Choice Health at Home - Kingfisher

“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 development of an individualized Plan of Care for two (Patients #3 and 4) of seven patients. Patient #3 A review of the plan of care dated 12/1/24 to 1/29/25 showed secondary diagnoses of hypertensive heart disease & chronic kidney disease, heart failure, and chronic kidney disease Stage 3B. The plan of care documented no specific interventions (such as obtain weights, degree of edema, adventitious lung sounds, cough, or measurement of abdomen/calf) and what signs and symptoms to notify to the physician regarding the secondary diagnosis. Patient #4 A review of the plan of care dated 11/29/24 to 1/27/25 showed a primary diagnosis of unspecified combined systolic and diastolic (congestive) heart failure. The plan of care documented no specific interventions (such as obtain weights, degree of edema, adventitious lung sounds, cough, or measurement of abdomen/calf) and what signs and symptoms to notify the physician regarding the primary diagnosis. On 01/07/25 at 2:40 pm, Staff B stated the plan of care for Patients #3 and 4 were not individual specific to their diagnoses.”

“Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure communication/coordination with the physician on a wound that deteriorated for one (Patients #1) of seven patients. Findings: Patient #1 A plan of care dated 11/02/24 - 12/31/24 showed wound care three times weekly, with weekly wound measurements. A nurses note dated 12/3/24 showed the wound measurement of 3.9 x 3.2 x 2.1. A nurses note dated 12/11/24 showed the wound measurement of 5.9 x 3 x 1.1 the physician was not notified of the change in wound size. On 1/07/25 at 1:06 pm, Staff A stated any change to a wound should result in a physician notification.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on record review and interview, the agency failed to provide a current Plan of Care to the Assisted Living Facilities for three (Patients #2, 3, and 4) of three patients residing in Assisted Living Facilities. Findings: Patient #2 A review of the assisted living center clinical record showed no Plan of Care. Patient #3 A review of the assisted living center clinical record showed a Plan of Care dated 10/2/24 to 11/30/24 with no Plan of Care for the current certification period of 12/1/24 to 1/29/25. Patient #4 A review of the assisted living center clinical record showed a Plan of Care dated 6/2/24 to 7/31/24 with no Plan of Care for the current certification period of11/29/24 to 1/27/25. On 1/07/25 at 08:45 am Assisted Living Staff #1 stated there was no Plan of Care for Patient #3. On 1/07/25 at 10:00 am Assisted Living Staff #2 stated there is no current Plan of Care for Patient #2. On 1/07/25 at 11:00 am Assisted Living Staff #3 stated there is no current Plan of Care for Patient #4. On 1/07/25 at 12:30 pm Staff A stated she was not aware that the assisted living staff did not have copies of the Plan of Care for Patient #2, 3, and 4.”