Every finding on record at Full-Care Home Health, LLC

Substantial Allegation Survey Substantial Allegation 101376 The following deficiency is based upon substantial allegation 101376 completed on 11/01/23. Full-Care Home Health 368243, is not in compliance with the requirements found at 42 CFR Part 484, Subpart B, C for 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 record review, interview, and policy review, the agency failed to ensure that each patient received the home health services that are written in the individualized plan of care for two of three patients reviewed for care and services at the frequency/duration ordered, care planned or scheduled (Patient #10 and #40). This could affect all patients receiving services for the agency. The current patient census was 39. Findings include: 1. Review of Patient #40's medical record revealed a 04/12/23 start of care date. Review of the physician ordered plan of care for the certification period dated 04/12/23 through 06/10/23 and 08/10/23 through 10/08/23 revealed the patient was to receive 20 hours of home health aide services per week. Review of the time sheets revealed for the week of 05/01/23 revealed the patient was provided 14.5 hours of home health aide services instead of 20 hours as care planned. The time sheet was approved for 20 hours, and the agency billed for 20 hours when 14.5 hours were provided. There was no physician notification that hours were not provided as ordered. Review of the time sheets for the week of 05/08/23 revealed the patient was provided 18.25 hours of home health aide services instead of 20 hours as care planned. The time sheet was approved for 20 hours, and the agency billed for 20 hours when 18.25 hours were provided. There was no physician notification that hours were not provided as ordered. Review of the time sheets for the week of 05/22/23 revealed the patient was provided 11.5 hours of home health aide services instead of 20 hours as care planned. There was no physician notification that hours were not provided as ordered. Review of the time sheets for the week of 08/07/23 revealed the patient was provided 14 hours of home health aide services instead of 20 hours as care planned. The time sheet was approved for 20 hours, and the agency billed for 20 hours when 14 hours was provided. There was no physician notification that hours were not provided as ordered. There were no hours provided 08/14/23 or 08/15/23. A Communication Note 08/14/23 indicated the patient was unable to open the door for the Home Health Aide (HHA), leading to a missed visit. Subsequently, the agency contacted the patient, who declined entry to the home health aide due to a missing key fob. The case manager was notified but there was no evidence of physician notification that hours were not provided as ordered. A Communication Note 08/15/23 indicated the agency reached out to the client to arrange for a replacement aide, but the patient declined and expressed a desire to temporarily be put her home health aide services on hold. She preferred to wait until she could persuade her daughter to take on the role as caregiver. The case manager was notified, but there was no documentation the physician was notified that services were put on hold. Interview 10/31/23 at 2:39 P.M. with Staff C revealed she did not know she had to contact the agency when she finished her work and went home early. Interview 10/31/23 at 3:21 P.M. with Staff D verified the aide did not provide the weekly hours as ordered on the plan of care. Further, the agency did not notify the physician of missed hours of care. 2. Review of Patient #10's medical record revealed a start of care date of 10/11/11. Review of the physician ordered plan of care for October 2022 through current revealed the patient was to receive 54 hours a week of home health aide services. Review of the time sheets from October of 2022 through current revealed the home health aide was only working 53 hours a week; however the agency was billing for 54 hours a week. Review of the communication log revealed no reason for the missed hour weekly. There was no documentation the patient's physician was notified that services were not provided as ordered during this past year. Interview 10/31/23 at 5:12 P.M. with Staff D verified the aide did not provide the weekly hours ordered on the plan of care. Further, the agency did not notify the physician of missed hours of care. The agency also billed for more hours than care provided. Review of the undated Missed Visit Policy revealed in the event that a home health care visit cannot be completed as scheduled, the responsible caregiver must immediately notify the supervisor and the client/patient or their designated representative of the situation. The caregiver should document the reason for the missed visit, whether it is due to unforeseen circumstances, emergencies or any other valid reason. Every effort should be made to reschedule the missed visit at the earliest convenience time for both the client/patient and the caregiver. The rescheduled visit should be documented in the client record. The supervisor must be promptly informed of any missed visit, and the caregiver should provide a detailed explanation of the circumstances leading to the missed visit. All details related to the missed visit, including the reason, actions taken, and communication with the client/patient, should be accurately documented in the client's record. A follow up communication with the patient/client should be conducted to address any concerns or questions they may have regarding the missed visit. This communication should be documented. The policy did not include that they would notify the physician or the case manager of the missed visit. This deficiency represents non-compliance investigated under Substantial Allegation 101376.

EMERGENCY PREPAREDNESS SURVEY At the time of the emergency preparedness survey completed on 10/26/22, Full-Care Home Health is in compliance with the provisions of 42 CFR Part 484.102, Conditions of Participation for Home Health Agencies

Partial Extended Recertification Survey The following deficiencies are based on the partial extended recertification survey completed on 10/26/22. Full-Care Home Health is not in compliance with the requirements found at 42 CFR Part 484, Subpart B, C, 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, interview and policy review, the agency failed to ensure the plan of care included all services that were being provided. This had the potential to affect one (Patient #1) of one patients receiving physical therapy services. The census was 36. Findings include: Review of Patient #1's medical record revealed a start of care date of 9/24/19 with diagnosis of infantile spinal muscular atrophy. Review of the plan of care for the recertification period of 9/08/22 through 11/06/22 revealed the patient was receiving skilled nursing and home health aide services. On 09/07/22 a physical therapy recertification was completed and services were extended to include further therapy visits twice a week for eight more weeks. Review of physical therapy notes revealed the patient was seen twice a week from 9/07/22 through 10/19/22. During a home visit on 10/24/22 at 12:55 PM with Patient #1, Physical Therapy Assistant (PTA) #1 revealed the patient stated he has been receiving physical therapy services for over a year. PTA #1 verified that he has been providing therapy services to Patient #1 for a year. During interview on 10/25/22 at 3:00 PM, the Administrator stated Patient #1 has been receiving physical therapy services for some time and verified that the plan of care did not reflect those services. Review of the agency policy titled "Plan of Care- CMS #485 and Physician Orders", undated, revealed the plan of care should include the types of services and frequency and duration of visits.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review, interview and policy review, the agency failed to ensure the skilled nurse provided wound care as ordered. This had the potential to affect one (Patient #7) of two discharged patient medical records reviewed. The census was 36. Findings include: Review of Patient #7's medical record revealed a start of care date of 11/24/22 with a diagnosis of paraplegia. Review of the plan of care for the recertification period of 07/23/22 through 09/20/22 revealed the skilled nurse was to provide daily dressing changes to the patients' stage IV pressure ulcer located on the sacrum. Review of skilled nursing notes revealed the skilled nurse completed visits on 09/01/22, 09/05/22, 09/06/22, 09/07/22, 09/08/22, 09/12/22 and 09/13/22 but did not document the dressing change was completed. A discharge assessment was completed on 10/17/22 due to the patient's request to be discharged. During interview on 10/26/22 at 1:30 PM, the Director of Nursing (DON) verified the plan of care/physicians orders for the period of 07/23/22 through 09/20/22 revealed the order was for the skilled nurse to provide daily dressing changes to the Stage IV decubitus ulcer. The DON verified the order did not state the family was to provide dressing changes. Review of the agency policy titled "Wound Care", dated November 2016, revealed the nurse will provide wound care as ordered by the physician.