Centerwell Home Health

“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 the plan of care contained patient specific education and safety measures to protect against injury for 1 of 17 patients (Patient #1) records reviewed for plans of care, in that: Patient #1’s POC did not include patient specific education and antiplatelet (decreased ability for platelets to adhere to each other to prevent clot formation) precautions as a safety measure for her use of Clopidogrel (an antiplatelet medication). This failure could place patients at risk of not receiving proper care and education, leading to complications and hospitalization. Findings included: Record review of Patient #1’s POC dated 12/7/25- 2/4/26 indicated a SOC date of 12/12/24, and indicated she was 77 years old with diagnosis including COPD (lung disease that causes difficulty breathing), atherosclerotic heart disease (buildup of plaque in the coronary arteries [blood vessels that supply blood to the heart], leading to reduced blood flow and increased risk of a heart attack), and hypertension (high blood pressure). The POC indicated Patient #1 was ordered SN visits once a week for nine weeks. The POC indicated she was on Clopidogrel 75 mg daily. The POC did not include education or antiplatelet precautions as a safety measure for use of the antiplatelet medication, Clopidogrel. Record review of the Medication Profile for Patient #1 dated 1/5/26 indicated she had orders for Clopidogrel 75 mg daily ordered on 1/2/25. During an interview on 1/6/26 at 3:21 pm, Patient #1 said she was on the medication Clopidogrel. During an interview and record review on 1/6/26 at 3:29 pm, LVN D said the RN was responsible for completing the POC. LVN D said patients taking Clopidogrel should have antiplatelet precautions as a safety measure on their POC. LVN D reviewed Patient #1’s POC dated 12/7/25- 2/4/26 and confirmed the antiplatelet precautions was not included on her safety measures. LVN D said the antiplatelet precautions should have been listed on the POC as a safety measure since Patient #1 was taking Clopidogrel. LVN D said she knew the antiplatelet precautions were on Patient #1’s previous POC and that they (the agency nurses) were teaching Patient #1 on Clopidogrel previously. LVN D said the safety measures were supposed to carry over on the POC. LVN D said the nurse might have missed the antiplatelet precaution when completing the new POC. During a telephone interview and record review on 1/6/26 at 4:48 pm, RN B said the RNs were responsible for completing the POC. RN B said for patient’s taking Clopidogrel, antiplatelet precautions should be included as a safety measure on the POC. RN B said antiplatelet precautions should have been listed on Patient #1’s POC dated 12/7/25- 2/4/26. RN B said he probably overlooked the antiplatelet precautions on the POC. RN B said if safety measures were not included on the patient’s POC the other nurses would not know what was going on with the patient and what medications the patient was on. During an interview and record review on 1/7/26 at 2:32 pm the Alternate Administrator/ Supervising Nurse said the RNs were responsible for completing the patient’s POC. The Alternate Administrator/ Supervising Nurse said for patient’s taking Clopidogrel, antiplatelet precautions should be included as a safety measure on the POC. The Alternate Administrator/ Supervising Nurse said antiplatelet precautions would indicate to the nurse they may need to review labs to determine if the blood was within normal range. The Alternate Administrator/ Supervising Nurse said patients on antiplatelet medication were at risk for free bleeding meaning they were at risk for severe injury because they would bleed easier if they fell or cut themselves. The Alternate Administrator/ Supervising Nurse reviewed Patient #1’s POC dated 12/7/25- 2/4/26 and confirmed antiplatelet precautions were not listed as a safety measure. The Alternate Administrator/ Supervising Nurse said antiplatelet precautions should have been listed on Patient #1’s POC since she was on Clopidogrel. The Alternate Administrator/ Supervising Nurse said if safety measures were not included on the patient’s POC something might be overlooked by staff like her potential for bleeding. During an interview and record review on 1/7/26 at 3:02 pm the Administrator/ Alternate Supervising Nurse said the field RN was responsible for completing the patients POC. The Administrator/ Alternate Supervising Nurse said patients taking Clopidogrel should have safety measures on their POC for the medication. The Administrator/ Alternate Supervising Nurse said the safety measure would mean the clinician would be teaching the patient on safety and watching for injuries since the patient would be at an increased risk for bleeding and bruising. The Administrator/ Alternate Supervising Nurse said Patient #1’s POC should have had antiplatelet precautions as a safety measure since she was taking Clopidogrel. The Administrator/ Alternate Supervising Nurse said if a safety measure was not included on the POC the clinician wouldn’t look for it and wouldn’t be teaching the patient what to look for or what they were at risk for. Review of Clopidogrel side effects accessed at https://www.drugs.com/sfx/clopidogrel-side-effects.html on 1/8/26 indicated “... Tell all medical doctors, dentists, nurses, and pharmacists you go to that you are taking this medicine. Clopidogrel may increase the risk of serious bleeding during a surgery, other medical procedures, or some kinds of dental work. You may need to stop using this medicine at least 5 days before a surgery, medical procedure, or dental work. Do not stop taking your medicine without your doctor’s permission. While you are using this medicine, if you have any kind of bleeding, it may take longer than usual to stop, especially if you hurt yourself. Stay away from rough sports or other situations where you could be bruised, cut, or injured. Be careful when using sharp objects, including razors and fingernail clippers. This medicine may increase your risk of bleeding or bruising. This risk may increase if you are also using other medicines, including blood thinners, other antiplatelet medicines, or NSAIDs. Check with your doctor right away if you notice any unusual bleeding or bruising, black, tarry stools, blood in the urine or stools, or pinpoint red spots on your skin. Avoid picking your nose. If you need to blow your nose, blow it gently. Do not change your dose or Stop taking clopidogrel without checking first with your doctor. Check with your doctor right away if you have a change in mental status, dark or bloody urine, difficulty with speaking, fever, pale color of the skin, pinpoint red spots on the skin, seizures, weakness, yellow eyes or skin. These may be symptoms of a rare and serious condition called thrombotic thrombocytopenic purpura (the formation of clots in the in blood vessels, leading to low platelet [cell] count and potential organ damage). This medicine may cause allergic reactions, including angioedema (swelling of the tissue below the skin), which can be life-threatening and require medical attention. Check with your doctor right away if you have large, hive-like swelling on the face, eyelids, lips, tongue, throat, hands, legs, feet, sex organs. …” Record review of a Care Planning policy dated 09/2024 indicated “…Policy… The individualized POC must specify: … Patient (and/or if applicable caregiver/family/authorized representative) education/counseling and training associated with care and services ordered. … The Plan of Care … will be developed in collaboration with the physician/allowed practitioner and Home Health Clinical Associates following the initial/comprehensive assessment and will contain integrated orders from all physicians or allowed practitioners involved in the POC to assure coordination of all services and interventions provided to the patient. The individualized POC … must include: … safety measures to protect patient from injury, description of the patient’s risk for emergency department visits and hospital readmission to include interventions to address the underlying risk factors, patient-specific interventions …””