Elara Caring Xxv

“Patient/payer will no longer pay for services CFR(s): 484.50(d)(2) The patient or payer will no longer pay for the services provided by the HHA; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure advance beneficiary notice and/or HHCOC notices were provided to two (Patients #14 and 15) of 17 patients. Findings: Patient #15 A review of the clinical record showed no advance notice of discharge, HHCOC, or physician communications prior to discharge from the agency on 08/26/25 for no Face-to-Face evaluation requirement for services. On 11/17/25 at 1:39 p.m., Staff A stated there were no advance notice of discharge given to the patient prior to the discharge from the agency. Patient #16 A review of the clinical record showed no advance notice of discharge, HHCOC, or physician communications prior to discharge from the agency on 07/03/25 for no insurance authorization for services. On 11/17/25 at 1:40 p.m., Staff A stated there were no advance notice of discharge given to the patient prior to the discharge from the agency.”

“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 individualized patient POC included: 1. Skilled intervention goals for one (Patient #4) of 17 patients. 2. SN catheter treatment/interventions due date or last changed treatment date for urinary catheter management for two (Patients #5 and #6) of 17 patients. Findings: Patient #4 A review of the POC dated 10/07/25 to 12/05/25 showed orders for SN to conduct assessment and monitoring of patient’s weight or ankle circumference measurements every visit. The POC showed no goals related to skilled interventions of SN to conduct assessment and monitoring of patient’s weight or ankle circumference measurements every visit. On 11/19/25 at 12:44 p.m., Staff A stated the POC did not include goals for assessment and monitoring of the patient’s weight or ankle circumference measurements. Patient #5 A review of the POC dated 09/01/25 to 10/30/25 showed orders for SN to conduct foley catheter 18 French/10 cubic centimeters catheter change every month. A review of SN visit notes showed SN visits were conducted on 10/14/25, 10/21/25, 10/30/25, 11/04/25 and on 11/12/25 and showed no foley catheter intervention last changed or monthly change due date, no physician notifications and no change in orders. On 11/19/25 at 12:52 p.m., Staff A stated the POC did not include last changed or monthly change due date for the foley catheter. Patient #6 A review of the POC dated 10/10/25 to 12/18/25 showed orders for SN to conduct foley catheter 18 French/10 cubic centimeters catheter change every month. A review of SN visit notes showed SN visits were conducted on 09/04/25, 09/11/25, 09/25/25, 10/02/25 and on 10/26/25 and showed no foley catheter intervention last changed or monthly change due date, no physician notifications and no change in orders. On 11/19/25 at 1:00 p.m., Staff A stated the POC did not include last changed or monthly change due date for the foley catheter.”

“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 care was coordinated between the agency and physician for one (Patient #15) of 17 patients. Findings: Patient #15 A review of the POC dated 07/10/25 to 09/07/25 showed orders for a SN visit frequency and duration of one time a week for two weeks, one time every two weeks for four weeks, one time a week for one week, then one time every two weeks for two weeks. A review of the clinical record showed SN visits were conducted on 07/10/25 at the start of care and on 07/18/25 and showed no other SN visits prior to the discharge date of 08/26/25 (six visits ordered, two visits conducted). The clinical record showed no physician communications or coordination of care notes and showed no changes in orders. On 11/19/25 at 1:39 p.m., Staff A stated the agency should have: 1. Continued to provide the services that were ordered by the physician. 2. Notified the physician and obtained orders to place the patient’s services on hold due to not meeting the Face-to-Face evaluation requirement for services.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure: 1. SN reported to physician blood sugar reading outside of reporting parameters for one (Patient #4) of 17 patients. 2. SN visits were conducted as ordered for one (Patient #5) of 17 patients. 3. SN conducted weight and/or ankle circumference measurements each visit as ordered for two (Patients #7 and #9) of 17 patients. 4. SN reported to physician heart rate reading outside of reporting parameters for one (Patient #11) of 17 patients. 5. SN reported to physician oxygen saturation reading outside of reporting parameters for one (Patient #12) of 17 patients. Findings: Patient #4 A review of the POC dated 10/07/25 to 11/22/25 showed orders for a SN and PT to assess, monitor and instruct patient’s health conditions and report to physician changes in condition and blood sugar greater than 300 each visit. A review of a PT visit note dated 10/10/25 showed a blood sugar level of 304 and showed a faxed physician notification communications dated 10/13/25 (three days after the PT visit) with no additional physician follow up communication. A review of a SN visit note dated 10/21/25 showed the patient reported blood sugar levels were running in the 300’s and EMS was called to the home. The SN visit note showed no physician notification or coordination of care notes. On 11/19/25 at 12:44 p.m., Staff A stated: 1. The SN did not notify the physician of the patient’s report of blood sugar levels were running in the 300’s and EMS was called to the home. 2. The patient continued to experience blood sugar levels of greater than 300. Patient #5 A review of the POC dated 09/01/25 to 10/30/25 showed orders for a SN visit frequency and duration of one time a week for five weeks, then one time every two weeks for four weeks. A review of the clinical record showed during the week of 10/05/25 to 10/11/25 no SN visits were conducted (one visit ordered, no visits conducted). The clinical record showed no physician communications or coordination of care notes and showed no changes in orders. On 11/19/25 at 1:39 p.m., Staff A stated during the week of 10/05/25 to 10/11/25 an SN visit should have been conducted as ordered. Patient #7 A review of the POC dated 10/29/25 to 12/27/25 showed orders for SN to assess and instruct the patients’ weight or ankle circumference every visit and report finding outside of reporting parameters to the physician. A review of SN visit notes dated 11/06/25 showed no weight or ankle circumference assessment and showed no patient or caregiver refusal, no physician notification and no changes in orders. On 11/19/25 at 1:10 p.m., Staff A stated the SN should have conducted either an assessment of the patient’s weight or ankle circumference measurement. Patient #9 A review of the POC dated 10/07/25 to 12/05/25 showed orders for SN to assess and instruct the patients’ weight or ankle circumference every visit and report finding outside of reporting parameters to the physician. A review of SN visit notes dated 10/07/25, 10/14/25 and 10/28/25 showed no weight or ankle circumference assessment, no patient or caregiver refusal, no physician notification and no changes in orders. On 11/19/25 at 1:09 p.m., Staff A stated the SN should have conducted either an assessment of the patient’s weight or thigh circumference measurement as the patient had bilateral above the knee amputations. Patient #11 A review of the POC dated 09/24/25 to 11/22/25 showed orders for a SN to assess, monitor and instruct patient’s health conditions and report to physician changes in condition and heart rate less than 50 beats per minute each visit. A review of a SN visit note dated 10/14/25 showed the patient reported a fall with bruising injuries to his ribs and showed a heart rate of 47 bpm and showed no physician notification communications or coordination of care notes. A review of a SN visit note dated 10/16/25 showed a heart rate of 46 bpm and showed no physician notification communications or coordination of care notes. On 11/19/25 at 1:21 p.m., Staff A stated the SN did not notify the physician of the patient’s report of the fall with bruising injury or the patient’s continued heart rates of less than 50 bpm. Patient #12 A review of the POC dated 10/15/25 to 12/13/25 showed orders for a SN to assess, monitor and instruct patient’s health conditions and report to physician changes in condition and oxygen saturation rate of less than 90% each visit. A review of a SN visit note dated 10/16/25 showed an oxygen saturation rate of 88% and showed no physician notification or coordination of care notes. A review of a SN visit note dated 11/11/25 showed an oxygen saturation rate of 88% and showed no physician notification or coordination of care notes. On 11/19/25 at 1:32 p.m., Staff A stated the SN did not notify the physician of the patient’s continued oxygen saturation rate of less than 90%.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure clinical records were complete for two (Patients #3 and #9) of 17 patients. Findings: Patient #3 A review of the clinical record showed SN visit notes dated: · 08/07/25 was completed on 08/11/25 (three days after the visit was conducted) · 08/14/25 was completed on 08/18/25 (four days after the visit was conducted) · 08/21/25 was completed on 08/24/25 (three days after the visit was conducted) On 11/19/25 at 12:32 p.m., Staff A stated: 1. SN visit notes are to be completed within 2 days of when the visits were conducted. 2. The SN visit notes were not completed within 2 days of when the visit was conducted. Patient #9 A review of the clinical record showed SN visit notes dated: · 10/07/25 was completed on 10/14/25 (seven days after the visit was conducted) On 11/19/25 at 1:19 p.m., Staff A stated: 1. SN visit notes are to be completed within 2 days of when the visits were conducted. 2. The SN visit notes were not completed within 2 days of when the visit was conducted.”

“Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure clinical visit notes included the interventions conducted and patient responses for three (Patients #2, 3 and #8) of 17 patients. Findings: Patient #2 A review of the POC dated 10/05/25 to 12/03/25 showed orders for SN to perform wound care to buttock each visit. SN visit notes dated 10/15/25, 10/20/25, 11/10/25 and 11/13/25 showed no wound site interventions were performed during the visits. On 11/19/25 at 12:26 p.m., Staff A stated SN clinical visit notes for 10/15/25, 10/20/25, 11/10/25 and 11/13/25 documented the wound site assessments but showed no wound care was performed during the visits. Patient #3 A review of the POC dated 07/26/25 to 09/23/25 showed orders for SN to perform wound care to bilateral great toe each visit. SN visit notes dated 08/01/25, 08/07/25 and 08/14/25 showed no wound site interventions were performed during the visits. On 11/19/25 at 12:32 p.m., Staff A stated SN clinical visit notes for 08/01/25, 08/07/25 and 08/14/25 documented the wound site assessments but showed no wound site care was performed during the visits. Patient #8 A review of the POC dated 09/27/25 to 11/25/25 showed orders for SN to perform surgical incision care interventions to lumbar spine each visit. SN visit note dated 11/04/25 showed no surgical incision site interventions were performed during the visits On 11/19/25 at 1:12 p.m., Staff A stated SN clinical visit note for 11/04/25 documented the surgical incision assessment but showed no surgical incision interventions were performed during the visit.”