Haven Home Health & Hospice

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on record review and staff interview, the agency failed to develop a plan care to outline services provided for two (Patient #6 and 11) of 13 patients. Patient #6 A review of the clinical record showed an admission date of 01/18/25 with no plan of care having been developed as of 01/30/25 (twelve after admission to the agency). Patient #11 A review of the clinical record showed an admission date of 01/17/25 with no plan of care having been developed as of 01/30/25 (thirteen days after admission to the agency). On 01/29/25 at 1:10 pm., Staff D stated there was no plan of care for Patients #6 and 11.”

“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 eight (Patients #1, 3, 4, 5, 7, 8 and 12) of 13 patients reviewed. Patient #1 A review of the plan of care dated 10/18/24 to 12/16/24 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 #3 A review of the plan of care dated 12/09/24 to 02/06/25 showed a primary diagnosis of hypertensive heart and chronic kidney disease with heart failure 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 diabetes mellitus type II 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 01/18/25 to 03/18/25 showed a primary diagnosis of dementia 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 11/13/24 to 01/11/25 showed a primary diagnosis of malignant neoplasm of lower lobe, right bronchus or lung 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 10/28/24 to 12/26/24 showed a primary diagnosis of polyarthritis 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 11/30/24 to 01/28/25 showed a primary diagnosis of infectious gastroenteritis and colitis with no patient specific individualized interventions or goals developed for the management of the primary diagnosis. On 01/29/25 at 2:00 pm., Staff D stated the plan of care for Patients #1, 3, 4, 5, 7, 8 and 12 were not patient specific and 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. notify the physician of significant weight changes for one (Patient #3) of 13 patients and 2. promptly notify the physician of pain levels outside of ordered parameters for one (Patient #8) of 13 patients. 1. Patient #3 A review of the plan of care dated 12/09/24 to 02/06/25 showed a skilled nurse frequency of one visit per week for nine weeks and documented a primary diagnosis of hypertensive heart disease and chronic kidney disease with heart failure. A review of the clinical records showed the following: A skilled nurse assessment dated 12/17/24 documented a weight of 214 pounds for the week of 12/15/24 to 12/21/24. A skilled nurse assessment dated 12/26/24 documented a weight of 204 pounds (a ten-pound weight loss) for the week of 12/22/24 to 12/28/24 with no documentation of physician notification of a significant weight loss. A skilled nurse assessment dated 12/30/24 documented a weight of 216 pounds (a twelve-pound weight gain) for the week of 12/29/24 to 01/04/25 with no documentation of physician notification of a significant weight gain. 2. Patient #8 A plan of care dated 10/28/24 to 12/26/24 showed a skilled nurse frequency of one visit per week for nine weeks and documented the physician was to be notified of a pain level greater than 5 on the classic 1-10 pain scale. A review of the clinical record showed the following: A skilled nurse assessment dated 11/07/24 documented a pain level of 6 on the classic 1-10 pain scale with no physician notification of the pain level exceeding the ordered parameter. A skilled nurse assessment dated 11/14/24 documented a pain level of 6 on the classic 1-10 pain scale with no physician notification of the pain level exceeding the ordered parameter. A skilled nurse assessment dated 11/22/24 documented a pain level of 6 on the classic 1-10 pain scale with no physician notification of the pain level exceeding the ordered parameter. A skilled nurse assessment dated 11/27/24 documented a pain level of 6 on the classic 1-10 pain scale with no physician notification of the pain level exceeding the ordered parameter. A skilled nurse assessment dated 12/04/24 documented a pain level of 6 on the classic 1-10 pain scale with no physician notification of the pain level exceeding the ordered parameter. A skilled nurse assessment dated 12/18/24 documented a pain level of 6 on the classic 1-10 pain scale with no physician notification of the pain level exceeding the ordered parameter. On 01/29/25 at 1:55 pm., Staff D stated: 1. the physician should have been notified of the significant weight loss and weight gain for Patient #3 and 2. the physician was not notified of the pain levels exceeding the ordered parameters for Patient #8.”