Every finding on record at Bay Nursing, Inc

From 10/31/23 through 11/3/23, the Michigan Department of Licensing and Regulatory Affairs conducted a recertification survey at Bay Nursing, Inc. This was a standard survey. The requirements for participation in Medicare at 42 CFR 484.102 Emergency Preparedness were not reviewed.

A Medicare recertification survey was conducted by the Michigan Department of Licensing and Regulatory Affairs from 10/31/23 through 11/3/23 at: Bay Nursing Inc. 255 N. Bailey St. Romeo, MI 48065 This agency has no branches or sub-units. Clinical records reviewed for this survey included 7 records with home visits, 5 records without home visits, and 5 discharged 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.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure that 2 (P's #10, 11) patients observed during home visits and 2 (P's #3, 5) records reviewed 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 17 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-10: The patient's start of care (SOC) was 10/26/23 with diagnoses that included Right Tibia Fracture and Chronic Obstructive Pulmonary Disease. During the record review on 11/1/23 at 10:30 a.m., it was noted that the plan of care (POC) ordered Skilled Nursing (SN), Home Health Aide (HHa), Physical Therapy (PT) and Occupational Therapy (OT) services to be provide. On 11/1/23, during a scheduled survey home visit with the Skilled 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) and Clinical Manager (CM #1) during an interview on 11/3/23 at 9:20 a.m. P-11: The patient's SOC was 10/27/23 with diagnoses that included Pathological Fracture Thoracic level 11-12, Heart Failure and Diabetes Mellitus. During the record review on 11//23 at 3:30 p.m., it was noted that the POC ordered SN, PT and OT services to be provided. On 11/1/23, during a scheduled survey home visit with the OT (OT #1) it was noted that the patient's admission packet was void of a completed calendar of proposed visits to be made by OT# or any of the other ordered disciplines. During the visit, OT #1 informed the patient of when the next home visit would take place, to which the patient responded, "I have an appointment with my primary care physician." OT #1 then gave another date and time and the patient responded, "That won't work because I see my Cardiologist that day." OT #1 then stated, "Okay then, I can see you on Tuesday at 10:00 a.m." There was no indication that the patient had been informed in advance of care, of the days and times in which services would be provided as per this requirement. These findings were reviewed with and acknowledged by Adm #1 and CM #1 during an interview on 11/3/23 at 10:05 a.m. P-3: The Start of Care (SOC) was dated 8/10/23. The Plan of Care (POC) identified diagnoses of Diabetes Type 2, Acute Kidney Disease and Alzheimer’s. During record review on 11/1/23, it was noted that the referral stated, “Home Care Orders – Specify services requested: Skilled nursing, Occupation Therapy, Physical Therapy and Home Health Aide (HHA).” The consent signed by the patient on 8/10/23 and the comprehensive assessment completed by Registered Nurse on 8/10/23 were blank under HHA section and there was no documentation of the patient refusing HHA. P-5: The Start of Care (SOC) was dated 5/23/23. The Plan of Care (POC) identified diagnoses of Urinary Tract Infection and Weakness. During record review on 11/1/23, it was noted that the referral stated, “Skilled Services. SN (Skilled Nursing), PT (Physical Therapy), OT (Occupational Therapy). ST (Speech Therapy), MSW (Medical Social Worker) and HHA (Home Health Aide).” The consent signed by the patient on 5/23/23 and the comprehensive assessment completed by Registered Nurse on 5/23/23 were blank under HHA section and there was no documentation of the patient refusing HHA. These findings were reviewed with and acknowledged by the ADM#1 (Administrator) during an interview on 11/3/23 at 11:10 am.

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 13 of 17 records reviewed (P#s 1, 2, 3, 4, 5, 6, 7, 8, 9, 16, 17, 18, and 19), from a total of 17 records reviewed, resulting in incomplete clinical information to aide in determining the needs of the patient and for measuring the patient's progress toward goals/outcomes. Findings included: P-1: The Start of Care (SOC) was dated 9/22/23. The Plan of Care (POC) identified diagnoses of Venous Stasis Ulcer, Diabetes Type 2 and Cellulitis. During record review on 10/31/23, it was noted that the SOC comprehensive assessment dated 9/22/23, documented under "Primary Diagnosis and Other Diagnoses", all 13 diagnoses were blank under onset/exacerbation and date of the onset/exacerbation. No onset, exacerbation, prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. P-2: The Start of Care (SOC) was dated 7/19/23. The Plan of Care (POC) identified diagnoses of Multiple Sclerosis and Left Buttock Stage 3 Pressure Ulcer. During record review on 10/31/23, it was noted that the SOC comprehensive assessment dated 7/19/23, documented under "Primary Diagnosis and Other Diagnoses", all 14 diagnoses were blank under onset/exacerbation and date of the onset/exacerbation. No onset, exacerbation, prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. P-3: The Start of Care (SOC) was dated 8/10/23. The Plan of Care (POC) identified diagnoses of Diabetes Type 2, Acute Kidney Disease and Alzheimer’s. During record review on 11/1/23, it was noted that the SOC comprehensive assessment dated 8/10/23, documented under "Primary Diagnosis and Other Diagnoses", all 24 diagnoses were blank under onset/exacerbation and date of the onset/exacerbation. No onset, exacerbation, prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. P-4: The Start of Care (SOC) was dated 10/6/23. The Plan of Care (POC) identified diagnoses of Osteoarthritis, Chronic Pain and Chronic Obstructive Pulmonary Disease. During record review on 11/1/23, it was noted that the SOC comprehensive assessment dated 10/6/23, documented under "Primary Diagnosis and Other Diagnoses", all 16 diagnoses were blank under onset/exacerbation and date of the onset/exacerbation. No onset, exacerbation, prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. P-5: The Start of Care (SOC) was dated 5/23/23. The Plan of Care (POC) identified diagnoses of Urinary Tract Infection and Weakness. During record review on 11/1/23, it was noted that the SOC comprehensive assessment dated 5/23/23, documented under "Primary Diagnosis and Other Diagnoses", all 22 diagnoses were blank under onset/exacerbation and date of the onset/exacerbation. No onset, exacerbation, prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. These findings were reviewed with and acknowledged by the ADM#1 (Administrator) during an interview on 11/3/23 at 11:00 am. P-14: This 83-year-old patient was admitted to home care on 10/18/23 with a diagnosis of inguinal hernia repair, chronic obstructive pulmonary disease (COPD), and atrial fibrillation. During record review on 11/1/23, it was noted that the start of care comprehensive assessment dated 10/18/23, failed to contain dates of diagnosis onset or exacerbation for the primary diagnosis (Section M1021) of encounter for surgical after care following surgery on the digestive system or the additional 10 secondary/other diagnoses (Section M1023). P-15: This 89-year-old patient was admitted to home care on 8/8/23 with a diagnosis of type 2 diabetes mellitus with diabetic polyneuropathy, hyperglycemia, and chronic kidney disease. During record review on 11/1/23, it was noted that the start of care comprehensive assessment dated 8/8/23, failed to contain dates of diagnosis onset or exacerbation for the primary diagnosis (Section M1021) of type 2 diabetes mellitus with diabetic polyneuropathy or the additional 15 secondary/other diagnoses (Section M1023). P-16: This 71-year-old patient was admitted to home care on 9/20/23 with a diagnosis abscess of the epididymis or testis, diabetes mellitus, and primary hypertension. During record review on 11/2/23, it was noted that the start of care assessment dated 9/20/23, failed to contain dates of diagnosis onset or exacerbation for the primary diagnosis (Section M1021) of abscess of the epididymis or testis or the additional 10 secondary/other diagnoses (Section M1023). It was also noted that the skilled nursing start of care assessment, dated 9/20/23 failed to include a baseline blood sugar level to accurately assess and monitor diabetes mellitus. Blood sugar levels remained unmonitored for the next 6 visits. Nursing began documenting blood sugar levels on visit 8 (October 20). P-17: This 67-year-old patient was admitted to home care on 9/23/23 with a diagnosis of urinary tract infection, pressure ulcers, acute kidney failure, and type 2 diabetes mellitus. During record review on 11/3/23, it was noted that the start of care assessment dated 9/23/23, failed to contain dates of diagnosis onset or exacerbation for the primary diagnosis (Section M1021) of urinary tract infection or the additional 19 secondary/other diagnoses (Section M1023). It was also noted that the skilled nursing start of care assessment, dated 9/23/23, failed to include a baseline blood sugar level to accurately assess and monitor diabetes mellitus. These findings were reviewed and acknowledged by the administrator (ADM-1), the clinical manager (CM-1), and the director of rehab (CM-2) during an interview on 11/3/23 at 12:30 p.m. P-6: This 80-year-old was admitted to the agency on 10/9/23 with diagnoses which included type 2 Diabetes; chronic kidney disease; and anemia. The medical record was reviewed on 11/1/23. During review of the start of care (SOC) comprehensive assessment dated 10/9/23, it was noted there was no date next to the “Primary Diagnosis”, or 17 “Other” diagnoses listed making it unclear whether the diagnosis was a new onset, exacerbation, or chronic problem and how the agency would use this information to determine the patient’s status in developing the plan of care (POC). P-7: This 84-year-old was admitted to the agency on 10/11/23 with diagnoses which included fracture of the right elbow; recent falls; and type 2 Diabetes. The medical record was reviewed on 11/2/23. During review of the SOC comprehensive assessment dated 10/11/23, it was noted there was no date next to the “Primary Diagnosis”, or 7 “Other” diagnoses listed making it unclear whether the diagnosis was a new onset, exacerbation, or chronic problem and how the agency would use this information to determine the patient’s status in developing the POC. P-8: This 88-year-old was admitted to the agency on 10/11/23 with diagnoses which included type 2 Diabetes; Osteomyelitis (infection in the bone) of the lower legs; and heart disease. The medical record was reviewed on 11/2/23. During review of the SOC comprehensive assessment dated 10/11/23, it was noted there was no date next to the “Primary Diagnosis”, or 24 “Other” diagnoses listed making it unclear whether the diagnosis was a new onset, exacerbation, or chronic problem and how the agency would use this information to determine the patient’s status in developing the POC. P-9: This 76-year-old was admitted to the agency on 6/28/23 with diagnoses which included pressure ulcer to the right heel; chronic ulcer of left buttock; and type 2 Diabetes. The medical record was reviewed on 11/3/23. During review of the SOC comprehensive assessment dated 6/28/23, it was noted there was no date next to the “Primary Diagnosis”, or 18 “Other” diagnoses listed making it unclear whether the diagnosis was a new onset, exacerbation, or chronic problem and how the agency would use this information to determine the patient’s status in developing the plan of care POC. The above findings were reviewed and acknowledged by the ADM#1 (Administrator) during an interview on 11/3/23 at 1:15p.m. ADM#1 stated that it was a coding issue, and they were looking into changing how dates can be properly added.

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 an accurate review of all medications to determine potential adverse effects or duplicate drug therapy in 2 of 17 (P-14, and 16) records reviewed, resulting in the potential for harmful medication effects for all patients serviced by this agency. Findings include: P-14: This 83-year-old patient was admitted to home care on 10/18/23 with a diagnosis of inguinal hernia repair, chronic obstructive pulmonary disease (COPD), and atrial fibrillation. During record review on 11/1/23, it was noted that the initial assessment, dated 10/18/23, stated (under M2001 Drug Regimen Review) "no issues found during review" while the patient medication record dated 10/18/23, indicates patient was prescribed duplicate medications and no changes were made by the physician. P-16: This 71-year-old patient was admitted to home care on 9/20/23 with a diagnosis abscess of the epididymis or testis, diabetes mellitus, and primary hypertension. During record review on 11/2/23, it was noted that the initial RN assessment, dated 9/20/23, stated (under M2001 Drug Regimen Review) "no issues found during review" while the patient medication record dated 9/20/23, indicates patient was prescribed duplicate medications and no changes were made by the physician. These findings were reviewed and acknowledged by the administrator (ADM-1), the clinical manager (CM-1), and the director of rehab (CM-2) during an interview on 11/3/23 at 12:30 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 document review and interview, it was determined that the agency failed to ensure the Plan of Care included objectively measurable and individualized goals in 11 of 17 records reviewed (P’s #1, 2, 3, 5, 6, 7, 8, 9, 15, 16, and 17), resulting in a potential for failure to measure progress toward achievement of desired outcomes. Findings include: P-1: The Start of Care (SOC) was dated 9/22/23. The Plan of Care (POC) identified diagnoses of Venous Stasis Ulcer, Diabetes Type 2 and Cellulitis. During record review on 10/31/23, it was noted that the goals within the POC were not measurable. For example, one goal stated, “Patient/Caregiver will verbalize/demonstrate understanding of pathophysiology, s/s (signs and symptoms) of complications and management of the following endocrine disease Process DM by End of episode.” Additionally, another goal stated, “The Patient/Caregiver will verbalize understanding of Best Care practice as it relates to their condition by end of episode.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-2: The Start of Care (SOC) was dated 7/19/23. The Plan of Care (POC) identified diagnoses of Multiple Sclerosis and Left Buttock Stage 3 Pressure Ulcer. During record review on 10/31/23, it was noted that the goals within the POC were not measurable. For example, one goal stated, “Patient/CG will be able to verbalize/demonstrate management of medication regimen and independence in administration of medications.” Additionally, another goal stated, “The patient/caregiver will demonstrate techniques to prevent and/or correct aspiration.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-3: The Start of Care (SOC) was dated 8/10/23. The Plan of Care (POC) identified diagnoses of Diabetes Type 2, Acute Kidney Disease and Alzheimer’s. During record review on 11/1/23, it was noted that the goals within the POC were not measurable. For example, one goal stated, “Patient/Caregiver will verbalize/demonstrate understanding of pathophysiology, s/s complications and management of the following endocrine disease Process DM1 by 8/10/2023.” Additionally, another goal stated, “Patient/CG will be able to verbalize/demonstrate management of medication regimen and independence in administration of medications.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-5: The Start of Care (SOC) was dated 5/23/23. The Plan of Care (POC) identified diagnoses of Urinary Tract Infection and Weakness. During record review on 11/1/23, it was noted that the goals within the POC were not measurable. For example, one goal stated, “Patient will verbalize an understanding of methods to promote adequate pain control and an acceptable level of pain relief by EOE (End of Episode).” Additionally, another goal stated, “The Patient/Caregiver will verbalize understanding of Best Care practice as it relates to their condition by end of episode.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. These findings were reviewed with and acknowledged by the ADM#1 (Administrator) during an interview on 11/3/23 at 11:35 am. P-15: This 89-year-old patient was admitted to home care on 8/8/23 with a diagnosis of type 2 diabetes mellitus with diabetic polyneuropathy, hyperglycemia, and chronic kidney disease. During record review on 11/1/23, it was noted that the plan of care failed to include measurable nursing goals that are individualized to address patient needs. For example, one goal stated, “patient will verbalize understanding of disease process and management of diabetes by end of episode.” P-16: This 71-year-old patient was admitted to home care on 9/20/23 with a diagnosis abscess of the epididymis or testis, diabetes mellitus, and primary hypertension. During record review on 11/2/23, it was noted that the plan of care failed to include measurable nursing goals that are individualized to address patient needs. For example, one goal stated, “the patient/caregiver will verbalize understanding of Best Care practice as it relates to their condition by end of episode.” P-17: This 67-year-old patient was admitted to home care on 9/23/23 with a diagnosis of urinary tract infection, pressure ulcers, acute kidney failure, and type 2 diabetes mellitus. During record review on 11/3/23, it was noted that the plan of care failed to include measurable nursing goals that are individualized to address patient needs. For example, one goal stated, “patient/caregiver will verbalize/demonstrate understanding of pathophysiology, signs/symptoms, complications, and management of the following endocrine disease process diabetes mellitus by end of episode.” There was no evidence of how the goals could be objectively measured to determine progress toward meeting the goals. These findings were reviewed and acknowledged by the administrator (ADM-1), the clinical manager (CM-1), and the director of rehab (CM-2) during an interview on 11/3/23 at 12:30 p.m. P-6: This 80-year-old was admitted to the agency on 10/9/23 with diagnoses which included type 2 Diabetes; chronic kidney disease; and anemia. The medical record was reviewed on 11/1/23. During review of the plan of care (POC) dated 10/9/23, the following examples of skilled nursing (SN) goals were noted: Patient will verbalize an understanding of methods to promote adequate pain control and an acceptable level of pain relief by end of episode; Patient/caregiver will verbalize/demonstrate understanding of pathophysiology, signs/symptoms of complications and management of the following endocrine disease process- Diabetes Mellitus, by 12/7/23. It was unclear how the SN goals would be objectively measured to determine the patient’s progress toward the goals. P-7: This 84-year-old was admitted to the agency on 10/11/23 with diagnoses which included fracture of the right elbow; recent falls; and type 2 Diabetes. The medical record was reviewed on 11/2/23. During review of the POC dated 10/11/23, the following examples of SN goals were noted: The patient/caregiver will verbalize understanding of Best Care practice as it relates to their condition by the end of episode; Patient/caregiver will verbalize/demonstrate understanding of pathophysiology, signs and symptoms of complications and management of the following endocrine disease process- Diabetes by 12/9/23. It was unclear how the SN goals would be objectively measured to determine the patient’s progress toward the goals. P-8: This 88-year-old was admitted to the agency on 10/11/23 with diagnoses which included type 2 Diabetes; Osteomyelitis (infection in the bone) of the lower legs; and heart disease. The medical record was reviewed on 11/2/23. During review of the POC dated 10/11/23, the following examples of SN goals were noted: Patient/caregiver will verbalize/demonstrate understanding of pathophysiology, signs/symptoms of complications and management of the following endocrine disease process- Diabetes Mellitus type 2, by 12/9/23. The patient/caregiver will verbalize understanding of Best Care practice as it relates to their condition by the end of episode. It was unclear how the SN goals would be objectively measured to determine the patient’s progress toward the goals. P-9: This 76-year-old was admitted to the agency on 6/28/23 with diagnoses which included pressure ulcer to the right heel; chronic ulcer of left buttock; and type 2 Diabetes. The medical record was reviewed on 11/3/23. During review of the POC dated 6/28/23, the following examples of SN goals were noted: Wound(s) will heal without complication by end of episode; Patient will verbalize an understanding of methods to promote adequate pain control and an acceptable level of pain relief by end of episode. It was unclear how the SN goals would be objectively measured to determine the patient’s progress toward the goals. The above findings were reviewed and acknowledged by the ADM#1 (Administrator) during an interview on 11/3/23 at 1:15p.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 interview and record review, the Agency failed to ensure Skilled Nursing prepared clear written patient care instructions for the home health aide regarding client needs, and safety precautions prior to the provision of care in 3 (P#'s 7, 12, and 13) records in which Home Health Aide services were ordered, from a total of 17 sampled records reviewed, resulting in the potential for the provision of unsafe care and unmet care needs. Findings include: P-7: This 84-year-old was admitted to the agency on 10/11/23 with diagnoses which included fracture of the right elbow; recent falls; and type 2 Diabetes. The medical record was reviewed on 11/2/23. The plan of care dated 10/11/23 included orders for a home health aide and had the following safety measures documented: Keep pathway clear; Slow position change; Fall precautions; Use of assistive devices; and Standard precautions/infection control. When reviewing the Aide Care Plan dated for 10/11/23 through 12/9/23, it was noted that there were no safety measures included. In the section “Additional Comments” of the Aide Care Plan, there were letters, Q, R, U, following the word “PRECAUTIONS”. On 11/3/23, the administrator (ADM #1) provided a copy of a laminated document for surveyor review that contained a list of letters along side of what the letters meant and stated that the laminated document was given to staff and that was how staff knew what precautions to follow for each patient. On 11/3/23 at 2:10 p.m., a phone interview was conducted with an agency home health aide (HHa #1) to identify understanding of the letter code system. HHa #1 was queried to the meaning of the precaution letter Q on the Aide Care Plan. After a several second pause and no response, HHa #1 was queried to whether she was looking for the answer and HHa #1 stated that she was looking and had a way of remembering all the codes but did not provide an answer to the meaning of the precaution letter Q. After another several second pause, the call was disconnected without explanation. Call back to HHa #1 was attempted immediately following the disconnection but went unanswered. No further contact was able to be made with HHa #1 prior to exiting the survey. It is unclear if HHa #1 had the laminated document, knowledge of the letter codes, or the ability to quickly determine the safety measures for patient’s that HHa #1 may be caring for. P-12: The patient's start of care (SOC) was 10/1/23 with diagnoses that included Fractur of Right Fibula and Hypertension. During the record review on 11/2/23 at 6:00 p.m., it was noted that the plan of care (POC) specified the following safety precautions and equipment: Fall Precautions, Slow position change, Unna boots. The "Aide Care Plan" was void of these safety precautions and equipment. The Aide Care Plan documented, "Observe for the following symptoms and report to SN (skilled nurse) if present: A, C, D, E G, H, I, K, Q, R, S, U." P-13: The patient's SOC was 10/25/23 with diagnoses that included Spinal Stenosis, DVT and Delirium. The POC ordered SN, HHa, PT, OT and Medical Social Work (MSW) services to be provided. During the record review on 11/2/23 at 7:00, it was noted that the Aide Care Plan was void of the following safety precautions as listed in the POC: Support during transfer and ambulation, Fall Precautions, Anticoagulant Precautions. The Aide Care Plan documented, "Symptom Codes: Q, R, U." During an interview on 11/3/23 at 10:45 a.m., the Administrator (Adm #1) was queried regarding the above findings. When asked to elaborate on what the letters meant on the aide care plan. Adm #1 reported, "We use a code system so the Aides know what each of the letters mean." Adm #1 then provided a laminated paper document which contained letters and their prospective meanings next to them. On 11/3/23 at 2:10 p.m., a member of the survey team conducted a telephone interview with the Home Health Aide (HHa #1). When queried as to the meaning of the letters on the Aide Care Plan, HHa #1 stated that she could not recall what any of the letters meant. The Registered Nurse failed to prepare clear written patient care instructions for the home health aide regarding the client's needs.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on interview and record review, the Agency failed to ensure the Home Health Aide provided care and services as ordered in the plan of care for 1 (P-12) patient who required assistance with grooming, from a total of 17 sampled records reviewed, resulting in the potential for poor hygiene and unmet needs. Findings include: P-12: The patient's start of care was 10/1/23 with diagnoses that included Fracture Right Fibula and Hypertension. The plan of care ordered Home Health Aide (HHa) services to be provided at a frequency of 2x/wk. x 2wks., 1x/wk. x 6 wks. During the clinical record review on 11/2/23 at 6:00pm, it was noted that the Aide Care Plan, dated 10/1/23, ordered "Partial Bath/Sponge..., Shower..." Further review of the record revealed an Aide missed visit note dated 10/3/23 which documented the patient did not have a shower chair. There was no documented evidence that the Aide followed the plan of care in provision of a sponge or partial bath in the absence of a shower chair. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 11/3/23 at 10:15 a.m.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure clinical notes were accurate for 1 of 17 (P# 1) records reviewed, resulting in the potential to negatively affect the health and well-being of these patients. Findings include: **Agency Policy: "Ongoing Assessments," (Undated). The policy states, "The scope and intensity of ongoing assessments will be determined by the patient’s diagnoses, condition, desire for care, response to previous care, and the care setting. Procedure: 1 During each home visit, the clinician or other discipline will re-evaluate the patient according to the problems identified during the initial visit and subsequent visits. 2. Using the standards of care identified by the organization, the clinician will reassess the patient (as appropriate) for: … I. Functional status. J. Safety/home environment… 3. Reassessments should focus on: … B. Changes in patient condition…" P-1: The Start of Care (SOC) was dated 9/22/23. The Plan of Care (POC) identified diagnoses of Venous Stasis Ulcer, Diabetes Type 2 and Cellulitis. During record review on 10/31/23, it was noted that the Skilled Nurse (SN) documented a “Missed Visit” on 10/9/23 that stated, “Pt (Patient) states no visit due to on the way to hospital due to a fall…” The following SN visit on 10/11/23, 2 days after the fall, the SN failed to document a reassessment of the patient’s condition after the fall. The agency failed to follow policy by documenting an ongoing assessment of the patient's condition and potential home safety. These findings were reviewed with and acknowledged by the ADM#1 (Administrator) during an interview on 11/3/23 at 11:00 am.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the discharge/transfer summary was complete, provided the patient's current health status at the time of discharge/transfer, and forwarded to the physician/receiving facility within the required time frame as per this requirement in 4 (P's #3, 12, 13, and 15) records from a total of 17 records reviewed, resulting in the potential for unidentified continuing health care concerns, lack of continuity of care and unmet care needs. Findings include: P-3: The Start of Care (SOC) was dated 8/10/23. The Plan of Care (POC) identified diagnoses of Diabetes Type 2, Acute Kidney Disease and Alzheimer’s. During record review on 11/1/23, it was noted that the Skilled Nursing transfer summary dated 9/15/23 stated, "Summary of Care: Please see Patient Profile." The patient profile contained patient intake information and SOC documentation. The transfer summary failed to detail the course of care provided, responses to treatment, any potential continuing needs, and failed to document the patient's health status at the time of transfer in measurable terms. These findings were reviewed with and acknowledged by the ADM#1 (Administrator) during an interview on 11/3/23 at 11:30 am. Policy 2-041.1, TRANSFER SUMMARY (no date) states “All patients transferred from the organization will have a transfer summary completed and filed in the clinical record. Within 2 business days of transfer…” Policy No. 2-043.1, DISCHARGE SUMMARY (no date) states, “A copy of the discharge summary will be provided to the patient’s primary care practitioner or other health care professional…after discharge from the organization within five (5) business days of the patient’s discharge.” P-15: This 89-year-old patient was admitted to home care on 8/8/23 with a diagnosis of type 2 diabetes mellitus with diabetic polyneuropathy, hyperglycemia, and chronic kidney disease. During record review on 11/1/23, it was noted that the patient was readmitted to the hospital on 8/19/23 and discharged home on 8/21/23. Home care resumed on 8/22/23. There was no documented evidence that a transfer summary was completed or sent to the facility accepting the patient. This patient was discharged from the agency on 9/27/23. The record indicates the discharge summary was faxed to the primary care provider on 10/5/23, 8 days (or 6 business days) after the discharge. This agency failed to follow its own policies related to transfer and discharge summary. This finding was reviewed and acknowledged by the administrator (ADM-1), the clinical manager (CM-1), and the director of rehab (CM-2) during an interview on 11/3/23 at 12:30 p.m. P-12: The patient's start of care (SOC) was 10/1/23 with diagnoses that included Fracture Right Fibula and Hypertension. The plan of care (POC) ordered Skilled Nursing (SN), Home Health Aide (HHa), Physical Therapy (PT), Occupational Therapy (OT) and Medical Social Work (MSW) services to be provided. During the record review on 11/2/23 at 6:00, it was noted that the patient was discharged from OT services on 10/17/23. The OT Discharge Summary was sent to the Physician on 10/28/23, which was 11 days after the date of discharge. The patient was discharged from PT services on 10/20/23. The PT Discharge Summary was sent to the Physician on 10/28/23, which was 8 days after the date of discharge from services. The Agency failed to ensure 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 Clinical Manager (CM #1) during an interview on 11/3/23 at 10:15 a.m. P-13: The patient's SOC was 10/25/23 with diagnoses that included Spinal Stenosis, DVT and Delirium. The POC ordered SN, HHa, PT, OT and MSW services to be provided. During the clinical record review on 11/2/23 at 7:20 p.m., it was noted that the patient was transferred to an inpatient facility on 10/27/23 for unspecified/undocumented reasons. The Transfer Summary was completed 3 days after the transfer to an inpatient facility, on 10/30/23, and failed to include detailed rationale for the transfer. These findings were discussed with Adm #1 and CM #1 during an interview on 11/3/23 at 10:45 a.m. to which Adm #1 stated the Agency didn't become aware of the transfer until 10/30/23. Further review of the clinical record revealed a HHa missed visit note dated 10/27/23 at 9:31 a.m. which documented, "Received message after arrival that patient was sent via EMS to TBH (Troy Beaumont Hospital) for mental status changes... Supervisor notified: Yes." Additionally, a "Patient Communication" note dated 10/27/23 documented, "Confirmed from hospital patient admitted today in room 5515. MD and staff notified." The agency failed to ensure a detailed Transfer Summary was sent to the Physician and Receiving facility within 2 days of becoming aware of the transfer as per this requirement.