Centerwell Home Health

“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, it was determined that the agency failed to ensure services were provided in accordance to the ordered visit frequency for 1 (P-13) of 2 patients order to have Home Health Aide services, from a total of 13 sampled records reviewed, resulting in the potential for poor grooming and unmet care needs. Findings include: P-13: The patient’s start of care was 1/8/25 with diagnoses that included Pressure Ulcers, Neurogenic Bladder and Diabetes Mellitus. During the record review on 3/5/25 at 1:00 p.m., it was noted that Home Health Aide services were ordered to be provided at a frequency of 2x/wk. x 1 wk., 3x/wk. x 2 wks. A Physician’s order revised the Aide visit frequency to reflect that Aide services were to be provided 1x/wk. x 5 wks. beginning on 1/30/25. During the review, it was noted that the Aide missed 1 of 3 scheduled visits during the week of 1/19/25. During an interview with the Administrator on 3/5/25 at 1:28 p.m., it was reported that the patient was hospitalized for observation on 1/27/25. A Coordination Note dated 1/29/25 stated the patient refused care from the additional private duty aide. There was no documented evidence that the patient refused care and services from the agency provided Aide. The Home Health Aide only made 1 visit during the week of 1/26/25. There was no documented rationale as to why only 1 visit had been made by the Aide. Additionally, there were no Aide visits conducted during the week of 2/2/25. When queried, the Administrator reported, “We hadn’t coordinated visits with the other agency.” The agency failed to honor the Physician ordered visit frequency. These findings were reviewed with and acknowledged by the Administrator during the above interviews.”

“Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This Standard is not met as evidenced by: Based on record review and interview, it was determined the Agency failed to ensure the Skilled Nurse prepared clear written patient care instructions for the home health aide regarding client needs, and precautions prior to the provision of care in 1 (P-13) of 2 records in which Home Health Aide services were ordered, from a total of 13 sampled records reviewed, resulting in the potential for the provision of unsafe care and unmet care needs. Findings include: P-13: The patient’s start of care was 1/8/25 with diagnoses that included Stage III Pressure Ulcer, Stage II Pressure Ulcers and Neurogenic Bladder. During the record review on 3/5/25 at 1:00 p.m., it was noted that the patient was admitted with an indwelling catheter related Stage III penile pressure sore, Stage II pressure ulcer to right posterior ankle and a wound to his right thigh near catheter. All of the above sites required wound care. During a review of the “Aide Care Plan Report” dated 1/8/25, it was noted that there were no instructions or guidance provided as to what the Aide would be required to do if the patient’s wound dressings should become soiled or dislodged. These findings were reviewed with and acknowledged by the Administrator during an interview on 3/5/25 at 1:28 p.m.”

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on observation, interview and record review, the Agency failed to ensure that 1 (P-12) of 2 patients observed during home visits, from a total of 13 sampled records reviewed, were included in the overall planning of care including informing the patient/caregiver in advance of the days in which services would be provided, and failed to ensure that 1 (P-7) of 13 records reviewed were included in their overall planning of care including informing the patient/caregiver in advance of which services would be provided and disciplines that will furnish care, resulting lack of inclusion in planning, the potential for missed visits and unmet care needs. Findings include: Policy: 03-11 Care Planning, 9/2024 stated, “The patient (and/or if applicable caregiver/family/authorized representative) will be provided POC details and written instructions to include: discipline-specific visits, frequency and duration.” P-12: The patient’s start of care was 2/12/25 with diagnoses that included congestive Heart Failure, Chronic Pain and diabetes Mellitus. During the clinical record review on 3/5/25 at 9:15 a.m., it was noted that the Plan of Care ordered Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT) and Medical Social Work (MSW) services to be provided. On 3/4/25 at 1:30 p.m., a scheduled survey home visit was conducted with the Registered Nurse (RN #1). During the visit, the patient and his significant other (SO #1) were asked for permission to review the agency admission packet. Upon review, there was no completed calendar of proposed visits to be conducted by the ordered disciplines. During the visit, SO #1 inquired of RN #1, “Is anybody coming out tomorrow? We haven’t heard anything.” RN #1 stated, “I would have to check and see when the other disciplines are coming out.” RN #1 reviewed her computer tablet and stated, “It seems like OT, PT and MSW may be coming out this Thursday and Friday. I’m not sure which days or times.” SO #1 stated, “The Physical Therapist (assistant) said he would be off all this week.” When asked how the patient was made aware of the disciplines scheduled dates and times of service, both the patient and SO #1 responded, “They (disciplines) call us and tell us when they’re coming, but we haven’t heard anything.” RN #1 then approached a calendar that was taped to the wall. The calendar had one entry written by a different nurse. The remainder of the calendar was void of any of the other ordered disciplines, dates, and times that services would be provided. The agency failed to ensure the patient was included in the overall planning of his care. These findings were reviewed with and acknowledged by the Administrator during an interview on 3/5/25 at 11:17 a.m. P-7: The Start of Care (SOC) was dated 2/21/25. The Plan of Care (POC) identified diagnoses of Diabetes Type 2, Chronic Kidney Disease Stage 5 and Congestive Heart Failure. During record review on 2/28/25, it was noted that the referral stated, “Referral Comments: …will need RN (Registered Nurse), PT (Physical Therapy), OT (Occupational Therapy), HHA (Home Health Aide)”. The consent signed by the patient on 2/21/25 and the comprehensive assessment completed by the RN on 2/21/25 were blank under the Home Health Aide (HHA) section and there was no documentation of the patient refusing HHA. The agency failed to provide services as ordered. This finding was reviewed with and acknowledged by the Adm #1 (Administrator) during an interview on 3/5/25 at 12:50 pm.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: (1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on record review and interview, the agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient’s current health status based on past medical history that included dates of onset, exacerbations, treatments and outcomes, and history of events leading to current home care needs in 6 (P-3, P-4, P-5, P-6, P-7, P-10) of 13 records reviewed, resulting in incomplete clinical information to aide in determining the needs of the patient. Findings included: **Agency Policy: “03-05 Patient Assessments” (Reviewed 08/2024). The policy states, “Initial Comprehensive Assessments… Each patient’s: current health, psychosocial, functional and cognitive status will be accurately assessed…” P-3: The Start of Care (SOC) was dated 12/16/24. The Plan of Care (POC) identified diagnoses of Congestive Heart Failure, Peripheral Vascular Disease and Chronic Obstructive Pulmonary Disease. During record review on 2/28/25, it was noted that the SOC comprehensive assessment dated 12/16/24, documented under “Primary Diagnosis and Other Diagnoses”, all 298 diagnoses had an exacerbation or onset date of 12/16/24. No prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. P-4: The Start of Care (SOC) was dated 11/20/24. The Plan of Care (POC) identified diagnoses of Congestive Heart Failure, Diabetes Type 2 and Stage 2 Pressure Ulcer. During record review on 2/28/25, it was noted that the SOC comprehensive assessment dated 11/20/24, documented under “Primary Diagnosis and Other Diagnoses”, all 22 diagnoses had an exacerbation or onset date of 11/20/24. No prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. P-5: The Start of Care (SOC) was dated 12/15/24. The Plan of Care (POC) identified diagnoses of Sepsis, Chronic Obstructive Pulmonary Disease and Pneumonia. During record review on 3/5/25, it was noted that the SOC comprehensive assessment dated 12/15/24, documented under “Primary Diagnosis and Other Diagnoses”, all 15 diagnoses had an exacerbation or onset date of 12/15/24. No prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. P-6: The Start of Care (SOC) was dated 1/18/25. The Plan of Care (POC) identified diagnoses of Venous Insufficiency, Lymphedema, and Diabetes Type 2. During record review on 3/5/25, it was noted that the SOC comprehensive assessment dated 1/18/25, documented under “Primary Diagnosis and Other Diagnoses”, all 22 diagnoses had an exacerbation or onset date of 1/18/25. No prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. P-7: The Start of Care (SOC) was dated 2/21/25. The Plan of Care (POC) identified diagnoses of Diabetes Type 2, Chronic Kidney Disease Stage 5 and Congestive Heart Failure. During record review on 2/28/25, it was noted that the SOC comprehensive assessment dated 2/21/25, documented under “Primary Diagnosis and Other Diagnoses”, all 30 diagnoses had an exacerbation or onset date of 2/21/25. No prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. P-10: The Start of Care (SOC) was dated 2/16/25. The Plan of Care (POC) identified diagnoses of Oral Cancer, Chronic Obstructive Pulmonary Disease and Hypertension. During record review on 3/5/25, it was noted that the SOC comprehensive assessment dated 2/16/25, documented under “Primary Diagnosis and Other Diagnoses”, all 14 diagnoses had an exacerbation or onset date of 2/16/25. No prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. These findings were reviewed with and acknowledged by the Adm #1 (Administrator) during an interview on 3/5/25 at 12:45 pm.”

“Patient’s needs CFR(s): 484.55(c)(4) The patient’s medical, nursing, rehabilitative, social, and discharge planning needs; This Element is not met as evidenced by: Based on observation, interview and record review, it was determined the Agency failed to ensure the patient’s Activity of Daily Living needs were adequately met in the patient’s home for 2 (P-11, P-12) patients assessed as needing assistance with grooming, from a total of 13 sampled records reviewed, resulting in the potential for poor hygiene, psychological decline and unmet care needs. Findings include: Policy: 03-03 Admission and Non-Admission Criteria Policy, 5/2024 stated, “Initial Acceptance Criteria: Reasonable expectation that the patient’s overall medical needs - to include nursing, rehabilitative and social services - can be adequately met in their place of residence.” P-11: the patient’s start of care (SOC) was 2/18/25 with diagnoses that included Septic Shock with resultant Urinary Tract Infections requiring antibiotic therapy, Hypertension and diabetes Mellitus. During the clinical record review on 3/4/25 at 10:50 a.m., it was noted that the Plan of Care (POC) ordered Skilled Nursing (SN) and Occupational Therapy (OT) services to be provided. Section M1800 of the Initial comprehensive Assessment stated that someone must assist with grooming and dressing and documented, “Patient lives in condo with spouse who is currently receiving respite care due to her own health issues.” There was no evidence that a Home Health Aide had been offered/provided to offer assistance with grooming. The record further indicated the patient had a PICC (Peripherally Inserted Central Catheter) line to his right upper extremity for antibiotic therapy administration. On 3/4/25 at 12:00 p.m., a scheduled home visit was conducted with the Occupational Therapist (OT #1). During the visit, a young lady was present and was identified as being the patient’s wife’s assigned caregiver. The patient’s daughter, who was also present during the visit, reported that the patient’s wife has paid caregivers and sometimes when she (paid caregiver) is there, if requested, she will assist the patient with a shower. The patient’s daughter further stated, “Before he (the patient) became sick, he could take care of himself and shower himself. Now, since his illness, he needs assistance, and he uses a walker and a cane.” There was no documented caregiver assigned to provide assistance with the patient’s grooming and no documented evidence that a Home Health Aide had been offered and/or provided. Additionally, during the OT visit, the patient requested that OT #1 assist with giving him a shower and stated, “She (patient’s daughter) can wrap my arm with Saran wrap and then I can have a shower.” OT #1 initially agreed by stating “Okay, we can do that.” OT #1 then stepped away, returned, and stated, “So this is what I’m going to do, today I’m going to be working with seeing how well you can transfer…” OT #1 then assisted the patient to the kitchen with use of a walker and to the laundry room and subsequently concluded the visit. Upon completion of the visit, after exiting the patient’s home, OT #1 was queried as to why she didn’t provide assistance with showering as requested by the patient and reported, “I felt like we’ve already accomplished those goals.” OT #1 failed to provide assistance with showering as requested. These findings were reviewed with and acknowledged by the Administrator (Adm #1) during an interview on 3/5/25 at 10:58 a.m. who reported, OT #1 followed up with the patient’s son today (3/5/25) and his son was okay with the plan of care. Adm #1 was asked if the patient was his own responsible party or if he had a guardian or power of attorney who made decisions on his behalf and reported, No. He is his own responsible party and can make his own decisions. It was concluded that the agency failed to ensure the patient’s ADL needs were adequately met in the patient’s home. P-12: The patient’s SOC was 2/12/25 with diagnoses that included Congestive Heart Failure, Chronic Pain and diabetes Mellitus. During the clinical record review on 3/5/25 at 9:15 a.m., it was noted that the POC ordered SN, PT, OT and Medical social work (MSW) services to be provided. Section M1800 of the Initial Comprehensive Assessment stated, “someone must assist with dressing, able to assist with bed bath, grooming..., Patient reported having a stroke this summer (2024).” Section (E) (GG0100A) documented, “patient needed partial assistance from another person to complete any activities.” On 3/4/25 at 1:30 p.m., a scheduled survey home visit was conducted with the Registered Nurse (RN #1). Upon arrival, the patient was observed sitting on side of his bed in the living room. The patient had an unkempt appearance and poorly groomed hair. His feet were bare, visibly dry and ashy, and his clothes appeared wrinkled and dirty. The patient was noted to have an unsteady gait when attempting to ambulate with use of a walker and RN #1 as contact guard. The patient’s significant other (SO #1) stated, “None of his kids come to visit him or help out.” The patient then stated, “If they (Home Health Agency) could just send someone out to help me, I’d appreciate it because she (SO #1) has dementia and is doing the best she can, but she can’t do everything. They never sent anybody out to help me.” When asked who assists with bathing and dressing, SO #1 stated, “I try to wipe him off but it’s hard.” The agency failed to ensure the patient’s activity of daily living needs were adequately met in the patient’s home. These findings were reviewed with and acknowledged by Adm #1 during an interview on 3/5/25 at 11:17 a.m.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment included a review of all medications the patient was currently taking for drug allergies in 1 (P-2) of 13 sample records reviewed, potentially resulting in unknown complications related to an allergic reaction and poor patient outcomes. Findings include: **Agency Policy: “03-41 Medication Review and Documentation” (Revised 10/2024). The policy states, “A Drug Regime Review (DRR) and medication reconciliation will include all patient/OTC (Over the Counter) medications and will be performed during the initial comprehensive assessment, each comprehensive assessment thereafter and when a new medication is added to the patient plan of care. Medications are reviewed for potential clinically significant issues/concerns. All medication issues/concerns will be reported to the patient’s physician/allowed practitioner to include but is not limited to: … drug reactions…side effects/drug interactions...” P-2: The Start of Care (SOC) was dated 1/10/25. The Plan of Care (POC) identified diagnoses of Left Knee Replacement and Hypertension. During record review on 3/4/25, it was noted that the referral stated, “Allergies: … Ultram [Tramadol] – Nausea and Vomiting… Medications: …Tramadol HCl (tablet) Ultram 50mg Take 25mg by mouth every 4 hours as needed for pain.” The POC documented, “Allergies: …Tramadol.” The comprehensive assessment completed on 1/10/25 stated, “Clinical Summary (Focus: Focus of care - principle diagnosis, other pertinent diagnoses, clinical information, utilization of other disciplines, skilled services provided): … Patient first reported pain as 9/10 upon nurse arrival and was tearful, however, after taking another dose of Oxy (Oxycodone) and Tramadol, pain decreased to 6/10 by end of visit… Medication Understanding Changes: …Tramadol 25mg tablet… Side effects/Interactions: N (No).” Additionally, there was no documented evidence that the physician was notified of the potential medication concern of the patient taking a medication that they are allergic to. The agency failed to follow policy and review the medications for drug reactions related to taking a medication with a known allergy and reporting these findings to the physician. This finding was reviewed with and acknowledged by the Adm #1 (Administrator) during an interview on 3/5/25 at 1:15 pm.”

“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 document review and interview, it was determined that the agency failed to ensure the Plan of Care included allergies, objectively measurable and individualized goals in 8 (P-2, P-6, P-7, P-8, P-9, P-10, P-12, P-13) of 13 records reviewed resulting in a potential for failure to measure progress toward achievement of desired outcomes. Findings include: P-12: The patient’s start of care (SOC) was 2/12/25 with diagnoses that included Congestive Heart Failure (CHF), Chronic Pain and Diabetes Mellitus. During the clinical record review on 3/5/25 at 9:15 a.m., it was noted that the Plan of Care (POC) listed all diagnoses with the same onset/exacerbation date of 2/12/25, which was the date of admission. Additionally, the goals were unrealistic for the patient with CHF, such as, “weight gain of at least 5...” [sic] and “patient/caregiver verbalizes heart failure management as evidenced by improved cardiovascular status...” There was no indication of any teaching of what to look for in heart failure management or how these goals would be attained. Additionally, there were no interventions, reportable parameters or associated measurable goals that addressed all of the listed diagnoses said to have had an onset or exacerbated on the date of admission. These findings were discussed with and acknowledged by the Administrator (Adm #1) during an interview on 3/5/25 at 11:17 a.m. P-13: The patient’s SOC was 1/8/25 with diagnoses that included Stage III Pressure Ulcers, Stage II Pressure Ulcers and Neurogenic Bladder. The POC listed all diagnoses with same onset/exacerbation date of 1/8/25. The goals were not measurable such as, “Cardiovascular exacerbations are identified promptly and interventions initiated to minimize risks.” There was no indication of what exacerbations were to be identified, or any evidence of how the goals would be attained. These findings were discussed with and acknowledged by Adm #1 during an interview on 3/5/25 at 1:28 p.m. **Agency Policy: “03-11 Care Planning” (Reviewed 09/2024). The policy states, “The individualized POC is developed for the patient 60-day episode of care and must include: …patient-specific interventions and measurable outcomes/goals…” **Agency Policy: “03-05 Patient Assessments” (Reviewed 08/2024). The policy states, “Patient Medications: The Clinical Manager (or appropriate professional designee) will review medications for potential adverse reactions, allergies…” P-2: The Start of Care (SOC) was dated 1/10/25. The Plan of Care (POC) identified diagnoses of Left Knee Replacement and Hypertension. During record review on 3/4/25, it was noted that the goals within the POC were not measurable. For example, one goal stated, “Cardiovascular exacerbations are identified promptly and interventions initiated to minimize risks.” Additionally, another goal stated, “Patient/caregiver verbalizes/demonstrates cardiovascular disease management as evidenced by decreased symptoms and no unplanned hospitalizations by 3/7/25.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-6: The Start of Care (SOC) was dated 1/18/25. The Plan of Care (POC) identified diagnoses of Venous Insufficiency, Lymphedema, and Diabetes Type 2. During record review on 3/5/25, it was noted that the goals within the POC were not measurable. For example, one goal stated, “Patient/caregiver verbalizes/demonstrates cardiovascular disease management as evidenced by decreased symptoms and no unplanned hospitalizations by 3/18/25.” Additionally, another goal stated, “Patient/caregiver verbalizes/demonstrates peripheral vascular disease management as evidenced by improved peripheral vascular disease symptoms and no unplanned hospitalizations by 3/18/25.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. Additionally, it was noted that the POC dated 1/18/25 stated, “Allergies: Morphine.” The referral dated 1/17/25 documented the following allergies: Morphine, Ciprofloxacin, Ketorolac Tromethamine, Nonsteroidal Anit-Inflammatory Agents, Salicylates and Tramadol. The agency failed to document and accurately assess the patient’s allergies to Ciprofloxacin, Ketorolac Tromethamine, Nonsteroidal Anit-Inflammatory Agents, Salicylates and Tramadol. P-7: The Start of Care (SOC) was dated 2/21/25. The Plan of Care (POC) identified diagnoses of Diabetes Type 2, Chronic Kidney Disease Stage 5 and Congestive Heart Failure. During record review on 2/28/25, it was noted that the goals within the POC were not measurable. For example, one goal stated, “Cardiovascular exacerbations are identified promptly and interventions initiated to minimize risks.” Additionally, another goal stated, “Patient/caregiver verbalizes/demonstrates heart failure management as evidenced by teachback of importance of weighing self daily to stay within the parameters PCP has set, teachback ss (signs and symptoms) of fluid overload, improved cardiovascular status and no unplanned hospitalizations by 4/1/25.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-8: The Start of Care (SOC) was dated 10/27/24. The Plan of Care (POC) identified diagnoses of Stage 3 Pressure Ulcer, Hypertension and Urinary Tract Infection. During record review on 3/4/25, it was noted that the goals within the POC were not measurable. For example, one goal stated, “Cardiovascular exacerbations are identified promptly and interventions initiated to minimize risks.” Additionally, another goal stated, “Patient/caregiver verbalizes/demonstrates cardiovascular disease management as evidenced by decreased symptoms such as elevation in bp, hypotension, dizziness or hr outside parameters and no unplanned hospitalizations by 3/1/25.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. Additionally, it was noted that the POC dated 10/27/24 stated, “Allergies: All Sulfa; Methazole Trimethoprim.” The referral documented the following allergies: Morphine, Sulfamethoxazole and Trimethoprim. The agency failed to document and accurately assess the patient’s allergy to Morphine. P-9: The Start of Care (SOC) was dated 1/29/24. The Plan of Care (POC) identified diagnoses of Stage 3 Pressure Ulcer, Congestive Heart Failure and Paraplegia. During record review on 3/4/25, it was noted that the goals within the POC were not measurable. For example, one goal stated, “Cardiovascular exacerbations are identified promptly and interventions initiated to minimize risks.” Additionally, another goal stated, “Patient/caregiver verbalizes/demonstrates cardiovascular disease management as evidenced by decreased symptoms and no unplanned hospitalizations by 3/23/25.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-10: The Start of Care (SOC) was dated 2/16/25. The Plan of Care (POC) identified diagnoses of Oral Cancer, Chronic Obstructive Pulmonary Disease and Hypertension. During record review on 3/5/25, it was noted that the goals within the POC were not measurable. For example, one goal stated, “Cardiovascular exacerbations are identified promptly and interventions initiated to minimize risks.” Additionally, another goal stated, “Patient/caregiver verbalizes/demonstrates cardiovascular disease management as evidenced by decreased symptoms reported bp within parameters defined by MD, dietary modifications and no unplanned hospitalizations by 4/16/25.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. These findings were reviewed with and acknowledged by the Adm #1 (Administrator) during an interview on 3/5/25 at 12:55 pm.”

“Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Home Health Aide provided care in accordance with the plan of care for 1 (P-9) of 2 patients in which Home Health Aide services were provided, resulting in the potential for patients to receive sub-standard services from the agency. Agency Policy, “03-11 Care Planning” (Revised 09/2024). The policy states, “The RN (Registered Nurse) is responsible for supervising and developing the “care plan” for the Home Health Aide when ordered for the patient. The care plan includes tasks with frequency to be performed and relevant instructions related to the patient assigned.” P-9: The Start of Care (SOC) was dated 1/29/24. The Plan of Care (POC) identified diagnoses of Stage 3 Pressure Ulcer, Congestive Heart Failure and Paraplegia. During record review on 3/4/25, it was noted that the Home Health Aide (HHA) care plan was updated on 2/18/25 to include temperature, blood pressure, respirations, and pulse to be checked every visit. On 2/25/25, the HHA documented, “pulse: 63, respirations: 18.” The HHA failed to provide ordered services that included obtaining temperature and blood pressure, which could result in the potential for poor patient outcomes. This finding was reviewed with and acknowledged by the Adm #1 (Administrator) during an interview on 3/5/25 at 1:15 pm.”