Grand View Health at Home

“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 interview, record review, and agency policy review, the agency failed to include pertinent diagnoses on the patients’ plans of care (POC-an individualized and comprehensive plan that includes diagnoses, medications, and interventions that guide the staff in providing patient care) for 1 (P (Patient) #7) of 7 patients reviewed. An agency policy titled, “Care Planning, Coordination of Services and Quality of Care,” dated 2019, revealed, “The individualized plan of care must include the following:” including “All pertinent diagnoses.” Patient #7’s “Home Health Certification and Plan of Care,” dated 05/17/2023, revealed a “Start of Care Date” of 05/17/2023 and a “Certification Period” of 05/17/2023 to 07/14/2023. According to the POC, Patient #7 had a medical history that included diagnoses of joint replacement (post operative care after surgical replacement of a joint), and the patient had an artificial knee joint. The POC revealed Patient #7’s medication list included mirtazapine (used to treat depression), duloxetine (used to treat depression and anxiety), lisinopril (used to treat hypertension [HTN, high blood pressure]), and buspirone (a medication used to treat anxiety) daily. Further review did not reveal any diagnoses related to depression, HTN, or anxiety. Patient #7’s “OASIS-E [Outcome Assessment Information Set Version E] Start of Care,” dated 05/17/2023, revealed Patient #7 had a past medical history (PMH) that included depression, HTN, and anxiety. During a concurrent record review and interview on 07/10/2024 at 12:00 PM, the Administrator stated the agency’s definition of pertinent diagnosis was any diagnosis pertinent to the care being provided for the patient and would include any cardiac history, PMH, and any underlying conditions the patient may have. The Administrator confirmed that Patient #7’s “OASIS-E Start of Care” dated 05/17/2023 indicated the patient had hypertension and depression, confirmed the diagnoses were not included on the patient’s POC, and acknowledged the agency was not following their policy.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on interview, record review, and agency policy review, the agency failed to provide services as ordered by a physician for 1 (Patient #2) of 7 patients reviewed. Specifically, the agency failed to contact the physician, per instructions listed on the patient’s plan of care (POC), when their diastolic blood pressure (DBP-a measure that represents the pressure in the arteries when the heart is resting between beats, filling with blood) was outside the established parameters. An agency policy titled, “Care Planning, Coordination of Services and Quality of Care,” dated 2019, revealed, “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.” Patient #2’s “Home Health Certification and Plan of Care,” dated 05/24/2024, revealed a “Start of Care Date” of 05/24/2024 and a “Certification Period” of 05/24/2024 to 07/22/2024. According to the POC, Patient #2 had a medical history that included diagnoses of aftercare following joint replacement (post operative care after surgical replacement of a joint), asthma, and depression. Further review of the POC revealed “Orders and Treatments” included instructions to notify Patient #2’s physician of a DBP higher than 90 millimeters of mercury (mmHg) or less than 55 mmHg. Patient #2’s “LPN/LVN [Licensed Practical Nurse/Licensed Vocational Nurse]-Skilled Nursing Visit,” dated 06/24/2024, revealed staff documented Patient #2’s DBP was 101 mmHg. Further review revealed no evidence that agency staff notified Patient #2’s physician. Patent #2’s clinical record revealed no evidence the agency notified Patient #2’s physician of the patient’s 06/24/2024 DBP. During an interview on 07/09/2024 at 1:25 PM, Physical Therapist (PT) #1 stated that if he received a high blood pressure reading for a patient, he would likely reassess the patient’s blood pressure several times and if it continued to be elevated, he would contact the agency. During a concurrent record review and interview on 07/10/2024 at 12:00 PM, the Administrator (ADM) stated the agency expectation was clinicians to follow physician orders and interventions identified on the patients’ POCs. The ADM confirmed that on 06/24/2024, the agency staff documented Patient #2’s DBP as 101, and based on the orders, the staff should have immediately contacted the patient’s physician to notify them of the reading being outside of the expected ranges. The ADM acknowledged the agency was not following their policy.”