Every finding on record at Aquarius Home Care, LLC

A Medicare authorized recertification survey was conducted by the Michigan Department of Licensing and Regulatory Affairs on 2/5/24 through 2/8/24 at: Aquarius Home Care 29698 Dequindre Rd. Warren, MI 48092 This was a standard survey; therefore, Emergency Preparedness was not reviewed.

The following standard level deficiencies were identified during a Medicare authorized recertification survey conducted by the Michigan Department of Licensing and Regulatory Affairs on 2/5/24 through 2/8/24 at: Aquarius Home Care 29698 Dequindre Rd. Warren, MI 48092 This agency had no additional locations. Records reviewed: 3 records with home visits; 4 records without home visits, for a total of 7 records reviewed. At the conclusion of the survey, this agency was determined to be out of compliance, at a standard level, with the Conditions of Participation for 42 CFR 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 3 (P's #1, 2, 3) of 3 patients observed during home visits were included in the overall planning of their care including informing the patient/caregiver in advance of the days in which services would be provided, from a total of 7 sampled records reviewed, resulting in a lack of inclusion in planning, lack of informed consent, the potential for missed visits and unmet care needs. Findings include: P-1: The patient's start of care (SOC) was 1/11/24 with diagnoses that included Coronary Artery Disease and Heart Failure. During the record review on 2/5/24 at 1:55 p.m., it was noted that the plan of care (POC) ordered Skilled Nursing (SN) and Physical Therapy (PT) services to be provide. On 2/6/24 during a scheduled survey home visit with the Registered Nurse (RN #1), it was noted that the patient's admission packet was void of a completed calendar of proposed visits to be made by SN or any of the other ordered disciplines. These findings were reviewed with and acknowledged by the Administrator (Adm #1), Alternate Administrator (Adm #2) and Clinical Manager (CM #1) during an interview on 2/7/24 at 1:17 p.m. P-2: The patient's SOC was 12/15/23 with diagnoses that included Diabetes Mellitus and Congestive Heart Failure. During the record review on 2/6/24 at 2:55 p.m., it was noted that the POC ordered SN, PT and Occupational Therapy (OT) services to be provided. On 2/6/24 during a scheduled survey home visit with the Physical Therapist (PT #1), it was noted that the patient's admission packet was void of a completed calendar of proposed visits to be made by any of the ordered disciplines. These findings were reviewed with and acknowledged by Adm #1, Adm #2 and CM #1 during an interview on 2/7/24 at 1:26 p.m. P-3: The patient's SOC was 1/12/24 with diagnoses that included Multiple Sclerosis and Hemiplegia. During the record review on 2/7/24 at 9:55 a.m., it was noted that the POC ordered SN, PT and OT services to be provided. On 2/7/24 during a scheduled survey home visit with the Occupational Therapist (OT #1), it was noted that the patient's admission packet was void of a completed calendar of proposed visits to be made by any of the ordered disciplines. These findings were reviewed with and acknowledged by Adm #1, Adm #2 and CM #1 during an interview on 2/7/24.

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 observation, interview and record review, it was determined that the agency failed to ensure the patient's activity of daily living needs were adequately met in the patient's home for 2 (P#'s 2, 3) patients observed during home visits and required assistance with grooming, from a total of 7 sampled patients reviewed, resulting in the potential for poor hygiene, low self-esteem and unmet care needs. Findings include: Policy: Patient Admission Criteria, 9.3.1 stated, "Patients are accepted for treatment on the basis of a reasonable expectation that the patient’s medical, nursing and social needs can be met adequately by the Agency in the patient’s place of residence. Patients will be accepted for care only if Agency can meet a patient’s identified needs." P-2: The patient's start of care (SOC) was 12/15/23 with diagnoses that included Diabetes Mellitus, Congestive Heart Failure and Chronic Obstructive Pulmonary Disease. On 2/6/24 at 12:30 p.m., a scheduled survey home visit was conducted with the Physical Therapist (PT #1). Upon arrival, the patient was noted to be lying in bed, obese and bedbound. During the visit, PT #1 attempted to assist the patient with standing, however, the patient reported that it was too painful and difficult to stand. When the visit was completed, the patient was queried as to how she was able to groom and dress herself to which she replied, "My granddaughter helps me out sometimes when she's free." The patient then stated, "I wanted a home health aide but the last time I was with the agency, the aides did what they wanted to do. I could really use an aide. I had to hire a private caregiver when the agency didn't send one, but usually I just wait on my granddaughter. I only chose to come back to this agency because I like the therapist." During the record review on 2/6/24 at 2:55 p.m., section M1800 of the Comprehensive Assessment documented that someone must assist the patient to groom and dress self and depends entirely upon another person to dress lower body. Section M2102 documented, "Non-agency caregivers need training/supportive services to provide assistance." On 2/7/24 at 1:26 p.m., an interview was conducted with the Administrator (Adm #1), Alternate Administrator (Adm #2) and Clinical Manager (CM #1). When queried about the provision of Home Health Aide services, Adm #2 responded, "We had her as a patient last time and she (patient) requested the aides add bleach to her bath water. The patient is aware that we cannot bathe her with bleach. She's trying to make trouble for us. If we cannot provide the service, we would drop the patient." An article by the Mayo Clinic documented, "A bath with a small amount of bleach added to the water is safe for children and adults..., helps reduce bacteria on the skin..., helps reduce inflammation." Further review revealed no documented evidence that the patient's Physician had been consulted regarding her request to add bleach to her basin during bathing. P-3: The patient's SOC weas 1/12/24 with diagnoses that included Multiple Sclerosis, Scoliosis and Hemiplegia. During the record review on 2/7/24 at 9:55 a.m., it was noted that the comprehensive assessment listed the patient's son as the primary caregiver and stated, "patient lives alone with occasional short-term assistance, non-agency caregivers need training/supportive services to provide assistance, someone must assist with grooming, depends entirely upon another person to dress upper and lower body, unable to participate effectively in bathing and is bathed totally by another person, totally dependent in toileting, chairfast, unable to ambulate and is unable to wheel self..." On 2/7/24 at 11:00 a.m., a scheduled joint survey home visit was conducted with the Occupational Therapist (OT #1). Prior to entering the patient's unit, OT #1 informed the writer that the patient is supposed to have a private caregiver, if they decide to come. Upon entering, the patient was observed sitting in her motorized wheelchair. She was Mal positioned due to her diagnosis of scoliosis (abnormal curvature of the spine). The patient's clothes were baggy and twisted around her waist and she appeared ungroomed. During the visit, the patient stated, "The caregiver was supposed to come. She missed the last time. I wish I had more people who could help me. I just keep the same clothes on, even at night. My sister has 8 grandchildren, and my son is immature and told me, "20 years of helping you Mother is quite a bit." There was no documented evidence that the patient had been offered the services of a home health aide to assist with activities of daily living. These findings were reviewed with and acknowledged by Adm #1, Adm #2 and CM #1 during an interview on 2/7/24.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure the comprehensive assessment included a review of all medications at the start of care and the resumption of care, in 3 (P#'s 3, 5, 7) records, in order to determine any untoward effects, from a total of 7 sampled records reviewed, resulting in the potential for harmful medication effects for all patients currently serviced by this Agency. Findings include: Policy: Medication Profile, 11.8.1 stated, "The comprehensive assessment (OASIS) performed at time of admission includes a review of all medications that the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicative drug therapy and noncompliance with drug therapy..., All prescribed medications, over-the-counter (OTC) medications and home remedies will be documented on the medication profile as well as..." P-3: The patient's start of care (SOC) was 1/12/24 with diagnoses that included Multiple Sclerosis and Hemiplegia. On 2/7/24 at 11:00 a.m., a scheduled survey home visit with the Occupational Therapist (OT #1). During the conversation with the patient and OT #1, the patient stated, "I take so many supplements, I couldn't possible catch covid. When looking at the patient's plan of care (POC), it was noted that only 3 medications were listed. This writer asked the patient if she was taking anymore medications to which she pointed at a plastic shelf with multiple drawers and stated, "Some of my medications are in there." The patient then gave permission to review her medications. Upon review, there were multiple bottles of supplements, laxatives, vitamins, melatonin, creatine, probiotics and more. There were 34 bottles of medications in the drawers. Additionally, there was a Ziploc bag with pills and what appeared to be additional supplements, and there was a small tray of medications observed next to the patient's bathroom. None of the aforementioned medications had been listed on the patient's POC. The agency failed to conduct a comprehensive review of all the patient's medications at the start of care. These findings were reviewed with the Administrator (Adm #1), Alternate Administrator (Adm #2) and Clinical Manager (CM #1) during an interview on 2/7/24. During the interview, Adm #1 stated, "We have had that discussion with RN #1 because that has been a problem." There was no documented evidence that justified RN #1's failure to conduct a comprehensive drug review of all the patient's medications. P-5: The patient's SOC was 3/10/23 with diagnoses that included Diabetes Mellitus and Chronic Obstructive Pulmonary disease. During the record review on 2/7/24, there was no evidence that a comprehensive drug review had been conducted at the SOC. Further review revealed the patient was transferred to an inpatient facility on 3/18/23 due to abdominal pain and resumed care with the agency's services on 3/22/23. There was no documented evidence that a comprehensive drug review was conducted upon resumption of care to the agency's services. These findings were reviewed with and acknowledged by Adm #1, Adm #2 and CM #1 during an interview on 2/8/24. P-7: The patient's SOC was 2/2/24 with a diagnosis of Osteoarthritis. During the drug review on 2/8/24 at 12:05 p.m., there was no documented evidence that a comprehensive drug review had been conducted. These findings were reviewed with and acknowledged by Adm #1 during an interview on 2/8/24.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the plan of care covered all pertinent interventions with reportable parameters, and objectively measurable goals specific to the needs of the patient and failed to ensure all prescribed medications had been included in the plan of care, for 3 (P's #1, 2, 4) of 3 records, from a total of 7 sampled records reviewed, resulting in patients not receiving care specific to their individual needs, the potential for decline in overall health and poor patient outcomes. Findings include: P-1: The patient's start of care (SOC) was 1/11/24 with diagnoses that included Heart Failure and Coronary Artery Disease. During the record review on 2/5/24 at 1:55 p.m., it was noted that the plan of care (POC) was void of any interventions, reportable parameters or associated measurable goals to address the identified diagnoses. These findings were reviewed with and acknowledged by the Administrator (Adm #1) and Alternate Administrator (Adm #2) during an interview on 2/7/24 at 1:17 p.m. P-2: The patient's SOC was 12/15/23 with diagnoses that included Congestive Heart Failure, Chronic Obstructive Pulmonary Disease and Diabetes Mellitus. During the clinical record review on 2/6/24 at 2:55 p.m., it was noted that the POC was void of any interventions, reportable parameters or associated measurable goals to address the identified diagnoses. Further review of the record revealed the patient was transferred to an inpatient hospital on 12/24/23 due to shortness of breath. Care was resumed under the agency's services on 1/8/24. The record revealed the patient returned home from the hospital with a Stage III coccyx pressure sore. The agency failed to update the plan of care to reflect the patient's current diagnosis, needs and treatment regimen. These findings were reviewed with and acknowledged by Adm #1, Adm #2 and CM #1 during an interview on 2/8/24 at 10:43 a.m. P-4: The patient's SOC was 2/15/23 with diagnoses that included Congestive Heart Failure, Hypertensive Heart Disease and Diabetes Mellitus. During the clinical record review conducted on 2/7/24, it was noted that the POC was void of interventions, parameters, teaching and measurable goals that addressed the patient's identified diagnoses. These findings were reviewed with and acknowledged by Adm #1 during an interview on 2/8/24 at 9:29 a.m. who reported, "The plan of care could be done better."

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, interview and record review, the Agency failed to ensure its disciplines utilized Infection Control standards of practice during the provision of care and services for 1 (P-1) patient observed during a home visit from a total of 7 sampled records reviewed, resulting in the potential for the development and spread of infection. Findings include: P-1: The patient's start of care (SOC) was 1/11/24 with diagnoses that included Heart Failure and Coronary Artery Disease. On 2/6/24 at 11:00 a.m., a joint survey home visit was conducted with the Registered Nurse (RN #1). During the visit, RN #1 assessed the vital signs (blood pressure, temperature, oxygen saturation, bowel sounds and peripheral edema and pulses). After checking the patient's blood pressure, RN #1 placed his stethoscope around his neck. RN #1 did not clean his equipment prior to placing it around her neck. RN #1 then placed the unit used to check the patient's oxygen level, as well as the blood pressure equipment and thermometer in his work bag without sanitizing the equipment first. It was further noted that RN #1 donned a pair of gloves at the beginning of the visit and kept the same gloves on until the conclusion of the visit. RN #1 failed to utilize Infection Control standards of practice during the provision of care. Upon completion of the visit, RN #1 acknowledged the above observations. These findings were reviewed with and acknowledged by the Administrator and Alternate Administrator during an interview on 2/7/24 at 1:17 p.m. These findings were revi

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the agency P-2: The patient's SOC was 12/15/23 with diagnoses that included Congestive Heart Failure, Diabetes Mellitus and Chronic Obstructive Pulmonary Disease. During the clinical record review on 2/6/24 at 2:55 p.m., it was noted that the Initial Comprehensive Assessment had a baseline documented weight of 410 pounds (lbs.). It was not clear if this was an actual or stated weight. A review of the Skilled Nursing Visit Notes documented the following: 12/15/23 410 lbs., 1/8/24 410 lbs. "actual weight", 1/17/24, no documented weight, 1/24/24 no documented weight, 2/2/24 no documented weight. On 2/6/24 at 12:30 p.m. a scheduled survey home visit was conducted with the Physical Therapist. The patient was observed to be obese and bedbound with limited mobility and observed to have difficulty when attempting to stand for PT session. A Hoyer lift (transfer aid) was observed at the foot of the patient's bed. On 2/8/24 at 9:20 a.m., the Alternate Administrator (Adm #2) was asked what method was used to assess the patient's weights, in light of her diagnosis of Congestive Heart Failure. Adm #2 reported, "I don't know if he (RN #1) is weighing her. When asked what method was used to ascertain the patient's fluid level and to determine if there was a weight gain, Adm #2 was unable to respond. Adm #2 continued, "I think that weight (410) came from the hospital records. I think that's why he (RN #1) put "actual." There was no other documentation in the clinical record that indicated the patient's weights were assessed in light of her admitting diagnoses. The agency failed to ensure its skilled disciplines performed accurate baseline and ongoing assessments of the patient's weight and health status.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure services were provided as ordered by the Physician for 1 (P-1) patient who required Occupational Therapy services, from a total of 7 sampled records reviewed, resulting in the potential for physiological decline and unmet care needs. Findings include: P-1: The patient's start of care was 1/11/24 with diagnoses that included Coronary Artery Disease, Heart Failure and Falls. During the record review on 2/5/24 at 1:55 p.m., it was noted that the referral for home care ordered Occupational Therapy (OT), Physical Therapy (PT) and Skilled Nursing (SN) services to be provided. Further review revealed that Occupational Therapy services had not been provided. Additionally, there was no documented evidence that the patient declined services or that the Physician had been made aware that services were not provided. These findings were reviewed with and acknowledged by the Administrator (Adm #1) and Alternate Administrator (Adm #2) during an interview on 2/7/24 at 1:17 p.m. Adm #2 reported, "This service was not provided. I don’t think we had anyone available. I think the patient had bugs but I didn’t document anything. I think the Physician ended up only ordering PT and SN."

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 insure a detailed discharge summary was sent to the physician within 5 business days of discharge for 2 (P#'s 4, 5) discharge records reviewed; and failed to ensure a detailed transfer summary was sent to the receiving health care facility within 2 business of becoming aware of the transfer for 1 (P-2) patient who was transferred to an inpatient facility, from a total of 7 sampled records reviewed, resulting in a lack of continuity of care and the potential for unmet care needs. Findings include: Policy 9.31.1 stated, "A Discharge Summary will be sent within 5 business days of patient discharge to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient. The original Discharge Summary form from each service will be filed in the medical record." Policy: Transfer/Referral Criteria 9.29.1 stated, "A written Transfer Summary concerning the Agency’s involvement with the patient, e.g., summary of care/services provided, patient’s current physical and psychosocial status, instructions/referrals provided to patient, current reconciled medication list (with an explanation of how to obtain clarification), advance directives, any continuing symptom management needs, e.g., pain, nausea or dyspnea, and reasons for transfer or referral will be completed. Transfer Summary will be provided: - Within two business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or - Within two business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time the Agency becomes aware of the transfer." P-4: The patient's start of care was 2/15/23 with diagnoses that included Congestive Heart Failure and Diabetes Mellitus. During the clinical record review on 2/7/24, it was noted that the plan of care (POC) ordered Skilled Nursing (SN) and Physical Therapy (PT) services to be provided. The patient was discharged from PT services on 3/21/23 and discharged from SN services on 3/29/23. Upon further review, there was no documented evidence that the Discharge Summaries were sent to the Physician within 5 days of the date of discharge. These findings were reviewed with and acknowledged by the Administrator (Adm #1) and Alternate Administrator (Adm #2) during an interview on 2/8/24 at 9:29 a.m. P-5: The patient's SOC was 3/10/23 with diagnoses that included Diabetes Mellitus, Chronic Obstructive Pulmonary Disease and Hypertension. During the record review on 2/7/24, it was noted that the referral for home care ordered OT, PT, SN and Home Health Aide (HHa) services to be provided. Speech Therapy (ST) and Medical Social Work (MSW) were added services to be provided. The patient was discharged from MSW on 4/18/23, ST on 4/20/23, OT on 4/26/23, PT on 4/27/23 and SN on 5/3/23. No ST Discharge Summary had been completed at the time of this review. Adm #2 provided a Fax cover sheet which indicated all Discharge Summaries were sent to the Physician on 5/12/23. This was greater than 5 days after the date of discharge from each service. These findings were reviewed with and acknowledged by Adm #1, Adm #2 and the Clinical Manager (CM #1) during an interview on 2/8/24 at 11:10 a.m. P-2: The patient's SOC was 12/15/23 with diagnoses that included Diabetes Mellitus, Congestive Heart Failure and Chronic Obstructive Pulmonary Disease. During the clinical record review on 2/6/24 at 2:55 p.m., it was noted that the patient was transferred to an inpatient facility due to shortness of breath. The Transfer Oasis/Comprehensive Assessment was completed 4 days later on 12/28/23. Upon further review, there was no documented evidence that a transfer summary had been sent to the receiving facility within 2 days of becoming aware of the transfer. These findings were reviewed with and acknowledged by Adm #1, Adm #2 and CM #1 during an interview on 2/8/24 at 10:42 a.m. Adm #2 reported, "We sent them (documents) to the Physician, but we didn't send anything to the receiving facility."

An authorized Covid-19 Focused Infection Control Emergency Preparedness survey was conducted by the Michigan Department of Licensing and Regulatory Affairs on 1/26/21 through 1/29/21 at: Aquarius Home Care, LLC 29698 Dequindre Rd. Warren, MI 48092 At the survey's conclusion, Aquarius Home Care, LLC was determined to be in substantial compliance with the regulatory requirements for the Condition of Participation 42 CFR §484.102, Emergency Preparedness.

The following Condition and Standard level deficiencies were identified during the Medicare Re-certification survey, currently with a Focused Covid-19 Infection Control survey conducted on 1/26/21 through 1/29/21 by the Michigan Department of Licensing and Regulatory Affairs at: Aquarius Home Care, LLC 29698 Dequindre Rd. Warren, MI 48092 At the time of the survey, the agency did not operate any branch offices or subunits. The services the agency provides are: Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), Medical Social Work (MSW), Speech Therapy, and Home Health Aide (HHa) Clinical records reviewed for this survey: 3 records with home visits and 4 records without home visits for a total of 7 records reviewed. Condition level deficiency identified at: 42 CFR §484.55: Comprehensive Assessment of Patients As a result of the Condition level noncompliance, the Agency is prohibited for 2 years from offering a Home Health Aide training and competency evaluation or a competency evaluation program as specified in 42 CFR §484.80(f)(3).

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the Agency failed to ensure 1 (MR #5) of 6 patients with Physical Therapy services ordered, was included in the overall planning of care including the timeliness of services received; and failed to inform the patient in advance of the days in which services would be provided resulting in inconsistent visits, lack of inclusion, the potential for physical decline, and subsequent cessation of treatment. findings include: MR #5: The patient's start of care was 12/10/20 with diagnoses that included Stroke, right sided hemiplegia, hemiparesis and Urinary Tract Infection. During the clinical record review on 1/26/21 at 2:09 p.m., it was noted that Physical Therapy (PT) services were ordered at a frequency of 2x/wk. x 4 wks., 1x/wk. x 2 wks. PT missed 5 of the 12 scheduled home visits. On 1/27/21 at 10:00 a.m., a home visit was conducted by the Skilled Nurse (RN #1) after completion of the visit, the patient was queried about her services with the agency and reported, "I had to stop seeing the Therapist. She (PT #1) would call me on her way home to set up a visit because she said I was her last stop before she went home. That didn't work for me because sometimes it was my bedtime. She wanted to see me at the last part of the day." Upon review of the patient's in home admission packet, it was noted that the calendar for visit frequencies was blank. PT #1 had not provided the patient with a proposed visit schedule. The Agency failed to ensure the patient was included in planning her visits. These findings were reviewed with and acknowledged by the Administrator (Adm #1) during an interview on 1/27/21 at 1:43 p.m. who reported, "I'll have to speak to the Therapist. I try to tell the staff to complete the patient's calendars but it's not being done. The patient has a say as to when she is able to be seen."

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: This Condition of Participation has NOT been met. As evidenced by: Based on record review and interview, it was determined that the Agency failed to ensure the Registered Nurse conducted the initial assessment visit within 48 hours of referral, to determine the immediate care needs of the patient, including homebound status for 1 (MR # 5) record in which Skilled Nursing services were needed, from a total of 7 records reviewed, resulting in delay in needed care and services and the potential for unmet care needs (G514); failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status based on past medical history that included accurate dates of exacerbation, past treatments and outcomes, and history of events leading to current home care needs; failed to include individualized information and fails to reflect the patient's current health status in 6 of 7 records reviewed (MR# 1, 2, 3, 4, 5 and 6) resulting in incomplete clinical information to aid in determining the needs of the patient and possible unmet patient needs (G528); and failed to follow up on the initial medication review and inform the Physician, in a timely manner, of severe drug interactions in 4 (MR's #2, 5, 6, 7) of 4 records with severe drug interactions identified, from a total of 7 sampled records reviewed, resulting in the potential for harmful medication effects and poor patient outcomes (G536). The cumulative effect of these systemic problems could potentially have a negative effect on the agency's ability to provide quality care as a Condition of Participation in the area of: Comprehensive Assessment of Patients 42 CFR §484.55.

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 visit within 48 hours of referral, to determine the immediate care needs of the patient, including homebound status for 1 (MR # 5) record in which Skilled Nursing services were needed, from a total of 7 records reviewed, resulting in delay in needed care and services and the potential for unmet care needs. Findings include: Policy: "Initial Assessments/Comprehensive Assessments", Revised October 2017 stated, "A RN, PT, or SLP must conduct the initial assessment visit within 48 hours of referral..." MR #5: The patient's start of care (SOC) was 12/10/21 with diagnoses that included Stroke, Hemiplegia and Hemiparesis, Urinary Tract Infection and Chronic Kidney disease. During the record review on 1/26/21 at 2:09 p.m., it was noted that the Plan of Care ordered Skilled Nursing 1x/wk. x 9 wks.; Home Health Aide 1x/wk. x 9 wks.; and Physical Therapy 2x/wk. x 4 wks., 1x/wk x 2 wks. The referral for home care was dated 12/4/20. Further review revealed that the Nurse (RN #1) did not conduct the Initial Assessment of the patient until 12/10/20 which was 6 days after the referral for home care. There was no documented evidence in the clinical record of the patient's request for delayed service, or that the Physician had been notified in advance of the delay in care. These findings were reviewed with and acknowledged by the Administrator (Adm #1) during an interview on 1/28/21 at 2:59 p.m.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on record review 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 accurate dates of onset/exacerbation, past treatments and outcomes, and history of events leading to current home care needs; failed to include individualized information; and failed to reflect the patient's current health status in 6 of 7 records reviewed (MR# 1, 2, 3, 4, 5 and 6) resulting in incomplete clinical information to aid in determining the needs of the patient and possible unmet patient needs. Findings included: MR #1: The Plan of Care (POC), dated 12-10-20, identified diagnoses of hypertensive heart and chronic kidney disease, end stage kidney disease, congestive heart failure, dependence on kidney dialysis, difficulty swallowing, diabetes, peripheral vascular disease and pulmonary embolism (blood clot in lungs). During the record review it was noted that the start of care (SOC) comprehensive assessment dated 12-10-20, documented under "Primary Diagnosis" and "Other Diagnoses", all 7 diagnoses had the same date of exacerbation documented, 12-10-20. On the start of care comprehensive assessment dated 12-10-20, the nurse documented "Primary Reason for Home Care: for skilled observation and assessment of overall condition with health teachings on disease management and home safety and pain management." The nurse also documented "(M1340) Does this patient have a Surgical Wound? Yes, patient has at least one observable surgical wound." and "(M1342) Status of Most Problematic Surgical Wound that is Observable: Newly epithelialized." There was no documentation of when/why the patient had surgery or where the surgical wound was located. There was no documentation of accurate onset/exacerbation dates, prior treatments, outcomes, what the patient's needs were as related to the above diagnoses or the events leading to home care referral. MR #2: The Plan of Care, dated 1-12-21, identified diagnoses of diabetes, peripheral vascular disease, right below the knee amputation, chronic kidney disease, atherosclerotic heart disease, depression, esophagitis (inflammation of the throat), anemia (low red blood cell count) and long term use of insulin. During the record review it was noted that the start of care comprehensive assessment dated 1-12-21, documented under "Primary Diagnosis" and "Other Diagnoses", all 9 diagnoses had the same date of exacerbation documented, 1-12-21. On the start of care comprehensive assessment dated 1-12-21, the nurse documented "Primary Reason for Home Care: SN for skilled observation and assessment of unstable health condition and for teaching on disease processes and medications compliance and for skilled wound care, dressing changes and teachings. PT and OT- for strengthening gait and balance training,and pain management. HHA-to assist with personal care and light housekeeping.." There was no documentation of where the patient's wound was, date/circumstances of onset, appearance/status or wound care/dressing change procedures. There was no documentation of accurate onset/exacerbation dates, prior treatments, outcomes, what the patient's needs were as related to the above diagnoses or the events leading to home care referral. MR #3: The Plan of Care, dated 2-27-20, stated the patient was admitted for physical therapy, occupational therapy and home health aide services with the diagnoses of hypertensive heart disease, heart failure, muscle weakness, hemiplegia/hemiparesis following a stroke, urinary tract infection, diabetes and blindness. During the record review it was noted that on the start of care comprehensive assessment dated 2-27-20, the Physical Therapist documented under "Primary Diagnosis" and "Other Diagnoses", all 7 diagnoses had the same date of exacerbation documented, 2-27-20. A "Physican Orders" form (referral) dated 2-25-20, stated, "Patient was hospitalized due to change in mental status which was resolved during this hospital stay. Patient was also treated with UTI [urinary tract infection], heart failure, HTN [hypertension], DM [diabetes] and metabolic encephalopathy (chemical imbalance of the blood affecting brain function) while admitted. Patient is referred to home health due to mentioned medical conditions." On the start of care comprehensive assessment dated 2-27-20, the Physical Therapist documented "Primary Reason for Home Care: recent hospitalization for CHF [congestive heart failure], HTN, UTI, Hx [history] of CVA [cerebral vascular accident/stroke], patient presents with generalized weakness, shortness of breath, impaired transfers, impaired balance and gait, difficulty with ADLs/IADLs." There was no documentation of accurate onset/exacerbation dates, prior treatments, outcomes, what the patient's needs were as related to the above diagnoses or the potential need for nursing services to monitor the patient's medical conditions for which they were hospitalized just prior to home care admission. MR #4: The Plan of Care, dated 11-25-20, identified diagnoses of breast cancer, nipple discharge, multiple sclerosis, hypertension, trigeminal neuralgia (facial nerve pain), glaucoma, cataracts and skin/subcuteous tissue disorder. During the record review it was noted that the start of care comprehensive assessment dated 11-25-20, documented under "Primary Diagnosis" and "Other Diagnoses", all 8 diagnoses had the same date of exacerbation documented, 11-25-20. On the start of care comprehensive assessment dated 12-10-20, the nurse documented "Primary Reason for Home Care: Patient with R breast nipple wound. s/p biopsy. SN for wound care, symptom managment." There was no documentation of accurate onset/exacerbation dates, prior treatments, outcomes, what the patient's needs were as related to the above diagnoses or the events leading to home care referral. Policy: "Initial Assessments/Comprehensive Assessments", Revised October 2017 stated, "The comprehensive assessment will identify the patient's need for home care..., The Initial comprehensive Assessment also includes relevant diagnoses and current health status, relevant medical history..." MR 5: The patient's start of care (SOC) was 12/10/20 with diagnoses that included Stroke with right-sided hemiplegia and Urinary Tract Infection. The clinical record review was conducted on 1/26/21 at 2:09 p.m. The Initial Comprehensive Assessment dated 12/10/20 completed by the Registered Nurse revealed the following: Section M0104/date of referral was left blank. Section 1021 Primary diagnosis listed a diagnosis of Hemiplegia and Hemiparesis following Stroke with a date of 12/10/20. Section 1023 "Other diagnoses" listed Urinary Tract Infection, Chronic Kidney Disease, Bipolar Disorder, Psychosis and Anxiety Disorder. All diagnoses had an onset/exacerbation date of 12/10/20 (Date of admission to home care). "Primary Reason for Home Health" documented, "for skilled observation and assessment of unstable health condition ..." Present pain level was recorded as 3/10. The section that asked, "How does the pain interfere/impact their functional/activity level was left blank. The section regarding the Endocrine system was left blank. There was no history of the status of the above diseases including onsets, treatments for past medical history problems and outcomes from the treatments. Further, there was no documentation of the events that led to the need for home care. These findings were reviewed with and acknowledged by the Administrator (Adm #1) on 1/28/21 at 3:17 p.m. MR #6: The patient's SOC was 12/21/20 with diagnoses that included Venous Insufficiency, Peripheral Vascular Disease (PVD), Chronic Obstructive Pulmonary disease (COPD) and Heart Failure. The clinical record review was conducted on 1/28/21 at 10:33 a.m. The Initial Comprehensive Assessment dated 12/21/20 completed by the Physical Therapist revealed: Section M0104/date of referral, was left blank. Section 1021 Primary diagnosis listed Venous Insufficiency. M1023/Other Diagnoses listed PVD, COPD, Heart Failure, Osteoarthritis, Hallux Valgus and Hammer toes. All the listed diagnoses had an onset/exacerbation date of 12/10/20 (Date of admission to home care). There was no history of the status of the above diseases including onsets, treatments for past medical history problems and outcomes from the treatments. These findings were reviewed with and acknowledged by Adm #1 during an interview on 1/28/21 at 3:30 p.m.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review and interview, it was determined that the Agency failed to follow up on the initial medication review and inform the Physician, in a timely manner, of severe drug interactions in 4 (MR's #2, 5, 6, 7) of 4 records with severe drug interactions identified, from a total of 7 sampled records reviewed, resulting in the potential for harmful medication effects and poor patient outcomes. Findings include: MR #5: The patient's SOC was 12/10/20 with diagnoses that included Stroke with right sided hemiplegia and hemiparesis, and Urinary Tract Infection. The clinical record review was conducted on 1/26/21 at 2:09 p.m. Section M2001 (Drug Regimen Review) of the Initial Comprehensive Assessment documented, "Yes - Issues found during review." Section M2003 documented, "Did the agency contact a physician by midnight of the next calendar day..., Yes." During the review, it was noted that of the patient's 24 prescribed medications, there were varying Severity levels identified ranging from 1 (Duplicate/low potential for drug/drug interaction) to 5 (Contraindicated unless benefits outweigh risks and no alternatives available). The drug report for the patient's prescribed medications yielded the following: Severity 4 (S4) interactions: Lamotrigine and Tramadol increase sedation, probable serious and possibly life-threatening interaction; Haloperidol and Aripiprazole increase sedation, probable serious and possible life threatening interaction; Lamotrigine and Aripiprazole both increase sedation, probable serious and possibly life threatening interaction; Lamotrigine and Haloperidol both increase sedation, probable serious and possibly life threatening drug interaction; Diphenhydramine and Haloperidol increase sedation, possibly life threatening interaction; Diphenhydramine and Tramadol increase sedation, possible life threatening drug interaction. Severity 5 (S5) interactions: Carvedilol increased risk of bradycardia, hypotension, angina. Contraindicated unless benefits outweigh risks..., Aripiprazole increased risk of akathisia, dyskinesia. Contraindicated unless benefits outweigh risks..." All 8 of the above interactions indicated "Probable serious and possibly life threatening drug/drug interactions such as low blood pressure, chest pain, slowing of heart rate, involuntary movements. On 1/27/21 at 3:03 p.m., the Administrator was queried about the medication review process. When asked if the Physician had been notified of the above drug interactions, Adm #1 replied, "Yes. We wait until we complete the 485 (Plan of Care/POC). We put the drug report findings on the POC and we send it all at that time." When asked how soon after the drug review, was the Physician notified, Adm #1 reported, We sent it out by mail on 12/15/20." Adm #1 was directed to section M2003 of the comprehensive assessment regarding the timely notification of the Physician and how the agency's current practice for notifying the physician well exceeded the "notification by midnight the next day" requirement. Upon review, Adm #1 acknowledged the findings and reported, "We'll have to come up with a new system. It's hard to get in contact with the Physician so we don't call them. We've just been sending the reports by mail when we complete the 485. The agency failed to ensure the Physician was notified of the above severe drug interactions by midnight of the next day in order to approve, modify or discontinue use of the medications. MR #6: The patient's SOC was 12/21/20 with diagnoses that included Peripheral Vascular Disease, Heart Failure and Venous Insufficiency. Section M2001 of the comprehensive assessment revealed, "Yes - Issues found during review." Of the patient's 9 prescribed medications, the following Severity level 4 (S4) drug/drug interactions were identified: Tramadol and Tizanidine, Alprazolam and Levocetirizine, Alprazolam and Tizanidine, Tramadol, Tizanidine and Levocetirizine, Alprazolam and Tramadol. All of the above interactions indicated "Probable serious and possibly life threatening drug/drug interactions." There was no documented evidence that the Physician had been notified of the above severe drug interactions by midnight of the next day in order to address any potential medication concerns. The above findings were reviewed with and confirmed by Adm #1 during an interview on 1/28/21 at 10:15 a.m. who reported, "We don't call the Physician. We just mail the results of the drug review after we complete the 485/POC." MR #7: The patient's SOC was 5/1/20 with diagnoses that included Myocardial Infarction (Heart Attack), Atrial Fibrillation and Coronary Artery Disease. During the record review on 1/28/21 at 1:54 p.m., it was noted that section M2001 of the Initial Comprehensive Assessment documented, "Yes - Issues found during review." The drug report provided by the agency revealed Severity Level 4 (S4) drug interactions between Methocarbamol and Tramadol/both increase sedation. Probable serious and possibly life threatening drug/drug interactions. There was no documented evidence that the Physician had been notified of the above severe drug interactions by midnight of the next day in order to address any potential medication concerns. During the clinical record review of the above records, it was noted that the section of the Plan of Care/POC to be completed by the Physician that documented, "I have reviewed the attached drug interaction for this episode..., Continue current medications..., New orders..." was left blank on all records. The agency failed to notify the Physician of the severe drug interactions by midnight of the next day, and failed to clarify if medications were to be continued or discontinued due to the level of severity. These findings were discussed with and acknowledged by Adm #1 during an interview on 1/28/21 at 3:39 p.m. MR #2: The plan of care dated 1-12-21 stated the patient was admitted with diagnoses that included diabetes, peripheral vascular disease, kidney disease, depression and anemia. The plan of care specified the patient was taking 17 medications. Section (M2001) of the comprehensive assessment dated 1-12-21, revealed, "No - No issues found during review." On the "Drug Interactions" report section of the plan of care, the following Severity level 4 (S4) drug/drug interactions were identified: "Hydrocodone and Mirtazapine both increase sedation. Probable serious and possibly life-threatening drug/drug interaction."; and Clopidogrel [Plavix], Mirtazapine, Atorvastatin [Lipitor] and Hydrocodone all have "Possible serious drug/drug interaction." On the start of care assessment section "(M2003) Medication Follow-up: Did the agency contact a physician (or physician-designee) by midnight of the next calendar day and complete prescribed/recommended actions in response to the identified potential clinically significant medication issues?" was left blank. During an interview on 1-26-21 at 3:30 PM Adm #1 stated, "We report all level 4 and level 5 medication interactions to the physician." On 1/27/21 at 3:03 p.m., the Administrator was queried about the medication review process. When asked if the Physician had been notified of the above drug interactions, Adm #1 replied, "Yes. We wait until we complete the 485 (Plan of Care/POC). We put the drug report findings on the POC and we send it all at that time." When asked how soon after the drug review, was the Physician notified, Adm #1 reported, We sent it out by mail on 1/19/21." There was no documented evidence that the Physician had been notified of the above severe drug interactions by midnight of the next day in order to address any potential medication concerns.

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, it was determined the agency failed to ensure the plan of care included complete and pertinent orders and measureable goals in 4 of 7 records reviewed out of a total of 7 records reviewed (MR1, 2, 3 and 4), resulting in incomplete care for the patient and potential for unidentified goals. Findings include: Findings include: MR #1: The plan of care, dated 12-10-20 stated the patient was admitted with diagnoses that included hypertensive heart disease with chronic kidney disease, congestive heart failure, dependence on kidney dialysis, peripheral vascular disease and diabetes. The plan of care included a physician's order for the nurse to "Monitor glucometer readings for variations and compliance. Notify physician of Fasting Blood Sugar > 200 and 300 and/or Random Blood Sugar >300 and 200 and 300 and/or Random Blood Sugar >300 and <70mg%." The plan of care did not include the frequency for monitoring the patient's blood sugar and diabetes safety precautions. The plan of care included goals such as: "Patient's cardiovascular and pulmonary condition will be stabilized by 03/06/2021."; "The patient/caregiver will verbalize and demonstrate compliance/adherence to diabetes regime as evidenced by maintenance of blood sugar levels within acceptable limits by 03/06/2021."; and "Patient's pain will be controlled and managed at patient's own comfort level as verbalized by the patient by 02/06/2021." The goals on the plan of care were not objectively measurable. On the start of care comprehensive assessment dated 1-12-21, the nurse documented, "Primary reason for Home Health:... for skilled wound care, dressing changes and teachings..." The plan of care did not contain diagnoses, interventions or goals related to the wound care and dressing changes needed as identified in the start of care assessment. MR #3: The plan of care dated 2-27-20 stated the patient was admitted with diagnoses that included hypertensive heart disease, heart failure, hemiplegia left side, urinary tract infection and diabetes. The plan of care included goals such as: "Demonstrates effective pain management within 7 weeks."; and "Patient to be independent with safety issues in 7 weeks." The goals on the plan of care were not objectively measurable. MR #4: The plan of care dated 11-25-20 stated the patient was admitted with diagnoses that included breast cancer, nipple discharge, encounter for wound dressing changes, multiple sclerosis and hypertension. The plan of care included goals such as: "Patient's cardiovascular and pulmonary condition will be stabilized by 01/23/2021."; "Patient's pain will be controlled and managed at patient's own comfort level as verbalized by the patient by 12/26/2020."; and "The patient's wound drainage will decrease by 01/23/2021." The goals on the plan of care were not objectively measurable.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to include contact information for the Home Health Agency's Clinical Manager in the Patient Admission/Orientation Packet, resulting in the potential for unaddressed patient concerns. Findings include: On 1/26/21 at 12:30 p.m., the Agency's Admission packet was reviewed. The packet included a consent form, admission agreement, Beneficiary notice and patient rights and responsibilities forms and Emergency Preparedness documents. Upon review, it was noted that there was no contact information for the Agency's Clinical Manager. These findings were reviewed with and confirmed by the Administrator (Adm #1) during an interview on 1/28/21 at 3:00 p.m.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on observation and interview, the agency failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control of infectious and communicable diseases including Covid-19, and failed to develop a method of screening visitors, staff employed by this agency, and those granted clinical privileges, resulting in the potential development and spread of the Covid-19 infection between staff and the agency's 10 current patients. Findings include: On 1/26/21 at 11:45 a.m., upon entering the suite, the writer was greeted. The QA Quality Assurance) Coordinator attempted to take the writer's temperature, however the thermometer was non-functional. There were no questions of recent exposure, signs and symptoms or recent travel. The writer was then escorted to a conference room. Upon surveyor #2's arrival, it was noted that the office staff did not attempt to check for temperature and again, failed to ask Covid-19 screening questions. There was no protocol in place for screening of visitors. Further review revealed that office staff had not been undergoing screening in order to determine the presence of Covid-19. When queried as to how direct care/field staff were being screened prior to patient contact, the Administrator (Adm #1) reported that all field staff have to complete a screening form in the patient's chart prior to documenting. It was determined that there was no pre-screening in place for field staff prior to making contact with the patients. The screening form would only be assessed after the visit/contact was completed. Adm #1 acknowledged there was no screening process in place for office or field staff at the time of discovery.

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, it was determined that the Agency failed to ensure that Medical Social Work services were provided for 1 (MR #7) of 2 records with Medical Social Work services ordered, and failed to provide nursing and physical therapy services as ordered in the plan of care in 1 of 7 records reviewed (MR#1) from a total of 7 sample records reviewed, resulting in the absence of needed community resources and the potential for unmet care needs. Findings include: MR #7: The patient's start of care (SOC) was 5/1/20 with diagnoses that included Non-ST Elevation/Myocardial Infarction, Atrial Fibrillation and Chronic Obstructive pulmonary Disease. The clinical record review was conducted on 1/28/21 at 1:54 p.m. During the review, it was noted that a referral for home care services, dated 4/30/20, ordered "MSW (Medical Social Work) to consult and refer to community resources." At the time of the clinical record review, MSW services had not been provided. These findings were reviewed with and acknowledged by the Administrator (Adm #1) during an interview on 1/29/21 at 9:51 a.m. MR #1: The physical therapy evaluation/plan of care, dated 12-23-20, ordered physical therapy services to be provided 1 time per week for 1 week then 2 times per week for 5 weeks. During the review of week #5, 12-27-20 to 1-2-21, it was noted that 1 physical therapy visit was provided on 1-1-21, with a missed visit documented on 12-30-20. There was no documented notification to the physician that the physical therapy services were not provided as ordered in the plan of care. The plan of care, dated 12-10-20, stated the patient was admitted with diagnoses that included hypertensive heart and kidney disease, dialysis and diabetes. The plan of care include an order for nursing to "Monitor glucometer readings for variations and compliance. Notify physician of Fasting Blood Sugar > 200 and 300 and/or Random Blood Sugar > 300 and < 70mg%." During the review of the seven nursing visits documented between 12-10-20 and 1-20-21, it was noted that there were no blood sugar monitoring done by the nurse as ordered in the plan of care.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure on-site supervisory visits to the patient's home were made in order to supervise the care provided by the Home Health Aide for 2 (MR #3 and 5) of 4 records with Home Health Aide services ordered, from a total of 7 sampled records reviewed resulting in the potential for the provision of unsafe care and unmet care needs. Findings include: MR #5: The patient's start of care was 12/10/20 with diagnoses that included Stroke, Hemiplegia and Urinary Tract Infection. The plan of Care ordered Skilled Nursing, Physical Therapy and Home Health Aide (HHa) services were ordered at a frequency of 1x/wk. x 9 wks. During a review of the clinical record on 1/26/21 at 2:09 p.m., there was no documented evidence that any supervisory visits had been conducted. These findings were reviewed with and acknowledged by the Administrator (Adm #1) during an interview on 1/28/21 at 2:59 p.m. MR #3: The plan of care, dated 2-27-20, stated the patient was admitted for physical therapy, occupational therapy and home health aide services with diagnoses that included hypertensive heart disease, heart failure, muscle weakness, hemiplegia and hemiparesis followinf a stroke, urinary tract infection, diabetes and blindness. During the review of the home health aide visit notes, it was noted that the home health aide provided 7 visits in 4 weeks between 2-29-20 and 3-19-20. During the review of the Physical therapy visit notes, it was noted that the Physical Therapist provided 6 visits in 4 weeks between 2-27-20 and 3-19-20. There were no documented home health aide supervision visits found in the record for the 4 weeks the patient was receiving services. During an interview on 1-29-20 at 1:55 PM, Adm #1 stated, "The therapist should have done home health aide supervision every two weeks."