Every finding on record at Rapha Home Health Care LLC

Substantial Allegation Survey Substantial Allegation 61623 An entrance conference was conducted with administrative staff on 01/18/22 and an exit conference was conducted with administrative staff on 01/19/22. Rapha Home Health Care LLC 369250, was in substantial compliance with the requirements at 42 CFR Part 484 Subpart B, C for Home Health Agencies in regard to the allegations contained in substantial allegation 61623 completed on 01/19/22.

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 medical record review, staff interview, and policy review, the agency failed to ensure the individualized plan of care included the frequency and duration of visits to be made for one of three medical record reviewed (Patient #1). The agency census was 3. Findings include: Review of the policy titled Plan of Care - CMS #485 and Physician Orders Number 9.10.1, revised March 2019, revealed skilled nursing and other home health services will be in accordance with a Plan of Care based on the patient’s diagnosis and assessment of immediate and long range needs and resources. The individualized plan of care must include the frequency and duration of visits to be made. Review of the medical record for Patient #1 revealed a start of care date of 10/18/21 for diagnoses to include hypertension, diabetes, and chronic respiratory failure. Review of the plan of care revealed orders for home health aide services to assist with personal care needs and activities of daily living. The aide was to provide effective personal hygiene, assist with bathing, dressing, hair care, skin/foot care, and check pressure areas, assist with ambulation, transfer in/out of bathroom, and light housekeeping and report abnormal findings to the supervising nurse. The plan of care failed to include the frequency and duration of aide visits to be provided. Review of the home health aide visit notes revealed aide services were provided on 10/19/21, 10/20/21, 10/21/21, and 10/22/21. This finding was confirmed with Staff A in an interview on 01/18/22 at 3:31 PM.