Johns Hopkins Pediatrics at Home Inc.

“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 patient medical record reviews and interviews with staff conducted on December 10-13, 2024, the agency failed to follow procedures for missed visits for two out of sixteen records reviewed. The failure to reschedule missed visits, notify the appropriate medical provider, document the potential critical impact jeopardizes patient safety, continuity of care, and treatment outcomes. Patients: #6, #7 Patient number six according to clinical records had a missed skilled nursing visit week eight. There was no documentation of attempts to reschedule the visit, no notification to the responsible physician, and no documentation addressing the potential impact of the missed treatment. Patient number seven according to clinical records had a missed physical therapy visit in week two. There was no documentation of attempts to reschedule the visit, no notification to the responsible physician, and no documentation addressing the potential impact of the missed treatment. When asked the agency staff had no further documentation or explanation for the communication failure.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on review of patient records and interview with agency staff, the agency staff did not communicate delays in the start of care noted for 2 out of 13 patients placing the patients at risk for adverse or negative health care outcomes. Patients: #2, #3 Findings included: The home health agency furnishing services must maintain communication to ensure that their efforts are coordinated effectively and support the objectives outlined in the patients plan of care. 1.All clinical staff members have the responsibility to communicate or refer patient care related issues to other professional disciplines to ensure the provision of optimal health care services and to prevent adverse outcomes. This did not occur, as evidenced by the review of patient records on 12/10/24. Delay of care noted during the medical record review, for patient number two the referral was dated 6/12/24 and start of care was noted on 6/19/2024. For patient number three, the referral was dated 7/5/24 and the start of care was noted on 7/9/24. When asked the agency staff had no further documentation or explanation for the delays in care.”

“Revisions communicated to patient and MDs CFR(s): 484.60(c)(3)(i) (i) Any revision to the plan of care due to a change in patient health status must be communicated to the patient, representative (if any), caregiver, and all physicians or allowed practitioner’s issuing orders for the HHA plan of care. This Element is not met as evidenced by: Based on record review and staff interviews the agency failed to notify a Physician or practitioner that issued patient orders when a revision in the care was required due to a change in the health status. This failure occurred for one out of sixteen patient medical records reviewed placing the patients at risk for adverse or negative health care outcomes. Patient: #12 Failure to communicate therapy services frequency change for patient number twelve on 11/6/24. On 12/13/2024, during the review of patient number twelve’s medical records the medical provider ordered physical therapy once a week for nine weeks. The patient started physical therapy services on 10/16/24. On 11/6/24 the physical therapist noted a plan to decrease the treatments to two to three times per month due to the patient’s progress. The patient then received physical therapy services on 11/18/24 12/3/24 and 12/11/24. On further review of the medical record there was no mention or other documentation noting consulting or communicating a need for frequency change with the medical provider. No new orders were documented. When asked the agency staff had no further documentation or explanation for the communication failure with the medical provider.”