administrator, confirmed the agency had not provided Transfer/Discharge summaries for the above patient.”