Caring Angels Home Health, 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 policy review, medical record review, and interviews, it was determined the facility failed to individualize the plan of care, by using the same visit frequency range for the services provided, for ten (10) out of ten (10) patients reviewed, patient 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10. This failure has the potential to negatively impact all patients receiving care from the agency. A policy was reviewed titled, “Care Plan Policy,” no effective date listed. The policy states in part, “Purpose: To establish a standardized process for developing, implementing, and updating individualized patient care plans that address identified problems, goals, interventions, and assessments—while specifically evaluating and managing pain and nutrition needs. This ensures coordinated, patient-centered, and outcome-driven care in compliance with regulatory requirements. Policy Statement: PathWell will develop a written, individualized plan of care for each patient, in collaboration with the patient/caregiver and ordering physician, based on the comprehensive assessment and identified needs. The plan will: ● Address all current problems affecting the patient’s health status. ● Include measurable goals, evidence-based interventions, and timelines. ● Incorporate regular assessments to track progress and adjust care as needed…2. Goals ● Written in measurable, time-bound terms (e.g., “Patient will ambulate 50 [fifty] feet with a walker within 2 [two] weeks without shortness of breath.”) ● Reflect both clinical outcomes and patient-identified goals for independence and quality of life. ● Include both short-term and long-term objectives. 3. Interventions ● Evidence-based, discipline-specific actions to address each identified problem. ● Include frequency and duration (e.g., “SN [skilled nurse] to assess wound healing 2x/[two times] a week for 4 [four] weeks”)...” The “Home Health Certification and Plan of Care,” with a start of care (SOC) of 11/10/25, was reviewed for patient 1. The document states in part, “...Orders and Treatments…SN: 1-3w9 [one to three times a week for nine weeks], 3 [three] prn [as needed] visits for changes in health condition…SN Interventions:...Patient has post op bandage in place, [spouse] educated to monitor and if bandage becomes more wet to contact home health so we can replace bandage and assess incision. SN to monitor wound for s/s of infection and proper wound healing at each visit 1-3W9 [one to three times a week for nine weeks]…” The “Home Health Certification and Plan of Care,” with a SOC of 10/02/25, was reviewed for patient 2. The document states in part, “...Orders and Treatments…SN: 1-3w9 [one to three times a week for nine weeks], 3 [three] PRN visits for changes in health condition.” A PT [physical therapy] Evaluation completed on 10/03/25 at 1:40 p.m. states in part, “...Frequency and Duration:...Effective Date: 10/03/2025. Frequency: 1-3w9 [one to three times a week for nine weeks]…” The “Home Health Certification and Plan of Care,” with a SOC of 05/22/25 for the recertification period beginning 11/18/25, was reviewed for patient 3. The document states in part, “...Orders and Treatments…SN: 1-3w9 [one to three times a week for nine weeks, 3 [three] PRN visits for change in health condition and wound care.” The “Home Health Certification and Plan of Care,” with a SOC of 10/09/25, was reviewed for patient 4. The document states in part, “...Orders and Treatments…SN: 1-3w9 [one to three times a week for nine weeks, 3 [three] prn visits for changes in health condition.” A OT [occupational therapy] Evaluation completed on 10/21/25 at 10:00 a.m. states in part, “...Frequency and Duration:...Effective Date: 10/21/2025. Frequency: 1-3w9 [one to three times a week for nine weeks…” The “Home Health Certification and Plan of Care” with a SOC of 11/07/25, was reviewed for patient 5. The document states in part, “...Orders and Treatments…SN: 1-3w9 [one to three times a week for nine weeks, 3 [three] prn visits for changes in health condition.” A PT Evaluation completed on 11/11/25 at 1:20 p.m. states in part, “...Frequency and Duration:...Effective Date: 11/10/2025. Frequency: 1-3w9 [one to three times a week for nine weeks…” The “Home Health Certification and Plan of Care” with a SOC of 09/07/25 was reviewed for patient 6. The document states in part, “...Orders and Treatments…SN: 1-3w9 [one to three times a week for nine weeks, 3 [three] prn visits for change in condition.” A PT Evaluation completed on 09/12/25 at 10:55 a.m. states in part, “...Frequency and Duration:...Effective Date: 09/12/2025. Frequency: 1-3w9 [one to three times a week for nine weeks…” The “Home Health Certification and Plan of Care” with a SOC of 11/06/25 was reviewed for patient 7. The document states in part, “...Orders and Treatments…SN: 1-3w9 [one to three times a week for nine weeks, 3 [three] prn visits for changes in health condition.” The “Home Health Certification and Plan of Care” with a SOC of 12/14/25 was reviewed for patient 8. The document states in part, “...Orders and Treatments…SN: 1w3 [one time a week for three weeks.” A OT Evaluation completed on 12/16/25 at 9:00 a.m. states in part, “...Frequency and Duration:...Effective Date: 12/16/2025. Frequency: 1-3w9 [one to three times a week for nine weeks…” The “Home Health Certification and Plan of Care” with a SOC of 11/17/25 was reviewed for patient 9. The document states in part, “...Orders and Treatments…SN: 1-3wx9 [one to three times a week for nine weeks, 3 [three] PRN as per change in condition.” The “Home Health Certification and Plan of Care” with a SOC of 12/12/25 was reviewed for patient 10. The document states in part, “...Orders and Treatments…SN: 1-3w9 [one to three times a week for nine weeks, 3 [three] prn visits for changes in health condition.” A PT Evaluation completed on 12/15/25 at 10:50 a.m. states in part, “...Frequency and Duration:...Effective Date: 12/15/2025. Frequency: 1-3W9 [one to three times a week for nine weeks…” A OT Evaluation completed on 12/15/25 at 2:00 p.m. states in part, “...Frequency and Duration:...Effective Date: 12/15/2025. Frequency: 1-3W9 [one to three times a week for nine weeks…” A telephone interview was conducted with staff 3 on 01/05/26 at 12:30 p.m. Regarding the patient’s plan of care, staff 3 states, “The plan of care always says one [1] to three [3] times a week for every patient.” A telephone interview was conducted with staff 2 on 01/06/26 at 9:39 a.m. Regarding the agency’s plans of care, staff 2 states in part, “We allow a range of visits to give flexibility so we don’t have to call the doctor. This is not out of compliance with CMS [Center for Medicare and Medicaid Services]. The frequencies of the actual visits are included in the goals and interventions, which are all in the care plan…When the patient is initially seen, the nurses, PT, and OT can request the schedule for the frequency that they see fit for the patient. In the PT and OT evaluation, the frequency recommended is in the notes. They let the scheduler know what is assigned, and the scheduler pre-populates the schedule in the computer to secure the visits. I hear your point on personalization, that is, and I feel that it is specified in the goals and interventions…””