Every finding on record at Platinum Home Health Services Ltd

AMENDED 10/22/24 SUBSTANTIAL ALLEGATION SURVEY SUBSTANTIAL ALLEGATION 109166 EXTENDED SURVEY At the time of the substantial allegation extended survey completed on 09/24/24, Platinum Home Health Services is in compliance with the provisions of 42 CFR Part 484, Subpart B, C, Home Health Agencies.in regard to allegations contained in substantial allegation number 109166.

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: See G572, G574, G580 and G588. Based on record review and interview, the agency failed to ensure a comprehensive assessment was done the last five days of every 60 days beginning with the start of care date. This affected two (Patients #1 and #2) of three patient records reviewed. The census was 139. Findings include: 1. Review of the medical record for Patient #1 revealed a comprehensive assessment was not completed every 60 days. 2. Review of the medical record for Patient #2 revealed a comprehensive assessment was not completed every 60 days. During an interview on 09/23/24 at 11:30 AM., the Director of Nursing confirmed a comprehensive assessment was not done every 60 days. Review of the agency policy titled “Client Reassessment/Update of Comprehensive Assessment” with no effective date revealed reassessment of the comprehensive assessment must be done at least every second calendar month beginning with start of care (within last 5 days of the episode, including day 60).

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on record review and staff interview, the agency failed to ensure all patients received 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; failed to ensure the physician’s plan of care included all the diagnoses, type of service to provide, supplies and equipment needed, frequency and duration of visits, rehabilitation potential, activities permitted, nutritional requirements or safety measures to protect against injury; failed to ensure all services were by physician’s order; and failed to ensure the individualized plan of care was reviewed and revised by the physician no less frequently than once every 60 days, beginning with the start of care date. See G572, G574, G580 and G588.

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 all patients received 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. This affected one (Patient #2) of two non-skilled patient records reviewed. The census was 139. Findings include: Review of the medical record for Patient #2 did not reveal a physician’s plan of care. During an interview on 09/23/24 at 2:15 PM, the Director of Nursing (DON) was unable to provide a physician's plan of care. he DON provided the Aide Care Plan and stated this was their plan of care. The DON stated they follow the service plan by the case manager. The DON stated the service plan determines the needs of the patient 100 percent of the time. Review of the agency policy titled “Plan of Care” with no effective date revealed an individualized Plan of Care signed by a physician shall be required for each client receiving home health and personal care services.

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 physician’s plan of care included all the diagnoses, type of service to provide, supplies and equipment needed, frequency and duration of visits, rehabilitation potential, activities permitted, nutritional requirements or safety measures to protect against injury. This affected one (Patient #1) of one non-skilled patient with a plan of care reviewed. This could potentially affect all non-skilled patients. The census was 139. Findings include: Review of the medical record for Patient #1 and physician’s plan of care dated 07/12/23 did not reveal all the diagnoses, type of service to provide, supplies and equipment needed, frequency and duration of visits, rehabilitation potential, activities permitted, nutritional requirements or safety measures to protect against injury. During an interview on 09/24/24 at 11:58 AM, the Director of Nursing confirmed this finding. Review of the agency policy titled “Plan of Care” with no effective date revealed the Plan of Care shall include all pertinent diagnosis(es), principle and secondary, including dates of onset, type, frequency, and duration of all visits/services, medical supplies and equipment required, rehabilitation potential, activities permitted or restrictions, specific dietary or nutritional requirements or restrictions and any safety measures to protect against injury.

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, interview and policy review, the agency failed to ensure all services were by physician’s order. This affected two (Patients #1 and #2) of two non-skilled patients reviewed. The census was 139. Findings include: 1. Review of the medical record for Patient #1 revealed home health aide (HHA) visit sheets for the weeks of 06/03/24 and 06/10/24 documented the HHA provided 15 hours per week for assistance with personal care and activities of daily living. There were no signed physician’s orders for these services. 2. Review of the medical record for Patient #2 revealed HHA visit sheets for the weeks of 04/08/24 and 04/15/24 documented the HHA provided 20 hours per week for assistance with personal care and activities of daily living. There were no signed physician’s orders for these services. During an interview on 09/23/24 3:22 PM, the Director of Nursing confirmed there were no signed physician’s orders for the services provided. Review of the agency policy titled “Physician’s Orders” with no effective date revealed all medications, treatments and services provided to clients must be ordered by a Physician.

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on record review, interview and policy review, the agency failed to ensure the individualized plan of care was reviewed and revised by the physician no less frequently than once every 60 days, beginning with the start of care date. This affected two (Patients #1 and #2) of two non-skilled patient records reviewed. The census was 139. Findings include: 1. Review of the medical record for Patient #1 revealed a start of care 05/15/23 and a physician’s plan of care for the certification period 07/12/23 to 06/30/24. 2. Review of the medical record for Patient #2 revealed no physician’s plan of care. During an interview on 09/23/24 at 2:28 PM, the Director of Nursing (DON) stated they follow the service plan and sometimes the authorization period is up to one year. The DON was unable to provide a physician's plan of care for Patient #2. The DON provided the Aide Care Plan and stated this was their plan of care. The DON stated they follow the service plan by the case manager. The DON stated the service plan determines the needs of the patient 100 percent of the time. The DON confirmed the plan of cares were not reviewed every 60 days by a physician. Review of the agency policy titled “Plan of Care” with no effective date revealed the total Plan of Care shall be reviewed by the attending physician and agency personnel as often as the severity of the client's condition requires, but at least one time every 60 days.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review, interview and policy review, the agency failed to ensure a completed discharge summary was sent to the primary care practitioner. This affected two (Patients #1 and #2) of three discharged patients reviewed. The census was 139. Findings include: 1. Review of the medical record for Patient #1 revealed a discharge date of 06/17/24. No discharge summary was found. 2. Review of the medical record for Patient #2 revealed a discharge date of 05/23/24. No discharge summary was found. During an interview on 09/23/24 at 4:08 PM, the Director of Nursing confirmed there were no discharge summaries, and the physician had not been notified. Review of the agency policy titled “Client Discharge Process” with no effective date revealed documentation will show evidence that the decision was not made unilaterally. The client, family and physician participated in the decision to discharge client from the agency. Agency staff will complete a discharge summary, and a copy of the discharge summary is mailed to the physician upon request.