Adal Home Healthcare 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 record review and interview, the facility failed to provide services per plan of care. This affected three (Patients #10, #63 and #64) of three patients reviewed. This had the potential to affect all 62 current patients. Findings include: 1. Record review revealed Patient #63 stated care on 03/22/24. She was discharged 04/26/24. The patient had diagnoses including unilateral primary osteoarthritis of the right hip, body mass index of 45 to 49, epilepsy, and schizophrenia. She utilized a walker, bedside commode, and wheelchair. Functional limitations included bladder incontinence, hearing, ambulation and speech. She was forgetful and agitated. Her prognosis was fair. Review of the certification period of 03/20/24 to 05/20/24 revealed the physician ordered a skilled nurse visit once every 60 days and home health aide (HHA) services 14 hours per week, two hours a day seven days a week. Patient #63’s plan of care included to shower daily and wash her hair every week, skin care, peri care and oral care care every visit, nail care every week , assist with dressing, combing hair, and medication reminder every visit. She was to dangle on the side of bed every visit ,assist range of motion, transfer, and ambulation every visit. They were to make bed every visit and change linens every week . They were to do light housekeeping every visit and meal set up every visit. The HHA was to assist patient with daily living, shopping/getting groceries, preparing meals, running errands/appointments, and cleaning/maintaining a home. Review of the aide time sheets revealed HHA F and H did not follow the plan of care. During the 33 days she was a patient with the facility from 04/21/24 to 04/24/24 she had a shower two of five days, instead of daily and did not have her hair washed. There were no refusals documented. On 18 of 33 days the aides did not comb her hair. Her hair was not combed at all 04/20/24-04/25/24. There was no evidence of mouth care being provided nine of 33 days and no mouth care was documented as provided 04/20/24-04/25/24. There was no documentation of pericare or nail care for the 33 days, when the nail care was to be weekly and pericare every visit. She was to dangle on side of bed and have range of motion every visit. She did not dangle on the side of the bed or have range of motion any of the 33 days. She was to be assisted with ambulation every visit. There was no evidence of her being assisted the week of 03/24/24 and was only assisted three of five days 04/2124 to 04/25/24. There was no evidence of the bed being made any of the 33 days when it was care planned to be made every visit. Bedding was to be changed weekly. Bedding was documented as being changed the week of 03/31/24. There was no evidence of the bedding being changed between 04/07/24 and her discharge on 04/26/24. During an interview on 10/11/24 at 12:10 P.M., the Administrator verified the time sheets of HHA F and HHA H did not provide the services per plan of care. 2. Record review revealed Patient #10 started care on 09/13/23. start of care date. The patient’s diagnoses included chronic obstructive pulmonary disease and type two diabetes. She was on oxygen and utilized a wheelchair, elevated toilet seat, cane, walker, wheelchair and a bedside commode. She had functional limitations with hearing and ambulation. Her mental status was oriented but forgetful. She had a poor prognosis. REview of the certification period of 09/07/24 to 11/05/24 revealed she was ordered a skilled nurse visit once every 60 days and home health services of 49 hours per week. Her plan of care included to shower daily and wash her hair every week, skin care, peri care and oral care every visit, nail care every week, assist with dressing, combing hair, and medication reminder every visit. She was to assist with ambulation every visit, make bed, and change linen every visit. They were to do light housekeeping every visit and meal set up every visit. The HHA was to assist patient with activities of daily living, personal care, light housekeeping, groceries, shopping and running errands. Review of the time sheets from 09/08/24 to 09/28/24 revealed there was no oral care, combing of hair, or assisting with dressing documented as being provided between 09/08/24 to 09/21/24. There was no evidence of assist with ambulation between 09/08/24 and 09/28/24. There was no evidence of the bed being made eight of 18 days, or linens changed five of 18 days. Light housekeeping and meal set up was not completed four of 18 days. During an interview on 10/11/24 at 2:10 P.M., the Administrator verified the time sheets of HHA I did not reflect the aide providing the services per plan of care. The Administrator stated some of the care planned areas were to be provided only if needed. He verified there were no refusals documented on the timesheets. There was no evidence of self care reflected on the time sheets. During an interview 10/11/24 at 3:23 P.M., Patient #10 stated she ambulates with help sometimes. She wears incontinent briefs but does use the toilet. She can comb her hair and brush her teeth. She needs help with bathing, ambulating, and housekeeping. Sometimes it all gets done and sometimes not. For the most part she is satisfied. 3. Record review revealed Patient #64 started care on 06/28/23. She had diagnoses including hypertension, fibromyalgia, and dorsalgia. Functional limitations were in endurance and ambulation. She was allowed up as tolerated with the cane and human assistance. She was oriented but forgetful. Her prognosis was fair. She was ordered a skilled nurse visit every 60 days and home health aide services for 42 hours per week. Review of the aide plan of care revealed the patient was to have oral care and skin care every visit. There was no evidence of oral care between 07/21/24 and 08/10/24 and no skin care the week of 08/04/24. There was not a time sheet provided to the facility for 08/11/24. On 08/12/24, the patient’s case manager called and stopped services During an interview 10/11/124 at 2:10 P.M., the Administrator verified not all care planned services were documented as completed.”