Abiding Care Services Inc.

“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: This is a repeated violation cited at G574 on 02/17/2023. Based on record review and interview, the agency failed to ensure the plan of cares included the psychosocial status and patient-specific interventions in two of two records reviewed (Patient 1 and 2) in that: a. In one of two records reviewed (Patient 1), the plan of care did not include patient-specific interventions and vital sign parameters to report to the doctor/ordering practitioner. b. In one of two records reviewed (Patient 2), the plan of care did not include the psychosocial status; patient-specific interventions; vital sign and weight parameters to report to the physician/ordering practitioner. These failures placed patients in jeopardy of harm from agency staff who could not address the patient’s risk factors and types of services needed for appropriate care and placed them at risk of a declining health status and complications. Findings included: According to the Cleveland Clinic, last updated 08/07/2024 (retrieved from https://my.clevelandclinic.org/health/treatments/prosthetic-leg): Possible complications of using an artificial leg include rubbing/irritation/damage to the skin and development of pressure sores/wounds. According to the Cleveland Clinic, last updated 05/10/2022 (retrieved from https://my.clevelandclinic.org/health/diseases/22962-hypervolemia): How can I prevent fluid overload: eat a low salt diet; monitor the amount of daily fluid consumption; keep track of how much you weigh. The Administrator stated on 02/23/2026 at 1:15 PM during an interview with Surveyor 1 that the Alternate Administrator/DON was responsible for ensuring the plan of cares included all required elements. Patient 1: Record review of the electronic and paper medical record included a plan of care dated 02/20/2024 to 04/19/2024 with a start of care date of 02/20/2024. The physician ordered the nurse to visit the patient once every nine weeks. The plan of care included a diagnosis of heart disease, low heart rate, joint pain, and lung disease. The plan of care included the patient had an amputation and required the use of an artificial leg. Section 21, orders for discipline and treatments on the plan of care read, “SN: 1 visit(s), every (sic) for 9 week(s) Pain status: patient will continue to take pain medication as prescribed.” The plan of care did not include any patient-specific orders or interventions. The plan of care did not include orders for the nurse to assess the amputation stump where the artificial leg attached for signs and symptoms of skin irritation/breakdown or wound development or out of range vital sign parameters to report to the physician/ordering practitioner for blood pressure, heart rate, blood oxygen level, respiratory rate, and temperature. Surveyor 1 conducted an interview with the Alternate Administrator/DON on 02/27/2026 at 12:30 PM, the surveyor presented the findings and asked why all required elements were not included in the plan of care and agency policy followed. Alternate Administrator/DON stated she was confused because she remembered charting some of the things that were missing or why they would not be included in the plan of care. The Alternate Administrator/DON further stated the agency had changed charting systems and the people with the new system helped her transfer information from the old system to the new system and maybe some of the information did not transfer into the new system. Surveyor 1 conducted an interview with the Administrator on 02/27/2026 at 2:20 PM, the surveyor presented the findings and asked why all required elements were not included in the plan of care and agency policy was not followed. The Administrator stated the agency had a problem with their software vendor archiving agency’s documents. Patient 2: Record review of the electronic and paper medical record included a plan of care dated 04/11/2023 to 06/09/2023 with a start of care date of 12/12/2022. The physician ordered the nurse to visit the patient once every nine weeks. The plan of care included a diagnosis of fluid overload (the body retains too much fluid, leading to swelling, high blood pressure, and potential organ complications), lung disease, high blood pressure and hip pain. The plan of care included a section titled, “Psychosocial”, that included sleep/rest: adequate. The plan of care did not include interpersonal relationships in the immediate family, financial status, homemaker/household needs, vocational rehabilitation needs, family social problems and transportation needs. The plan of care did not include out of range parameters to report to the physician/ordering practitioner for the heart rate, blood oxygen level, respiratory rate, temperature, weights. The plan of care did not include orders for the nurse to monitor the patients weight for signs and symptoms of fluid overload. Surveyor 2 conducted an interview with the Alternate Administrator/DON on 02/27/2026 at 12:37 PM, the surveyor presented the findings and asked why the psychosocial status was not included in the plan of care. The Alternate Administrator/DON stated she did not know why that information was missing. Surveyor 2 conducted an interview with the Alternate Administrator/DON on 02/27/2026 at 12:41 PM, the surveyor presented the findings and asked why patient-specific interventions; and vital sign and weight parameters to report to the physician/ordering practitioner were not included in the plan of care. The Alternate Administrator/DON stated there was a place [in the patient’s electronic record] where she typically charted that information and it could be wrong information pulled up on the patient form. Agency policy titled, “Plan of Care (Plan of Treatment)” undated, read in part, “…The plan of care must be established and authorized in writing by the physician based on an evaluation of the patient’s immediate and long term needs. The HHA staff… shall have a substantial role in assessing patient needs, consulting with the physician, and helping to develop the overall plan of care…””