Brookestone Home Health & Hospice

“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, policy and procedure review, and staff interview, the agency failed to include on the patient’s individualized Plan of Care, all the requirements specified by this regulation for 4 of 10 patient records reviewed (Patients 3, 4, 6, and 7). The total sample size was 10. The census was 158. Findings are: A. Review of the agency’s policy and procedure, titled 7.15, Plan of Care / Physician Orders, revised 12/11/17, revealed: 1. The policy included a list of requirements to include on the Plan of Care, including, but not limited to, the patient’s mental, psychosocial, and cognitive status, supplies needed for services, and measurable outcome and goals as identified by the agency and the patient. B. Review of Patient 3’s clinical record revealed: 1. Home Health Certification and Plan of Care (POC) for the certification period of 12/30/23 through 2/27/24, included orders for Skilled Nurse (SN), Physical Therapy (PT), Occupational Therapy (OT), and Home Health Aide (HHA) services. 2. The POC did not include measurable outcomes and goals as identified by the home health agency and the patient, for the SN, PT and HHA services. C. Review of Patient 4’s clinical record revealed: 1. POC for the certification periods of 11/23/23 through 1/21/24 and 1/22/24 through 3/21/24, included orders for SN. 2. The POC’s did not include measurable outcomes and goals as identified by the home health agency and the patient for the SN services. D. Review of Patient 6’s clinical record revealed: 1. POC for the certification period of 12/29/23 through 2/26/24, included orders for SN and HHA services. 2. The POC did not include measurable outcomes and goals as identified by the home health agency and the patient, on the POC for the SN and HHA services. 3. The POC did not include the patient’s mental, psychosocial, cognitive status, and supplies needed for services. E. Review of Patient 7’s clinical record revealed: 1. POC for the certification period of 1/20/24 through 3/19/24, included orders for SN, OT, and HHA services. 2. The POC did not include measurable outcomes and goals as identified by the home health agency and the patient for the SN, OT, and HHA services. F. During an interview on 2/5/24 at 9:45 AM, the Administrator confirmed that the agency failed to include on the patient’s individualized POC, all the requirements specified by this regulation for Patients 3, 4, 6, and 7.”

“Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient’s updated comprehensive assessment, and contain information concerning the patient’s progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This Element is not met as evidenced by: Based on record review, policy and procedure review, and staff interview, the agency failed to include patient’s progress towards the measurable outcomes and goals identified by the home health agency and the patient, for 6 of 6 patients (Patients 1, 2, 3, 4, 6, and 7) who had revised/updated Plan of Care. The total sample size was 10. The census was 158. Findings are: A. Review of the agency’s policy and procedure, titled 7.15 Plan of Care/Physician Orders, revised 12/11/17, revealed: 1. The policy did not require the revised/updated Plan of Care to include information regarding the patient’s progress towards the measurable outcomes and goals as identified by the home health agency and the patient. B. Review of clinical records revealed: 1. Patient 1’s Home Health Certification and Plan of Care (POC) for the certification period of 12/13/23 through 2/10/24, did not include the patient’s progress towards the measurable outcomes and goals as identified by the home health agency and the patient. 2. Patient 2’s POC for the certification periods of 12/1/23 through 1/29/24 and 1/30/24 through 3/29/24, did not include the patient’s progress towards the measurable outcomes and goals as identified by the home health agency and the patient. 3. Patient 3’s POC for the certification periods of 12/30/23 through 2/7/24, did not include the patient’s progress towards the measurable outcomes and goals identified by the home health agency and the patient. 4. Patient 4’s POC for the certification periods 11/23/23 through 1/21/24 and 1/22/24 through 3/21/24, did not include the patient’s progress towards the measurable outcomes and goals as identified by the home health agency and the patient. 5. Patient 6’s POC for the certification period 12/29/23 through 2/26/24, did not include the patient’s progress towards the measurable outcomes and goals as identified by the home health agency and the patient. 6. Patient 7’s POC for the certification period 1/20/24 through 3/19/24, did not include the patient’s progress towards the measurable outcomes and goals as identified by the home health agency and the patient. C. During an interview on 2/5/24 at 9:45 AM, the Administrator confirmed that the progress towards the measurable outcomes and goals as identified by the home health agency and the patient were not included on the POC for Patients 1, 2, 3, 4, 6, and 7, and the policy titled 7.15 Plan of Care/Physician Orders, revised 12/11/17, did not include the requirement to include information regarding the patient’s progress towards the measurable outcomes and goals as identified by the home health on the revised/updated POC.”