Every finding on record at All Americans Home Health Care

A Medicare emergency preparedness survey was conducted by the Michigan Department of Licensing and Regulatory Affairs (MDLARA) from 4/1/25 to 4/3/25 at: All Americans Home Health Care 1397 S. Linden Rd. suite D Flint, MI 48532 This agency had no other locations at the time of survey. The services the agency provides are: Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), Medical Social Work (MSW), Speech Therapy (ST) and Home Health Aide (HHa). Clinical records reviewed for this survey: 3 active records with home visits, 2 active records with no home visit, and 2 discharged records, for a total of 7 records reviewed. At the conclusion of the survey the agency was found to be in compliance with the conditions of participation for Emergency Preparedness at 42 CFR part 484.22.

A Medicare recertification survey was conducted by the Michigan Department of Licensing and Regulatory Affairs (MDLARA) from 4/1/25 to 4/3/25 at: All Americans Home Health Care 1397 S. Linden Rd. suite D Flint, MI 48532 This agency had no other locations at the time of survey. The services the agency provides are: Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), Medical Social Work (MSW), Speech Therapy (ST) and Home Health Aide (HHa). Clinical records reviewed for this survey: 3 active records with home visits, 2 active records with no home visit, and 2 discharged records, for a total of 7 records reviewed. At the conclusion of the survey the agency was found to be out of compliance with the conditions of participation for Home Health Agencies at 42 CFR part 484.

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 4 (MR's # 1, 2, 5, 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 8/23/24, with diagnoses of hypertensive heart disease with heart failure, and chronic kidney disease. During record review on 4/3/25, it was discovered that the nursing goals on the plan of care (POC) were not measurable. For example, "Improved endurance by 10/21/24." another stated, "Improved independence by 10/21/24." 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 2/26/25, with diagnoses of type 2 diabetes mellitus with chronic obstructive pulmonary disease, hypertension, and dementia. During record review on 4/3/25, it was discovered that the nursing goals on the POC were not measurable. For example, "Bowel status will be within normal limits for patient by 3/26/25." another stated, "Urinary elimination will be within normal limits by 3/26/25." 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 3/17/25, with diagnoses of sacral fracture, hypertension, and congestive heart failure. During record review on 4/2/25, it was discovered that the nursing goals on the POC were not measurable. For example, "Increased activity tolerance by 4/9/25." another stated, "Patient/Caregiver will demonstrate proper body mechanics by 4/9/25." 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 1/30/25, with diagnoses of wound, dementia, and anxiety. During record review on 4/1/25, it was discovered that the nursing goals on the POC were not measurable. For example, "Patient/Caregiver will demonstrate safe and effective wound care, supply management, dressing change, disposal of soiled dressings, monitoring for infection, and signs or symptoms of infection by 3/1/25." another stated, "Patient/caregiver will demonstrate knowledge of and compliance with medication management, does, route, and schedule...by 3/1/25." There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. During an interview on 4/3/25, at 5:05 p.m., the Director of Clinical Services (DOCS) acknowledged the above findings.

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 included in the record for 2 of 2 (P-1, P-6) discharge records reviewed, from a total sample of 7 records reviewed, resulting in a lack of information to ensure continuity of care. Findings include: P-1: The start of care (SOC) was dated 8/23/24, with diagnoses of chronic kidney disease, congestive heart failure, and hypertension. During record review on 4/3/25, it was noted that the record contained a discharge OASIS dated 10/21/24. The discharge OASIS failed to include frequency of visits, and medications the patient was on at the time of discharge. There was no evidence of a discharge summary in the record. P-6: The SOC was dated 7/3/24, with diagnoses of heart failure, venous insufficiency, and hypertension. During record review on 4/1/25, it was noted that the record contained a discharge OASIS dated 8/26/24. The discharge OASIS failed to include frequency of visits, and medications the patient was on at the time of discharge. There was no evidence of a discharge summary in the record. During an interview on 4/3/25, at 5:05 p.m., the Director of Clinical Services (DOCS) acknowledged the above findings

On 5/16/22 through 5/18/22, the Michigan Department of Licensing and Regulatory Affairs conducted a recertification survey at All Americans Home Health Care. This was a standard survey. The requirements for participation in Medicare at 42 CFR 484.102 Emergency Preparedness were not reviewed.

A Medicare Authorized Recertification and Infection Control Survey was conducted by the Michigan Department of Licensing and Regulatory Affairs (MDLARA) from May 16, 2022 through May 18, 2022 at: All Americans Home Health and Hospice Care 1397 S. Linden Road, Suite D Flint, MI 48532 The survey included 3 home visits with record reviews, 2 active records without home visits were reviewed, and 2 discharged records were reviewed for a total of 10 records reviewed. The agency was found to be in compliance with staff vaccination requirements. At the conclusion of the survey the agency was found to be out of compliance with standard level deficiencies for the conditions of participation for home health agencies at: 42 CFR Part 484.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to inform the patient in advance of the disciplines that will furnish care in 1 records reviewed (MR# 3) from a total sample of 7 records reviewed, resulting in the patient not having knowledge of the plan for treatment and potential unmet care needs. Findings include: MR#3: The Start of Care (SOC) was dated 3/30/22. The Plan of Care (POC) identified diagnoses of Cervical Laminectomy, A-Fib, Hypertension and Diabetes Type 2. During record review on 5/16/22, it was noted that the referral dated 3/29/22 ordered Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT) and Home Health Aide (HHA). The signed consent frequencies stated, “Services provided: Skilled Nurse: 2w (2 times for one week), Speech Therapy: Eval and treat, Physical Therapy: Eval and treat. Home Health Aide: blank.” The “Orders for discipline and treatment” within the OASIS (Outcome and Assessment Information Set) documented, “SN: 2w2, 1w1, 2 prn (as needed) falls and labs, PT: Eval and treat, OT: Eval and treat, HHA: 2w3.” Additionally, the POC stated, “SN: 1 x week for 4 weeks starting 4/1/22. The agency failed to provide an accurate written frequency of services to be provided to the patient. These findings were reviewed with and acknowledged by the Director of Nursing (DON#1) during an interview on 5/17/22 at 3:10 pm.

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 agency failed to provide all services as ordered in the Plan of Care in 1 of 7 (MR#2) records reviewed, resulting in the patient not receiving all services to assist in improving the health status of the patient. Findings included: MR#2: The patient was admitted to the agency on 5/6/2022. The Plan of Care for the certification period 5/6/2022 to 7/4/2022 identified diagnoses of Encounter for Other Orthopedic Aftercare, Fracture of Left Ilium, Polyosteoarthritis, Hypertension, Gout, History of falling, and Unspecified Abnormalities of Gait and Mobility. The following Home Health Care services were ordered on the Plan of Care: Skilled Nursing (SN): 1x weekx1week. (Week 1); 2 PRN visits for change in condition; (SN): 2xweekx2weeks (week 2); SN 1xweekx1week week 4). Physical Therapy (PT): 1 PRN visit starting 5/6/2022 for Evaluation. 2xweekx3weeks starting 5/10/2022. Occupational Therapy (OT): 1 PRN visit starting 5/6/2022 for evaluation. OT 2xweekx2 (week 2). Home Health Aide (HHa) 2xweekx3weeks starting 5/10/2022. Upon review of the record on 5/17/2022, it was noted that no Home Health Aide Services had been provided. The record included an Inter-Office Communication Note dated 5/13/2022 at 6:24 pm by the Home Health aide that stated: "tried to reach resident many different times, contacted nurse and office, waiting to hear back from the resident, will try again during the week next week." {sic} During a survey home visit conducted on 5/17/2022 at 12:00 p.m. with the Physical Therapist, the patient's caregiver (the patient's daughter) was asked if the patient needed any help with personal care. The caregiver stated, "right now I am the one providing the care, but some help would be appreciated." When asked if any calls had been received from the agency's home health aide to schedule an appointment, the response was, "not that I know about, but if I am not here, there is always someone available to answer the phone and my mother (the patient) is also able to use the phone and is here everyday, all day long. The nurse, physical therapist, and occupational therapist have not had any problems contacting our family to make appointments." The Home Health aide failed to provide aide services as ordered by the physician, and failed to notify the physician of a delay or missed visits in providing Home Health Aide Services to the patient. These findings were reviewed and acknowledged by the Director of Nursing on 5/18/2022 at 12:30 p.m.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on record review, policy 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 2 of 7 sampled records reviewed (MR#s 1 and 2), resulting in incomplete clinical information to aid in determining the current and future care needs of the patient and the patient's progress towards goals. **Agency Policy #1-016: "Initial and Comprehensive Assessment", Revised December 2018. The policy states, "During the initial and comprehensive patient assessment, all baseline data to be used in measuring the patient's progress towards goals and other relevant information will be documented in the patient's clinical record, including blood pressure, temperature, pulse, respiration, skin, pain status, height/weight, nutritional status, and other relevant data related to pertinent physical findings; past medical and surgical care including dates of onset/exacerbation, use of emergent care since last assessment. MR#1: The Start of Care (SOC) was dated 4/29/2022. The Plan of Care for the certification period 4/29/2022 to 6/27/2022 identified diagnoses of Diabetes type 2 with Hyperglycemia, Ulcerative Colitis, Heart Failure, Chronic Obstructive Pulmonary Disease, and Hypertension. Upon review of the Start of Care Comprehensive Assessment, under the category of "(1021): Primary Diagnosis and (M1023) Other Diagnoses" there were 9 diagnoses identified, all with the same date of onset of 4/29/2022. Under the Category of "(M1028: Active Diagnoses-Comorbidities and Co-existing Conditions)", the Skilled Nurse only identified 1 diagnosis (Diabetes Mellitus). There was no documentation of the patient's past medical history that included the unique dates of onset, exacerbations, treatments, and outcomes and how the "Other Diagnoses" had contributed to the current health of the patient or the need for the current home health care admission. In addition, for this patient diagnosed with congestive heart failure with a history of lower extremity edema, the skilled nurse documented a subjective measurement of 2+ rather than obtaining an objective measurement of the patient's lower extremity edema on the Start of Care Assessment to use as a baseline measure for future assessments in determining the status of the patient's heart failure diagnosis. MR#2: The SOC was dated 5/6/2022. The Plan of Care for the certification period 5/6/2022 to 7/4/2022 identified diagnoses of "Encounter for orthopedic aftercare, Fracture of left ilium, Polyosteoarthritis, Hypertension, and Gout. Upon review of the Start of Care Comprehensive Assessment, under the category of "(1021): Primary Diagnosis and (M1023) Other Diagnoses" there were 11 diagnoses identified, all with the same date of of onset of 5/6/2022." Under the Category of "(M1028: Active Diagnoses-Comorbidities and Co-existing Conditions)", the Skilled Nurse documented, "None of the above." There was no documentation of the patient's past medical history that included the unique dates of onset, exacerbations, treatments, and outcomes and how the contribution of the listed diagnoses had contributed to the current health of the patient or the need for the current home health care admission. These findings were reviewed and acknowledged by the Director of Nursing (DON#1) during an interview on 5/18/2022 at 12:30 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 observation, record review, and interview, it was determined the Agency failed to ensure the comprehensive assessment included a review of all medications to determine any adverse effects; failed to document the findings of the drug regime review as required, and failed to ensure the physician was notified of potential severe drug interactions and duplicative drug therapies in 3 (MR#'s 3, 4 and 7) of 7 sampled records, resulting in the potential for harmful medication effects for all 56 patients currently serviced by this Agency. Findings included: MR# 7: The start of care (SOC) was dated 1/22/22, with diagnoses that included dressing change, peripheral vascular disease, heart failure and diabetes. During record review on 5/17/22, it was discovered that the medication profile was not filled out or signed. The area for interactions was left blank. When the drugs were entered into Drugs.com, there were 14 moderate, 2 minor, 8 food/drug interactions and 2 duplicate drugs. None of these findings were indicated on the medication profile. There was no documented evidence that a registered nurse (RN) reviewed the medications. During an interview on 5/18/22 at 1:30 p.m., the director of nursing (DON#1) acknowledged the above findings. MR#3: The Start of Care (SOC) was dated 3/30/22. The Plan of Care (POC) identified diagnoses of Cervical Laminectomy, A-Fib, Hypertension and Diabetes Type 2. During record review on 5/16/22, it was noted that the hospital discharge referral dated 3/29/22 showed that two medications were changed. Humalog 100 unit/ML administer 20 units subcutaneous TID (three times daily) with meal. Insulin lispro 100 unit/ML administer 10 units daily with meals. The medication profile dated 3/30/22 states, “Insulin Lispro (Humalog KwikPen) 200 unit/ML subcutaneous 20 units three times per day and Insulin Lispro (Humalog KwikPen) 200 unit/ML subcutaneous 10 units daily.” There was no documentation of the physician being contacted regarding the discrepancy of the 100 unit and 200 unit medications and the daily administered dose instead of three times daily per the discharge paperwork. MR#4: The Start of Care (SOC) was dated 1/28/22. The Plan of Care (POC) identified diagnoses of Lymphedema, Chronic Obstructive Pulmonary Disease and Chronic Kidney Disease. During record review on 5/17/22, During a joint in-home observation visit on 5/17/22 with the Home Health Aide, it was noted that the patient is taking Bumex 1mg BID (two times a day) and Flomax 0.4mg daily. Review of the medication profile on 5/17/22 noted that these medications were not on the medication profile but were on the referral dated 1/22/22. There is no documented medication reconciliation completed with the physician to determine an accurate home medication regimen. These findings were reviewed with and acknowledged by the Director of Nursing (DON#1) during an interview on 5/17/22 at 3:45 pm.

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, policy review, and interview, it was determined the Home Health Agency (HHA) failed to ensure the goals on the Plan of Care (POC) were measurable in 7 of 7 records reviewed (M.R.#s 1, 2, 3, 4, 5, 6, and 7), and failed to ensure reportable parameters were included on the POC, resulting in the potential for a plan of care not meeting the patient's needs. Findings include: MR# 5: The start of care (SOC) was dated 5/5/22, with diagnoses that included wound dressing changes, peripheral vascular disease and diabetes mellitus. During record review on 5/18/22, it was discovered that the goals on the POC were not measurable, for example, one goal stated, "Blood pressure range will be within physician established parameters by ___." There were no parameters documented on the POC and there was no time frame documented for completion of the goal. Another stated, "Peripheral edema will improve from grade ___ to grade ___ by ___." There were no numbers documented associated with the grade, and there was no time frame documented for completion of the goal. There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. MR# 6: The start of care (SOC) was dated 2/10/22, with diagnoses that included surgical aftercare, gastroesophageal reflux disease, and urinary incontinence. During record review on 5/16/22, it was discovered that the goals on the POC were not measurable, for example, one goal stated, "SPO2 will be within physician established parameters by 3/19/22." There were no parameters documented on the POC. Another stated, "Patient/Caregiver will state understanding of measures to manage disease and identify signs/symptoms to report by 3/19/22." There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. MR# 7: The start of care (SOC) was dated 1/22/22, with diagnoses that included dressing change, peripheral vascular disease, heart failure and diabetes. During record review on 5/17/22, it was discovered that the goals on the POC were not measurable, for example, one goal stated, "SPO2 will be within physician established parameters by ___." There were no parameters documented on the POC, and there was no time frame documented for completion of the goal." Another stated, "Patient/Caregiver will demonstrate self monitoring of pulse/blood pressure/weights, and reporting readings outside physician established parameters by ___." There were no parameters documented on the POC, and there was no time frame documented for completion of the goal. There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. The POC also failed to include blood sugar parameters (For when to notify the physician) with a diagnosis of diabetes mellitus, and failed to include any heart failure parameters (Weights, edema measurements) with a diagnosis of heart failure. During an interview on 5/18/22 at 1:30 p.m., the director of nursing (DON#1) acknowledged the above findings. MR#3: The Start of Care (SOC) was dated 3/30/22. The Plan of Care (POC) identified diagnoses of Cervical Laminectomy, A-Fib, Hypertension and Diabetes Type 2. During record review on 5/16/22, it was noted that the goals within the POC were not measurable. For example, one goal stated, “Pt (Patient) will demonstrate energy conservation techniques.” Additionally, another goal stated, “Pt will state understanding of measures to manage disease and identify S/S (signs and symptoms) to report.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. Furthermore, the POC failed to contain reportable heart rate parameters. MR#4: The Start of Care (SOC) was dated 1/28/22. The Plan of Care (POC) identified diagnoses of Lymphedema, Chronic Obstructive Pulmonary Disease and Chronic Kidney Disease. During record review on 5/17/22, it was noted that the goals within the POC were not measurable. For example, one goal stated, “Pt (Patient) will demonstrate energy conservation techniques by____.” Additionally, another goal stated, “Pt will state understanding of measures to manage disease and identify S/S to report by _____.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. These findings were reviewed with and acknowledged by the Director of Nursing (DON#1) during an interview on 5/17/22 at 3:15 pm. **Agency Policy# 1-007: "Care Planning Process", revised December 2018. The policy states, "The patient-specific clinical plan of care includes: Measurable outcomes and goals identified by the organization and the patient anticipated to occur as a result of implementing and coordinating the plan of care." MR#1: The Start of Care (SOC) was dated 4/29/2022. The Plan of Care for the certification period 4/29/2022 to 6/27/2022 identified diagnoses of Diabetes type 2 with Hyperglycemia, Ulcerative Colitis, Heart Failure, Chronic Obstructive Pulmonary Disease, and Hypertension. Upon review of the Plan of care, it was noted the goals on the plan of care were not objectively measurable to determine the patient's progress towards goals. Findings included: "Patient will demonstrate energy conservation techniques; Bowel status will be within normal limits for patient; Patient will verbalize/demonstrate measures to manage pain: medication management/alternative pain relief measures, behavior modification to avoid factors that increase pain/use of pain scale to identify intensity and determine comfort goals." These goals are not objectively measurable to determine the patient's progress toward goals. MR#2: The SOC was dated 5/6/2022. The Plan of Care for the certification period 5/6/2022 to 7/4/2022 identified diagnoses of "Encounter for orthopedic aftercare, Fracture of left ilium, Polyosteoarthritis, Hypertension, and Gout. Upon review of the Plan of care, it was noted the goals on the plan of care were not objectively measurable to determine the patient's progress towards goals. Findings included: "To get stronger; Patient will verbalize/demonstrate understanding of symptom management, resource utilization and medication management to reduce unplanned hospital or emergency department visits; PT goal: demonstrates ability to follow home exercise program to improve functional status." These goals are not objectively measurable to determine the patient's progress towards goals. These findings were reviewed and acknowledged with the Director of Nursing (DON#1) on 5/18/2022 at 12:30 p.m.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure services were provided only as ordered by the physician in 1 of 7 (MR# 3) records reviewed, resulting in the potential for the provision of inappropriate care and services Findings include: MR#3: The Start of Care (SOC) was dated 3/30/22. The Plan of Care (POC) identified diagnoses of Cervical Laminectomy, A-Fib, Hypertension and Diabetes Type 2. During record review on 5/16/22, it was noted that POC contained the following reportable blood pressure (BP) ranges: systolic is greater than 160 or less than 100; diastolic is greater than 100 or less than 50. Additionally, the POC failed to contain a reportable heart rate. On 4/1/22, the Skilled Nurse (SN) documented a BP of “90/50” and within the skilled intervention section stated, “Patient’s vitals are WNL (within normal limits).” Additionally, on 4/7/22, the SN documented a pulse of “50” and again stated, “Patient’s vitals are WNL.” Furthermore, on 4/26/22, the Physical Therapy Assistant (PTA) documented a BP of “172/82.” All three visits had blank documentation under the section “Physician Contacted Re:.” There was no documented evidence that the SN or PTA notified the physician of the low BP reading, the low heart rate reading or the high BP reading. These findings were reviewed with and acknowledged by the Director of Nursing (DON#1) during an interview on 5/17/22 at 3:05 pm and confirmed that the low heart rate parameter is less than 60.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation and record review, the agency failed to prepare and provide the patient and the caregiver written information regarding the patient's medication regimen via the medication profile in 1 0f 7 records reviewed (MR#2). Findings included: MR#2: The SOC was dated 5/6/2022. The Plan of Care for the certification period 5/6/2022 to 7/4/2022 identified diagnoses of "Encounter for orthopedic aftercare, Fracture of left ilium, Polyosteoarthritis, Hypertension, and Gout." The patient's "Home Information Handbook", provided by the agency upon the patient's admission on 5/6/2022 was reviewed during a survey home visit on 5/17/22 at 12:00 p.m. with the physical therapist. The patient's medication profile was not found in the patient's home care packet. There was no written information found regarding the patient's medication regimen based on the results of the medication profile. During an interview on 5/17/2022 at 12:45 p.m., the patient's daughter, who was the identified caregiver for this patient, was asked if there was a list of medications or a profile provided by the agency of the patient's current medications. The daughter proceeded to look through the patient's home packet, and then searched through a stack of papers next to the packet with no success. The caregiver stated, "We keep all the documents the agency gives us right here in case any family members need to review any instructions before giving care. I don't see a list of her medications." The agency failed to provide the patient and caregiver written information regarding the patient's medication regimen.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on record review and interview, it was determined the Registered Nurse (RN) failed to include safety precautions on the aide's care plan, in 1 of 2 records reviewed in which Home Health Aide (HHa) services were provided (MR#7) resulting in the potential for the provision of unsafe care. Findings included: MR #7: The Plan of Care (POC) dated 1/22/22, documented the following diagnoses, "Peripheral vascular disease, heart failure, diabetes mellitus and dressing changes." During review of the Home Health Aide (HHa) POC dated 11/19/21, it was discovered that no diabetic precautions were documented for a patient with nail care and nail filing ordered. During an interview on 5/18/22 at 1:30 p.m., after a review of the aide's care plan, the Director of Nursing (DON#1), acknowledged the above findings.

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 observation, record review and interview, the agency failed to ensure clinical notes were accurate for 1 of 7 (MR# 3) records reviewed, resulting in the potential to negatively affect the health and well-being of these patients. Findings include: MR#3: The Start of Care (SOC) was dated 3/30/22. The Plan of Care (POC) identified diagnoses of Cervical Laminectomy, A-Fib, Hypertension and Diabetes Type 2. During record review on 5/16/22, it was noted that the POC ordered Skilled Nursing (SN) at a frequency of 1w4 (1 time a week for 4 weeks) effective 4/1/22. The comprehensive assessment dated 3/30/22 documented a blood sugar reading of 132. The following 4 SN visits contained no blood sugar readings: 4/1/22, 4/7/22, 4/14/22 and SN Discharge 4/22/22. The agency failed to ensure that the medical record was complete and accurate. These findings were reviewed with and acknowledged by the Director of Nursing (DON#1) during an interview on 5/17/22 at 3:35 pm.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review, policy review, and interview, the Agency failed to ensure the transfer summaries were complete, detailed, and provided the patient's current health status at the time of transfer, forwarded to the physician and receiving facility, and included the name of the facility in which the patient was transferred in 2 (MR#1 and 7) of 2 records in which the patient was transferred to the hospital from a total of 7 records reviewed, resulting in no record of the facility caring for the patient. MR# 7: The start of care (SOC) was dated 1/22/22, with diagnoses that included dressing change, peripheral vascular disease, heart failure and diabetes. During record review on 5/17/22, it was discovered that no transfer summary was documented in the record and the transfer OASIS dated 3/10/22, failed to document a summary of the patient's care provided, health status, and the name of the facility being transferred to. The OASIS documented "Kidney failure" as the only patient related clinical information. During an interview on 5/18/22 at 1:30 p.m., the director of nursing (DON#1) acknowledged the above findings. **Agency Policy No-1-023: "Transfer Summary," Revised December, 2018. The policy states, "Within 48 hours of transfer, the transferring clinician will complete a transfer summary that includes, as appropriate: The reason for transfer, continuing symptom management needs, Medication profile, A summary of the care provided and the progress toward achieving goals, the existence of any Advance Directives, face to face encounter, if during initial certification, the date of transfer, which is the date of the last visit made, and a copy of the transfer summary will be sent to the physician within 72 hours of transfer. MR#1: The Start of Care (SOC) was dated 4/29/2022. The Plan of Care for the certification period 4/29/2022 to 6/27/2022 identified diagnoses of Diabetes type 2 with Hyperglycemia, Ulcerative Colitis, Heart Failure, Chronic Obstructive Pulmonary Disease, and Hypertension. During a review of the record on 5/17/2022, it was documented that the patient had been transferred to the hospital from the physician's office due to a finding of hypotension. Further review of the record revealed the transfer summary was blank with the exception of check marks next to "physician notified; report given to institution or agency assuming care with notification of Advance Directive status; and Medication Profile provided (per agency policy)." There was no documentation of the name of the facility to which the patient had been transferred and admitted. There was no written summary of the health status, and care provided by the agency documented on the transfer summary. The only clinical information documented on the transfer summary was, "The patient states the Primary Care Provider sent patient to hospital at appointment due to hypotension." There was no documentation such as a fax receipt that a copy of the transfer summary was sent to the physician within 72 hours of transfer. These findings were reviewed and acknowledged during an interview with the Director of Nursing (DON#1) on 5/18/22 at 12:30 p.m.