Joab Homehealth 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 record review and interview, the agency failed to ensure the plan of care included all pertinent diagnoses; psychosocial and cognitive status; types of supplies; rehabilitation potential; functional limitations; all medications; safety measures to protect against injury; patient-specific interventions and information related to advanced directives in six of seven records reviewed (Patient 1, 2, 3, 4, 5 and 6) in that: a. In one of seven records reviewed (Patient 1), the plan of care did not include diabetic (high blood sugar levels) supplies, bleeding safety measures for a blood thinning medication, blood sugar parameters to report to the physician and Tylenol (pain medication). b. In one of seven records reviewed (Patient 2), the plan of care did not include specific wound care orders with steps to follow, wound care supplies and Tramadol (pain medication). c. In one of seven records reviewed (Patient 3), the plan of care did not include diabetic supplies and Lidoderm patches (pain medication). d. In one of seven records reviewed (Patient 4), the plan of care did not include a diagnosis of multiple sclerosis (the body’s own immune system progressively attacks and damages nerve tissue). e. In one of seven records reviewed (Patient 5), the plan of care did not include Acetaminophen (pain medication). f. In one of seven records reviewed (Patient 6), the plan of care did not include the psychosocial and cognitive status; rehabilitation potential; functional limitations; safety measures to protect against seizures (involuntary movements); allergies and information related to advanced directives. These failures placed patients in jeopardy of harm from agency staff who could not address the patients’ risk factors and types of services needed for appropriate care and placed them at risk of a declining health status and complications. Findings included: Patient 1: Record review of the electronic and paper medical record included a plan of care dated 05/09/2025 to 07/07/2025 signed by the Adm/DON on 05/08/2025 with a start of care date of 05/14/2024. The physician ordered the nurse to visit the patient once a week for nine weeks. The plan of care included a diagnosis of diabetes, a diabetes medication (insulin) administered with a needle to lower blood sugar levels (Toujeo inject 10 units daily), and a blood thinning medication, (Clopidogrel 75 milligrams by mouth daily). Also included in the plan of care were orders for the nurse to check the blood sugar levels as needed and to prepare/administer the insulin. The plan of care did not include diabetic supplies, bleeding safety measures for a blood thinning medication and blood sugar parameters to report to the physician. Nurse visits were conducted by the Adm/DON on 05/14/2025, 05/21/2025, 05/28/2025, 06/04/2025, 06/12/2025, 06/19/2025, 06/26/2025 and 07/03/2025. On page 3, the eight visit notes included a current pain medication: Tylenol 325mg 1-2 tablets. Blood sugar readings were recorded on the eight visit notes with a range of 110-115 that were performed by the Adm/DON or the caregiver. The eight notes included the patient’s caregiver administer the daily insulin. The plan of care did not include the medication, Tylenol. In an interview with the Administrator/DON on 07/22/2025 at 3:00 PM, the surveyor reviewed the findings and asked why the plan of care did not include diabetic supplies, bleeding safety measures for a blood thinning medication, blood sugar parameters to report to the physician and the medication, Tylenol. The Adm/DON stated she didn’t know it was required to include supplies on the plan of care if the agency did not provide them to the patient and that she missed putting bleeding precautions and blood sugar parameters on the plan of care. The Adm/DON further stated the patient was taking Tylenol and she forgot to add it to the plan of care. Patient 2: Record review of the electronic and paper medical record included a plan of care dated 01/15/2025 to 03/15/2025 signed by the Adm/DON on 01/10/2025 with a start of care date of 07/25/2023. The physician ordered the nurse to visit the patient once a week for nine weeks to perform wound care to the right leg. The plan of care included a diagnosis of an open wound to the right lower leg and a chronic ulcer to the right lower leg with muscle tissue death. The plan of care read in part, “… WOUND TREATMENT: SN to place chux (disposable pad) under Rt leg to absorb drainage and don (put on) gloves to perform aseptic technique to Rt… lower leg wound. SN to change Rt lateral lower leg outer wound dressing when saturated and apply new dressing…” The plan of care did not include specific wound care orders with steps to follow and wound care supplies to use for the nurse when performing dressing changes. Nurse visits were conducted by the Adm/DON on 01/17/2025, 01/22/2025, 01/29/2025, 02/05/2025, 02/12/2025, 02/19/2025, 02/26/2025 and 03/05/2025. On page 3, the eight visit notes included a current prescription pain medication: Tramadol 50 milligrams. The plan of care did not include the medication, Tramadol. In an interview with the Administrator/DON on 07/22/2025 at 3:05 PM, the surveyor reviewed the findings and asked why the plan of care did not include specific wound care orders, wound care supplies and the medication, Tramadol. The Adm/DON stated she should have included specific wound care orders instead of being vague so it would not cause confusion and she forgot to add the wound care supplies to the plan of care. The Adm/DON further stated the patient took Tramadol and it should have been included on the plan of care but she forgot to add it. Patient 3: Record review of the electronic and paper medical record included a plan of care dated 06/21/2024 to 08/19/2024 signed by the Adm/DON on 06/19/2024 with a start of care date of 06/27/2023. The physician ordered the nurse to visit the patient once a week for nine weeks. The plan of care included a diagnosis of diabetes. Medications for the diabetes included: Novolin 70/30 insulin inject 15 units in the morning under the skin; Novolin 70/30 inject 10 units under the skin in the evening and Lispro insulin inject under the skin three times daily as follows: 0 units for a blood sugar reading of 70-150; 1 unit for a blood sugar reading of 151-200; 2 units for a blood sugar reading of 201-250; 3 units for a blood sugar reading of 251-300; 4 units for a blood sugar reading of 301-350; 5 units for a blood sugar reading of 350 and greater. Notify the nurse practitioner and doctor if the blood sugar exceeds 350. Also included in the plan of care were orders for the nurse to check the blood sugar levels every visit if not already done by the patient/caregiver. The plan of care did not include diabetic supplies. Nurse visits were conducted by the Adm/DON on 06/25/2024, 07/02/2024, 07/04/2024, 07/07/2024, 07/09/2024, 07/16/2024, 07/23/2024, 07/30/2024, and 08/06/2024. On page 3, the nine visit notes included a current prescription pain medication: Lidoderm 5% 1 patch daily as needed, apply to painful area for 12 hours and take patch off for 12 hours. Blood sugar readings were recorded on the nine visit notes with a range of 119-137. The plan of care did not include the medication, Lidoderm. In an interview with the Administrator/DON on 07/22/2025 at 3:20 PM, the surveyor reviewed the findings and asked why the plan of care did not include diabetic supplies and the medication, Lidoderm. The Adm/DON stated she did not know the supplies needed to be included since they weren’t supplied by the agency. The Adm/DON further stated the patient used Lidoderm patches for pain but she forgot to add them to the plan of care. Patient 4: Record review of the electronic and paper medical record included a plan of care dated 09/07/2024 to 11/05/2024 signed by the Adm/DON on 09/06/2024 with a start of care date of 05/10/2024. Physician A ordered the nurse to visit the patient once a week for one week then three times a week for eight weeks. The plan of care included a diagnosis of an advanced bedsore to the lower back, immobility syndrome and bed confinement. The record included an order signed and dated by Physician A on 04/11/2024 that read in part, “… [Page 1] Patient has multiple sclerosis which has progressed and left patient crippled…” The plan of care did not include a diagnosis of multiple sclerosis. In an interview with the Administrator/DON on 07/22/2025 at 3:25 PM, the surveyor reviewed the findings and asked why the plan of care did not include a diagnosis of multiple sclerosis. The Adm/DON stated the patient had contractures (loss of joint mobility) but she did not know it was caused by multiple sclerosis and she must have missed the documentation from Physician A that included the diagnosis. Patient 5: Record review of the electronic and paper medical record included a plan of care dated 08/02/2023 to 09/30/2023 signed by the Adm/DON on 08/01/2023 with a start of care date of 10/06/2022. The physician ordered the nurse to visit the patient once a week for nine weeks. The plan of care included a diagnosis of chronic pain and joint pain. Nurse visits were conducted by the Adm/DON on 08/04/2023, 08/09/2023, 08/16/2023, 08/23/2023, 08/30/2023, 09/06/2023, 09/13/2023 and 09/20/2023. On page 3, the eight visit notes included a current prescription pain medication: Acetaminophen 650 milligrams 1-2 tablets three times daily by mouth as needed for pain. The plan of care did not include the medication, Acetaminophen. In an interview with the Administrator/DON on 07/22/2025 at 3:30 PM, the surveyor reviewed the findings and asked why the plan of care did not include the medication, Acetaminophen. The Adm/DON stated the patient took Acetaminophen and she needed to keep the plan of care updated. Patient 6: Record review of the electronic and paper medical record included a plan of care dated 11/29/2023 to 01/27/2024 signed by the Adm/DON on 11/28/2023 with a start of care date of 08/01/2023. The physician ordered the nurse to visit the patient once a week for nine weeks. The plan of care included a diagnosis of high blood pressure, arthritis and seizures. The plan of care did not include the psychosocial and cognitive status; rehabilitation potential; functional limitations; safety measures to protect against seizures; allergies and information related to advanced directives. In an interview with the Administrator/DON on 07/22/2025 at 3:32 PM, the surveyor reviewed the findings and asked why the plan of care did not include the psychosocial and cognitive status; rehabilitation potential; functional limitations; safety measures to protect against seizures; allergies and information related to advanced directives. The Adm/DON stated she did not know how she missed adding the items to the plan of care and wished she had an answer. In an interview with the Administrator/DON on 07/16/2025 at 1:20 PM, the surveyor asked who was responsible for ensuring the plan of cares included all the required elements. The Adm/DON stated she was. In an interview with the Administrator/DON on 07/22/2025 at 3:40 PM, the surveyor asked how the failure to include all required elements on the plan of care could impact patients. The Adm/DON stated she was the only nurse that conducted patient visits and knew what the orders were, but if another nurse made visits, it would have been unsafe for the patients since all of the information wasn’t included on the plan of cares. The surveyor asked why the agency’s policy was not followed. The Adm/DON stated she did not know she was doing it wrong and not following the policy. Agency policy titled, “Plan of Care TX.6” with a revision date of 03/16/2004 read in part, “… Purpose To ensure that care provided is appropriately planned in a timely manner to meet the patient’s specific needs and problems… Procedure I. The appropriate licensed professional staff member, with physician participation, is responsible for developing the plan of care… 3. The 485, which includes the following plan of care elements, will serve as the initial plan of care: patient diagnosis/problem… interventions and care…””

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on record review and interview, the agency failed to complete and send a discharge/transfer summary to the primary care practitioner or other health care professional who would be responsible for providing care and services to the patient within five business days of the date of discharge from the agency for six of six discharge records reviewed (Patient 2, 3, 4, 5, 6 and 7). This failure placed the patient’s health and safety at risk if the patients had healthcare needs that the primary care practitioner was not aware of when the patient was discharged/transferred. Findings included: During the entrance conference on 07/16/2025 at 1:20 PM, the surveyor requested a list of discharged patients for the past 6-months. Patient 2: Record review of the electronic and paper medical record included a plan of care dated 01/15/2025 to 03/15/2025 signed by the Adm/DON on 01/10/2025 with a start of care date of 07/25/2023. The physician ordered the nurse to visit the patient once a week for nine weeks. The record included a discharge nursing assessment signed and dated by the Adm/DON on 03/13/2025. The discharge assessment did not include the discharge reason. The record did not include a discharge summary. There was no evidence a completed discharge summary was sent to the primary care practitioner or other health care professional who would be responsible for providing care and services to the patient following agency discharge. The discharge roster included Patient 2 was discharged from the agency on 06/13/2025 due to goals met. During an interview with the Adm/DON on 07/22/2025 at 3:20 PM, the surveyor asked why Patient 2 was discharged. The Adm/DON stated the patient was discharged due to goals met. The surveyor asked why a discharge summary wasn’t completed and sent to the physician or other health care professional who would be responsible for providing care and services to the patient following agency discharge. The Adm/DON stated she told the doctors the discharge summary was available upon request but the doctor did not request one. The Adm/DON further stated she was unaware she was supposed to complete and send a discharge summary to the doctor unless they asked for it. Patient 3: Record review of the electronic and paper medical record included a plan of care dated 06/21/2024 to 08/19/2024 signed by the Adm/DON on 06/19/2024 with a start of care date of 06/27/2023. The physician ordered the nurse to visit the patient once a week for nine weeks. The record included a discharge nursing assessment signed and dated by the Adm/DON on 08/12/2024. The discharge assessment did not include the discharge reason. The record included a discharge summary signed and dated by the Adm/DON on 08/12/2024 that read in part, “… Discharge date: 08/12/2024… CIRCUMSTANCES OF DISCHARGE… the physician responsible for the home health agency… plan of care and HHA agreed that the HHA could no longer meet the patient’s needs, based on the patient’s acuity…” There was no evidence the discharge summary was sent to the primary care practitioner or other health care professional who would be responsible for providing care and services to the patient following agency discharge. During an interview with the Adm/DON on 07/22/2025 at 3:20 PM, the surveyor asked why Patient 3 was discharged. The Adm/DON stated because the client transferred to hospice. The surveyor asked if the discharge summary was sent to the physician. The Adm/DON stated, “No.” The Adm/DON stated she didn’t normally complete a discharge summary unless the doctor requested it, and Patient 3’s doctor had not requested one. Patient 4: Record review of the electronic and paper medical record included a plan of care dated 09/07/2024 to 11/05/2024 signed by the Adm/DON on 09/06/2024 with a start of care date of 05/10/2024. Physician A ordered the nurse to visit the patient once a week for one week then three times a week for eight weeks. The record included a discharge nursing assessment signed and dated by the Adm/DON on 10/11/2024. The discharge assessment did not include the discharge reason. The record included a form titled, “Advance Beneficiary Notice of Non-Coverage” that read in part, “… Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect Medicare may not pay for the skilled nurse… Reason Medicare May Not Pay: Pt’s (sic) has another home health… provider…” The record included a form titled, “Home Health Change of Care Notice” that read in part, “… Starting 10/11/2024, your home health agency will change the items/services listed below… skilled nursing… reason for change Per Patient’s request…” The record did not include a discharge summary. There was no evidence a discharge/transfer summary was sent to the primary care practitioner or other health care professional who would be responsible for providing care and services to the patient following agency discharge. During an interview with the Adm/DON on 07/22/2025 at 3:25 PM, the surveyor asked why Patient 4 was discharged. The Adm/DON stated per the patient’s request because he went to another home health agency. The surveyor asked why a discharge/transfer summary wasn’t completed and sent to the physician or other health care professional who would be responsible for providing care and services to the patient following agency discharge. The Adm/DON stated it was the same answer given for Patient 2 (Adm/DON was unaware she was supposed to complete and send a discharge summary to the doctor unless they asked for it). Patient 5: Record review of the electronic and paper medical record included a plan of care dated 08/02/2023 to 09/30/2023 signed by the Adm/DON on 08/01/2023 with a start of care date of 10/06/2022. The physician ordered the nurse to visit the patient once a week for nine weeks. The record included a discharge nursing assessment signed and dated by the Adm/DON on 09/29/2023. The discharge assessment did not include the discharge reason. The record included a discharge summary that was not dated or signed that read in part, “… Discharge date: 09/29/2023… Patient goals not (sic) at this time, unable to locate patient to provide care… Reason for discharge… Goals Met…” A check mark had been placed next to the form that read in part, “… D/C summary available (sic) upon request…” There was no evidence the discharge summary was sent to the primary care practitioner or other health care professional who would be responsible for providing care and services to the patient following agency discharge. During an interview with the Adm/DON on 07/22/2025 at 3:30 PM, the surveyor asked why Patient 5 was discharged. The Adm/DON stated goals were met. The surveyor asked why the discharge/transfer summary wasn’t sent to the physician or other health care professional who would be responsible for providing care and services to the patient following agency discharge. The Adm/DON stated it was the same answer given for Patient 2 (Adm/DON was unaware she was supposed to complete and send a discharge summary to the doctor unless they asked for it). Patient 6: Record review of the electronic and paper medical record included a plan of care dated 11/29/2023 to 01/27/2024 signed by the Adm/DON on 11/28/2023 with a start of care date of 08/01/2023. The physician ordered the nurse to visit the patient once a week for nine weeks. The record included a discharge nursing assessment signed and dated by the Adm/DON on 01/26/2024. The discharge assessment did not include the discharge reason. The record did not include a discharge summary. There was no evidence a completed discharge summary was sent to the primary care practitioner or other health care professional who would be responsible for providing care and services to the patient following agency discharge. During an interview with the Adm/DON on 07/22/2025 at 3:32 PM, the surveyor asked why Patient 6 was discharged. The Adm/DON stated the patient was discharged per the patient’s request. The surveyor asked why a discharge summary wasn’t completed and sent to the physician or other health care professional who would be responsible for providing care and services to the patient following agency discharge. The Adm/DON stated it was the same answer given for Patient 2 (Adm/DON was unaware she was supposed to complete and send a discharge summary to the doctor unless they asked for it). Patient 7: Record review of the electronic and paper medical record included a plan of care dated 11/22/2022 to 01/09/2023 signed by the Adm/DON on 11/08/2022 with a start of care date of 09/17/2021. The physician ordered the nurse to visit the patient once a week for nine weeks. The record included a discharge nursing assessment signed and dated by the Adm/DON on 01/09/2023. The discharge assessment did not include the discharge reason. The record included a form titled, “Home Health Change of Care Notice” that read in part, “… Your home health care is going to change… Reason for change: Health plan changed …” The record included a form titled, “Advance Beneficiary Notice of Non-Coverage” that read in part, “… Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect Medicare may not pay for the skilled nursing… Reason Medicare May Not Pay: Health plan changed …” The record included a physician order dated and signed by the Adm/DON on 01/09/2023 and signed and dated by Physician B on 01/18/2023 that read in part, “… patient discharged due to health plan insurane (sic) change…” The record did not include a discharge summary. There was no evidence a completed discharge summary was sent to the primary care practitioner or other health care professional who would be responsible for providing care and services to the patient following agency discharge. During an interview with the Adm/DON on 07/22/2025 at 3:40 PM, the surveyor asked why a discharge/transfer summary wasn’t completed and sent to the physician or other health care professional who would be responsible for providing care and services to the patient following agency discharge. The Adm/DON stated it was the same answer given for Patient 2 (Adm/DON was unaware she was supposed to complete and send a discharge summary to the doctor unless they asked for it). During an interview with the Administrator/DON on 07/22/2025 at 3:40 PM, the surveyor asked why agency policy was not followed. The Adm/DON stated she did not know she was doing it wrong and that she was not following agency policy. Agency policy titled, “Patient Discharge PE.6” with a revision date of 08/01/14 read in part, “… PURPOSE To assess each patient’s discharge planning and/or continuing care needs prior to discharge from Agency. To provide for continuity of care as well as appropriate and timely post-discharge care and documentation… POLICY Agency will assess each patient’s discharge planning and/or continuing care needs on an ongoing basis and will involve the physician, the patient and the caregiver in the planning process… PROCEDURE… 2. Patient Discharge… 2.11 Medical record documentation for discharge includes, but is not limited to… Discharge Summary…””