Care Plus Home Health Care, Inc.

“Property and person treated with respect CFR(s): 484.50(c)(1) Have his or her property and person treated with respect; This Element is not met as evidenced by: Based on record review and interview the agency failed to ensure a complaint regarding lack of respect for the patient was fully investigated for one (Complainant #1) of one complainant. Complainant #1 A review of administrative records showed a complaint dated 09/19/24 which documented the complainant requested Staff E not return “because she was too rough”. The investigation/findings section failed to address any investigation into the patient being treated “rough”. The actions taken section of the complaint form failed to address any reference to the “rough” behavior of Staff E. On 11/19/24 at 1:40 pm., Staff A stated the complaint investigation for Complainant #1 failed to document any investigation into the reported “rough” treatment by Staff E.”

“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 seven (Patient #1, 2, 3, 4, 5, 6 and 7) of 7 patients. Patient #1 A review of the plan of care dated 08/11/24 to 10/09/24 showed a primary diagnosis of paroxysmal atrial fibrillation with no patient specific individualized interventions developed for the management of the primary diagnosis. Patient #2 A review of the plan of care dated 08/18/24 to 10/16/24 showed a primary diagnosis of hypertensive heart disease with heart failure with no patient specific individualized interventions developed for the management of the primary diagnosis. Patient #3 A review of the plan of care dated 09/16/24 to 11/14/24 showed a primary diagnosis of corns and callosities with no patient specific individualized interventions developed for the management of the primary diagnosis. Patient #4 A review of the plan of care dated 09/20/24 to 11/18/24 showed a primary diagnosis of metabolic encephalopathy with no patient specific individualized interventions developed for the management of the primary diagnosis. Patient #5 A review of the plan of care dated 07/25/24 to 09/22/24 showed a primary diagnosis of Friedreich ataxia with no patient specific individualized interventions developed for the management of the primary diagnosis. Patient #6 A review of the plan of care dated 07/18/24 to 09/15/24 showed a primary diagnosis of chronic respiratory failure, unspecified with hypoxia or hypercapnia with no patient specific individualized interventions developed for the management of the primary diagnosis. Patient #7 A review of the plan of care dated 08/07/24 to 10/05/24 showed a primary diagnosis of type II diabetes mellitus with foot ulcer with no patient specific individualized interventions developed for the management of the primary diagnosis. On 11/19/24 at 1:50 pm, Staff A stated the plan of care for Patients #1, 2, 3, 4, 5, 6 and 7 did not include patient specific individualized interventions for the management of the primary diagnosis.”

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure skilled nurse frequencies were followed as ordered for one (Patient #7) of 7 patients. Patient #7 A plan of care dated 08/07/24 to 10/05/24 showed a primary diagnosis of type II diabetes mellitus with foot ulcer and documented a skilled nurse frequency of one visit per week for one week and two visits per week for eight weeks. A review of the clinical records showed the following: A physician’s order dated 08/23/24 showed an order for home health skilled nurse three times weekly except on days completed by wound center. Skilled nurse assessments dated 09/02/24 and 09/06/24 were completed for the week of 09/02/24 to 09/08/24 (two of three completed visits) with no physician orders for a change in frequency, no refusal of visits or offer to reschedule missed visits. A physician’s order dated 09/10/24 showed an order for home health skilled nurse three times weekly except on days completed by wound center. Skilled nurse assessments dated 09/09/24 and 09/13/24 were completed for the week of 09/09/24 to 09/15/24 (two of three completed visits) with no physician orders for a change in frequency, no refusal of visits or offer to reschedule missed visits. Skilled nurse assessments dated 09/16/24 and 09/19/24 were completed for the week of 09/16/24 to 09/22/24 (two of three completed visits) with no physician orders for a change in frequency, no refusal of visits or offer to reschedule missed visits. On 11/19/24 at 1:00 pm., Staff A stated the physician ordered frequency was not followed for Patient #7.”