Breathitt County HHA

“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 interview, record review, and policy review, the facility failed to ensure that patients care plans are individualized and have measurable outcomes specific to the patient for 3 (Patient #1-3) of 3 patients reviewed for care plans. The failure had the likelihood for patients not to be evaluated of the effectiveness of the skilled interventions. Findings Included: An agency policy titled, “Initial Assessment/Comprehensive Assessments” last revised 12/2025, revealed, “8. The Initial Comprehensive Assessment also includes: Relevant diagnoses and current health status, including all active health and medical problems. Relevant medical history. Prognosis. Physical assessment/review of systems and pertinent physical findings. Age-specific and gender-specific findings, as appropriate. Drug allergies, sensitivities, past adverse drug reactions and past history of medication compliance. Strengths, goals and care preferences, including information that may be used to demonstrate the patient’s progress toward achievement of the goals identified by the patient and measurable outcomes identified by the Agency. Patient #1’s “Plan of Care,” dated 01/01/2025 revealed the agency admitted Patient #1 on 12/30/2025 with diagnoses that included spinal stenosis (a condition where the narrowing of the spaces within the spine places pressure on the nerves and spinal cord). Per the Home Health Plan of Care, Patient #1’s Skilled Nursing Short-Term and Long-Term goals revealed that there were no goals that were individualized or measurable to the patient. Patient #2’s “Plan of Care,” dated 10/29/2025 revealed the agency admitted Patient #2 on 10/29/2025 with diagnoses that included pressure ulcer (a condition where damage to the skin and underlying tissue caused by prolonged pressure, friction, or shear). Per the Home Health Plan of Care, Patient #2’s Skilled Nursing Short-Term and Long-Term goals revealed that there were no goals that were individualized or measurable to the patient. Patient #3’s “Plan of Care,” dated 12/08/2025 revealed the agency admitted Patient #2 on 10/09/2025 with diagnoses that included neuromuscular dysfunction of bladder (dysfunction of the bladder caused by nerve damage, resulting in loss of bladder control). Per the Home Health Plan of Care, Patient #2’s Skilled Nursing Short-Term and Long-Term goals revealed that there were no goals that were individualized or measurable to the patient. During an interview on 01/22/2026 at 9:30 AM, Registered Nurse #1 stated that during NDOC EMR training, staff were instructed that goals were autogenerated and did not require manual creation, but she recognized that goals could be more patient-specific and measurable. During an interview on 01/22/2026 at 9:00 AM, Home Health Director stated that during training on the NDOC EMR (electronic medical record) system, staff were informed that goals and care plans were automatically generated based on assessment data; however, she acknowledged that goals could be better individualized and made more measurable, which was her expectations for staff.”

“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 interview, and facility document review, the facility failed to provide their patients with a written visit schedule for 3 (Patient #1-3) of 3 patients reviewed for visit schedules. The failure had the likelihood for patients to miss their scheduled visit. Findings included: During an interview on 01/20/2026 at 4:50 PM, Patient #1 stated that they did not have a written visit schedule and would just communicate the visit schedule via phone with the Physical Therapist and Physical Therapist Assistants. During an interview on 01/21/2026 at 9:50 AM, Patient #2 stated that they did not have written visit schedule and would just communicate via phone. During an interview on 01/21/2026 at 10:43 AM, Patient #3 stated that they did not have a written visit schedule but communicated with staff by phone. During an interview on 01/22/2026 at 9:30 AM, Registered Nurse #1 stated that written visit schedules were previously completed at admission; however, due to the reduced patient census and established routines, written schedules were not consistently maintained. She acknowledged that written schedules should be kept current. During an interview on 01/22/2026 at 9:00 AM, Home Health Director stated that staff were expected to update the paper schedule included in the patient admission packet and replace it as needed.”