Jefferson Community Health & Life 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 record review, policy and procedure review, and staff interview, the agency failed to include patient specific interventions and/or treatments on the plan of care for 2 of 7 (Patient 3 and 5) patient records reviewed. The census was 6. Findings are: A. Review of the agency policy and procedure titled Patient Plan of Care, dated 2017, revealed: 1. Each patient must have a written plan of care that specifies the care and services necessary to meet the specific needs identified by the physician or in the comprehensive assessment. 2. The data from assessments/reassessments are analyzed and utilized for identifying and prioritizing the patient’s problems and needs, and for determining, evaluating and adjusting the plan of care or services. 3. All patient care orders must be included in the plan of care. B. Review of clinical record revealed: 1. Patient 3’s Home Health Certification and Plan of Care (POC) for the certification periods of 9/27/25 through 11/25/25 and 11/26/25 through 1/24/26 included: a. Goals: pulse will remain within established parameters, will be without signs or symptoms of urinary tract infections (UTI), blood pressure will remain within established parameters, will be free from injury. b. The POC failed to include any interventions to meet the goals identified. 2. Patient 5’s Home Health Certification and Plan of Care for the certification period of 11/24/25 through 1/22/26 included the following: a. Diagnoses: Stage 4 pressure ulcer of the sacral region (a wound involving skin, muscle and/or bone, and underlying tissues) and a colostomy. b. Goals: to be free from injury, will be without signs or symptoms of UTI, foley (a flexible tube inserted through the urethra into the bladder to drain urine) will remain patent (open, clear, and unobstructed, allowing normal flow), wound will decrease in size. c. The POC failed to include any interventions or treatments to meet the goals identified. C. During an interview on 1/8/26 at 11:20 AM, the Administrator confirmed the agency failed to include interventions and/or treatments on the POC for Patient 3 and Patient 5.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on record review, policy and procedure review, and staff interview the agency failed to notify the physician to obtain orders to extend therapy services beyond the original duration identified on the plan of care for 1 of 1 (Patient 2) patient who received therapy services. The sample size was 7. The census was 6. Findings are: A. Review of the agency policy and procedure titled Patient Plan of Care, dated 2017, revealed: 1. Each patient must have a written plan of care that specifies the care and services necessary to meet the specific needs identified by the physician or in the comprehensive assessment. 2. The data from assessments/reassessments are analyzed and utilized for identifying and prioritizing the patient’s problems and needs, and for determining, evaluating and adjusting the plan of care or services. 3. Is to be reviewed and revised by the physician and home health as frequently as the patient’s condition requires. 4. All patient care orders must be included in the plan of care. B. Review of the policy and procedure titled Medical Policies and Physician’s Orders, dated 2017, revealed: 1. The physician is informed promptly of any changes in the patient’s condition or status that suggest a need to alter the plan of care or that suggest that measurable outcomes are not being achieved. 2. The professional will document all communication with the physician. 3. Oral orders must be sent for confirmation and signature by the physician. 4. Orders may be changed between 60-day renewals. Those changes will also be sent to the physician for signature and approval of the change/new order. C. Review of Patient 2’s clinical record revealed: 1. The agency received a referral on 12/1/25 for home health nursing, physical therapy (PT) and occupational therapy (OT) to evaluate and treat. 2. A Physical Therapy Evaluation completed on 12/5/25 included orders for PT one time per week for one week, then two times per week for three weeks (total of 4 weeks, with 7 total visits). 3. PT Visit notes dated 12/5/25 (week 1); 12/9/25, 12/11/25 (week 2); 12/16/25, 12/18/25 (week 3); 12/23/25, 12/26/25 (week 4); and 12/29/25,1/2/26 (week 5). 4. There was no documentation that the physician was contacted to extend the PT plan of care for an additional 2 visits for 1 week. 5. An Occupational Therapy Evaluation completed on 12/8/25 included orders for OT two times per week for four weeks (8 visits). 6. OT Visit notes/Missed Visit notes dated 12/8/25, 12/10/25 (week 1); 12/15/25, 12/17/25 (week 2); 12/22/25, 12/26/25 (week 3); 12/29/25, 12/31/25 (week 4); 1/6/26 (week 5). 7. There was no documentation that the physician was contacted to extend the OT plan of care for an additional visit for 1 week. D. During an interview on 1/8/26 at 11:20 AM, the Administrator confirmed the agency failed to ensure the PT and OT notified the physician to obtain orders to extend therapy services beyond the original duration identified on the plan of care for Patient 2.”

“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 ensure the patient’s progress towards the agency and patient identified goals were included on the revised/updated plan of care for 3 of 3 patients (Patient 1, 3, and 4) who had a revised/updated plan of care. The sample size was 7. The census was 6. Findings are: A. Review of the agency policy and procedure titled Patient Plan of Care, dated 2017, revealed: 1. Each patient must have a written plan of care that specifies the care and services necessary to meet the specific needs identified by the physician or in the comprehensive assessment. 2. The data from assessments/reassessments are analyzed and utilized for identifying and prioritizing the patient’s problems and needs, and for determining, evaluating and adjusting the plan of care or services. 3. Is to be reviewed and revised by the physician and home health as frequently as the patient’s condition requires, but at least every 60 days. 4. The revised plan of care is to include current information from the comprehensive assessment and information concerning the patient’s progress towards outcomes specified in the plan of care. B. Review of Clinical records revealed: 1.Patient 1’s Home Health Certification and Plan of Care for the certification periods of 9/7/25 through 11/5/25 and 11/6/25 through 1/4/26 did not include the patient’s progress towards the agency and patient identified goals. 2.Patient 3’s Home Health Certification and Plan of Care for the certification periods of 9/27/25 through 11/25/25 and 11/26/25 through 1/24/26 did not include the patient’s progress towards the agency and patient identified goals. 3.Patient 4’s Home Health Certification and Plan of Care for the certification periods of 10/20/25 through 12/18/25 and 12/19/25 through 2/16/26 did not include the patient’s progress towards the agency and patient identified goals. C. During an interview on 1/8/26 at 11:20 AM, the Administrator confirmed the agency failed to include the patient’s progress towards the agency and patient identified goals on the plan of care for Patient 1, 3 and 4.”