High Point Home Health LP

“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 interview, the agency failed to ensure that each patient who received services had a written plan of care signed by a Doctor of Medicine for 3 of 3 active patients (Patient #1, #2 and #3) whose records were reviewed in that: 1) Patient #1’s plan of care for certification period 04/03/26 through 06/01/26 was not signed by a Doctor of Medicine. 2) Patient #2’s plan of care for certification period 05/09/26 through 07/07/26 was not signed by a Doctor of Medicine. 3) Patient #3’s plan of care for certification period 04/28/26 through 06/26/26 was not signed by a Doctor of Medicine. The failure of the agency to obtain a physician’s signature on the written plan of care had the potential to result in care being provided without documented physician authorization, increasing the risk that services may not reflect the patient’s current medical needs or physician-directed treatment. The findings included: 1) Review of Patient #1’s “Home Health Certification and Plan of Care” for certification period 04/03/26 through 06/01/26 revealed a 77-year-old male with a primary diagnosis of Age-related physical debility (gradual loss of strength, endurance, and overall physical function) and other diagnoses of Diabetes Mellitus II (elevated levels of sugar in the blood), hypertension (the force of the blood against the artery walls in too high), and long-term use of insulin (medication to help maintain blood sugars). Patient #1 with SN frequency of once-a-month times one month, then three times a month for one month, and three as needed visits and HHA visits of 8 hours a week. The attending physician for Patient #1 was listed as MD AA. Additionally, the plan of care for Patient #1 did not include a signature by a Doctor of Medicine (MD AA). Review of skilled nursing notes for certification period 04/03/26 through 06/01/26 documented that RN B provided services on 04/01/26 and 05/28/26. Furthermore Patient #1 received home health aide services by HHA E for the following dates: 04/03/26, 04/07/26 through 04/10/26, 04/14/26 through 04/17/26, 04/21/26 through 04/24/26, 04/28/26 through 05/01/26, 05/05/26 through 05/08/26, 05/12/26 through 05/15/26, 05/19/26 through 05/22/26, and 05/26/26 through 05/29/26. 2) Further review of Patient #2’s “Home Health Certification and Plan of Care” for certification period 05/09/26 through 07/07/26 revealed a 81-year-old male with a primary diagnosis of Age-related physical debility (gradual loss of strength, endurance, and overall physical function) and other diagnoses of thrombosis (formation of blood clots), weakness, hypotension (low blood pressure), end stage renal failure (kidneys can no longer filter waste, balance fluids, or maintain essential mineral levels), diabetes mellitus with neuropathy (nerve damage due to high blood sugars), Alzheimer’s disease (affects memory, thinking, and behavior), Post-Traumatic stress disorder (triggered by experiencing or witnessing a traumatic event, causing persistent distressing symptoms that interfere with daily life), and abnormalities of gait/mobility (unusual patterns of walking or movement). Patient #2 with SN frequency of two times a month for two months and four as needed visits and 8 hours a week for HHA. The attending physician for Patient #2 was listed as MD BB. Additionally, the plan of care for Patient #2 did not include a signature by a Doctor of Medicine (MD BB). Review of skilled nursing notes for certification period 05/09/26 through 07/07/26 documented that RN A provided services on 05/07/26, 05/14/26, 05/22/26, and 07/06/26. Furthermore Patient #2 received home health aide services by HHA E for the following dates: 05/25/26 through 05/28/26, 06/01/26 through 06/04/26, 06/08/26-06/11/26, 06/15/26 through 06/18/26, 06/22/26 through 07/02/26, and 07/06/26 through 07/07/26. 3) Additional review of Patient #3’s “Home Health Certification and Plan of Care” for certification period 04/28/26 through 06/26/26 revealed an 82-year-old male with a primary diagnosis of unspecified fall. Patient #3 with SN frequency of once-a-month times three months and three as needed visits and 5 hours a week for HHA. The attending physician for Patient #3 was listed as MD CC. The plan of care for Patient #3 did not include a signature by a Doctor of Medicine (MD CC). Review of skilled nursing notes for certification period 04/28/26 through 06/26/26 documented that RN D provided services on 04/24/26 and 06/24/26 for Patient #3. Furthermore Patient #3 received home health aide services by HHA F for the following dates: 05/05/26 through 05/08/26, 05/11/26 through 05/14/26, 05/18/26 through 05/21/26, 05/25/26 through 05/28/26, 06/01/26 through 06/04/26, 06/08/26 through 06/11/26, 06/15/26 through 06/18/26, and 06/22/26 through 06/25/26. The surveyor conducted an interview with Adm/DON on 08/05/26 at 2:30 pm and the surveyor presented the above findings which included the plan of cares not being signed by a Doctor of Medicine for Patients #1, #2, and #3. Adm DON was in agreement with the findings for Patients #1, #2, and #3 and confirmed that they did not have signature by a Doctor of Medicine on their plan of cares. The Adm/DON confirmed that the agency was responsible [KW14.1]for ensuring a signature by a Doctor of Medicine on the plan of care for each patient. The surveyor asked what was the agency’s policy for obtaining signatures by a Doctor of Medicine on the plan of care. The Adm/DON confirmed signatures by a Doctor of Medicine was required within 30 days. Adm/DON further confirmed the process of obtaining signatures by a Doctor of Medicine as submitting the plan of care to the VA via email, once received by the VA, the agency waited until they were returned to the agency. The surveyor asked what follow-up occurred when signatures by Doctor of Medicine were delayed. Adm/DON stated, “We try to resubmit them and let the VA know that we need to get physician signatures, but we have a very hard time getting these signatures from the VA.” The surveyor asked why the plan of cares were not signed according to agency policy. Adm/DON stated, “We send them and we don’t get a response. We will call and they say wait until we get to your agency.” Adm/DON further confirmed that not obtaining physician signatures created the potential for patient harm or could create a safety risk to patients. The surveyor conducted additional interview with Alt Adm/Alt DON on 08/06/26 at 9:00 am and the surveyor presented the above findings which included the plan of cares not signed by a Doctor of Medicine for Patients #1, #2, and #3. Adm DON was in agreement with the findings for Patients #1, #2, and #3 and confirmed that they did not have a signature by a Doctor of Medicine on their plan of cares. The Alt Adm/Alt DON confirmed that the agency was responsible for ensuring a signature by a Doctor of Medicine on the plan of care for each patient. The surveyor asked what was the agency’s policy for obtaining a signature by a Doctor of Medicine for the plan of care. The Alt Adm/Alt DON confirmed by the end of the certification period. Alt Adm/Alt DON further confirmed the process of obtaining physician signatures as submitting the plan of care to the VA via email. The surveyor asked what follow-up occurred when signatures by a Doctor of Medicine were delayed. Alt Adm/Alt DON stated, “We make phone calls to the VA; however, the VA prefers emails.” The surveyor asked why the plan of cares were not signed according to agency policy. Adm/DON stated, “The VA takes a while to send us documents back and they can sit on orders for a very long time.” Alt Adm/Alt DON further confirmed that not obtaining physician signatures created the potential for patient harm or could create a safety risk to patients and could have a negative effect on the patient and especially with the agency being out of compliance. Review of an agency policy manual contained a policy titled “Plan of Care” it was numbered PC-23 and had a revision date of 07/2025, quoted in part, “…The treatment plan must be a written plan of treatment which must be signed and approved by a physician within thirty (30) days of the physicians orders….” The agency did not dispute the surveyor’s findings. The agency was afforded the opportunity to provide additional information. No additional information was presented to this surveyor upon exit on 08/06/26.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure that onsite supervisory visits were conducted by an appropriate skilled professional for Home Health Aides every 14 days for 2 of 3 patients (Patient #1 and Patient #3) whose records were reviewed and received home health aide services. This deficient practice resulted in the agency’s failure to ensure that Hom Health Aide services were being delivered safely, and in accordance with their plan of care, placing patients at risk for undetected deficiencies in care, failure to identify changes in condition, unmet care needs, delayed corrective interventions, compromised patient safety, and adverse patient outcomes. The findings included: 1) Record review of Patient #1’s electronic medical record (EMR) included a “Patient Profile” that indicated a start of care as 08/22/22. Further review of Patient #1’s “Home Health Certification and Plan of Care” for certification period 04/03/26 through 06/01/26 revealed a 77-year-old male with a primary diagnosis of Age-related physical debility (gradual loss of strength, endurance, and overall physical function) and other diagnoses of Diabetes Mellitus II (elevated levels of sugar in the blood), hypertension (the force of the blood against the artery walls in too high), and long-term use of insulin (medication to help maintain blood sugars). The POC documented the following orders for care: •SN frequency: Once-a-month times 1 month, then 3 times a month for 1 month, and 3 as needed visits. •HHA visits of 8 hours a week. Record review of Patient #1’s EMR included an “Aide Care Plan” signed and dated 04/01/26 that documented an aide frequency of 8 hours a week. Additional instructions revealed, “RN to supervise Home Health Aide every 14 days.” Record review of Patient #1’s EMR indicated a, “Missed Visit-HHA supervisory visit”, with the following dates: 04/15/26, 04/19/26, 05/06/26, and 05/28/26. Furthermore, only one HHA supervisory visit was conducted on 05/28/26 for certification period 04/03/26 through 06/01/26. Record review of Patient #1’s EMR failed to reveal documentation of an RN conducting an on-site supervisory visit in the patients home every 14 days as required by agency policy. 2) Record review of Patient #3’s electronic medical record (EMR) included a “Patient Profile” that indicated a start of care as 02/27/26. Further review of Patient #3’s “Home Health Certification and Plan of Care” for certification period 04/28/26 through 06/26/26 revealed an 82-year-old male with a primary diagnosis of unspecified fall. The POC documented the following orders for care: •SN frequency: Once-a-month times 3 months and 3 as needed visits. •HHA visits of 5 hours a week. Record review of Patient #3’s EMR included an “Aide Care Plan” signed and dated 04/24/26 that documented an aide frequency of 7 hours a week. Additional instructions revealed, “RN to supervise Home Health Aide every 14 days.” Record review of Patient #3’s EMR indicated a “Missed Visit-HHA supervisory visit” with the following dates: 05/08/26, 05/22/26, 06/05/26. Furthermore, HHA supervisory visit was conducted on 06/19/26 & 06/24/26 for certification period 04/03/26 through 06/01/26. Record review of Patient #3’s EMR failed to reveal documentation of an RN conducting an on-site supervisory visit in the patients home every 14 days as required by agency policy. The surveyor conducted an interview with Adm/DON on 08/05/26 at 2:30 pm, and the surveyor presented the above findings which included not conducting on-site home health aide supervisory visits every 14 days for Patient #1 and Patient #3. The Adm/DON confirmed that home health visits were to be conducted every 14 days by an RN and further confirmed there were missed supervisory visits for Patient #1 and Patient #3. Additionally, supervisory visits for home health aides were not conducted every 14 days for Patient #1 and Patient #3. The surveyor asked who was responsible for conducted home health aide supervisory visits. The Adm/DON stated, “RNs but I am responsible as well.” The Adm/DON confirmed he was not aware of missed home health aide supervisory visits or that they were not conducted. The surveyor asked why supervisory visits were not conducted every 14 days per agency policy and regulation. Adm/DON stated, “I don’t know why they weren’t completed.” Surveyor further asked, could missed supervisory visits have placed patients at harm or at risk. Adm/DON stated, “Yes there could be risks to the patient. If the patient is having an ongoing issue, the agency would not be aware, and this could place patients at risk for health issues, safety, and hospitalization.” Furthermore, Adm/DON confirmed that patients’ condition could have gone unnoticed and the aide could have performed care incorrectly without supervision. In additional interview with Alt Adm/Alt DON on 08/06/26 at 9:00 am. The surveyor presented the above findings which included not conducting on-site home health aide supervisory visits every 14 days for Patient #1 and Patient #3. The Alt Adm/Alt DON confirmed that home health visits were to be conducted every 14 days by an RN and further confirmed there were missed supervisory visits for Patient #1 and Patient #3. Additionally, supervisory visits for home health aides were not conducted every 14 days for Patient #1 and Patient #3. The surveyor asked who was responsible for conducted home health aide supervisory visits. Alt Adm/Alt DON confirmed that RNs were responsible for conducting supervisory visits for the home health aide. The surveyor asked why supervisory visits were not conducted every 14 days per agency policy and regulation. Adm/DON confirmed that Patient #1 and Patient #3 would not answer the phone or door when supervisory visits were attempted. Surveyor further asked, could the lack of supervision have affected patient care. The Alt Adm/DON stated, “I don’t think it has affected patient care. They got supervisory visits every 60 days at the recertification. However, there could be a lack of communication between the agency and the patient. Patients would not be able to report changes in condition or if they need a change in the plan of care.” The surveyor additionally asked, what risks could occur to the patient if supervisory visits were not conducted. The Alt Adm/Alt DON stated, “Safety concerns, neglect, and maybe the home health aide is not conducting services according to the care plan.” Review of an agency policy manual contained a policy titled “Home Health Aides/Personal Care Aide” it was numbered PC-14 and had a revision date of 07/2025, quoted in part, “Policy…Home health aide supervision ensures that aides furnish care in a safe [KW13.1]and effective manner, including: following the plan of care…maintaining open communication process with the patient…demonstrating competency with assigned tasks…complying with infection prevention and control policies and procedures…reporting changes in patients condition and honoring patient rights…If home health aide services are provided to a patient who is receiving skilled nursing…a registered nurse…must make an onsite to the patient’s home no less frequently than every 14 days…” The agency did not dispute the surveyor’s findings. The agency was afforded the opportunity to provide additional information. No additional information was presented to this surveyor upon exit on 08/06/26.”