Renaissance Home Healthcare Services

“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 safety precautions were included on the plan of care for 1 (P-5) of 7 records reviewed, and failed to ensure the plan of care included parameters to notify the physician for 4 (P-2, 3, 6, 7) of 7 records reviewed, resulting in the potential for poor patient outcomes and no assurance the physician is notified of vital signs or excessive pain ratings. Findings include: P-2: This patient was admitted to home care on 9/27/24 with diagnoses of type 2 diabetes with high blood sugars, high blood pressure, and abnormal gait. The patient received skilled nursing and physical therapy services. During record review on 12/2/24, it was noted that the 9/27/24 plan of care failed to include parameters to notify the physician regarding the patient’s blood sugar readings, blood pressure, and pain. The findings were reviewed with and acknowledged by the administrator (Admin-A) during an interview on 12/5/24 at 10:00 a.m. P-3: This patient was admitted to home care on 9/27/24 with diagnoses of hyperlipidemia (high concentration of fats or lipids in the blood), high blood pressure, and generalized anxiety disorder. The patient received skilled nursing and physical therapy services. During record review on 12/2/24, it was noted that the 9/27/24 plan of care failed to include parameters to notify the physician regarding the patient’s blood pressure. Agency Policy – Care Plan Management and Evaluation (III-16, no date). Assessment and Reassessment Guidelines. Use of Standards of Practice: Each disciplines standards of practice will be referenced for decision-making regarding patient care. Agency will use the following standard ranges for physician contact when parameters are out of range… P-5: This 65-year-old patient was admitted to home care on 7/31/24 with diagnoses of acute bronchitis, peripheral vascular disease, and debility. The patient received skilled nursing services. A review of the patient’s medication list indicates the patient takes a blood thinner, Plavix. During record review on 12/3/24, it was noted that the plan of care failed to include bleeding precautions. P-6: This 86-year-old patient was admitted to home care on 9/27/24 with diagnoses of hyperlipidemia, hypertension, and abnormal gait. The patient received skilled nursing and physical therapy services. During record review on 12/2/24, it was noted that the plan of care failed to include parameters for reporting vital signs or pain levels to the physician. P-7: This 68-year-old patient was admitted to home care on 9/27/24 with diagnoses of chronic obstructive pulmonary disease (COPD), and essential hypertension. The patient received skilled nursing and physical therapy services. During record review on 12/2/24, it was noted that the plan of care failed to include parameters for reporting vital signs or pain levels to the physician. These findings were reviewed and acknowledged by the administrator/director of nursing on 12/5/24 at 9:45 a.m.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the clinical record was complete and included accurate physical therapy notes for 1 (P-6) of 7 records reviewed, resulting in the potential for the lack of continuity of care. Findings include: P-6: This 86-year-old patient was admitted to home care on 9/27/24 with diagnoses of hyperlipidemia, hypertension, and abnormal gait. During record review on 12/2/24, it was noted that the physical therapists discharge summary, dated 11/12/24, states “patient goes to dialysis 3 days a week.” There was no evidence the patient received dialysis in the start of care assessment, or in the Face-to-Face encounter signed by the patient’s physician on 9/26/24. This finding was reviewed and acknowledged by the administrator/director of nursing on 12/5/24 at 9:45 a.m.”

“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 sent to the physician within 5 business days of discharge for 7 (P-1, 2, 3, 4, 5, 6, 7) of 7 discharge records reviewed, resulting in a lack of information to ensure continuity of care. Findings include: P-1: This patient was admitted to home care on 8/9/24 with diagnoses of right foot surgical incision due to fracture, high blood pressure, and pain to the right ankle and joints. During record review on 12/2/24, it was noted that the patient was discharged from agency services on 11/21/24. There was no evidence that a detailed discharge summary report was sent to the physician within 5 days of the patient’s discharge. P-2: This patient was admitted to home care on 9/27/24 with diagnoses of type 2 diabetes with high blood sugars, high blood pressure, and abnormal gait. During record review on 12/2/24, it was noted that the patient was discharged from agency services on 11/12/24. There was no evidence that a detailed discharge summary report was sent to the physician within 5 days of the patient’s discharge. P-3: This patient was admitted to home care on 9/27/24 with diagnoses of hyperlipidemia (high concentration of fats or lipids in the blood), high blood pressure, and generalized anxiety disorder. During record review on 12/2/24, it was noted that the patient was discharged from agency services on 11/12/24. There was no evidence that a detailed discharge summary report was sent to the physician within 5 days of the patient’s discharge. P-4: This patient was admitted to home care on 3/8/24 with diagnoses of high blood pressure, right shoulder pain, and abnormal gait. During record review on 12/3/24, it was noted that the patient was discharged from agency services on 7/2/24. The discharge summary was signed by the physician and dated 7/11/24. This is nine days after the patient was discharged. There was no evidence to indicate when the discharge summary was sent to the physician. The findings were reviewed with and acknowledged by the administrator (Admin-A) during an interview on 12/5/24 at 10:00 a.m. P-5: This 65-year-old patient was admitted to home care on 7/31/24 with diagnoses of acute bronchitis, peripheral vascular disease, and debility. During record review on 12/3/24, it was noted that the patient was discharged from agency services on 11/14/24. There was no evidence that a detailed discharge summary report was sent to the physician within 5 days of the patient’s discharge. P-6: This 86-year-old patient was admitted to home care on 9/27/24 with diagnoses of hyperlipidemia, hypertension, and abnormal gait. During record review on 12/2/24, it was noted that the patient was discharged from agency services on 11/12/24. There was no evidence that a detailed discharge summary report was sent to the physician within 5 days of the patient’s discharge. P-7: This 68-year-old patient was admitted to home care on 9/27/24 with diagnoses of chronic obstructive pulmonary disease (COPD), and essential hypertension. During record review on 12/2/24, it was noted that the patient was discharged from agency services on 11/12/24. There was no evidence that a detailed discharge summary report was sent to the physician within 5 days of the patient’s discharge. These findings were reviewed and acknowledged by the administrator/director of nursing on 12/5/24 at 9:45 a.m.”