1st Aid Healthcare Corp

“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 interviews with agency staff, the agency failed to ensure the plan of cares were developed, implemented, and updated to include all pertinent diagnoses; the frequency and duration of visits to be made; rehabilitation potential; patient and caregiver education and training; patient-specific interventions and education; and measurable outcomes and goals in five of nine patient records (Patient #1, 3, 5, 6, and 7) in that: In two of nine records reviewed (Patient 1 and 5), the plan of cares did not include all pertinent diagnoses. In two of nine records reviewed (Patient 5 and 7), the plan of cares did not include the frequency and duration of visits to be made. In one of nine records reviewed (Patient 3), the plan of care did not include rehabilitation potential. In two of nine records reviewed (Patient 1 and 3), the plan of cares did not include patient and caregiver education and training. In one of nine records reviewed (Patient 1), the plan of care did not include patient-specific interventions and education related to wound care. In two of nine records reviewed (Patient 6 and 7), the plan of cares did not include measurable outcomes and goals.This failure could result in inconsistent care, unmet patient needs, and negative patient outcomes. Findings include: Patient 1: Record review of Patient 1’s active record included a POC dated 3/27/26 with a start of care date of 3/27/26. The physician ordered skilled nursing visits twice a week for eight weeks to provide wound care. The record included an incorrect diagnosis. Patient 1’s POC had a diagnosis of pressure ulcer (areas of damaged skin and tissue caused by sustained pressure that reduces blood flow to vulnerable areas of the body) of the elbow. However, Patient 1 was being treated for a pressure ulcer of the coccyx/sacral area (two distinct but interconnected bony structures at the very base of your spine). Patient 1’s POC was also missing patient/family specific education/interventions related to pressure ulcers and wound care. During an interview with RN A on 5/21/2026 at 1:15pm, Surveyor 2 asked why Patient 1’s POC had an incorrect diagnosis. RN A replied that she completed the start of care and that she noticed yesterday that it was incorrect. She continued to state, “that was an error on my part”. Additionally, Surveyor 2 asked why the POC was missing patient/family specific education/interventions related to pressure ulcer and wound care. RN A replied that it should have been on there and she wasn’t sure why it wasn’t on the plan of care. Surveyor 2 asked why agency policies were not followed and RN A stated, “I’m not sure. It was just missed.” During an interview with the DON on 5/21/2026 at 2:00pm, Surveyor 2 asked why Patient 1’s POC would have the incorrect diagnosis. The DON replied “It may have been transcribed incorrectly. A typo or something.” In response to Surveyor 2 asking why the POC would be missing patient specific education, the DON responded “I’m not sure why that information is not on there. It should be.” Patient 3: Review of Patient 3’s record included a POC dated 4/17/2026 with a start of care date 4/17/26. The POC included the diagnoses of Parkinson’s disease (a progressive neurological disorder caused by the death of dopamine-producing brain cells), iron deficiency anemia (a common blood condition that occurs when your body lacks sufficient iron to produce hemoglobin), and constipation. The physician ordered for the patient to be admitted to skilled services, to perform a 60 day recertification if needed, and for physical therapy to evaluate and treat per protocol. Record review revealed the plan of care was missing the patient’s rehab potential, and patient and caregiver education and training. During an interview with RN A 5/21/2026 at 12:57pm, Surveyor 2 asked why the above elements were missing from the POC. RN A responded, “They should have been on there. I am still learning OASIS [Outcome and Assessment Information Set (a standardized data set that measures quality and outcomes of home health patients)]. I do complete everything you’re supposed to. The program usually clues you in on what is required, I had zero errors and warning, so I had no idea about the emergency risk.” Patient 5: Review of Patient 5’s record included a POC dated 4/30/2026 with a start of care of 4/30/2026. Patient 5 had diagnoses of essential hypertension (the most common form of high blood pressure) and localized edema (the accumulation of fluid in a specific part of the body, such as a single limb, joint, or the face). Record review revealed the POC was missing the diagnoses of cognitive change and B12 deficiency, as well as the frequency of skilled nursing visits. During an interview with DON on 5/21/26 at 145pm Surveyor 1 asked why the POC was missing the above elements. DON replied that they should have been on there. During an interview with RN A on 5/21/26 at 2pm, Surveyor 1 asked why the POC was missing the above elements. RN A replied “I’m still learning and it was overlooked.” Patient 6: Review of Patient 6’s record included a POC dated 3/10/26 with a start of care of 3/10/2026. The POC had the diagnoses of aftercare following joint replacement surgery (replaces damaged joint surfaces with artificial implants to relieve pain and restore mobility). Record review reviewed the POC was missing patient specific goals related to pain. Patient 7: Review of Patient 7’s record included a POC dated 8/15/25 with a start of care date of 6/16/25. The POC had the diagnoses of Atherosclerotic heart disease of native coronary artery without angina pectoris (a condition where plaque builds up in the heart’s original blood vessels, restricting blood flow but causing no chest pain or discomfort) and hypertensive disease without heart failure (refers to structural or functional cardiac change, such as an enlarged heart muscle caused by long-term high blood pressure, prior to the development of heart failure), and chronic obstructive pulmonary disease (group of progressive lung diseases that block airflow and make breathing difficult). The POC was missing the frequency of skilled nursing visits, and patient specific goals. During an interview with the DON on 5/21/26 at 1:52pm, the DON stated that the patient goals should have been on the POC. During an interview with the DON 5/21/2026 at 1:55pm, Surveyor 1 asked why the above elements were missing from all the POCs mentioned above and why agency policies were not followed? DON replied, “the only reason I can come up with is miscommunication.” During an interview with Adm and Alt Adm on 5/22/2026 at 1:27pm, Surveyor 2 questioned why the above mentioned POCs had incorrect or missing diagnoses, were missing the additional required elements mentioned above, and why policies weren’t followed. Adm replied, “It was a new nurse, and I’m very disappointed. Extremely disappointed and frustrated. I don’t know why the policies weren’t followed. It’s embarrassing and unacceptable.” Agency policy PC.35 titled, “Plan of Care”, revised 1/1/26, reads in part… “Procedure III…A. The individualized plan of care must include the following…All pertinent diagnoses; … frequency and duration of visits; … rehabilitation potential; … A description of the patient’s/client’s risk for emergency department visits; … Patient/client and caregiver education and training; …Patient/client specific interventions and education; …Measurable outcomes and goals…””