Nina’s Health Care Zanesville

“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, agency policy and procedures, and staff interview the agency failed to provide home health aides services per the physician’s orders for one (Patient #1) in a sample of three patients. The agency census was 65. Findings include: Review of the medical record and the physician’s plan of care for Patient #1 revealed the patient was admitted with diagnoses which included Post Traumatic Stress Disorder (PTSD), anxiety, and generalized weakness. The physician’s order directed Patient #1 to have 10 hours of home health aide services weekly for nine weeks for assistance with Activities of Daily Living (ADLS) and Instrumental Activities of Daily living (IADL). The Medicare certification period under review was 04/26/24 through 06/24/24. The medical record documented the registered nurse made an initial nursing visit on 04/26/24. The medical record documented the aide completed one home health visit on Sunday 05/12/24. The physician was notified of the missed visits between 04/26/24 and 05/11/24. However, the agency was unable to provide any documentation aide services were provided per the physician’s plan of care between 05/13/24 and 05/28/24. The agency was unable to provide documentation Patient #1’s physician was notified that the services were not provided per the physician’s orders and the plan of care during this time frame as well. Interview on 06/24/24 at 10:48 AM with Staff C confirmed Patient #1 was ordered home health aide services five hours per day twice per week on Saturdays and Sundays and that no aide services were provided during the certification period of 04/26/24 to 06/28/24 except one home health visit completed on 05/12/24. Staff C was unable to provide documentation the agency notified the patient to initiate the back up plan. Interview with Administrative Staff A on 06/24/24 at 1:15 PM confirmed the agency accepted the patient and agreed to provide 10 hours of home health aide services twice per week on Saturdays and Sundays. Staff A confirmed the agency only provided home health care services on one day, 05/12/24 between the start of care on 04/26/24 and discharge on 05/28/24. Staff A verbalized the patient’s physician was notified of the missed visits between 04/26/24 and 05/11/24 and provided no new orders. Staff A confirmed the agency failed to provide any home health aide services between 05/13/24 and the patient’s request for discharge on 05/28/24 Review of the agency’s undated policy and procedure titled, “Patients Plan of Care,” directed: “To ensure that patients were accepted for care on the basis of a reasonable expectation that the patient’s medical, nursing, and social needs can be met adequately by the agency in the patient’s place of residence. The policy further directed, the home health care staff members promptly inform the physician of any changes that suggest a need to alter the patient’s Plan of Care.” This deficiency substantiated the allegation in Substantial Allegation 106730.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on medical record review, agency policy and procedures, and staff interview the agency failed to notify the physician of missed visits for one (Patient #1) in a sample of three patients. The agency census was 65. Findings include: Review of the medical record and the physician’s plan of care for Patient #1 revealed the patient was admitted with diagnoses which included Post Traumatic Stress Disorder (PTSD), anxiety, and generalized weakness. The physician’s order directed Patient #1 to have 10 hours of home health aide services weekly for nine weeks for assistance with Activities of Daily Living (ADLS) and Instrumental Activities of Daily Living (IADL). The registered nurse made an initial nursing visit on 04/26/24 for the Medicare certification period of 04/26/24 through 06/24/24. The agency was unable to provide any documentation that home health aide services were provided between 05/13/24 and 05/28/24 nor was the agency able to provide documentation the physician was notified of the missed visits for Patient #1 between 05/13/24 and 05/28/24. Interview on 06/24/24 at 10:48 AM with Staff C confirmed Patient #1 was ordered home health aide services five hours per day twice per week on Saturdays and Sundays and that no aide services were provided during the certification period of 04/26/24 to 06/28/24 except one home health visit completed on 05/12/24. Staff C confirmed the agency failed to notify the physician of missed visits that occurred between 05/13/24 and the patient’s request for discharge from the agency on 05/28/24. Review of the agency’s undated policy and procedure titled, “Patients Plan of Care,” directed: “To ensure that patients were accepted for care on the basis of a reasonable expectation that the patient’s medical, nursing, and social needs can be met adequately by the agency in the patient’s place of residence. The policy further directed, the home health care staff members promptly inform the physician of any changes that suggest a need to alter the patient’s Plan of Care.” This deficiency was an incidental finding identified during the complaint investigation.”