Every finding on record at Accelerated Homecare Services, Inc

An unannounced standard Emergency Preparedness survey was conducted on 6/24/25 through 6/27/25 by the Michigan Department of Licensing and Regulatory Affairs. During the survey, Accelerated Homecare Services, Inc was found to be out of compliance with the requirements for participation in Medicare at 42 CFR 484.102: Emergency Preparedness.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop 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: (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 all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [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. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Emergency Preparedness (EP) plan was reviewed and updated at least every 2 (2023 and 2024) of 2 years, resulting in the potential for an unprepared staff response in the event of an emergency. Findings include: The agency’s Emergency Preparedness (EP) binder was reviewed on 6/24/25 at 12:22 PM. During review of the binder, it was noted there was no documented evidence of when the EP plan was last reviewed and updated. During an interview with the alternate clinical manager (RN-1) on 6/25/25 at 2:56 PM, RN-1 was asked when the EP plan was last reviewed and updated. RN-1 stated the EP plan has not been reviewed or updated since before the agency was bought by the current owner in May of 2023; however, she was unable to provide an exact date. RN-1 acknowledged the findings at the time of interview. A review of the agency policy titled “Disaster Readiness and Emergency Management Plan”(not dated) revealed, “The Agency will perform a facility-based and community-based risk assessment utilizing an all-hazard approach in order to develop an emergency plan to identify potential disasters likely to occur in the agency’s service area, which is reviewed annually or as the need arises.” The alternate administrator (Alt-Adm) also reviewed and acknowledged the findings during an interview on 6/27/25 at 9:18 AM.

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), §485.542(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, the agency failed to ensure the hazard vulnerability assessment (HVA) was reviewed and updated at least every 2 (2023 and 2024) of 2 years, resulting in the potential for an unprepared staff response in the event of an emergency. Findings include: The agency’s Emergency Preparedness (EP) binder was reviewed on 6/24/25 at 12:22 PM. During review of the binder, it was noted the last hazard vulnerability assessment (HVA) was dated 1/20/22. During an interview with the alternate clinical manager (RN-1) on 6/25/25 at 2:56 PM, RN-1 stated the HVA has not been updated since the agency was bought by the current owner in May of 2023. RN-1 acknowledged the findings at the time of interview. A review of the agency policy titled “Disaster Readiness and Emergency Management Plan”(not dated) revealed, “The Agency will perform a facility-based and community-based risk assessment utilizing an all-hazard approach in order to develop an emergency plan to identify potential disasters likely to occur in the agency’s service area, which is reviewed annually or as the need arises.” The alternate administrator (Alt-Adm) also reviewed and acknowledged the findings during an interview on 6/27/25 at 9:18 AM.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(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]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Emergency Preparedness (EP) communication plan included updated staff names and contact information for 8 of 14 staff, resulting in the potential for an unprepared staff response in the event of an emergency. Findings include: The agency’s Emergency Preparedness (EP) binder was reviewed on 6/24/25 at 12:22 PM. During review of the binder, it was noted the emergency phone tree in the communication plan section listed the names and contact information for the previous administrator (RN-1), the office manager (OM), and 2 contract companies. During an interview with RN-1 on 6/25/25 at 3:38 PM, RN-1 reviewed this document and RN-1 stated, “that’s the old one.” At 4:01 PM, RN-1 provided a document titled “Emergency Fan-Out Call Tree: Accelerated Homecare Service”. This document included the name and phone number of the current administrator (Adm); however, it only included 6 of 14 other employees listed on the staff list. Additionally, there was no contact information listed for any of the other staff. A review of the agency policy titled “Disaster Readiness and Emergency Management Plan” (not dated) revealed, “A current listing of staff and all applicable contact numbers (i.e. home phone, cell phone, emergency numbers, emergency contact numbers of family/friends if employee is unreachable) will be maintained.” The policy also indicated the “Disaster calling tree is utilized for contacting Agency staff.” The Adm, RN-1, and alternate administrator (Alt-Adm) reviewed and acknowledged the findings during an interview on 6/25/25 at 4:05 PM.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure initial Emergency Preparedness (EP) training was provided for 1 (Adm) of 8 employees reviewed, resulting in the potential for an unprepared staff response in the event of an emergency. Findings include: The agency’s Emergency Preparedness (EP) binder was reviewed on 6/24/25 at 12:22 PM. During review of the binder, it was noted the administrator (Adm) was listed as the “Emergency Incident Commander” on the emergency phone tree. Upon review of the personnel file for Adm on 6/26/25 at 12:55 PM, it was determined there was no documented evidence Adm received initial EP training. A review of the agency policy titled “Disaster Readiness and Emergency Management Plan” (not dated) revealed, “Each staff member receives initial training during orientation and at least annually thereafter.” During an interview with the alternate administrator (Alt-Adm) on 6/26/25 at 9:23 AM, Alt-Adm was asked to provide documentation that Adm received initial EP training. Alt-Adm reported Adm was present for EP training as “he is the boss”, however, Alt-Adm acknowledged Adm did not sign the form indicating he completed the training. Alt-Adm acknowledged the findings at the time of interview.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure Emergency Preparedness (EP) testing included the required criteria in 3 (2023, 2024, and 2025) of 3 years reviewed, resulting in the potential for an unprepared staff response on the event of an emergency. Findings include: The agency’s Emergency Preparedness (EP) binder was reviewed on 6/24/25 at 12:22 PM. During review of the binder, the following was noted regarding the EP testing drills: 1. There was no documentation of a drill completed in 2023. 2. The documentation for 2024 was an actual event regarding a pending snowstorm in the area. Upon review of the documentation, it was noted there was no documentation regarding if a snowstorm actually occurred or if the emergency plan had to be activated as a result. Additionally, there was no follow-up documentation to analyze the agency’s performance in following the EP plan. 3. The documentation for 2025 was a tabletop drill for an active shooter. Upon review of the documentation, it was noted there was no documentation of the emergency scenario that was presented to staff to review and discuss. A review of the agency policy titled “Disaster Readiness and Emergency Management Plan” (not dated) revealed, “Emergency drills will be conducted at least annually.” The policy also indicated, “Exercises will incorporate likely disaster scenarios that allow the Agency to assess its handling of communications, resources and assets, staff and patients. Exercises will review and confirm: Staff communication procedures and content; Assigned staff roles related to essential response functions; How Agency will communicate with patients during an emergency." Additionally, "Exercises must sufficiently stress Agency’s plan to identify weaknesses;...Analyze the Agency's response to and maintain documentation of all drills, tabletop exercises and emergency events.” [sic] The administrator (Adm), alternate clinical manager (RN-1), and alternate administrator (Alt-Adm) reviewed and acknowledged the findings during an interview on 6/25/25 at 4:05 PM.

A Medicare recertification survey was conducted by the Michigan Department of Licensing and Regulatory Affairs from 6/24/25 through 6/27/25 at: Accelerated Homecare Services 17520 W. 12 Mile Rd. Suite 100 Southfield, MI 48076 At the time of the survey, the agency did not have any branch offices or subunits. The services the agency provides are: Skilled Nursing (SN), Physical Therapy (PT), Physical Therapy Assistant (PTA), Occupational Therapy (OT), Speech Therapy (ST), Medical Social Work (MSW), and Home Health Aide (HHa). Records reviewed: 3 active records with home visits, 2 active records without home visits, 1 active record with a transfer and resumption of care (without a home visit), and 1 discharged record were chosen for a total sample of 7 records. At the conclusion of the survey, the agency was found to be not in compliance for the Conditions of Participation for Home Health Agencies at: 42 CFR Part §484. The following Condition level deficiencies were identified at: 42 CFR § 484.65 Quality assessment and performance improvement 42 CFR § 484.70: Infection prevention and control 42 CFR § 484.75 Skilled professional services 42 CFR § 484.110: Clinical records 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 record review and interview, the agency failed to ensure patients were informed of the disciplines that would furnish care and the frequency of visits in 4 (P-1, P-2, P-4, P-7) of 7 total sample records reviewed, resulting in the potential for unmet care needs. Findings include: Patient #7 (P-7) was admitted to the home care agency on 5/7/25, with diagnoses of hypertension, chronic low back pain, and gastro-esophageal reflux disease (GERD). On 6/25/25 at 10 AM., during a joint home visit with skilled nursing, it was observed the signed copy of P-7's Plan of Care was void of all information such as: "Orders and Treatments", "Disciplines on case and frequency of visits", "Reason for admission", "Interventions/treatment to be provided", topics to be educated on, safety precautions, and patient goals. In addition, the form "Home Care Consent and Admission Service Agreement" was observed to be blank for assigned disciplines and intended home visit frequency. The alternate administrator (Alt-Adm) and the alternate clinical manager (Alt-CM) reviewed and acknowledged the findings above during an interview on 6/27/25 at 10:57 AM. Patient #1 (P-1) was admitted to this home care agency on 5/14/25 with the diagnoses of type I diabetes mellitus, hypertension (high blood pressure), and morbid obesity. During record review on 6/24/25, it was noted the patient was receiving services from skilled nursing 1 time a week for 4 weeks and physical therapy 2 times a week for 1 week and 1 time a week for 6 weeks. Upon review of the consent form signed by the patient upon admission, it was determined the agency failed to include information regarding initial services and frequency as the form was left blank. Patient #2 (P-2) was admitted to this home care agency on 5/29/25 with the diagnoses of type II diabetes mellitus, hypertension (high blood pressure), and weakness. During record review on 6/25/25, it was noted the patient was receiving services from skilled nursing 1 time a week for 4 weeks and physical therapy 2 times a week for 5 weeks and 1 time a week for 1 week. Upon review of the consent form signed by the patient upon admission, it was determined the agency failed to include information regarding initial services and frequency as the form was left blank. Patient #4 (P-4) was admitted to this home care agency on 6/5/25 with the diagnoses of cerebrovascular disease, hypertension (high blood pressure), and gait abnormalities. During record review on 6/26/25, it was noted the patient was receiving services from skilled nursing 1 time a week for 1 week. The patient was supposed to be receiving physical therapy 2 times a week for 5 weeks according to the plan of care, however, the patient had not been evaluated by physical therapy yet. Upon review of the consent form signed by the patient upon admission, it was noted check marks indicated the patient would receive services from skilled nursing, physical therapy, occupational therapy, and social work. Upon further review of the record, it was determined occupational therapy and social work services were not ordered, received, or included on the plan of care. A review of the agency policy titled, “Admission Information” (revised February 2024) revealed, “At time of admission, the Agency will provide each patient with a statement of the scope of services provided directly and/or through contractual/written agreement.” The alternate administrator (Alt-Adm) reviewed and acknowledged the findings during an interview on 6/27/25 at 9:18 AM.

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to provide an ordered skilled service on the plan of care for 3 (P-3, P-4, and P-7) of 4 records reviewed with physical therapy services, from a total of 7 sampled records reviewed, resulting in the potential for unmet clinical needs. Findings include: Patient #7 (P-7) was admitted to the home care agency on 5/7/25, with diagnoses of hypertension, chronic low back pain, and gastro-esophageal reflux disease (GERD). On 6/25/25, record review for the referral for home care ordered skilled nursing (SN) and physical therapy (PT) to evaluate and treat the patient. The Plan of Care (POC) effective 5/7/25, documented PT services were refused by P-7. However, during a joint home visit on 6/25/25 at 10 AM. with SN, P-7 was found to be alert and oriented x 2-3 and ambulatory with a cane. P-7 was then asked if she wanted to get stronger so she could walk better and be safer. P-7 responded, "I sure would like that!" Subsequently, P-7 was asked why she refused PT services. P-7 replied, "I never refused physical therapy." SN was asked why PT services were not provided then as ordered? SN stated the granddaughter and brother of P-7 chose to decline PT services. The alternate administrator (Alt-Adm) and the alternate clinical manager (Alt-CM) were asked during an interview on 6/26/25 at 12:32 if the agency had any paperwork which showed full DPOA (Durable Power of Attorney) over P-7's medical decisions by another individual such as the granddaughter or brother above. The Alt-Adm and Alt-CM both acknowledged there was no DPOA paperwork, and that P-7 was able to give informed consent. The agency failed to ensure P-7's rights were granted in receiving the ordered PT services found in the POC. Patient #3 (P-3) was admitted to this home care agency on 11/6/24 with the diagnoses of hypertension (high blood pressure), fatigue, and dementia. During record review on 6/25/25, it was noted the referral (dated 10/18/24) ordered services from physical therapy and skilled nursing. Upon further review of the record, it was determined physical therapy never evaluated the patient. There was no documentation regarding why the patient did not receive physical therapy as ordered. Patient #4 (P-4) was admitted to this home care agency on 6/5/25 with the diagnoses of cerebrovascular disease, hypertension (high blood pressure), and gait abnormalities. During record review on 6/26/25, it was noted the referral (dated 6/5/25) ordered services from physical therapy and skilled nursing. Upon further review of the record, it was determined physical therapy had not evaluated the patient as of 6/25/25. There was no documentation regarding why the patient did not receive physical therapy as ordered. A review of agency policy titled “Plan of Care – CMS #485 and Physician/Practitioner Orders” (revised February 2025) revealed, “20. Care and services provided will be provided according to physician/practitioner orders.” During an interview with the alternate administrator (Alt-Adm) on 6/27/25 at 9:18 AM, Alt-Adm was asked why physical therapy had not evaluated P-3 and P-4. Alt-Adm stated the patients "may have refused," however, she acknowledged there was no documentation to support that. Alt-Adm acknowledged the findings at the time of interview.

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 assessment was performed within 48 hours of referral to determine immediate care needs and Medicare eligibility in 4 (P-1, P-2, P-3, P-5) of 7 total sampled records reviewed, resulting in the potential for unmet care needs and poor patient outcomes. Findings include: Patient #5 (P-5) was admitted to the home care agency on 5/23/25, with diagnoses which included hypertension, chronic kidney disease, gout, diabetes type-2, and epilepsy. On 6/25/25, record review found a physician face-to-face visit on 4/14/25, and an insurance “Authorization/Referral Request" form submitted by the agency for payment reimbursement. However, no evidence of a physician referral for home care was found in the medical record. Subsequently, there was no time of receipt for the referral to note when the 48-hour window started to initiate the start of care visit. The alternate administrator (Alt-Adm) and the alternate clinical manager (Alt-CM) reviewed and acknowledged the findings above during an interview on 6/27/25 at 11:14 AM. Patient #1 (P-1) was admitted to this home care agency on 5/14/25 with the diagnoses of type I diabetes mellitus, hypertension (high blood pressure), and morbid obesity. During record review on 6/24/25, it was noted the referral for home care services was written on 5/8/25. Upon further review of the record, it was determined the initial assessment did not occur until 5/14/25 – 7 days after the referral. There was no documentation regarding the reason for the delay. Patient #2 (P-2) was admitted to this home care agency on 5/29/25 with the diagnoses of type II diabetes mellitus, hypertension (high blood pressure), and weakness. During record review on 6/25/25, it was noted the referral for home care services was written on 5/21/25. Upon further review of the record, it was determined the initial assessment did not occur until 5/29/25 – 8 days after the referral. There was no documentation regarding the reason for the delay. Patient #3 (P-3) was admitted to this home care agency on 11/6/24 with the diagnoses of hypertension (high blood pressure), fatigue, and dementia. During record review on 6/25/25, it was noted the referral for home care services was written on 10/18/24. Upon further review of the record, it was determined the initial assessment did not occur until 11/6/24 – 19 days after the referral. There was no documentation regarding the reason for the delay. A review of the agency policy titled “Initial Assessments/Comprehensive Assessments” (revised February 2025) revealed, “A RN, PT or SLP must conduct the initial assessment visit within 48 hours of referral, within 48 hours of the patient’s return home or on the physician/practitioner-ordered start of care date.” The alternate administrator (Alt-Adm) reviewed and acknowledged the findings during an interview on 6/27/25 at 9:18 AM.

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 the comprehensive assessment accurately reflected the patient’s current health status at the time of admission for 2 (P-1, P-2) of 7 records reviewed, resulting in incomplete clinical information to aide in determining the needs of these patients to assist developing the plan of care. Findings include: Patient #1 (P-1) was admitted to this home care agency on 5/14/25 with the diagnoses of type I diabetes mellitus, hypertension (high blood pressure), and morbid obesity. During record review on 6/24/25, it was noted the Outcome and Assessment Information Set (OASIS) indicated the primary diagnosis was “Type 1 diabetes mellitus without complications.” Upon further review of the OASIS, it was noted the blood sugar section indicated the patient had Type II diabetes for “over 30 years.” This information is conflicting and does not show a clear picture of the patient’s status. Additionally, it was noted the OASIS reported the patient was “Dependent upon adaptive device(s) such as: wheelchair, walker,” and used a manual wheelchair under the “Prior Device Use" section. The OASIS also reported “Yes” under the question, “Does patient use wheelchair and/or scooter?” Upon further review of the OASIS, it was noted neither wheelchair nor walker were marked under the section labeled “DME” (durable medical equipment). It is unclear whether the patient used a wheelchair. Patient #2 (P-2) was admitted to this home care agency on 5/29/25 with the diagnoses of type II diabetes mellitus, hypertension (high blood pressure), and weakness. During record review on 6/25/25, it was noted the OASIS reported the patient needed “supervision or touching assistance” to walk 150 feet, to walk 10 feet uneven surfaces, to go up and down a curb, and to go up and down 4-12 stairs without a railing. Upon further review of the OASIS, it was noted the patient “needed some help” with ambulation and was “dependent” on stairs prior to admission. Upon review of the physical therapy evaluation dated 6/7/25, it was documented the patient could only walk 15 feet and needed minimal assistance. This information is conflicting and does not show a clear picture of the patient’s status. A review of agency policy titled “Initial Assessments/Comprehensive Assessments” (revised February 2025) revealed, “The Initial Comprehensive Assessment also includes: Relevant diagnoses and current health status, including all active health and medical problems.” The alternate administrator (Alt-Adm) reviewed and acknowledged the findings during an interview on 6/27/25 at 9:18 AM.

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 medical record identified and reconciled patient medication interactions in 4 (P-1, P-2, P-3, P-7) of 7 total sampled records reviewed, resulting in the potential for adverse effects and poor patient outcomes. Findings include: Patient #7 (P-7) was admitted to the home care agency on 5/7/25, with diagnoses of hypertension, chronic low back pain, and gastro-esophageal reflux disease (GERD). On 6/25/25 at 10 AM., during a joint home visit with skilled nursing (SN), it was observed that P-7's medications available for use on the bedside nightstand did not match the current medication list found in the active plan of care (POC) for P-7. The 5 listed medications on the POC were found with the correct information. However, the following medications had no documented evidence that a review had taken place to check for potential interactions or expiration dates: Brimonidine Tartrate 0.2% solution (lowers pressure in the eye), Diclofenac Sodium Topical 1% (lowers eye inflammation), Lidocaine 5% topical (pain relief), Ammonium lactate 12% topical cream (treats dry skin), and Ventolin HFA 108 mcg. (helps breathing), all of which were non-expired. The two following medications that were also unaccounted for were severely expired: Doxycycline (antibiotic) 100 mg., with an expiration date of 4/22/21, and QVAR (helps with breathing) 80 mcg., had an expiration date of 6/7/16. No documentation was found which indicated SN tried to discover all prescribed medications in the home and documented education given to discard the severely expired medications noted above. The alternate clinical manager reviewed and acknowledged the findings on 6/26/25 at 9:35 AM., who noted this did not meet agency expectations or its policy referenced below. The agency's policy titled "Medication Reconciliation" (Revised February 2024) 8.15.1 stated, "The Agency will reconcile patient's medications at time of admission and on an ongoing basis 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 non-compliance with drug therapy." (sic) Patient #1 (P-1) was admitted to this home care agency on 5/14/25 with the diagnoses of type I diabetes mellitus, hypertension (high blood pressure), and morbid obesity. During record review on 6/24/25, it was noted the Outcome and Assessment and Information Set (OASIS) reported “No – No issues found during review” under the section titled “Drug Regimen Review.” Upon running a drug interaction report on the agency’s electronic medication record (EMR) system, it was determined there were 5 moderate drug-to-drug interactions. Additionally, a skilled nursing note dated 6/17/25 stated “used to take monjaro but but caused him constipation.” [sic] Upon review of the mediation profile, it was determined Mounjaro was never removed from the active medication list. Patient #2 (P-2) was admitted to this home care agency on 5/29/25 with the diagnoses of type II diabetes mellitus, hypertension (high blood pressure), and weakness. During record review on 6/25/25, it was noted the OASIS reported “No – No issues found during review” under the section titled “Drug Regimen Review.” Upon running a drug interaction report on the agency’s EMR system, it was determined there were 3 moderate drug-to-drug interactions. Additionally, a skilled nursing note dated 6/13/25 stated, “Patient started on amox-clav 500-125 mg. for 2 days and loratadine 10 mg daily for runny nose.” [sic] Upon review of the mediation profile, it was determined Loratadine was never reconciled on an updated medication profile to check for any interactions. Patient #3 (P-3) was admitted to this home care agency on 11/6/24 with the diagnoses of hypertension (high blood pressure), fatigue, and dementia. During record review on 6/25/25, it was noted the OASIS reported “Yes – Issues found during review.” Additionally, the OASIS indicated a medication follow-up was completed “by midnight of the next calendar day” and competed “prescribed/recommended actions and reasons to the identified potentially significant medication issues.” Upon review of the fax confirmation sheet located in the clinical record, it was determined the medication interaction report with 12 moderate interactions wasn’t faxed to the physician until 1/30/25 – 84 days after the interactions were identified. During the entrance interview on 6/24/25 at 10:53 AM, the alternate clinical manager (RN-1) was asked what level interactions were reported to the physician. RN-1 stated all moderate and severe drug interactions were reported to and reconciled with the physician and that the communication should be documented in the record. RN-1 also reported the medications should be reconciled every time a new medication is added, and the list should be updated when a medication is discontinued. A review of the agency policy titled “Medication Profile” (revised February 2024) revealed, “The comprehensive assessment (OASIS) performed at time of admission includes a review of all medications that 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, duplicative drug therapy and noncompliance with drug therapy.” The policy also stated, “The nurse or therapist will add all new/changed medication(s) to the medication profile. Discontinued (“D/C”) medications will be documented and dated. The medication profile will be reviewed every home visit and updated as changes occur.” The alternate administrator (Alt-Adm) reviewed and acknowledged the findings during an interview on 6/27/25 at 9:18 AM.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure services were provided only as ordered by the physician in 1 (P-7) of 4 records reviewed with physical therapy services provided, out of a total sample of 7 records reviewed, resulting in the potential to negatively affect all 43 patients currently serviced by the agency. Findings include: Patient #7 (P-7) was admitted to the home care agency on 5/7/25, with diagnoses of hypertension, chronic low back pain, and gastro-esophageal reflux disease (GERD). On 6/26/25, record review noted the referral for home care (dated 5/5/25), ordered skilled nursing (SN) and physical therapy (PT) to evaluate and treat the patient. The Plan of Care (POC) effective 5/7/25, documented PT services were refused by P-7. No physician order was found in the medical record reauthorizing PT services to treat the patient after the documented refusal by P-7. Further review noted that PT services provided home visits with treatments on 5/23/25, 5/27/25, 5.31.25, 6.4.25, 6/6/25, 6/9/25, and 6/11/25 without any physician order. The alternate clinical manager (Alt-CM) reviewed and acknowledged this finding during an interview on 6/26/25 at 2:42 PM. In addition, during a joint home visit on 6/25/25 at 10 AM. with SN, P-7 was found to be alert and oriented x 2-3 and ambulatory with a cane. P-7 was then asked if she wanted to get stronger so she could walk better and be safer. P-7 responded, "I sure would like that!" Subsequently, P-7 was asked why she refused PT services. P-7 replied, "I never refused physical therapy." SN was asked why PT services were not provided then as ordered? SN stated the granddaughter and brother of P-7 chose to decline PT services. The alternate administrator (Alt-Adm) and the Alt-CM were asked during an interview on 6/26/25 at 12:32 if the agency had any paperwork which showed full DPOA (Durable Power of Attorney) over P-7's medical decisions by another individual such as the granddaughter or brother above. The Alt-Adm and Alt-CM both acknowledged there was no DPOA paperwork, and that P-7 was able to give informed consent. The agency failed to fulfill the PT order in the POC effective 5/7/25 as the patient did not refuse and failed to obtain an order to authorize the PT visits noted above. The Alt-Adm and Alt-CM reviewed and acknowledged the findings above during an interview on 6/27/25 at 10:57 AM.

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on record review and interview, it was determined the agency failed to provide evidence of its efforts to measure, track and analyze it's quality indicators and show measurable improvement in patient care and services (See G 642); failed to develop Performance Improvement activities, as part of the agency's Quality Assessment Performance Improvement program, in order to track and trend adverse patient events, analyze the cause and implement preventive interventions (See G 654); failed to document any of the required annual quality improvement projects since 2023 through 6/27/25, including the reasoning for conducting these projects and the measurable progress achieved each year (See G 658); and failed to ensure the agency had an active and functioning Quality Assessment and Performance Improvement program that addressed priorities for improved quality of care and patient safety which evaluated its effectiveness (See G660). The cumulative effect of these systemic problems resulted in the agency's inability to ensure the provision of quality health care for all 43 patients currently receiving services from the Home Health Agency regarding the condition of participation of 42 CFR§484.65 Quality Assessment and Performance Improvement (QAPI).

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on record review and interview, it was determined the agency failed to develop, implement, and maintain a Quality Assessment and Performance Improvement (QAPI) program which provided documentation of its efforts to measure, track and analyze quality indicators that represented pre-established performance improvement projects (PIP's) designed to optimize patient care services, resulting in the inability to determine the quality of services provided and the potential for unmet care needs for all 43 patients currently being served by this agency. Findings include: On 6/26/25, the agency's QAPI documentation was reviewed which revealed a failure to document efforts to systematically collect data, monitor, analyze and improve patient outcomes based off the Governing Body approved PIP's. Review of the QAPI binder for the last 3 years noted 2 QAPI meetings dated 5/19/25 and 5/23/25. Documentation concerning both QAPI meetings mentioned the idea of monitoring medication management. However, no evidence was found within the QAPI program that showed an effort was made by the agency to identify ways to improve the delivery of patient care in measurable terms. Subsequently, no data was found in the agency's QAPI program for the last 3 years. The alternate administrator (Alt-Adm) and the alternate clinical manager (Alt-CM) reviewed and acknowledged the findings above during an interview on 6/26/25 at 9:48 AM.

Track adverse patient events CFR(s): 484.65(c)(2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to develop performance improvement activities, as part of the agency's Quality Assessment Performance Improvement (QAPI) program, to track and trend adverse patient events, analyze the cause and implement preventive interventions, resulting in the potential for the rendering of substandard care and unmet care needs for all 43 patients currently receiving services. On 6/26/25, during review of the agency's QAPI documents since 2022, it was noted there was no evidence that the agency had attempted to implement any quality improvement measures or activities that would serve to track/trend adverse patient events, analyze causative factors and implement preventive interventions. The alternate administrator (Alt-Adm) and the alternate clinical manager (Alt-CM) reviewed and acknowledged the findings above during an interview on 6/26/25 at 9:51 AM.

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and interview, it was determined the agency failed to develop a Performance Improvement Project (PIP) within its Quality Assessment Performance Improvement (QAPI) program, resulting in the agency's inability to effectively monitor proposed improvements in patient care, health outcomes, patient safety, quality of care and overall performance for all 43 patients currently receiving services from this agency. Findings include: On 6/26/25, review of the agency's QAPI binder for the last 3 years noted 2 QAPI meetings dated 5/19/25 and 5/23/25. Documentation concerning both QAPI meetings mentioned the idea of monitoring medication management. However, no evidence was found within the QAPI program that showed an effort was made by the agency to identify ways to improve medication management or a methodology to collect data in this area. Further, no evidence was found of another patient care area to develop a potential PIP. The alternate administrator (Alt-Adm) and the alternate clinical manager (Alt-CM) reviewed and acknowledged the findings above during an interview on 6/26/25 at 9:53 AM.

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on record review and interview, it was determined the Governing Body failed to ensure the agency had an active and functioning Quality Assessment and Performance Improvement (QAPI) program that addressed priorities for improved quality of care, maintained patient safety standards, and was evaluated for its effectiveness, resulting in the potential to adversely affect the quality of care to all 43 patients currently receiving services and all 95 patients admitted over the past year. Findings include: On 6/26/25, the agency's QAPI documentation was reviewed and revealed a failure to document efforts to systematically collect data, monitor, analyze and improve patient outcomes based off the Governing Body (GB) meeting minutes. Review of the agency's QAPI binder for the last 3 years noted 2 QAPI meetings dated 5/19/25 and 5/23/25. Documentation concerning both QAPI meetings mentioned the idea of monitoring medication management. However, no evidence was found within the QAPI program that showed an effort was made by the agency's GB to ensure its QAPI program detailed key components such as patient safety and quality care measures are implemented and maintained. The alternate administrator (Alt-Adm) and the alternate clinical manager (Alt-CM) reviewed and acknowledged the findings above during an interview on 6/26/25 at 9:55 AM.

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 home health agency failed to develop an infection control program that focused on infection prevention and control, including communicable diseases for the last 3 years (See G682); failed to ensure the infection control program was active and provided surveillance, identification, prevention, control and investigation of infectious and communicable diseases and was a part of the agency's Quality Assessment and Performance Improvement program for the last 3 years (See G684); and failed to provide infection control education to all direct and contracted staff for the last 3 years (See G686). The cumulative effects of these systemic problems resulted in the agency's inability to ensure the provision of safe health care to all 43 patients currently receiving services for the condition of participation of 42 CFR§484.70 Infection Prevention and Control.

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 record review and interview, the agency failed to develop an infection control program which monitored staff's performance to ensure infection control policies and accepted standard practices to prevent the transmission of infections and communicable diseases were followed in the last 3 years, resulting in a lack of oversight concerning infection control practices used during patient care by agency staff and the potential for poor clinical outcomes for all 43 patients currently receiving services. Findings include: On 6/26/25, a request was submitted to agency administration to review the agency's infection control program for the last 3 years. Both the alternate administrator (Alt-Adm) and the alternate clinical manager (Alt-CM) stated that there was no infection control education, or in-services that had been provided to its staff (direct or contracted) for the last 3 years during an interview on 6/26/25 at 9:57 AM.

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, prevention, control, and investigation of infections and communicable diseases as a part of the agency's Quality Assessment Performance Improvement (QAPI program), resulting in the potential spread of infections between patient care staff and the agency's 95 patients admitted in the past 12 months. Findings include: On 6/26/25, a request was submitted to the agency's administration to review its infection control program for the last 3 years. Both the alternate administrator (Alt-Adm) and the alternate clinical manager (Alt-CM) stated during an interview on 6/26/25 at 9:58 AM., that there was no evidence of infection control surveillance, identifying infectious diseases, data collection (with analysis) and planning which would be utilized to monitor its effectiveness for meeting infection control goals.

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure infection control training was provided to 7 (Alt-Adm, RN-1, RN-2, RN-3, LPN, RPT-1, and RPT-2) of 7 sampled clinical staff, resulting in the potential for a lack of staff education in infection control practices. Findings include: Personnel files for 7 clinical staff were reviewed on 6/26/25 at 9:23 AM. During review of the files, it was noted there was no documentation of initial infection control training for the alternate administrator (Alt-Adm), alternate clinical manager (RN-1), 2 registered nurses (RN-2 and RN-3), licensed practical nurse (LPN), and 2 registered physical therapists (RPT-1 and RPT-2). The files for a RN-2 and LPN contained an orientation checklist form that included infection control, however, these forms were left blank. During an interview with RN-1 on 6/26/25 at 12:57 PM, RN-1 was asked where to find evidence of initial training for infection control. RN-1 stated it should be kept in the personnel files. RN-1 acknowledged the lack of documentation at the time of interview. A review of agency policy titled “Bloodborne Pathogens Standard” (revised February 2025) revealed, “The Agency provides a training program to each of its employees at the time of initial employment as a part of employee orientation and annually thereafter.” The alternate administrator (Alt-Adm) also reviewed and acknowledged the findings during an interview on 6/27/25 at 9:18 AM.

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 record review and interview, the agency failed to ensure the physical therapist (PT) followed accepted standards of practice in assuming responsibility for care in 1 (P-7) of 4 patients reviewed who received PT services, from a total of 7 records reviewed (see G704); failed to ensure services were provided as ordered by the physician in the plan of care for 3 (P-1, P-3, P-7) of 7 total records reviewed (see G710); and failed to ensure skilled professionals prepared clinical notes per agency policy in 4 (P-1, P-2, P-3, and P-4) of 7 records reviewed (see G716), resulting in the potential for poor patient outcomes. Findings include: The cumulative effects of these systemic problems resulted in the agency's inability to ensure the provision of safe health care to all 43 patients currently receiving services for the condition of participation of 42 CFR§484.75: Skilled professional services.

Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This STANDARD is not met as evidenced by: Based on record review and interview, it was determined that the agency failed to ensure the physical therapist (PT) followed accepted standards of practice in assuming responsibility for the care of 1 (P-7) of 4 patients who received PT services, from a total of 7 sampled records reviewed, resulting in abrupt cessation of PT services and the potential for poor clinical outcomes. Findings include: Patient #7 (P-7) was admitted to the home care agency on 5/7/25, with diagnoses of hypertension, chronic low back pain, and gastro-esophageal reflux disease (GERD). On 6/26/25, record review noted an unauthorized physical therapy (PT) evaluation on 5/23/25, with an intended visit frequency of 1W1 (once a week time one week), followed by 2W5, and 1W1. PT provided home visits with treatments on 5/23/25 (above), 5/27/25, 5/31/25, 6/4/25, 6/6/25, 6/9/25, and 6/11/25. Additional record review found no explanation why PT services stopped providing services to P-7. No communication notes, refusal by the patient, and no physician notification were found within the medical record. As of 6/27/25, no further PT visits were evidenced after 6/11/25, no PT discharge summary was found, and no physician order that authorized the PT visits noted above were found in agency records. The alternate administrator (Alt-Adm) and the alternate clinical manager (Alt-CM) reviewed and acknowledged the findings above during an interview on 6/27/25 at 11:12 AM. The Alt-CM stated the agency failed to allow the PT visit notes to be uploaded into the agency's EMR (electronic medical records). Without evidenced documentation, the PT and agency professionals failed to responsibly authenticate physician orders (or lack of) and document the provision of all services rendered.

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, the agency failed to ensure services were provided as ordered by the physician in the plan of care for 3 (P-1, P-3, P-7) of 7 total sampled records reviewed, resulting in the potential for poor patient outcomes. Findings include: Patient #7 (P-7) was admitted to the home care agency on 5/7/25, with diagnoses of hypertension, chronic low back pain, and gastro-esophageal reflux disease (GERD). On 6/26/25, review of P-7's plan of care (POC) noted skilled nursing (SN) services had an ordered visit frequency of 1W6 (once a week time 6 weeks). Further record review noted after the initial start of care visit by SN on 5/7/25, the next SN visit occurred on 5/21/25. No evidence that P-7 had refused the SN visit, and no order or communication note which explained or excused the missed visit (5/11/25 through 5/17/25) was found in the medical records. The alternate administrator (Alt-Adm) and the alternate clinical manager (Alt-CM) reviewed and acknowledged the findings above during an interview on 6/27/25 at 10:59 AM. Patient #1 (P-1) was admitted to this home care agency on 5/14/25 with the diagnoses of type I diabetes mellitus, hypertension (high blood pressure), and morbid obesity. During record review on 6/24/25, it was determined the plan of care ordered skilled nursing 1 time a week for 4 weeks and physical therapy 2 times a week for 1 week and 1 time a week for 6 weeks. Upon further review of the record, it was determined there were no skilled nursing visits during weeks 3, 4, and 5. Additionally, there were no physical therapy visits during weeks 5 and 6. There was no documentation regarding the reason the patient was not seen. Patient #3 (P-3) was admitted to this home care agency on 11/6/24 with the diagnoses of hypertension (high blood pressure), fatigue, and dementia. During record review on 6/25/25, it was determined the plan of care ordered skilled nursing 1 time a week for 5 weeks. Upon further review of the record, it was determined there were no skilled nursing visits during weeks 4 and 5. There was no documentation regarding the reason the patient was not seen. A review of agency policy titled “Plan of Care – CMS #485 and Physician/Practitioner Orders” (revised February 2025) revealed, “20. Care and services provided will be provided according to physician/practitioner orders.” During an interview with the alternate administrator (Alt-Adm) on 6/27/25 at 9:18 AM, Alt-Adm was asked where missed visits were documented in the record. Alt-Adm reported they should be documented in a communication note; however, she acknowledged there were no communication notes for P-1 or P-3 regarding missed visits. Alt-Adm acknowledged the findings at the time of interview.

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 skilled professionals prepared clinical notes per agency policy in 4 (P-1, P-2, P-3, and P-4) of 7 records reviewed, resulting in the potential for poor coordination of care and poor patient outcomes. Findings include: During the entrance conference on 6/24/25 at 10:53 AM, the alternate clinical manager (RN-1) was asked about the agency expectation for the timeline for completion of visit notes. RN-1 stated, “2-3 days.” Upon review of visit notes for Patient #1 (P-1) on 6/25/25, it was determined the daily visit notes did not include a date and time stamp of when the note was completed by the clinician. On 6/25/25 at 11:31 AM, the office manager (OM) was asked how to know when the visit note was completed. OM was able to run a separate report that showed “date submitted.” OM stated this is when the note is complete and sent to her for review. A review of agency policy titled “Timely Submission of Patient Documentation” (revised February 2024) revealed, “Itineraries, with all visit reports attached, must be submitted the next scheduled work day, not exceeding three (3) business days. All patient visit reports from contract personnel must be submitted within three (3) business days from the date of the visit, e.g., PT, SLP, etc.” [sic] During review of the records for P-1, Patient #2 (P-2), Patient #3 (P-3), and Patient #4 (P-4) between 6/24/25 and 6/27/25, the following notes were found to be submitted after more than 3 days: P-1: The physical therapy evaluation visit was dated 5/20/25 and submitted on 6/9/25 (20 days). A skilled nursing visit was dated 5/22/25 and submitted on 5/26/25 (4 days). A physical therapy visit was dated 5/27/25 and was submitted on 6/25/25 (29 days). A physical therapy visit was dated 5/29/25 and was submitted on 6/25/25 (31 days). A physical therapy visit was dated 6/3/25 and had not been submitted as of 6/24/25 (21 days). P-2: A skilled nursing visit was dated 6/2/25 and was completed on 6/10/25 (8 days). The physical therapy evaluation was dated 6/7/25 and was submitted on 6/17/25 (10 days). A physical therapy visit was dated 6/10/25 and was submitted on 6/23/25 (13 days). A physical therapy visit was dated 6/12/25 and was submitted on 6/23/25 (11 days). A skilled nursing visit was dated 6/13/25 and was submitted on 6/23/25 (10 days). A physical therapy visit was dated 6/19/25 and was submitted on 6/24/25 (5 days). P-3: The skilled nursing start of care (initial evaluation) was dated 11/6/24 and was submitted on 1/3/25 (58 days). A skilled nursing visit was dated 11/14/24 and was submitted on 11/27/24 (13 days). A skilled nursing visit was dated 11/20/24 and had not been submitted as of 6/25/25 (217 days). A skilled nursing discharge visit was dated 12/4/24 and had not been submitted as of 6/25/25 (203 days). P-4: A skilled nursing visit was dated 6/13/25 and was submitted on 6/19/25 (6 days). The alternate administrator (Alt-Adm) also reviewed and acknowledged the findings during an interview on 6/27/25 at 9:18 AM.

Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) Standard: Administrator. The administrator must: (i) Be appointed by and report to the governing body; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the administrator was appointed by the governing body in 2 (2023 and 2024) of 2 years reviewed, resulting in the potential for a lack of direction and oversight for the agency. Findings include: During the entrance conference with the administrator (Adm) on 6/24/25 at 10:53 AM, it was determined Adm was the current administrator of the agency. On 6/25/25 at 10:23 AM, the alternate clinical manager (RN-1), who was also the previous administrator, was asked to provide documentation of when the current administrator (Adm) was appointed by the governing body. RN-1 provided governing body meeting minutes from 6/15/23 that indicated Adm was the new owner, however, the current alternate administrator (Alt-Adm) was listed as the administrator. It was also noted the “Authorization of Agency Responsibility” form located in the governing body binder was left blank. There was no evidence Adm was appointed by the governing body. A review of agency policy titled “Governing Body” (revised March 2018) revealed, “The Governing Body appoints a qualified Administrator or approves an Administrator selected by the corporation or another group and annual evaluates the Administrator’s performance.” The consultant (Con) and alternate administrator (Alt-Adm) also reviewed and acknowledged the findings during an interview on 6/25/25 at 12:12 PM.

Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure a qualified, pre-designated person was identified and approved by the governing body as the alternate administrator to be responsible in fulfilling the roll of the administrator in his absence in 2 (2023 and 2024) of 2 years reviewed, resulting in the potential for lack of direction and oversight for the agency. Findings include: During the entrance conference on 6/24/25 at 10:53 AM, the administrator (Adm) was asked for the name of the alternate administrator in the event of his absence. Adm stated the alternate administrator was Alt-Adm. Following review of the governing body meeting minutes on 6/25/25 at 10:23 AM, the alternate clinical manager (RN-1), who was also to the previous administrator, was asked to provide documentation of when Alt-Adm was appointed by the governing body. RN-1 provided governing body meeting minutes from 3/21/25 that indicated Alt-Adm was the DON (director of nursing)/Clinical Manager, however, there was no mention of her also being appointed as the alternate administrator. RN-1 also provided a form titled “Succession of Leadership” which stated Alt-Adm would be responsible for day-to-day operations in the absence of Adm, however, there were no signatures to indicate this position was approved and accepted. The consultant (Con) and alternate administrator (Alt-Adm) also reviewed and acknowledged the findings during an interview on 6/25/25 at 12:12 PM.

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 manager provided oversight in coordinating patient care for 19 of 43 active patients, resulting in the potential for missed visits and poor patient outcomes. Findings include: On 6/26/25 at 2:07 PM, the office manager (OM) was asked to provide the patient schedule for the week. Upon review of the schedule, it was determined only 24 of the current 43 active patients were scheduled for the week. OM was asked how the agency tracked who was scheduled to ensure frequencies in the plan of care were met. OM stated she “plotted” visits when the clinicians told her the frequency, however, she reported the agency does not track who has and has not been scheduled each week to ensure plan of care frequencies were met. OM also stated the clinicians often scheduled their own appointments and she added them to the schedule for them to document later, so more visits may show up on the schedule later in the week. OM reported it was more difficult to track patient visits since they recently admitted so many new patients, however, she acknowledged the importance. Upon further review of the schedule with OM at 2:27 PM, it was noted Patient #2 (P-2) was scheduled for one visit on 6/24/25. During a home visit with P-2 and the physical therapist (RPT-2) on 6/26/25 at 10:00 AM, P-2 and RPT-2 confirmed 6/26/25 was the second visit for the week. P-2 reported she was also seen on 6/23/25. A review of P-2’s plan of care confirmed physical therapy was ordered 2 times per week, however, these visits were not reflected in the "plotted" schedule or the patient record. OM stated the clinician can move the visits to the day they were done; however, she did not know why the second visit was not “plotted” on the schedule if the frequency was supposed to be 2 times per week. During an interview with the alternate administrator (Alt-Adm) on 6/27/25 at 9:18 AM, the above information was reviewed. Alt-Adm was asked how she coordinated patient care to ensure frequencies in the plan of care were met. Alt-Adm reported it was harder to coordinate patient care since they recently admitted so many new patients, however, she agreed she needed to do a better job. Alt-Adm was also unable to provide an explanation as to why 19 of the active patients were not on the weekly schedule. Alt-Adm acknowledged the findings at the time of interview.

Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure the clinical record contained goals in the patient plans of care in 7 (P-1, P-2, P-3, P-4, P-5, P-6, and P-7) of 7 records reviewed (see G116); failed to ensure a completed discharge summary was sent to the health care professional responsible for care of the patient after discharge within 5 business days of the patient’s discharge in 1 (P-3) of 1 discharged record reviewed (see G1022); and failed to ensure all clinical record entries were appropriately authenticated, dated, and timed in 7 (P-1, P-2, P-3, P-4, P-5, P-6, and P-7) of 7 records reviewed (see G1024), resulting in the potential for an incomplete clinical record and poor patient outcomes. Findings include: The cumulative effects of these systemic problems resulted in the agency's inability to ensure the provision of safe health care to all 43 patients currently receiving services for the condition of participation of 42 CFR§484.110: Clinical records.

Goals in the patient's plans of care CFR(s): 484.110(a)(3) Goals in the patient's plans of care and the patient's progress toward achieving them; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the clinical record contained goals in the patient plans of care in 7 (P-1, P-2, P-3, P-4, P-5, P-6, and P-7) of 7 records reviewed, resulting in the potential for unmet care needs and poor patient outcomes. Findings include: The medical records for Patient #1 (P-1), Patient #2 (P-2), Patient #3 (P-3), Patient #4 (P-4), Patient #5 (P-5), Patient #6 (P-6), and Patient #7 (P-7) were reviewed between 6/24/25 and 6/27/25. Upon review of the documentation, it was determined the records for P-1, P-2, P-3, P-4, P-5, P-6, and P-7 did not include any skilled nursing goals on the plans of care. A review of agency policy titled “Medical Record Content” (revised February 2024) revealed, “4. Each medical record will contain the following:…Identification of problems, interventions and goals (care planning) for each discipline and updates to the plan of care…”. During an interview with the alternate administrator (Alt-Adm) on 6/27/25 at 9:18 AM, Alt-Adm was asked to find the goals written by skilled nursing for P-1, P-2, P-3, P-4, P-5, P-6, and P-7. Alt-Adm stated they should be on the plans of care; however, she was unable to locate them for any of the patients listed above. Alt-Adm acknowledged the findings at the time of interview

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 a completed discharge summary was sent to the health care professional responsible for care of the patient after discharge within 5 business days of the patient’s discharge in 1 (P-3) of 1 discharged record reviewed; and failed to send out a transfer summary within 2 business days of becoming aware of an unplanned transfer in 1 (P-5) of 1 record reviewed with a transfer, resulting in the potential for unmet care needs following discharge and/or transfer. Findings include: Patient #5 (P-5) was admitted to the home care agency on 5/23/25, with diagnoses which included hypertension, chronic kidney disease, gout, diabetes type-2, and epilepsy. On 6/25/25, record review noted P-5 was transferred to the hospital on 6/10/25. No evidence that a transfer summary was sent to the receiving hospital within 2 days of the agency becoming aware of the transfer as required. The alternate administrator (Alt-Adm) and the alternate clinical manager (Alt-CM) reviewed and acknowledged the findings above during an interview on 6/27/25 at 11:12 AM. Patient #3 (P-3) was admitted to this home care agency on 11/6/24 with the diagnoses of hypertension (high blood pressure), fatigue, and dementia. During record review on 6/25/25, it was determined skilled nursing was ordered to see the patient 1 time a week for 5 weeks. The patient’s last visit with skilled nursing was documented on 11/20/24 (during week 3). Upon further review of the record, it was determined a discharge Outcome and Assessment Information Set (OASIS) was started on 12/4/24. This note was not completed or signed by the nurse; therefore, it could not have been sent to the physician within 5 business days of discharge. A review of agency policy titled “Discharge Summary” (revised February 2024) revealed, “A Discharge Summary will be sent within 5 business days of patient discharge to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient.” The alternate administrator (Alt-Adm) reviewed the findings during an interview on 6/27/25 at 9:18 AM. Alt-Adm was unsure why the discharge note was not completed and sent and acknowledged the findings at the time of interview.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure all clinical record entries were appropriately authenticated, dated, and timed in 7 (P-1, P-2, P-3, P-4, P-5, P-6, and P-7) of 7 records reviewed, resulting in an incomplete clinical record. Findings include: The medical records for Patient #1 (P-1), Patient #2 (P-2), Patient #3 (P-3), Patient #4 (P-4), Patient #5 (P-5), Patient #6 (P-6), and Patient #7 (P-7) were reviewed between 6/24/25 and 6/27/25. Upon review of the documentation, it was determined the clinical record entries for P-1, P-2, P-3, P-4, P-5, P-6 and P-7 did not include the title of the person who electronically signed the entries, the time the visits occurred, or the time and date the visit notes were signed/completed. A review of agency policy titled “Medical Record Entries and Authentication” (revised February 2024) revealed, “All entries in patient records will be legible, clear, complete and appropriately authenticated, dated and timed.” The policy also stated, “All entries in the medical records will be authenticated by staff signature and title.” During an interview with the office manager (OM) and alternate clinical manager (RN-1) on 6/25/25 at 11:31 AM, OM and RN-1 confirmed the medical record entries do not include authentication by title, the time the visit occurred, or the time and date the visit note was signed/completed. OM stated this is an issue with the electronical medical record system (EMR) they use. OM and RN-1 acknowledged the findings at the time of interview. The alternate administrator (Alt-Adm) also reviewed and acknowledged the findings during an interview on 6/27/25 at 9:18 AM.

On July 25, 2022, through July 28, 2022, an Emergency Preparedness survey was conducted by the Michigan Department of Licensing and Regulatory Affairs. At the survey, Accelerated Homecare Services was found to be not in substantial compliance with the requirements for participation in Medicare at 42 CFR 484.102 Emergency Preparedness.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure all staff including contracted staff received initial training and training at least every two years in the agency's Emergency Preparedness Plan for 7 of 9 (Staff E, F, G, H, I, J, and K) personnel files reviewed, resulting in the agency's inability to ensure staff actions align with the emergency plan. These deficient practices could have negatively affected the health and safety of the 108 patients admitted to the agency in the past 12 months. Findings include: The agency's emergency preparedness documentation and personnel files were reviewed on 7/27/22. Review of the documents indicates that there was no evidence that agency field Staff E (physical therapist, date of hire 3/18/13) and contracted field Staff F, G, H, I, J, and K (a mix of physical therapists, physical therapy assistants, and occupational therapists) had received initial training in the agency's Emergency Preparedness Plan. There was no evidence that these same field Staff E, F, G, H, I, J, and K had received emergency preparedness training at least every 2 years. The findings were reviewed with and acknowledged by Staff A (administrator) during an interview on 7/28/22 at 10:50 a.m.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure all staff including contracted staff participated in exercises or actual events to test the agency's emergency preparedness plan at least annually for 8 of 9 (Staff D, E, F, G, H, I, J, and K) personnel files reviewed, resulting in the agency's inability to ensure staff actions align with the emergency plan. These deficient practices could have negatively affected the health and safety of the 108 patients admitted to the agency in the past 12 months. Findings include: The agency's emergency preparedness documentation and personnel files were reviewed on 7/27/22. Review of the documents indicates that there was no evidence that field Staff D, E, F, G, H, I, J, and K had participated in exercises or actual events to test the agency's Emergency Preparedness Plan. The findings were reviewed with and acknowledged by Staff A (administrator) during an interview on 7/28/22 at 10:50 a.m.

A Medicare recertification survey was conducted by the Michigan Department of Licensing and Regulatory Affairs from 7/25/22 through 7/28/22 at: Accelerated Homecare Services 17520 W. 12 Mile Rd. Suite 100 Southfield, MI 48076 At the time of the survey, the agency did not have any branch offices or subunits. The services the agency provides are: Skilled Nursing (SN), Physical Therapy (PT), Physical Therapy Assistant (PTA), Occupational Therapy (OT), Speech Therapy (ST), Medical Social Work (MSW), and Home Health Aide (HHa). COVID-19 vaccinations were reviewed during this survey and the agency was found to not be in compliance with the Covid-19 Vaccine requirements stated at QSO-22-07-ALL Attachment G for Home Health Agencies. The following Condition level deficiencies were identified at: 42 CFR § 484.55: Comprehensive assessment of patients 42 CFR § 484.60: Care planning, coordination of services, and quality of care 42 CFR § 484.110: Clinical records 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).

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 initial assessment visit was conducted within 48 hours of referral to determine the immediate care needs of the patient for 2 of 7 (MR# 4, 6) records reviewed (refer to G-514); failed to ensure the comprehensive assessment was completed within 5 calendar days of providing hands on care for 1 of 7 (MR#7) records reviewed (refer to G-520); failed to ensure that the comprehensive assessment included a review of all medications for possible significant drug interactions in 2 of 7 (MR # 3 and 6) records reviewed (refer to G-536); and failed to ensure the comprehensive assessment was updated at the time of discharge from the agency for 1 of 7 (MR#6) records reviewed (refer to G-550). The cumulative effect of these systemic problems 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 of 42 CFR § 484.55: Comprehensive assessment of patients.

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 assessment visit was conducted within 48 hours of referral for 2 of 7 (MR# 4, 6) records reviewed, resulting in a delay in determining the immediate care and support needs for these patients. Findings include: MR#4: This patient had a coronary artery bypass graft X2 on 4/4/22. During record review on 7/26/22, it was noted that the referral for home care services was fax stamped on 4/6/22. The 4/6/22 referral from the hospital states the start of care for skilled nursing is the next day after discharge, anticipated discharge 4/8/22 with start of care on 4/9/22. The initial assessment visit was conducted by the skilled nurse on 4/11/22, which is 3 days after the patient was discharged from the hospital. There was no documentation to indicate the patient's discharge from the hospital was delayed and no indication the patient had requested a delay in home care services. The findings were reviewed with and acknowledged by the Administrator (Staff A) during an interview on 7/28/22 at 10:00 a.m. MR#6: The physician signed referral order dated 4/29/22, orders the agency to provide home care services for the patient's abnormal gait due to muscle weakness. During record review on 7/25/22, it was noted that the initial assessment visit by the skilled nurse was on 5/3/22, which is 4 days after the physician order. There was no documentation to indicate the patient had requested a delay in home care services. The findings were reviewed with and acknowledged by Staff A during an interview on 7/28/22 at 10:30 a.m.

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 within 5 calendar days of providing hands on care for 1 of 7 (MR#7) records reviewed, resulting in a lack of information to direct and support the care needs for this recent post-operative patient. Findings include: MR#7: This 71-year-old patient had a coronary artery by-pass graft x3 along with a wedge resection of the left upper lobe of the lung on 6/23/22 and was discharged from the hospital on 7/1/22. The registered nurse (Staff A) conducted the comprehensive assessment along with wound care on 7/2/22. During record review on 7/25/22, it was noted that the comprehensive assessment was incomplete. The assessment was blank of information in many areas, no diagnoses were listed, M1400 (Respiratory Status) thru M2200 (Therapy Need) were blank of information, no indication of the patient's nutritional needs, interventions provided or needed, and no indication of the disciplines needed to care for this patient. At the time of record review, it had been 23 days since the comprehensive assessment visit by Staff A. The findings were reviewed with Staff A (Administrator/registered nurse) during an interview on 7/25/22 at 1:00 p.m. Staff A explained that she was behind on her documentation.

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 that the comprehensive assessment included a review of all medications for possible significant drug interactions in 2 of 7 (MR # 3 and 6) records reviewed resulting in the potential for unrecognized adverse medication interactions for these two patients. Findings include: MR #3: This 85-year-old patient was admitted to the agency on 6/25/21 for skilled nursing care following a coronary artery bypass graft (CABG) on 6/15/21. During clinical record review on 7/26/22, it was noted when checking the Drug Interaction Report using the agency’s software that there was a potential major drug interaction between Atorvastatin and Multivitamin. There was no evidence in the clinical record that the nurse (Staff A) had reviewed the medications to identify significant drug interactions or was aware of this potential major drug interaction. There was no evidence that the physician was made aware of this potential major drug interaction. In an interview on 7/28/22 at 9:20 a.m., the Administrator (Staff A) acknowledged that the agency had not been checking medications for significant drug interactions and had not notified the physician. MR#6: This 97-year-old patient was admitted to home care on 5/3/22 with primary diagnoses of neuralgia and neuritis (nerve pain) and chronic pain syndrome. During record review on 7/25/22, it was noted that a Drug Interactions report, run on the agency's software, indicates a potential major interaction between Lyrica and Norco and to avoid this combination in older adults. There was no documented evidence that the registered nurse (Staff-A) recognized or was aware of the potential major interaction. There was no evidence that the physician was informed of the potential major drug interaction. The finding was reviewed with the Administrator (Staff A) during an interview on 7/28/22 at 10:30 a.m. Staff A acknowledged that the physician was not informed.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment was updated at the time of discharge from the agency for 1 of 7 (MR#6) records reviewed, resulting in a lack of information regarding the patient's health status and progress towards goals. Findings include: MR#6: This 97-year-old patient was admitted to home care on 5/3/22 with primary diagnoses of neuralgia and neuritis (nerve pain) and chronic pain syndrome. The patient received skilled nursing and physical therapy (PT) services. Record review on 7/25/22 indicates skilled nursing discharged the patient on 5/25/22 and PT services continued. The last documented visit note was by the physical therapy assistant on 6/24/22. It was unclear what had happened with this patient after 6/24/22. During an interview on 7/28/22 at 10:30 a.m., the finding was reviewed with the Administrator (Staff A) and the Office Manager (Staff B). Staff B explained that the PT discharged the patient from the agency on 6/28/22, which was 27-days ago. Staff A and Staff B acknowledged that there was no evidence the comprehensive assessment was updated at the time of discharge.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to maintain compliance with this condition of participation. The agency failed to ensure the plan of care was complete and included objectively measurable goals specific to the needs of the patient in 7 of 7 (MR #1, 2, 3, 4, 5, 6, 7) records reviewed (See G574); failed to ensure treatments were provided only as ordered by the physician in 1 of 6 (MR # 3) records reviewed (See G580); and failed to ensure the physician was notified of significant changes in the patient's condition for 1 of 1 (MR# 7) record review (See G590). 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 484.60, Care Planning, Coordination of Services, and Quality of Care.

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 was complete and included objectively measurable goals specific to the needs of the patient in 7 of 7 (MR #1, 2, 3, 4, 5, 6, 7) records reviewed, resulting in patients not receiving care specific to their individual needs and the potential for poor patient outcomes. Findings include: MR #1: This 64-year-old patient was admitted to the agency on 7/18/22 for skilled nursing care following a coronary artery bypass graft (CABG) on 7/11/22. The plan of care (POC) dated 7/18/22 was reviewed on 7/25/22. The POC failed to include measurable goals for this patient’s pain, cardiac and respiratory status. The POC included the following goals: Patient/Caregiver reports patient's pain within comfort level by 09/15/2022; and Patient/Caregiver cardiac/respiratory status will remain stable by 09/15/2022. It was unclear how these goals would be measured in terms that would enable nursing staff to accurately perform an objective evaluation of the patient's progress toward the goals. These findings were reviewed and acknowledged by the Administrator (Staff A) on 7/28/22 at 9:30 a.m. MR #2: This 64-year-old patient was admitted to the agency on 7/21/22 with diagnoses including right lung cancer; surgical wound aftercare following right lung surgery; chronic obstructive pulmonary disease, and oxygen dependence. The POC dated 7/21/22 was reviewed on 7/25/22. The POC failed to include a pain goal that was established by this patient who had surgical wounds. The start of care (SOC) dated 7/21/22 documented that the patient had pain of 5/10 on a pain scale where 0 is no pain and 10 is the worst pain. The POC included the following pain goals: Patient/Caregiver reports patient's pain within comfort level by 09/18/2022. The goal was not stated in measurable terms that would enable nursing staff to accurately perform an objective evaluation of the patient's progress toward the goals. These findings were reviewed and acknowledged by the Staff A on 7/28/22 at 9:25 a.m. MR #3: This 85-year-old patient was admitted to the agency on 6/25/21 for skilled nursing care following CABG surgery on 6/15/21. During record review on 7/26/22, it was noted on the POC dated 6/25/21 that the skilled nurse failed to include measurable nursing goals that were pertinent to the needs of this patient. The SOC documentation from 6/25/21 showed this patient was admitted with midsternal pain and shortness of breath with activity. The POC included the following goals: Verbalize knowledge of disease process including signs and symptoms of exacerbation, when to notify MD, and expected course or prognosis by date (no date given); and Wound will show weekly progress with no indication of infection. There were no other individualized goals listed for this patient. It was unclear how the listed goals would be measured in terms that would enable nursing staff to accurately perform an objective evaluation of the patient's progress toward the goals. These finding were reviewed and acknowledged by Staff A on 7/28/22 at 9:20 a.m. MR#7: This 71-year-old patient had a coronary artery bypass graft (CABG) x3 along with a wedge resection of the left upper lobe of the lung on 6/23/22 and was discharged from the hospital on 7/1/22. The patient was admitted to home care on 7/2/22. During record review on 7/25/22, it was noted that the plan of care (POC) was incomplete and had the words "DRAFT" across the pages of the POC. The POC failed to include pertinent diagnoses, mental status, services and frequency, supplies, equipment needs, functional limitations, activities permitted, and interventions and goals that are pertinent to the needs of this recent post-operative patient. The findings were reviewed with the Administrator (Staff A) on 7/28/22 at 10:35 a.m. Staff A acknowledged the findings and stated she completed the plan of care on 7/27/22, which is 23 days after the patient was admitted to home care services. Staff A explained the POC is usually completed in 1-2 days. MR#4: This 79-year-old patient had a CABG x2 on 4/4/22 and was discharged from the hospital on 4/8/22. The patient was admitted to home care services on 4/11/22 with weekly skilled nursing visits. During record review on 7/26/22, it was noted that the POC failed to include respiratory interventions and goals related to the patient's recent CABG. Standard respiratory interventions after a CABG include the use of the incentive spirometer and cough and deep breath. The POC included the following goals: Patient reports pain within comfort level and cardiac/respiratory status will remain stable. It was unclear how these goals were to be measured. The goals were not stated in measurable terms that would enable nursing staff to accurately perform an objective evaluation of the patient's progress toward his goals. MR#5: This patient had a CABG x4 on 6/20/22 and was admitted to home care on 7/22/22 with weekly skilled nursing visits. During record review on 7/26/22, it was noted that the POC included the following goal: Pain relieved or controlled within acceptable limits. There was no indication of the acceptable pain level for this patient. The goal was not stated in measurable terms that would enable nursing staff to accurately perform an objective evaluation of the patient's progress toward her goals. MR#6: This 97-year-old patient was admitted to home care on 5/3/22 with primary diagnoses of neuralgia and neuritis (nerve pain) and chronic pain syndrome. During record review on 7/25/22, it was noted that the POC included the following goal: Patient reports patient's pain within comfort level, pain relieved or controlled within acceptable limits, and cardiac/respiratory status will remain stable There was no indication of the acceptable pain level for this patient. There was no indication how to determine a stable cardiac/respiratory status for this patient. The goals were not stated in measurable terms that would enable nursing staff to accurately perform an objective evaluation of the patient's progress toward his goals.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure treatments were provided only as ordered by the physician in 1 of 6 (MR # 3) records reviewed in which wound care was provided, resulting in the potential to negatively affect the health and well-being of this patient. Findings include: MR# 3: This 85-year-old patient had a coronary bypass graft on 6/15/21 and was admitted to the agency on 6/25/21 for skilled nursing care. During record review on 7/26/22 of the plan of care dated 6/25/21, skilled nursing wound orders included an order to “measure wound every week”. The start of care done on 6/25/21 noted that the patient had 5 surgical wounds, each with initial measurements taken. There were no other measurements for any of the 5 wounds documented during the next 7 weeks of skilled nursing care with this agency. There was no documentation of a physician’s order to stop or change weekly wound measurements during the episode of care. This finding was reviewed and acknowledged by the Administrator (Staff A) on 7/28/22 at 9:20 a.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, the agency failed to ensure the physician was notified of significant changes in the patient's condition for 1 of 1 (MR# 7) record review for a patient with elevated blood pressure readings, resulting in the potential for poor patient outcomes for this patient. Findings include: MR#7: This 71-year-old patient had a coronary artery bypass graft (CABG) x3 along with a wedge resection of the left upper lobe of the lung on 6/23/22 and was discharged from the hospital on 7/1/22. The patient was admitted to home care on 7/2/22 with weekly skilled nursing visits. The comprehensive assessment on 7/2/22 notes the patient's blood pressure (BP) reading for the right arm at 93/55 and 89/53 for the left arm. On 7/6/22 the BP was 120/70. The skilled nurse failed to document a BP reading on the 7/8/22 visit. On 7/11/22, the nurse (Staff A) documented 120/70 BP on the right arm and 130/70 on the left arm. Three days later, on 7/14/22,Staff A documented a BP of 190/80 on the right arm and 180/90 on the left arm for this patient. This is a significant change in blood pressure for this recent CABG patient. There was no indication the physician was informed of the elevated blood pressure readings on 7/14/22. The findings were reviewed with Staff A during an interview on 7/28/22 at 10:35 a.m. Staff A explained that she informed the nurse practitioner but there was no documentation in the medical record for review.

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to collect and utilize quality indicator data and other relevant agency data in the design of its quality assessment and performance improvement program, resulting in the potential for poor quality outcomes for the 108 patients admitted to the agency in the past 12 months. Findings include: On 7/27/22, the agency provided for review, a binder titled, QAPI (Quality Assessment and Performance Improvement) 2020-2022. The documentation consisted of the agency's QAPI policies and QAPI meetings dated 7/13/20 and 1/11/21. There was no documented evidence of the agency's efforts in 2021 and 2022 to collect and utilize quality indicator data including data derived from OASIS (outcome and assessment information set) to track and trend the quality of care. The findings were reviewed with Staff A (administrator) during an interview on 7/28/22 at 10:55 a.m. Staff A explained that quarterly chart reviews are conducted to collect data however the data has not been utilized in the agency's QAPI program.

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure to conduct performance improvement projects from 2021 through 2022, resulting in no coordinated efforts to improve patient outcomes for the 108 patients admitted to the agency in the past 12 months. Findings include: On 7/27/22, the agency provided for review, a binder titled, QAPI (Quality Assessment and Performance Improvement) 2020-2022. The documentation consisted of the agency's QAPI policies and QAPI meetings dated 7/13/20 and 1/11/21. There was no documented evidence of the agency's performance improvement projects (PIPs) in 2021 and 2022. During an interview on 7/28/22 at 10:55 a.m., the Administrator (Staff A) reviewed and acknowledged the findings. Staff-A was unable to to provide details of the agency's PIPs in 2021 and 2022.

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 ensure to document and track the COVID-19 vaccination completion, exemption, or temporary delay status for 7 of 9 staff (Staff D, F, G, H, I , J, and K) that provide patient care, treatment, or other services for the agency. This has the potential to negatively affect the health and well-being of the agency's 6 current patients. Findings include: On 7/27/22 the office manager (Staff B) provided a list of names of current agency employees and COVID-19 vaccination records as of 7/27/22. The list contained names for 9 field staff and 2 office staff. A review of personnel files on 7/27/22 indicated that one directly employed registered nurse (Staff D) and 6 contracted employees that provide physical and occupational therapy services (Staff F, G, H, I, J, K) failed to have documentation of COVID-19 vaccination completion, exemption (medical or religious), or temporary delay status. These findings were reviewed with office manager (Staff B) on 7/27/22 at the time of discovery and she acknowledged that Staff D did not have the COVID-19 status in the personnel file and that the agency was unaware that they needed to have contracted staff COVID-19 vaccination in personnel files.

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, the Agency failed to ensure that skilled nursing services were provided as ordered by the physician in the plan of care in 2 of 7 (MR # 3, 7) records reviewed in which nursing services were ordered, resulting in the potential for poor patient outcomes for these patients. Findings include: MR #3: This 85-year-old patient had a coronary artery bypass graft (CABG) on 6/15/21 and was admitted to the agency on 6/25/21. During record review on 7/26/22, it was noted that the plan of care (POC) dated 6/25/21 included orders for skilled nursing (SN) visits to occur 2 times per week for 3 weeks and then 1 time per week for 2 weeks (a total of 5 weeks of SN visits). In the first week of care, one SN visit was missed. There was no documentation that the patient made a request for no SN visit that day and no documentation by the SN for the reason of the missed visit. There was no documentation that the SN informed the physician of this missed visit. In weeks 4 and 5 of care, there were no SN visits made. There was no documentation that the patient had made request for no SN visits during these weeks, and no documentation by the SN to show reason for no visits during these weeks. There was also no documentation that the SN informed the physician regarding this change in the ordered frequency of SN visits. On week 6 (outside of the 5 weeks ordered on the POC), there was one SN visit and in week 7 the patient was discharged from SN services. There was no documentation that the SN notified the physician for these changes to frequency. These findings were reviewed and acknowledged by the Administrator (Staff A) on 7/28/22 at 9:20 a.m. MR#7: This 71-year-old patient had a coronary artery bypass graft (CABG) x3 along with a wedge resection of the left upper lobe of the lung on 6/23/22 and was discharged from the hospital on 7/1/22. The patient was admitted to home care on 7/2/22. During record review on 7/25/22, it was noted that the referral documents, fax-stamped 7/1/22, contained a physician order that instructed the nurse to draw the following outpatient labs: complete blood count, comprehensive metabolic panel, and magnesium level weekly for two weeks. The nurse documented weekly nursing visits from 7/2/22 through 7/20/22. There was no documentation to indicate the skilled nurse followed the physician's order and ensured outpatient labs were drawn weekly for two weeks. The findings were reviewed with the registered nurse (Staff A) during an interview on 7/28/22 at 10:35 a.m. Staff A explained that the patient refused the lab work. There was no documentation of the patient's refusal and no indication the physician was informed.

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 physical therapists prepared clinical notes for 1 of 2 (MR# 6) records reviewed in which physical therapy services were provided, resulting in a lack of information regarding the health status of this patient. Findings include: MR#6: This 97-year-old patient was admitted to home care on 5/3/22 with primary diagnoses of neuralgia and neuritis (nerve pain) and chronic pain syndrome. The 5/3/22 plan of care ordered physical therapy (PT) to evaluate and treat the patient. The PT then made weekly visits to this patient. The last documented visit was by the physical therapy assistant on 6/24/22. It was unclear what had happened with this patient after that date. There was no documentation to indicate the patient had declined or delayed further visits. The agency's policy titled, Timely Submission of Patient Documentation (revised February 2021), details that all visit reports must be submitted the next scheduled work day not to exceed 3 business days. During an interview on 7/28/22 at 10:30 a.m., the finding was reviewed with the Administrator (Staff A) and the Office Manager (Staff B). Staff B explained that the PT discharged the patient from the agency on 6/28/22, which was 27-days ago. There was no documentation of clinical notes for review that indicate the patient was discharged from the agency.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the physical therapist communicated with the physician regarding the patient's need for continued therapy services for 1 of 2 (MR#6) records reviewed with physical therapy services, resulting in a lack of physician involvement regarding therapy services for this patient. Findings include: MR#6: This 97-year-old patient was admitted to home care on 5/3/22 with primary diagnoses of neuralgia and neuritis (nerve pain) and chronic pain syndrome. During record review on 7/25/22, it was noted that the plan of care ordered the physical therapist (PT) to evaluate and treat this patient. The PT evaluated the patient on 5/6/22 and determined the patient needed therapy once a week for one week, twice a week for three weeks, and once a week for one week. Those therapy services were provided at that frequency as ordered. On 6/3/22, the PT documented a 30-day functional re-assessment and determined the patient needed continued therapy twice a week for four weeks. There was no documented evidence the PT communicated with the physician regarding the patient's need for continued therapy services. The finding was reviewed with the Administrator (Staff A) during an interview on 7/28/22 at 10:30 a.m. Staff A acknowledged that there was no communication with the physician.

Services under arrangement CFR(s): 484.105(e)(1) The HHA must ensure that all services furnished under arrangement provided by other entities or individuals meet the requirements of this part and the requirements of section 1861(w) of the Act (42 U.S.C. 1395x (w)). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure 1 of 2 contracts (Contractor# 1) met the requirements of section 1861(w) of the Act (42 U.S.C. 1395x(w)), resulting in the potential to adversely affect the finances of all patients that received contracted services. Findings include: Contractor#1: On 7/27/22, the contract with Contractor#1 dated November 2017 to provide therapy services was reviewed. During review of the contract it was noted that the contract failed to include the regulatory language of section 1861(w) of the Act (42 U.S.C 1395x(w)), which states, "...receipt of payment by the...home health agency...with respect to services for which an individual is entitled to have payment made under this title, discharges the liability of such individual or any other person to pay for the services." The regulatory language ensures that both the contract agency and the home health agency would not simultaneously charge patients for covered services and items. The finding was reviewed with and acknowledged by Staff A (administrator) during an interview on 7/28/22 at 10:55 a.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 record review and interview, the agency failed to ensure a contract for services indicated the agency maintains overall responsibility for the services provided under arrangement for 1 of 2 (Contractor #1) contracts reviewed, resulting in a lack of overall responsibility by the agency for the services provided under arrangement. Findings include: During review of Contract#1 (dated 11/17/17) for therapy services under arrangement, it was noted that the contract failed to indicate that the home health agency maintains the overall responsibility for the services provided under arrangement. The finding was reviewed with and acknowledged by Staff A (administrator) during an interview on 7/28/22 at 10:55 a.m.

Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to maintain compliance with this condition of participation. The agency failed to ensure the clinical record contained a complete plan of care, a complete comprehensive assessment, updated comprehensive assessments, and physician orders for 2 of 7 (MR# 6 and 7) records reviewed (See G1012); failed to ensure the clinical record contained documentation regarding lab work that was ordered for 1 of 5 (MR#7) records reviewed (See G1014); failed to ensure the clinical record contained goals related to the patient's diagnoses for 1 of 7 (MR# 7) records reviewed (See G1016); and failed to ensure a detailed discharge summary was sent to the physician within 5 business days of discharge for 1 of 2 (MR# 4) discharge records reviewed (See G1022). 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 484.110, Clinical Records.

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 contained a complete plan of care, a complete comprehensive assessment, updated comprehensive assessments, and physician orders for 2 of 7 (MR# 6 and 7) records reviewed, resulting in a lack of information for the physician and all agency staff caring for these patients. Findings include: MR#7: This 71-year-old patient had a coronary artery by-pass graft x3 along with a wedge resection of the left upper lobe of the lung on 6/23/22, was discharged from the hospital on 7/1/22, and admitted to home care on 7/2/22. The registered nurse (Staff A) conducted the comprehensive assessment on 7/2/22. During record review on 7/25/22, it was noted that the comprehensive assessment was incomplete. The assessment was blank of information in many areas, no diagnoses were listed, M1400 (Respiratory Status) thru M2200 (Therapy Need) were blank of information, no indication of the patient's nutritional needs, interventions provided or needed, and no indication of the disciplines needed to care for this patient. At the time of record review, it had been 23 days since the comprehensive assessment visit by Staff A. Also, it was noted that the plan of care (POC) was incomplete and had the words "DRAFT" across the pages of the POC. The POC failed to include pertinent diagnoses, mental status, services and frequency, supplies, equipment needs, functional limitations, activities permitted, and interventions and goals that are pertinent to the needs of this recent post-operative patient. The findings were reviewed with the Administrator (Staff A) on 7/28/22 at 10:35 a.m. Staff A acknowledged the findings and stated she completed the plan of care on 7/27/22, which is 23 days after the patient was admitted to home care services. Staff A explained the POC is usually completed in 1-2 days. MR#6: This patient was admitted to home care on 5/3/22 with diagnoses of neuralgia and neuritis (nerve pain) and chronic pain syndrome. The 5/3/22 plan of care ordered skilled nursing and physical therapy (PT) services for this patient. On 6/3/22, the physical therapist documented a 30-day functional re-assessment of this patient and determined that the patient needed additional physical therapy. The physical therapy assistant provided 2 visits each week for the next three weeks (6/8/22 through 6/24/22). There was no documented evidence of a physician order to extend or continue physical therapy services beyond 6/3/22. During record review on 7/25/22, it was noted that the last documented visit note was by the physical therapy assistant on 6/24/22. It was unclear what had happened with this patient after 6/24/22. During an interview on 7/28/22 at 10:30 a.m., the finding was reviewed with the Administrator (Staff A) and the Office Manager (Staff B). Staff-B explained that PT discharged the patient from the agency on 6/28/22, which was 27-days ago. Staff A and Staff B acknowledged that there was no documentation of an updated comprehensive assessment at the time of discharge.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the clinical record contained documentation regarding lab work that was ordered for 1 of 5 (MR#7) records reviewed in which lab work was ordered, resulting in a lack of information for the physician regarding the health status of this post-operative patient. Findings include: MR#7: This 71-year-old patient had a coronary artery bypass graft (CABG) x3 along with a wedge resection of the left upper lobe of the lung on 6/23/22 and was discharged from the hospital on 7/1/22. The patient was admitted to home care on 7/2/22. During record review on 7/25/22, it was noted that the referral documents, fax-stamped 7/1/22, contained a physician order that instructed the nurse to draw the following outpatient labs: complete blood count, comprehensive metabolic panel, and magnesium level weekly for two weeks. The nurse documented six nursing visits from 7/2/22 through 7/20/22. There was no documentation to indicate the skilled nurse followed the physician's order and ensured the outpatient labs were drawn weekly for two weeks. The findings were reviewed with the registered nurse (Staff A) during an interview on 7/28/22 at 10:35 a.m. Staff A explained that the patient refused the lab work. There was no documentation in the clinical record of the patient's refusal and no documentation indicating the physician was informed that lab work was refused.

Goals in the patient's plans of care CFR(s): 484.110(a)(3) Goals in the patient's plans of care and the patient's progress toward achieving them; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the clinical record contained goals related to the patient's diagnoses for 1 of 7 (MR# 7) records reviewed, resulting in a lack of guidance in determining this patient's progress towards goals and discharge. Findings include: MR#7: This 71-year-old patient had a coronary artery bypass graft (CABG) x3 along with a wedge resection of the left upper lobe of the lung on 6/23/22 and was discharged from the hospital on 7/1/22. The patient was admitted to home care on 7/2/22. During record review on 7/25/22, it was noted that the plan of care (POC) was incomplete and had the words "DRAFT" across the pages of the POC. The POC had the following one goal listed: Reports patient's pain within comfort level. The POC failed to include additional goals pertinent to the needs of this recent post-operative patient, such as wound care, infection, cardiovascular, medications, nutrition, and respiratory status. The findings were reviewed with the Administrator (Staff A) on 7/28/22 at 10:35 a.m. Staff A acknowledged the findings and stated she completed the plan of care on 7/27/22, which is after the record was reviewed, and which is 23 days after the patient was admitted to home care services.

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 a detailed discharge summary was sent to the physician within 5 business days of discharge for 1 of 2 (MR# 4) discharge records reviewed, resulting in a lack of information to ensure continuity of care for the 95 patients discharged from the agency in the past 12 months. Findings include: MR#4: This patient was admitted to the agency on 4/11/22 and a discharge OASIS (outcome and assessment information set) was completed by the nurse on 5/3/22. During record review on 7/26/22, it was noted that there was no documented evidence a discharge summary was sent to the physician within 5 business days of the patient's discharge. The agency's policy titled, Discharge Summary (revised February 2021) states, a discharge summary will be sent within 5 business days of patient discharge to the primary care practitioner. The findings were reviewed with the Administrator (Staff A) and the office manager (Staff B) during an interview on 7/28/22 at 10:00 a.m. Staff B provided additional documentation to evidence that the discharge summary was faxed to the physician 5/18/22, which is 15 days after the patient was discharged from the agency.