Every finding on record at Red Bud Regional Home Care Services, LLC

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 04/14/2022. The Facility was in compliance with the Condition, 42 CFR 484.102, Establishment of the EP Program, for this survey.

A recertification survey was conducted on 04/014/2022. The Agency was not in compliance with Standards for Home Health Agencies, 42 CFR 484, as evidenced by:

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 document review and staff interview, it was determined for 1 of 14 (P #8) patients receiving skilled nursing services, the agency failed to ensure the frequency/duration of visits for were provided as ordered. This has the potential to affect all patients receiving services from an agency with a current census of 200. On 04/13/2022 at 2:00 PM, the medical record of Pt #8 was reviewed. Pt #8 was admitted on 09/22/2021, with the primary diagnosis of quadriplegia. The plan of care for certification period 09/22/2021 to 11/20/2021 indicated skilled nursing services was ordered for once a week, for two weeks. There was no evidence that a skilled nursing visit was conducted during the first week of 22 Sep thru 25 Sep 2022. On 04/14/2022 at 3:00 PM, an interview with the Executive Director (E #1) was conducted. E #1 confirmed there was a missed skilled nursing visit the first week and stated "There should have been a visit conducted during that week".

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: A. Based on document review and staff interview, it was determined for 2 of 17 (Pt #4, Pt #8) patients, the agency failed to ensure the individualized plan of care included all/correct pertinent diagnoses. This has the potential to affect all patients receiving care from an agency with a current census of 200 patients. On 04/13/2022 at 2:00 PM, the medical record of Pt #8 was reviewed. Pt #8 was admitted on 09/22/2021, with the primary diagnosis of quadriplegia, as indicated on the plan of care for certification period 09/22/2021 to 11/20/2021. Progress notes from the referring agency indicated the patient was paraplegic. On 04/12/2022 at 2:00 PM, the medical record of Pt #4 was reviewed. Pt #8 was admitted on 01/30/2022, with the primary diagnosis of dementia, hemiplegia, atrial fibrillation, as indicated on the plan of care (POC) for certification period 03/31/2022 to 05/29/2022. There was no diagnosis related to the orders for wound care. The (POC) included orders for skilled nursing to "perform/instruct/reinforce patient/caregiver procedure of wound care to pressure ulcer to left elbow." On 04/14/2022 at 9:30 AM, the policy "Provision of Care, Treatment and Services", revised 12/01/21, was reviewed. It reads "2. The plan of care includes: h. pertinent diagnosis(es)." On 04/13/2022 at 10:30 AM, an interview with the Executive Director (E #1) was conducted. E #1 reviewed the medical record for Pt #4 and confirmed there was no diagnosis included in the POC addressing the patient's wounds. E #1 stated "There should have been a diagnosis included in the POC for the patient's wounds." On 04/13/2022 at 2:30 PM, another interview with E #1 was conducted. E #1 confirmed that the diagnosis on the plan of care for Pt #8 did not match the diagnosis on the paperwork that was received from the referring agency.