All Americans Home Health Care

“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 objectively measurable goals specific to the individualized needs of the patient in 4 (MR’s # 1, 2, 5, 7) records, from a total of 7 sampled records reviewed, resulting the potential for poor patient outcomes and unmet care needs. Findings include: P-1: This patient was admitted to the agency on 8/23/24, with diagnoses of hypertensive heart disease with heart failure, and chronic kidney disease. During record review on 4/3/25, it was discovered that the nursing goals on the plan of care (POC) were not measurable. For example, “Improved endurance by 10/21/24.” another stated, “Improved independence by 10/21/24.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-2: This patient was admitted to the agency on 2/26/25, with diagnoses of type 2 diabetes mellitus with chronic obstructive pulmonary disease, hypertension, and dementia. During record review on 4/3/25, it was discovered that the nursing goals on the POC were not measurable. For example, “Bowel status will be within normal limits for patient by 3/26/25.” another stated, “Urinary elimination will be within normal limits by 3/26/25.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-5: This patient was admitted to the agency on 3/17/25, with diagnoses of sacral fracture, hypertension, and congestive heart failure. During record review on 4/2/25, it was discovered that the nursing goals on the POC were not measurable. For example, “Increased activity tolerance by 4/9/25.” another stated, “Patient/Caregiver will demonstrate proper body mechanics by 4/9/25.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-7: This patient was admitted to the agency on 1/30/25, with diagnoses of wound, dementia, and anxiety. During record review on 4/1/25, it was discovered that the nursing goals on the POC were not measurable. For example, “Patient/Caregiver will demonstrate safe and effective wound care, supply management, dressing change, disposal of soiled dressings, monitoring for infection, and signs or symptoms of infection by 3/1/25.” another stated, “Patient/caregiver will demonstrate knowledge of and compliance with medication management, does, route, and schedule...by 3/1/25.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. During an interview on 4/3/25, at 5:05 p.m., the Director of Clinical Services (DOCS) acknowledged the above findings.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure a detailed discharge summary was included in the record for 2 of 2 (P-1, P-6) discharge records reviewed, from a total sample of 7 records reviewed, resulting in a lack of information to ensure continuity of care. Findings include: P-1: The start of care (SOC) was dated 8/23/24, with diagnoses of chronic kidney disease, congestive heart failure, and hypertension. During record review on 4/3/25, it was noted that the record contained a discharge OASIS dated 10/21/24. The discharge OASIS failed to include frequency of visits, and medications the patient was on at the time of discharge. There was no evidence of a discharge summary in the record. P-6: The SOC was dated 7/3/24, with diagnoses of heart failure, venous insufficiency, and hypertension. During record review on 4/1/25, it was noted that the record contained a discharge OASIS dated 8/26/24. The discharge OASIS failed to include frequency of visits, and medications the patient was on at the time of discharge. There was no evidence of a discharge summary in the record. During an interview on 4/3/25, at 5:05 p.m., the Director of Clinical Services (DOCS) acknowledged the above findings”