Every finding on record at A Plus Home Health Agency LLC

Substantial Allegation Survey Substantial Allegation OH00122210 An entrance conference was conducted on 06/01/21 at 9:50 AM with administrative personnel, and an exit conference was completed on 06/07/21 at 12:25 PM with administrative personnel. The following deficiency is based on the Substantial Allegation OH00122210 completed on 06/07/21. A Plus Home Health Care Agency LLC 368415, is not in compliance with the requirements found at 42 CFR Part 484 Subpart B, C for Home Health Agencies.

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 medical record review and staff interview, the agency failed to ensure patients received home health services as written in the plan of care for two of four medical records reviewed (Patients #2 and #4). The agency census was 78. Findings include: 1. Review of the medical record for Patient #2 revealed a plan of care dated 05/06/21 to 07/04/21 that included orders for home health aide services 56 hours per week. The medical record contained documentation of 49 hours per week of home health aide services from 05/06/21 through 05/22/21. The medical record lacked documentation of physician notification the home health services were not provided as ordered. This was verified in an interview on 06/03/21 at 3:30 PM by Staff A. 2. Review of the medical record for Patient #4 revealed a plan of care dated 03/25/21 to 05/23/21 with orders for weekly skilled nursing visits and 28 hours of home health aide services per week, with four hour shifts per day. The medical record contained documentation of 12 hours of home health aide services from 04/08/21 to 04/10/21 in four hour shifts per day. The medical record contained documentation of 13 hours of home health aide services per week, in two and a half to three hour shifts per day, from 04/11/21 to 05/22/21. The medical record lacked documentation of physician notification the home health services were not provided as ordered. This was verified in an interview on 06/07/21 at 12:15 PM by Staff A.