Every finding on record at Cherry County Hospital

Cherry County Hospital Home Health is in compliance with the requirements of 42 CFR 484.102 Condition of Participation for Home Health Agencies.

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, policy and procedure review, and staff interview, the agency failed to include on the physician approved plan of care, the patients risk for rehospitalization and emergency department visits and the interventions to address those risk factors, and the Physical Therapy (PT) and Occupational Therapy (OT) measurable outcomes, goals, interventions, and/or frequency and duration of services for 7 of 7 patient records reviewed (Patient 1-7). The census was 8. Findings are: A. Review of the agency policy and procedure titled, Plan of Care (485), revised 6/16, revealed the plan of care was to include prognosis, including goals of treatment, specific types of services, and the duration of visits, and other miscellaneous items (any other item). The policy did not specify the need to include all items required at 484.60(a)(2) on the plan of care. B. Review of clinical records revealed: 1. Patient 1's Home Health Certification and Plan of Care (485) for the certification period of 5/9/22 through 7/7/22 did not include the patient's risk for rehospitalization and emergency department visits and the interventions to address those risk factors and did not include PT and OT measurable outcomes, goals, and patient specific interventions to be used to meet the outcomes and goals. 2. Patient 2's Home Health Certification and Plan of Care (485) for the certification period of 4/21/22 through 6/20/22 did not include the patient's risk for rehospitalization and emergency department visits and the interventions to address those risk factors and did not include PT and OT measurable outcomes, goals, and patient specific interventions to be used to meet the outcomes and goals. 3. Patient 3's Home Health Certification and Plan of Care (485) for the certification period of 5/13/22 through 7/11/22 did not include the patient's risk for rehospitalization and emergency department visits and the interventions to address those risk factors and did not include PT and OT measurable outcomes, goals, and patient specific interventions to be used to meet the outcomes and goals. 4. Patient 4's Home Health Certification and Plan of Care (485) for the certification period of 4/15/22 through 6/12/22 did not include the patient's risk for rehospitalization and emergency department visits and the interventions to address those risk factors and did not include PT and OT frequency and duration of services, measurable outcomes, goals, and patient specific interventions to be used to meet the outcomes and goals. 5. Patient 5's Home Health Certification and Plan of Care (485) for the certification period of 5/18/22 through 7/16/22 did not include the patient's risk for rehospitalization and emergency department visits and the interventions to address those risk factors and did not include PT and OT measurable outcomes, goals, and patient specific interventions to be used to meet the outcomes and goals. 6. Patient 6's Home Health Certification and Plan of Care (485) for the certification period of 4/21/22 through 6/20/22 did not include the patient's risk for rehospitalization and emergency department visits and the interventions to address those risk factors. 7. Patient 7's Home Health Certification and Plan of Care (485) for the certification period of 4/21/22 through 6/20/22 did not include the patient's risk for rehospitalization and emergency department visits and the interventions to address those risk factors and did not include PT and OT measurable outcomes, goals, and patient specific interventions to be used to meet the outcomes and goals. C. During an interview on 5/24/22 at 5:00 PM the Director of Home Health/Clinical Manager (DHH/CM) confirmed the agency failed to include on the physician approved plan of care, the patient's risk for rehospitalization and emergency department visits and the interventions to address those risk factors, and the PT and OT measurable outcomes, goals, and interventions for Patient's 1-7, and failed to include the frequency and duration for PT and OT services for Patient-4. The DHH/CM also confirmed the policy titled Plan of Care (485) did not list all items as required by the regulation at 484.60(a)(2).