Caring Hearts Home Health Services, Inc.

“Plan of care CFR(s): 484.60(a)(1) 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. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on medical record review, and staff interview, the agency failed to ensure patients received the home health services as written in the plan of care. for one of three medical records reviewed (Patient #1). This could affect all patients receiving services from the agency. The census was 37. Findings include: Review of the medical record for Patient #1 revealed an admission date of 03/07/23. The physician ordered plan of care plan for the certification period dated 01/01/24 to 02/29/24 included orders for home health aide services seven days a week, five to seven hours per visit, not to exceed 42 hours per week. The medical record contained documentation the week of 12/31/23 of four home health aide visits for six hours each and one home health aide visit for three hours, a total of 27 hours. The medical record contained documentation the week of 01/07/24 of one home health aide visit for six hours. The medical record contained documentation the week of 01/14/24 of four home health aide visits for six hours and one home health aide visit for five hours, a total of 29 hours. The medical record contained documentation the week of 01/21/24 of five home health aide visits for six hours, two home health aide visits for four hours, and four home health aide visits for two hours, a total of 46 hours. The medical record contained documentation the week of 01/28/24 of four home health aide visits for six hours, three home health aide visits for four hours, and six home health aide visits for two and a half hours, a total of 51 hours. The medical record lacked documentation of physician notification of care not provided as ordered or additional home health aide orders. The findings were verified in an interview on 02/13/24 at 1:30 PM with Staff B. This deficiency represents non-compliance investigated under Substantial Allegation 103647.”

“Plan of care CFR(s): 484.60(a)(1) 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. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on medical record review and staff interview, the agency failed to ensure patients received the home health services as written in the plan of care for two of four medical records reviewed (Patient #1 and #4). The agency census was 37. Findings include: 1. Review of the medical record for Patient #1 revealed an admission date of 03/07/23. The plans of care dated 09/03/23 to 11/01/23 and 11/02/23 to 12/31/23 included orders for a skilled nursing visit every 60 days and home health aide services 42 hours per week. Review of the home health aide timesheet for 10/15/23 through 10/21/23 revealed documentation of 42 hours with six hours each of the seven days that week and a line drawn through the dates of service 10/19/23, 10/20/23, and 10/21/23 with Staff C’s initials. Staff C added a note that Patient #1 reported that the home health aide was ill on those dates. The home health aide timesheet for 10/29/23 through 11/04/23 noted only 41 hours of home health aide services were provided that week. The medical record lacked documentation of any home health aide services on 11/05/23, with only 36 hours provided that week. The medical record lacked documentation of physician notification of care not provided as ordered. The medical record also contained skilled nursing visits on 10/18/23, 10/20/23, 10/24/23, 10/27/23, 10/30/23, 11/03/23, 11/08/23, and 11/10/23 with no documentation of physician orders for these visits. This was verified in an interview on 12/18/23 at 1:15 PM by Staff B. 2. Review of the medical record for Patient #4 revealed an admission date of 10/26/23. The plan of care dated 10/26/23 to 12/24/23 included orders for home health aide services for 14 hours per week. The medical record lacked documentation of home health aide visits or physician notification that care was not provided. Patient #4 was discharged on 11/27/23. This was verified in an interview on 12/18/23 at 1:15 PM by Staff B. This deficiency represents non-compliance investigated under Substantial Allegation 102485.”

“Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on medical record review and staff interview, the agency failed to assure communication with all physicians involved in the patient’s care for one of four medical records reviewed (Patient #2). The agency census was 37. Findings include: Review of the medical record for Patient #2 revealed consents and admission forms were signed on 11/21/23. The medical record revealed a discharge date of 12/07/23. The intake fax from the insurance company requested 15 hours per week of home health aide services and weekly nursing visits. The physician’s signed face to face encounter and start of care orders indicated the patient needed nursing and home health aide services but lacked a frequency. The plan of care was incomplete. The medical record lacked documentation of a comprehensive assessment, nursing visits, home health aide visits, or communication with the physician that services were not provided. This was verified in an interview on 12/18/23 at 1:15 PM by Staff B who stated the agency was not a provider for the patient’s insurance. This deficiency represents non-compliance investigated under Substantial Allegation 102485.”

“Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This Element is not met as evidenced by: Based on medical record review and staff interview, the agency failed to ensure the administrator was responsible for all day to day operations for one of four medical records reviewed (Patient #1). The agency census was 37. Findings include: Review of the medical record for Patient #1 revealed an admission date of 03/07/23. The plans of care dated 09/03/23 to 11/01/23 and 11/02/23 to 12/31/23 included orders for a skilled nursing visit every 60 days and home health aide services 42 hours per week. Review of the home health aide timesheet for 10/15/23 through 10/21/23 revealed documentation of 42 hours with six hours each of the seven days that week and a line drawn through the dates of service 10/19/23, 10/20/23, and 10/21/23 with Staff C’s initials. Staff C added a note that Patient #1 reported that the home health aide was ill on those dates. This was verified in an interview on 12/18/23 at 1:15 PM by Staff B. On 12/18/23 at 1:00 PM, Staff C was interviewed. Staff C stated that Staff D was sick and left at 2:00 or 3:00 PM from Patient #1’s home and did not return the next day. Staff C crossed those dates out on the timesheet and those hours were not billed. Staff D was pulled from Patient #1’s care but she still staffed another case. Staff C stated she spoke to Staff D regarding the need to call the office when she left a patient’s home early or did not work a scheduled shift. Staff C stated formal discipline was not done with Staff D. Review of the undated procedure titled, “Documentation of Service Delivery - Home Health Aide,” revealed falsification of the home health aide timesheet is a “violation of company policy, a violation of the Ohio Code of Conduct, and an illegal federal offense under the HIPPA guidelines”. Falsification of the home health aide timesheet will result in corrective action, up to and including termination of employment. This deficiency represents non-compliance investigated under Substantial Allegation 102485.”