Assured Home Health of Clinton

“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 agency failed to ensure an individualized plan of care for three (Patient #2, 3 and 5) of 7 patients. Patient #2 A review of the plan of care dated 03/23/24 to 05/21/24 showed a primary diagnosis of hypertensive chronic kidney disease with no individualized interventions developed for the management of the primary diagnosis. Patient #3 A review of the plan of care dated 03/15/24 to 05/13/24 showed a primary diagnosis of aftercare following joint replacement with no individualized interventions to the management of care to the identified location of the joint affected. Patient #5 A review of the plan of care dated 03/28/24 to 05/26/24 showed a primary diagnosis of hepatic encephalopathy with no individualized interventions developed for the management of the primary diagnosis. On 05/08/24 at 12:50 pm, Staff B stated the plan of care for Patients #2, 3 and 5 were not individualized for the management of the primary diagnosis.”

“Coordinate patient care CFR(s): 484.105(c)(2) Coordinating patient care, This Element is not met as evidenced by: Based on record review and interview, the agency failed to: 1. Ensure coordination of care regarding a significant weight gain for one (Patient #5) of seven patients and 2. Ensure coordination of care regarding elevated pulse reading outside of ordered parameters for one (Patient #6) of seven patients. 1. Patient #5 A review of the plan of care dated 03/28/24 to 05/26/24 showed a primary diagnosis of hepatic encephalopathy. A review of the clinical record showed the following: An initial skilled nurse assessment dated 03/28/24 documented a weight of 166#. A skilled nurse assessment dated 04/04/24 documented a weight of 172# (a six-pound weight gain in one week). A skilled nurse assessment dated 04/11/24 documented a weight of 180# (an eight-pound weight gain in one week and a 14-pound weight gain in two weeks). No documentation was found of notification of the significant weight gain to the physician. 2. Patient #6 A review of the plan of care dated 03/20/24 to 05/18/24 showed a primary diagnosis of pneumonia and documented a skilled nurse frequency of two visits per week for two weeks, one visit per week for three weeks and one visit every other week for four weeks, a physical therapy frequency of on visit per week for one week, two visits per week for three weeks and one visit per week for four weeks, a occupation therapy frequency of one visit per week for eight weeks and the physician was to be notified of a pulse greater than 100. A skilled nurse assessment dated 03/22/24 documented a pulse of 110. The physician was faxed notification of the out of parameter pulse with no documented follow-up regarding the elevated pulse. A skilled nurse assessment dated 03/26/24 documented a pulse of 104. The physician was faxed notification of the out of parameter pulse with no documented follow-up regarding the elevated pulse. A physical therapy assessment dated 03/26/24 documented a pulse of 104. The physician was faxed notification of the out of parameter pulse with no documented follow-up regarding the elevated pulse. An occupational therapy assessment dated 03/27/24 documented a pulse of 105. The physician was faxed notification of the out of parameter pulse with no documented follow-up regarding the elevated pulse. A skilled nurse assessment dated 03/29/24 documented a pulse of 114. The physician was faxed notification of the out of parameter pulse with no documented follow-up regarding the elevated pulse. A skilled nurse assessment dated 04/02/24 documented a pulse of 110. The physician was faxed notification of the out of parameter pulse with no documented follow-up regarding the elevated pulse. A physical therapy assessment dated 04/02/24 documented a pulse of 108. The physician was faxed notification of the out of parameter pulse with no documented follow-up regarding the elevated pulse. An occupational therapy assessment dated 04/03/24 documented a pulse of 107. The physician was faxed notification of the out of parameter pulse with no documented follow-up regarding the elevated pulse. A physical therapy assessment dated 04/04/24 documented a pulse of 102. The physician was faxed notification of the out of parameter pulse with no documented follow-up regarding the elevated pulse. A skilled nurse assessment dated 04/08/24 documented a pulse of 110. The physician was faxed notification of the out of parameter pulse with no documented follow-up regarding the elevated pulse. An occupational therapy assessment dated 04/08/24 documented a pulse of 108. The physician was faxed notification of the out of parameter pulse with no documented follow-up regarding the elevated pulse. A physical therapy assessment dated 04/12/24 documented a pulse of 108. The physician was faxed notification of the out of parameter pulse with no documented follow-up regarding the elevated pulse. An occupational therapy assessment dated 04/15/24 documented a pulse of 111. The physician was faxed notification of the out of parameter pulse with no documented follow-up regarding the elevated pulse. A skilled nurse assessment dated 04/16/24 documented a pulse of 110. The physician was faxed notification of the out of parameter pulse with no documented follow-up regarding the elevated pulse. A physical therapy assessment dated 04/18/24 documented a pulse of 118. The physician was faxed notification of the out of parameter pulse with no documented follow-up regarding the elevated pulse. On 05/08/24 at 1:10 pm., Staff B stated: 1. the physician should have been notified of the 14 pound weight gain for Patient #5 and 2. staff should have followed up in regard to the consistent out of parameter pulse for Patient #6.”