Calvary Hill Health Services LLC

“Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This Standard is not met as evidenced by: Based on record review, observation, and interview the agency failed to ensure a home health aide was given written patient care instructions prepared by a registered nurse for one (Patient # 2) of one patient record reviewed with home health aide services. The failure placed the patient’s health and safety at risk if care was not provided as established the patient’s plan of care. Patient # 2: Review of the clinical record for Patient # 2 revealed a POC for Patient # 2’s discharge episode with a SOC date of 10/25/2022. The POC contained a certification period of 02/22/2023 to 04/22/2023 dated and signed by the Admin/DON on 12/21/2022. The POC contained orders for SN visits one time per week for eight weeks. Continued review of the clinical record for Patient # 2 revealed the Patient’s episodes of care record from 02/22/2023 to 04/22/2023. Review of the patient episodes of care record (visit schedule) revealed that Patient # 2 received home health aide visits five times per week by Office Mgr./hha. Continued review of the record did not reveal that the Admin/DON provided the hha with written patient care instructions. During a home visit with Patient # 2 on 03/13/2025 at 10:00 a.m. the surveyor observed and reviewed the home admission folder. There was no written patient care instruction in the folder. The patient stated that all records were in the folder (no records removed since admission to the agency). During an interview with the Admin/DON on 03/17/2025 at 3:58 p.m. the surveyor reviewed the findings and asked why there was no home health aide care plan (written instructions for patient care) for Patient # 2. The Admin/DON stated, “That’s my error.” Review of agency policy titled; “Implementing Care and Treatment” last reviewed 05/02/24 read in part: “Purpose [:] To ensure patient/client care and treatment are provided as identified in the care planning process…V. Home health aides are members of the interdisciplinary team and are assigned to a specific patient/client by a registered nurse (RN)…within a time frame to meet the patient’s/client’s identified needs and per physician and/or non-physician practitioner orders. The home health aide will be provided with written patient/client care instructions prepared by that RN…””

“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 services that were provided based on a physician’s verbal orders, in that: the agency failed to ensure that the verbal orders were authenticated and dated by the physician in accordance with the HHA’s internal policies, in two (Patients #1 and #2) of two records reviewed that included unsigned verbal order. The failure placed the patients at risk to experience health complications because orders were not reviewed and signed by the physician. Findings included: Patient # 1: Review of the clinical records revealed a “Home Health Certification and Plan Of Care (POC)” with a SOC date of 07/02/2024. Review of the POC revealed a certification period 07/02/2024 to 08/30/2024 was e-signed by the Admin/DON on 07/02/2024. The POC contained orders for SN visits one time per week for nine weeks. Continued review of Patient # 1’s clinical records did not reveal that physician (Identifier 300) had authenticated (signed) and dated the verbal order (POC). Patient # 2: Further review of the clinical record for Patient # 2 revealed a POC for Patient # 2’s initial episode with a SOC date of 10/25/2022. The POC contained a certification period of 10/25/2022 to 12/23/2022 dated and signed by the Admin/DON on 10/25/2022. The POC contained orders for SN visits once every week. Continued review of Patient # 2’s clinical records did not reveal that physician (Identifier 400) and nurse practitioner (Identifier 500) had not authenticated (signed) and dated the verbal orders (POCs). Review of the clinical records for Patient # 2 revealed a POC for Patient # 2’s discharge episode with a SOC date of 10/25/2022. The POC contained a certification period of 02/22/2023 to 04/22/2023 dated and signed by the Admin/DON on 12/21/2022. The POC contained orders for SN visits one time per week for eight weeks. During an interview with the Admin/DON on 03/17/2025 at 3:36 p.m., the surveyor reviewed the findings and asked why verbal orders (POCs) were not authenticated and dated by physician (Identifier 330 and 400) and nurse practitioner (Identifier 500). The Admin/DON replied, “It’s another headache with (Identifier 100). It’s highly frustrating.” The Admin/DON stated that the agency faxed the records to the physician’s office location. Agency policy titled; “Orders for Care” last reviewed 05/01/2024 read in part “… XIII. The Plan of Care may be used as the verbal start of care when signed and dated by the RN. XIV. Verbal orders must be authenticated and dated by the physician and/or non-physician practitioner. Physician and/or non-physician practitioner signatures are obtained on Plan of Care and supplemental verbal orders within sixty (60) days…””

“Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This Element is not met as evidenced by: Based on record review and interview the agency failed to ensure that the patient’s individualized plan of care (POC) had been reviewed and revised by the patient’s physician no less frequently than once every 60 days, in two (Patients # 2 and # 4) of three discharged skilled patient records reviewed. The failure placed the patients at risk of harm due to lack of physician oversight if there were changes in the patient’s condition or if there was a need for additional care and services. Findings Included: Patient # 2: Further review of the clinical record for Patient # 2 revealed a POC for Patient # 2’s initial episode with a SOC date of 10/25/2022. The POC contained a certification period of 10/25/2022 to 12/23/2022 dated and signed by the Admin/DON on 10/25/2022. The POC contained orders for SN visits once every week. Continued review of the POC revealed that it read in part; “…I estimate continued services will be required for 30 days…” Continued review of the record did not reveal that a new POC was received after 30 days (due 11/24/2022). The POCs were not signed by physician identifier (400) and nurse practitioner (500). Review of the clinical record for Patient # 2 revealed a POC for Patient # 2’s discharge episode with a SOC date of 10/25/2022. The POC contained a certification period of 02/22/2023 to 04/22/2023 dated and signed by the Admin/DON on 12/21/2022. The POC contained orders for SN visits one time per week for eight weeks. Continued review of the POC revealed that it read in part; “…I estimate continued services will be required for 30 days…” Continued review of the record did not reveal that a new POC was received after 30 days (due 03/24/2023). Patient # 4: Review of the clinical record for Patient # 4 revealed a POC for Patient # 4’s discharge episode with a SOC date of 08/21/2024. The POC contained a certification period of 08/21/2024 to 10/19/2024 dated and signed by the Admin/DON on 02/07/2024. The POC contained orders for SN visits one time per week for nine weeks. Continued review of the POC revealed that it read in part; “…I estimate continued services will be required for 30 days…” Continued review of the record did not reveal that a new POC was received after 30 days (due 09/20/2024). During an interview with the Admin/DON on 03/17/2025 at approximately 3:42 p.m., the surveyor reviewed the findings and asked why Patients # 2 and 4 did not have individualized plan of care (POCs) that had been reviewed and revised by the patient’s physician at least every 60 days. The Adm replied, “It must have been a mistake in the drop down.” The surveyor asked what the agency’s process was for ensuring accuracy and that the POCs were reviewed and revised by the physicians every 60 days. The Admin/DON replied, “I will have to be more vigilant.” The surveyor asked how the failure could adversely affect the patients. The Admin/DON stated that the failure might impact the accuracy of services. Review of the agency policy titled; “Plan of Care” last reviewed 05/02/24 read in part: “ ... VI. The individualized Plan of Care must be reviewed and revised by the physician and/or non-physician practitioner who is responsible for the home health Plan of Care and the Agency as frequently as the patient’s/client’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. The Agency must promptly alert the relevant physician(s), and/or non-physician practitioner(s) to any changes in the patient’s/client’s condition or needs that suggest that outcomes are not being achieved and/or that the Plan of Care should be altered…””