Loving Care In-Home Health Services, L.L.C.

“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 agency failed to ensure: 1. SN frequencies were followed as ordered for three (Patients #2, 6 and 12) of 17 patients; 2. PT frequency was followed as ordered for one (Patient #2) of 17 patients; 3. SN notified the physician of missed visit as ordered for one (Patients #3) of 17 patients; and 4. PT and SN notified the physician of pain levels outside the ordered parameters for one (Patient #6) of 17 patients. 1. Patient #2 A review of the POC dated 03/31/24 to 05/29/24 showed a SN frequency of two visits per week for two weeks and one visit per week for seven weeks. A review of the medical record showed no SN visits were made from 03/31/24 to 05/11/24 (eight missed visits). Documentation showed no refusal of visits or services from the patient or caregiver and no contact made with the patient or caregiver and no physician order for a change in services. Patient #6 A review of the POC dated 03/06/24 to 05/04/24 showed a SN frequency of two visits per week for two weeks and one visit per week for seven weeks. A review of a SN missed visit dated 03/14/24 documented the reason as patient has conflicting doctors appointments, and no other visits made for the week of 03/10/24 to 03/16/24. Documentation showed no refusal of visits or services from the patient or caregiver and no contact made with the patient or caregiver and no physician order for a change in services. Patient #12 A review of the POC dated 03/19/24 to 05/17/24 showed a SN frequency of one visit per week for nine weeks. A review of a SN missed visit dated 04/04/24 documented the reason as patient refused, and no other visits made for the week of 03/31/24 to 04/06/24. Documentation showed no refusal of visits or services from the patient or caregiver and no contact made with the patient or caregiver and no physician order for a change in services. 2. Patient #2 A review of the POC dated 03/31/24 to 05/29/24 showed an order for PT to evaluate and treat. A review of the medical record showed no PT visits were made. Documentation showed no refusal of visits or services from the patient or caregiver and no contact made with the patient or caregiver and no physician order for a change in services. 3. Patient #3 A review of the POC dated 03/17/24 to 05/15/24 showed a SN frequency of one visit per week for nine weeks. A review of SN missed visit dated 03/18/24 showed no notification was made to the physician of the missed visit. Documentation showed no refusal of services from the patient or caregiver and no physician order for a change in services. 4. Patient #6 A review of the POC dated 03/06/24 to 05/04/24 showed an order for the physician to be notified of pain greater than eight out of 10. A review of the medical records showed the following: PT visit dated 03/12/24 showed the patient’s reported pain as nine out of 10. SN visit dated 04/01/24 showed the patient’s reported pain as 10 out of 10. PT visit dated 04/15/24 showed the patient’s reported pain as 10 out of 10. Documents showed no physician notifications for the reported pain levels greater than eight. On 06/13/24 at 11:05 a.m., Staff A stated: 1. the SN frequencies for Patients #2, 6 and 12 were not met as ordered by the physician; 2. the PT frequency for Patient #2 was not met as ordered by the physician; 3. no notification of SN missed visit was made to the physician for Patient #3; and 4. there was no documentation of physician notification of pain levels being out of parameters for Patient #6.”

“Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency’s overall management and operation, the provision of all home health services, fiscal operations, review of the agency’s budget and its operational plans, and its quality assessment and performance improvement program. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure governing body oversite of: 1. Ongoing patient centered QAPI Program activities for calendar year 2023 or 01/01/24 to 06/13/24; and 2. An operating budget, capital expenditure plan and allocation of resources activities for calendar year 2023 or 01/01/24 to 06/13/24. A review of administrative records showed no governing body oversite of ongoing patient centered QAPI Program activities; operating budget, capital expenditure plan and allocation of resources activities for calendar year 2023 or 01/01/24 to 06/13/24. On 06/13/24 at 11:45 a.m., Staff A stated administrative records showed no governing body oversite of ongoing patient centered QAPI Program activities, operating budget, capital expenditure plan and allocation of resources activities for calendar year 2023 or 01/01/24 to 06/13/24.”

“Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This Standard is not met as evidenced by: Based on observation and interview, the agency failed to ensure patients confidential information/records were safeguarded against loss or unauthorized use in the office setting. During a visit of the agency’s branch location on 06/12/24 at 4:10 p.m., a room door was unlocked and propped open. Multiple boxes containing confidential patient records were observed stored inside the room, unorganized, along with multiple electronic equipment’s. On 06/12/24 at 4:10 p.m., Staff I confirmed the boxes contained patient’s medical records and stated they were being stored inside the room along with IT (information technology) equipment’s. Staff I further stated the room door did not have a lock and was propped open to keep the room from overheating.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the initial assessments were performed within 48 hours of the referral for two (Patients #1 and 2) of 17 patients. Patient #1 A review of the clinical record showed a patient referral dated 11/27/23. A review of clinical documentation showed an initial patient assessment and SOC dated 12/20/23 (23 days later). Documentation showed no refusal of visits or services from the patient or caregiver and no contact made with the patient or caregiver and no physician order to delay the initial assessment. Patient #2 A review of the clinical record showed a patient referral dated 01/19/24. A review of clinical documentation showed an initial patient assessment and SOC dated 01/31/24 (12 days later). Documentation showed no refusal of visits or services from the patient or caregiver and no contact made with the patient or caregiver and no physician order to delay the initial assessment. On 06/13/24 at 11:10 a.m., Staff A stated the initial assessment for Patients #1 and 2 were not completed within 48 hours of the referral.”

“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 patient POC included the frequency and duration of visits to be made for three (Patients #8 and 12) of 17 patients. Patient #8 A review of the POC dated 03/06/24 to 05/04/24 showed an order for ST services which indicated continue with POC and no frequency and no duration of visits. Patient #12 A review of the POC dated 03/19/24 to 05/17/24 showed an order for PT and OT services which indicated continue with treatment and no frequency and no duration of visits. On 06/13/24 at 11:15 a.m., Staff A stated the POC did not contain the frequency and duration of visits to be made for Patients #8 and 12.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on record review and interview the agency failed to ensure completion of a transfer/discharge summary for two (Pt’s #13 and 15) of 17 patients. Patient #13 A review of the clinical record showed the patient was transferred to hospice care services on 01/03/24. Documentation showed no transfer summary, no in-patient follow up communication and no summary of care was provided to the physician and receiving hospice provider.Patient #15 A review of the clinical record showed the patient was discharged from the agency on 06/06/24. Documentation showed no discharge summary completed and no summary of care was provided to the patient/caregiver or physician.On 06/13/24 at 11:40 a.m., Staff A stated the transfer/discharge summaries for Patients #13 and 15 were not done and should have been completed after discharge.”