Every finding on record at Rolling Hills Healthcare, Inc.

Based on record review and interview the agency failed to ensure that care and services were provided in accordance with the plan of care in that hospice aide services were not conducted for 4 0f 14 patients (Patient #1, #4, #5 and #6) for which records were reviewed. Failure to follow the Plan of Care (POC) caused these patients to not receive care as ordered by the physician. --- Findings Included: Review of the clinical record for Pt #1 revealed a start of care date of 02/25/2025 with a terminal diagnosis of Senile Degeneration of the Brain. Review of the POC for the certification period 04/26/2025-06/01/25 revealed orders: HHA- 3WK8 (3 times per week for 8 weeks), 1WK1 (one time per week for 1 week). Review of the clinical record revealed HHA visits were provided 1 time during the week of 05/25/2025-05/31/2025 (Patient #1 was short 2 HHA visits). Review of the clinical record for Pt #4 revealed a start of care date of 04/28/2025 with a terminal diagnosis of Chronic Obstructive Pulmonary Disease (This long-term disease makes it hard to breathe). Review of the POC for the certification period 04/28/2025-06/28/2025 revealed orders: HHA services 2WK1, then 3WK12. Review of HHA visit notes revealed 1 HHA visit was conducted during the week of 04/28/2025-05/03/2025. During the week of 05/11/2025-05/17/2025 HHA visits were provided 2 times. During the week of 05/18/2025-05/24/2025 HHA visits were conducted 2 times. During the week of 05/25/2025-05/31/25 HHA services were provided 1 time.  Review of the clinical record for Pt #5 revealed a start of care date of 02/20/2025 with a terminal diagnosis of heart failure. Review of the POC for the certification period 04/21/2025-06/19/2025 revealed orders: HHA services 3WK8, 2WK1. Physician Orders dated 05/11/2025 read Effective 05/11/2025- HHA 2WK1, 3WK4 (3 times per week for 4 weeks), 2WK1. Review of the clinical record for the week of 05/18/2025-05/25/2025 revealed HHA services were provided 2 times. During the week of 05/25/2025-05/31/2025 HHA services were provided 1 time. Review of the clinical record for Pt #6 revealed a start of care date of 01/17/2025 with a terminal diagnosis of physical disability and aged related cognitive (mental) decline. Review of the POC for the certification period 04/17/2025-06/14/2025 revealed orders: HHA services 3WK12, 1WK1. Review of the clinical record for the week of 05/25/2025-05/31/2025 revealed HHA services were provided 1 time. On 08/05/2025 at 11:02 AM- An email request was sent to SN to request documentation of HHA visits or missed visit notes for Pt #1 for the weeks of 05/25/25-06/01/2025. Documentation of HHA visits or missed visits for Pt #4 for the weeks of 04/28/2025-05/3/25, 05/11/25-05/17/25, 05/18/25-05/24/25 and 05/25/25-05/31/25. Documentation of HHA visits or missed visit notes for Pt #5 for the weeks of 05/18/25-05/24/25 and 05/25/25-05/31/25. Documentation of HHA visits or missed visit notes for Pt #6 for the weeks 05/18/25-05/25/25 and 05/25/25-05/31/25. On 08/05/25025 at 12:21 PM SN replied through email. Regarding Pt #4 the case manager (RN- C) did not put the HHA order changes on the schedule. SN informed the surveyor that RN- C was no longer with the agency. SN stated Pts #5 & #6 did not receive HHA services because HHA #1 was out sick. Surveyor asked what the agency should have done to provide HHA services when the HHA was out sick. SN stated the assigned RN should provide personal care during the nurse visit. On 08/05/2025 at 12:48 PM- SN replied via email that at that time the agency only has one HHA because the agency did not have a large census. On 08/05/2025 at 3:33 PM a telephone interview was conducted with SN. Surveyor asked how the agency planned to provide HHA services when HHA #1 was unable to work. RN stated, “We have hired a second HHA (HHA #2). If there is no HHA available, the assigned RN should provide HHA services during the nurse visit.” Surveyor asked if any patients were harmed due to the failure. SN stated no. Surveyor asked who was responsible for review of patient’s medical records to ensure all visits and missed visits were documented. SN stated it was her responsibility. Surveyor asked if the MD was notified of the missed visits SN stated during IDG meetings any missed visits would have been discussed. On 08/06/2025 at 2:15 PM an interview was conducted with the A/ASN. The clinical records for Pts #1, #4, #5 and #6 were reviewed. A/ASN acknowledged HHA visits were not conducted as ordered, and HHA #1 failed to document the missed visits. A/ASN stated in July 2025 RN- C was demoted from Supervising Nurse to a RN Case Manager position. A/ASN stated she was terminated in October 2024 due to poor performance. A/ASN acknowledged the plan of care was not followed in that HHA services were not provided to Pts #1, #4, #5 and #6 as ordered. Contact information was requested for RN- C and RN- D. On 08/07/2025 at 10:15 AM a telephone interview was conducted with HHA #1. The clinical record for Pt #1 was reviewed. Surveyor asked if HHA visits were completed during the week of 05/25/25-05/31/25. HHA #1 stated, “No. I didn’t work that week because I had surgery. I notified RN- C that I would be absent during that time.” Surveyor asked if she documented missed visits during the week of 05/25/25-05/31/25 (2 missed visits). HHA #1 stated, “No. I didn’t think about it.”  In a continued telephone interview with HHA #1, the clinical record for Pt #4 was reviewed with HHA #1 for the weeks 04/28/25-05/03/25 (1 missed visit), 05/11/25-05/17/25 (1 missed visit), 05/18/25-05/24/25 (1 missed visit) and 05/25/25-05/31/25 (2 missed visits). HHA #1 acknowledged HHA visits were not conducted as ordered. Further interview and record review with HHA #1.The clinical record for Pt #5 was reviewed for the weeks of 05/18/25-05/24/25 (1 missed visit) and 05/25/25-05/31/25 (2 missed visits). HHA #1 stated she was on sick leave during that time period and did not complete the visits. The clinical record for Pt #6 was reviewed with HHA #1 for the week of 05/25/25-05/31/25 (2 missed visits). HHA #1 stated she was on sick leave during that time period and did not complete the visits. HHA #1 acknowledged she did not document the missed visits in the clinical record. Surveyor asked how many patients were assigned to her. HHA #1 stated, “I don’t know. I took care of 5-7 patients per day- Monday-Friday. I notified RN-C anytime I needed to take time off or was sick.” On 08/07/2025 at 10:50 AM a telephone interview was attempted with RN- C. The number was out of service. Review of the agency’s policy and procedure manual revealed a policy titled “The Plan of Care, Policy No. 4-027.1, Revised May 2023”, which read: “The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process. Care provided to the patient will be in accordance with the plan of care.”

Based on record review and interview the agency failed to document all missed visits for HHA services to show effective coordination of services in each patient record for 4 of 14 patients (Patient #1, #4, #5 and #6) for which records were reviewed., in thatThe agency failed to document 1 missed visit for Patient #1, The agency failed to document 5 missed visits for Patient #4. The agency failed to document 3 missed visits for Patient #5. The agency failed to document 2 missed visits for Patient #6.Failure to document missed HHA visits in the clinical record caused confusion regarding when HHA visits were missed, including the reason for the missed visit to ensure coordination of care with the IDG. --- Findings Included:Review of the clinical record for Pt #1 revealed a start of care date of 02/25/2025 with a terminal diagnosis of Senile Degeneration of the Brain. Review of the POC for the certification period 04/26/2025-06/01/25 revealed orders: HHA- 3WK8 (3 times per week for 8 weeks), 1WK1 (one time per week for 1 week). Review of the clinical record for the week of 05/25//2025-05/31/2025 revealed HHA visits were provided 1 time. The agency failed to document 2 missed visits during that period. Review of the clinical record for Pt #4 revealed a start of care date of 04/28/2025 with a terminal diagnosis of Chronic Obstructive Pulmonary Disease (his long-term disease makes it hard to breathe). Review of the POC for the certification period 04/28/2025-06/28/2025 revealed orders: HHA services 2WK1, then 3WK12. Review of HHA visit notes revealed 1 HHA visit was conducted during that time. The agency failed to document 1 missed visit. Review of visit notes for the week of 05/11/2025-05/17/2025 revealed HHA visits were provided 2 times. The agency failed to document 1 missed visit. Review of visit notes for the week of 05/18/2025-05/24/2025 revealed HHA visits were conducted 2 times. The agency failed to document 1 missed visit. Review of visit notes for the week of 05/25/2025-05/31/25 revealed HHA services were provided 1 time. The agency failed to document 2 missed visits. Review of the clinical record for Pt #5 revealed a start of care date of 02/20/2025 with a terminal diagnosis of Heart Failure. Review of the POC for the certification period 04/21/2025-06/19/2025 revealed orders: HHA services 3WK8, 2WK1. Physician Orders dated 05/11/2025 read Effective 05/11/2025- HHA 2WK1, 3WK4 (3 times per week for 4 weeks), 2WK1. Review of the clinical record for the week of 05/18/2025-05/25/2025 revealed HHA services were provided 2 times. The agency failed to document 1 missed visit. Review of visit notes for the week of 05/25/2025-05/31/2025 revealed HHA services were provided 1 time. The agency failed to document 2 missed visits.Review of the clinical record for Pt #6 revealed a start of care date of 01/17/2025 with a terminal diagnosis of physical disability and aged related cognitive (mental) decline. Review of the POC for the certification period 04/17/2025-06/14/2025 revealed orders: HHA services 3WK12, 1WK1. Review of the clinical record for the week of 05/25/2025-05/31/2025 revealed HHA services were provided 1 time. The agency failed to document 2 missed visits.A telephone interview was conducted on 08/05/2025 at 3:33 PM with SN. Surveyor asked who was responsible for review of clinical notes to ensure all visits and missed visits were accurately documented in the clinical records. SN stated it was her responsibility. Surveyor asked if the physician was notified of the missed visits for Pts #1, #4, #5 and #6. SN stated during IDG meetings missed visits were reported. On 08/07/2025 at 10:15 AM a telephone interview was conducted with HHA #1. The clinical record for Pt #1 was reviewed. Surveyor asked if HHA visits were completed during the week of 05/25/25-05/31/25. HHA #1 stated, “No. I didn’t work that week because I had surgery. I notified RN- C that I would be absent during that time.” Surveyor asked if she documented missed visits during the week of 05/25/25-05/31/25 (2 missed visits). HHA #1 stated, “No. I didn’t think about it.” The clinical record for Pt #4 was reviewed for the weeks 04/28/25-05/03/25 (1 missed visit), 05/11/25-05/17/25 (1 missed visit), 05/18/25-05/24/25 (1 missed visit) and 05/25/25-05/31/25 (2 missed visits). HHA #1 acknowledged HHA visits were not conducted as ordered and missed visit notes were not documented. The clinical record for Pt #5 was reviewed for the weeks of 05/18/25-05/24/25 (1 missed visit) and 05/25/25-05/31/25 (2 missed visits). HHA #1 stated she was on sick leave during that time period and did not complete the visits. HHA #1 acknowledged she did not document the missed visits in the clinical record. The clinical record for Pt #6 was reviewed with HHA #1 for the week of 05/25/25-05/31/25 (2 missed visits). HHA #1 stated she was on sick leave during that time period and did not complete the visits. Surveyor asked how many patients were assigned to her. HHA #1 stated, “I don’t know. I took care of 5-7 patients per day- Monday-Friday. I notified RN-C anytime I needed to take time off or was sick.  Review of the agency’s Policy and Procedure Manual revealed a policy titled “Missed Visits, Policy No. HH:2061.1, Reviewed 4/17” read, “Missed visits will be communicated to the clinical supervisor and the patient’s physician. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record.”