Every finding on record at Apollo Home Care, Inc

A Medicare emergency preparedness survey was conducted by the Michigan Department of Licensing and Regulatory Affairs from 7/22/25 to 7/25/25 at: Renewcare Home Health 30020 Schoenherr Rd. suite B Warren, MI 48088 For this survey 4 home visits with record reviews, 3 active records without a home visit and 3 discharged records were reviewed. At the conclusion of the survey the agency was found to be in compliance with the conditions of participation for home health agencies at: 42 CFR Part 484.102, Emergency Preparedness.

A Medicare recertification survey was conducted by the Michigan Department of Licensing and Regulatory Affairs from 7/22/25 to 7/25/25 at: Renewcare Home Health 30020 Schoenherr Rd. suite B Warren, MI 48088 For this survey 4 home visits with record reviews, 43 active records without a home visit and 3 discharged records were reviewed. At the conclusion of the survey the agency was found to be in substantial compliance with the conditions of participation for home health agencies at: 42 CFR Part 484.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient’s right to give consent for or refuse Speech Language Pathology services in advance of treatment in 1 (P-7) of 10 records reviewed resulting in lack of a Speech Therapy assessment and potentially resulting in unmet care needs for this patient. Findings include: Patient #7 (P-7): This 55-year-old was admitted to the home care agency on 7/5/25 with diagnoses including critical illness myopathy (generalized weakness from being critically ill); gastrostomy (artificial opening in abdomen for nutritional support); and Cholecystostomy drain (tube from gallbladder to outside of body to drain fluids). The medical record was reviewed on 7/22/25. During review, it was noted that the physician referral for home health services dated 7/1/25 included orders for the following disciplines: Registered Nurse (RN); Physical Therapy (PT); and Speech Language Pathology (SLP). The referral also included a diagnosis of dysphagia (difficulty with swallowing). The RN completed the comprehensive assessment on 7/5/25 and documented that the following services were offered: RN, PT, Occupational Therapy and home health aide services. There was no evidence in the medical record that SLP services were ever offered to P-7 by the home care agency or that P-7 refused SLP services. On 7/25/25 during interview at 10:20 a.m., the Administrator (Adm-1) reviewed and acknowledged the above finding. Adm-1 stated that she thought the service was requested by the hospital case manager in error and did not realize the physician requested SLP services.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the registered nurse conducted the initial assessment for immediate care and support needs within 48 hours of referral in 1 (P-6) of 10 records reviewed, and failed to ensure the registered nurse completed the initial assessment when both nursing and therapy services were ordered in 1 (P-10) of 10 records reviewed potentially resulting in a delay in services to maintain the patient’s health and safety. Findings include: Patient #6 (P-6): This 75-year-old was admitted to the home care agency on 2/25/25 with diagnoses including type 2 Diabetes and a chronic non-pressure wound to the lower right leg. The medical record was reviewed on 7/22/25. During review, it was noted that the physician referral for home health services was received by the agency on 2/17/25. The initial visit (comprehensive assessment) was completed by the Registered Nurse (RN) on 2/25/25 (8 days after receipt of referral). There was no evidence in the medical record indicating that the physician ordered a delay in the start of care or that P-6 requested a delay in the start of care. Patient #10 (P-10): This 63-year-old was admitted to the home care agency on 7/8/25 with diagnoses including Parkinson’s disease (progressive nerve disease affecting movement) and left sided weakness following a stroke. The medical record was reviewed on 7/25/25. During review, it was noted that the physician referral dated 7/3/25 included orders for the following home health services: RN; Physical Therapy (PT); Occupational Therapy; and Home Health Aide services. The initial (comprehensive assessment) was completed on 7/8/25 by PT services even though the referral order included RN services. On 7/25/25 during interview at 10:20 a.m., the Administrator (Adm-1) reviewed and acknowledged the above findings.

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 conduct a patient-specific, start of care (SOC) comprehensive assessment that accurately reflected the patient's current health status based on past medical history that included baseline patient information in 5 (P-1, P-3, P-4, P-8, and P-9) of 10 records reviewed, resulting in incomplete clinical information to aide in determining the needs of the patient. Findings include: Patient #8 (P-8): This 59-year-old was admitted to the home care agency on 7/10/25 with diagnoses including recent left knee replacement and type 2 Diabetes. The medical record was reviewed on 7/23/25. During review, it was noted that the comprehensive assessment was completed by the registered nurse (RN) on 7/10/25 and included the active diagnosis of Diabetes Mellites. Additionally, the RN documented under “Endocrine” assessment and checked the box indicating that P-8’s endocrine assessment was “WNL (Within Normal Limits)”, and marked “No” to the question “Is patient diabetic?” There was no further assessment regarding P-8’s diagnosis of Diabetes. Patient #9 (P-9): This 61-year-old was admitted to the home care agency on 7/18/25 with diagnoses including Chronic Obstructive Pulmonary Disease (progressive lung disease affecting breathing) and pneumonia. The medical record was reviewed on 7/25/25. During review, it was noted that the comprehensive assessment was completed by the RN on 7/18/25 and included documentation under “Fire Assessment for Patients with Oxygen” that P-9 did not use oxygen. Additionally, the RN documented under “DME” (or, Durable Medical Equipment) that P-9 had oxygen equipment in the home; and under “Respiratory” documented that P-9 was using oxygen at 2 liters via nasal cannula as needed. On 7/25/25 during interview at 10:20 a.m., the Administrator (Adm-1) reviewed and acknowledged the discrepancies in the patient's current health status which were noted on the above comprehensive assessments. Patient #1 (P-1) had a start of care date of 11/21/24, with diagnoses that included hypertension, chronic kidney disease, and congestive heart failure. During record review on 7/22/25, it was discovered that the SOC comprehensive assessment dated 11/21/24, failed to document an actual baseline weight, rather than a stated weight, and also failed to document baseline edema measurements, with a diagnosis of congestive heart failure. Patient #3 (P-3) had a start of care date of 5/24/25, with diagnoses that included diabetes mellitus, chronic obstructive pulmonary disease, and congestive heart failure. During record review on 7/23/25, it was discovered that the SOC comprehensive assessment dated 5/24/25, failed to document baseline edema measurements, for a patient with a diagnosis of congestive heart failure. Patient #4 (P-4) had a start of care date of 7/16/25, with diagnoses that included surgical aftercare, chronic kidney disease, and congestive heart failure. During record review on 7/24/25, it was discovered that the SOC comprehensive assessment dated 7/16/25, failed to document an actual baseline weight, rather than a stated weight, and also failed to document baseline edema measurements, with a diagnosis of congestive heart failure. The findings were reviewed with and acknowledged by the administrator (Adm-1) during an interview on 7/25/25, at 12:35 p.m.

Strengths, goals, and care preferences CFR(s): 484.55(c)(2) The patient's strengths, goals, and care preferences, including information that may be used to demonstrate the patient's progress toward achievement of the goals identified by the patient and the measurable outcomes identified by the HHA; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment identified patient goals and home health interventions needed to result in measurable outcomes in 1 (P-9) of 10 records reviewed potentially resulting in failure to measure changes in health status and identify ongoing patient progress or decline. Findings include: Patient #9 (P-9): This 61-year-old was admitted to the home care agency on 7/18/25 with diagnoses including Chronic Obstructive Pulmonary Disease (progressive lung disease affecting breathing) and pneumonia. The medical record was reviewed on 7/25/25. During review of the comprehensive assessment dated 7/18/25, it was noted that the registered nurse (RN) documented the following assessments: Under “Respiratory” assessment, the RN documented that P-9 was using oxygen at 2 liters via nasal cannula as needed. There were no interventions or goals entered regarding P-9’s use of oxygen or respiratory status. Under “Pain” assessment, the RN documented that P-9 had pain with an intensity of 4 on a 0-10 scale (0 is no pain and 10 is the worst pain) during the assessment. Additionally, the RN documented that P-9’s pain “Occasionally” interfered with sleep and “Occasionally” interfered with day-to-day activities. There were no goals entered regarding P-9’s pain. Under “GU” (genitourinary) assessment, the RN documented that P-9 had burning, frequency, urgency, and dysuria (discomfort) with urination, and that P-9’s urine was cloudy and odorous. There were no interventions or goals regarding P-9’s GU status. On 7/25/25 during interview at 10:20 a.m., the Administrator (Adm-1) reviewed and acknowledged the above findings.

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 the patients medications to identify any potential drug interactions and duplicate therapies in 2 (P-6, and P-10) of 10 records reviewed, and failed to ensure follow-up with the physician for medication reconciliation concerns for 3 (P-1, P-2, and P-5) of 10 records reviewed resulting in the potential for negative patient outcomes. Findings include: *Policy: Medications (Medication Screening) section 4 page 16 states, "Any potential interactions and/or sensitivities identified are immediately brought to the attention of the physician. Changes, additions, or new medications that are added after the start of care (SOC) assessment are entered into the profiling system as soon as the clinician becomes aware of the change/addition." Patient #1 (P-1) had a SOC date of 11/21/24, with diagnoses that included hypertension, chronic kidney disease, and congestive heart failure. During record review on 7/22/25, it was discovered that the SOC comprehensive assessment under section M2001 documented, "Issues found during drug review, physician notified." Review of the patient's medication reconciliation showed 8 drug/alcohol and 8 drug/drug reactions. There was no documented evidence in the record that the agency followed up with the physician regarding what was done about the issues found during the medication drug review. Patient #2 (P-2) had a SOC date of 7/18/25, with diagnoses that included hypertension, chronic kidney disease, and anemia. During record review on 7/22/25, it was discovered that the SOC comprehensive assessment under section M2001 documented, "Issues found during drug review, physician notified." Review of the patient's medication reconciliation showed 4 drug-food/alcohol and 1 drug/drug reactions. There was no documented evidence in the record that the agency followed up with the physician regarding what was done about the issues found during the medication drug review. Patient #5 (P-5) had a SOC date of 11/25/24, with diagnoses that included diabetes mellitus, COVID-19, and urinary tract infection. During record review on 7/25/25, it was discovered that the SOC comprehensive assessment under section M2001 documented, "Issues found during drug review, physician notified." Review of the patient's medication reconciliation showed 7 drug-food/alcohol and 2 drug/drug reactions. There was no documented evidence in the record that the agency followed up with the physician regarding what was done about the issues found during the medication drug review. The findings were reviewed with and acknowledged by the administrator (Adm-1) during an interview on 7/25/25, at 12:35 p.m. Patient #6 (P-6): This 75-year-old was admitted to the home care agency on 2/25/25 with diagnoses including type 2 Diabetes and a chronic non-pressure wound to the lower right leg. The medical record was reviewed on 7/22/25. During review of the comprehensive assessment completed by the registered nurse (RN) on 2/25/25, documentation reflected that no issues were found when the RN completed the drug regimen review of P-6’s medications. On 7/25/25, a “Medications Interactions” report (for P-6’s medication) was generated by the home care agency’s electronic medical record (EMR) system for surveyor review. It was noted that P-6’s “Medications Interactions” report showed duplicate drug therapy between 3 medications and 1 potential drug to drug interaction. There was no evidence that the drugs with duplicate therapy and the potential interaction were immediately reported to the physician per agency policy. Patient #10 (P-10): This 63-year-old was admitted to the home care agency on 7/8/25 with diagnoses including Parkinson’s disease (progressive nerve disease affecting movement) and left sided weakness following a stroke. The medical record was reviewed on 7/25/25. During review of the comprehensive assessment completed by the Physical Therapist (PT) on 7/8/25, documentation reflected that no issues were found when the PT completed the drug regimen review of P-10’s medications. On 7/25/25, a “Medications Interactions” report (for P-10’s medication) was generated by the home care agency’s EMR system for surveyor review. It was noted that P-10’s “Medications Interactions” report showed duplicate drug therapy between 2 medications and 1 potential drug to drug interaction. There was no evidence that the drugs with duplicate therapy and the potential interaction were immediately reported to the physician per agency policy. On 7/25/25 during interview at 10:20 a.m., the Administrator (Adm-1) reviewed and acknowledged the above findings.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the plan of care (POC) included safety precautions and parameters in 2 of 7 records (P-3, 5) reviewed, resulting in the potential for poor patient outcomes. Findings include: Policy: Patient Care Policy page 12, section 4 (Undated) stated, "The POC must contain all pertinent diagnoses, including: "Safety measures to protect against injury." Patient #3 (P-3) had a start of care date of 5/24/25, with diagnoses that included diabetes mellitus, chronic obstructive pulmonary disease, and congestive heart failure. During record review on 7/23/25, it was discovered that the POC dated 5/24/25, failed to include diabetic safety precautions for a patient with a diagnosis of diabetes. Patient #5 (P-5) had a start of care date of 11/25/24, with diagnoses that included diabetes mellitus, COVID-19, and urinary tract infection. During record review on 7/25/25, it was discovered that the POC dated 11/25/24, failed to include diabetic safety precautions and blood sugar parameters for a patient with a diagnosis of diabetes. The findings were reviewed with and acknowledged by the administrator (Adm-1) during an interview on 7/25/25, at 12:35 p.m.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure physical therapy (PT) and occupational therapy (OT) services were provided as ordered by the physician in the plan of care for 1 of 2 (P-4) records reviewed with PT and OT services ordered, from a total of 10 records reviewed, resulting in the potential for physical decline and negative patient outcomes. Findings include: Patient 4 (P-4): The SOC was dated 7/16/25. The POC identified diagnoses of surgical aftercare, chronic kidney disease, and congestive heart failure. During record review on 7/24/25, it was discovered that PT services were ordered at a frequency of 2 times a week for 3 to 4 weeks, and OT services were ordered at a frequency of 1 to 2 times a week for 3 to 4 weeks. No visits from PT or OT were documented in the record. There was no documentation in the record to indicate the patient had declined PT or OT services. The findings were reviewed with and acknowledged by the administrator (Adm-1) during an interview on 7/25/25 at 12:35 p.m.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on record review and interview, it was determined the agency failed to include safety precautions on the aide's care plan, in 1 of 3 records in which Home Health Aide (HHa) services were provided (P-5) resulting in the potential for the provision of unsafe care and negative patient outcomes. Findings included: Policy: Patient Care Policy page 12, section 4 (Undated) stated, "The POC must contain all pertinent diagnoses, including: "Safety measures to protect against injury." Patient #5 (P-5) had a start of care date of 11/25/24. The Plan of Care (POC) dated 11/25/24, documented the following diagnoses, "Diabetes mellitus, COVID-19, and urinary tract infection." During record review on 7/25/25, it was discovered that the aide POC dated 11/25/24, failed to document diabetic precautions for a patient with a diagnosis of diabetes and nail care ordered. The agency failed to follow their policy and ensure the aide plan of care included "Safety measures to protect against injury," to ensure the patient's safety and prevent potential negative outcomes. The findings were reviewed with and acknowledged by the administrator (Adm-1) during an interview on 7/25/25, at 12:35 p.m.

A Medicare recertification survey for Emergency Preparedness was conducted by the Michigan Department of Licensing and Regulatory Affairs from 8/8/22 through 8/11/22 at: Renewcare Home Health 30020 Schoenherr Rd, Suite B Warren, MI 48088 At the survey's conclusion, the agency was found to be in substantial compliance with the requirements for participation in Medicare/Medicaid at 42 CFR §484.102, Emergency Preparedness.

A Medicare recertification survey was conducted by the Michigan Department of Licensing and Regulatory Affairs from 8/8/22 through 8/11/22 at: Renewcare Home Health 30020 Schoenherr Rd, Suite B Warren, MI 48088 At the time of the survey, the agency did not have any branch offices or subunits. The services the agency provides are: Skilled Nursing (SN), Physical Therapy (PT), Physical Therapy Assistant (PTA), Occupational Therapy (OT), Certified Occupational Therapy Assistant (COTA), Speech Therapy (ST), Medical Social Work (MSW), and Home Health Aide (HHa). COVID-19 vaccinations were reviewed during this survey and the agency was found to be in compliance with the Covid-19 Vaccine requirements stated at QSO-22-07-ALL Attachment G for Home Health Agencies. Clinical records reviewed for this survey included 5 records with home visits; 4 active records without home visits; and 4 discharge records for a total of 13 records. 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: Home Health Agencies

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on record review, and interview, the Agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status based on past medical history that included dates of onset, exacerbations, treatments and outcomes, and history of events leading to current home care needs in 7 of 13 records reviewed (MR#s 7, 8, 9, 10, 11, 12, 13) resulting in incomplete clinical information to aide in determining the needs of the patient. Findings included: MR#7: The Start of Care (SOC) was dated 6/25/22. The Plan of Care (POC) for the certification period 6/25/22 to 8/23/22 identified diagnoses of Sepsis, Bacteremia, and Encounter for adjustment and management of Vascular Access Device (VAD) and pneumonia. A review of the record on 8/8/2022 revealed that there was no history of how long the patient had any of above diseases/conditions, and devices, or when and how the diseases occurred. There was no history of the status of the above disease process including treatments and past medical problems and outcomes of those treatments. The Comprehensive Assessment dated 6/25/2022 documented under "Past Medical History", 4 diagnoses consisting of Chest Pain, Thyroid Problems, Asthma, and GERD. There was no documentation of when these diseases had started, treatments provided, and current status of these diseases. In addition, under the category of Primary Diagnosis and Other Diagnoses, 25 Diagnoses were listed. None of the diagnoses included dates of onset. There was no documentation of prior treatments, outcomes, or history of how any of the 25 listed diagnoses had led to the need for home care. MR#8: The Start of Care (SOC) was dated 1/20/22. The Plan of Care (POC) for the certification period 1/20/22 to 3/20/22 identified diagnoses of Covid-19, pneumonia, Acute and Chronic respiratory failure with hypoxia, Chronic Obstructive Pulmonary Disease (COPD), Heart Failure (HF), Diabetes type 2 (DM2) Coronary Artery Disease (CAD) and Atrial Fibrillation (A-fib). A review of the record on 8/9/2022 revealed that there was no history of how long the patient had any of above diseases/conditions, or when and how the diseases occurred. There was no history of the status of the above disease processes including treatments for past medical problems and outcomes of those treatments. The Comprehensive Assessment dated 1/20/2022 had check-marks under "Past Medical History" to indicate the patient's history of diseases including 13 diagnoses consisting of CHF, Cardiomyopathy, Arrhythmia, Coronary Artery Disease, Hypertension, Cancer, Chronic Kidney Disease, Anemia, Diabetes, Thyroid Problems, COPD, Asthma, Urinary Incontinence and Hearing Loss. There was no documentation of when these diseases had started, treatments provided, and current status of these diseases. In addition, under the category of Primary Diagnosis and Other Diagnoses, 25 Diagnoses were listed. None of the diagnoses included dates of onset. There was no documentation of prior treatments, outcomes, or history of how any of the 25 listed diagnoses had led to the need for home care. MR#9: The Start of Care (SOC) was dated 11/14/2022. The Plan of Care (POC) for the certification period 11/14/2022 to 1/12/2022 identified diagnoses of Hypertension (HTN), Atrial Fibrillation (A-FIB), Aphasia, Occlusion of Bilateral Carotid Arteries (CAD); Osteoarthritis, Hypothyroidism, and Hyperlipidemia. A review of the record on 8/9/2022 revealed that there was no history of how long the patient had any of above diseases/conditions, or when and how the diseases occurred. There was no history of the status of the above disease processes including treatments for past medical problems and outcomes of those treatments. The Comprehensive Assessment dated 11/14/2021 had check-marks under "Past Medical History" to indicate the patient's history of diseases including 7 diagnoses consisting of Arrhythmia, HTN, Rheumatoid Arthritis, Falls, TIA, Depression, Abnormal Coagulation, and Thyroid Problems. There was no documentation of when these diseases had started, treatments provided, and current status of these diseases. In addition, under the category of Primary Diagnosis and Other Diagnoses, 17 Diagnoses were listed. None of the diagnoses included dates of onset. There was no documentation of prior treatments, outcomes, or history of how any of the 17 listed diagnoses had led to the need for home care. MR#10: The SOC was dated 7/17/2022. The POC for the certification period 7/17/22 to 9/14/2022 identified diagnoses of Diabetes type 2 (DM2), Osteomyelitis of left ankle and foot, Bacteremia, Hypertension (HTN), Encounter for adjustment and management (Vascular Access Device), and History of Falling. A review of the record on 8/10/22 revealed that there was no history of how long the patient had any of the above diseases/conditions, or when and how the diseases occurred. The Comprehensive Assessment dated 7/17/2022 had check-marks under "Past Medical History" to indicate the patient's history of diseases including 2 diagnoses consisting of Hypertension and Diabetes. There was no documentation of when these diseases had started, treatments provided, and current status of these diseases. In addition, under the category of Primary Diagnosis and Other Diagnoses of the Comprehensive Assessment, 9 Diagnoses were listed. None of the diagnoses included dates of onset. There was no documentation of prior treatments, outcomes, or history of how any of the 0 diagnoses had led to the need for home care. MR 11: The Start of Care (SOC) was dated 6/1/22. The Plan of Care (POC) for the certification period 6/1/22 to 7/30/22 identified diagnoses of Congestive Heart Failure, Encounter for Adjustment and Management Vascular Access Device, Therapeutic drug level monitoring, use of Anticoagulants, and presence of cardiac defibrillator. There was no history of the status of the above disease process including treatments and past medical problems and outcomes of those treatments. A review of the Comprehensive Assessment on 8/10/22 revealed that there was no documentation or history of how long the patient had any of the above diseases/conditions, or when and how the diseases occurred. In addition, under the category of Primary Diagnosis and Other Diagnoses of the Comprehensive Assessment, 9 Diagnoses were listed. None of the diagnoses included dates of onset. There was no documentation of prior treatments, outcomes, or history of how any of the 9 diagnoses had led to the need for home care. None of the diagnoses included dates of onset or treatments that had been provided. MR#12: The SOC was dated 8/5/2022. The POC for the certification period 8/5/2022 to 10/3/2022 identified diagnoses of "Critical Illness Myopathy, Rheumatoid Arthritis (RA), Muscle Weakness, Hypertension (HTN), Dementia, Schizophrenia, Osteoarthritis, Repeated Falls, and Reflux. There was no history of the status of the above disease processes including treatments and past medical problems and outcomes of those treatments. The Comprehensive Assessment dated 8/5/2022 had check-marks under "Past Medical History" to indicate the patient's history of diseases including 4 diagnoses consisting of Hypertension, depression, anxiety, and dementia. There was no documentation of when these diseases had started, treatments provided, and current status of these diseases. In addition, under the category of Primary Diagnosis and Other Diagnoses of the Comprehensive Assessment, 14 Diagnoses were listed. None of the diagnoses included dates of onset. There was no documentation of prior treatments, outcomes, or history of how any of the 14 diagnoses had led to the need for home care. MR#13: The SOC was dated 7/16/22. The POC for the certification period 7/16/22 to 9/13/2022 identified diagnoses of Malignant neoplasm of Left Ovary, Neoplasm related pain; Hypertension (HTN), Anxiety Disorder, and History of Falling." There was no documentation of the status of the above disease processes including treatments and past medical problems and outcomes of those treatments. A review of the record on 8/11/22 revealed documentation in the Comprehensive Assessment dated 7/16/2022 with checkmarks under "Past Medical History" to indicate the patient's history of diseases including 4 diagnoses consisting of Hypertension, Cancer, Vision Problems, and Nausea and Vomiting. There was no documentation of when these diseases had started, treatments provided, and current status of these diseases In addition, under the category of Primary Diagnosis and Other Diagnoses of the Comprehensive Assessment, 11 Diagnoses were listed. None of the diagnoses included dates of onset. There was no documentation of prior treatments, outcomes, or history of how any of the 11 diagnoses had led to the need for home care. These findings were reviewed and acknowledged by the Administrator (Staff-A), Assistant Administrator (Staff-B), and the Director of Nursing (Staff-C) during an interview on 8/11/2022 at 3:00 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 prescribed to the patient and include those medications in the medication reconciliation in its entirety for possible adverse effects or drug interactions in 2 (MR# 3 and 13) of 13 sample records reviewed resulting in the potential for undetected harmful medication side effects or interactions. Findings include: MR# 3: This 56-year-old patient was admitted to the agency on 7/11/22 with diagnoses which included wound care to right leg following hospital procedure complication; heart disease with heart failure, and diabetes type 2. On 8/9/22 the clinical record was reviewed. The start of care (SOC) dated 7/11/22 indicates in the pain assessment that the patient was taking Tylenol (no dosage listed) for pain. The skilled nursing note dated 7/13/22 indicates that the patient is taking Norco (no dosage listed) for pain. It was documented on 3 other SN notes dated: 7/25/22; 7/29/22; and 8/8/22 that Tylenol was being taken for pain. The POC dated 7/11/22 does not have any orders for either Tylenol or Norco. The most current Medication Reconciliation did not have any orders listed for Tylenol or Norco. There is no indication in the clinical record that the SN notified the physician that the patient was taking Tylenol and Norco. These findings were reviewed and acknowledged by the Administrator (Staff A), Assistant Administrator (Staff B), and the Director of Nursing (Staff C) on 8/11/22 at 1:00 p.m. MR#13: The SOC was dated 7/16/22. The POC for the certification period 7/16/22 to 9/13/2022 identified diagnoses of Malignant neoplasm of Left Ovary, Neoplasm related pain; Hypertension (HTN), Anxiety Disorder, and History of Falling." Upon review of the record under the category "(M2001): Drug Regimen Review" it was noted the registered nurse (RN# ) documented "No issues found during review." However, a review of the patient's current medications via "Drugs.Com" revealed a major interaction between 2 of the patient's current medications (Fentanyl and Oxycodone) which can result in respiratory distress and coma. This finding was reviewed and acknowledged by the Administrator (Staff-A), Assistant Administrator (Staff-B), and the Director of Nursing (Staff-C) during an interview on 8/11/2022 at 3:00 p.m.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review, policy review, and interview, the agency failed to include individualized and objectively measurable goals in the plan of care for 10 (MR#s 1, 3, 5, 7, 8, 9, 10, 11, 12, and 13) of 13 records reviewed resulting in the inability to determine the patient's progress towards goals. Findings included: MR# 1: This 65-year-old patient was admitted to the agency on 8/3/22 with diagnoses which included quadriplegia (paralysis of all 4 limbs), tracheostomy (surgical opening made to the windpipe to allow breathing), cystostomy (surgical opening made to the bladder to allow urine to drain), and diabetes type 2. On 8/9/22 the clinical record was reviewed. The plan of care (POC) dated 8/3/22 failed to include individualized and objectively measurable skilled nursing (SN) goals. Examples of the SN goals include: Wound(s) will be free from signs and symptoms of infection during 60 day episode; Patient skin integrity will remain intact during this episode; Patient will be free of signs and symptoms of respiratory distress during this episode; Patient will be free from signs and symptoms of hypo/hyperglycemia during this episode. There were no goals specific to care of tracheostomy or cystostomy. The goals are not stated in terms that would enable nursing staff to accurately perform an objective evaluation of the patients progress toward the goals. MR# 3: This 56-year-old patient was admitted to the agency on 7/11/22 with diagnoses which included wound care to right leg following hospital procedure complication; heart disease with heart failure, and diabetes type 2. On 8/9/22 the clinical record was reviewed. During review of the start of care (SOC) dated 7/11/22 it was noted that the patient had 10/10 pain to the right leg receiving the wound care (using a pain scale where 0 is no pain and 10 is the worst pain). The SOC also documented the patient’s goal for pain was 2/10. The SN made 7 additional visits during this patient’s certification period and documented pain levels between 4/10 and 8/10 at 6 of those 7 visits. When reviewing the POC dated 7/11/22, the SN failed to include any interventions or goals for this patient’s pain and there were no parameters of when to notify the physician regarding pain. The POC also failed to include other individualized objectively measurable SN goals. Examples of the SN goals include: Patient will have no hospitalizations during this certification period; Patient skin integrity will remain intact during this episode; Wound(s) will be free from signs and symptoms of infection during 60 day episode. The goals are not stated in terms that would enable nursing staff to accurately perform an objective evaluation of the patients progress toward the goals. MR#5: This 88-year-old patient was admitted to the agency on 1/20/22 with diagnoses which included COVID-19, difficulty swallowing, and dementia. On 8/10/22 the clinical record was reviewed. The POC dated 1/20/22 failed to include individualized objectively measurable SN goals. Examples of the SN goals include: Patient will be free from signs and symptoms of respiratory distress during the episode; Patient skin integrity will remain intact during this episode; The Patient/Caregiver will verbalize understanding of proper diabetic foot care by: 01/27/2022; The Patient/Caregiver will verbalize an understanding of skin conditions that must be reported to SN or physician immediately. The goals are not stated in terms that would enable nursing staff to accurately perform an objective evaluation of the patients progress toward the goals. These findings were reviewed and acknowledged by the Administrator (Staff A), Assistant Administrator (Staff B), and the Director of Nursing (Staff C) during interview on 8/11/22 beginning at 1:00 p.m. **Agency Policy: "Plan of Care," no date. The policy states, "The plan of care, based on the patient's immediate and long-term needs, which shall include but is not limited to the following: The types of services, supplies, and equipment required, the frequency of the visits to be made, functional limitations, all medications and treatments, safety measures to protect against injury. The plan must include measurable therapy treatment goals which pertain directly to the patient's illness or injury, and the patient's resultant impairment." MR#7: The Start of Care (SOC) was dated 6/25/22. The Plan of Care (POC) for the certification period 6/25/22 to 8/23/22 identified diagnoses of Sepsis and Bacteremia. Upon review of the Plan of Care it was noted the goals in the Plan of Care were not objectively measurable. Examples included: "Wounds will be free from signs and symptoms of infection during 60-day episode; Patient skin integrity will remain intact during this episode; Patient will be free from signs and symptoms of respiratory distress during the episode;" MR#8: The Start of Care (SOC) was dated 1/20/22. The Plan of Care (POC) for the certification period 1/20/22 to 3/20/22 identified diagnoses of Covid-19, pneumonia, Acute and Chronic respiratory failure with hypoxia, Chronic Obstructive Pulmonary Disease (COPD), Heart Failure (HF), Diabetes type 2 (DM2) Coronary Artery Disease (CAD) and Atrial Fibrillation (A-fib). Upon review of the goals on the POC it was noted the goals were not objectively measurable. Examples included: "Patient will verbalize understanding of proper use of pain medication by 1/27/22; Wounds will be free from signs and symptoms of infection during 60-day episode; Patient skin integrity will remain intact; Patient and Caregiver will verbalize an understanding of factors that contribute to shortness of breath." These goals are not objectively measurable to determine the patient's progress towards goals. MR#9: The Start of Care (SOC) was dated 11/14/2022. The Plan of Care (POC) for the certification period 11/14/2022 to 1/12/2022 identified diagnoses of Hypertension (HTN), Atrial Fibrillation (A-FIB), Aphasia, Occlusion of Bilateral Carotid Arteries (CAD); Osteoarthritis, Hypothyroidism, and Hyperlipidemia. Upon review of the Plan of Care, it was noted the goals were not objectively measurable to determine the patient's progress toward achieving the goals. Examples included: "The patient's skin integrity will remain intact during the episode; Patient will remain from increased confusion during the episode; Caregiver will verbalize understanding of proper orientation techniques to use when patient is disoriented; Home Exercise program will be established by physical therapist; Home exercise program will be established by occupational therapist." These goals are not objectively measurable to determine the patient's progress towards achievement of the goals. MR#10: The SOC was dated 7/17/2022. The POC for the certification period /17/22 to 9/14/2022 identified diagnoses of Diabetes type 2 (DM2), Osteomyelitis of left ankle and foot, Bacteremia, Hypertension (HTN), and History of Falling. Upon review of the goals on the POC it was noted the goals were not objectively measurable to determine the patient's progress towards goals. Examples include: "Wounds will be free of signs and symptoms of infection during 60-day episode; Patient skin integrity will remain intact during this episode; Patient will be free from signs and symptoms of hypo/hyperglycemia during the episode." These goals are not objectively measurable to determine the patient's progress towards achieving the goals. MR#11: The SOC was dated 6/1/2022. The POC for the certification period 6/1/22 to 7/30/22 identified diagnosis of Congestive Heart Failure (CHF), Presence of implanted Automatic defibrillator, and long-term use of anticoagulants. A review of the goals on the POC revealed the goals were not objectively measurable to determine the patient's progress towards goals. Examples included: "The Patient/Caregiver will verbalize understanding of individualized emergency plan by 6/1/22; Patient skin integrity will remain intact during this episode; Patient/Caregiver will verbalize an understanding of factors that contribute to shortness of breath; and Caregiver is independent with milrinone infusion and pump." These goals are not objectively measurable to determine the patient's progress towards goals. MR#12: The SOC was dated 8/5/2022. The POC for the certification period 8/5/2022 to 10/3/2022 identified diagnoses of "Critical Illness Myopathy, Rheumatoid Arthritis (RA), Muscle Weakness, Hypertension (HTN), Dementia, Schizophrenia, Osteoarthritis, Repeated Falls, and Reflux. A review of the Goals on the POC revealed the goals are not objectively measurable to determine the patient's progress towards goals. Examples included: "Home Exercise Program (HEP) will be established by the physical therapist; Patient's ADL/IADL needs will be met with assistance of home health aide; Wounds will be free from signs and symptoms of infection during 60-day episode; The patient will have no hospitalizations during the episode." These goals are not objectively measurable to determine the patient's progress towards goals. MR#13: The SOC was dated 7/16/22. The POC for the certification period 7/16/22 to 9/ 13/2022 identified diagnoses of Malignant neoplasm of Left Ovary, Neoplasm related pain; Hypertension (HTN), Anxiety Disorder, and History of Falling." Upon review of the record, it was determined the goals on the POC were not objectively measurable. Examples include: "Patient/Caregiver will verbalize understanding of individualized Emergency Plan by 7/22/22, Patient will verbalize understanding of proper use of pain medication by 7/22/22, Patient/Caregiver will verbalize understanding of foods that contribute to acid reflux/indigestion by 7/29/22; Patient/Caregiver will have no or significantly improved episodes of nausea or vomiting." These goals are not objectively measurable to determine the patient's progress towards goals." These findings were reviewed and acknowledged by the Administrator (Staff-A), Assistant Administrator (Staff-B), and the Director of Nursing (Staff-C) during an interview on 8/11/2022 at 3:00 p.m.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation and interview, the agency failed to ensure the home health aide followed accepted standards of practice in infection control for 1 of 1 (MR# 1) patients in which home health aide services were observed, from a total of 5 home visits, resulting in the potential for the development and spread of infection. Findings include: MR# 1: This 65-year-old patient was admitted to the agency on 8/3/22 with diagnoses which include quadriplegia (paralysis of all 4 limbs), tracheostomy (surgical opening made to the windpipe to allow breathing), cystostomy (surgical opening made to the bladder to allow urine to drain), and diabetes type 2. On 8/9/22 a joint home visit was scheduled with an home health aide (Staff E) via the Administrator (Staff A) for 11 a.m. on 8/9/22. Upon surveyor arrival to the patient’s home, Staff E was already in the patients’ home and had started the visit. During the visit, Staff E was observed with gloves on and washing the patient beginning with the legs, then moving to the patient’s buttocks and it was noted that the patient had a bowel movement. After Staff E cleaned up the bowel movement and buttocks area, she continued and washed the patients back, repositioned the patient, and then washed the genital area with the same contaminated gloves . Staff E then placed a clean gown on the patient, touched the bed sheets, pillows, and bed control before removing those gloves and washing her hands. During an interview on 8/10/22 at 1:35 p.m., Staff E was asked when she would change her gloves during a bed bath, and she stated that she would change them if the patient had a “bad bowel movement”. Staff E failed to remove her gloves and wash her hands before moving from a contaminated body site to a clean body site during patient care. These findings were reviewed and acknowledged by Staff A, Assistant Administrator (Staff B), and the Director of Nursing (Staff C) on 8/11/22 at 1:00 p.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 document the reason for Transfer from the Home Health Care Agency to the Hospital in 2 of 2 records reviewed (MR#s 7 and 8) in which the Patient was transferred to the Hospital. Findings Included: MR#7: The Start of Care (SOC) was dated 6/25/22. The Plan of Care (POC) for the certification period 6/25/22 to 8/23/22 identified diagnoses of Sepsis, Bacteremia, and Encounter for adjustment and management of Vascular Access Device (VAD) and pneumonia. This patient was transferred from Home Care to the hospital emergency room on 7/11/22. Upon review of the Transfer Summary dated 7/11/22, it was noted the patient was admitted to the hospital. The Registered Nurse documented on the Transfer Summary under (M2310): Reason for Emergent Care, Other than above Reasons," and under (M2410): To which Inpatient Facility has the patient been admitted? Hospital" and the "Reason for Hospitalization: Other than above reasons, Reason Unknown." It was noted the Registered Nurse documented on the Transfer Summary, "Transfer Summary sent to physician upon request." However, under care Coordination, there was no indication that the physician had been notified of discharge summary availability, though the scheduler was notified. A Resumption of Care was initiated for this patient on 7/13/22. On 7/19/2022, another transfer and admission to the hospital from an emergency room visit occurred. RN- documented again, the reason was unknown. MR#8: The Start of Care (SOC) was dated 1/20/22. The Plan of Care (POC) for the certification period 1/20/22 to 3/20/22 identified diagnoses of Covid-19, pneumonia, Acute and Chronic respiratory failure with hypoxia, Chronic Obstructive Pulmonary Disease (COPD), Heart Failure (HF), Diabetes type 2 (DM2) Coronary Artery Disease (CAD) and Atrial Fibrillation (A-Fib). Upon review of the record, it was noted this patient was transferred to a hospital with hospital admission on 1/20/22 due to the patient "experiencing blisters to Lower extremities possibly due to an allergic reaction." Yet the RN documented "other than above reasons on the Transfer OASIS. These findings were reviewed and acknowledged by the Administrator (Staff-A), Assistant Administrator (Staff B), and the Director of Nursing (Staff-C) during an interview on 8/11/2022 at 3:00 p.m.