Every finding on record at Able Care, L L C

A Medicare emergency preparedness survey was conducted from 1/20/26 through 1/26/26 by the Michigan Department of Licensing and Regulatory Affairs at: Able Care 21790 Coolidge Highway Ste. B-107 48237 Oak Park, MI At the time of the survey, the agency had no other locations. Clinical records reviewed for this survey included 2 discharge records and 5 active records with 2 home visits. At the conclusion of the survey the agency was found to be in compliance with the conditions of participation for emergency preparedness at 42 CFR part §484.102.

A Medicare recertification survey was conducted from 1/20/26 through 1/26/26 by the Michigan Department of Licensing and Regulatory Affairs at: Able Care 21790 Coolidge Highway Ste. B-107 48237 Oak Park, MI At the time of the survey, the agency had no other locations. Clinical records reviewed for this survey included 2 discharge records and 5 active records with 2 home visits. At the conclusion of the survey the agency was found to be out of compliance with the conditions of participation for home health agencies at 42 CFR part §484.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the right of the patient to consent to or refuse care before treatment in 1 (P-1) of 7 records reviewed, potentially resulting in limited care options for this patient. Findings include: Patient #1 (P-1): This patient was admitted to the home health agency on 10/8/25 with a primary diagnosis of chronic obstructive pulmonary disease. The record was reviewed on 1/21/26. During review, it was noted that the agency’s home care consent form signed by P-1 on 10/8/25 did not include which initial disciplines would be providing care, or the frequency of care. Agency policy titled “Consent for Care/Treatment” (undated) was provided for surveyor review on 1/26/26. On page one (noted as page 256), it stated “To establish, from the onset, the patient/client/legal guardian’s permission for (agency) and it’s personnel to render care as requested and as per physician’s orders… Every effort shall be made to ensure the signer fully understands what he/she is agreeing to.” On 1/26/26 at 10:40 a.m., an interview was conducted with the agency Administrator (Adm-1) and the Clinical Director (CD-1). During the interview, CD-1 acknowledged this finding.

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure the physical therapist conducted an initial assessment within 48 hours of the physician referral in 1 (P-4) of 7 records reviewed (see G516); failed to ensure that a comprehensive assessment was completed timely in 1 (P-4) of 7 records reviewed (see G520); and failed to ensure the comprehensive assessment accurately reflected the patient’s current health status at the time of admission for 1 (P-4) of 7 records reviewed (see G528). The cumulative effect of these systemic problems resulted in the agency's inability to ensure the provision of quality care for the condition of participation at 42 CFR §484.55: Comprehensive assessment of patients.

Skilled professional performs assessment CFR(s): 484.55(a)(2) When rehabilitation therapy service (speech language pathology, physical therapy, or occupational therapy) is the only service ordered by the physician or allowed practitioner who is responsible for the home health plan of care, the initial assessment visit may be made by the appropriate rehabilitation skilled professional. For Medicare patients, an occupational therapist may complete the initial assessment when occupational therapy is ordered with another qualifying rehabilitation therapy service (speech-language pathology or physical therapy) that establishes program eligibility. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the physical therapist (PT) conducted an initial assessment within 48 hours of the physician referral in 1 (P-4) of 7 records reviewed, resulting in a delay in assessment of immediate care needs and the potential for a poor patient outcome. Patient#4 (P-4): This patient was referred to this agency with a physician referral dated 1/13/26 for PT services related to weakness and a diagnosis of congested heart failure. During an interview and record view on 1/26/26 at 1:36 PM, review found no evidence of an initial assessment by PT services. At time of discovery the administrator (ADM-1) and clinical director (CD-1) acknowledged and confirmed that an initial assessment was not completed within 48 hours.

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment was completed timely for 1 (P-4) of 7 total sample records reviewed, resulting in a delay in assessment of immediate care and support needs of the patient and the potential for poor patient outcomes. Patient #4 (P-4): This patient was referred to this agency with a physician referral dated 1/13/26 for physical therapy (PT) services related to weakness and a diagnosis of congested heart failure. During an interview and record review on 1/26/26 at 1:36 PM, no evidence was found of that the initial and comprehensive assessments were performed by PT services. At time of discovery the administrator (ADM-1) and clinical director (CD-1) acknowledged and confirmed the initial and comprehensive assessments were not completed.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: (1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure that a comprehensive assessment accurately reflected the patient's current health status at the time of admission for 1 (P-4) of 7 total sample records reviewed, resulting in incomplete clinical information gathering and possible poor patient outcomes. Patient #4 (P-4): The date of physician referral was 1/13/26 for physical therapy services. No evidence was found that the initial and comprehensive assessments (CA) were performed by the agency as of 1/26/26. During the interview on 1/26/26 at 1:36 PM, the administrator (ADM-1) and clinical director (CD-1) acknowledged and confirmed that the initial and comprehensive assessments were not completed.

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 and interview, the Physical Therapist (PT) failed to provide services in accordance with the Plan of Care (POC) for 1 (P-7) of 5 records reviewed with PT services, and failed to sign the plan of care for 1 patient (P-2) from a total of 7 sampled records reviewed, resulting in the potential for decline in physical functioning, unmet care needs and no physician oversite. Findings include: Patient #7 (P-7): The admission to home care was on 10/22/24, with diagnoses which included osteoarthritis, cerebral infarction (brain stroke), and Down syndrome. On 1/22/26, review of P-7's POC (effective 8/18/25) ordered Physical Therapy (PT) services to be provided at a frequency of once weekly times 9 weeks. On 1/22/26, record review noted PT missed 3 consecutive weekly visits (9/27/25, 10/2/25, and 10/9/25). The PT missed visit (MV) notes documented the following for each MV: "No Answer to Phone Call." Skilled nursing performed a ROC (resumption of care) visit on 9/26/25. There was no documented effort of PT services trying to make up any of the missed visits to fulfill the order. During an interview on 1/26/26 at 12:34, the Clinical Director (CD-1) and Administrator reviewed and acknowledged the above findings. CD-1 further stated, “That falls into my court." Patient #2 (P-2): The admission to home care was on 7/25/25, with diagnoses which included polyosteoarthritis, sacroiliitis, and L hip replacement. On 1/20/26, review of P-2's Plan of Care (POC) dated 7/25/25 had a physician signature date of 10/16/25, 83 days after the start of care (SOC). During an interview on 1/21/26 at 3:30 p.m., the Administrator (Adm-1) and the Clinical Director (CD-1), acknowledged the above finding.

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 and interview, the agency failed to ensure the Plan of Care (POC) was detailed and individualized in 4 (Patient/P-2, P-4, P-5 and P-7) of 7 total records reviewed, resulting in the potential for poor clinical outcomes and unidentified goals, unmet patient goals. Findings include: Patient #5 (P-5): This active patient had an admission to home care on 7/30/24, with diagnoses which included COPD (chronic obstructive pulmonary disease, CHF (congestive heart failure), diabetes type-2 and abnormal gait. During record review on 1/22/26, P-5's POC (effective 7/30/24) failed to have any type of pre-established weight or measuring parameters to monitoring for exacerbation (worsening) of fluid overload caused by P-5's CHF diagnosis. Further record review noted during a hospital admission, P-5's weight was documented as being 117 pounds on 1/28/25. Two days later during a resumption of care (1/30/25) by home care's PT services, noted a documented weight of 126 pounds. This 9-pound weight gain had no weight parameters to report, subsequently there was no physician communication found in the medical record of this significant weight gain. The POC also failed to include blood sugar safety parameters despite having an abnormally high reading (191 mg/dL) during the face-to-face physician visit on 8/29/24. During record review on 1/22/26, P-5's POC (7/30/24) noted 25 of 26 SN goals were not written in measurable terms that could be tracked and trended to show progress made (or lack of). In addition, 26 of 26 goals were generic, non-patient specific that had no improvement from a pre-established measurable baseline. Examples include as follow: "Patient will have no hospitalizations during certification period; The patient will be free from injury during certification period; Patient will be free from falls during certification period." Patient #7 (P-7): The admission to home care was on 10/22/24, with diagnoses which included osteoarthritis, cerebral infarction (brain stroke), and Down syndrome. During record review on 1/22/26, P-7's POC (10/22/24) noted 14 of 15 were not written in measurable terms that could be tracked and trended to show progress made (or lack of). In addition, 15 of 15 goals were generic, non-patient specific that had no improvement from a pre-established measurable baseline. Examples include as follow: "Patient will have no hospitalizations during certification period; The patient will be free from injury during certification period; Patient will be free from falls during certification period." Further, the one goal that was semi-measurable was written as follows: "Patient will achieve a pain level less than 0/10 within 2 weeks." This indicated P-7's pain, which was documented as "0" at the start of care, would be an acceptable goal if it had increased to 9/10 scale (10 being the worst possible) which would be inappropriate. During an interview on 1/26/26 at 12:28 PM, the Administrator and Clinical Director reviewed and acknowledged the above findings. Patient #4 (P-4) was admitted to the agency on 10/22/25 with a diagnosis of lymphedema, pressure ulcer stage 2, and chronic venous hypertension with ulcer of lower extremities. On 01/22/26, a review of the plan of care effective 10/22/25, revealed 21 out of 21 listed goals were not written in objective measurable terms. For example, “The Patient/Caregiver will verbalize and demonstrate edema-relieving measures by: 12/20/2025”. Another goal stated, “Patient will be without signs/symptoms of UTI (pain, foul odor, cloudy or blood-tinged urine and fever) during this episode”. During an interview on 1/26/26 at 1:00 PM, with the Administrator (ADM-1) and Clinical Director (CD-1), both reviewed and acknowledged the findings above. Patient #2 (P-2): The admission to home care was on 7/25/25, with diagnoses which included polyosteoarthritis, sacroiliitis, and L hip replacement. On 1/20/26, review of P-2's Plan of Care (POC) dated 7/25/25 revealed that only 1 of 17 goals were measurable. Example, "Wounds will heal without complications." Another example, "The Patient/Caregiver will verbalize understanding of symptoms of cardiac complications and when to call 911." There was no way to ascertain progress toward goals for 16 of the 17 patient goals. During an interview on 1/21/26 at 3:30 p.m., the Administrator (Adm-1) and the Clinical Director (CD-1), acknowledged the above finding.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the plan of care was revised after nursing services were added in 1 (P-1) of 7 records reviewed, resulting in no measurable outcomes or goals for nursing services to track patient progress. Findings include: Patient #1 (P-1): This patient was admitted to the home health agency on 10/8/25 with a primary diagnosis of chronic obstructive pulmonary disease. The record was reviewed on 1/21/26. During review, it was noted that the referral dated 10/1/25 included orders for physical therapy only. The start of care comprehensive assessment was completed on 10/8/25 by the physical therapist. The plan of care (POC) for the certification period of 10/8/25 through 12/6/25 included interventions, measurable outcomes and goals, and orders for physical therapy. A physician order dated 10/10/25 (2 days after the start of care) was noted in the medical record and included orders for skilled nursing (SN) once every other week to monitor cardiovascular status, medication regimen, and disease management. A nursing visit note titled "SN Evaluation” was completed on 10/10/25. There was no revision to the POC found within the medical record for the certification period stated above which included interventions, measurable outcomes, and goals related to nursing services. Agency policy titled “Plan of Care” (undated), was provided for surveyor review on 1/26/26. On page one (noted as page 317), it stated “The Plan of Care or service is developed or revised within three working days of the initiation of each service or of reassessment of the patient/client… The RN develops the care plan following the initial visit to best meet the patient/client needs.” On 1/26/26 at 10:40 a.m., an interview was conducted with the agency Administrator (Adm-1) and the Clinical Director (CD-1). During the interview, CD-1 acknowledged the above finding.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation and interview, the agency failed to ensure staff followed expected infection control standards of practice during 1 (P-1) of 3 joint home visits conducted during the survey, potentially resulting in the risk of communicable disease transmission. Findings include: On 1/21/26 at 3:30 p.m., a joint home visit was conducted with an agency physical therapy assistant (PTA-1). During the visit, PTA-1 was observed while retrieving unused gloves and vital sign equipment from his patient supply bag (brought in with him for the visit). After putting the unused gloves on and performing multiple patient tasks, PTA-1 placed both of his gloved hands (dirty) back into the bag to search for alcohol prep pads. When he was ready to clean his vital sign monitoring equipment with the alcohol prep pads, PTA-1 removed the glove from his right hand while holding the equipment in his gloved left hand (dirty) to wipe the equipment down. PTA-1 did not take the dirty glove off the left hand or cleanse his hands until after each piece of equipment had been wiped down. On 1/26/26 at 10:40 a.m., an interview was conducted with the agency Administrator (Adm-1) and the Clinical Director (CD-1). During the interview, the above findings were reviewed. CD-1 agreed that PTA-1 did not follow agency infection control expectation as he should not have used dirty gloves to enter his bag and should not have wiped down equipment without first removing both dirty gloves and washing his hands.

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on record review and interview, the home care agency failed to ensure skilled nursing (SN) provided appropriate supervision of services provided by the Licensed Practical Nurse (LPN) every 30 days for 1 (Patient/P-5) of 4 records reviewed with LPN services, resulting in a lack of supervision and oversight of patient care services and the potential for poor clinical outcomes. Findings include: Patient #5 (P-5): The admission to home care was on 7/30/24, with diagnoses which included COPD (chronic obstructive pulmonary disease, CHF (congestive heart failure) and abnormal gait. On 1/22/26, record review noted the Plan of Care (POC) ordered a SN visit frequency of once-a-week times 9 weeks effective 9/23/25. Further review noted the last documented RN supervisory note was on 10/23/25. LPN services provided subsequent care to P-5 on: 11/6/25, 11/13/25, 11/26/25 (after recertification), 12/10/25, 12/18/25, and 12/26/25. No evidence was found in the medical record indicating the RN had provided any supervision over LPN services since 10/23/25. The findings above were reviewed and acknowledged by the agency's Clinical Director (CD-1) during an interview on 1/26/26 at 12:14 PM. CD-1 was queried at 12:16 PM what the agency expectation was for the time interval that the RN was to document supervision of LPN services. CD-1 replied, "Every 30 days."

Rehab services supervised by PT, OT CFR(s): 484.75(c)(2) Rehabilitative therapy services are provided under the supervision of an occupational therapist or physical therapist that meets the requirements of §484.115(f) or (h), respectively. This ELEMENT is not met as evidenced by: Based on record review and interview, the home care agency failed to ensure Physical Therapy (PT) provided appropriate supervision of services provided by the Physical Therapy Assistant (PTA) every 30 days for 1 (Patient/P-7) of 3 records reviewed with PTA services, resulting in a lack of supervision and oversight of patient care services and the potential for poor clinical outcomes. Findings include: Patient #7 (P-7): The admission to home care was on 10/22/24, with diagnoses which included osteoarthritis, cerebral infarction (brain stroke), and Down syndrome. On 1/22/26, record review noted the Plan of Care (POC) ordered a PT visit frequency of once-a-week times 8 weeks effective 8/16/25 which was also the last documented PT supervisory note. P-7 had a PT re-evaluation on 10/14/25 with a visit frequency of once-a-week times 6 weeks. During the times noted above, PTA services provided care to P-7 on: 8/18/25, 8/27/25, 9/2/25, 9/8/25, 10/24/25 (after 3 consecutive missed visits and re-evaluation on 10/14/25), 10/30/25, 11/4/25, 11/11/25, and 11/17/25. No evidence was found in the medical record indicating the PT had provided any supervision over PTA services as required since 8/16/25. The findings above were reviewed and acknowledged by the agency's Clinical Director (CD-1) during an interview on 1/26/26 at 12:17 PM. CD-1 was queried at 12:19 PM what the agency expectation was for the time interval that PT was to document supervision of PTA services. CD-1 replied, "Every 30 days."

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the registered nurse included all pertinent safety measures in the home health aide (HHa) plan of care in 1 (Patient/P-7) of 1 record reviewed with home health aide services, resulting in the potential for the provision of unsafe care. Findings include: Patient #7 (P-7): The admission to home care was on 10/22/24, with diagnoses which included osteoarthritis, cerebral infarction (brain stroke), and Down syndrome. P-5's plan of care documented the following safety precautions: "Keep side rails up, slow position change, support during transfers and ambulation, seizure precautions..." When comparing these precautions to those listed on the HHa plan of care, it was noted the HHa plan of care failed to include seizure precautions or that the bed rails needed to be up to help ensure patient safety. These findings were reviewed with and acknowledged by the Administrator and Clinical Director during an interview on 1/26/26 at 12:18 PM.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on record review and interview, the Clinical Director (CD-1) failed to ensure the oversight of: coordination of patient care (see G0962); physician referrals for the initiation of home care services (see G0964); and the development of an individualized plan of care (see G0968), resulting in the agency’s potential mismanagement of resources essential for delivering optimal care, which may result in unmet care needs and poor patient outcomes. The cumulative effect of these systemic problems resulted in the Agency's inability to ensure the provision of quality health care in a safe environment for the condition of participation of 42 CFR§484.105 Organization and Administration of Services. .

Coordinate patient care CFR(s): 484.105(c)(2) Coordinating patient care, This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Clinical Director (CD-1) coordinated patient care for 1 (P-4) of 7 total sample records reviewed, resulting in the potential decline in physical functioning, unidentified health concerns and unmet care needs. Patient #4 (P4): This patient was recertified (12/21/25 to 2/18/26) with diagnoses of lymphedema and chronic venous hypertension with lower extremity ulcer. P-4 had a change in health insurance effective January 1, 2026, that resulted in the need for the agency to discharge the patient prior to the completion of this episode. The following outlines the admission, discharge, services performed, and continuity of patient care needs. Recertification episode (12/21/25-2/18/26) ordered skilled nursing (SN) services with a visit frequency of 1w8 (one day a week for eight weeks).12/22/25: Order to hold PT services.12/23/25: SN/LPN visit- Visit documented in the electronic medical record (EMR).12/29/26: SN/LPN visit- Documented in EMR as a late entry on 1/22/26.1/2/26 Discharge- Documented in the EMR as a late entry on 1/22/26.Services provided after discharge:1/6/26: SN/LPN visit- Not documented in the EMR.1/12/26: SN/LPN visit- Not documented in the EMR.1/22/26: SN/LPN visit- Not documented in the EMR.1/13/26 Physician referral for PT services The following record review and interview based on the outline above provides supported evidence of the agency’s lack of care coordination for P-4. The review of records on 1/21/26 noted an order dated 12/22/25 by the clinical coordinator (CD-1) that documented the following: "... patient is unable to tolerate Physical Therapy services... Physical Therapy on hold". This order is confusing considering PT was never ordered. No documented evidence of follow-up on the patient’s status or clarification of the need for PT services. The review of the Plan of Care (POC) effective 12/21/25, ordered for SN services with a visit frequency of 1w8. As of 1/21/26, the clinical record documented the patient was seen by SN (1 of 8 ordered visits) on 12/23/25. CD-1 was queried on 1/21/26 at 2:10 PM, regarding the lack of ordered SN visits and responded, “There should be an order to show that visits decreased”. No orders were evidenced that visits were to be decreased. Further review on 1/22/26 at 3:00 PM, noted that P-4's medical record was amended on 1/22/26 and included the clinical entries of an SN/LPN visit 12/29/25 and an Agency discharge dated 1/2/26. The interview continued at time of the review with ADM-1 and CD-1 acknowledging the above findings which did not reflect agency policy referenced below. Agency Policy: "Home Health Services Documentation", pg.263 (undated) stated," Documentation is completed in a timely manner...". Follow up interview with ADM-1 and CD-1 on 1/26/26 at 1:15 PM was performed to ascertain what timeliness meant. CD-1 responded to the agency’s expectation that documentation is to be updated and completed weekly starting Tuesday and ending every Monday. On 1/22/26 at 3:30 PM, ADM-1 and CD-1 were queried about P-4’s discharge from the agency. Both explained that P-4 remained an active patient and had three weekly visits (1/6/26,1/12/26, and 1/22/26) after discharge. ADM-1 and CD-1 further explained that the LPN cannot document visits until the discharge is processed in the EMR software. Further review of the record on 1/22/26 at 3:35 PM found no evidence of efforts from the agency to execute an alternative documentation method to verify services provided or coordinate patient care. ADM-1 and CD-1 reviewed and acknowledged the above findings, which did not reflect agency policy referenced below. Policy review on 1/26/26 titled, “Coordination of Services” pg.336, (undated) stated, "As an integral part of providing quality care to the patients/clients… it is necessary that the various disciplines (including physicians) involved in the care communicate with each other on a regular basis… Documentation of such communication shall be placed in the medical record.” On 1/26/26 the agency supplied this surveyor with a home care referral effective 1/13/26. The referral ordered "PT Service Need-Weakness". No evidence was found during the review of an attempt to coordinate PT services or that services had been performed. During the interview on 1/26/26 at 1:36 PM, ADM-1 and CD-1 reviewed and verified all findings above and that PT services were not provided as ordered.

Coordinate referrals; CFR(s): 484.105(c)(3) Coordinating referrals, This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Clinical Director (CD-1) coordinated referrals for 1 (P4) of 7 records reviewed, resulting in the potential decline in physical functioning, unidentified health concerns and unmet care needs. Patient #4 (P-4): This patient was recertified on 1/13/26, for physical therapy (PT) services related to weakness and a diagnosis of congested heart failure. Review of the clinical record on 1/26/26, noted a failure by the agency to incorporate the home care referral into the medial record. The agency however provided documentation that was outside of the agency's medical record to the surveyor on 1/26/26. This outside documentation was the physician's referral for home care on 1/13/26 which neglected any efforts by CD-1 to coordinate the provision of ordered PT services. The above findings were reviewed with and acknowledged by the administrator (ADM-1) and CD-1on 1/26/25 at 1:45 PM. Both further acknowledged that this did not meet agency expectation nor its policy referenced below. Agency Policy: “Referrals: Care, Treatment & Services”, pg.323, (undated) states, “Appropriate staff is assigned according to the disciplines ordered on the referral ... Actual “Start of Care” [sic] is usually within 24 hours of receipt of the referral, but no more than 48 hours...”.

Assure implementation of plan of care CFR(s): 484.105(c)(5) Assuring the development, implementation, and updates of the individualized plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Clinical Director (CD-1) provided oversight of the development, implementation, and updates of an individualized care plan for 1 (P4) of 7 records reviewed, resulting in the potential of unidentified health concerns and unmet care needs. Patient #4 (P-4): This patient was recertified (12/21/25 to 2/18/26) with diagnoses of lymphedema and chronic venous hypertension with lower extremity ulcer. During record review on 1/21/26, it was noted the Plan of Care (POC) effective 12/21/25, failed to incorporate the treatment/interventions needed to meet the clinical needs of the patient noted below. Evidence was noted during record review that strongly indicated P-4's need for weekly dressing changes and unna boot application (specialized treatment with, semi rigid compression bandages, medicated with zinc) noted below. The recertification physician face-to face (dated 12/10/25) documented under the HPI (history of present illness) section, “RN continue to come for dressing change/unna boots".OASIS-E1 Recertification (dated 12/18/25) under Skilled Interventions documented, “Recertification of skilled nursing services is medically necessary… recurrent skin integrity issues, chronic bilateral lower-extremity (BLE) lymphedema requiring ongoing weekly multilayer compression wraps and overall functional decline”. The last physician order on 8/23/25, documented “Weekly cleanse BIL lower extremities with NS wound cleanser, apply caloseptine and medahoney (medications to aid healing) to BIL lower extremities, apply triple layer unna boot, kerlix and coban”. [sic].The LPN visit note 12/23/25 documented "Writer (LPN-1) removed old UNA boots, applied new Unna boots to BLE (bilateral lower extremities) measuring 12 cm Ble. no open pressure ulcers or wounds. discoloration and redness present BLE...". [sic] The 12/29/25 LPN visit not also had documentation of unna boot application.Review of the POC found no interventions for dressing changes or multilayer compression wraps (unna boots) noted above. The administrator (ADM-1) and clinical director (CD-1) acknowledged and confirmed on 1/26/25 at 1:45 PM the findings above, which did not meet agency expectations or its policy referenced below. Agency Policy: “Plan of Care: Care, Treatment & Services”, pg.317 (undated) stated, “The Plan of Care or services consistently reflects current problems, goals and interventions corresponding to the care provided.”

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the clinical record was complete and included consent for treatment for home care services as required in 1 (Patient/P-7) of 7 total sample records reviewed, resulting in the agency not having a complete clinical record and the failure to secure HIPAA (Health Insurance Portability and Accountability Act) related documentation in an appropriate timeframe. P-7: The admission to home care was on 10/22/24, with diagnoses which included osteoarthritis, cerebral infarction (brain stroke), and Down syndrome. On 1/20/26 at 3:50 PM, record review of a binder which contained patient signed consents since 2023, found no evidence of P-7's consent for home care services. When agency's Clinical Director (CD-1) was asked to provide evidence of P-7's consent, CD-1 stated they would look for it. On 1/21/26 at 4:10 PM, a copy of P-7's consent from 10/22/24 was found in the patient consent binder. When CD-1 was queried where it was found since it was not made available on 1/21/26, CD-1 stated a clinician had kept the consent at their home since admission (last 15 months). Documented effort to retrieve the original copy of P-7's consent was not found in any agency records. The Administrator and CD-1 acknowledged the above findings during an interview on 1/26/26 at 12:05 PM.

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 and interview, the agency failed to ensure discharge summaries were sent to the physician within 5 business days of discharge in 4 (P-4, P-5, P-6 and P-7) of 4 records reviewed in which the patient was discharged from service; and failed to ensure transfer summaries were sent to the physician within 2 business days of transfer in 1 (P-5) of 1 record review with a hospital transfer, resulting in the physician not having knowledge of the patient's health status at the time of discharge and the potential to negatively affect all 10 patients currently receiving services from this agency. Findings include: Patient #5 (P-5): The admission to home care was on 7/30/24, with diagnoses which included COPD (chronic obstructive pulmonary disease, CHF (congestive heart failure) and abnormal gait. On 1/22/26, record review noted P-5 was discharged from PT services on 5/3/25 and on 1/26/26 at 11:25 AM during an interview, the agency's Administrator (Adm-1) and Clinical Director (CD-1) were asked to provide documentation to verify the time the discharge summary was sent out to the physician for review. Both Adm-1 and CD-1 acknowledged during the interview that the agency does not currently have a process in place that documents the time(s) discharge summaries are sent out. Further record review found that P-5 was transferred to the hospital on 1/28/25 due to GI (gastro-intestinal) issues. Adm-1 and CD-1 were asked at 11:28 AM to provide documentation to verify the time the transfer summary was sent out to the receiving hospital/physician for review. Again, both Adm-1 and CD-1 acknowledged during the interview that the agency does not currently have a process in place that documents the time(s) transfer summaries are sent out. Patient #7 (P-7): The admission to home care was on 10/22/24, with diagnoses which included osteoarthritis, cerebral infarction (brain stroke), and Down syndrome. On 1/22/26, record review noted P-7 was discharged from PT services on 12/10/25 and on 1/26/26 at 12:57 AM during an interview, the agency's Administrator (Adm-1) and Clinical Director (CD-1) were asked to provide documentation to verify the time the discharge summary was sent out to the physician for review. Both Adm-1 and CD-1 acknowledged again during the interview that the agency does not have a process that documents the time(s) discharge summaries are sent out. Patient #4- P-4’s start of care was on 10/22/25, episode period 10/22/25 to 12/20/25, for skilled nursing and physical therapy (PT) services. Record review on 1/21/26 indicated that the PT discharge summary was completed on 12/10/25 and signed by the physician on 1/12/26. There is no documented evidence that discharge summary was sent to the physician within 5 business days of the patient’s discharge. During the interview with the agency’s administrator (ADM-1) and clinical director (CD-1) on 01/21/26 at 12.34 PM it was confirmed that the discharge summary was not sent to the physician within 5 days of the patient’s discharge confirming findings above. Additionally, P-4 was recertified (12/21/25 through 2/18/26). The record review on 1/21/26 noted that the agency had a planned discharge on 12/30/25 that was not documented. During the interview with ADM-1 and CD-1 on 1/21/26 at 2:10 PM they explained P-4’s insurance changed from United Health Care to Humana effective January 1, 2026, requiring the patient to be discharged pending Humana authorization. During the interview with P-4 on 1/21/25 at 2:50 PM, he confirmed the new insurance began in January 2026. The record review on 1/22/26 at 3:00 PM noted that the discharge scheduled for 12/30/25 was completed on 1/2/26 by the registered nurse and documented to the record on 1/22/26 (20 days after discharge). There was no documented evidence that the discharge summary was sent to the physician within 5 business days of the patient’s discharge. During the interview with ADM-1 and CD-1 on 01/22/26 at 3:11 PM it was confirmed that the documentation of the 1/2/26 discharge was on 1/22/26 and that the discharge summary was not sent to the physician within 5 days of the patient’s discharge confirming findings above. Patient #6- P-6 was admitted on 08/25/25 for Physical Therapy (PT) services with the primary diagnosis of type 2 diabetes, heart failure, and a left ankle fracture. Record review on 01/21/26 indicates that the discharge OASIS (outcome and assessment information set) was completed by PT on 09/25/25. There was no documented evidence that a discharge summary was sent to the physician within 5 business days of the patient’s discharge. A review of the agency’s policy 1/26/26 titled “Discharge” pp. 156-157 (undated), states, “A discharge summary shall be completed on all patients from the agency with copies forwarded to the physician upon request”.

The following Condition level deficiencies were identified during a Medicare authorized Emergency Preparedness survey conducted by the Michigan Department of Licensing and Regulatory Affairs on 1/3/23 through 1/5/23 at: Able Care 21790 Coolidge Hwy, Suite B-107 Oak Park, MI 48237 At the conclusion of the survey, the following Conditions were identified: 42 CFR §484.102: Emergency Preparedness. As a result of the Condition level noncompliance, the Agency is prohibited for 2 years from offering a Home Health Aide training and competency evaluation or a competency evaluation program as specified in 42 CFR §484.80(f)(3).

Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to develop an Emergency Preparedness Program that included an all-hazards risk assessment, addressed patient population, services provided and delegation of authority, cooperation and collaboration, a communication plan, training, and testing. These practices could affect the health and safety of all agency patients in the event of a natural, man-made, or facility-based emergency. The cumulative effect of these systemic problems resulted in the agency's inability to ensure patient safety during an emergency which could result in the agency not providing quality health care. Findings include: 1. The agency failed to develop an emergency preparedness plan using a facility-based and community-based risk assessment and utilizing an all-hazards approach. (See E0006) 2. The agency failed to address patient population, identify types of services the agency would provide in an emergency and the delegation of authority in an event of an emergency. (See E0007) 3. The agency failed to include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. (See E0009) 4. The agency failed to develop and maintain an Emergency Preparedness communication plan and ensure the communication plan was reviewed and updated at least annually. (See E0029) 5. The agency failed to develop and maintain an Emergency Preparedness training and testing program that is based on the emergency plan, risk assessment, policies, procedures, and the communication plan. The training and testing program must be reviewed and updated at least annually. (See 0036)

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on record review and interview, it was determined the agency failed to develop an Emergency Preparedness Plan using a facility-based and community-based risk assessment, and utilizing an all- hazards approach, resulting in the potential to negatively affect all agency patients. Findings include: During review of the agency's EP program on 1/5/23 at 10:30 a.m., it was discovered that the agency had an all-hazards risk assessment sheet in the EP binder, but it was not filled out. During an interview on 1/5/23 at 12:15 p.m., the administrator (Adm#1) and the clinical manager (CM#1) were questioned about the blank document, they said that is what their consultant gave them. There was no documented evidence the agency had developed an emergency preparedness program based on an all-hazards assessment. During an interview at 12:15 p.m., Adm#1 and CM#1 acknowledged they were unaware of the all-hazards risk assessment requirement.

EP Program Patient Population CFR(s): 484.102(a)(3) §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: ["Persons at risk" does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This STANDARD is not met as evidenced by: Based on document review and interview, the facility failed to address patient population, identify types of services the Agency would provide in an emergency and the delegation of authority in an event of an emergency, resulting in the potential to hinder the agency's ability to provide continued patient care for all patients receiving care. Findings include: During review of the agency's emergency preparedness program on 1/5/23, it was discovered that the program failed to identify patient populations, and the type of services the agency could provide during an emergency. Further, delegations of authority and succession plans were not documented in program. These findings were acknowledged by the administrator (Adm#1) and the clinical manager (CM#1) during an interview on 1/5/23 at 12:15 p.m.

Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency. This STANDARD is not met as evidenced by: Based on record review and interview, the Home Health Agency (HHA) failed to include a process for cooperation and collaboration with local, regional, State and Federal emergency preparedness officials to maintain an integrated response during a disaster or emergency; and failed to document their efforts in contacting these officials to engage in planning for an integrated emergency response, resulting in ineffective Emergency Preparedness planning. Findings include: During a review of the agency's Emergency Preparedness Program and policies on 1/5/23 at 10:30 a.m., it was noted that the policy failed to include documented evidence of the facility's efforts to contact the above officials and, when applicable, of its participation in collaborative and cooperative planning efforts. These findings were reviewed with the administrator (Adm#1) and the clinical manager (CM#1) during an interview on 1/5/23 at 12:15 p.m. When questioned regarding the above concerns, Adm#1 and CM#1 said they were not aware of the requirement to contact, or document attempts to contact the above officials.

Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to develop and maintain an Emergency Preparedness communication plan and ensure the communication plan was reviewed and updated at least every 2 years. This deficient practice could affect the health and safety of all agency patients in the event of a natural, man-made, or facility-based emergency. Findings include: During a review of the agency's Emergency Preparedness Program and policies on 1/5/23 at 10:30 a.m., it was noted that the policy failed to include documented evidence of the facility's Emergency Preparedness communication plan that is reviewed and updated at least every 2 years. These findings were reviewed with the administrator (Adm#1) and the clinical manager (CM#1) during an interview on 1/5/23 at 12:15 p.m. When questioned regarding the above concerns, Adm#1 and CM#1 said their consultant gave them a lot of Emergency Preparedness information but did not show them how to put that information together into a program.

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to develop and maintain an Emergency Preparedness training and testing program that is based on the emergency plan, risk assessment, policies, procedures, and the communication plan. The training and testing program must be reviewed and updated at least every 2 years. This deficient practice could affect the health and safety of all agency patients in the event of a natural, man-made, or facility-based emergency. Findings include: During a review of the agency's Emergency Preparedness Program and policies on 1/5/23 at 10:30 a.m., it was noted that the program failed to include documented evidence of the facility's Emergency Preparedness initial employee training. The only training documented was in-services for employees. These findings were reviewed with the administrator (Adm#1) and the clinical manager (CM#1) during an interview on 1/5/23 at 12:15 p.m. When questioned regarding the above concerns, Adm#1 and CM#1 were unable to locate initial employee Emergency Preparedness training. They also stated that they were unaware of the requirement to have an Emergency Preparedness training and testing program.

The following Condition and Standard level deficiencies were identified during a Medicare authorized Recertification survey concurrent with the QSO 22-07-ALL Vaccine Mandate review, conducted by the Michigan Department of Licensing and Regulatory Affairs on 1/3/23 through 1/5/23 at: Able Care 21790 Coolidge Hwy, Suite B-107 Oak Park, MI 48237 Services provided: Skilled Nursing, Physical Therapy, Occupational Therapy, Medical social work, Speech Therapy and Home Health Aide. Records reviewed: 3 records with home visits, 2 active records without home visits, and 2 discharged records for a total of 7 records reviewed. At the conclusion of the survey, the following Conditions were identified: 42 CFR §484.70: Infection Control. 42 CFR §484.75: Skilled Professional Services. 42 CFR §484.102: Emergency Preparedness. As a result of the Condition level noncompliance, the Agency is prohibited for 2 years from offering a Home Health Aide training and competency evaluation or a competency evaluation program as specified in 42 CFR §484.80(f)(3).

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the Agency failed to ensure that 1 (MR's #6) of 3 patients observed during home visits, were included in the overall planning of care including informing the patient/caregiver in advance of the days and times in which services would be provided, from a total of 7 sampled records reviewed, resulting lack of inclusion in planning, the potential for missed visits and unmet care needs. Findings include: MR #6: The patient's start of care was 12/28/22 with diagnoses that included CVA (stroke) and Hypertensive Heart Disease. During the clinical record review on 1/4/23 at 9:30 a.m., it was noted that Skilled Nursing, Occupational Therapy, Physical Therapy and Speech Therapy services were ordered to be provided. On 1/4/23 at 4:30 p.m., a scheduled joint home visit was conducted with the Registered Nurse (RN #1). During a review of the patient's admission packet, it was noted that there was no calendar of proposed visits to be made by the RN. Upon completion of the visit, the patient verbalized that he has no idea when the disciplines will visit his home. Further, the patient stated, he would prefer to have his visits earlier in the day because his ride takes him to run his errands. Post visit, RN #1 was queried about his process for informing the patient of the scheduled visits and reported, "I sometimes use a calendar for the ones (patients) who can't remember, but he's (patient) with it so I just tell him when I'm coming back." When asked if it was the patient's preference to have evening visits, RN #1 reported, "Well, I have 2 jobs, so I see them (patients) when I can, after I leave work." The Nurse failed to ensure the patient was included in the overall planning of his care. These findings were reviewed with and acknowledged by the Administrator (Adm #1) and Clinical Manager (CM #1) during an interview on 1/5/23 at 9:41 a.m., to which Adm #1 responded, "He (RN #1) has another job, and our other nurse is on vacation."

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the patient received proper written notice (Notice of Medicare Provider Non-Coverage) in advance of the agency terminating on-going care for 1 (MR #5) of 2 discharged records, from a total of 7 sampled records reviewed, resulting in the patient being denied the right to appeal the decision to end Medicare covered services. Findings include: The patient's start of care was 10/4/22 with diagnoses that included Hypertensive Heart Disease and Chronic Kidney Disease. During the record review on 1/4/23 at 11:00 a.m., it was noted that the patient discharged from the Agency's services on 11/26/22. There was no documented evidence that the patient was provided the "Notice of Medicare Provider Non-Coverage" prior to being discharged from the Agency. The Agency failed to ensure the patient received proper written Notice of Medicare Provider Non-Coverage in advance of the agency terminating on-going care. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 1/4/23 at 2:00 p.m.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the Initial Comprehensive Assessment was conducted within 48 hours of the date of referral for 4 (MR's #4, 5, 6, 7) of 3 records where start of care services was delayed, from a total of 7 sampled records reviewed, resulting in delay in needed care and services and the potential for declining health status and unmet care needs. Findings include: MR #4: The patient's start of care (SOC) was 10/11/22 with diagnoses that included Hypertensive Heart Disease, Congestive Heart Failure, and diabetes Mellitus. During the clinical record review on 1/4/23 at 1:30 p.m., it was noted that the referral for home care was dated 10/3/22 and ordered Physical Therapy, Medical Social work, Skilled Nursing and Occupational Therapy. Upon further review, it was noted that the SOC was not conducted until 10/11/22 (8 days after the date of referral). The Agency failed to ensure the Initial Comprehensive Assessment was conducted within 48 hours from the date of referral. MR #5: The patient's SOC was 10/4/22 with diagnoses that included Hypertensive Heart Disease, Polyarthritis and Chronic Kidney Disease. During the record review on 1/4/23 at 11:00 a.m., it was noted that the referral for home care was dated 9/28/22 and ordered Skilled Nursing, Home Health Aide, Physical Therapy services to be provided. The SOC was conducted on 10/4/22 (6 days after the date of referral). The Agency failed to ensure the Initial Comprehensive Assessment was conducted within 48 hours from the date of referral. MR #6: The patient's SOC was 12/28/22 with diagnoses that included CVA/Stroke and Hypertensive Heart Disease. The referral foe home care was dated 12/20/22 and ordered Skilled Nursing, Occupational Therapy, Physical Therapy and Speech Therapy. During the clinical record review on 1/4/23 at 9:30 a.m., it was noted that the SOC was conducted on 12/28/22 (8 days after the date of referral to home care). The Agency failed to ensure the Initial Comprehensive Assessment was conducted within 48 hours from the date of referral. MR #7: The patient's SOC was 12/13/22 with diagnoses that included Arthritis, Chronic Kidney Disease, ESRD (End Stage Renal Disease and COPD (Chronic Obstructive Pulmonary Disease. During the record review on 1/5/23 at 10:34 a.m., it was noted that the referral for home care was dated 11/16/22 and ordered Skilled Nursing, Physical Therapy and Occupational Therapy. The SOC assessment was conducted 27 days after the date of the referral. The Agency failed to ensure the Initial Comprehensive Assessment was conducted within 48 hours from the date of referral. The findings identified in the above-mentioned records were reviewed with and acknowledged by the Administrator and Clinical Manager during interviews on 1/4/23 at 2:00 p.m., and again on 1/5/23. The Clinical Manager stated, "Sometimes we have to wait in order to verify insurances."

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status based on past medical history that included dates of onset, exacerbations, treatments and outcomes, and history of events leading to current home care needs; and fails to reflect the patient's current health status in 2 of 7 records reviewed (MR#s 1, 2), resulting in incomplete clinical information to aide in determining the needs of the patient. Findings included: MR #1: The SOC was dated 11/28/22. The Plan of Care (POC) identified the diagnoses of hemiplegia, cerebral infarct, hypertension and diabetes mellitus. A review of the Comprehensive Assessment (OASIS) on 1/3/23, showed under the category (M1021): "Patient Diagnoses", the only information provided was a list of diagnoses, all having the same onset and exacerbation date. There was no information about the onset, exacerbations, prior treatments and outcomes of the hypertension or diabetes diagnoses. MR#2: The SOC was dated 11/30/22. The Plan of Care (POC) identified the diagnoses of Poly osteoarthritis, hypertension and pain. A review of the Comprehensive Assessment (OASIS) on 1/3/23, showed under the category (M1021): "Patient Diagnoses", the only information provided was a list of diagnoses, all having the same onset and exacerbation date. There was no information about the onset, exacerbations, prior treatments and outcomes, or history of how the above illnesses/events led to the need for the current home care admission. The administrator (Adm#1) and the clinical manager (CM#1) acknowledged the above findings during an interview on 1/5/23 at 12:15 p.m.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the registered nurse conducted a review of the patient's medications for any potential adverse effects such as: side effects, drug interactions, and duplicate drug therapy for 4 of 7 (MR# 1, 2, 3, 6) records reviewed, and failed to notify the physician of adverse findings. This deficient practice results in the potential for unrecognized adverse effects due to medications that could affect all agency patients. Findings include: MR#1: This patient was admitted to the agency on 11/28/22 with diagnoses of hemiplegia, cerebral infarct, hypertension and diabetes. The comprehensive assessment was completed by physical therapy on 11/28/22. During record review on 1/3/23, it was noted that the comprehensive assessment documented under (M2001) that no issues were found during review of the medications. A medication review was acknowledged and signed by skilled nursing on 11/30/22, two days after the comprehensive assessment, and stated no issues found during medication review. A review of the medications on Drugs.com found 1 major, 40 moderate, 3 minor, 10 food and 2 duplicate medications. On the comprehensive assessment under (M2003), did the agency contact the physician by midnight of the next calendar day regarding adverse findings, was blank. There is no documented evidence in the record that the physician was notified of adverse medication findings. MR#2: The SOC was dated 11/30/22. The Plan of Care (POC) identified the diagnoses of Poly osteoarthritis, hypertension and pain. A review of the Comprehensive Assessment (OASIS) on 1/4/23, showed under the category (M2001) that physical therapy documented, "Medication issues were found." The Medication Record dated 12/2/22 and signed by skilled nursing stated, "No issues found." A review of the medications on Drugs.com found 1 major, 9 moderate, 1 minor, 4 food and 3 duplicate medications. On the comprehensive assessment under (M2003), did the agency contact the physician by midnight of the next calendar day regarding adverse findings, was blank. There is no documented evidence in the record that the physician was notified of adverse medication findings. MR#3: This patient was admitted to the agency on 9/27/22 with diagnoses of hemiplegia, cerebral infarct and poly osteoarthritis. The comprehensive assessment was completed by physical therapy on 9/27/22. During record review on 1/4/23, it was noted that the comprehensive assessment documented under (M2001) that issues were found during review of the medications. A medication review form was signed by skilled nursing on 11/28/22, for the recertification period. There is no evidence in the record that a skilled nurse reviewed the medications for the start of care certification period. A review of the medications on Drugs.com found 4 major, 4 moderate, 5 food and 3 duplicate medications. On the comprehensive assessment under (M2003), did the agency contact the physician by midnight of the next calendar day regarding adverse findings, was blank. There is no documented evidence in the record that the physician was notified of adverse medication findings. The administrator (Adm#1) and the clinical manager (CM#1) acknowledged the above findings during an interview on 1/5/23 at 12:15 p.m. MR #6: The patient's start of care was 12/28/22 with diagnoses that included Hypertensive Heart Disease and CVA (stroke). On 1/4/23 at 9:30 a.m., during the clinical record review, section M2001 of the "Initial Comprehensive Assessment" dated 12/28/22, completed by the Physical Therapist (PT) documented, "Yes - Issues found during (medication) review." There was no documented evidence of what issues had been identified during the review. The "Patient Medication Record" completed by the Clinical Manager (CM #1) documented, "Physician contacted regarding medication discrepancies: N/A (No discrepancies); Physician notified of severe medication interactions? N/A (No interactions)." The Medication Record was not consistent with the findings of the Drug Regime Review conducted by the PT. The patient's 11 prescribed medications were entered in "Drugs.com" (online medication interaction checker) and revealed: 1 major drug to drug interactions, 14 moderate drug to drug interactions, 1 major drug to food interaction and 5 moderate drug to food interactions. During the review, it was noted that CM #1 conducted the review 2 days after the SOC. There was no documented evidence that a drug review had been conducted at the SOC to determine any untoward reactions. Additionally, there was no documented evidence that the Physician had been notified of the identified interactions. These findings were reviewed with and acknowledged by the Administrator (Adm #1) and CM #1 during an interview on 1/5/23 at 9:41 a.m.

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 and interview, the Agency failed to ensure that services were provided in accordance with the Plan of Care for 1 (MR #5) of 1 patient who was ordered to receive Home Health Aide services, from a total of 7 sampled records reviewed, resulting in the potential for poor grooming and low self-esteem. Findings include: Policy: "Assessment & Care Planning" undated stated, "Care is provided to the patient/client based on the plan of care..." MR #5: The patient's start of care was 10/4/22 with diagnoses that included Hypertensive Heart Disease, Polyarthritis and Chronic Kidney disease. During the record review on 1/4/23 at 11:00 a.m., it was noted that the referral for home care dated 9/28/22 ordered Home Health Aide (HHa) services to be provided. The patient was discharged from the Agency's services on 11/26/22. At the time of this review, no HHa services had been provided. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 1/4/23 at 2:00 p.m.

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 and interview, the Agency failed to ensure the plan of care covered all pertinent interventions with reportable parameters, safety precautions and objectively measurable goals specific to the needs of the patient in 5 (MR's #1, 4, 5, 6, 7) of 5 records, from a total of 7 sampled records reviewed, resulting in patients not receiving care specific to their individual needs and the potential for poor patient outcomes. Findings include: Policy: “Assessment/Plan of Care” undated stated, “All pertinent diagnoses (include dates of onset and or exacerbation); Types of services, supplies; Treatment; Patient specific interventions, measurable outcomes and goals; Activities permitted and precautions, including safety measures; Therapy parameters will be provided consistent with the standards of practice; The plan may be expanded to meet the patient needs.” MR #4: The patient’s start of care (SOC) was 10/11/22 with diagnoses that included Hypertensive Heart Disease with Heart Failure and Diabetes Mellitus. During the clinical record review on 1/4/23 at 1:30 p.m., it was noted that the patient was ordered to receive Skilled Nursing, Physical Therapy (PT), Occupational Therapy (OT) and Medical Social Work (MSW) services. The plan of care (POC) revealed the following: The dates of the listed diagnoses all had the same date as the date of admission to the Agency (10/11/22), MSW indicated "N/A", however, the patient did receive MSW services. There was no frequency included. There was no CHF (Congestive Heart Failure) guidance including interventions to monitor weight and edema, reportable parameters or associated goals. There were no Diabetic goals. These findings were reviewed and acknowledged by the Administrator (Adm #1) and Clinical Manager (CM #1) during an interview on 1/5/23 at 9:20 a.m. MR #5: The patient's SOC was 10/4/22 with diagnoses that included Hypertensive Heart Disease, Chronic Kidney Disease and Polyarthritis. The record review was conducted on 1/4/23 at 11:00 a.m. and revealed the patient received dialysis three times per week and had an AV Graft/Fistula (dialysis access site) to her left arm. The POC was noted to be void of any CHF interventions which included monitoring weight and edema. There was no mention of the patient's dialysis access site or associated precautions such as bleeding, and there were no goals that addressed any of the above diagnoses or pain. These findings were reviewed with and acknowledged by Adm #1 and CM #1 during an interview on 1/4/23 at 2:00 p.m. MR #6: The patient's SOC was 12/28/22 with diagnoses that included Hypertensive Heart Disease and CVA (stroke). The POC ordered SN, PT, OT and ST services to be provided. During the review on 1/4/23 at 9:30 a.m., it was noted that the patient complained of 6/10 pain at the time of admission. The referral for home care indicated the patient had seizures and currently prescribed Carbamazepine (seizure medication). The referral also indicated the patient was prescribed a low salt diet. The POC was void of the needed seizure precautions, CHF management and reportable pain parameters. Additionally, there were no associated goals to address any of the above diagnoses. These findings were reviewed with and acknowledged by Adm #1 and CM #1 during an interview on 1/5/23 at 9:41 a.m. MR #7: The patient's SOC was 12/13/22 with diagnoses that included Chronic Kidney Disease, End Stage Renal Failure and Chronic Obstructive Pulmonary Disease. During the record review on 1/5/23 at 10:34 a.m., it was noted that the patient had underwent dialysis 3x/wk. and had a right chest wall (RCW) Permacath (used for dialysis). All the listed diagnoses on the POC reflected the same dates of onset/exacerbation (12/13/22). There were no safety precautions regarding the patient's RCW dialysis catheter. Further, there were no interventions or measurable goals that addressed the above diagnoses. These findings were reviewed with and acknowledged by Adm #1 and CM #1 during an interview on 1/5/23 at 11:39 a.m. MR#1: This patient was admitted to the agency on 11/28/22 with diagnoses of hemiplegia, cerebral infarct, hypertension and diabetes. During record review on 1/3/23, it was discovered that the patient's plan of care dated 11/28/22 failed to include bleeding/anticoagulant precautions, diabetic precautions, and blood sugar parameters for when to notify the physician. The administrator (Adm#1) and the clinical manager (CM#1) acknowledged the above findings during an interview on 1/5/23 at 12:15 p.m.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, it was determined that the Agency failed to ensure the Physician was promptly notified of 1 (MR #6) of 1 patient observed during a home visit with low vital signs, from a total of 7 sampled records reviewed, resulting in the potential for unaddressed health conditions, decline in physiological functioning and unmet care needs. Findings include: MR #6: The patient's start of care was 12/28/22 with diagnoses that included Hypertensive Heart Disease and CVA (stroke). During the record review on 1/4/23 at 9:30 a.m., it was noted that the plan of care ordered Skilled Nursing services to be provided and documented: "Notify Physician of pulse < (less than) 60." On 1/4/23 at 4:30 p.m., a scheduled joint home visit was conducted with the Registered Nurse (RN #1). During the visit, RN #1 placed a pulse oximeter unit (used to read pulse and oxygen level) on patients left ring finger and got a reading of 58 (outside of the reportable parameters). RN #1 stated, "Let me see if it will climb to 59." The patient's pulse reading remained at 58. RN #1 then wrote the reading on a piece of paper and concluded the visit. RN #1 did not promptly notify the Physician as indicated in the plan of care. The record was again reviewed on 1/5/23. There was no documented evidence that the Physician had been notified of the patient's low pulse rate. These findings were reviewed with and acknowledged by the Administrator (Adm #1) and Clinical Manager (CM #1) during an interview on 1/5/23 at 9:41 a.m.

Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This CONDITION is not met as evidenced by: Based on record review and interview, the Agency failed to maintain a coordinated agency-wide program for the surveillance, identification, and prevention of COVID-19; and failed to develop a method of screening all staff employed by this agency, specifically who were granted clinical privileges, resulting in the potential development and spread of a contagious viral infection between agency staff and the agency's 14 current patients (G684); failed to establish Vaccine protocol written policies and procedures that included (i) and (ii) the requirement for staff vaccination or exemption; (iii) implementation of additional precautions to mitigate the transmission and spread of Covid-19; (vii) a process for tracking/documenting information provided by staff who have requested/been granted an exemption from the Covid-19 requirements; (v) documentation of medical exemptions as appropriate; (xi) Contingency plans for staff who are not fully vaccinated for Covid-19, and failed to ensure that all staff were vaccinated or had an approved exemption in accordance with this requirement, resulting in the potential for the development and spread of the Covid-19 virus to staff and all patients serviced by this Agency (G687). The cumulative effect of these systemic practices may result in the inability of the Home Health Agency to provide quality services in a safe environment for the Condition of Participation: §484.70 Infection Control.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on record review and interview, the Agency failed to maintain a coordinated agency-wide program for the surveillance, identification, and prevention of COVID-19; and failed to develop a method of screening all staff employed by this agency, specifically who were granted clinical privileges, resulting in the potential development and spread of a contagious viral infection between staff and all patients currently serviced by this Agency. Findings include: On 1/4/23, the Agency's Administrator (Adm #1) was queried regarding the process or tool used for the screening of field staff for potential COVID-19 infections, prior to rendering care and services and reported, "Well, if they (field staff) are sick, they know to stay home." Adm #1 further reported, "They (staff) assess the patient for Covid-19 during the home visits." When asked if there was documented evidence that field staff were pre-screened for Covid-19 prior to the provision of care and services, Adm #1 was unable to provide such evidence. There was no documented evidence that field staff had been pre-screened for Covid-19 prior to providing care and services. The above findings were discussed with and acknowledged by the Administrator (Adm #1) at the time of discovery.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on record review and interview, the Agency failed to establish Vaccine protocol written policies and procedures that included (i) and (ii) the requirement for staff vaccination or exemption; (iii) implementation of additional precautions to mitigate the transmission and spread of Covid-19; (vii) a process for tracking/documenting information provided by staff who have requested/been granted an exemption from the Covid-19 requirements; (v) documentation of medical exemptions as appropriate; (xi) Contingency plans for staff who are not fully vaccinated for Covid-19, and failed to ensure that all staff were vaccinated or had an approved exemption in accordance with this requirement, resulting in the potential for the development and spread of the Covid-19 virus to staff and all patients serviced by this Agency. Findings include: On 1/3/23 at 11:00 a.m., during the Entrance Conference, a request was made to review the Agency's Vaccination policy. On 1/4/23, the Administrator (Adm #1) presented a document titled, "Guidelines for Coronavirus (Covid-19)." Upon review, it was noted that the document did not address any of the requirements of this section. Adm #1 provided a staff list with associated vaccination cards. Upon review, it was noted that of the 12 staff persons listed, 3 field staff had not been vaccinated or presented with any approved medical or religious waivers. These findings were reviewed with and acknowledged by Adm #1 and the Clinical Manager at the time of discovery.

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: Based on observation, record review and interview, it was determined that the Agency failed to ensure the Skilled Disciplines performed appropriate baseline assessments and re-assessments of the patient's health status and needs in 2 (MR's #4, 6) records of patients with diagnoses of Congestive Heart Failure, and Kidney Disease, from a total of 7 sampled records reviewed, resulting in the potential for unidentified health concerns, decline in physical functioning, and poor patient outcomes (G706); failed to ensure the Speech Therapist assisted the Physician in evaluating the patient's level of functioning and helped to develop the plan of care for 1 (MR #6) of 1 record in which Speech Therapy services were ordered due to difficulty speaking, from a total sample of 7 records reviewed, resulting in the potential for decline in physical functioning and unmet care needs (G708); failed to ensure skilled services were provided in accordance with the Physician's orders and Plan of Care for 3 (MR's #4, 6, 7) records, from a total of 7 sampled records reviewed, resulting in the potential for unidentified health concerns, physiological decline, and unmet patient care needs (G710); failed to ensure the clinical record was completed and included detailed Skilled Nursing and Physical Therapy notes for 2 (MR's #6, 7) records with the ordered services, from a total of 7 sampled records reviewed, resulting in the potential for undocumented, unidentified health concerns, and unmet patient needs (G716). The cumulative effects of this systemic problem resulted in the Home Health Agency's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation: 42 CFR 484.75 Skilled Professional Services.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on observation, record review and interview, it was determined that the Agency failed to ensure the Skilled Disciplines performed appropriate baseline assessments and re-assessments of the patient's health status and needs in 2 (MR's #4, 6) records of patients with diagnoses of Congestive Heart Failure, and Kidney Disease, from a total of 7 sampled records reviewed, resulting in the potential for unidentified health concerns, decline in physical functioning, and poor patient outcomes. Findings included: Policy: "Assessment & Care Planning" undated, stated, "The appropriate discipline completes the initial comprehensive assessment which serves as a baseline for care planning and subsequent assessments..., Each patient/client is assessed on a continuous basis." MR #4: The patient's start of care (SOC) was 10/11/22 with diagnoses that included Hypertensive Heart Disease with Heart Failure and Diabetes Mellitus. The initial comprehensive assessment, dated 10/11/22 completed by the Physical Therapist, failed to include a baseline blood sugar and an actual baseline patient weight. According to the Skilled Nurse (SN) visit notes dated 10/18/22 and 11/17/22, the Nurse failed to assess the patient's weights, edema and blood sugar. The disciplines failed to conduct appropriate assessments/re-assessments of the patient's health status. These findings were reviewed with and acknowledged by the Administrator (Adm #1) and the Clinical Manager (CM #1) during an interview on 1/5/23 at 9:20 a.m. MR #6: The patient's SOC was 12/28/22 with diagnoses that included Hypertensive Heart Disease and CVA (stroke). During the record review on 1/4/23 at 9:30 a.m., it was noted that the initial comprehensive assessment dated 12/28/22, completed by the Physical Therapist failed to include an actual baseline weight. On 1/4/23 at 4:30 p.m., a scheduled home visit was conducted with the Registered Nurse (RN #1). During the visit, RN #1 failed to assess the patient's temperature. Further, RN #1 checked the patient's legs for edema and stated, "You have some swelling in your right leg, but it's nothing crazy." RN #1 failed to objectively measure the patient's lower right extremity with use of a tape measure. These findings were reviewed with and acknowledged by Adm #1 and CM #1 during an interview on 1/5/23 at 9:41 a.m. to which CM #1 responded, "He (RN #1) was supposed to use a measuring tape."

Development and evaluation of plan of care CFR(s): 484.75(b)(2) Development and evaluation of the plan of care in partnership with the patient, representative (if any), and caregiver(s); This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the Agency failed to ensure the Speech Therapist assisted the Physician in evaluating the patient's level of functioning and helped to develop the plan of care for 1 (MR #6) of 1 record in which Speech Therapy services were ordered due to difficulty speaking, from a total sample of 7 records reviewed, resulting in the potential for decline in physical functioning and unmet care needs. Findings include: MR #6: The patient's start of care was 12/28/22 with diagnoses that included CVA (stroke and Hypertensive Heart Disease. During the clinical record review on 1/4/23 at 9:30 a.m., it was noted that the referral for home care dated 12/20/22 ordered Skilled Nursing, Speech Therapy, Occupational Therapy and Physical Therapy services to be provided. On 1/4/23 at 4:30 p.m., a joint home visit was conducted with the Registered Nurse (RN #1). During the visit, it was noted that the patient had great difficulty formulating sentence structures due to a constant stutter. The patient was able to articulate, "I'm supposed to be seen by a Speech Therapist, but they haven't been here, and I haven't heard anything." At the time of this review, the Speech Therapist had not evaluated the patient in order to assist the Physician in evaluating the patient's level of functioning. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 1/5/23 at 9:41 a.m.

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, it was determined that the Agency failed to ensure skilled services were provided in accordance with the Physician's orders and Plan of Care for 3 (MR's #4, 6, 7) records, from a total of 7 sampled records reviewed, resulting in the potential for unidentified health concerns, physiological decline, and unmet patient care needs. Findings include: Policy: "Assessment & Care Planning" undated, stated, "All patients/clients are generally assessed within 24 hours of the receipt of the referral..., Other professional staff complete an initial assessment specific to their discipline and/or clinical focus..., This assessment to be completed within 24 - 48 hours." MR #4: The patient's start of care (SOC) was 10/11/22 with diagnoses that included Hypertensive Heart Disease with Heart Failure and diabetes Mellitus. During the record review on 1/4/23 at 1;30 p.m., it was noted that the referral for home care, dated 10/3/22, ordered Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT) and Medical Social Work (MSW). The Plan of Care (POC) ordered SN to evaluate the patient the week of 10/11/22, however, SN did not evaluate the patient until 10/18/22 (7 days after the SOC). The OT did not conduct their initial evaluation until 10/19/22 (8 days after the SOC). The above ordered services were not provided in accordance with the Physician's orders, POC or the Agency's policy. These findings were reviewed with and acknowledged by the Administrator (Adm #1) and the Clinical Manager (CM #1) during an interview on 1/5/23 at 9:20 a.m. MR #6: The patient's SOC was 12/28/22 with diagnoses that included CVA (stroke) and Hypertensive Heart Disease. During the record review on 1/4/23 at 9:30 a.m., it was noted that the referral for home care dated 12/20/22 ordered SN, OT, PT and Speech Therapy (ST) services to be provided. The POC ordered the SN evaluation to be conducted the week of 12/28/22. At the time of this review, the SN evaluation had not been conducted as ordered. On 1/4/23 at 4:30 p.m., a scheduled home visit was conducted with the Registered Nurse (RN #1). During the visit, the patient presented with great difficulty speaking and had a significant stutter (a speech disorder in which the flow of speech is disrupted by involuntary repetitions and prolongations of sounds, syllables, words, or phrases as well as involuntary silent pauses or blocks in which the person who stutters is unable to produce sounds). The patient managed to articulate that he was supposed to be seen by a Speech Therapist, yet he is unsure when they will be here. "They (Agency) didn't tell me when they (ST) would be coming." At the time of this review, no ST services had been provided as ordered in the POC and in accordance with the Agency's policy. These findings were reviewed with and acknowledged by Adm #1 and CM #1 during an interview on 1/5/23 at 9:41 a.m. to which CM #1 reported, "I've spoken with this patient, so I know he has difficulty speaking. ST should have gone out to see the patient by now. We've had issues with obtaining a Speech therapy. We haven't received a response from the contracted Agency." Adm #1 reported, "He (patient) stutters a lot." MR #7: The patient's SOC was 12/13/22 with diagnoses that included Chronic Kidney Disease and End Stage Renal Failure. During the record review on 1/5/23 at 10:34 a.m., it was noted that the referral for home care dated 11/16/22 ordered SN, PT and OT services to be provided. The POC ordered SN to evaluate the patient the week of 12/14/22. At the time of this review, SN had not evaluated the patient as ordered by the Physician and in accordance with the POC. These findings were reviewed with and acknowledged by Adm #1 and CM #1 during an interview on 1/5/23 at 11:39 a.m.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the clinical record was completed and included detailed Skilled Nursing and Physical Therapy notes for 4 (MR's #1, 3, 6, 7) records with the ordered services, from a total of 7 sampled records reviewed, resulting in the potential for undocumented, unidentified health concerns, and unmet patient needs. Findings include: Policy: "Home Health Services Documentation" undated stated, "Able Care, LLC staff and contract staff shall document the provisions of patient care of service..., Documentation is completed in a timely manner." MR #6: The patient's start of care (SOC) was 12/28/22 with diagnoses that included CVA (stroke) and Hypertensive Heart Disease. During the record review on 1/4/23 at 9:30 a.m., it was noted that the patient was ordered to receive Skilled Nursing (SN) and Physical Therapy (PT) services. At the time of this review, there were no SN visit notes available for review. Further review revealed that PT conducted the initial evaluation on 12/28/22 and was to see the patient 2x/wk. z 5 wks. At the time of this review, there were no PT visit notes available for review after the initial PT visit on 12/28/22. These findings were reviewed with and acknowledged by the Administrator (Adm #1) and Clinical Manager (CM #1) during an interview on 1/5/23 at 9:41 a.m. MR #7: The patient's SOC was 12/13/22 with diagnoses of Chronic Kidney Disease, COPD and End Stage Renal Disease. During the record review on 1/5/23 at 10:34 a.m., it was noted that the patient was ordered to receive SN, PT and Occupational Therapy (OT) services. The PT saw the patient on 12/13/22. There were no other PT visit notes available for review by the survey's end. Additionally, there were no SN visit notes in the clinical record. These findings were reviewed with and acknowledged by Adm #1 and CM #1 during an interview on 1/5/23 at 11:39 a.m. CM #1 further acknowledged that there is no way to ascertain if the visits were actually made without supporting documentation. MR#1: This patient was admitted to the agency on 11/28/22 with diagnoses of hemiplegia, cerebral infarct, hypertension and diabetes. The comprehensive assessment was completed by physical therapy on 11/28/22. During record review on 1/3/23, it was noted that the physical therapy notes for visits on 12/16/22, 12/23/22, and 12/27/22 had not been submitted. MR#3: This patient was admitted to the agency on 9/27/22 with diagnoses of hemiplegia, cerebral infarct and poly osteoarthritis. The comprehensive assessment was completed by physical therapy on 9/27/22. During record review on 1/4/23, it was noted that the physical therapy notes for visits on 12/16/22, 12/23/22, and 12/28/22 had not been submitted. The administrator (Adm#1) and the clinical manager (CM#1) acknowledged the above findings and stated, "Our expectation is that visit notes be submitted by Tuesday of the next week" during an interview on 1/5/23 at 12:15 p.m.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on record review and interview, it was determined the Agency failed to ensure Skilled Nursing prepared clear written patient care instructions for the home health aide regarding client needs, and safety precautions prior to providing care in 1 (MR #5) of 1 record in which Home Health Aide services were ordered, from a total of 7 sampled records reviewed, resulting in the potential for the provision of unsafe care and unmet care needs. Findings include: Policy: Home Health aide Services" undated, stated, "Home Health Aide care shall be given according to the plan of treatment and the Home Health Aide Care Plan and assignment as developed and updated by the RN/Therapist Case Manager." The patient's start of care was 10/4/22 with diagnoses that included Hypertensive Heart Disease, Polyarthritis and Chronic Kidney Disease. On 1/4/23 at 11:00 a.m., during a review of the clinical record, it was noted that the referral for home care dated 9/28/22 ordered Home Health Aide services to be provided. At the time of this review, no Aide Care Plan had been created by the Registered Nurse that directed the course of care. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 1/4/23 at 2:00 p.m.

Must have a written agreement CFR(s): 484.105(e)(2)(i-iv) An HHA must have a written agreement with another agency, with an organization, or with an individual when that entity or individual furnishes services under arrangement to the HHA's patients. The HHA must maintain overall responsibility for the services provided under arrangement, as well as the manner in which they are furnished. The agency, organization, or individual providing services under arrangement may not have been: (i) Denied Medicare or Medicaid enrollment; (ii) Been excluded or terminated from any federal health care program or Medicaid; (iii) Had its Medicare or Medicaid billing privileges revoked; or (iv) Been debarred from participating in any government program. This ELEMENT is not met as evidenced by: Based on interview, the Agency failed to establish a written agreement with its contracted agency that specified the terms of the agreement including 1). The Agency must maintain overall responsibility for the services provided under arrangement, as well as the manner in which they are furnished; 2). The Agency providing services under arrangement may not have been denied Medicare/Medicaid enrollment, been excluded or terminated from any federal health care program, or 3). The Agency may not have had its Medicare/Medicaid billing privileges revoked, resulting in the potential for unauthorized, unregulated treatment and poor patient outcomes for all patients currently serviced by this Agency. Findings include: On 1/3/22 at 11:00 a.m., during the Entrance Conference, the Administrator (Adm #1) was asked what services were provided by the Agency to which she replied, Skilled Nursing, Physical Therapy, Occupational Therapy, Speech Therapy, Medical Social Work and Home Health Aide services. Adm #1 was then asked which of the services were directly employed by the Agency to which she responded, "All of our employees are contracted with Michigan Rehab Services Provider. We don't have any direct hire employees." On 1/3/22, during the Entrance Conference, on 1/4/22 and again on 1/5/22, multiple requests were made to review the Agency's contract/agreement with Michigan Rehab Services Provider. Adm #1 repeatedly stated that she was unable to locate a contract. Further, no contract/agreement with the above-mentioned agency had been provided by the end of the survey. These findings were reviewed with and acknowledged by the Administrator at the time of discovery.

Skilled services furnished CFR(s): 484.105(f) Standard: Services furnished. Skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis, in a place of residence used as a patient's home. An HHA must provide at least one of the services described in this subsection directly, but may provide the second service and additional services under arrangement with another agency or organization. This STANDARD is not met as evidenced by: Based on interview, the Agency failed to ensure that at least one qualifying service was provided directly by agency employees, resulting in the potential for interruption in continuity of care and unmet care needs for all patients currently serviced by this agency. Findings include: On 1/3/22 at 11:00 a.m., during the Entrance Conference, the Administrator (Adm #1) was queried as to what services were provided by the agency and reported, "We provide Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), Medical Social Work (MSW), Speech Therapy (ST) and Home Health Aide (HHa) services." When asked which service(s) were provided directly by the Agency, Adm #1 responded, "All of our employees are contracted. We don't have any direct hire employees." The Agency failed to ensure that at least one qualifying skilled service was provided directly by agency employees. These findings were reviewed with and acknowledged by Adm #1 at the time of discovery.