Ridgeview Home Care Services

“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 interview and document review the agency failed to document the clinical impact and educate the client of the clinical impact of the missed visit for 3 of 17 patients (P6, P10, P12) reviewed for missed visits as indicated per the POC. P6’s plan of care (POC) for the certification period 11/18/24 to 1/16/25, indicated P6’s start of care (SOC) was 11/18/24, and diagnosis included Spondylosis (a type of arthritis that causes the spine to wear down over time) of the lower back, Irritable Bowel, and kidney disease. P6 received physician orders for skilled nursing (SN) twice per week for disease management, INR checks (blood test to check how thick or thin the blood is), and patient education. P6 also had physician orders for Occupation therapy (OT) once per week for five weeks for activities of daily living (ADL) retraining and home safety modifications. P6 also had physician orders for physical therapy visits (PT) twice per week for four weeks then once per week for two weeks for strengthening, balance exercises, transfer and gait training. Review of P6’s medical record indicated there was a missed PT visit on 11/25/24. The record lacked documentation of the clinical impact of the missed visit or that education was completed with P6 regarding the clinical impact of the missed visit. During a joint interview on 12/3/24 at 4:02 p.m., clinical manager (CM) and therapy manager (TM) verified P6, P10, and P12 had not received all the visits per the POC. CM and TM stated they were unaware that the clinical impact of the missed visit should have been documented or that education of the clinical impact of the missed visit should have been done with P6, P10, and P12. The agency Visit Documentation Checklist in Epic Remote client identified a missed visit is defined as a visit that was not completed within the week it was ordered. Checklist identified agency staff were to attempt to reschedule visit. Checklist lacked direction on documenting clinical impact of the missed visit or providing education to the patient regarding the potential clinical impact of the missed visit. P12’s plan of care (POC) for the certification period of 7/15/2024 to 9/12/2024, indicated P12’s start of care was 5/16/24, and diagnoses of pressure ulcer of right heel stage three (a wound that affects the top two layers of skin and fatty tissue), venous insufficiency (a venous disease that occurs when the veins in the legs are damaged making it harder for blood to return to the heart), dementia, Type two diabetes, multiple sclerosis and chronic obstructive pulmonary disease (COPD). P12’s care plan included skilled nursing visits (SN) three times per week for one week, four visits as needed, two visits per week for 1 week and three visits per week for five weeks for right lower extremity wound care, care plan (CP) status assessment, vital signs (VS), pain management, medication management and home safety. P12’s medical record indicated missed SN visits on 7/19/24, 7/21/24 and 7/28/24 with no documentation of the clinical impact or potential impacts of the missed visits being discussed with P12 and/or their representative. P10’s plan of care with a recertification period of 6/14/24-8/12/24, indicated intact cognition and diagnoses of type II diabetes mellitus with diabetic neuropathy, stage II pressure ulcer on his left and right buttocks, and hypertensive chronic kidney disease (CKD). It further indicated P10 was admitted to homecare on 6/14/24, with physician’s orders for a registered nurse to provide medication education, management, and assessment of effectiveness, pain assessment, pain relief management, and wound management. There was also an order for occupational therapy to provide deconditioning and rehabilitation, assessment and education, and a home exercise program for function and safety. These visits were ordered for 2 visits per week per discipline. P10 required assistance with transfers/ambulation and was unable to ambulate short distances without frequent rest periods. P10’s missed visit documentation dated 6/13/24-7/12/24, indicated P10 had two missed visits for skilled nursing (6/21/24, 6/28/24) and one missed visit for occupational therapy (6/28/24). The documentation lacked the potential clinical impact of missed treatments or services.”