Vivie Home Health

“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, make attempts to reschedule the missed visit and document the potential clinical impact of the missed service for 1 of 17 patients (P10) reviewed for home health visits. Findings include: P10’s plan of care (POC) 2/3/25 to 4/3/25, identified a start of care (SOC) date 12/5/24. Diagnoses included fracture of the left humerus, high blood pressure, diabetes, heart disease and dementia. Services were ordered for physical therapy two times per week for four weeks then one time per week for three weeks. An additional order was received on 2/28/25, for skilled nurse visits one time per week for four weeks for various assessments, teach/reinforce disease and symptom management and review, reconcile and teaching related to use of medications. Review of P10’s skilled nurse visits (SNV) completed during the recertification period identified no SNV had been provided the week of 3/2/25. The medical record lacked evidence P10 had been contacted to reschedule the missed visit as well as what the potential clinical impact may have been related to the missed visit. Observation of P10’s skilled nurse home visit on 3/31/25, at 11:30 a.m. registered nurse (RN)-B conducted various assessments and education related to disease and symptom management, skin care and assisted P10’s family member (FM)-A to setup two weeks of medications. FM-A demonstrated difficulty managing the medication setup without frequent input from RN-B. RN-B stated FM-A was unable to setup P10’s medications safely without some assistance. During interview on 3/31/25, at 2:00 p.m. clinical manager (CM)-B stated the agency’s process was to document a missed visit in the patients’ medical record and identify why the visit was missed. CM-B stated there should have been some documentation in P10’s medical record as to why the visit was missed and if attempts were made to reschedule as well as a phone call to check with the patient and instruction regarding the patient’s medications. CM-B thought a nurse had phoned to check in with the patient and ensure medications were available for the week but was unsure why the documentation was lacking in P10’s medical record. The agency policy Coordination of Patient care revised March 2019, identified the agency would integrate orders from all physicians to assure the coordination of all services and interventions provided to the patient and coordinate care delivery to meet the patient’s needs and involve the patient, representative and caregiver as appropriate in the coordination of care activities.”

“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 durable medical equipment (DME) on 2 of 7 patient’s (P9, P14) plan of care (POC) reviewed during home visits and 1 of 5 (P12) active chart reviews. Findings include: P9’s POC with certification period 2/15/25 to 4/15/25, indicated a start of care on 10/18/24. P9’s POC included diagnoses of non-pressure chronic ulcer of right heal and spinal stenosis. P9’s section on the POC that indicated DME and supplies included “skin care” and “wound care products.” P9’s start of care assessment completed on 10/18/24, included P9 had an assistive device of a walker. The section titled “durable medical equipment available” included cane, grab bars, shower bench, and four wheeled walker. During home visit on 3/31/25 at 2:00 p.m., P9 was observed utilizing a four wheeled walker. P12’s POC with certification period 2/10/25 to 4/10/25, indicated a start of care date of 2/10/25. P12’s POC included diagnoses of atrial fibrillation and macular degeneration. P12’s section on the POC that indicated DME and supplies indicated, “none.” P12’s start of care assessment completed on 2/10/25 included P12 had an assistive device of a walker. The section titled “durable medical equipment available” included toilet seat riser and four wheeled walker. P14’s POC with certification period 2/16/25 to 4/16/25, indicated a start of care date of 12/18/24. P14’s POC included diagnoses of spinal stenosis and chronic pain syndrome. P14’s section on the POC that indicated DME and supplies indicated, “none.” P14’s start of care assessment completed 12/18/24, included P14 had an assistive device of walker and wheelchair. The section titled “durable medial equipment available” included grab bars, hand-held shower, shower chair, and four wheeled walker. During home visit on 4/1/25 at 10:00 a.m., P14 was observed with a four wheeled walker. During interview on 4/1/25 at 12:40 p.m., registered nurse (RN)-A confirmed she completed the admission assessment for P14. RN-A confirmed P14 had the DME listed on the start of care assessment. RN-A stated she believed the DME selected during the admission assessment then flowed onto the 485 physician orders (POC). During interview on 4/1/25 at 3:34 p.m., clinical manager (CM)-A confirmed DME was assessed and noted in the start of care assessment. CM-A confirmed R14’s POC DME included none, which did not match the start of care assessment charting. CM-A stated the charts are reviewed by a quality team prior to being sent to providers for signature. CM-A stated the 485 (POC) should have included all DME to fully capture the patient’s needs. During interview on 4/1/25 at 4:00 p.m., quality manager (QM)-A confirmed all charts and 485’s (POCs) are reviewed prior to being submitted. QM-A confirmed the DME section from the start of care assessment does not automatically flow onto the 485 (POC) DME section. Agency policy for 485 (POC) physician orders dated March 2019, included care and services will be provided according to physician orders and orders are current and updated. The policy included the individualized plan of care must include the types of services, supplies and equipment required.”