Elara Caring

“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 record review and interview, the agency failed to ensure the patient’s written individualized POC (Plan Of Care) was followed as evidenced by the SN (Skilled Nurse) failing to obtain weights and/or measurements as ordered for 3 (#2, #4, and #8) out of 13 (#1-#13) sampled patients. Patient #8. Review of the patient’s electronic clinical record revealed the start of care date was 02/22/2025. The patient diagnosis included Hypertensive Heart Disease with Heart Failure. The certification period reviewed was 06/22/2025 to 08/20/2025. Review of the patient’s POC for certification period 06/22/2025 to 08/20/2025 revealed the following orders: SN 1wk3, 1every2wk6 (skilled nurse visit one time a week for three weeks, one visit every two weeks for six weeks). Further review of the POC revealed orders, “Skilled nurse for o/a (observation and assessment), teaching and self-management related to heart failure, instruct patient/caregiver on signs and symptoms of exacerbation to report and importance of obtaining and recording daily weight and/or measurements. Patient is unable to weigh, SN or trained patient/caregiver to obtain measurement of left calf in cm (centimeters) daily and report an increase of 2 cm or > (greater) to physician…” Review of the patient’s SN visit notes dated 06/24/2025, 07/02/2025, and 07/10/2025 revealed no evidence the patient’s weight or left calf measurement was obtained for those visits. On 07/14/2025 at 1:54 p.m., an interview was conducted with S1Admin (Administrator) and after a review of the patient’s electronic clinical records, she verified there was no evidence the SN ensured the patient’s weight or left calf measurement was obtained for those visits made on 06/24/2025, 07/02/2025, and 07/10/2025. Patient #4. Review of the patient’s electronic clinical record revealed the start of care date was 03/27/2025. The patient’s diagnoses included cellulitis of the right lower limb and unspecified systolic (congestive) heart failure. The certification period reviewed was 05/26/2025-07/24/2025. Review of the patient’s POC for certification period 05/26/2025- 07/24/2025 revealed orders for skilled nurse visits. Further review of the patient’s POC revealed orders for: “Skilled nurse for observation/assessment….related to heart failure…instruct patient on…importance of obtaining and recording daily weight and/or measurements. Patient is unable to weigh, SN to obtain measurement of left thigh …” Review of the patient’s skilled nurse visits dated 06/06/2025, 06/20/2025, 06/23/2025, and 07/02/2025 revealed no evidence that an assessment of the patient’s weight or measurements of patient’s left thigh was obtained for those visits. Further review of the patient’s skilled nurse visits dated 06/02/2025, 06/09/2025, 06/13/2025, 06/16/2025, 06/27/2025, 07/04/2025, and 07/07/2025 revealed that the patient’s measurements were obtained from his right thigh. On 07/15/2025 at 11:55 a.m., an interview and record review was conducted with S1ADM. She confirmed there was no evidence to reflect that an assessment was done on the patient’s weight or left thigh measurements for the above referenced dates. She stated the orders read that patient #4 was to have his left thigh measured if unable to obtain his weight, and the documentation reflected the right thigh was measured. Patient #2: Review of the patient’s electronic clinical record revealed the start of care date was 05/30/2025. The patient’s diagnoses included in part, Hypertensive heart disease with heart failure, chronic diastolic (congestive) heart failure and lymphedema. The certification period reviewed was 05/30/2025 to 07/28/2025.Review of the patient’s POC for certification period 05/30/2025 to 07/28/2025.revealed an order for skilled nurse 1wk1, 3wk8, 1wk1 (skilled nurse visits one time a week for one week; skilled nurse visits three times a week for eight weeks; and skilled nurse visits one time a week for one week.) Further review of the patient’s POC revealed an order that read in part, “…SN to weigh at visits if not yet obtained per patient or caregiver…” Review of the SN (skilled nurse) note visit report dated 06/30/2025 revealed no assessment of the patient’s weight and/or left calf measurement was obtained during the visit. On 07/15/2025 at 1:15 p.m., a record review and interview was conducted with S1ADM (Administrator). She confirmed that the patient’s weight and/or left calf circumference was not obtained during the SN visit on 06/30/2025.”

“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 interview, the agency failed to coordinate care delivery to meet the patient’s needs as evidenced by the SN (skilled nurse) failing to communicate a change in the patient’s condition to the physician for 1 (#2) out of 13 sampled patients. Review of the agency’s policy titled “Plan of Care and Coordination of Care”, with a revision date of 03/01/2025, read in part: Policy: (provider’s name) will ensure that the physician or allowed practitioner is promptly notified to any changes in the patient’s condition or needs that suggest outcomes are not being achieved and/or that the plan of care should be altered…(provider name) coordinates care by: Ensuring communication with all physicians or allowed practitioners involved in the plan of care. Integrating orders for all physicians and allowed practitioners involved in the plan of care to ensure the coordination of all services and interventions provided to the patient…Coordination of care will be documented in the clinical record or in minutes of case conferences… Patient #2: Review of the patient’s electronic clinical record revealed the start of care date was 05/30/2025. The patient’s diagnoses included in part, Hypertensive heart disease with heart failure, chronic diastolic (congestive) heart failure and lymphedema. The certification period reviewed was 05/30/2025 to 07/28/2025. Review of the patient’s POC (Plan of Care) for certification period 05/30/2025 to 07/28/2025 revealed an order for skilled nurse 1wk1, 3wk8, 1wk1 (skilled nurse visits one time a week for one week; skilled nurse visits three times a week for eight weeks; and skilled nurse visits one time a week for one week.) Further review of the patient’s POC revealed an order that read in part, “A weight gain of 2 lbs (pounds) or > (more) overnight or 5 lbs or > in 1 week to be reported to physician/provider. SN to weigh at visits if not yet obtained per patient or caregiver. If unable to weigh, SN or trained caregiver to obtain baseline measurement of left calf in CM (centimeter) daily and report an increase of 2 cm or > to physician/provider. Review of the patient’s SN visit note report dated 06/16/2025 revealed the patient’s weight was 264.1 pounds. Review of the patient’s SN visit note report dated 06/18/2025 reveled the patient’s weight was 271 pounds ( a 6.9 pound weight gain in 48 hours) Further review of the note under assessment/abnormal findings, the SN indicated the following, “…increased SOB (shortness of breath) with exertion or CP (chest pain) +1 pitting edema noted to BLE (bilateral lower extremities)…” Review of the patient’s SN visit note report dated 07/04/2025 revealed the patient’s left calf circumference was 50cm. Review of the patient’s SN visit note report dated 07/07/2025 revealed the patient’s left calf circumference was 52cm. Review of the patient’s clinical record revealed no documented evidence the patient’s physician was notified that the patient had a 6.9 pound weight gain in 48 hours and a 2cm increase in her left calf. On 07/15/2025 at 1:15 p.m., a record review and interview was conducted with S1ADM (Administrator). S1ADM verified there was no documented evidence in the patient’s clinical record that the SN notified the patient’s physician that the patient had a 6.9 weight gain in 48 hours and a 2cm increase in her left calf. She confirmed that the SN should have notified the physician.”