Every finding on record at Alta Home Health Care, LLC

SUBSTANTIAL ALLEGATION SURVEY SUBSTANTIAL ALLEGATION 108394 The following deficiency is based upon substantial allegation 108394 completed on 08/15/24. Alta Home Health Care is not in compliance with the requirements found at 42 CFR Part 484 Subpart B, C, 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 the home health services as written in the plan of care. This affected four of four medical records reviewed (Patients #1, #2, #3, and #4). The agency census was 77. Findings include: 1. Review of the medical record for Patient #1 revealed plans of care dated 04/14/24 to 06/12/24 and 06/13/24 to 08/11/24 with orders for skilled nursing seven times per week and home health aide services 43 hours per week. Review of the medical record from 06/02/24 through 08/10/24 revealed skilled nursing visits once a week the weeks of 06/02/24 and 07/14/24. Skilled nursing was provided three times a week the week of 07/07/24, twice a week the week of 07/28/24, and five times a week the week of 08/04/24. The medical record lacked documentation of any skilled nursing visits the weeks of 06/09/24, 06/16/24, 06/23/24, 06/30/24, and 07/21/24. The medical record contained documentation of 43 hours of home health aide services per week during this time period, except for the week of 06/30/24 when the patient only received 38 hours. The only missed visit documented was on 07/08/24 for nursing. The medical record lacked documentation the physician was notified that care was not provided as ordered. On 08/15/24 at 12:50 PM, Staff A verified the above findings. 2. Review of the medical record for Patient #2 revealed a plan of care dated 05/28/24 to 07/26/24 with orders for skilled nursing twice a week. Review of the medical record revealed one skilled nursing visit the week of 07/21/24. The medical record lacked documentation the physician was notified the care was not provided as ordered. On 08/15/24 at 2:50 PM, Staff A verified the physician was not notified of the missing nursing visit. 3. Review of the medical record for Patient #3 revealed a plan of care dated 05/22/24 to 07/20/24 with orders for skilled nursing once a week, 14 hours per week and home health aide services 14 hours per week. The medical record contained a plan of care dated 07/21/24 to 09/18/24 with orders for skilled nursing 7-14 times a week, 14 hours per week and home health aide services 28 hours per week. Review of the medical record from 06/16/24 through 08/15/24 revealed seven visits a week, each visit one hour or less, the weeks of 06/16/24, 06/23/24, 06/30/24, 07/07/24, 07/21/24, 07/28/24, and 08/04/24. The week of 07/14/24 contained five skilled nursing visits. The medical record contained seven home health aide visits per week the weeks of 06/16/24 and 06/23/24. The medical record lacked documentation of any home health aide visits after 06/29/24. A communication note dated 07/17/24 noted aide services were canceled. The medical record lacked documentation the physician was notified the care was not provided as ordered. On 08/15/24 at 2:50 PM, Staff A verified the physician was not notified when the aide services stopped and that the patient only received daily nursing visits. 4. Review of the medical record for Patient #4 revealed a plan of care dated 06/13/24 to 08/11/24 with orders for skilled nursing seven times a week and home health aide services 28 hours per week. Review of the medical record revealed two nursing visits per week and 20 to 24 hours of home health aide services the weeks of 07/21/24, 07/28/24, and 08/04/24. The medical record lacked documentation the physician was notified the services were not provided as ordered. On 08/15/24 at 3:00 PM, Staff A verified the above findings.