Unique Home Health Care Solutions, LLC

“Content of the comprehensive assessment CFR(s): 484.55(c) 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: This Standard 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 and baseline data for future assessments, in 3 of 3 records reviewed (MR# 1, 2, 3) out of a total of 3 records reviewed, resulting in the potential for unmet care needs. Findings include: P-1: The patient was admitted on 03/23/23, with diagnoses of weakness, type 2 diabetes mellitus (DM), and congestive heart failure. Upon review of the comprehensive assessment on 11/07/2023, it was noted that the skilled nurse failed to obtain objective data for future assessments to measure the patient’s specific status. For example, the registered nurse (RN) failed to document a baseline blood sugar, with a diagnosis of diabetes, and failed to document a baseline weight with a diagnosis of congestive heart failure. P-2: The patient was admitted on 02/07/23, with diagnoses of hemiplegia, chronic obstructive pulmonary disease, type 2 diabetes mellitus (DM), and congestive heart failure. Upon review of the comprehensive assessment on 11/07/2023, it was noted that the skilled nurse failed to obtain objective data for future assessments to measure the patient’s specific status. For example, the registered nurse (RN) failed to document a baseline blood sugar, with a diagnosis of diabetes, and failed to document a baseline weight with a diagnosis of congestive heart failure. P-3: The patient was admitted on 04/06/23, with diagnoses of type 2 diabetes mellitus (DM), congestive heart failure, and lymphedema. Upon review of the comprehensive assessment on 11/07/2023, it was noted that the skilled nurse failed to obtain objective data for future assessments to measure the patient’s specific status. For example, the registered nurse (RN) failed to document a baseline blood sugar, with a diagnosis of diabetes, and failed to document a baseline weight with a diagnosis of congestive heart failure. During an interview on 11/08/2023 at 3:30 p.m., the administrator (Adm), the alternate administrator (AAdm), and the clinical manager (CM), acknowledged the above findings.”

“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 (POC) covered all pertinent interventions with reportable parameters, and objectively measurable goals specific to the individualized needs of the patient in 3 (P-1, 2, 3) records, from a total of 3 sampled records reviewed, resulting in the potential for poor patient outcomes and unmet care needs. Findings include: P-1: The patient was admitted on 03/23/23, with diagnoses of weakness, type 2 diabetes mellitus (DM), and congestive heart failure (CHF). Skilled nursing (SN), physical therapy (PT), and occupational therapy (OT) were ordered. Upon review of the record on 11/07/2023, it was noted that the POC had no patient goals for skilled nursing. The only goals on the plan of care were for PT and OT. There was no evidence of how patient progress could be ascertained with no measurable goals on the plan of care for SN. The POC also failed to document weight parameters with a diagnosis of CHF. P-2: The patient was admitted on 02/07/23, with diagnoses of hemiplegia, chronic obstructive pulmonary disease, type 2 diabetes mellitus (DM), and congestive heart failure. Upon review of the record on 11/07/2023, it was noted that the goals on the POC were not measurable, for example, one goal stated, “Patient/caregiver will verbalize measure [sic] to manage neurological condition by 3/25/23.” Another stated, “Dyspnea will decrease by 3/25/23.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. The POC also failed to document weight parameters with a diagnosis of CHF. P-3: The patient was admitted on 04/06/23, with diagnoses of type 2 diabetes mellitus (DM), congestive heart failure, and lymphedema. Upon review of the record on 11/07/2023, it was noted that the goals on the POC were not measurable, for example, one goal stated, “Patient/caregiver will verbalize understanding of proper O2 use and safety precautions by 4/6/23.” Another stated, “Patient will demonstrate energy conservation techniques by 4/6/23.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. The POC also failed to document weight parameters with a diagnosis of CHF. During an interview on 11/08/2023 at 3:30 p.m., the administrator (Adm), the alternate administrator (AAdm), and the clinical manager (CM), acknowledged the above findings.”