Elite Home Care, LLC

“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 ten (Patient #1. 2, 3, 4, 5, 6, 7, 8, 9 and 10) of 10 patients. Patient #1 A review of the plan of care dated 10/18/24 to 12/16/24 showed a primary diagnosis of hypertensive heart and chronic kidney disease with no patient specific interventions developed for the management of the primary diagnosis. Patient #2 A review of the plan of care dated 10/26/24 to 12/24/24 showed a primary diagnosis of metabolic encephalopathy with no patient specific interventions developed for the management of the primary diagnosis. Patient #3 A review of the plan of care dated 11/07/24 to 01/05/24 showed a primary diagnosis of psychophysiologic insomnia with no patient specific interventions developed for the management of the primary diagnosis. Patient #4 A review of the plan of care dated 09/27/24 to 11/25/24 showed a primary diagnosis of Parkinsonism with no patient specific interventions developed for the management of the primary diagnosis. Patient #5 A review of the plan of care dated 09/07/24 to 11/05/24 showed a primary diagnosis of aphasia following cerebral infarction with no patient specific interventions developed for the management of the primary diagnosis. Patient #6 A review of the plan of care dated 09/01/24 to 10/30/24 showed a primary diagnosis of idiopathic pulmonary fibrosis with no patient specific interventions developed for the management of the primary diagnosis. Patient #7 A review of the plan of care dated 08/08/24 to 10/06/24 showed a primary diagnosis of encounter for change and removal of non-surgical wound dressing with no patient specific interventions developed for the management of the primary diagnosis. Patient #8 A review of the plan of care dated 09/19/24 to 11/17/24 showed a primary diagnosis of encounter for surgical aftercare following surgery on the digestive system with no patient specific interventions developed for the management of the primary diagnosis. Patient #9 A review of the plan of care dated 10/13/24 to 12/11/24 showed a primary diagnosis of diabetes mellitus type II with diabetic peripheral angiopath [sic] without gangrene with no patient specific interventions developed for the management of the primary diagnosis. Patient #10 A review of the plan of care dated 08/23/24 to 10/21/24 showed a primary diagnosis of hypertensive heart and chronic kidney disease without heart failure with no patient specific interventions developed for the management of the primary diagnosis. On 11/21/24 at 12:50 pm, Staff B stated the plan of care for Patients #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10 were not individualized for the management of the primary diagnosis.”