Every finding on record at Medicall Home Health Services, LLC

A recertification survey was initiated on 9/16/25. Agency census: Licensed and Certified Home Health – 83 Licensed Home Health – 0 Personal Assistance Services – 132 Total Census – 215 Intake 521322

A recertification survey was initial on 9/16/25. Agency census: Licensed and Certified Home Health – 83 Licensed Home Health – 0 Personal Assistance Services – 132 Total Census – 215 Intake 521322 Abbreviations: LVN-licensed vocational nurse

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 patients' plan of care was complete and included all the required elements including patient specific interventions in 1 (Patient # 1) of 5 records reviewed. The plans of care failed to include interventions specific to diagnosis of chronic systolic congestive heart failure (the heart’s main pumping chamber, the left ventricle, is weak and enlarged, so it can’t squeeze blood out to your body forcefully enough over a long period) for monitoring for heart failure. These failures placed a patient at risk of an exacerbation of heart failure with subsequent emergency room visits and/or hospital re-admissions. Findings include: Patient #1-review of Patient #1’s chart revealed a plan of care dated 7/28/25 through 9/25/25 with a start of care of 7/28/25. The plan of care was electronically signed by the Alternate Supervising Nurse on 8/2/25 with a diagnosis of chronic systolic congestive heart failure (the heart’s main pumping chamber, the left ventricle, is weak and enlarged, so it can’t squeeze blood out to your body forcefully enough over a long period). The plan of care did not include the interventions monitoring for heart failure and parameters for reporting to the physician. An interview was conducted on 9/17/25 at 12:23 am with the Administrator/Supervising Nurse. The surveyor reviewed the Plan of Care for Patient #1 with Administrator/Supervising Nurse in that the plan of care did not include interventions to monitor for fluid overload with a diagnosis of congestive heart failure. Administrator/Supervising Nurse said, “That is the design that we have with this new software. I have been addressing the problems with the software company.” The surveyor asked how the plan of care not including interventions specific to the patient’s primary diagnosis could affect the patients. Administrator/Supervising Nurse said, “It is addressed, the patient has a plan of care in their home.” An interview was conducted on 9/24/25 12:23 pm with the Alternate Supervising Nurse. The surveyor asked the Alernate Supervising Nurse who was responsible for ensuring the plan of care for Patient #1 included specific interventions and treatments. The Alternate Supervising Nurse said, “I am.” The surveyor reviewed Patient #1’s plan of care in that it failed to include interventions to monitor for fluid overload for congestive heart failure. The Alternate Supervising Nurse said, “With this new software we can’t put in our own interventions.” The surveyor asked the Alternate Supervising Nurse how interventions not being in the plan of care to monitor for heart failure could affect the patient.” The Alternate Supervising Nurse said, “It’s not directing the LVN’s on the interventions needed.” Agency policy Plan of Care PC.35 revised 050224 read in part…”Purpose To ensure the care provided is appropriately planned in a timely manner to meet the patient’s/client’s specific needs and problems…Policy I. The Agency will use data/information gathered during patient/client assessment in the care planning process which involves the identification of patient/client goals, actions or interventions that will resolve or alleviate the patient’s/client’s problems and/or needs…III. A. The individualized Plan of care must include the following: …14. Patient/client-specific interventions and education.”…