On Call Home Health and Rehab Services

“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 interview and record review, 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 2 of 10 patients reviewed for plan of care. (Patient #1, Patient #2) The agency did not ensure Patient #1’s plan of care included bleeding precautions or teaching for Aspirin (blood thinner). The agency did not ensure Patient #2’s plan of care included the location of his PICC (peripherally inserted central catheter used to deliver medication, fluids or blood products directly into the blood stream) line. This failure could place patients at risk of not recognizing symptoms of bleeding or not receiving proper care/instruction leading to complications and hospitalization. . Record review of a plan of care for certification period 3/1/2025-4/29/2025 indicated Patient #1 was admitted to the agency on 3/1/2025 with diagnosis including acute respiratory failure, pneumonia (lung infection), high blood pressure and long term (current) use of Aspirin (blood thinner). The plan of care indicated Patient #1 was to receive skilled nursing once weekly for ten weeks. The plan of care indicated Patient #1 was to receive Aspirin 81 mg one tablet every morning for blood clot prevention. The plan of care did not indicate any teaching related to signs or symptoms of bleeding and did not address bleeding precautions. 2. Record review of a plan of care for certification period 3/7/2025-5/5/2025 indicated Patient #2 was admitted to the agency on 3/7/2025 with diagnosis including cholangitis (infection of liver bile ducts), complication of liver transplant, and hepatic failure (loss of liver function). The plan of care indicated the skilled nurse was to obtain intravenous (small tube or catheter inserted into a vein to allow administration of fluids or medications) access via PICC line and aseptic technique for medication infusion. The plan of care did not indicate the location of the PICC line. During an interview on 4/22/2025 at 10:00 a.m., RN B said anticoagulant or bleeding precautions should be on the plan of care of any patient on Coumadin (blood thinner), aspirin (blood thinner) or any other blood thinner. RN B said this was important so that clinicians could teach clients on bleeding precautions and signs and symptoms to report to the agency. During an interview on 4/23/2025 at 9:47 a.m., RN A said she performed start of care and recertification assessments and based on the patient’s diagnosis and assessment developed the plan of care. RN A said if the patient had a PICC line the plan of care should include what the PICC line was used for, dressing changes, medications, and line flushes to keep the line open. RN A said she was unaware the plan of care was to include the location of the PICC line. RN A said any patient on a blood thinner should have bleeding or anticoagulation precautions on the plan of care. RN A said all of this was important to ensure education on potential complications, to ensure the patient knows when to report to the agency and what to look for. During an interview on 3/23/2025 at 10:05 a.m., the VP of quality said if a patient was on any type of blood thinner, she expected the plan of care to include bleeding precautions/ anticoagulant precautions. The VP of quality said the plan of care for a patient with a PICC line should include the location and type of PICC line. The VP of quality said these were both high risk findings and the patient needed to be educated on side effects and the risks with bleeding and the PICC line. During an interview on 4/23/2025 at 10:15 a.m. the DON said Patient #1’s plan of care should have included bleeding precautions for her aspirin use. The DON said the plan of care should include bleeding precautions for any patient receiving a blood thinner. The DON said it was important for clinicians to educate patients on signs and symptoms of bleeding to report to the agency. The DON said the location of the PICC line was usually documented on the assessment, she did not think they documented the location on the plan of care. The DON said it was important to know the location of the PICC line and for it to be assessed during each visit. During an interview on 4/23/2025 the Administrator said the agency had recently gone through some changes in processes that could have led to some things being left off the plan of cares. The Administrator said it was very important for each plan of care to have the proper safety precautions and the location of the PICC line for patient safety and proper patient education. Record review of a policy titled Care, Treatment, and Service Care Planning process revised April 2021 indicated 4. Based on those assessments and conclusions, the individualized plan of care must include the following (but is not limited to): k. safety measures to protect against injury; N. Patient specific interventions and education”

“Participate in the HHA’s QAPI program; CFR(s): 484.75(b)(8) Participation in the HHA’s QAPI program; and This Element is not met as evidenced by: Based on interview and record review, the agency failed to include in its quality assessment and performance improvement (QAPI) committee the required staff in for 3 of 3 years (2023, 2024 and 2025) reviewed. The agency did not ensure a member of each scope of service attended all QAPI meetings in 2023, 2024 and 2025. This failure could prevent the agency from identifying problems in the service categories that were not represented and therefore could place the patients at risk of receiving substandard care and services. Findings included: Record review of QAPI meeting minutes dated 10/23/2023 included a sign in sheet for members that included the DON/Administrator, ADON/ Alternate Administrator, members of nursing staff and members of therapy. The sign in sheet did not indicate a social worker or aide was present for the meeting. Record review of QAPI meeting minutes dated 1/18/2024 included a sign in sheet for members who attended the meeting and included the DON/Administrator, ADON/Alternate Administrator, members of nursing staff and members of therapy. The sign in sheet did not indicate a social worker or aide was present for the meeting. Record review of QAPI meeting minutes dated 4/17/2024 included a sign in sheet for members who attended the meeting and included the DON/Administrator, ADON/Alternate Administrator, members of nursing staff and members of therapy. The sign in sheet did not indicate a social worker or aide was present for the meeting. Record review of QAPI meeting minutes dated 7/2/2025 included a sign in sheet for members who attended the meeting and included the DON/Administrator, ADON/Alternate Administrator, members of nursing staff and members of therapy. The sign in sheet did not indicate a social worker or aide was present for the meeting. Record review of QAPI meeting minutes dated 1/23/2025 indicated a sign in sheet for members who attended the meeting and included the DON/Administrator, ADON/Alternate Administrator, members of nursing staff and members of therapy. The sign in sheet did not indicate a social worker or aide was present for the meeting. Record review of an untitled report indicated the agencies home health aides saw eighty patients from 2023-present. Record review of an untitled report indicated the agencies social worker saw eleven patients from 2023- present. During an interview on 4/21/2025 at 2:45 p.m., the QAPI director said neither an aide or a social worker attended the agencies QAPI meetings. During an interview on 4/21/2025 at 3:15 p.m., the Administrator said the agencies aide and social worker did not attend QAPI meetings unless they were involved in a performance improvement project. During an interview on 4/21/2025 at 3:26 p.m., the Alternate Administrator said she ran a report and the agencies social worker saw eleven patients from 2023- present and the aides saw eighty patients from 2023- present. During an interview on 4/23/2025 at 9:52 a.m., the QAPI Administrator said for this agencies license number the regional director, DON, Administrator, and alternate were invited to QAPI meetings. The QAPI Administrator said they tried to have all disciplines represented at the meetings, but it was not always accomplished. The QAPI Administrator said the aides and social worker were invited to come to the meetings but were not full-time staff and did not always make it to the meetings. She said there was no reason why they had not attended the meetings since the agencies last survey. During an interview on 4/23/2025 at 9:56 a.m., the QAPI director said there were monthly QAPI calls with the agency and quarterly performance meetings. The director said the Administrator and alternate attended the meetings and if they could pull staff, they did but it was hit or miss. The director said they had requested numerous times for an aide to attend but due to workload this had not happened. The director said the agency social worker was contracted therefore making it difficult to get them to attend the meetings. During an interview on 4/23/2025 at 10:15 a.m., the DON said she and the Administrator attended all the QAPI meetings with the corporate office. The DON said the social worker was contracted and it could be difficult to get them to meetings. The DON said she did not think they had ever had an aide be present at the meetings. During an interview on 4/23/2025 at 10:30 a.m., the Administrator s[aid QAPI was done at the corporate level. She said she and the DON both attended the meetings. The Administrator said prior to the buy out of the agency, the Administrator, DON, a member of nursing, a member of therapy and social worker attended the meetings. The Administrator said she did not recall having an aide attend the meetings. Record review of a policy titled 2025 quality improvement plan did not address QAPI members.”