Via Life Home Health Care

“Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient’s 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) that a discharge for cause is being considered; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure documentation of notification of the potential for discharge for cause was provided to the patient for one patient (Patient #10) of 17 patients. A review of the plan of care dated 10/29/24 to 12/27/24 showed a primary diagnosis of hypertensive chronic kidney disease with a skilled nurse frequency of one visit per week for nine weeks. A review of the clinical record showed the following; A start of care assessment dated 10/29/24 documented no power of attorney or medical power of attorney. Skilled nurse assessments dated 10/29/24, 11/05/24, 11/12/24, 11/21/24 and 11/27/24 documented no behaviors or attempts to resolve unacceptable behaviors and no documentation of reason for potential discharge was provided to the patient. A skilled nurse discharge note was dated 11/27/24. On 01/24/25 at 1:25 pm., Staff B stated Patient #10 was not provided information in regard to the potential for discharge for cause.”

“Make efforts to resolve the problem(s) CFR(s): 484.50(d)(5)(ii) (ii) Make efforts to resolve the problem(s) presented by the patient’s behavior, the behavior of other persons in the patient’s home, or situation; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure documentation of efforts to resolve the patient’s behavior for one (Patient #10) of 17 patients. A review of the plan of care dated 10/29/24 to 12/27/24 showed a primary diagnosis of hypertensive chronic kidney disease with a skilled nurse frequency of one visit per week for nine weeks. A review of the clinical record showed the following; A start of care assessment dated 10/29/24 documented no power of attorney or medical power of attorney. Skilled nurse assessments dated 10/29/24, 11/05/24, 11/12/24, 11/21/24 and 11/27/24 documented no behaviors or attempts to resolve unacceptable behaviors and no documentation of reason for potential discharge was provided to the patient.. A skilled nurse discharge note was dated 11/27/24. On 01/24/25 at 1:25 pm., Staff B stated Patient #10 was not informed of or provided the opportunity to correct unacceptable behaviors.”

“Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure it provided contact information to other agencies to provide care for one (Patient #10) of 17 patients. A review of the plan of care dated 10/29/24 to 12/27/24 showed a primary diagnosis of hypertensive chronic kidney disease with a skilled nurse frequency of one visit per week for nine weeks. A review of the clinical record showed the following; A start of care assessment dated 10/29/24 documented no power of attorney or medical power of attorney. Skilled nurse assessments dated 10/29/24, 11/05/24, 11/12/24, 11/21/24 and 11/27/24 documented no behaviors or attempts to resolve unacceptable behaviors and no documentation of reason for potential discharge was provided to the patient.. A skilled nurse discharge note was dated 11/27/24. On 01/24/25 at 1:25 pm., Staff B stated Patient #10 was not provided contact information for other agencies to provide care.”

“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 was developed for eleven (Patients #1, 2, 4, 5, 6, 10, 11, 12, 13, 14 and 15) of 17 patients. Patient #1 A review of the plan of care dated 11/25/24 to 01/23/25 showed a primary diagnosis of paranoid schizophrenia with no patient specific individualized interventions or goals developed for the management of the primary diagnosis. Patient #2 A review of the plan of care dated 10/18/24 to 12/16/24 showed a primary diagnosis of hypertension with no patient specific individualized interventions or goals developed for the management of the primary diagnosis. Patient #4 A review of the plan of care dated 10/18/24 to 12/16/24 showed a primary diagnosis of paranoid schizophrenia with no patient specific individualized interventions or goals developed for the management of the primary diagnosis. Patient #5 A review of the plan of care dated 01/07/25 to 03/07/25 showed a no plan of care development. Patient #6 A review of the plan of care dated 10/23/24 to 12/21/24 showed a primary diagnosis of chronic obstructive pulmonary disease with no patient specific individualized interventions or goals developed for the management of the primary diagnosis. Patient #10 A review of the plan of care dated 10/29/24 to 12/27/24 showed a primary diagnosis of hypertensive chronic kidney disease with no patient specific individualized interventions or goals developed for the management of the primary diagnosis. Patient #11 A review of the plan of care dated 11/22/24 to 01/20/25 showed a primary diagnosis of dementia with no patient specific individualized interventions or goals developed for the management of the primary diagnosis. Patient #12 A review of the plan of care dated 12/21/24 to 02/18/25 showed a primary diagnosis of urinary tract infection with no patient specific individualized interventions or goals developed for the management of the primary diagnosis. Patient #13 A review of the plan of care dated 01/16/25 to 03/16/25 showed a no plan of care development. Patient #14 A review of the plan of care dated 01/16/25 to 03/16/25 showed a no plan of care development. Patient #15 A review of the plan of care dated 12/13/24 to 02/10/25 showed a primary diagnosis of diabetes mellitus type II with no patient specific individualized interventions or goals developed for the management of the primary diagnosis. On 01/24/25 at 1:50 pm, Staff B stated the plan of care for Patients #1, 2, 4, 5, 6, 10, 11, 12, 13, 14 and 15 were not individualized for the management of the primary diagnosis.”

“Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient’s updated comprehensive assessment, and contain information concerning the patient’s progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the plan of care was updated to reflect services provided for the current certification period for one (Patient #10) of 17 patients. A review of the plan of care dated 10/29/24 to 12/27/24 showed a primary diagnosis of hypertensive chronic kidney disease with no updated skilled nurse frequencies, no updated physical therapy frequencies, updated occupational therapy frequencies or home health aide frequencies (all frequencies were stated to start the week of 08/28/24). On 01/24/25 at 2:00 pm., Staff B stated the plan of care for Patient #10 did not update the frequencies for skilled nurse, physical therapy, occupational therapy or home health aide.”