Every finding on record at Allied Home Health Care & Nursing Services, LLC

The following deficiencies were identified during a Medicare authorized Emergency Preparedness survey conducted by the Michigan Department of Licensing and Regulatory Affairs on 12/2/24 through 12/5/24 at: Allied Home Health Care & Nursing Services, LLC 4800 Cadieux Rd. Detroit, MI 48224 This agency had no additional locations. At the conclusion of the survey, this agency was determined to be noncompliant with the Conditions of Participation at 42 CFR 484 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 develop an Emergency Preparedness plan that had been reviewed and updated at least every 2 years, resulting in lack of direction for Agency personnel in the event of an actual emergency or disaster. This deficient practice could affect the health and safety of all directly employed staff, regularly utilized contracted staff and all 21 patients actively serviced by this Agency in the event of an actual emergency or disaster. Findings include: On 12/4/24 at 1:41 p.m., the agency's Emergency Preparedness documentation was reviewed with the Clinical Manager (CM #1). During the review, there was no documented evidence that showed the Emergency Preparedness plan had been reviewed/updated at least every 2 years in accordance with the requirements of this section. During the review, CM #1 reported the last update was in 2020. These findings were reviewed with and confirmed by the Clinical Manager at the time of discovery.

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 an Emergency Preparedness plan existed that was based on a documented facility and community-based risk assessment from an all-hazards approach, that had been updated at least every 2 years, resulting in the potential for lack of preparedness and poor patient and staff outcomes, in the event of an actual emergency. Findings include: On 12/4/24 at 1:41 p.m., the agency's Emergency Preparedness documents were reviewed with the Clinical Manager (CM #1). The Risk Assessment document was dated for the calendar year 2020. The Emergency Preparedness plan had not been updated at least every 2 years, based on a facility and community-based risk assessment from an all-hazards approach. These findings were reviewed with and confirmed by CM #1 at the time of discovery.

The following deficiencies were identified during a Medicare authorized recertification survey conducted by the Michigan Department of Licensing and Regulatory Affairs on 12/2/24 through 12/5/24 at: Allied Home Health Care & Nursing Services, LLC 4800 Cadieux Rd. Detroit, MI 48224 This agency had no additional locations. Records reviewed: 3 records with home visits, 2 discharged records, 2 active records without home visits, for a total of 7 records reviewed. At the conclusion of the survey, this agency was determined to be noncompliant with the Conditions of Participation at 42 CFR 484 Home Health Agencies.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the Agency failed to ensure that 2 (P-1, P-2) of 3 patients observed during home visits, from a total of 7 sampled records reviewed, were included in the overall planning of care including informing the patient/caregiver in advance of the days in which services would be provided, resulting lack of inclusion in planning, the potential for missed visits and unmet care needs. Findings include: P-1: The patient's start of care (SOC) was 10/15/24 with diagnoses that included Schizoaffective Disorder and Diabetes Mellitus. During the record review on 12/3/24, it was noted that Physical Therapy (PT) and Occupational Therapy (OT) services were ordered to be provided. On 12/3/24 at 9:00 a.m., a scheduled survey home visit was conducted with the OT. During a review of the patient's admission packet, it was noted that the calendar of proposed visits to be made by the OT and PT was blank. P-2: The patient's SOC was 7/10/24 with diagnoses that included Cardiomyopathy and Kidney disease with Heart Failure. During the record review on 12/3/24 at 2:40 p.m., it was noted that Skilled Nursing (SN) services were ordered to be provided. On 12/3/24 a scheduled survey home visit was conducted with the SN. During the visit, there was no completed calendar of proposed visits to be made by the SN. The agency failed to ensure a calendar of proposed visits had been provided at the SOC to assist the patient with participating in planning his care and daily routine. These findings were reviewed with and acknowledged by the Clinical Manager during an interview on 12/5/24 at 10:05 a.m.

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the patient received proper written notice (Notice of Medicare Provider Non-Coverage) in advance of the agency terminating on-going care for 1 (P-3) of 2 discharged records, resulting in the patient being denied the right to appeal the decision to end covered services. Findings include: P-3: The patient's start of care was 12/19/23 with diagnoses that included Parkingson's Disease, Diabetes Mellitus and COPD (Chronic Obstructive Pulmonary Disease). The Plan of Care ordered Skilled Nursing (SN), Physical Therapy (PT) and Occupational Therapy (OT) services to be provided. During the clinical record review on 12/4/24 at 9:50 a.m., it was noted that the patient was discharged from the agency's services on 2/15/24. The "Notice of Medicare Non-Coverage" was provided to and signed by the patient on the same date of 2/15/24, which was the same date of the patient's discharge from the agency's services. The Agency failed to ensure the patient received proper written Notice of Medicare Provider Non-Coverage in advance of the agency terminating on-going care. These findings were reviewed with and acknowledged by the Clinical Manager during an interview on 12/5/24 at 10:30 a.m.

Skilled professional performs assessment CFR(s): 484.55(a)(2) When rehabilitation therapy service (speech language pathology, physical therapy, or occupational therapy) is the only service ordered by the physician or allowed practitioner who is responsible for the home health plan of care, the initial assessment visit may be made by the appropriate rehabilitation skilled professional. For Medicare patients, an occupational therapist may complete the initial assessment when occupational therapy is ordered with another qualifying rehabilitation therapy service (speech-language pathology or physical therapy) that establishes program eligibility. This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the Initial Comprehensive Assessment was conducted within 48 hours of the date of referral for 1 (P-1) record reviewed where start of care services was delayed, from a total of 7 sampled records reviewed, resulting in delay in needed care and services and the potential for decline in health status and unmet care needs. Findings include: P-1: The patient's start of care was 10/15/24 with diagnoses that included Depression, Schizoaffective Disorder and Diabetes Mellitus. During the record review on 12/3/24, it was noted that the referral for home care was dated 10/10/24 and ordered Physical Therapy and Occupational Therapy services to be provided. Upon further review, it was noted that the SOC was delayed by 5 days. Further, there was no documented justification for the delay in needed care and services. These findings were reviewed with and acknowledged by the Clinical Manager during an interview on 12/5/24 at 9"36 a.m.

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 and included the events leading to the need for home care services in 2 (P-1, P-3) records, from a total of 7 sampled records reviewed, resulting in incomplete/inaccurate clinical information to aide in determining the needs of the patient. Findings include: P-1: The patient's start of care (SOC) was 10/15/24 with diagnoses that included Depression, Schizoaffective Disorder and Diabetes Mellitus. During the review on 12/3/24, it was noted that section M1021 of the Initial Comprehensive Assessment dated 10/15/24, listed 16 diagnoses with an onset of 1010/24. There was no documented history of the identified illnesses. Additionally, Section M2001 stated, "No issues found during review." However, the agency's Drug Interaction Report documented positive drug to drug interactions. The Comprehensive Assessment failed to paint an accurate clinical picture of the patient's health status at the time of admission. P-3: The patient's SOC was 12/19/23 with diagnoses that included Parkinson's Disease, Diabetes Mellitus and COPD. During the record review on 12/4/24 at 9:50 a.m., it was noted that section M1021 of the comprehensive Assessment dated 12/19/23, listed 13 diagnoses all having an onset date of 10/13/23. There was no documented history or resolution of the listed diagnoses. The Comprehensive Assessment failed to paint an accurate clinical picture of the patient's health status at the time of admission. The above findings were reviewed with and acknowledged by the Clinical Manager during an interview on 12/5/24 at 10:30 a.m.

Patient's needs CFR(s): 484.55(c)(4) The patient's medical, nursing, rehabilitative, social, and discharge planning needs; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient's activity of daily living needs were adequately met in the patient's home for 1 (P-3) patient who required assistance with grooming, from a total of 7 sampled records reviewed, resulting in the potential for poor hygiene, lack of self-esteem and unmet care needs. Findings include: P-3: the patient's start of care was 12/19/23 with diagnoses that included Parkinson's Disease, Diabetes Mellitus and COPD. During the record review on 12/4/24 at 9:50 a.m., it was noted that section M1800 (Grooming) of the Initial Comprehensive Assessment dated 12/19/23 documented, someone must assist with grooming, dressing, bathing, toileting. There was no documentation of a willing caregiver and no documented evidence that a Home Health Aide was offered or provided to assist with activities of daily living. These findings were reviewed with and acknowledged by the Clinical Manager (CM #1) during an interview on 12/5/24 at 10:30 a.m.

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 the discharge summaries were complete and detailed the course of care provided, including progress toward goals and failed to ensure the summaries were forwarded to the Physician within 5 days of the date of discharge for 2 (P-3, P-5) of 2 discharged records, from a total of 7 sampled records reviewed, resulting in the Physician not having a clear picture of the health status of the patient at the time of discharge and the potential for unmet continuing care needs. Findings include: P-5: The start of care (SOC) was dated 3/22/23, with diagnoses of surgical aftercare and spinal fusion. During record review on 12/3/24, it was noted that the record contained a skilled nursing discharge summary dated 11/30/23. The discharge summary failed to include progress towards, and patient outcomes in meeting the goals in the plan of care. These findings were reviewed and acknowledged during an interview with the clinical manager (CM #1) on 12/5/24 at 2:50 p.m. P-3: The patient's start of care was 12/19/23 with diagnoses that included Parkinson's Disease, Diabetes Mellitus and COPD. The Plan of Care ordered Skilled Nursing (SN), Physical Therapy (PT) and Occupational Therapy (OT) services to be provided. During the clinical record review on 12/4/24 at 9:50 a.m., it was noted that the patient was discharged from PT services on 1/26/24. The patient was discharged from SN services on 1/31/24 and discharged from OT services on 2/15/24. The SN Discharge Summary dated 1/31/24, was void of a summary of care with responses and overall health status at the time of discharge. Further, there was no indication of which, if any, goals were met versus not met. Additionally, there was no documented evidence that the summary was forwarded to the Physician within 5 days of the date of discharge. The patient was discharged from OT and the agency's services on 2/15/24. There was no documented evidence that the OT Discharge Summary was forwarded to the Physician within 5 days of the date of discharge. These findings were reviewed with and acknowledged by the Clinical Manager during an interview on 12/5/24 at 10:30 a.m.

A Medicare recertification survey, concurrent with a Focused Infection Control survey, was conducted by the Michigan Department of Licensing and Regulatory Affairs from September 14th, 2021 to September 17th, 2021 at: Allied Home Health Care and Nursing Services, LLC 4800 Cadieux Road Detroit, Michigan 48224-2271 At the time of the survey, the agency did not operate any branch offices or subunits. Clinical records reviewed for this survey included 3 records with home visits; and 4 records without home visits which included 2 active and 2 discharge records for a total of 7 records reviewed. 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.

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 document review and interview, the agency failed to conduct a patient-specific comprehensive assessment that accurately reflected the patient's current health status based on a past medical history that included dates of onset, exacerbations, treatments, outcomes, and events leading to the need for current home care services in 5 of 7 records reviewed (MR#s 1, 2, 3, 4, and 7), resulting in incomplete information to aid in determining the needs of the patient, and determining the patient's progress towards goals. Findings included: MR#1:The Start of Care (SOC) was dated 6/17/2021. The Plan of Care (POC) for the certification 6/17/21 to 8/15/21 identified a primary diagnosis of cellulitis of right lower limb, Coronary Artery Disease (CAD), Hypertensive Heart and Chronic Kidney Disease (CKD) with heart failure (CHF), Diabetes Type 2 (DM2), and anemia. The patient was receiving Skilled Nursing (SN), Physical Therapy (PT), and Occupational Therapy (OT) Services. Upon review of the Start of Care Comprehensive Assessment, it was noted under "(M10021/1023) Diagnoses and Symptom Control" the following diagnoses were listed: "Cellulitis of right limb, Atherosclerotic Heart Disease of native coronary artery without angina pectoris, hypertensive heart and kidney disease with heart failure and unspecified chronic kidney disease., acute on chronic diastolic (congestive) heart failure, Type 2 diabetes with diabetic chronic kidney disease stage 3, anemia, paroxysmal atrial fibrillation, Chronic Obstructive pulmonary disease, asthma, schizophrenia, and gastrointestinal hemorrhage, There was no history of how long the patient had any of the above 12 listed diseases/conditions, no documentation of date of onset, no history of the current status of the above diseases including treatments and outcomes of those treatments. There was no documented evidence of an assessment of the events that led to the patient's current needs for home care services, and home care referral. MR#2: The SOC was dated 7/30/2021. The POC for the certification period 7/30/21 to 9/27/21 identified diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Chronic respiratory failure, Anxiety disorder, Chronic Kidney Disease (CKD), Hypertension, Hyperlipidemia, and Weakness. The patient was receiving Skilled Nursing (SN) services. Upon review of the Start of Care Comprehensive Assessment, it was noted under "(M10021/1023) Diagnoses and Symptom Control" the following diagnoses were listed: Chronic Obstructive Pulmonary Disease with acute exacerbation, Chronic respiratory failure with hypoxia, anxiety disorder, chronic kidney disease, Hypertension, Weakness, Unsteadiness on feet, gastro-esophageal reflux disease without esophagitis, Nicotine dependence. There was no history of how long the patient had any of the above 10 listed diseases/conditions, no documentation of date of onset, no history of the current status of the above diseases including treatments and outcomes of those treatments. There was no documented evidence of an assessment of the events that led to the patient's current needs for home care services and the home care referral. MR#3: The SOC was dated 6/11/2020. The POC for the certification period 6/11/20 to 8/9/20 identified diagnoses of Chronic Venous Insufficiency, Non-pressure chronic ulcer of right and left lower leg, lymphedema, hypertension (HTN), Diabetes type 2 (DM2). The patient was receiving Skilled Nursing (SN) services. Upon review of the Start of Care Comprehensive Assessment, it was noted under "(M10021/1023) Diagnoses and Symptom Control" the following diagnoses were listed: "Venous insufficiency, non-pressure chronic ulcer of right and left lower legs, lymphedema, hypertension, Diabetes type 2, long-term use of insulin, long-term use of aspirin." There was no history of how long the patient had any of the above 12 listed diseases/conditions, no documentation of date of onset, no history of the current status of the above diseases including treatments and outcomes of those treatments. There was no documented evidence of an assessment of the events that led to the patient's current home care needs and home care referral. These findings were reviewed and acknowledged by the Administrator (ADM#1) on 9/17/21 at 3:30 p.m. MR#4: The SOC was dated 8/9/2021, which included diagnoses of left TKR (total knee replacement), Anemia, Altered Mental Status, Heart Disease, Hypertension, and Diabetes. On 9/16/21, during review of the Start of Care (SOC) Comprehensive Assessment completed by SN, it was noted under sections "M10021/1023, Diagnoses and Symptom Control" all the diagnoses listed above in addition to others (13 total), failed to document date(s) of onset, severity, or patient needs concerning the treatments, interventions, and outcomes for all listed diagnoses. Further, the SOC assessment documented the patient had several falls prior to the TKR surgery, but no documentation was found which elaborated the extent or severity of Anemia (low blood count) and Altered Mental Status (confusion) which are clinically significant in contributing to patient falls. MR#7: The SOC was dated 6/28/2021, which included diagnoses of Bipolar Disorder, Delusional Disorders, Hypertensive Chronic Kidney Disease, and Atrial Fibrillation. On 9/17/21, during review of the SOC Comprehensive Assessment completed by SN, it was noted under sections "M10021/1023, Diagnoses and Symptom Control" all the diagnoses listed above among others (7 total), failed to document date(s) of onset, severity, or patient needs concerning the treatments, interventions, and outcomes for all listed diagnoses. In addition, section M1740 "Cognitive, Behavioral and Psychiatric Symptoms" had the following boxes checked concerning the patient's mental well-being: "Impaired decision making, Verbal disruption (yelling, threatening, excessive profanity), Physical aggression (combative to self and others), Delusional, hallucinatory, or paranoid behavior." No documentation was found which detailed the extent of the safety risk posed to the patient/staff while providing care for the patient. Also, during clinical record review, it was discovered the patient had a public appointed guardian due to the psychotic behaviors noted above. However, documentation concerning this pertinent finding was not found within the SOC assessment. These findings were reviewed and acknowledged by ADM#1 during an interview on 9/17/21 at 3:30 PM. The agency failed to ensure that the SOC assessments were detailed and comprehensive as stipulated by the Agency's policy below. Policy: "III.8 Comprehensive Assessment and OASIS Data Collection Start of Care" (undated) stated, "The comprehensive assessment will include, at a minimum: Demographic information and medical history (including dates), Current health, psychological, functional, and cognitive status; Precautions..."

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, policy 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 and failed to provide documented evidence that the physician was notified of identified drug interactions in 3 (MR#s 2, 3, and 4) of 7 records reviewed, resulting in the potential for harmful medication effects for all 57 patients currently serviced by this Agency. Findings included: MR#2: The SOC was dated 7/30/2021. The POC for the certification period 7/30/21 to 9/27/21 identified diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Chronic respiratory failure, Anxiety disorder, Chronic Kidney Disease (CKD), Hypertension, Hyperlipidemia, and Weakness. The patient was receiving Skilled Nursing (SN) services. Upon review of the Comprehensive Assessment under the category of "M2001: Drug Regimen Review," the Skilled Nurse (RN#1) documented "No issues found during the review." However, a review of the patient's prescribed medications via "Drugs.com," revealed 4 major interactions with the patient's current medications as follows: Lovastatin combined with advair; Buspirone combined with trazadone; Buspirone combined with tramadol; and Trazadone combined with tramadol all result in major interactions. MR#3: The SOC was dated 6/11/2020. The POC for the certification period 6/11/20 to 8/9/20 identified diagnoses of Chronic Venous Insufficiency, , Non-pressure chronic ulcer of right and left lower leg, lymphedema, hypertension (HTN), Diabetes type 2 (DM2). The patient was receiving Skilled Nursing (SN) and Physical Therapy (PT) services. Upon review of the Comprehensive Assessment under the category of "M2001: Drug Regimen Review," the Skilled Nurse (RN#1) documented "No issues found during the review." However, a review of the patient's prescribed medications via "Drugs.com," revealed a major interaction with the concurrent use of cyclobenzaprine and hydrocodone. These findings were reviewed and acknowledged by the Administrator (ADM#1) during an interview on 9/17/21 at 3:30 p.m. MR#4: The SOC was dated 8/9/2021, which included diagnoses of left TKR (total knee replacement), Anemia, Altered Mental Status, Heart Disease, Hypertension, and Diabetes. On 9/16/21, during review of the Comprehensive Assessment completed by SN, section M2001 "Drug Regimen Review" documented "Issues found during the review." Subsequent review of the patient's Medication Reconciliation found 8 major or severe drug interactions listed. A request was made to DON#1on 9/15/21 at 9:20 AM to review when these interactions were sent to the physician, and what the physician's response was. DON#1 after reviewing the patient's chart stated, "I don't see where it has been sent out yet, so we wouldn't have a response back either." The Agency failed to ensure major or severe drug interactions were sent to the physician for review, and if any changes were warranted as stipulated by the Agency's policy below. Policy: "III.21 Adverse Drug Reactions" (undated) stated, "The Agency will attempt to obtain specific orders for treatment of adverse drug reactions on each patient where such a reaction is possible."

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, the Agency failed to ensure the plan of care covered all pertinent interventions with reportable parameters, safety precautions and objectively measurable goals in 7 of 7 (MR#s 1, 2, 3, 4, 5, 6, and 7) records reviewed, resulting in the potential for poor patient outcomes for all 57 patients currently serviced by this Agency. Findings included: MR#1:The Start of Care (SOC) was dated 6/17/2021. The Plan of Care (POC) for the certification 6/17/21 to 8/15/21 identified a primary diagnosis of cellulitis of right lower limb, Coronary Artery Disease (CAD), Hypertensive Heart and Chronic Kidney Disease (CKD) with heart failure (CHF), Diabetes Type 2 (DM2), and anemia. The patient was receiving Skilled Nursing (SN), Physical Therapy (PT), and Occupational Therapy (OT) Services. Upon review of the POC, it was noted the goals were not objectively measurable. Examples include: "Patient/Caregiver reports patient's pain within comfort level by end of certification," however, there was no numerical documentation on a 1 to 10 scale that defined the patient's comfort level for pain to determine the patient's progress toward this goal. In addition, other goals on the POC included: "Patient will verbalize understanding of prescribed diets and importance of dietary changes needed by 7/30/21; Patient will be knowledgeable in oxygen safety by 7/2/21; Patient verbalizes understanding of diabetic foot care by (no date documented)." These goals are not objectively measurable to determine the patient's progress toward achieving these goals. In addition, for this patient diagnosed with Diabetes type 2, the POC failed to include blood sugar parameters to report to the physician. Also, the POC failed to include safety measures to address the patient's diagnosis of diabetes. MR#2: The SOC was dated 7/30/2021. The POC for the certification period 7/30/21 to 9/27/21 identified diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Chronic respiratory failure, Anxiety disorder, Chronic Kidney Disease (CKD), Hypertension, Hyperlipidemia, and Weakness. The patient was receiving Skilled Nursing (SN) services. During a review of the POC, it was noted the goals were not objectively measurable to determine the patient's progress towards goals. Examples included: "Patient will be knowledgeable in oxygen safety by 8/6/21; Patient/caregiver will demonstrate knowledge of diet by 9/3/21; Disease process will stabilize without complications by 9/3/21". These goals are not objectively measurable to determine the patient's progress toward achieving goals. MR#3: The SOC was dated 6/11/2020. The POC for the certification period 6/11/20 to 8/9/20 identified diagnoses of Chronic Venous Insufficiency, Non-pressure chronic ulcer of right and left lower leg, lymphedema, hypertension (HTN), Diabetes type 2 (DM2). The patient was receiving Skilled Nursing (SN) services. During a review of the Plan of Care, it was noted the goals were not objectively measurable to determine the patient's progress towards goals. Examples included: "Patient unable to change dressings safely due to obesity and impaired functional status, patient's sister is unwilling to change dressing; Patient/caregiver cardiac status will remain stable by 7/18/21; Patient/caregiver verbalizes information about community resources and how to obtain assistance by 8/9/2020." In addition, for this patient diagnosed with Diabetes, type 2 and currently taking daily insulin with meals, the POC failed to include blood sugar parameters to report to the physician. Also, the POC failed to include safety measures to address the patient's diagnosis of diabetes. In addition, diabetic supplies were not listed under "Durable Medical Equipment and supplies. These findings were reviewed and acknowledged by the Administrator (ADM#1) during an interview on 9/17/21 at 3:30 p.m. MR #4: The SOC was dated 8/9/2021, which included diagnoses of left TKR (total knee replacement), Anemia, Altered Mental Status, Heart Disease, Hypertension, and Diabetes. The plan of care (POC) ordered skilled nursing (SN) visit frequencies of 2WK2 (twice a week for 2 weeks), and 1WK5. Review of the POC on 9/15/21 noted that 12 of 12 listed goals by SN were not objectively measurable for assessing patient improvement. Examples included: "Pt/Cg (patient/caregiver) will demonstrate knowledge of medications by 9/10/21; Pt/Cg will be knowledgeable in s/s (signs and symptoms) of infection by 8/13/21; Patient will verbalize understanding of possible complications of TKA (total knee arthroplasty) by 8/20/21." The Agency failed to ensure the listed goals by SN were written in measurable, individualized terms to meet the patient's specific needs. During an interview on 9/15/21 at 9:20 AM, DON#1 acknowledged the above findings and stated, "I'll make sure to have an educational in-service on how to make the goals more measurable." MR #5: The patient was admitted on 12/28/18 with diagnoses that included diabetes, pressure ulcer-left heel, and peripheral vascular disease. The POC ordered SN visit frequencies of 3WK8, and 1 WK 1. Review of the POC on 9/16/21 noted that 10 of 11 listed goals by SN were not objectively measurable for assessing patient improvement. Examples included: "Pt/Cg will verbalize understanding of diabetic foot care by 10/1/2021; Patient will verbalize/demonstrate energy conservation strategies by end of episode; Pt/Cg competence (sic) in following emergency plan by 8/20/2021." MR #6: The patient was admitted on 7/12/21 with diagnoses that included cerebral infarction (stroke), atrial fibrillation, heart disease with failure, and diabetes. The POC ordered SN visit frequencies of 1WK9. Review of the POC on 9/16/21 noted that 9 of 10 listed goals by SN were not objectively measurable for assessing patient improvement. Examples included: "Pt/Cg will demonstrate knowledge of medications and diet by end of cert; Pt/Cg will verbalize understanding of diabetic foot care by 8/20/2021; Pt/Cg will verbalize/demonstrate energy conservation strategies by 8/6/2021." In addition, the Comprehensive Assessment (section M1400) identified the patient's use of oxygen. However, the POC failed to list under "Safety Measures" any oxygen precautions as stipulated by Agency policy referenced below. MR#7: The SOC was dated 6/28/2021, which included diagnoses of bipolar disorder, delusional disorders, hypertensive chronic kidney disease, and atrial fibrillation. The POC ordered SN visit frequencies of 1WK9. Review of the POC on 9/17/21 noted that 9 of 9 listed goals by SN were not objectively measurable for assessing patient improvement. Examples included: "Pt/Cg will demonstrate correct use of medication by 8/24/2021; Pt/Cg reports patient's pain within comfort level by 7/30/2021; Pt/Cg will verbalize/demonstrate energy conservation strategies by 7/16/2021." Policy: "III.7 Professional/Ancillary Care Plans" (undated) stated, "Each care plan will include: Specific, individualized, measurable goals and interventions, including goals related to patient/caregiver education and training... Safety measures including use of specific equipment."

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 that discharge and transfer summaries were complete, provided the patient's current health status at the time of discharge and transfer, documented progress toward goals, and provided an updated medication list in 2 of 3 records (MR#'s 4, 7) who were discharged/transferred from a total of 7 records reviewed, resulting in the potential for unidentified continuing health care concerns and unmet care needs. Findings include: MR#4: The SOC was dated 8/9/2021, which included diagnoses of left TKR (total knee replacement), Anemia, Altered Mental Status, Heart Disease, Hypertension, and Diabetes. On 9/16/21, during review of the clinical record, a transfer OASIS (outcome and assessment information set) was completed by Skilled Nursing (SN) on 9/1/21. Review of the transfer OASIS noted failure to incorporate pertinent findings including: history with clinical data, treatments furnished, current medications, and outcomes in meeting goals in the plan of care. In addition, inaccuracies were noted, such as section M2005 "Medication Intervention" which documented, "NA-There were no potential clinically significant medication issues identified since SOC or patient is not taking any medications." The comments section was also blank. However, review of the patient's Medication Reconciliation found 8 major/severe drug were discovered during the SOC assessment, with no evidence of physician acknowledgment and approval for the continuation of the patient's medications. These findings were reviewed with and confirmed by DON#1 during an interview on 9/15/21 at 9:20 AM. The facility failed to provide a comprehensive and detailed transfer OASIS as stipulated by Agency policy referenced below. Policy: "III.10 Transfer/Transfer OASIS" (undated) stated, "When a patient is transferred to another facility or level of care, relevant information regarding the patient's condition and care requirements will be provided in writing... Relevant information includes when appropriate: Reason for admission to home health; Reason for transfer and conditions under which the transfer occurred; Types care/services provided, frequency of services, and progress toward goals, Medications the patient is taking at time of transfer..." MR #7: The SOC was dated 6/28/2021, which included diagnoses of Bipolar Disorder, Delusional Disorders, Hypertensive Chronic Kidney Disease, and Atrial Fibrillation. During record review on 9/17/21, it was noted the patient was transferred and hospitalized from 7/8/21 through 7/12/21. Subsequent review of the transfer summary (dated 7/8/21) found no documentation which explained the reason(s) for the emergent transfer. Further review of the discharge summaries performed by skilled nursing (8/25/21-from Agency) and physical therapy (8/23/21-from discipline), found no documentation which made note of the patient's hospitalization of 5 days, or what the outcome was concerning the hospitalization. ADM#1 acknowledged these findings during an interview on 9/17/21 at 0945 AM. ADM#1 after reviewing the clinical record stated, "I think it had to do with his medications, but I'm not seeing anything written down which explains what happened." The Agency failed to provide a comprehensive and detailed discharge summary as stipulated by Agency policy referenced below. Policy: "III.11 Discharge Planning, Discharge Summary and Discharge OASIS" (undated) stated, "The discharge summary will include but is not limited to: Admission and discharge dates; Reason for admission; Reason for discharge; Status of problems throughout the course of care..."