Every finding on record at Best Home Health Care Services, Inc

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Dates: June 19th, 20th, and 21st of 2023. Active census: 44 At this Emergency Preparedness survey, Best Home Care Services was found in compliance with Emergency Preparedness Requirements for Medicare Participating Providers and Suppliers, 42 CFR 484.102. QR by A4 on 06/27/2023

This visit was for a Federal Recertification and State Re-Licensure Survey of a Home Health Provider. Survey Dates: June 19th, 20th, and 21st of 2023. 12-Month Unduplicated Skilled Admissions: 8 Partially Extended Survey Announced June 19th of 2023 at 11:15 AM. These deficiencies reflect State Findings cited in accordance with 410 IAC 17.

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 ensure the Plan of Care included the Cognitive Status, Risk for Emergency Department visits and Hospital Readmission, Patient-specific Interventions and Education, & Measurable Outcomes/Goals with progression towards Goals in 7 of 7 patient records reviewed (Clinical record #1, #2, #3, #4, #5, #6, and #7). Findings include: 1. An undated policy titled, "Plan of Care", was provided by the administrator on 6/20/2023 at 11:09 AM. The policy indicated but was not limited to, "1. An individualized Plan of Care signed by a physician shall be required for each patient receiving home health and personal care services. 2.The Plan of Care shall be completed in full to include: … b. Mental status…o. Instructions to patient/caregiver…t. Other appropriate items…u. All of the above items must always be addressed in the Plan of Care." 2. Patient #1, SOC (start of care) 03/08/2022, POC (plan of care) was reviewed for the certification period 04/22/2023-06/20/2023. The POC failed to include the Cognitive Status, Risk for Emergency Department visits and Hospital Readmission, Patient-specific Interventions and Education, & Measurable Outcomes/Goals with progression towards Goals. 3. Patient #2, SOC 01/12/2022, POC was reviewed for the certification period 05/07/2023-07/05/2023. The POC failed to include the Cognitive Status, Risk for Emergency Department visits and Hospital Readmission, Patient-specific Interventions and Education, & Measurable Outcomes/Goals with progression towards Goals. 4. Patient #3, SOC 02/18/2013, POC was reviewed for the certification period 04/27/2023-06/25/2023. The POC failed to include the Risk for Emergency Department visits and Hospital Readmission, Patient-specific Interventions and Education, & Measurable Outcomes/Goals with progression towards Goals. 5. Patient #4, SOC 06/28/2022, POC was reviewed for the certification period 04/24/2023-06/22/2023. The POC failed to include the Cognitive Status, Risk for Emergency Department visits and Hospital Readmission, Patient-specific Interventions and Education, & Measurable Outcomes/Goals with progression towards Goals. 6. Patient #5, SOC 03/11/2016, POC was reviewed for the certification period 06/03/2023-08/01/2023. The POC failed to include the Risk for Emergency Department visits and Hospital Readmission, Patient-specific Interventions and Education, & Measurable Outcomes/Goals with progression towards Goals. 7. Patient #6, SOC 01/20/2023, POC was reviewed for the certification period 03/21/2023-05/19/2023. The POC failed to include the Risk for Emergency Department visits and Hospital Readmission, Patient-specific Interventions and Education, & Measurable Outcomes/Goals with progression towards Goals. 8. Patient #7, SOC 09/21/2022, POC was reviewed for the certification period 01/19/2023-03/19/2023. The POC failed to include the Cognitive Status, Risk for Emergency Department visits and Hospital Readmission, Patient-specific Interventions and Education, & Measurable Outcomes/Goals with progression towards Goals. 9. During an interview on 06/19/2023 at 2:45 PM. the Administrator acknowledged Cognitive Status and Risk for Emergency Department visits and Hospital Readmission were absent from POC. 10. During an interview on 6/20/2023 at 2:25 PM. the Administrator stated Rehab Potential in POC was sufficient for Patient Goals and agreed Patient-specific Interventions and Education, & Measurable Outcomes/Goals with progression towards Goals not included on POC. 17-13-1(a)(1)(xiii)