Home Health Associates LLC

“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 individualized plan of care included the types of services required for 1 of 7 patient records reviewed for plans of care. (Patient #2 Patient #2’s POC did not include an order for aide services. This failure could place patients at risk of not receiving necessary services to meet the patient’s needs. Findings included: Record review of a RN Oasis Recertification assessment for Patient #2 dated 03/21/25 indicated patient had limited mobility and had to use his left hand to maneuver right arm. Patient was right side dominant making it difficult for patient to manage his activities of daily living and care independently. Patient had no range of motion of right shoulder due to shoulder injury which made ambulating with walker more difficult… patient required increased assistance with activities of daily living, grooming, showering, toileting, meals, housekeeping, and medications. Record review of Patient #2’s POC dated 03/26/25 to 05/24/25 indicated a SOC date of 09/27/24, and indicated he was 87 years old with diagnoses including type 2 diabetes (body either doesn’t produce enough insulin, or it resists insulin) with diabetic neuropathy (nerve damage), orthostatic hypotension (sudden drop in blood pressure when transitioning from a lying or sitting position to standing and can lead to dizziness, lightheadedness, and fainting), hypertension (high blood pressure), repeated falls, dementia (loss of memory), anxiety (feelings of worry), major depressive disorder (persistent low mood), and chronic obstructive pulmonary disorder (lung disease that makes it difficult to breathe). The POC indicated Patient #7 was ordered skilled nursing visits 2 times a week for 2 weeks then 1 time a week for 7 weeks, and physical therapy 1 time a week for 1 week for evaluation. The POC did not include orders for home health aide services. Review of a Master Calendar for Patient #2 dated 03/26/25 to 05/24/25 indicated home health aide visits were scheduled twice a week on Tuesday’s and Thursdays from 03/26/25 to 05/24/25. Review of an Aide Care Plan for Patient #2 dated 03/26/25 to 05/24/25 indicated “activity” included assist with ambulation each visit. Further review indicated “personal care” each visit included assist to dress, comb hair, foot care, nail care, shampoo hair, shave, skin care, shower, and universal precautions. During a home visit/interview on 04/22/25 at 9:05 a.m., Patient #2 said he had been on the agency’s services for 1 year “this time”. He said he currently received an aide 2 times a week for a shower. He said he received aide services the whole time he had been with the agency. During an interview on 04/22/25 at 9:17 a.m., RN D said she thought Patient #2’s aide services were off and on, but she was not sure. During an interview on 04/22/25 at 10:39 a.m., RN D said Patient #2 was on aide services during the previous certification period. She said the aide services with the frequency should be on the POC. During an interview on 04/22/25 at 11:50 a.m., the RN Administrator/Supervising Nurse said sometimes there was a separate order for aide services if it was ordered after and not on the POC. She said she would look in Patient #2’s electronic medical record to see if there was an order for aide services. During an interview on 04/22/25 at 11:58 a.m., the RN Administrator/Supervising Nurse said she spoke to the RN Alternate Supervising/QA Nurse, and she was not seeing it (aide order) on the POC either. The Administrator said there was an aide care plan that was signed by the doctor and asked if that would count as an order. The Administrator said the consultant said that was why the aide POC was signed was because it counted as a physician’s order. The Administrator said the POC went through QA. During an interview on 04/22/25 at 12:31 p.m., the RN Alternate Supervising/QA Nurse said she was the assistant director of nursing and did QA also. She said she audited all POCs and looked for orders, frequencies, made sure the POC was signed by the doctor, made sure teaching matched diagnosis, and had lab orders if needed. She said the POC was developed by the nurses but sometimes the PRN nurses didn’t know how to develop the POC so she would do the POC when she QA’d the OASIS. She said once the OASIS was done the POC prepopulated, and some nurses didn’t know how to do it so she would do it for them. The RN Alternate Supervising/QA Nurse said the POC was updated with any changes, changes in frequency, and changes in orders. She said the POC was also updated on recertification or if the patient had been in hospital. She said she didn’t do Patient #2’s recertification but did the POC. The RN Alternate Supervising/QA Nurse said Patient #2 was on aide services. She said aide services required a physician order. She said the agency consultant said if the aide care plan was signed that was sufficient as an order. She said she noticed the aide care plan did not have the frequency so that would not work. The RN Alternate Supervising/QA Nurse said when she QA’d Patient #2’s POC she must have missed putting an order on there. She said the POC was supposed to have aide services and frequency. The RN Alternate Supervising/QA Nurse said since the agency’s consultant said the aide care plan would work, she thought it would, but the order was not covered since the aide frequency was not included on aide care plan. She said the services and frequency were supposed to be on the POC. The RN Alternate/Supervising/QA Nurse said by aide services not being on the POC the patient was not supposed to be getting aide services because there was no order for the aide to be there. She said it was an overlook on her part. During an interview on 04/22/25 at 2:08 p.m., the RN Administrator/Supervising Nurse said POCs were developed normally by the person who did the recertification. She said she and the RN Alternate Supervising Nurse had helped with some POCs if there was a new nurse or they were teaching on how to do it. She said POCs were generated from the OASIS and updated at every recertification. The RN Administrator/Supervising Nurse said aide services required a physician order and frequency and it was supposed to be on the POC. She said all POCs were audited by the RN Alternate Supervising/QA Nurse. The RN Administrator/Supervising Nurse said if aide services were not on the POC, there would be a separate order. She said if aide services were not on the POC, services could be missed even if visits were scheduled. She said if there was no order and services were not on the POC then the agency did not have an order and the aide was not supposed to be going. She said the POC policy indicated the frequency and services had to be on the POC for every discipline and frequency. Record review of a Plan of Care policy dated 05/02/24 indicated “…Ill. Each patient/client must receive an individualized written Plan of Care, including any revisions or additions. The individualized Plan of Care must specify the care and services necessary to meet the patient/client-specific needs as identified in the comprehensive assessment… A. The individualized Plan of Care must include the following… 3. The types of services, supplies, and equipment required… 4. The frequency and duration of visits to be made…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… VIII. Drugs, services, and treatments are administered only as ordered by a physician and/or non­physician practitioner…””

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure services were administered only as ordered by a physician for 1 of 7 patient records reviewed. (Patient #2) Patient #2 received home health aide services/visits without a physician’s order. This failure could place patients at risk of receiving services not approved by a physician. Findings included: Record review of a RN Oasis Recertification assessment for Patient #2 dated 03/21/25 indicated patient had limited mobility and had to use his left hand to maneuver right arm. Patient was right side dominant making it difficult for patient to manage his activities of daily living and care independently. Patient had no range of motion of right shoulder due to shoulder injury which made ambulating with walker more difficult… patient required increased assistance with activities of daily living, grooming, showering, toileting, meals, housekeeping, and medications. Further review indicated discontinued interventions were home health aide frequency 2 times a week for assistance with activities of daily living. Record review of Patient #2’s POC dated 03/26/25 to 05/24/25 indicated a SOC date of 09/27/24, and indicated he was 87 years old with diagnoses including type 2 diabetes (body either doesn’t produce enough insulin, or it resists insulin) with diabetic neuropathy (nerve damage), orthostatic hypotension (sudden drop in blood pressure when transitioning from a lying or sitting position to standing and can lead to dizziness, lightheadedness, and fainting), hypertension (high blood pressure), repeated falls, dementia (loss of memory), anxiety (feelings of worry), major depressive disorder (persistent low mood), and chronic obstructive pulmonary disorder (lung disease that makes it difficult to breathe). The POC indicated Patient #7 was ordered skilled nursing visits 2 times a week for 2 weeks then 1 time a week for 7 weeks, and physical therapy 1 time a week for 1 week for evaluation. The POC did not include orders for home health aide services. Review of a Master Calendar for Patient #2 dated 03/26/25 to 05/24/25 indicated home health aide visits were completed on 03/27/25, 04/01/25, 04/03/25, 04/08/25, 04/10/25, 04/15/25 and 04/17/25. The calendar indicated home health aide visits were scheduled for 04/22/25, 04/24/25, 04/29/25, 05/01/25, 05/06/25, 05/08/25, 05/13/25, 05/15/25, 05/20/25, and 05/22/25. The calendar indicated home health aide visits were scheduled twice a week on Tuesday’s and Thursdays from 03/26/25 to 05/24/25. Review of an Aide Care Plan for Patient #2 dated 03/26/25 to 05/24/25 indicated “activity” included assist with ambulation each visit. Further review indicated “personal care” each visit included assist to dress, comb hair, foot care, nail care, shampoo hair, shave, skin care, shower, and universal precautions. Review of Patient #2’s clinical record did not include an order for home health aide services/visits for the certification period of 03/26/25 to 05/24/25. During a home visit/interview on 04/22/25 at 9:05 a.m., Patient #2 said he had been on the agency’s services for 1 year “this time”. He said he currently received an aide 2 times a week for a shower. He said he received aide services the whole time he had been with the agency. During an interview on 04/22/25 at 9:17 a.m., RN D said she thought Patient #2’s aide services were off and on, but she was not sure. During an interview on 04/22/25 at 10:39 a.m., RN D said Patient #2 was on aide services during the previous certification period. She said the aide services with the frequency should be on the POC. During an interview on 04/22/25 at 11:50 a.m., the RN Administrator/Supervising Nurse said sometimes there was a separate order for aide services if it was ordered after and not on the POC. She said she would look in Patient #2’s electronic medical record to see if there was an order for aide services. During an interview on 04/22/25 at 11:58 a.m., the RN Administrator/Supervising Nurse said she spoke to the RN Alternate Supervising/QA Nurse, and she was not seeing it (aide order) on the POC either. The Administrator said there was an aide care plan that was signed by the doctor and asked if that would count as an order. The Administrator said the consultant said that was why the aide POC was signed was because it counted as a physician’s order. The Administrator said the POC went through QA. During an interview on 04/22/25 at 12:31 p.m., the RN Alternate Supervising/QA Nurse said she was the assistant director of nursing and did QA also. She said she audited all POCs and looked for orders, frequencies, made sure the POC was signed by the doctor, made sure teaching matched diagnosis, and had lab orders if needed. She said the POC was developed by the nurses but sometimes the PRN nurses didn’t know how to develop the POC so she would do the POC when she QA’d the OASIS. She said once the OASIS was done the POC prepopulated, and some nurses didn’t know how to do it so she would do it for them. The RN Alternate Supervising/QA Nurse said the POC was updated with any changes, changes in frequency, and changes in orders. She said the POC was also updated on recertification or if the patient had been in hospital. She said she didn’t do Patient #2’s recertification but did the POC. The RN Alternate Supervising/QA Nurse said Patient #2 was on aide services. She said aide services required a physician order. She said the agency consultant said if the aide care plan was signed that was sufficient as an order. She said she noticed the aide care plan did not have the frequency so that would not work. The RN Alternate Supervising/QA Nurse said when she QA’d Patient #2’s POC she must have missed putting an order on there. She said the POC was supposed to have aide services and frequency. The RN Alternate Supervising/QA Nurse said since the agency’s consultant said the aide care plan would work, she thought it would, but the order was not covered since the aide frequency was not included on aide care plan. She said the services and frequency were supposed to be on the POC. The RN Alternate/Supervising/QA Nurse said by aide services not being on the POC the patient was not supposed to be getting aide services because there was no order for the aide to be there. She said it was an overlook on her part. During an interview on 04/22/25 at 2:08 p.m., the RN Administrator/Supervising Nurse said POCs were developed normally by the person who did the recertification. She said she and the RN Alternate Supervising Nurse had helped with some POCs if there was a new nurse or they were teaching on how to do it. She said POCs were generated from the OASIS and updated at every recertification. The RN Administrator/Supervising Nurse said aide services required a physician order and frequency and it was supposed to be on the POC. She said all POCs were audited by the RN Alternate Supervising/QA Nurse. The RN Administrator/Supervising Nurse said if aide services were not on the POC, there would be a separate order. She said if aide services were not on the POC, services could be missed even if visits were scheduled. She said if there was no order and services were not on the POC then the agency did not have an order and the aide was not supposed to be going. She said the POC policy indicated the frequency and services had to be on the POC for every discipline and frequency. Record review of an Orders for Care policy dated 05/01/24 indicated “…The Agency will obtain orders and provide care in accordance with physician’s and/or non-physician practitioner’s orders which are established prior to initiating patient/client care and reviewed/revised by the physician and/or non-physician practitioner every sixty (60) days and as needed.…” Record review of a Plan of Care policy dated 05/02/24 indicated “…Ill. Each patient/client must receive an individualized written Plan of Care, including any revisions or additions. The individualized Plan of Care must specify the care and services necessary to meet the patient/client-specific needs as identified in the comprehensive assessment… A. The individualized Plan of Care must include the following… 3. The types of services, supplies, and equipment required… 4. The frequency and duration of visits to be made…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… VIII. Drugs, services, and treatments are administered only as ordered by a physician and/or non­physician practitioner…””