Every finding on record at Advanced Home Care, Inc

A Medicare authorized Recertification survey was conducted from 8/13/24-8/19/24 at: Advanced Home Care 580 Kirts Blvd., Suite 309 Troy, MI 48084 Records reviewed: 5 active records with 3 home visits and 2 discharged records were reviewed, for a total of 10 records reviewed. This agency has no branch locations. This was a standard survey. The requirements for Emergency Preparedness were not reviewed.

The following standard level citations were identified during a Medicare authorized Recertification survey from 8/13/24-8/19/24 at: Advanced Home Care 580 Kirts Blvd., Suite 309 Troy, MI 48084 Records reviewed: 5 active records with 3 home visits and 2 discharged records were reviewed, for a total of 10 records reviewed. This agency has no branch locations.

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 included objectively measurable goals specific to the individualized needs of the patient in 6 (MR's # 1, 2, 4, 5, 6, 7) records, from a total of 7 sampled records reviewed, resulting the potential for poor patient outcomes and unmet care needs. Findings include: P-1: This patient was admitted to the agency on 4/20/23 with diagnoses of chronic obstructive pulmonary disease, hypertensive heart disease with heart failure, and atrial fibrillation. During record review on 3/13/24, it was discovered that the nursing goals on the plan of care (POC) were not measurable. For example, "Patient and caregiver will be able to identify fall risk factors during episode of care." another stated, "Patient's activity level will improve due to effective pain control by 5/20/23." There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-2: This patient was admitted to the agency on 8/11/23, with diagnoses of type 2 diabetes mellitus with neuropathy, chronic kidney disease and dementia. During record review on 3/14/24, it was discovered that the nursing goals on the POC were not measurable. For example, "Patient and caregiver will be able to identify fall risk factors by 8/11/23." another stated, "Patient's and caregiver will adapt optimally and develop effective coping skills related to change in body image or limitations during episode of care." There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-4: This patient was admitted to the agency on 3/6/24, with diagnoses of joint replacement, and poly osteoarthritis." During record review on 3/14/24, it was discovered that the nursing goals on the POC were not measurable. For example, "Patient will demonstrate compliance with medication regimen as evidenced by correct administration, reporting side effects or adverse reactions by 3/12/24." another stated, "Patient will demonstrate return to stable musculoskeletal status related to hip surgery with improvement/maintenance of maximal level of functioning by 3/12/24." There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-5: This patient was admitted to the agency on 8/11/23, with diagnoses of malignant neoplasm, and neoplasm of brain. During record review on 3/14/24, it was discovered that the nursing goals on the POC were not measurable. For example, "Patient will demonstrate understanding of individual emergency preparedness plan by 3/30/24." another stated, "Patient/caregiver will demonstrate steps to protect oneself and others from COVID-19 infection by 3/30/24." There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-6: This patient was admitted to the agency on 2/27/24, with diagnoses of pulmonary hypertension, respiratory failure with hypoxia, and breast cancer. During record review on 3/18/24, it was discovered that the nursing goals on the POC were not measurable. For example, "Patient caregiver will verbalize and demonstrate safe management of oxygen by 3/16/24." another stated, "Patient/caregiver demonstrate [sic] ability to effectively manage medication regimen by 3/16/24." There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-7: This patient was admitted to the agency on 2/27/24, with diagnoses of infection, type 2 diabetes, and hypertension. During record review on 3/18/24, it was discovered that the nursing goals on the POC were not measurable. For example, "Patient will demonstrate competence with self-management of depression and anxiety as evidenced by adherence to medication regimen, ." another stated, "Patient/caregiver demonstrate [sic] ability to effectively manage medication regimen by 3/16/24." There was no evidence of how these goals could be objectively measured to ascertain progress toward goals.

Development and evaluation of plan of care CFR(s): 484.75(b)(2) Development and evaluation of the plan of care in partnership with the patient, representative (if any), and caregiver(s); This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the physical therapist and occupational therapist assisted the physician in evaluating the patient's level of function and helped to develop the plan of care for 2 of 7 (P-5, 6) records reviewed, resulting in the potential for decline in physical functioning and unmet care needs for these 2 patients. Findings include: Agency policy: Administrative Policy Manual, Patient/Client Assessment Guidelines. PE.10, page 2 of 2, IX. "An assessment performed due to an intra-agency referral will be completed as follows: B. Physical therapy-four days. C. Occupational Therapy-four days." P-5: This patient was admitted to the agency on 3/11/24, with diagnoses of malignant neoplasm, and neoplasm of brain. Review of the POC on 3/14/24 showed physical therapy (PT) services were ordered for an Evaluation and Treatment visit. As of 3/19/24, there was no documented evidence of a PT visit, 8 days after the start of care. P-6: This patient was admitted to the agency on 2/27/24, with diagnoses of pulmonary hypertension, respiratory failure with hypoxia, and breast cancer. Review of the POC on 3/18/24, showed PT services were ordered with a frequency of 1 visit a week for 1 week, 2 visits a week for 4 weeks, and 1 visit a week for 2 weeks. Occupational Therapy (OT) was ordered with a frequency of 1 visit a week for 4 weeks. The patient transferred to the hospital on 3/3/24 and resumed services with the agency on 3/6/24. PT's first visit after the resumption of care was 3/13/24, seven days after resumption of services. OT's first visit after the resumption of care was 3/12/24, six days after the resumption of care. There was no documentation in the record for a delay in care after the resumption of care, and there was no documented evidence the agency notified the physician of the delay in care after the resumption of care. During an interview on 3/19/24 at 3:30 p.m., the administrator (Staff-1) acknowledged the above findings and stated, "Nursing is required to do the initial visit within 48 hours and other disciplines (Including physical therapy) within 4 days.

On 3/11/21, an Emergency Preparedness survey was conducted by the Michigan Department of Licensing and Regulatory Affairs. At the survey, Advanced Home Care was found to be in substantial compliance with the requirements for participation in Medicare at 42 CFR 484.102 Emergency Preparedness.

The following standard level citations were identified during a Medicare authorized Recertification survey along with a COVID-19 Focused Infection Control survey on 3/9/21 through 3/12/21 at: Advanced Home Care 580 Kirts Blvd., Suite 309 Troy, MI 48084 Records reviewed: 4 records with home visits and 6 records without home visits, for a total of 10 records reviewed. This agency has no branch locations.

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure patients were informed of the Administrator's name and business contact information, resulting in the potential for patient complaints or concerns to go unaddressed which could affect the quality of care for the agency's 39 current patients. Findings include: The agency provides their patients with a folder that contains many papers and forms including a consent for care, COVID-19 information, patient privacy rights, emergency plan, and a medication profile. On 3/9/21, the contents of the agency's admission folder were reviewed. There was no documentation of the administrator's name and contact information to enable patients to express their concerns or complaints. The finding was reviewed with and acknowledged by the Administrator during an interview on 3/12/21 at 9:20 a.m.

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to advise patients of the names, addresses and telephone numbers of Federally funded and State funded entities that serve the areas where the patients reside, resulting in a lack of information regarding available resources which has the potential to affect the quality of care for the agency's 39 current patients. Findings include: On 3/9/21, the contents of the agency's admission folder were reviewed. The folder contained a sheet of paper entitled, Senior Alert, which provides the phone numbers to a variety of resources. However, the list of resources failed to include the names, addresses and phone numbers for the following Federally funded and State funded agencies: Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, and Aging and Disability Resource Center. The finding was reviewed with and confirmed by the Administrator during an interview on 3/12/21 at 9:20 a.m.

Content of the comprehensive assessment CFR(s): 484.55(c) 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: This STANDARD is not met as evidenced by: Based on record review and interview, the Agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status based on past medical history that included dates of onset, exacerbations, treatments and outcomes, measurable data to use as a baseline for future assessments, and history of events leading to current home care needs for 10 of 10 sampled records reviewed (MR#s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10), resulting in incomplete clinical information to aid in determining the current and future care needs of the patient. Findings included: MR#1: The Start of Care (SOC) was dated 1/6/2021. The Plan of Care (POC) identified the primary diagnosis of Urinary Tract Infection (UTI) and secondary diagnoses of Diabetes Type 2 (DM2), Hypertension (HTN), Parkinson's Disease, Coronary Artery Disease (CAD), and two stage 1 pressure ulcers of (1) the right and (2) the left buttocks. Upon review of the Comprehensive Assessment, documentation under the category of "Patient History and Diagnoses," consisted of the patient's temperature, blood pressure, pulse, respirations, oxygen (O2) saturation, height, weight, and Body Mass Index (BMI). There was no information found in the comprehensive assessment of an assessment of the patient's past medical history that included dates of onset, exacerbations, past medical treatments and outcomes, measurable data to use as a baseline for future assessments or a history of events leading to the need for the current home care admission. MR#2: The SOC was dated 8/10/2020. The POC identified at primary diagnosis of Type 2 Diabetes (DM2) with Hyperglycemia, and secondary diagnoses DM2 with Chronic Kidney Disease (CKD), HTN, Colostomy, and Neoplasm of Brain. Upon review of the Comprehensive Assessment, documentation under the category of "Patient History and Diagnoses," consisted of the patient's temperature, blood pressure, pulse, respirations, oxygen (O2) saturation, height, weight, and Body Mass Index (BMI). There was no information found in the comprehensive assessment of an assessment of the patient's past medical history that included dates of onset, exacerbations, past medical treatments and outcomes, measurable data to use as a baseline for future assessments or a history of events leading to the need for the current home care admission. MR#3: The SOC was dated 7/29/2020. The POC identified a primary diagnosis of Parkinson's Disease, and secondary diagnoses of Osteoporosis with pathological fracture, HTN, DM2, and atrial fibrillation. Upon review of the Comprehensive Assessment, documentation under the category of "Patient History and Diagnoses," consisted of the patient's temperature, blood pressure, pulse, respirations, oxygen (O2) saturation, height, weight, and Body Mass Index (BMI). There was no information found in the comprehensive assessment of an assessment of the patient's past medical history that included dates of onset, exacerbations, past medical treatments and outcomes, measurable data to use as a baseline for future assessments or a history of events leading to the need for the current home care admission. MR#4: The SOC was dated 2/19/21. The POC identified a primary diagnosis of Attention of new Colostomy, and secondary diagnoses of Diverticulitis of large intestine with perforation and abscess, gastro-esophageal reflux, and chronic myelomonocytic leukemia. Upon review of the Comprehensive Assessment, documentation under the category of "Patient History and Diagnoses," consisted of the patient's temperature, blood pressure, pulse, respirations, oxygen (O2) saturation, height, weight, and Body Mass Index (BMI). There was no information found in the comprehensive assessment of an assessment of the patient's past medical history that included dates of onset, exacerbations, past medical treatments and outcomes, measurable data to use as a baseline for future assessments or a history of events leading to the need for the current home care admission. MR#5: The SOC was dated 2/19/21. The POC identified a primary diagnosis of Radiculopathy of lumbar region, post-procedural pain, post-laminectomy syndrome, and HTN. Upon review of the Comprehensive Assessment, documentation under the category of "Patient History and Diagnoses," consisted of the patient's temperature, blood pressure, pulse, respirations, oxygen (O2) saturation, height, weight, and Body Mass Index (BMI). There was no information found in the comprehensive assessment of an assessment of the patient's past medical history that included dates of onset, exacerbations, past medical treatments and outcomes, measurable data to use as a baseline for future assessments or a history of events leading to the need for the current home care admission. These findings were reviewed and acknowledged by the Clinical Services Manager (CM-C) during an interview on 3/12/21 at 1:15 p.m. MR#6: The 2/23/21 POC identified diagnoses of fracture of right arm humerus, high blood pressure, and atherosclerosis (clogging or hardening of arteries) of coronary artery bypass graft. During record review on 3/10/21, it was noted that the Comprehensive Assessment included a section titled "Patient History & Diagnoses" that consisted of the patient's vital signs (temperature, pulse rate, blood pressure, respiration rate, and oxygen saturation). There was no indication of an assessment of the patient's past medical history that included dates of onset, exacerbations, past medical treatments and outcomes, measurable data to use as a baseline for future assessments or a history of events leading to the need for the current home care admission. The comprehensive assessment failed to note when the patient had fractured her right arm whether it was one day ago or weeks ago. There was no indication if the patient's arm was in a cast, a brace, or a sling. There was no indication whether the patient's diagnosis of high blood pressure was an acute or new onset health issue or whether it was a long-term chronic health issue. The comprehensive assessment failed to provide a complete picture of the patient's status to assist in developing the patient's plan of care. MR#7: The 2/18/21 POC identified a primary diagnosis of type 2 diabetes with diabetic neuropathy (nerve damage), and secondary diagnoses of high blood pressure heart disease and heart failure. During record review on 3/10/21, it was noted that the Comprehensive Assessment included a section titled "Patient History & Diagnoses" that consisted of the patient's weight and vital signs. There was no indication of an assessment of the patient's past medical history that included dates of onset, exacerbations, past medical treatments and outcomes, measurable data to use as a baseline for future assessments or a history of events leading to the need for the current home care admission. The comprehensive assessment failed to note whether the patient's diagnosis of diabetes with neuropathy was a new onset health issue or a long-term chronic issue. The section of the Comprehensive Assessment titled "Endocrine" noted that the patient is diagnosed with diabetes but is not taking any hypoglycemics (medications to lower blood sugar levels) at this time. There was no indication of the patient's current blood sugar level, the patient's typical range of blood sugar levels, whether the patient has a glucometer to monitor blood sugar levels, and an assessment of the patient's ability to use a glucometer. The comprehensive assessment failed to provide a complete picture of the patient's endocrine status regarding a primary diagnosis of diabetes with neuropathy that would lead to the need for the current home care admission. MR#8: The 6/13/20 POC identified a primary diagnosis of diabetes and secondary diagnoses of high blood pressure and right-sided hemiplegia (paralysis affecting one side of the body). During record review on 3/9/21, it was noted that the Comprehensive Assessment included a section titled "Patient History & Diagnoses" that consisted of the patient's height, weight, body mass index and vital signs. There was no indication of an assessment of the patient's past medical history that included dates of onset, exacerbations, past medical treatments and outcomes, measurable data to use as a baseline for future assessments or a history of events leading to the need for the current home care admission. The comprehensive assessment failed to note whether the patient's diagnosis of diabetes was a new onset health issue or a long-term chronic issue. The section of the Comprehensive Assessment titled "Endocrine" noted that the patient is diagnosed with diabetes, however the patient doesn't take blood sugar levels because she's not on insulin. There was no indication of the patient's current blood sugar level, whether the patient has a glucometer to monitor blood sugar levels, and an assessment of the patient's ability to use a glucometer with a diagnosis of right-sided hemiplegia. The comprehensive assessment failed to provide a complete picture of the patient's endocrine status regarding a primary diagnosis of diabetes that would lead to the need for the current home care admission. MR#9: This 95-year-old patient was admitted to the agency on 2/26/21 with a primary diagnosis of sarcopenia (muscle loss that occurs with aging and/or immobility) and a secondary diagnosis of muscle weakness. During record review on 3/9/21, it was noted that the Comprehensive Assessment included a section titled "Patient History & Diagnoses" that consisted of the patient's height, weight, body mass index and vital signs. There was no indication of an assessment of the patient's past medical history that included dates of onset, exacerbations, past medical treatments and outcomes, or a history of events leading to the need for the current home care admission. MR#10: This 79-year-old patient was admitted to the agency on 2/25/21 with a primary diagnosis of degeneration of the spinal column with compressed nerves and a secondary diagnosis of sarcopenia. During record review on 3/9/21, it was noted that the Comprehensive Assessment included a section titled "Patient History & Diagnoses" that consisted of the patient's height, weight, body mass index and vital signs. There was no indication of an assessment of the patient's past medical history that included dates of onset, exacerbations, past medical treatments and outcomes, or a history of events leading to the need for the current home care admission. The findings were reviewed with and acknowledged by the Clinical Services Manager (CM-C) during an interview on 3/11/21 at 12:15 p.m.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment included a review of all medications the patiently is currently using to determine any interactions, adverse effects, and duplicate drug therapy in 1 of 10 (MR#8) records reviewed, resulting in the potential for harmful medication effects for this one patient. Findings include: MR#8: This 78-year-old patient was admitted to the agency on 6/13/20 with diagnoses of diabetes and high blood pressure. During record review on 3/9/21, it was noted that the physician history and physical dated 6/9/20 lists the patient's current medications as follows: Lasix, WelChol, Potassium Chloride, Biotin, Benazepril, Carvedilol, Clopidogrel, and a new medication was added for this patient; Lantus Solostar U-100 insulin for blood sugars over 300. The 6/13/20 plan of care lists the following medications: Carvedilol, Aspirin, Clopidogrel, Benazepril, and Glipizide. The two lists are incongruent and there was no documentation to indicate the skilled nurse recognized the differences and contacted the physician to reconcile the medications. The skilled nurse did not include Lasix, WelChol, Potassium Chloride, Biotin, and Lantus Solostar insulin in the medication review to determine interactions, adverse effects, or duplicate drug therapy. The findings were reviewed with and acknowledged by the Clinical Services Manager (CM-C) during an interview on 3/11/21 at 12:15 p.m.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the plan of care covered all pertinent interventions with reportable safety parameters, and objectively measurable goals specific to the needs of the patient for 9 records reviewed (MR#s 1, 2, 3, 4, 5, 6, 7, 8, 10) from a total sample of 10 records reviewed, resulting in patients not receiving care specific to their individual needs and the potential for poor patient outcomes. Findings included: MR#1: The Start of Care (SOC) was dated 1/6/2021. The Plan of Care (POC) identified the primary diagnosis of Urinary Tract Infection (UTI) and secondary diagnoses of Diabetes Type 2 (DM2), Hypertension (HTN), Parkinson's Disease, Coronary Artery Disease (CAD), and two (2) stage 1 pressure ulcers of (1) the right and (2) the left buttocks. Upon review of the plan of care, it was noted the Goals on the POC were not objectively measurable. Examples include: "Patient will receive safe and effective personal care during this episode; Patient and caregiver will be able to identify fall risk factors; Occupational Therapy evaluation will be performed and a plan of care to increase functional independence with ADLs and IADLs will be established and countersigned by physician; Patient will attain optimal effectiveness of pain management regimen; Patient/caregiver will be able to demonstrate strategies for symptom management of Diabetes by 1/23/21." These goals are not objectively measurable to determine the patient's progress toward goals. In addition, the POC failed to include an intervention for the frequency of diabetic testing for this patient currently using insulin to manage diabetes. There was no indication of how many times per day the blood sugar should be tested such as before meals, after meals, upon wakening, at bedtime, etc. including the daily recording of testing results to be reviewed by the skilled nurse. MR#2: The SOC was dated 8/10/2020. The POC for the certification period of 1/15/20 to 3/14/20 identified at primary diagnosis of Type 2 Diabetes (DM2) with Hyperglycemia, and secondary diagnoses DM2 with Chronic Kidney Disease (CKD), HTN, Colostomy, and Neoplasm of Brain. Upon review of the plan of care, it was noted the Goals on the POC were not objectively measurable. Examples included: "Proper management of ostomy; Patient will receive safe and effective personal care during this episode of care; Patient/Caregiver will demonstrate measures to prevent skin breakdown, skin integrity will be maintained throughout this episode of care; Caregiver will be knowledgeable on the management of ostomy." MR#3: The SOC was dated 7/29/2020. The POC identified a primary diagnosis of Parkinson's Disease, and secondary diagnoses of Osteoporosis with pathological fracture, HTN, DM2, and atrial fibrillation. Upon review of the plan of care, it was noted the Goals on the POC were not objectively measurable. Examples include: "Patient/Caregiver will demonstrate measures for proper diabetic foot care, including daily foot examinations and the ability to identify risk factors and prevention methods; Patient will be able to verbalize need to have Advance Care Planning documents to ensure wishes are carried out by 9/8/2020; Patient will demonstrate understanding of individual emergency preparedness plan by 8/8/2020." In addition, the POC included ordered parameters for reporting to the physician diabetic testing that was out of range of the ordered parameters as follows: "Blood Sugar, Fasting: greater than 200 or less than 70 and Blood Sugar, Random: greater than 350 or less than 70." However, the POC failed to include orders for the frequency per day of monitoring the blood sugar levels. MR#4: The SOC was dated 2/19/21. The POC identified a primary diagnosis of Attention of new Colostomy, and secondary diagnoses of Diverticulitis of large intestine with perforation and abscess, gastro-esophageal reflux, and chronic myelomonocytic leukemia. Upon review of the plan of care, it was noted the Goals on the POC were not objectively measurable. Examples included: "Patient able to perform colostomy without difficulty; Patient/Caregiver will adapt optimally and develop effective coping skills related to change in body image or limitations by 3/20/21; Patient will attain optimal effectiveness of pain management regimen by 3/20/21." MR#5: The SOC was dated 2/19/21. The POC identified a primary diagnosis of Radiculopathy of lumbar region, post-procedural pain, post-laminectomy syndrome, and HTN. Upon review of the plan of care, it was noted the Goals on the POC were not objectively measurable. Examples included: "Patient will demonstrate understanding of individual emergency preparedness plan; Patient will attain optimal effectiveness of pain management regimen; Patient/caregiver will be able to verbalize need to have Advance Care Planning documents to ensure wishes are carried out by 2/27/21. In addition, the POC included an order for the PT to "assess surgical site for healing/complications; teach patient/caregiver care of incision and wound to prevent infection, signs/symptoms to report immediately and who to contact." However, the order did not include information of how the patient/caregiver would perform the care of the incision, any medications or lotions used to prevent infection, what symptoms would need to be reported, and the person the patient would need to contact if the "symptoms were to occur." These findings were reviewed and acknowledged by the Clinical Services Manager (CM-C) during an interview on 3/12/21 at 1:15 p.m. MR#6: This patient was admitted to the agency on 2/23/21 with diagnoses of fracture of right arm humerus, high blood pressure, and atherosclerosis (clogging or hardening of arteries) of coronary artery bypass graft. During record review on 3/10/21, it was noted that the POC failed to have measurable outcomes and goals. The skilled nursing goals include the following examples: Patient and caregiver will be able to identify fall risk factors by 3/20/21; patient will be free of falls/injury during this episode of care; and patient will demonstrate ability to effectively manage medication regimen by 2/27/21. MR#7: This patient was admitted to the agency on 2/18/21 with a primary diagnosis of type 2 diabetes with diabetic neuropathy (nerve damage), and secondary diagnoses of high blood pressure heart disease and heart failure. During record review on 3/10/21, it was noted that the POC failed to have measurable outcomes and goals. The skilled nursing goals include the following examples: Patient and caregiver will be able to identify fall risk factors by 3/27/21; patient will be free of falls/injury during this episode of care; and patient/caregiver will demonstrate ability to effectively manage medication regimen by 3/27/21. MR#8: This patient was admitted to the agency on 6/13/20 with a primary diagnosis of diabetes and secondary diagnoses of high blood pressure and right-sided hemiplegia (paralysis affecting one side of the body). During record review on 3/9/21, it was noted that the POC failed to have measurable outcomes and goals. The skilled nursing goals include the following examples: Patient and caregiver will be able to identify fall risk factors by 7/11/20; patient will be free of falls/injury during this episode of care; patient will demonstrate ability to effectively manage medication regimen by 7/11/20; and Physical Therapy evaluation will be performed and a plan of care to increase functional independence will be established and countersigned by the physician. MR#10: This 79-year-old patient was admitted to the agency on 2/25/21 with a primary diagnosis of degeneration of the spinal column with compressed nerves and a secondary diagnosis of sarcopenia (muscle loss that occurs with aging and/or immobility). During record review on 3/9/21, it was noted that the POC failed to have measurable outcomes and goals. The skilled nursing goals include the following examples: Patient and caregiver will be able to identify fall risk factors by 3/27/21; patient will be free of falls/injury during this episode of care; patient will demonstrate ability to effectively manage medication regimen by 3/6/21; and Physical Therapy evaluation will be performed and a plan of care to increase functional independence will be established and countersigned by the physician. The findings were reviewed with and acknowledged by the Clinical Services Manager (CM-C) during an interview on 3/11/21 at 12:15 p.m.

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 observation, record review and interview, the agency failed to maintain the agency-wide surveillance program for the identification and prevention of COVID-19 for staff and patients, resulting in the potential development and spread of a contagious viral infection between agency staff and the agency's 39 current patients. Findings included: Upon arriving at the agency on 3/9/2021 at 10:45 a.m., it was observed a sign posted on the entrance door indicated the agency would be taking the temperature of every visitor entering the agency along with questions regarding each visitor's current health status regarding signs and symptoms of covid-19 and possible visitor contacts who may have tested to be positive for COVID-19. Upon knocking on the door to the agency's suite, an employee of the agency opened the door and greeted and escorted this writer to an office desk without first being screened for Covid-19. Throughout the survey, administrative and field staff were observed entering and exiting the agency's suite. The agency failed to abide by the directions for COVID-19 screening that was posted on the entrance door to the suite. The agency did have new policies developed for tracking of symptoms for staff and patients, but these policies were not always followed. For example, the agency had a protocol for patient visits including the taking of each patient's temperature upon entrance to the residence, and survey questions related to risks and signs and symptoms of COVID-19 that were to be answered by the patient. It was observed during two joint home visits (MR#4 at 3:30 p.m with the Occupational Therapist), and (MR#5 at 11:00 a.m. with the Registered Nurse) both occurring on 3/10/2021, that patient's temperatures were taken, but neither patient was asked the survey questions developed for COVID-19. Also, it was noted that all patients whose records were reviewed had documentation of the temperature at the Start of Care visits along with answers to the COVID-19 survey questions, however, the survey for questions with patient responses were not always documented on the following-up visit notes to be used for tracking purposes. Examples include: MR#1: The Start of Care (SOC) was dated 1/6/2021. The Plan of Care (POC) identified the primary diagnosis of Urinary Tract Infection (UTI) and secondary diagnoses of Diabetes Type 2 (DM2), Hypertension (HTN), Parkinson's Disease, Coronary Artery Disease (CAD), and two (2) stage 1 pressure ulcers of (1) the right and (2) the left buttocks. The COVID-19 questionnaire was completed on the SOC visit dated 1/6 /2021, however there were only 2 additional COVID-19 surveys completed and documented on 1/8/21 1/15/21 out of a total of 33 visits completed by the Registered Nurse (RN), Home Health Aide (HHa), Physical Therapist (PT) and Occupational Therapist (OT) MR#2: The SOC was dated 1/15/21. The POC for the certification period of 1/15/21 to 3/14/21 identified at primary diagnosis of Type 2 Diabetes (DM2) with Hyperglycemia, and secondary diagnoses DM2 with Chronic Kidney Disease (CKD), HTN, Colostomy, and Neoplasm of Brain. However, out of a total of 10 visits provided by the RN, PT, and OT, there was no documentation of COVID-19 survey questions. MR#3: The SOC was dated 7/29/2020. The POC identified a primary diagnosis of Parkinson's Disease, and secondary diagnoses of Osteoporosis with pathological fracture, HTN, DM2, and atrial fibrillation. There were 5 COVID-19 survey questionnaires dated 7/29, 8/10, 8/12, 8/17, 8/19 documented in the record our of a total of 19 visits provided by PT, OT, and Speech Therapy (ST). MR#4: The SOC was dated 2/19/21. The POC identified a primary diagnosis of Attention of new Colostomy, and secondary diagnoses of Diverticulitis of large intestine with perforation and abscess, gastro-esophageal reflux, and chronic myelomonocytic leukemia. However, there were a total of 2 COVID-19 survey questionnaires dated 12/21/20 and 2/19/21 out of 4 visits provided by the RN. MR#5: The SOC was dated 2/19/21. The POC identified a primary diagnosis of Radiculopathy of lumbar region, post-procedural pain, post-laminectomy syndrome, and HTN. It was noted the COVID-19 survey questionnaire was completed and documented in the SOC OASIS, however, there were no further COVID-19 survey questioners documented in the following 9 visits provided by the PT and OT. During an interview with the Clinical Services Manager (CM-C) on 3/12/21 at 1:15 p.m. CM-C was queried if the questionnaires would be used should one of the staff members or patients became COVID-19 positive while the agency was providing care to the patients. The response was, "the COVID-19 questions should be asked at every visit."

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on record review and interview, it was determined that the agency failed to ensure the registered nurse performed assessments and re-assessments using objective measurements to determine if the patient's health status was improving or worsening during the course of care and failed to document specific daily blood sugar results rather than documenting in ranges in 1 of 8 (MR#2) records reviewed in which nursing services were provided out of a total sample of 10 records reviewed, which resulted in the potential for unidentified patient needs and decline in the patient's diabetic health. Findings included: MR#2: The SOC was dated 8/11/2020. The POC for the certification period of 8/11/20 to 8/24/20 identified at primary diagnosis of Type 2 Diabetes (DM2) with Hyperglycemia, and secondary diagnoses DM2 with Chronic Kidney Disease (CKD), HTN, Colostomy, and Neoplasm of Brain. The patient was currently taking daily insulin 3 times per day on a sliding scale to control the diabetes. Upon review of the record on 3/11/2021, it was noted there were no specific daily blood sugar results documented 3 times per day in the visit notes. The Registered Nurse (RN-E) documented Blood Sugar results in ranges only. The patient's blood sugar testing was recorded in the patient's visit notes dated 8/11/2020, 8/12/2020, 8/17/2020, 8/20/2020 and 8/24/2020 as follows: "SOC OASIS dated 8/11/2020 documented a fasting range of 80 to 170 mg/dl with no random blood sugar results or ranges. 8/12/2020: "Fasting 80 to 170 mg/dl and Random 80-170 mg/d". 8/17/2020: "Fasting 80 to 150 mg/dl and Random 120 to 150 mg/dl". 8/20/2020: "Fasting: 80 to 161 mg/dl and Random 80 to 161 mg/dl". The Discharge OASIS dated 8/24/20 documented the following blood sugar results as "Fasting: 70 to 130 mg/dl and Random of 70 to 200 mg/dl". The POC included an order to test the patient 3 times daily using the following sliding scale: 150-200 6 units; 201-250 7 units; 251-300 8 units; 301 -350 9 units. There was no evidence found in the record of the actual blood sugar results during the SN home visits and on a daily basis to determine the amount of insulin based on the sliding scale that the patient was to receive, nor how much insulin the patient had received as required by the physician order. In addition, RN-E failed to document the patient's lower extremity edema in objective terms to determine if the patient's edema was improving or becoming worse. For example, RN-E documented on 8/12 and 8/17 "Edema, Pitting, Bilateral Ankles, grade 2+," rather than using a tape measure to determine if the patient's edema was improving or becoming worse. These findings were reviewed and acknowledged by the Clinical Services Manager (CM-C) during an interview on 3/12/21 at 1:15 p.m after CM-C reviewed the record in regards to the documentation of the blood sugar results.

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 transfer summary was sent to the physician within 2 business days of becoming aware of an unplanned transfer for 1 of 2 (MR#s 7) records reviewed in which the patient was transferred from the agency to an inpatient facility, resulting in the physician or receiving agency not having knowledge of the patient's health status at the time of transfer which has the potential to negatively affect the health and well-being of this one patient. Findings include: MR#7: This 78-year-old patient was admitted to the agency on 2/18/21. During record review on 3/10/21 it was noted that a transfer OASIS (outcome and assessment information set) dated 2/27/21 was blank. A communication note dated 3/2/21, states the patient was admitted to the hospital on Saturday (2/27/21). There was no documented evidence that key information such as a summary of all medications, the plan of care, and a summary of services provided were sent to the physician or the inpatient facility. The agency failed to follow its own policy titled, Discharge/Transfer Policy (not dated), which states a completed transfer summary is completed within two (2) business days of becoming aware of an unplanned transfer. The findings were reviewed with and acknowledged by the Clinical Services Manager (CM-C) during an interview on 3/11/21 at 12:15 p.m.

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 the signature of the Medical Social Worker's (MSW) on the Evaluation visit note was accurately recorded on the date the patient was actually evaluated in 1 (MR#2) of a total of 2 sampled records reviewed in which the MSW provided services. Findings included: MR#2: The SOC was dated 8/10/2020. The POC identified at primary diagnosis of Type 2 Diabetes (DM2) with Hyperglycemia, and secondary diagnoses DM2 with Chronic Kidney Disease (CKD), HTN, Colostomy, and Neoplasm of Brain. Upon review of the record on 3/13/2021, it was noted that the Evaluation visit was dated and completed on 8/15/2021 by MSW-J. However, the document was electronically signed by MSW-J on 8/14/2021, the day before the evaluation visit was completed. This finding was reviewed and acknowledged by the Clinical Services Manager (CM-C) during an interview on 3/12/21 at 1:15 p.m