Prime Homecare Agency

“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 that services were provided at the ordered frequency and as ordered in the Plan of Care for 1 (P-1) patient who required Occupational Therapy, Medical social work and speech Therapy services, from a total of 13 sampled records reviewed, resulting in the potential for unmet care needs. Findings include: P-1: The patient’s start of care was 7/24/24 with diagnoses that included Hemiplegia (paralysis) following cerebral infarction (stroke) and Dysphagia (difficulty swallowing). The referral for home care dated 7/19/24 ordered Skilled Nursing (SN), Physical Therapy (PT), Home Health Aide (HHa) and Speech Therapy (ST) to be provided. A Physician’s order dated 7/24/24 ordered Occupational Therapy and Medical Social Work Services to also be provided. during the record review on 1/23/25 at 1:35 p.m., it was noted that the OT missed 1 of the 2 visits ordered for the week of 8/4/24 with a documented rationale of “no answer to locked door or phone.” There was no evidence that the OT attempted to honor the ordered visit frequency the remainder of the week as per this requirement. A Physician’s order dated 7/24/24 ordered MSW to begin services the week of 7/24/24 (the 1st week of service). A notation within the record documented that the patient requested services to begin the 2nd week of service. However, upon further review, ST and MSW services were not provided until the 3rd week of service. There was no documented rationale for the additional delay in needed care and services. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 1/29/25 at 1:10 p.m.”

“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 interview and record review, the Agency failed to ensure Skilled Nursing prepared clear written patient care instructions for the home health aide regarding client needs, and safety precautions prior to the provision of care in 1 (P-3) record 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-3: The patient’s start of care was 1/7/25 with diagnoses that included artificial abdominal opening/wound, failure to thrive and polyneuropathy. The Plan of Care ordered Home Health Aide services to be provided at a frequency of 1x/wk. x 1 wk., 2x/wk. x 3 wks. During the clinical record review, it was noted that the Aide Care Plan was void of any instructions or guidance on what measures to take during bathing/showering in light of the patient’s abdominal wound. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 1/29/25 at 1:41 p.m.”

“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 record review and interview, the agency failed to conduct the initial assessment visit within 48 hours of the referral, resulting in a delay of the patient’s home health care needs in 1 of 15 records reviewed. Findings included: P-7: The Start of Care was dated 8/1/2024. The Plan of Care identified a primary diagnosis of Diabetes Type 2, and secondary diagnoses of Sarcoidosis, Hemiplegia of left side following cerebral infarction, Heart Failure, Chronic Kidney Disease, and Depression. Upon review of the record, it was noted the referral was dated July 23, 2024. However, the Start of Care date documented on the Plan of Care was August 1, 2024, 9 days after the referral and physician ordered Start of Care date. There was no further evidence found in the record that the physician had ordered a delayed start of care. This finding was reviewed and acknowledged by the Administrator (Admin-A) and Clinical Manager (CM-C) on 1/29/25 at 3:15 p.m.”

“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 ensure the comprehensive assessment accurately reflected the patient’s current health status for 2 (P-10, P-6) of 13 records reviewed, resulting in either no clinical information or incorrect clinical information necessary to determine the needs of this patient. Findings include: P-10: This patient was admitted to home care on 1/9/25 with diagnoses of aphasia (language disorder that affects ability to understand and express language) following a cerebral infarct (stroke) and dysphasia (language disorder that affects ability to understand or use spoken language). The patient was hospitalized for worsening dysphasia from 12/30/24 to 1/8/25. During record review on 1/24/25, it was noted that the 1/9/25 comprehensive assessment completed by the registered nurse listed the patient’s primary diagnosis of aphasia following a stroke and 22 secondary/other diagnoses all with an onset date of 12/30/24, which is the date the patient was hospitalized. The diagnoses included chronic kidney disease stage 3, chronic pain, history of nicotine dependence, and history of infectious and parasitic diseases. These diagnoses indicate a long history of illness, not a current onset as indicated in the comprehensive assessment. The findings were reviewed with and confirmed during an interview with the administrator (Admin-A) and the clinical manager (CM-C) on 1/29/25 at 2:05 p.m. P-6: The Start of Care (SOC) dated 1/6/2025 included diagnoses of Congestive Heart Failure, Coronary Artery Disease, Cardiomyopathy, Heart Arrythmia, Myocardial Infarction, and Falls. The patient also had a history of osteoarthritis, gait problems, Chronic Kidney Disease, Anemia, Diabetes type 2, and Coronary Artery Disease. Upon review of the record, it was noted there were no blood sugar results or normal blood sugar ranges, documented on the Comprehensive Assessment to use as a baseline for treating the patient’s diabetes. Further review of the Comprehensive noted the following documentation, “Edema Bilateral legs - dependent and pitting”, however there were no objective or subjective measurements taken to use as a baseline measure for future assessments to determine if the edema was improving or becoming worse. These findings were reviewed with and confirmed during an interview with the administrator (Admin-A) and the clinical manager (CM-C) on 1/29/25 at 3:00 p.m.”

“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 record review and interview, the agency failed to ensure that activity of daily living needs were adequately met in the patient’s home for 1 (P-1) patient who required assistance with grooming, from a total of 13 sampled records reviewed, resulting in the potential for poor grooming, psychological decline and unmet care needs. Findings include: P-1: The patient’s start of care was 7/24/24 with diagnoses that included Hemiplegia and Dysphagia. The referral for home care dated 7/19/24 ordered Skilled Nursing, Physical Therapy, Home Health Aide and Speech Therapy services to be provided. A Physician’s order dated 7/24/24 ordered Occupational Therapy and Medical Social Work services to be provided. During the record review on 1/23/25 at 1:35 p.m., it was noted that section M1800 of the Initial Comprehensive Assessment documented, “Someone must assist with grooming, dressing upper and lower body, unable to participate in bathing and is bathed totally by another person, is totally dependent in toileting...” There was no documented, available and willing caregiver listed who would provide assistance with grooming. The patient’s “Admission Consent”, signed by the patient and the agency representative on 7/24/24, documented that Home Health Aide services would be provided at a frequency of 1x/wk. x 1wk., 2x/wk. x 3wks., 1x/wk. x 2wks. A Medical social Work visit note dated 8/7/24 documented, “Patient’s daughter currently is assisting with showers, however, her ability to continue to do so will become less and less as she is overwhelmed.” At the time of this review, there was no documented evidence that Home Health Aide services were provided as ordered. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 1/29/25 at 1:10 p.m.”

“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 interview, the agency failed to ensure the plan of care included parameters to notify the physician for 1 (P-10) of 13 records reviewed, resulting in no assurance the physician is notified of excessive pain ratings. Findings include: P-10: This patient was admitted to home care on 1/9/25 with a primary diagnosis of aphasia following a stroke and secondary diagnoses of low back pain and other chronic pain. During record review on 1/24/25, it was noted that the 1/9/25 plan of care failed to include parameters to notify the physician regarding the patient’s pain. The speech therapy visit note dated 1/13/25, noted that the patient reported a pain intensity of 8/10 (scale 0 none to 10 extreme) in his back and legs. The plan of care failed to include reportable pain parameters for this patient with pain issues. There was no documentation to indicate the physician was informed of the patient’s elevated pain level. The findings were reviewed with and confirmed during an interview with the administrator (Admin-A) and the clinical manager (CM-C) on 1/29/25 at 2:05 p.m. CM-C stated we report pain greater than 6 to the physician.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Physician was promptly notified of 2 (P-1, P-4) patients who experienced a significant change in condition with resultant hospitalization, from a total of 13 sampled records reviewed, resulting in lack of continuity of care and the potential for unmet care needs. findings include: P-1: The patient’s start of care (SOC) was 7/24/24 with diagnoses that included Hemiplegia (one-sided paralysis) and Dysphagia (difficulty swallowing). During the clinical record review on 1/23/25 at 1:35 p.m., it was noted that the patient was transferred to an inpatient facility on 8/12/24 due to “headache, daughter states hospital noted bleed on brain.” Upon further review, there was no documented evidence that the patient’s Physician had been promptly notified of the transfer to an inpatient facility with resultant hospitalization. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 1/29/25 at 1:10 p.m. P-4: The patient’s SOC was 12/30/24 with diagnoses that included Polyarthritis, Gout and Diabetes Mellitus. During the record review on 1/28/25 at 11:45 a.m., it was noted that the patient was transferred to an inpatient facility on 1/6/25 due to “extreme joint pain due to Rheumatoid Arthritis.” Upon further review, there was no documented evidence that the patient’s Physician had been promptly notified of the transfer to an inpatient facility with resultant hospitalization. These findings were reviewed with and confirmed by the Administrator and Clinical Manager during an interview on 1/29/25 at 1:55 p.m.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure skilled professionals provided services as ordered by the physician in the plan of care for 1 (P-10) of 13 records reviewed, resulting in the potential for a poor outcome for this patient. Findings include: P-10: This patient was admitted to home care on 1/9/25 with diagnoses of aphasia following a stroke and dysphasia. The 1/9/25 plan of care ordered skilled nursing (SN) to provide 2 visits per week for 2 weeks and then once a week for 3 weeks (2w2, 1w3); physical therapy (PT) and speech therapy (ST) were to evaluate and treat this patient. After their respective evaluations, PT was to provide visits at a frequency of 2w3, 1w5, and ST was to provide visits at a frequency of 1w1, 2w4. During record review on 1/24/25, it was noted that the SN had a missed visit note dated 1/22/25 that stated the patient had an appointment. There was no documentation of attempts to make the home visits the 3 remaining days of the week. The PT failed to document 2 visits had been conducted the week of January 19, 2025. There was no documentation that the patient declined the visits or that the physician was informed that the visits had not been conducted as ordered in the plan of care. On 1/15/25, ST documented a missed visit note that the ST was unable to complete a visit on this date due to being unavailable. It was unclear as to who was unavailable, the ST or the patient. There was no documentation of attempts to make the home visits the 3 remaining days of the week. The SN, PT, and ST failed to provide services at the frequency and duration ordered by the physician in the plan of care. The findings were reviewed with and confirmed during an interview with the administrator (Admin-A) and the clinical manager (CM-C) on 1/29/25 at 2:05 p.m. Admin-A explained that they have been working with staff and conducting in-service education regarding this matter.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure its skilled disciplines conducted the required Home Health Aide supervisory visits at least every 14 days to ensure the adequate provision of care and services for 1 (P-3) patient ordered to receive Aide services, from a total of 13 sampled records reviewed, resulting in the potential for the rendering of unsafe care and unmet care needs. Findings include: P-3: The patient’s start of care was 1/7/25 with diagnoses that included Abdominal wound, Failure to thrive and Polyneuropathy. During the record review on 1/24/25 at 1:35 p.m., it was noted that Home Health Aide (HHa) services were ordered at a frequency of 1x/wk. x 1 wk., 2x/wk. x 3 wks. The record reflected that HHa services began on 1/10/25. Upon further review, no HHa supervisory visits had been conducted by the survey’s exit date of 1/29/25. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 1/29/25 at 1:41 p.m.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the medical record contained all clinical notes for 1 (P-11) of 13 records reviewed, resulting in a lack of information for the physician and all agency staff caring for this patient. Findings include: P-11: This 70-year-old patient was admitted to home care services on 1/10/25 with diagnoses of status post left knee joint replacement, falls, and chronic pain. The 1/10/25 plan of care ordered the skilled nurse (SN) to make one visit the first week, two visits each week for two weeks, and then one visit each week for two weeks. During record review on 1/24/25, it was noted that two SN clinical notes dated 1/13/25 and 1/15/25 were blank of information. There was no documentation to indicate the patient had declined these visits. During the entrance conference on 1/23/25 at 11:10 a.m., the administrator (Admin-A) explained that clinical notes are completed within 5 days of the visit. The agency has no policy regarding the completion of clinical notes for agency personnel. The findings were reviewed with and confirmed during an interview with Admin-A and the clinical manager (CM-C) on 1/29/25 at 2:05 p.m. Admin-A explained that the nurse has been on vacation and the notes are late.”