Every finding on record at Alfa Home Healthcare LLC

Substantial Allegation Survey Substantial Allegation 102374 No deficiencies were cited related to the allegation contained in substantial allegation102374 completed on 12/13/23; however, the facility was found not to be in compliance with all requirements for Home Health Agency participation and the following deficiencies are cited. Alfa Home Healthcare LLC 369067, is not in compliance with the requirements at 42 CFR Part 484, Subpart B, C for Home Health Agencies.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and staff interview, the agency failed to ensure all patient care orders were recorded in the plan of care for one of three patients reviewed (Patient #1). This had the potential to affect all patients receiving services from this agency. The census was 95. Findings include: Review of Patient #1's medical record revealed the physician ordered plan of care for the certification period dated 06/08/23 through 08/06/23 included orders for skilled nursing services three times per week. Review of an addendum by an advanced level provider dated 06/08/23 revealed the skilled nursing services should be decreased to two times per week. Review of the physician ordered plan of care for the certification period dated 08/07/23 through 10/05/23 revealed orders for skilled nursing services three times per week. There was no order to change the skilled nursing services from two times per week as ordered on 06/08/23 to three times per week. Interview with Staff C on 12/13/23 at 11:17 AM revealed there was an additional addendum for skilled nursing services to be provided one time every week starting 08/02/23 (prior to the certification period). Staff C provided the addendum for review which confirmed skilled nursing services should be provided one time per week as of 08/02/23. Staff C confirmed the physician ordered plan of care had not been updated to reflect the correct number of skilled nursing visits to be completed.

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on record review and staff interview, the agency failed to ensure the individualized plan of care was reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care no less frequently than once every 60 days for one of three patients reviewed (Patient #1). This had the potential to affect all patients receiving services from this agency. The census was 95. Findings include: Review of Patient #1's medical record revealed the physician ordered plan of care for the certification period dated 06/08/23 through 08/06/23 revealed orders for 42 hours of Speech Therapy (ST) to be completed every week. Further review of the patient's record revealed home health aide (HHA) services were documented as being provided 42 hours each week. There was no documentation ST was provided during the certification period. Review of the physician ordered plan of care for the certification period dated 08/07/23 through 10/05/23 revealed orders for 42 hours of ST every week. Further review revealed 42 hours of HHA services was provided every week. There was no documentation ST was provided during the certification period. Interview with Staff C on 12/13/23 at 11:17 A.M. confirmed the physician ordered plan of care included orders for ST and not HHA services which was what the patient was receiving. Additionally, Staff C stated that all physician ordered plans of care for 2023 reflected 42 hours of ST and no orders for HHA services.