Elite Home Health

“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 policy review, clinical record review, and interview, the provider failed to ensure that each patient’s written individualized plan of care (POC) included all safety measures regarding high-risk medications in three of six full records reviewed (Records/Patients #2, #3, and #5). This deficient practice has the potential to affect all the patients served by the provider. Review of the provider’s policy titled, “Plan of Care (POC),” revised 04/01/2025, showed in part: - Each patient has an individualized POC developed in consultation with the patient, physician or authorized practitioner, and staff that integrates comprehensive assessment findings to address patient problems, needs, and goals, as well as to address specific services being provided; - The POC is developed for all patients and updated no less than every 60 days; - The POC includes: * Medications and treatments; * Safety measures to protect against injury; and * Patient specific interventions and education, measurable outcomes and goals identified by the provider and patient. Review of the provider’s policy titled, “High Risk Medications,” revised 12/01/2023, showed in part: - Patients receive oral and written information regarding high-risk medications prescribed for the patient on an ongoing basis while being cared for by the provider; - The provider identifies the following drug categories as high risk. Medications in these categories would be considered high risk medications: * Anticoagulants including Xarelto and Eliquis (medications used to thin the blood); * Hypoglycemics including Insulins (medications used to lower blood sugar); and - Upon review of the medication list, the clinician will identify any high-risk medications, assess patient/caregiver’s knowledge, and obtain physician/authorized practitioner’s orders and educate as needed per identified knowledge deficit. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 03/06/2025, with primary diagnosis of age-related osteoporosis (abnormal loss of bone density) with current left femur (bone in the thigh) fracture (a break in a bone), and additional diagnosis which included long term (current) use of anticoagulant (medication that stop blood from clotting too easily) and history of falls. The patient resided at an assisted living facility apartment with caregivers checking on him/her. Review of the Plan of Care (POC), dated 03/06/2025 to 05/04/2025, showed in part the following: - Diagnosis which included age-related osteoporosis with current left femur fracture; - Long term (current) use of anticoagulants; - History of falls; - Xarelto (anticoagulant) 15 milligram tablet, take one by mouth every night; and - Physical Therapy (PT) ordered for gait training, exercise therapeutic exercises and balance training. Review of the PT recert note dated 04/30/2025, showed a verbal order was received for POC and frequency approval to continue PT to further address deficits and achieve maximal functional level. Review of the Plan of Care (POC), dated 05/05/2025 to 07/03/2025, showed in part the following: - Diagnosis which included age-related osteoporosis with current left femur fracture; - Long term (current) use of anticoagulants; - History of falls; - Xarelto 15 milligram tablet, take one by mouth every night; and - Physical Therapy ordered for gait training, exercise therapeutic exercises and balance training. Per interview conducted during observation, on 06/03/2025 at 10:52 AM, the patient stated he/she had no new bruising or bleeding with the Xarelto. Review of the POC dated 03/06/2025 to 05/04/2025 and 05/05/2025 to 07/03/2025, failed to show individualized interventions for high-risk medications (the patient has had previous falls, and is prescribed Xarelto, an anticoagulant medication. During an interview on 06/03/2025 at 10:16 AM, clinical manager A stated that best practice would be for the Xarelto to be on the POC, but it was not the primary focus is why it was not on the POC with interventions of bleeding precautions. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to home health services on 04/10/2025, with primary diagnosis of unspecified fracture of left patella (a break in the bone that covers the knee joint), subsequent encounter for a closed fracture with routine healing, and additional diagnosis which included type I diabetes mellitus (a group of diseases that results in too much sugar in the blood) with diabetic polyneuropathy (many nerves throughout the body are damaged), and problems related to health literacy (inability to understand and use health information). The patient resided alone in his/her own home and received assistance from family members. Review of the Plan of Care (POC), dated 04/10/2025 to 06/08/2025, showed in part the following: - Diagnosis which included unspecified fracture of left patella, subsequent encounter for a closed fracture with routine healing, Type I diabetes mellitus with diabetic polyneuropathy, and problems related to health literacy; - Insulin Lispro (fast acting insulin used to lower blood sugar levels) 100 unit/milliliter (ml) subcutaneous pen, inject 14 units subcutaneously at breakfast, 10 units at lunch, 10 units at dinner (Max=50 units daily); - Lantus (long-acting insulin used to lower blood sugar levels) U-100 insulin 100 unit/ml subcutaneous solution, inject 33 units subcutaneously every morning; and - PT ordered for gait training, transfers, and therapeutic exercises. Review of the PT OASIS admission note dated 04/10/2025, showed a verbal order was received to continue PT at one time per a week for eight weeks. Review of the POC dated 04/10/2025 to 06/08/2025, failed to show individualized interventions for high-risk medications (the patient had problems related health literacy, and is prescribed two different insulins) to lower blood sugars. During an interview on 06/04/2025 at 09:38 AM, clinical manager A stated that best practice would be for the insulin, a high-risk medication to be on the POC with interventions. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 05/12/2025, with a primary diagnosis of Paroxysmal Atrial Fibrillation (an abnormal heart rhythm characterized by rapid and irregular heartbeat), and additional diagnosis which included a cardiac pacemaker implant, Chronic Kidney Failure, and long term / current use of anticoagulant medication (medication that stop blood from clotting too easily). The patient lived at home alone. Review of the Plan of Care (POC) , dated 05/12/2025 to 07/10/2025, showed in part the following: - Diagnoses which included Paroxysmal Atrial Fibrillation, cardiac pacemaker implant, and long term / current use of anticoagulant medication; - A history of falls; and - Physical Therapy ordered for transfer, gait, and fall prevention. Review of the POC dated 09/05/2023 to 11/03/20233, failed to show: - Individualized interventions for high-risk medications ( the patient has had previous falls, and is prescribed Apixaban, sold under the brand name Eliquis, an anticoagulant medication). During an interview on 06/03/2023 at 09:16 AM, the Clinical Manager A stated that Patient #3 was currently prescribed the anticoagulant medication, and had been prescribed anticoagulant medication on a long term basis. Clinical Manager A stated that this medication should have been addressed in the initial POC, but was not addressed.”