In House Home Health Inc.

“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, interview and policy review, the agency failed to ensure a plan of care included a list of skilled nursing interventions for 1 of 8 sampled patients (Patient #8). Findings include: Patient #8 On 05/26/2023, the agency admitted Patient #8 with pressure ulcer of right buttock, stage 2. The agency certified the patient from 05/26/2023 through 07/24/2023. The agency recertified the patient from 07/25/2023 through 08/03/2023. The agency’s plans of care typically displayed sections in the following order: Orders and Treatments, Skilled Nurse Interventions and Goals and Outcomes. The recertification period lacked documented evidence of a section of skilled nurse interventions. On 11/08/2024 at 4:00 PM, the Administrator confirmed the finding. Procedure #3n of the Care Planning, Coordination of Services and Medical Orders policy provided revealed the individualized plan of care would be completed at the time of recertification and would include patient specific interventions and education.”

“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 record review, interview and policy review, the agency failed to ensure it conducted or discontinued an occupational therapy evaluation for 1 of 8 sampled patients (Patient #1) and failed to ensure skilled nursing visits were conducted as ordered for 1 of 8 sampled patients (Patient #5). Findings include: 1.) Patient #1 On 10/12/2024, the agency admitted Patient #1 with third degree burns of left lower extremity. On 10/20/2024 and again on 10/22/2024, a physician ordered an occupational therapy evaluation. The clinical record lacked documented evidence the agency conducted and documented the evaluation or that a physician cancelled the evaluation. On 11/08/2024 at 3:45 PM, the Administrator and Registered Nurse Director confirmed the evaluation was not addressed. 2.) Patient #5 On10/13/2024, the agency admitted Patient #5 with encounter for surgical aftercare regarding an ostomy. The patient was certified from 10/13/2024 through 12/11/2024. On 10/13/2024, the plan of care revealed a physician ordered skilled nursing visits three times the first week and twice the second week of the episode. For the first week, the clinical record revealed five skilled nursing visits conducted and documented dated 10/13/2024, 10/14/2024, 10/17/2024 x 2 visits and 10/18/2024. For the second week, the clinical record revealed three skilled nursing visits conducted and documented dated 10/21/2024, 10/23/2024 and 10/25/2024. The clinical record lacked documented evidence of a physician order for increased skilled nursing visit frequency for those weeks. On 11/08/2024 at 4:00 PM, the Administrator confirmed the findings. Procedure #3d of the Care Planning, Coordination of Services and Medical Orders policy provided revealed the individualized plan of care would be completed at the time of admission and would include the frequency and duration of visits to be made.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on record review, interview and policy review, the agency failed to document wound measurements for 1 of 8 sampled patients (Patient #2), skilled nursing visit assessments for 1 of 8 sampled patients (Patient #5) and failed to include a wound care order and calmoseptine on successive plans of care for 1 of 8 sampled patients (Patient #6). Findings include: 1.) Patient #2 On 07/05/2024, the agency admitted Patient #2 with dehiscence of amputated stump. The patient was certified from 07/05/2024 through 09/02/2024. The patient was recertified from 09/03/2024 through 11/01/2024. On 09/03/2024, the plan of care revealed skilled nursing visits twice weekly for wound care. A wound care specialist was ordered to do weekly wound care weekly. The clinical record revealed skilled nursing visits documented wound measurements on skilled nursing visits dated 10/02/2024 and 10/17/2024. The clinical record lacked documented wound measurements on the two skilled nursing visits dated 10/04/2024 and 10/11/2024. On 11/08/2024 at 4:00 PM, the Administrator indicated measurements were completed weekly. The Documentation of Clinical Notes/Reports policy provided revealed weekly measurements were required for wounds. 2.) Patient #5 On10/13/2024, the agency admitted Patient #5 with encounter for surgical aftercare regarding an ostomy. The patient was certified from 10/13/2024 through 12/11/2024. On 10/13/2024, the plan of care revealed skilled nursing visits three times the first week and twice the second week of the episode. The clinical record revealed two skilled nursing visits dated 10/17/2024, and both skilled nursing visits lacked documented evidence of a cardiovascular assessment. The skilled nursing visit dated 10/23/2024 lacked documented evidence of cardiovascular, genitourinary, musculoskeletal, psychosocial and pain assessments. On 11/08/2024 at 4:00 PM, the Administrator indicated nurses were expected to complete and document each assessment area for each visit conducted. 3.) Patient #6 On 10/23/2023, the agency admitted Patient #6 with pressure ulcer of right buttock, stage 2. The patient was certified from 10/23/2023 through 12/21/2023. On 10/23/2023, the plan of care revealed twice weekly skilled nursing visits for 8 weeks and then weekly thereafter. On 10/23/2023, the plan of care revealed wound care as cleanse with normal saline and gauze and apply duoderm. On 12/18/2023, the agency recertified the patient from 12/22/2023 through 02/19/2024. The agency continued weekly skilled nursing visits and performed the same wound care at each visit dated 12/24/2023, 01/01/2024 and 01/08/2024. The clinical record lacked documented evidence the wound care order was carried over from the start of care of episode to the recertification episode as an order, treatment or intervention. The original order appeared under the goals to be addressed with each subsequent skilled nursing visit. The skilled nursing visits dated 12/24/2023, 01/08/2024 and 01/15/2024 demonstrated the nurse was aware caregivers used calmoseptine on the patient, but it was not listed on the plan of care. On 11/08/2024 in the afternoon, the Registered Nurse Director and Administrator confirmed the finding. Procedure #3j of the Care Planning, Coordination of Services and Medical Orders policy provided revealed the individualized plan of care would be completed at the time of recertification and would include all medications and treatments.”