Frontier Health Care Services, LLC

“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 record review and interview, the facility failed to ensure each patient received personal care services as written. This affected one (Patient #17) of three patients reviewed. This could affect all patients receiving services from the facility. The active census was 16. Findings include: Review of the medical record for Patient #17 revealed an admission date of 10/02/23. Diagnoses included type 2 diabetes, myocardial infarction, chronic obstructive pulmonary disease, and hypertension. Functional limitations included bowel and bladder incontinence. He used a cane. The patient was oriented with a fair prognosis. Review of the Passport Service Plan Report referral documented home health aide (HHA) services were to be 14 hours a week. Assistance was to be provided with skin care, hair care, shaving, oral care, ambulation, housekeeping, vacuum, sweep, wet mop, dusting, dishes, refrigerator, laundry, change bed linens, shopping, bathing, dressing/grooming, mobility/transfer, toileting, trash removal, grocery list preparation and shopping and prescription pickup. Review of the HHA timesheets revealed no personal hygiene was provided for the time frame of 02/19/24 to 03/16/24. During an interview on 07/29/24 at 3:15 P.M., Office Manager Staff G verified the HHA did not document on the timesheets the provision any personal care services.”

“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 and interview, the facility failed to ensure plans of care included the services to be provided and the frequency and duration of visits to be made. This affected two (Patient’s #5 and #17 of three records reviewed. The active census was 16. Findings include: 1. Record review revealed Patient #17 was admitted on 10/02/23. Diagnoses included type 2 diabetes, myocardial infarction, chronic obstructive pulmonary disease, and hypertension. Functional limitations included bowel and bladder incontinence. He used a cane. The patient was oriented with a fair prognosis. Review of the plan of care and certification assessment dated 01/30/24 to 03/29/24 revealed no home health aide (HHA) hours listed or the frequency of care or services to be provided by the HHA. Review of the Passport Service Plan Report referral documented aide services were to be 14 hours a week. Assistance was to be provided with skin care, hair care, shaving, oral care, ambulation, housekeeping, vacuum, sweep, wet mop, dusting, dishes, refrigerator, laundry, change bed linens, shopping, bathing, dressing/grooming, mobility/transfer, toileting, tub and sink care, trash removal, grocery list preparation and shopping and prescription pickup. 2. Record review revealed Patient #5 was admitted on 06/20/23. Diagnoses included diabetes, complex regional pain syndrome, anxiety disorder, and chronic venous insufficiency of bilateral lower extremities. Functional limitations included amputation and endurance. The patient was forgetful and depressed. Review of the current plan of care and certification assessment for the dates 06/14/24 to 08/12/24 revealed there were no HHA hours listed or services to be provided by the HHA. Review of the insurance referral documented HHA services were to be 14 hours a week. Assistance was to be provided with meal preparation, housekeeping, laundry, shopping, bathing, dressing/grooming, mobility/transfer, toileting, feeding and supervision. During an interview on 07/29/24 at 3:15 P.M., Office Manager Staff G verified the aide hours and frequency were to be on the plan of care and the certification assessment, and the hours were not listed as well as the HHA services to be provided for both patients.”