Morrill County Comm. Hosp. Home Health Agency

“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 the agency’s determination of the patient’s risk for emergency department visits and rehospitalization on the Plan of Care for 6 of 7 (Patients 1, 2, 3, 4, 6, and 7) patient records reviewed. The total sample size was 7. The census was 27. Findings are: A. The review of the agency’s policy and procedure titled Morrill County Home Health Medical Records Policy, reviewed 5/6/2020, revealed the agency’s policy did not include the agency’s determination of the patient’s risk for emergency department visits and rehospitalization to be included on the patient’s Plan of Care. B. Review of clinical records revealed: 1. Patient 1’s Home Health Certification and Plan of Care (POC), for the certification periods 10/10/23 through 12/8/23 and 12/9/23 through 2/6/24, did not include the agency’s determination of the patient’s risk for emergency department visits and rehospitalization. 2. Patient 2’s POC, for the certification periods of 11/13/23 through 1/11/24 and 1/12/24 through 3/11/24, did not include the agency’s determination of the patient’s risk for emergency department visits and rehospitalization. 3. Patient 3’s POC, for the certification periods of 11/9/23 through 1/7/24 and 1/8/24 through 3/7/24, did not include the agency’s determination of the patient’s risk for emergency department visits and rehospitalization. 4. Patient 4’s POC, for the certification period of 1/31/24 through 3/30/24, did not include the agency’s determination of the patient’s risk for emergency department visits and rehospitalization. 5. Patient 6’s POC, for the certification period of 11/21/23 through 1/19/24, did not include the agency’s determination of the patient’s risk for emergency department visits and rehospitalization. 6. Patient 7’s POC, for the certification period of 9/15/23 through 11/13/23, did not include the agency’s determination of the patient’s risk for emergency department visits and rehospitalization. C. During an interview on 2/8/24 at 9 AM, the Home Health Director confirmed the agency failed to include on the POC the agency’s determination of the patient’s risk for emergency department visits and rehospitalization for Patients 1, 2, 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, on the Plan of Care, the patient’s progress towards the patient’s measurable outcomes and goals identified by the agency and the patient for 3 of 3 (Patients 1, 2, 3) patients who had a revised/updated Plan of Care. The total sample size was 7. The census was 27. Findings are: A. Review of the agency’s policy and procedure titled Morrill County Home Health Medical Records Policy, modified 5/6/2016, revealed the Plan of Care was to include the patient’s response to interventions and progress towards goals. B. Review of clinical records revealed: 1. Patient 1’s Home Health Certification and Plan of Care (POC), for the certification periods 10/10/23 through 12/8/23 and 12/9/23 through 2/6/24, did not include the patient’s progress towards the measurable outcomes and goals identified by the agency and the patient. 2. Patient 2’s POC, for the certification periods of 11/13/23 through 1/11/24 and 1/12/24 through 3/11/24, did not include the patient’s progress towards the measurable outcomes and goals identified by the agency and the patient. 3. Patient 3’s POC, for the certification periods of 11/9/23 through 1/7/24 and 1/8/24 through 3/7/24, did not include the patient’s progress towards the measurable outcomes and goals identified by the agency and the patient. C. During an interview on 2/8/24 at 9 AM, the Home Health Director confirmed the revised/updated POCs for Patients 1, 2, and 3, did not include the patient’s progress towards the measurable outcomes and goals identified by the agency and the patient.”