Horizon Home Care and Hospice

“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 develop individualized and/or measurable Plan of Care (POC) goals to meet the needs of the patient in 7 of 17 patient records reviewed (Patient #2, #3, #5, #6, #7, #10 and #11). Findings include: Record review of Patient #2’s “Home Health Certification and Plan of Care” dated 06/16/2025 to 08/14/2025 revealed Patient #2 had a primary diagnosis of “Encounter for Orthopedic Aftercare” with a secondary diagnosis of “Cutaneous Abscess of Right Foot.” Patient #2 receives skilled nursing care 3 times per week for wound care. Patient #2’s POC goals revealed “Patient will demonstrate improved wound status as evidence by a decrease in size/drainage of wound, absence of infection, and decreased pain.” The goals are not measurable with time specific dates and/or individualized to meet the patient needs. Record review of Patient #6’s “Home Health Certification and Plan of Care” dated 05/04/2025 to 07/02/2025 revealed Patient #6 had a primary diagnosis of “Encounter for Attention to Colostomy”. Patient #6 receives skilled nursing care 3 times per week for colostomy care and wound care for a buttock wound. Patient #6’s POC goals revealed “Patient will demonstrate improved wound status as evidence by a decrease in size/drainage of wound, absence of infection, and decreased pain.” The goals are not measurable with time specific dates and/or individualized to meet the patient needs. Record review of Patient #11’s “Home Health Certification and Plan of Care” dated 06/15/2025 to 08/13/2025 revealed Patient #11 had a primary diagnosis of “Gastrointestinal Hemorrhage” and has additional diagnosis of “Other Specified Chronic Obstructive Pulmonary Disease.” Patient #11 receives skilled nursing care 1 time per week. The POC orders revealed in part, “Skilled Nurse to observe and assess cardiovascular system to identify changes and intervene to minimize complications...May perform oxygen saturation levels PRN (as needed) for signs and symptoms of possible respiratory complications. Goals: Abnormal oxygen saturation levels will be reported to physician.” The goals are not measurable with time specific dates and/or individualized goal parameters to meet the patient needs. During an interview on 06/25/2025 at 10:15 AM with Substitute Administrator B, findings for Patient #2, #6, and #11 were reviewed. Substitute Administrator B agreed that the goals were either not measurable or not individualized for Patients #2, #6, and #11. Findings include: Review of agency policy titled, “Care Planning Process- Home care” dated 02/04/2025 revealed in part, “The initial Plan of Care will include: Patient-specific interventions and education; measurable outcomes and goals identified by the Agency and the patient.” Record review of Patient #3’s “Home Health Certification and Plan of Care” for certification period 05/28/2025 to 07/26/2025 revealed primary diagnosis of “Displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing” receiving SN care 3 times per week for wound care. POC goals revealed “Wound status will improve as evidence by a decrease in size/drainage of wound, absence of infection, and decreased pain.” The goals are not measurable with time specific dates and/or individualized to meet the patient needs. Record review of Patient #5’s “Home Health Certification and Plan of Care” for certification period 06/10/2025 to 08/08/2025 revealed primary diagnosis of “Type 2 Diabetes Mellitus with other skin ulcer” receiving SN care 3 times per week for wound care. POC goals revealed “Wound status will improve as evidence by a decrease in size/drainage of wound, absence of infection, and decreased pain.” The goals are not measurable with time specific dates and/or individualized to meet the patient needs. Record review of Patient #7’s “Home Health Certification and Plan of Care” for certification period 05/16/2025 to 07/12/2025 revealed primary diagnosis of “Postural Orthostatic Tachycardia Syndrome (POTS) receiving SN care 1 time per week for intravenous (IV) infusion. POC goals revealed “IV fluids/meds will be administered per orders. Patient will verbalize/demonstrate tolerance.” The goals are not measurable with time specific dates and/or individualized to meet the patient needs. Record review of Patient #10’s “Home Health Certification and Plan of Care” for certification period 05/16/2025 to 07/14/2025 revealed primary diagnosis of “Pressure ulcer of right buttock, stage 2” receiving SN care 1 time per week for wound care. POC goals revealed “Wound status will improve as evidence by a decrease in size/drainage of wound, absence of infection, and decreased pain.” The goals are not measurable with time specific dates and/or individualized to meet the patient needs.”

“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 record review and interview, the agency Registered Nurse (RN) failed to supervise the Home Health Aide (HHA) no less than every 14 days in 1 of 2 patients (Patient #10) receiving HHA services in a total of 17 patient records reviewed. Findings include: Review of agency policy titled, “Clinical Supervision / Joint Visits” dated 02/20/2025 revealed in part, “4. The case manager for patients receiving home health aide with skilled services or hospice services will complete a direct or indirect supervisory visit for paraprofessional staff to evaluate staff competency and patient experience at least every 14 days…5. Direct or indirect supervisory visits for both skilled and non-skilled services with home health aide will be completed in the medical record on the appropriate supervisory visit form…” Record review of Patient #10’s medical record with start of care date of 11/17/2024 revealed “Skilled Nurse (SN) 1 time per week. HHA 2 times per week.” SN visit note documentation revealed HHA supervision was documented to be occurring every 60 days on 01/15/2025, 03/14/2025 and 05/13/2025. During an interview on 06/25/2025 at 8:20 AM, Substitute Administrator B stated, “I could not find that supervisory visits were completed at least every 14 days for this patient.””