Every finding on record at Keystonecare Home Health, LLC

Based on the findings of an unannounced onsite complaint investigation conducted November 29, 2022, and completed off-site on November 30, 2022, Keystone Care, LLC was found not to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: 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 review of agency policy, clinical record (CR) reviews, and interview with agency staff, the agency failed to obtain a physician's signature on the Home Health Certification and Plan of Care (POC) in accordance with agency policy for one (1) of three (3) CR reviewed. (CR #3) Findings include: Review of agency policy "1.41 Physician Orders Homecare" on November 29, 2022, at approximately 1:30 P.M. states, "All orders must be signed by a physician and received back in the office within thirty (30) days." Review of CR on November 29, 2022, from approximately 10:30 A.M. to 12:30 P.M. revealed the following: CR #3, start of care October 15, 2022, contained a POC with certification period October 15, 2022, through December 13, 2022. The POC was signed by the physician on November 24, 2022. An interview with the agency President and Executive Director, the Executive Assistant, and the Senior Vice President of Operations confirmed the above findings.