Compassion Home Care, Inc.

“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 seven (Patients #1, 3, 4, 5, 6, 7 and 8) of 14 patients. Patient #1 A review of the plan of care dated 11/23/24 to 01/21/25 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 #3 A review of the plan of care dated 11/12/24 to 01/10/25 showed a primary diagnosis of chronic venous hypertension with ulcer to lower extremities 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 10/15/24 to 12/13/24 showed a primary diagnosis of multiple sclerosis with no patient specific individualized interventions or goals developed for the management of the primary diagnosis. Patient #6 A review of the plan of care dated 11/21/24 to 01/19/25 showed a primary diagnosis of hypertensive heart disease with heart failure with no patient specific individualized interventions or goals developed for the management of the primary diagnosis. Patient #7 A review of the plan of care dated 11/11/24 to 01/09/25 showed a primary diagnosis of hypertensive heart chronic kidney disease with heart failure with no patient specific individualized interventions or goals developed for the management of the primary diagnosis. Patient #8 A review of the plan of care dated 11/18/24 to 01/16/25 showed a primary diagnosis of atrial fibrillation with no patient specific individualized interventions or goals developed for the management of the primary diagnosis. On 12/10/24 at 2:14 pm, Staff C stated the plan of care for Patients #3, 4, 6, 7 and 8 were not individualized for the management of the primary diagnosis. On 12/10/24 at 2:25 pm, Staff A stated the plan of care for Patients #1 and 5 were not individualized for the management of the primary diagnosis.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on record review and interview, the agency failed to: 1. promptly notify the physician of a significant weight loss for one (Patient #4) of 14 patients; 2. promptly notify the physician of weights outside of ordered parameters for one (Patient #4) of 14 patients; and 3. promptly notify the physician of pain levels outside of ordered parameters for one (Patient #4) of patients. Patient #4 1. A review of the plan of care dated 10/15/24 to 12/13/24 showed a primary diagnosis of multiple sclerosis and documented a skilled nurse frequency of one visit per week for nine weeks. A review of the clinical record showed the following: A skilled nurse assessment dated 11/27/24 documented the patient weight of 123 pounds. A skilled nurse assessment dated 12/05/24 documented the patient’s weight of 110 pounds (a 13-pound weight loss within an 8-day period), with no physician notification of the significant weight loss. 2. A review of the plan of care dated 10/15/24 to 12/13/24 showed the physician was to be notified of weights less than 105 pounds and greater than 115 pounds. A skilled nurse assessment dated 10/17/24 documented a weight of 122 pounds (7 pounds greater than the high parameter) and documented the physician was not notified until 10/18/24 (one day after the assessment). A skilled nurse assessment dated 10/24/24 documented a weight of 122 pounds (7 pounds greater than the high parameter) and documented the physician was not notified until 10/25/24 (one day after the assessment). A skilled nurse assessment dated 10/31/24 documented a weight of 123 pounds (8 pounds greater than the high parameter) and documented the physician was not notified until 11/01/24 (one day after the assessment). A skilled nurse assessment dated 11/07/24 documented a weight of 124 pounds (9 pounds greater than the high parameter) and documented the physician was not notified until 11/08/24 (one day after the assessment). A skilled nurse assessment dated 11/14/24 documented a weight of 123 pounds (8 pounds greater than the high parameter) and documented the physician was not notified until 11/15/24 (one day after the assessment). A skilled nurse assessment dated 11/21/24 documented a weight of 124 pounds (9 pounds greater than the high parameter) and documented the physician was not notified until 11/22/24 (one day after the assessment). A skilled nurse assessment dated 11/27/24 documented a weight of 123 pounds (8 pounds greater than the high parameter) and documented the physician was not notified until 11/29/24 (two days after the assessment). 3. A review of the plan of care dated 10/15/24 to 12/13/24 showed the physician was to be notified of a pain level greater than a 7 of 10 on the classic 1-10 pain scale. A skilled nurse assessment dated 10/17/24 documented a pain level of 8 and documented the physician was not notified until 10/18/24 (one day after the assessment). A skilled nurse assessment dated 10/24/24 documented a pain level of 8 and documented the physician was not notified until 10/25/24 (one day after the assessment). A skilled nurse assessment dated 10/31/24 documented a pain level of 8 and documented the physician was not notified until 11/01/24 (one day after the assessment). A skilled nurse assessment dated 11/07/24 documented a pain level of 8 and documented the physician was not notified until 11/08/24 (one day after the assessment). A skilled nurse assessment dated 11/21/24 documented a pain level of 8 and documented the physician was not notified until 11/22/24 (one day after the assessment). On 12/10/24 at 2:30 pm., Staff C stated: 1. the physician was not notified of the 13-pound weight loss for Patient #4 and should have been notified of the significant weight loss; 2. the physician was not notified the day of the weights for Patient #4 exceeding the ordered parameters; and 3. the physician was not notified the day of the pain levels exceeding the ordered parameters for Patient #4.”