Best Health Care Services, LLC

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on review of clinical records and interview, it was determined the agency’s staff failed to ensure home health services were provided according to the patient’s individualized plan of care for three (3) of seven (7) clinical records that required an assessment of weight, blood glucose and/or Skilled Nurse frequency visits as ordered by the physician were reviewed in the survey sample (Clinical record for Patients #s: 1, 3 and 5). 1. The clinical record for Patient #1 was reviewed for the recertification period of January 08, 2025 to March 08, 2025. The patient’s plan of care contained orders as follows: Skilled Nurse to assess patient’s weight log every visit. The clinical record failed to contain documentation that the nurse assessed the patient’s weight log for the above recertification period. On March 12, 2025 at 4:36 PM, Staff Member #1 revealed the patient was bedbound and unable to weigh but was not documented in the clinical record. In addition, the patient’s plan of care contained orders for Skilled Nurse to visit for one (1) week for two (2) weeks. The clinical record indicated one (1) Skilled Nurse visit the week of January 12, 2025 (week 2) and one (1) Skilled Nurse visit the week of February 2, 2025 (week 5). The clinical record failed to follow the plan of orders for the Skilled Nurse visit frequency. On March 12, 2025 at 4:36 PM, Staff Member #1 revealed the Skilled Nurse schedule was incorrect on the plan of care. 2. The clinical record for Patient #3 was reviewed for the recertification period of October 24, 2024 to December 22, 2024. The patient’s plan of care contained orders as follows: Skilled Nurse to notify the physician of fasting blood sugar greater than 130 or less than 60. Notify physician of Random blood sugar greater than 140 or less than 70. The clinical record failed to contain documentation that the nurse assessed the blood sugar on the above noted recertification period. On March 12, 2025 at 4:36 PM, Staff Member #1 did not reveal why the patient’s blood sugars were not assessed. 3. The clinical record for Patient #5 was reviewed for the certification period of February 26, 2025 to April 26, 2025. The patient’s plan of care contained orders for Skilled Nurse to visit two (2) times for two (2) weeks. The clinical record indicated one (1) Skilled Nurse visit the week of February 26, 2025 (week 1) and one (1) Skilled Nurse visit the week of March 02, 2025 (week 2). The clinical record failed to follow the plan of orders for the Skilled Nurse visit frequency. On March 12, 2025 at 4:36 PM, Staff Member #1 revealed the Skilled Nurse schedule should have been one (1) week for one (1) week and two (2) times for two (2) weeks. Staff Member #1 also revealed an effective date of February 02, 2025 for two (2) times for two (2) weeks should have been specified and was not put on the Recertification OASIS to pull over to the plan of care.”

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on a review of clinical records and interview it was determined the agency failed to ensure patients were informed about and consented to the frequency of proposed visits in advance of starting care for three (3) of seven (7) patients in the survey sample (Clinical record for Patient #’s: 1, 2 and 5). 1. The informed consent signed at the time of admission and prior to services being provided for Patient #1 with a start of care date of May 13, 2024 failed to contain documentation of the frequency of Skilled Nursing and Physical Therapy services the patient would be receiving. 2. The informed consent signed at the time of admission and prior to services being provided for Patient #2 with a start of care date of August 14, 2024 failed to contain documentation of the frequency of Skilled Nursing, Physical Therapy and Occupation Therapy services the patient would be receiving. 3. The informed consent signed at the time of admission and prior to services being provided for Patient #5 with a start of care date of February 26, 2025 failed to contain documentation of the frequency of Skilled Nursing, Physical Therapy and Occupation Therapy services the patient would be receiving. On March 12, 2025 at 4:36 PM, Staff Member #1 revealed the clinicians have been reminded to fill out the disciplines frequency of visits on the consent multiple times as there is a place on the consent to document this.”

“Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This Element is not met as evidenced by: Based on review of clinical records and interview it was determined the agency failed to document informing patients verbally and in writing regarding the financial liability for two (2) of seven (7) patients reviewed in the survey sample (Clinical records for Patient #’s: 2 and 5). The clinical record for Patient #2 with a start of care date of August 14, 2024 failed to contain documentation that the patient was made aware of the extent to which payment for HHA services may be expected from Medicare and the charges the individual may have to pay before care was initiated. The clinical record for Patient #5 with a start of care date of February 26, 2025 failed to contain documentation that the patient was made aware of the extent to which payment for HHA services may be expected from Medicare and the charges the individual may have to pay before care was initiated. On March 12, 2025 at 4:36 PM, Staff Member #1 revealed the clinicians have a place on the consent to document this.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on clinical record review, interview and agency procedure, it was determined the agency failed to ensure accurate and complete medication lists were documented in two (2) of seven (7) clinical records reviewed in the survey sample (Clinical records for Patient #’s: 1 and 7). 1. The clinical record for Patient #1 was reviewed for the period of January 08, 2025 to March 08, 2025. The plan of care indicated Skilled Nurse visits once a week for two (2) weeks. The Skilled Nursing visit of January 16, 2025 indicated the nurse gave a B12 (Vitamin B12 also known as cyanocobalamin) IM (Intramuscular injection). The agency’s medication list failed to contain the B12 IM medication. On March 12, 2025 at 4:36 PM, Staff Member #1 revealed a physician’s order for the B12 IM written and signed on March 03, 2025, however the nurse failed to put this information on the OASIS recertification to enable the information to transfer to the plan of care for this recertification period. 2. The clinical record for Patient #7 was reviewed for the period of January 15, 2025 to March 15, 2025. The plan of care indicated the patient’s DME (Durable Medical Equipment) contained oxygen and the orders and treatment contained oxygen at 2 lpm NC (nasal cannula) continuous. The agency’s medication list failed to contain the oxygen. On March 12, 2025 at 4:36 PM, Staff Member #1 revealed the agency knows oxygen is listed as a medication. The agency failed to update each patient’s medication profile as noted above. On March 13, 2025 the agency’s process for the care plan was reviewed as follows: “Care Planning Process policy No. 1-007” with a revision date of May 2022. The process indicated the plan of care will include all medications.”

“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 a review of clinical records and staff interview it was determined the agency staff failed to ensure a plan of care contained specific location of a wound with wound care, specific blood sugar parameters and an IM (intramuscular injection) treatment order by the physician for four (four) of six (6) patients in the survey sample whom had a wound, blood sugar parameters or an IM (Clinical record for Patient #s: 1, 3, 5 and 7). 1. The clinical record for Patient #1 was reviewed for the recertification period of January 08, 2025 to March 08, 2025. The clinical record indicated the patient received a B12 IM (intramuscular injection) on January 16, 2025 by the agency’s Skilled Nurse. On March 12, 2025 at 4:36 PM, Staff Member #1 revealed a physician’s order and signed on January 03, 2025 for the patient to receive B12 IM but was not documented into the Recertification OASIS to be able to transfer to the patient’s plan of care. The plan of care failed to contain the B12 IM order. 2. The clinical record for Patient #3 was reviewed for the recertification period of October 24, 2024 to December 22, 2024. The plan of care contained orders as follows: Skilled nursing services for post-surgical wound care for twice a week for five (5) weeks. The clinical record indicated the Skilled Nurse provided wound care to the patient’s vulva, urethra and rectal area with Normal Saline for the above noted recertification period. On March 12, 2025 at 4:36 PM, Staff Member #1 did not reveal why the plan of correction did not contain the specific site for the wound or the wound care. The plan of care failed to contain the specific wound location and wound care. 3. The clinical record for Patient #5 was reviewed for the recertification period of February 26, 2025 to April 26, 2025. The plan of care contained incomplete blood sugar orders as follows: Notify physician of Fasting blood sugar greater than 200 or less than _____. Random blood sugar greater than 300 or less than _______. On March 12, 2025 at 4:36 PM, Staff Member #1 did not reveal why the blood sugar parameters were incomplete. The plan of care failed to contain complete blood sugar parameters. 4. The clinical record for Patient #7 was reviewed for the certification period of January 15, 2025 to March 15, 2025. The plan of care contained wound care as follows: wash with soap and water two (2) times daily and assess for skin breakdown every visit. Skilled nurse to instruct client/caregiver on signs and symptoms of wound infection to report to physician. Skilled Nurse to assess/evaluate wound(s) at each dressing change and prn (as needed) for signs and symptoms of infection. In addition, the plan of care indicated the primary diagnosis is malignant neoplasm of nipple and areola of right female breast and has a Pleur X (tube placed into the lung to drain fluid) drain to the right side chest. The clinical record indicated Skilled Nursing drained the Pleur X this certification period and cleansed with Normal Saline. The plan of care failed to describe a specific location for wound care regarding the wound with soap and water two (2) times daily whether it be the right female breast or the Pleur X. On March 12, 2025 at 4:36 PM, Staff Member #1 did not reveal what wound location was ordered to be washed with soap and water or what procedure is needed to care for a Pleur X. The plan of care failed to contain specific location of wound ordered for soap and water twice a day and the specifics to take care of a Pleur X drain regarding how much to drain, what technique to use such as clean technique or sterile or what dressing to use.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on clinical record review and interview, it was determined the agency failed to ensure the physician was notified of the patient’s condition that may suggest outcomes are not being met or changes are needed in the plan of care. Specifically, the physician was not notified about out of range vital sign parameters for two (2) of seven (7) clinical records reviewed in the survey sample (Clinical record for Patient #’s: 1 and 4). 1. The clinical record for Patient #1 was reviewed for the recertification period of January 08, 2025 to March 08, 2025. The patient’s plan of care contained orders as follows: Skilled Nurse to notify physician of systolic blood pressure less than 100. The clinical record indicated a systolic blood pressure of 99 on February 06, 2025 and a systolic blood pressure of 90 on February 14, 2025. The clinical record failed to notify the physician of the above out of range parameters. On March 12, 2025 at 4:36 PM, Staff Member #1 revealed the vital sign parameters should have been changed if the patient is known to have low systolic blood pressure. 2. The clinical record for Patient #4 was reviewed for the recertification period of June 28, 2024 to August 26, 2024. The patient’s plan of care contained orders as follows: Skilled Nurse to notify physician of pulse less than 60. The clinical record indicated an apical pulse of 55 on July 26, 2024. The clinical record failed to notify the physician of the above out of range parameter. On March 12, 2025 at 4:36 PM, Staff Member #1 revealed the low pulse should have been communicated to the physician.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on a review of clinical records and interview, it was determined the agency failed to provide a supervisory visit for a home health aide every 14 days by a Registered Nurse or other appropriate skilled professional for one (1) of one (1) patient’s receiving home health aide services in the clinical records reviewed in the survey sample. (Clinical record for Patient #4). 1. The clinical record for Patient #4 was reviewed for the recertification period of June 28, 2024 to August 26, 2024. The patient’s plan of care contained orders for a home health aide three (3) times a week for eight (8) weeks. The clinical record failed to indicate a home health aide supervisory visits from the dates of July 27, 2024 to August 23, 2024 (27 days). On March 12, 2025 at 4:36 PM, Staff Member #1 revealed the home health aide did not have a supervisory visit for the above noted time frame.”

“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 a review of clinical records and interview, it was determined the agency failed to send the patient’s discharge summary to the primary care physician or primary care practitioner within 5 business days from the date of the final visit for one (1) of two (2) closed clinical records reviewed in the survey sample. (Clinical record for Patient #3). The clinical record for Patient #3 was reviewed for the certification period of October 21, 2024 to December 22, 2024. The record revealed that the patient was discharged from the agency on December 22, 2024. No discharge summary was sent to the primary physician. On March 12, 2025 at 4:46 PM, Staff Member #1 revealed waiting on the insurance to determine if the patient would be recertified again but then insurance denied services so the discharge summary should have been sent but was not.”