Kelton Home Health 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 observations, interviews and record reviews, the agency failed to ensure the plan of care contained the required elements to cover all supplies and equipment required, patient specific interventions and education, and safety measures to protect against injury for 4 of 10 patients reviewed for plan of care. (Patient#1, Patient#2, Patient#3, Patient#4) The agency did not ensure the plan of care including bleeding precautions for Patient#1, Patient#2, Patient#3 and Patient#4. The agency did not ensure Patient #2’s POC included the location of the dialysis access or where Patient #4 received dialysis. This failure could place patients at risk of injury, improper care and instruction leading to complications and hospitalization. Findings included: 1 Record review of a plan of care dated 1/3/2026-3/3/2026 indicated Patient #1 was 86 years old, admitted on 1/8/2025 with diagnosis including congestive heart failure (chronic heart condition where the heart muscle is too weak or stiff to pump blood efficiently), cardiomyopathy (disease of the heart muscle), high blood pressure, and atrial fibrillation (irregular heart rhythm). The plan of care indicated Patient #1 was prescribed Eliquis (a blood thinner to reduce stroke and blood clots) 5mg 2 times per day. The plan of care did not indicated bleeding precautions or teaching regarding bleeding precautions. 2 Record review of a plan of care dated 12/16/2025-02/13/2026 indicated Patient #2 was 79 years old, admitted on 08/18/2025 with diagnosis including chronic kidney disease stage 5 (kidney failure where kidneys function less than 15 percent capacity), dependance on renal dialysis (life sustaining, long term requirement for kidney failure, usually due to end stage renal disease), arteriovenous fistula (created surgically in the arm to provide access for dialysis) and history of transient ischemic attack (temporary blockage of blood flow to the brain causing stroke like symptoms). The plan of care indicated that Patient #2 received dialysis on Tuesdays, Thursdays and Saturdays. The plan of care did not indicate where Patient #2’s arteriovenous access device was located or where Patient #2 went for dialysis or dialysis physician. The plan of care indicated that Patient #2 was prescribed Aspirin (blood thinner) 81 mg daily. The plan of care did not indicate any bleeding precautions under safety precautions. 3 Record review of a plan of care dated 1/18/2026-3/18/2026 indicated Patient #3 was 92 years old, admitted on 11/30/2023 with diagnosis including glaucoma (eye disease that damages the optic nerve leading to permanent vision loss or blindness), osteoarthritis (wear and tear joint disease) right knee, polyneuropathy (damage to multiple peripheral nerves leading to symmetric, distal symptoms such as tingling, numbness, burning pain and muscle weakness often to the feet and hands), high blood pressure and atrial fibrillation (abnormal heart rhythm). The plan of care indicated Patient #3 was prescribed Aspirin (blood thinner) 325 mg one tablet daily. The plan of care did not indicate any bleeding precautions under safety precautions. During a record review on 2/10/2026 at 9:30 a.m., a medication list inside Patient #3’s home indicated he was prescribed Aspirin 325 mg daily. During an interview on 2/10/2026 at 9:32 a.m., RN B said Patient #3 took 325 mg of Aspirin daily due to his history of atrial fibrillation. During an interview on 2/10/2026 at 9:35 a.m., Patient #3 said his daughter filled his pill planners for him to take daily. He said whatever was on that medication list was what he was taking because that is what his daughter put in the pill planner for him to take. 4 Record review of a plan of care dated 12/12/2025-02/09/2025 indicated Patient #4 was 91 years old, admitted on 6/15/2026 with diagnosis including stage 3 pressure ulcer to the sacrum ( localized injury to the skin and underlying tissue over the tailbone (sacrum), caused by prolonged pressure, friction, or shear, typically in immobile or bedridden individuals), urinary tract infection (bacteria in the urinary tract), atrial fibrillation (abnormal heart rhythm), high blood pressure and history of transient ischemic attack (temporary blockage of blood flow to the brain causing stroke like symptoms). The plan of care indicated Patient #4 was prescribed Apixaban (blood thinner) 5 mg one tablet twice per day. During an interview on 2/10/2026 at 10:40 a.m., RN B said she assessments and the plan of care for patients of the agency. RN B said the plan of care included orders, goals, safety precautions, supplies and medications for each patient. RN B said Patient #4 was taking aspirin due to his history of atrial fibrillation and this should be included on his plan of care including bleeding precautions and teaching. RN B said this was important so that each nurse would know how to care for each patient, what to educate the patient and family on and signs and symptoms to report to the physician. During an interview on 2/11/2026 at 9:18 a.m., RN B said Patient #1 should have anticoagulation or bleeding precautions and teaching for her Eliquis. RN B said the administrator/DON reviewed all of the plan of cares prior to them being locked to ensure accuracy. RN B said individualized plan of cares are important for patient safety and for other nurses seeing patients to be aware of the needs of each particular patient . During an interview on 2/11/2026 at 9:42 a.m., RN D said she was a field nurse and primarily did assessments including admissions, recertifications, resumption of cares, and discharges. RN D said the administrator / DON reviewed all of the plan of cares prior to them being locked. RN D said a plan of care should include all orders, goals, medications, safety precautions and supplies needed and should be individualized to each patient. RN D said if a patient is taking any type of blood thinner the plan of care should include bleeding precautions and teaching. RN D said Patient #2 should have had bleeding precautions on his plan of care as well as the location of his dialysis access and what facility he received dialysis from. RN D said this was all very important for patient safety and continuity of care. During an interview on 2/11/2026 at 10:00 a.m., the Alternate DON/ Alternate Administrator said he had been in this position since October of 2025. He said he primarily did field assessment visits and was training with the Administrator/DON for the alternate positions. The Alternate DON/ Alternate Administrator said the Administrator/DON reviewed all of the plan of cares for the agency. He said Patient #4 should have had bleeding precautions on his plan of care due to him being prescribed Aspirin and Eliquis for a blood thinner. The Alternate DON/Alternate Administrator said it was important to ensure the plan of cares included safety precautions so that hospitalization is decreased and patients and families are educated on signs and symptoms of bleeding to report to the agency nurses or physician. During an interview on 2/11/2026 at 2:00 p.m., the Administrator/DON said he reviewed all of the plan of cares for the agency. He said Patient #1, Patient #2, Patient #3 and Patient #4 should have had bleeding precautions on their plan of cares. The Administrator/ DON said Patient #4 should have proper dialysis details including access location and the location where she received her dialysis on the plan of care. The Administrator / DON said all patient needs are different and independent and the plan of care must address all needs for safety for patient safety. Record review of a policy 01/01/26 titled Plan of Care indicated III. A. The individualized plan of care must include the following: 10. All medications and treatments; 11. Safety measures to protect against injury; 14. Patient/client specific interventions and education.”