Every finding on record at Passionate Home Health Services Inc

An Emergency Preparedness recertification survey was initiated on 08/01/2025. Census: Licensed and Certified- 37 Licensed Home Health- 0 Personal Assistance Services- 0 Agency remained in compliance with Conditions of Participation for Emergency Preparedness, no deficiencies were cited.

A recertification and complaint survey for Intake # 446256 was initiated on 08/01/2025. Census: Licensed and Certified- 37 Licensed Home Health- 0 Personal Assistance Services- 0 Acronyms: POC- Plan of Care SN- skilled nurse PAS- Personal Assistance Services SNV- skilled nurse visit DON- Director of Nurses/ Supervising Nurse EHR- Electronic Health Records

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 and interview, the agency failed to document in the patient record coordination of services between the Agency and all providers involved in the care for 5 (Patients #1, 2, 3, 4 and #5) of 5 active patients’ records reviewed whose POC included instructions for the SN to report a pain level above 5 to the physician. This meant the agency potentially failed to document information coordinated with physicians regarding patients elevated pain to address ongoing care and treatment interventions for pain management. FINDINGS INCLUDE: Patient #1: Record review revealed a POC dated 06/12/2025 to 08/10/2025 with a SOC date 06/12/2025. The POC included, “… Notify the Physician if: … Pain greater than 5/10 on a scale of 0-10, …” Review of the comprehensive assessment dated 06/12/2025 revealed the patient reported a pain level of 9, page 12. Page 36 noted, “COORDINATION OF CARE” with Physician, SN check marked and “Regarding: Plan of Care.” A blank section titled, “Physician Contacted regarding: Date: Time: Spoke with: “ The agency did not document coordination of care with the patient’s physician for the elevated pain level. Review of the SNV notes dated: 06/14/2025; 06/19/2025; 06/21/2025; 06/23/2025; 07/05/2025; 07/12/2025 and 07/26/2025 revealed the patient reported a pain level of 6. The SNV notes included a section on each note, “Care Coordination” with Physician; RN; Supervising Nurse; Clinical Manager” check marked. A “Comments:” section was blank on each SN note. The agency did not document coordination of care with the patient’s physician for the elevated pain level. Review of the patient’s record revealed no documented coordination of care with the patient’s physician for elevated pain levels. Patient #2: Record review revealed a POC dated 05/04/2025 to 07/02/2025 with a SOC date 03/05/2025. The POC included, “… Notify the Physician if: … Pain greater than 5/10 on a scale of 0-10, …” Review of the comprehensive assessment dated 05/03/2025 revealed the patient reported a pain level of 9, page 8. Page 25 noted, “COORDINATION OF CARE” with Physician, SN check marked and “Regarding: Plan of Care.” A blank section titled, “Physician Contacted regarding: Date: Time: Spoke with: “ The agency did not document coordination of care with the patient’s physician for the elevated pain level. Review of the SNV notes dated: 05/07/2025; 05/21/2025; 06/04/2025 and 06/08/2025 revealed the patient reported a pain level of 6. The SNV notes included a section on each note, “Care Coordination” with Physician; RN; Supervising Nurse; Clinical Manager” check marked. A “Comments:” section was blank on each SN note. The agency did not document coordination of care with the patient’s physician for the elevated pain level. Review of the patient’s record revealed no documented coordination of care with the patient’s physician for elevated pain levels. Patient #3: Record review revealed a POC dated 05/05/2025 to 07/03/2025 with a SOC date 05/05/2025. The POC included, “… Notify the Physician if: … Pain greater than 5/10 on a scale of 0-10, …” Review of the SNV notes dated: 05/29/2025 and 06/12/2025 revealed the patient reported a pain level of 6. The SNV notes included a section on each note, “Care Coordination” with Physician; RN; Supervising Nurse; Clinical Manager” check marked. A “Comments:” section was blank on each SN note. The agency did not document coordination of care with the patient’s physician for the elevated pain level. Review of the comprehensive assessment dated 07/03/2025 revealed the patient reported a pain level of 6, page 8. Page 25 noted, “COORDINATION OF CARE” with Physician, SN check marked and “Regarding: Plan of Care.” A blank section titled, “Physician Contacted regarding: Date: Time: Spoke with: “ The agency did not document coordination of care with the patient’s physician for the elevated pain level. Review of the patient’s record revealed no documented coordination of care with the patient’s physician for elevated pain levels. Patient #4: Record review revealed a POC dated 05/05/2025 to 07/03/2025 with a SOC date 05/05/2025. The POC included, “… Notify the Physician if: … Pain greater than 5/10 on a scale of 0-10, …” Review of the SNV notes dated: 06/03/2025 and 06/17/2025 revealed the patient reported a pain level of 6. The SNV notes included a section on each note, “Care Coordination” with Physician; RN; Supervising Nurse; Clinical Manager” check marked. A “Comments:” section was blank on each SN note. The agency did not document coordination of care with the patient’s physician for the elevated pain level. Review of the patient’s record revealed no documented coordination of care with the patient’s physician for elevated pain levels. Patient #5: Record review revealed a POC dated 05/13/2025 to 07/11/2025 with a SOC date 11/14/2024. The POC included, “… Notify the Physician if: … Pain greater than 5/10 on a scale of 0-10, …” Review of the comprehensive assessment dated 05/12/2025 revealed the patient reported a pain level of 9, page 8. Page 25 noted, “COORDINATION OF CARE” with Physician, SN check marked and “Regarding: Plan of Care.” A blank section titled, “Physician Contacted regarding: Date: Time: Spoke with: “ The agency did not document coordination of care with the patient’s physician for the elevated pain level. Review of the SNV notes dated: 05/16/2025; 05/23/2025 and 06/16/2025 revealed the patient reported a pain level of 6. The SNV notes included a section on each note, “Care Coordination” with Physician; RN; Supervising Nurse; Clinical Manager” check marked. A “Comments:” section was blank on each SN note. The agency did not document coordination of care with the patient’s physician for the elevated pain level. Review of the patient’s record revealed no documented coordination of care with the patient’s physician for elevated pain levels. In an interview with the Administrator/DON at 1:45 PM, the surveyor reviewed the findings from the patient records review. The surveyor asked if anyone else in the agency was making home visits to patients. The Administrator/DON stated, “at this time, I’m the only one.” The surveyor asked if the Administrator/DON was the clinician that completed all the SNV’s for Patient’s #1-5 that were reviewed. Administrator/DON said, “Yes.” The surveyor asked why there was no coordination with the physicians when the Patients #1, 2, 3, 4 and 5 had elevated pain levels, (above the physician ordered parameter). The Administrator/DON stated, “when it’s (level) 8 or 9 they (physician) start a new medication or the patient can go for a steroid injection. I call the doctor, they (physicians) are always available.” The surveyor asked why no communication notes were found regarding elevated pain levels. The Administrator/DON stated, “when it’s high (pain level) I call the doctor and they give us a new order and it’s written on the medication profile.” The surveyor stated medication profiles were reviewed with the patient records and the medications were the same as the plans of care, no additional pain medications were added to the medication profiles. The surveyor asked if the EHR pre-filled the medication profiles when the comprehensive assessments were completed. The Administrator said, “Yes.” The surveyor asked why there was no coordination of care documented that the physician had been notified of the elevated pain levels for Patient’s #1, 2, 3, 4 and 5 as directed on the plans of care. The Administrator stated it should have been documented, but she must not have documented it (coordination of care). The surveyor asked if the agency consultant reviewed the SNV notes. The Administrator/DON stated everything was reviewed quarterly by the consultant. Agency policy, dated 05/01/2024, quoted in part, “Monitoring Patient Care/Coordination of Care, PC. 45, Purpose: To ensure coordination of patient/client care and treatment. Policy: … I. The Agency will monitor, evaluate, and report to the patient’s/client’s physician and/or non-physician practitioner regarding the patient’s/client’s progress toward achieving goals established on the plan of care. … Procedure: III. … This will be documented on a communication note and will serve as coordination of care. …”