Sanford Canby Medical Center Home Care

“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 observation, interview and document review, the agency failed to ensure visits were conducted as required in the plan of care and document the potential clinical impact of the missed service for 1 of 5 patients (P4) active records reviewed. Findings include: P4’s plan of care (POC) with certification period 4/7/24 to 6/5/25, identified a start of care (SOC) date of 4/18/23. Diagnoses included cirrhosis of the liver and anxiety disorder. Services were ordered for skilled nurse visits once a week for nine weeks and home health aide visit once per week for nine weeks to assist with personal cares. Review of P4’s home health aide (HHA) visits completed during the recertification period identified there was a missed HHA visit on 4/9/25 and no HHA visit had been provided the week of 4/7/25. The medical record lacked documentation of what the potential clinical impact may have been related to the missed visit. During an interview on 5/13/25 at 3:40 p.m., administrator verified P4 had not received a HHA visit the week of 4/7/25, and that the potential clinical impact of the missed visit had not been documented in P4’s medical record. Administrator stated she was unsure why the potential clinical impact of the missed visit had not been documented in P4’s medical record and her expectation was the the potential clinical impact of the missed visit would have been documented in P4’s chart. Review of an agency policy titled Provider Orders and Notification, Home-Health Enterprise dated 9/23/24, identified all provider orders were to be documented in the POC. Identified the provider must be notified of any missed visits. The policy lacked direction on documenting the potential clinical impact of missed visits.”

“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 observation, interview and document review, the agency failed to include all medications on 1 of 3 patient’s (P6) plan of care (POC). Further the agency failed to include all durable medical equipment (DME) on the POC for 1 of 3 (P3) reviewed for home visits. Findings include: P6 P6’s POC with certification period 5/4/25 to 7/2/25, indicated a start of care on 3/31/20. P6’s POC included diagnoses of hypertension (elevated blood pressure) and legal blindness. P6’s medication section on the POC included the following medications: Tylenol, Norvasc, Aspirin, Plavix, Nitrostat tablets, Fish oil, Primidone, Crestor and Vitamin D3. P6’s skilled nursing Non Certified Recertification Assessment dated 4/29/25, included the following medications: Tylenol, Norvasc, Aspirin, Plavix, Nitrostat tablets, Fish oil, Primidone, Crestor and Vitamin D3. During a home visit on 5/13/25 at 11:10 a.m., registered nurse (RN)-A used P6’s physician orders dated 5/12/25 to set up R6’s medications. Orders included the following medications Tylenol, Norvasc, Aspirin, Plavix, Nitrostat tablets, Fish oil, Primidone, Crestor, Vitamin D3 and Nitroglycerin patch with a start date of 1/24/25. During an interview on 5/13/25 at 1:20 p.m., RN-A verified P6 had a current order for the nitroglycerin patch and that the Nitroglycerin patch was not on P6’s POC. RN-A stated she was unsure why the Nitroglycerin patch was not on P6’s POC since P6 had been on the patch since 1/24/25.RN-A stated her expectation was that R6’s POC would have included the Nitroglycerin patch. P3 P3’s POC with certification period 4/25/25 to 6/23/25, indicated a start of care on 4/25/25. P3’s POC included diagnoses of pneumonia and prostate cancer. P3’s section on the POC that indicated DME supplies included Bath bench/chair, grab bars, hand held shower, mediset (container used to set up medications), CPAP, raised toilet seat. P3’s start of care assessment completed 4/25/25, identified P3 required the use of a front wheeled walker or four wheeled walker at all times for mobility. During a home visit on 5/12/25 at 1:10 p.m., P3 was observed using a four wheeled walker. During an interview on 5/13/25 at 3:30 p.m. administrator verified P6 had a current order for a nitroglycerin patch with a start date of 1/24/25. Verified P3’s four wheeled walker was identified on P3’s SOC assessment but was not included on P3’s POC. Administrator stated she was unsure why the medications were not on the POC since they all should have pulled from the SOC assessments however, DME equipment had to be manually entered into the POC. Administrator stated her expectation was all medications and DME supplies would have been on the POC for all patients. Review of an agency policy titled Provider Orders and Notification, Home Health-Enterprise dated 9/23/24, identified the agency should provide services that conform to provider orders. Identified All drugs and treatments that are ordered by the providers would be noted on the POC (485). .”