Every finding on record at Dignity Home Health Service LLC

Substantial Allegation Survey Substantial Allegation 103634 An entrance conference was conducted on 01/25/24 at 9:20 AM with the Office Manager. An exit conference was conducted on 01/25/24 at 4:25 PM with administrative staff. No deficiencies were cited related to allegation contained in substantial allegation 103634 completed on 01/25/24; however, the facility was found not to be in compliance with all requirements for Home Health Agency participation and the following deficiencies are cited. Dignity Home Health Services LLC 369197, is in substantial compliance with the requirements at 42 CFR Part 484, Subpart B, C 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 review, and staff interview, the agency failed to ensure the written plan of care included patient-specific interventions and education, measurable outcomes and goals, types of service required and frequency and duration of visits to be made for three of three patient records reviewed (Patient #1, #2 and #3). The census was 19. Findings include: Review of the agency policy titled, “Plan of Care – CMS #485 and Physician’s Orders,” revised 10/2017, revealed each patient must receive an individualized written plan of care that must include patient-specific interventions and education, measurable outcomes and goals identified by the agency and the patient, types of service required and frequency and duration of visits to be made. 1. Review of Patient #1's medical record and the physician ordered plan of care dated 01/05/24 revealed the home health aide (HHA) was to provide 14 hours a week for one week and 35 hours per week for eight weeks. The plan of care did not include what service the HHA was supposed to provide and did not include any HHA - related measurable goals. 2. Review of Patient #2's medical record and the physician ordered plan of care dated 11/13/23 revealed the home health aide (HHA) was to provide 14 hours a week for eight weeks. The plan of care did not. The plan of care did not include what service the HHA was supposed to provide and did not include any HHA - related measurable goals. 3. Review of Patient #3's medical record and the physician ordered plan of care dated 10/24/23 revealed it did not include what services were to be provided, no frequency and duration of visits, and no measurable goals and outcomes. Interview on 01/25/24 at 3:50 PM with Staff E confirmed the plans of care did not include the required components.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review, policy review, and staff interview, the agency failed to ensure services provided were according to physician’s orders for one of three patients reviewed (Patient #3). This could affect all patients receiving services from the agency. The census was 19. Findings include: Review of agency policy titled, “Plan of Care – CMS #485 and Physician’s Orders,” revised 10/2017, revealed care and services provided will be provided according to physician’s orders. Review of Patient #3's medical record and physician ordered plan of care dated 10/24/23 revealed a start of care date of 10/24/23. The plan of care did not include any orders for the services to be provided. Further review of the record revealed the registered nurse opened the case on 10/24/23. Review of the visit notes from 10/31/23 to 12/19/23 revealed home health aide (HHA) services were provided twice a week for five hours a day. Interview on 01/25/24 at 12:28 PM with Staff E confirmed there were no orders for the services provided.