Care Options for Kids

“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 a review of agency policy, a review of the clinical records, and an interview with the agency Administrator, the agency failed to ensure treatments were administered by agency staff in accordance with the written orders of the physician, for three (3) of seven (7) clinical records (CR) reviewed (CR#1, CR#2, CR#7). Agency policy/procedure was reviewed on November 6, 2025 at approximately 12:00 p.m. Policy ‘Initial Assessment and Development of Plan of Care’ ‘Procedure’ (6) “There is a written Plan of Care established based on the assessment of the client, in consultation with the physician, ...” (8) “The Plan of Care includes: ..... (p) “Interventions.” (r) Treatments/orders.” A review of CRs was completed on November 6, 2025 at approximately 11:45 a.m. The patients start of care (SOC) is listed below. CR#1 SOC 07/22/25: Patients recertification of the Plan of Care for the period of 09/20/25 - 11/18/25 reviewed. Plan of Care ‘Orders for treatment and Discipline (Specify Amount/Frequency/Duration)’ include SN (skilled nurse) to complete head to toe assessment to include ......at beginning and end of shift ...” No documentation provided of the skilled nurse completing a head to toe assessment at the end of skilled nursing visit shifts through the above time period. No documentation provided of the physician being notified of physician orders not being followed as ordered. CR#2 SOC 10/09/25: Patients certification of the Plan of Care for the period of 10/09/25 - 12/07/25 reviewed. Plan of Care ‘Orders for treatment and Discipline (Specify Amount/Frequency/Duration)’ include SN (skilled nurse) to complete head to toe assessment to include ......at beginning and end of shift ...” No documentation provided of the skilled nurse completing a head to toe assessment at the end of skilled nursing visit shifts through the above time period. No documentation provided of the physician being notified of physician orders not being followed as ordered. CR#7 SOC 08/11/25: Patients certification of the Plan of Care for the period of 08/11/25 - 10/09/25 reviewed. Plan of Care ‘Orders for treatment and Discipline (Specify Amount/Frequency/Duration)’ include SN (skilled nurse) to complete head to toe assessment to include ......at beginning and end of shift ...” No documentation provided of the skilled nurse completing a head to toe assessment at the end of skilled nursing visit shifts through the above time period. No documentation provided of the physician being notified of physician orders not being followed as ordered. An interview conducted with agency Administrator on November 6, 2025 at approximately 12:15 p.m. confirmed the above findings.”

“Make complaints to the HHA CFR(s): 484.50(c)(3) Make complaints to the HHA regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the HHA; This Element is not met as evidenced by: Based on a review of agency policy, a review of the patient clinical records, and an interview with the agency Administrator, the agency failed to follow the grievance/complaint policy for one (1) of one (1) grievance/complaint logs reviewed (Complaint Log #1). Agency policy/procedure was reviewed on November 6, 2025 at approximately 12:00 p.m. Policy ‘Report of Grievance or Complaint’ ‘Procedure’ (6)(a) “The Administrator, Alternate Administrator, Director of Human Resources, and/or qualified designee shall notify the complainant of the results of the investigation and the Agency’s plan to resolve any issue identified within five (5) business days of receiving the grievance/complaint/concern.” A review of the agency incident/complaint log was conducted on 11/6/25 at approximately 11:00 a.m. Complaint Log #1: Complaint from (family member) of patient (clinical record #7) received by the agency via telephone on 08/28/25. No documentation provided of the agency notifying the complainant of the results of the investigation and the Agency’s plan to resolve any issue identified within five (5) business days of receiving the complaint, per policy. An interview conducted with agency Administrator on November 6, 2025 at approximately 12:15 p.m. confirmed the above findings.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on a review of agency policy, review of clinical records, and an interview with the agency Administrator, the agency failed to complete the initial assessment visit within 48 hours of referral, or within 48 hours of the patients return home, or on the physician-ordered start of care date, for one (1) of two (2) clinical record (CR) referrals reviewed (CR#7). Agency policy/procedure was reviewed on November 6, 2025 at approximately 12:00 p.m. Policy ‘Initial Assessment and Development of Plan of Care’ ‘Procedure’ (1) “A registered nurse conducts an initial assessment to determine eligibility, immediate care and supports needs of the client. ...” (2) The initial assessment visit is held on the physician-ordered start of care date.” A review of CRs was completed on November 6, 2025 at approximately 11:45 a.m. The patients start of care (SOC) is listed below. CR#7 SOC 08/11/25: Patients certification of the Plan of Care for the period of 08/11/25 - 10/09/25 reviewed. Documentation provided of patient (family) referral on 07/17/25. No documentation provided of the registered nurse completing the initial visit within 48 hours of referral, or within 48 hours of the patient’s return home, or on a physician or allowed practitioner - ordered start of care date. Documentation provided of an initial registered nurse visit on 08/11/25. (25 days after referral). An interview conducted with agency Administrator on November 6, 2025 at approximately 12:15 p.m. confirmed the above findings.”

“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 a review of agency policy, a review of the clinical records, and an interview with the agency Administrator, the agency failed to ensure the Plan of Treatment accurately listed the frequency of visits, for six (6) of seven (7) clinical records (CR) reviewed (CR#2 - CR#7). Agency policy/procedure was reviewed on November 6, 2025 at approximately 12:00 p.m. Policy ‘Initial Assessment and Development of Plan of Care’ ‘Procedure’ (6) “There is a written Plan of Care established based on the assessment of the client, in consultation with the physician, .... (8) The Plan of Care includes: ....(g) Orders for all disciplines include amount, frequency, and duration of visits to be made.” A review of CRs was completed on November 6, 2025 at approximately 11:45 a.m. The patients start of care (SOC) is listed below. CR#2 SOC 10/09/25: Patients certification of the Plan of Care for the period of 10/09/25 - 12/07/25 reviewed. Plan of Treatment section ‘Orders for treatment and Discipline (Specify Amount/Frequency/Duration)’ “PDN (private duty nursing) - 50 hours weekly. Duration: 10/09/25-12/07/25, total not to exceed: 500 (hours) and “Client is receiving SN (skilled nurse) care 7-9 hours/day x 4-5 days week x 60 days.” The skilled nursing hours of care to be provided in the signed physician Plan of Treatment are conflicting and do not equal each other. CR#3 SOC 07/07/25: Patients recertification of the Plan of Care for the period of 09/05/25 - 11/03/25 reviewed. Plan of Treatment section ‘Orders for treatment and Discipline (Specify Amount/Frequency/Duration)’ “PDN (private duty nursing) - 112 hours weekly. Duration: 09/05/25-11/03/25, total not to exceed: 1120 (hours) and “Client is receiving 6-18 hours/day x 4-5 days week x 60 days and 2 hours/day x 1 day/week x 60 days.” The skilled nursing hours of care to be provided in the signed physician Plan of Treatment are conflicting and do not equal each other. CR#4 SOC 09/25/25: Patients certification of the Plan of Care for the period of 09/25/25 - 11/23/25 reviewed. Plan of Treatment section ‘Orders for treatment and Discipline (Specify Amount/Frequency/Duration)’ “PDN (private duty nursing) - 68 hours weekly. Duration: 9/25/25-11/23/25, total not to exceed: 680 (hours) and “Client is receiving SN (skilled nurse) shift care 4-5 hours/day x 1-2 days week x 60 days.” The skilled nursing hours of care to be provided in the signed physician Plan of Treatment are conflicting and do not equal each other. CR#5 SOC 09/26/25: Patients certification of the Plan of Care for the period of 09/26/25 - 11/24/25 reviewed. Plan of Treatment section ‘Orders for treatment and Discipline (Specify Amount/Frequency/Duration)’ “PDN (private duty nursing) - 45 hours weekly. Duration: 9/26/25-11/24/25, total not to exceed: 450 (hours) and “Client is receiving SN (skilled nurse) shift care 8-9 hours/day x 1-2 days week x 60 days.” The skilled nursing hours of care to be provided in the signed physician Plan of Treatment are conflicting and do not equal each other. CR#6 SOC 09/17/25: Patients certification of the Plan of Care for the period of 09/17/25 - 11/15/25 reviewed. Plan of Treatment section ‘Orders for treatment and Discipline (Specify Amount/Frequency/Duration)’ “PDN (private duty nursing) - 40 hours weekly. Duration: 9/17/25-11/15/25, total not to exceed: 360 (hours) and “Client is receiving SN (skilled nurse) shift care 8 hours/night x 7 nights week and 8 hours/day Monday through Friday when (family) is working. COFK is providing 8 hours/day x 5 days/week x 60 days.” The skilled nursing hours of care to be provided in the signed physician Plan of Treatment are conflicting and do not equal each other. CR#7 SOC 08/11/25: Patients certification of the Plan of Care for the period of 08/11/25 - 10/09/25 reviewed. Plan of Treatment section ‘Orders for treatment and Discipline (Specify Amount/Frequency/Duration)’ “PDN (private duty nursing) - 154 hours weekly. Duration: 8/11/25-10/09/25, total not to exceed: 1380 (hours) and “Client is receiving 8-10 hours/day x 4 -5 days/week x 60 days.” The skilled nursing hours of care to be provided in the signed physician Plan of Treatment are conflicting and do not equal each other. An interview conducted with agency Administrator on November 6, 2025 at approximately 12:15 p.m. confirmed the above findings.”

“A qualified HH aide successfully completed: CFR(s): 484.80(a)(1)(i-iv) A qualified home health aide is a person who has successfully completed: (i) A training and competency evaluation program as specified in paragraphs (b) and (c) respectively of this section; or (ii) A competency evaluation program that meets the requirements of paragraph (c) of this section; or (iii) A nurse aide training and competency evaluation program approved by the state as meeting the requirements of §483.151 through §483.154 of this chapter, and is currently listed in good standing on the state nurse aide registry; or (iv) The requirements of a state licensure program that meets the provisions of paragraphs (b) and (c) of this section. This Element is not met as evidenced by: Based on a review of agency policy, a review of employee files, and an interview with the agency Director of Nursing, the agency failed to ensure home health aide competency training was completed for one (1) out of three (3) employee files (ELF) aide training reviewed (EF#7). Agency policy/procedure was reviewed on November 10, 2025 at approximately 1:00 p.m. Policy ‘Certification Requirements for Home Health Aide Services’ ‘Purpose’ “To ensure guidelines are established and implemented in regard to education, experience, or certification requirements for Home Health Aides.” ‘Scope’ “This procedure applies to all Home Health Aides employed by the agency.” ‘Procedure’ (1) All home health aide services must be provided by individuals who meet the personnel requirements specified in 42 CFR 484.80(a). A qualified Home Health Aide is a person who has successfully completed:... (a) A training and competency evaluation program (classroom and supervised practical training must total at least 75 hours) as specified in 42 CFR 484.80 (b) and (c); or (b) A competency evaluation program that meets the requirements of 42 CFR 484.80(c); and (c) A nurse aide training and competency evaluation program approved by the state as meeting the requirements of 42 CFR 483.151 through 42 CFR 483.154,and is currently listed in good standing on the state nurse aide registry; and (d) The requirements of a state licensure program that meets the provisions of 42 CFR 484.80(b) and (c). A review of Efs was conducted on November 4, 2025 at approximately 11:00 a.m. The employees date of hire (DOH) is listed below. EF#7 DOH 09/17/25: Documentation provided of a job description signed on 09/15/25, ‘Home Health Aide (HHA)’. Documentation provided of a ‘Certificate of Completion’ certificate which includes “ .... has successfully completed Personal Care Aide Upgrade program approved by the New York State Department of Health and is qualified as a Home Health Aide as of February 28, 2011 ....” No documentation provided of completing a training and competency evaluation program (classroom and supervised practical training must total at least 75 hours). An interview conducted with agency Administrator on November 6, 2025 at approximately 12:15 p.m. confirmed the above findings.”