Eclate Health Care Solutions 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: Based on record review and interview, the agency failed to ensure the plan of care included all required elements in three of three records reviewed (Patient 1, 2 and 3) in that: In two of three records reviewed (Patient 1 and 2) the plan of cares did not include the frequency and duration of nursing visits to be made, 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; patient and caregiver education and training to facilitate timely discharge; patient-specific interventions and education and measurable outcomes and goals identified by the agency and the patient. In three of three records reviewed (Patient 1, 2 and 3) the plan of cares did not include the rehabilitation potential. These failures placed patients at risk of harm from agency staff who could not address the patients’ risk factors and type of services needed for appropriate care, placing patients at risk of declining health status and the need for hospitalizations and long term care facility placement. Findings include: Patient 1: Record review of the medical record included a plan of care dated 03/20/2021 to 04/15/2021 signed by RN A on 03/15/2021. The plan of care did not include the nursing frequency and duration of visits to be made; 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; patient and caregiver education and training to facilitate timely discharge; patient-specific interventions and education and measurable outcomes and goals identified by the agency and the patient and the rehabilitation potential. Patient 2: Record review of the medical record included a plan of care dated 04/10/2021 to 06/08/2021 signed by RN A on 04/05/2021. The plan of care did not include the nursing frequency and duration of visits to be made; 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; patient and caregiver education and training to facilitate timely discharge; patient-specific interventions and education and measurable outcomes and goals identified by the agency and the patient and the rehabilitation potential. Patient 3: Record review of the medical record included a plan of care dated 02/04/2021 to 04/04/2021 signed by RN B on 03/15/2021. The plan of care did not include the rehabilitation potential. Administrator A stated during an interview on 04/03/2024 at 1:45 PM: The DON was not available for an interview but the ADON was available. The ADON stated during an interview on 04/04/2024 at 12:42 PM: She was appointed the ADON in 2020. It had been a while since the agency provided services for Patient 1, 2 and 3 and she did not remember why the missing information was not included on the plan of cares. The nurse that completed the visit was responsible for completing the plan of care for the patients. The DON or ADON was responsible for ensuring the plan of cares included all the required elements. The DON was responsible for following the agency’s policy regarding the plan of cares; if the DON was not available, the ADON was responsible. RN A and RN B were former agency employees and were not interviewed. Agency policy titled, “Plan of Care TX.6” with a revision date of 04/17/2006 read in part, “… POLICY Agency will utilize data/information gathered during patient assessments in the care planning process which involves the identification of patient goals, actions or interventions that will resolve or alleviate the patient’s problems and/or needs… The patient/caregiver, as well as the patient’s physician, will be encouraged to participate in the patient’s care planning process to determine mutually agreed upon goals… Procedure 1. The appropriate licensed professional staff member, with physician participation, is responsible for developing the plan of care... 3. The 485 [plan of care], which includes the following plan of care elements, is developed in consultation with staff, client, physician and other providers involved in the client’s care and will serve as the initial plan of care: goals/outcomes… frequency and duration of visits… discharge plan… rehabilitation potential…” Agency policy titled, “Responsibilities of the Director of Home Health Services LD.7” with a revision date of 09/21/2004 read in part, “…PURPOSE To define the responsibilities of the Director of Home Health Services to ensure safe, appropriate delivery of patient care… DEFINITION Supervising Nurse is the responsible registered nurse for supervising skilled services provided by the agency… This person may also be known as the Director of Nurses, Director of Home Health Services or a similar title… POLICY Director of Home Health Services… is responsible for the daily direction of patient care and participates in activities relevant to professional services furnished… PROCEDURE 1. Agency defines the responsibilities of the Director of Home Health Services to include but not be limited to… 1.3 Collaborating on development and implementation of policies and procedures which guide and support the provision of care…””