Devine Home Health Agency 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 the plan of care included a description of the patient’s risk for emergency department visits and hospital re-admission, and information related to advance directives in 7 (Patient #’s 1, 2, 3, 4, 5, 6, and 7) of 7 records reviewed This failure placed the Patients at risk of not receiving adequate care. Findings include: Review of Patient #1’s chart revealed a plan of care with a certification period of 8/23/24 through 10/21/24. The plan of care included the primary diagnosis of pressure ulcer of unspecified buttock stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle.) The plan of care was signed and dated by Supervising Nurse on 8/23/24. The plan of care did not include a description of the patient’s risk for emergency department visits or hospital re-admission, and information related to advance directives. Review of Client #2’s chart revealed a Plan of Care with a certification period of 10/16/24 through 12/14/24. The plan of care included the primary diagnosis of bilateral primary osteoarthritis of knee (a degenerative joint disease that affects both knees). The plan of care was signed and dated by Supervising Nurse on 10/16/24. The plan of care did not include a description of the patient’s risk for emergency department visits or hospital re-admission, and information related to advance directives. Review of Patient #3’s chart revealed a Plan of Care with a certification period of 11/8/24 through 1/6/25. The plan of care included the primary diagnosis of age-related osteoporosis (a bone disease that develops when bone mineral density and bone mass decrease). The plan of care was signed and dated by Supervising Nurse on 11/8/24. The plan of care did not include a description of the patient’s risk for emergency department visits or hospital re-admission, and information related to advance directives. Review of Patient #4’s chart revealed a Plan of Care with a certification period of 10/14/23 through 12/12/23. The plan of care included the primary diagnosis of essential primary hypertension (high blood pressure with no clear identifiable cause). The plan of care was signed and dated by Supervising Nurse on 10/9/23. The plan of care did not include a description of the patient’s risk for emergency department visits or hospital re-admission, and information related to advance directives. Review of Patient #5’s chart revealed a Plan of Care with a certification period of 6/26/23 through 8/24/23. The plan of care included the primary diagnosis of muscle weakness (your muscles don’t feel as strong as usual, making it difficult to move normally). The plan of care was signed and dated by Supervising Nurse on 6/26/23. The plan of care did not include a description of the patient’s risk for emergency department visits or hospital re-admission, and information related to advance directives. Review of Patient #6’s chart revealed a Plan of Care with a certification period of 1/12/24 through 3/11/24. The plan of care included the primary diagnosis of essential primary hypertension (high blood pressure with no clear identifiable cause). The plan of care was signed and dated by Supervising Nurse on 1/11/24. The plan of care did not include a description of the patient’s risk for emergency department visits or hospital re-admission, and information related to advance directives. Review of Patient #7’s chart revealed a Plan of Care with a certification period of 1/12/24 through 3/11/24. The plan of care included the primary diagnosis of hereditary ataxia unspecified (poor coordination with balance, walking, fine motor skills passed down through the generations). The plan of care was signed and dated by Supervising Nurse on 8/14/24. The plan of care did not include a description of the patient’s risk for emergency department visits or hospital re-admission, and information related to advance directives. An interview was conducted on 11/18/24 at 1:35 pm with the Supervising Nurse. The surveyor reviewed the agency policy PC.35 Plan of care with the Supervising Nurse related to the plan of care must include the patients’ risk for emergency department visits and hospital readmissions and information related to advance directive. The surveyor reviewed that Patient #’s 1, 2, 3, 4, 5, 6, and 7 plans of care did not include advance directive information, patient risks for emergency department visits and hospital readmissions. The Supervising Nurse said, “I missed that.” The surveyor asked the Supervising Nurse who was responsible for the completion of the plans of care. The Supervising Nurse said, “I am.” The Surveyor asked Supervising Nurse how not including the patient risk for emergency department visits and hospital readmissions and advance directive information could affect the patients. The Supervising Nurse said, “maybe their care.” Agency policy PC.35 Plan of Care last reviewed on 5/2/24 read in part…” Procedure… III. A. The individualized plan of care must include the following, …12. A description of the patient’s/client’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors…16. Information related to any advance directive…””

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on record review and interviews, the agency failed to ensure physician’s verbal orders were authenticated and dated by the physician in accordance with applicable state laws and regulations, as well as the HHA’s internal policies in 7 (Patient #’s 1, 2, 3, 4, 5, 6, and 7) of 7 Patients records were reviewed. The failure placed Patients 1, 2, 3, 4, 5, 6, and 7 at risk to not have care and treatment provided as ordered and to experience complications, since orders were not reviewed and signed by the physician. Findings include: Review of Patient #1’s chart revealed a plan of care with a certification period of 8/23/24 through 10/21/24. The plan of care included the primary diagnosis of pressure ulcer of unspecified buttock stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle.) The review revealed no physician signature as of 11/19/24 on Patient #1’s orders. Review of Patient #2’s chart revealed a Plan of Care with a certification period of 10/16/24 through 12/14/24. The plan of care included the primary diagnosis of bilateral primary osteoarthritis of knee (a degenerative joint disease that affects both knees). The review revealed no physician signature as of 11/19/24 on Patient #2’s orders. Review of Patient #3’s chart revealed a Plan of Care with a certification period of 11/8/24 through 1/6/25. The plan of care included the primary diagnosis of age-related osteoporosis (a bone disease that develops when bone mineral density and bone mass decrease). The review revealed no physician signature as of 11/19/24 on Patient #3’s orders. Review of Patient #4’s chart revealed a Plan of Care with a certification period of 10/14/23 through 12/12/23. The plan of care included the primary diagnosis of essential primary hypertension (high blood pressure with no clear identifiable cause). The review revealed no physician signature as of 11/19/24 on Patient #4’s orders. Review of Patient #5’s chart revealed a Plan of Care with a certification period of 6/26/23 through 8/24/23. The plan of care included the primary diagnosis of muscle weakness (your muscles don’t feel as strong as usual, making it difficult to move normally). The review revealed no physician signature as of 11/19/24 on Patient #5’s orders. Review of Patient #6’s chart revealed a Plan of Care with a certification period of 1/12/24 through 3/11/24. The plan of care included the primary diagnosis of essential primary hypertension (high blood pressure with no clear identifiable cause). The review revealed no physician signature as of 11/19/24 on Patient #6’s orders. Review of Patient #7’s chart revealed a Plan of Care with a certification period of 1/12/24 through 3/11/24. The plan of care included the primary diagnosis of hereditary ataxia unspecified (poor coordination with balance, walking, fine motor skills passed down through the generations). The review revealed no physician signature as of 11/19/24 on Patient #7’s orders. An interview was conducted on 11/18/24 at 1:30 pm with the Administrator and Supervising Nurse. The surveyor reviewed agency policy Timelines IM.35 with Administrator and Supervising Nurse in that physician orders are to be signed within 60 days. Surveyor reviewed that Patient #’s 1, 2, 3, 4, 5, 6, and 7 plans of care had not been signed by the physician and/or non-physician practitioner to date. The Administrator said, “We send the orders to them (the VA), but they (the orders) are not returned signed.” The surveyor asked who is responsible for ensuring the plan of care/orders are signed. The Administrator said, “I am.” Surveyor asked how the orders not being signed could affect the patients. The Administrator said, “I don’t think it will, the VA sends the orders, but they don’t sign our orders.” Surveyor asked did he mean the referral from the VA. The Administrator said, “Yes, it always includes everything we are supposed to provide and the authorization.” Agency policy: IM.35 Timelines revised 5/2/24 read in part… “Purpose To establish timely parameters for all medical record information …Procedure…G. Physician and/or non-physician practitioner signature are obtained on the Plan of Care (POC) and supplemental verbal orders within 60 day and prior to billing.”…”