Every finding on record at Care First Home Health Services, Inc

The following standard level deficiencies were identified during a Medicare authorized Emergency Preparedness Survey, conducted by the Michigan Department of Licensing and Regulatory Affairs, on 4/15/24 through 4/18/24 at: Care First Home Health Services 1000 John R. St. Suite 205 Troy, MI 48083 At the conclusion of the survey, this agency was determined to be non-compliant, at a standard level, with the Condition of Participation at 42 CFR §484.102, Emergency Preparedness.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on record review and interview, the Agency failed to develop an emergency preparedness plan that had been reviewed and updated at least every 2 years, resulting in lack of direction for Agency personnel in the event of an actual emergency or disaster. This deficient practice could affect the health and safety of all staff and patients. Findings include: On 4/17/24 at 9:55 a.m., a review of the agency's Emergency Preparedness Plan was conducted. Upon review, it was noted that the Plan had not been reviewed or updated as per this requirement. The Plan was undated. The agency's Risk Assessment which drives the course of the Emergency Preparedness Plan was dated 2019. There was no further information to review to support that the Emergency Preparedness Plan had been updated. These findings were reviewed with and acknowledged by the Administrator at the time of discovery.

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to develop and maintain an Emergency Preparedness training and testing program that was based on the emergency plan, risk assessment, policies, procedures, and the communication plan, that had been updated at least every 2 years. This deficient practice could negatively affect the health and safety of all patients currently serviced by this agency in the event of an actual disaster. Findings include: On 4/17/24 at 9:55 a.m., the agency's Emergency Preparedness documents were reviewed. During the review, it was noted that the Risk Assessment, which drives the Emergency Preparedness Plan was dated 2019. The Emergency Preparedness Plan was undated. There was no documented evidence that these documents had been reviewed or updated since 2019. Additionally, when asked if all staff had received training in Emergency Preparedness policies and procedures, the Administrator reported that all staff had not received the required training. These findings were reviewed with and acknowledged by the Administrator at the time of discovery. The agency failed to ensure its Emergency Preparedness Plan included all the elements, as per this requirement and had been updated at least every 2 years.

A Medicare recertification survey was conducted by the Michigan Department of Licensing and Regulatory Affairs on 4/15/24 through 4/18/24 at: Care First Home Health Services 1000 John R Rd. Suite 205 Troy, MI 48083 The agency had no additional branch locations. Records reviewed for the survey: 3 active records with home visits; 2 active records without home visits; 2 discharge records; and 1 additional record which included home health aide services to capture additional standard survey processes for a total of 8 records reviewed. At the conclusion of the survey, the agency was found to be out of compliance with standard level deficiencies, for the Conditions of Participation for Home Health Agencies at: 42 CFR Part 484.

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the patient received proper written Notice of Medicare Provider Non-Coverage in advance of the Agency terminating on-going care for 1 (P-1) of 2 discharged records, resulting in the patient being denied the right to appeal the decision to end Medicare covered services. Findings include: P-1: The patient's start of care was 12/7/23 with diagnoses that included Neck Fracture, Rib Fracture and Impaired mobility. During the clinical record review on 4/15/24, it was noted that the patient was discharged from the agency's services on 1/16/24. A document titled, "Notice of Medicare Non-Coverage" documented, "The effective date coverage of your current home health services will end: 1/16/24." The document was provided to and signed by the patient on the same date of discharge, 1/16/24. There was no documented evidence that the Notice of Non-Coverage was provided to the patient prior to being discharged from the agency's services. These findings were reviewed with and acknowledged by the Administrator during an interview on 4/17/24 at 3:11 p.m.

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 initial assessment was conducted within 48 hours of the patient’s return home to determine the patient’s immediate care needs and homebound status in 1 (P-5) of 8 sample records reviewed resulting in a delay in care and services, and the potential to negatively impact the patient’s health. Findings include: Agency policy titled “Assessments: Initial Comprehensive” (undated), was reviewed on 4/18/24. On the second (un-numbered) page of the policy, it stated “5. Initial Assessment and Time Frame: A RN, PT, OT or SLP must conduct the initial assessment visit within 48 hours of referral, within 48 hours of the patient’s return home or on the physician-ordered start of care date.” P-5: This 92-year-old was admitted to agency on 4/12/24 for diagnoses which included periprosthetic fracture (broken bone occurring around orthopedic prosthesis); dementia; and chronic kidney disease. The medical record was reviewed on 4/17/24. During review it was noted that the referral for home therapy services was dated 4/5/24 and stated that the patient would be returning home on 4/9/24. The initial assessment visit was made by the physical therapist on 4/12/24 (3 days after the patient returned home). There was no documentation indicating that the patient or patient’s representative requested a delay in the initial assessment visit. On 4/18/24 during interview at 12:35 p.m. with the Administrator (Staff A), and the Quality Assurance Nurse (Staff B), Staff A was queried regarding the date that this patient returned home and why there had been a delay in the initial assessment visit. Staff A stated that the patient retuned home on 4/9/24 as indicated on the referral, and that he could not find documentation indicating a reason for the initial assessment visit delay.

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 prescribed to the patient and include all medications in the medication reconciliation in its entirety for possible drug interactions and duplicate therapy per agency policy in 1 (P-5) of 8 sample records reviewed resulting in the potential for undetected harmful medication interactions or duplications. Findings include: Agency policy titled “Assessments: Initial Comprehensive” (undated), was reviewed on 4/18/24. On the third (un-numbered) page of the policy, it stated “7. Drug Regimen Review… Each patient’s comprehensive assessment includes a review of all medications the patient is currently taking… to identify… Drug interactions… Duplicate therapy… Medication Reconciliation must be completed and for all major drug interactions must include documentation of physician notification”. P-5: This 92-year-old was admitted to agency on 4/12/24 for diagnoses which included periprosthetic fracture (broken bone occurring around orthopedic prosthesis); dementia; and chronic kidney disease. A joint home visit was made to the assisted living facility with the physical therapist (PT) on 4/17/24 at 9 a.m. During the visit, the assisted living facility staff provided a facility medication administration record (MAR) for review which included all the medications the facility had on file and could administer for the patient. During medical record review on 4/17/24, a comparison was made between the facility MAR and the agency medication record. The following medications were found to be on the assisted living facility MAR and not on the agency medication record: Refresh Tears 0.5% Solution and Acetaminophen 500 mg tabs. Those medications were not included in the comprehensive assessment medication reconciliation or the agency drug interaction review. This finding was reviewed and acknowledged by the Administrator (Staff A), and the Quality Assurance Nurse (Staff B) on 4/18/24 at 12:35 p.m.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a plan of care was established that directed the course of care provided for 1 (P-4) of 1 patient to which a plan of care had not been established prior to the provision of care and services, from a total of 7 sampled records reviewed, resulting in the potential for the provision of unsafe care and poor patient outcomes. Findings include: Policy: PLAN OF CARE, undated, stated, "Each patient has a unique and individualized Plan of Care. The plan is developed and evaluated in partnership with the patient, legal patient assigned representative and caregivers. All clinical services are implemented only in accordance with the Physician's Plan of Care as a written guide for the delivery of care." P-4: The patient's start of care was 4/10/24 with diagnoses that included Abdominal pain, Joint pains and Weakness. On 4/16/24 at 2:00 p.m., during the clinical record review, it was noted that a Plan of Care that directed the course of care to be provided was not available and had not been initiated. A History and Physical report dated 4/3/24 listed the patient's diagnoses, medications, history of present illnesses, allergies and documented, "Current Plans: Home Health Care Evaluation and Treatment." None of the aforementioned information had been added to the Plan of Care. At the time of the record review, Skilled Nursing (SN) had made 3 visits to see the patient. There was no Plan of Care that directed the course of care. These findings were reviewed with and acknowledged by the Administrator and Alternate Clinical Manager during interviews on both 4/17/24 and 4/18/24.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Physician was promptly notified of a significant change in condition for 1 (P-2) patient who had negative fluctuations in weight and failed to promptly notify the Physician of major drug interactions and duplicate drug therapy in 3 (P#'s 2, 3, 4) records from a total of 7 sampled records reviewed, resulting in the potential for unidentified, untreated heath concerns and harmful medication effects. Findings include: Policy: Assessments: Initial Comprehensive, undated, stated, "Medication Reconciliation must be completed and for all major drug interactions must include documentation of physician notification." [sic] P-2: The patient's start of care (SOC) was 2/29/24 with diagnoses that included Surgical Aftercare (pacemaker placement), Congestive Heart Failure and Diabetes Mellitus. The Plan of Care (POC) ordered Skilled Nursing (SN) to instruct patient on daily weight (wt.) self-monitoring..., Report weight gain of 2 lb. (pounds)/1 day, 5 lb./1 wk. On 4/16/24 at 10:00 a.m., during the clinical record review, the following was noted: On admission, the patient weighed 196 lbs., on 3/4/24 the patient had a recorded weight of 196 lbs., on 3/12/24 the patient's weight was 180 lbs. (16 lb. wt. loss), on 3/21/24 the patient's recorded weight was 175 lbs. (5lb. wt. loss), on 4/4/24 the patient's recorded weight was 155 lbs. (20 lb. wt. loss), on 4/9/24 the patient's weight was recorded as 185 lbs. (30 lb. wt. gain), on 4/16/24 the patient's weight was recorded as 175 lbs. Further review of the clinical record revealed no documented evidence that the Physician had been promptly notified of the patient's weight losses or gains. Further review of the record revealed that the agency conducted a drug review of the patient's prescribed medications at the SOC via Drugs.com (online drug interaction checker) that revealed 3 Major drug to drugs interactions. The "Patient Communication" note dated 3/1/24 documented the Physician had been made aware of these findings. During a review of the report, it was noted that there were additional Major drug to food interactions identified. There was no documented evidence that the Physician had been notified of these additional findings as instruction per the agency's policy. P-3: The patient's SOC was 3/13/24 with diagnoses that included Repeated Falls and Sarcopenia. During the record review on 4/16/24 at 2:30 p.m., it was noted that section M2001 of the comprehensive assessment stated, "No issues found during review." A drugs.com interaction report conducted by the agency identified major drug to food interactions and duplicate drug therapy. There was no documented evidence that the Physician had been promptly notified of these findings. P-4: The patient's SOC was 4/10/24 with diagnoses that included Abdominal Pain, Joint Pains and Weakness. During the record review on 4/16/24 at 2:00 p.m., it was noted that section M2001 of the comprehensive assessment stated, yes, issues found during review. A drug interaction report conducted by the agency, revealed 3 major drug-to-drug interactions. The report also included 2 Major drug-to-food interactions that had not been reported to the Physician as instructed in the agency's policy. The above findings were reviewed with and confirmed by the Alternate Clinical Manager during an interview on 4/17/24 at 2:00 p.m. who stated, "I only report the Major drug-to-drug interactions to the Physician. I didn't report the major drug to food interactions." These findings were also discussed with and acknowledged by the Administrator during an interview on 4/17/24 at 3:30 p.m.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure the physical therapist followed standards of practice per agency policy to prevent the transmission of infections and communicable diseases for 1 (P-6) of 3 patients with whom a joint home visit was conducted potentially resulting in the spread of infectious agents to all current patients seen by the physical therapist. Findings include: Agency policy titled “Exposure Control Plan: OSHA Regulations” (undated), was reviewed on 4/18/24. On page 3., it stated “Patient equipment must be cleaned after patient use with cleaning supplies that contain between 60%-90% alcohol for antisepsis and disinfection of equipment.” P-6: This 92-year-old was admitted to agency on 3/14/24 with diagnoses which included osteoarthritis in both hips; intervertebral disc degeneration; and high blood pressure. On 4/16/24 a joint home visit was conducted along with the physical therapist (PT) at 1 p.m. During the visit, the PT retrieved a thermometer, blood pressure cuff, pulse oximeter, and a squeezable hand exercise ball from a bag brought into the home by the PT. After the equipment described above was used with the patient, the PT rubbed each piece with a hand sanitizer product before placing back into the bag. After the visit, the PT was queried to what product was to be used for disinfection of equipment and she stated that she used the hand sanitizer to clean shared equipment. On 4/18/24 at 9:00 a.m., the Administrator (Staff A) was queried as to their policy regarding using a product labeled for use on hands and the disinfection process of shared patient equipment. Staff A stated that staff should not be using a product labeled for use on hands for disinfection of equipment, and they should be using a 60%-90% alcohol product which is labeled for use on equipment.

Development and evaluation of plan of care CFR(s): 484.75(b)(2) Development and evaluation of the plan of care in partnership with the patient, representative (if any), and caregiver(s); This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the Physical Therapist assisted the physician in evaluating the patient's level of function and helped to develop the plan of care for 1 (P-4) record in which Physical Therapy services were ordered, from a total sample of 7 records reviewed, resulting in the potential for decline in physical functioning and unmet care needs. Findings include: P-4: The patient's start of care was 4/10/24 with diagnoses that included Abdominal pain, Joint Pains and Weakness. The referral for home care, dated 4/3/24, ordered Skilled Nursing (SN) and Physical Therapy (PT) services to be provided. At the time of this clinical record review on 4/16/24 at 2:00 p.m., the Physical Therapy evaluation had not yet been conducted. On 4/15/24, during the Entrance Conference, the Administrator was asked of his expectation of when disciplines (PT) should conduct their initial evaluation and reported, "All disciplines should conduct their evaluations within 48 hours of the date of the referral, unless the patient requests a different date." The Physical Therapist failed to conduct the Therapy evaluation as ordered by the Physician. These findings were reviewed with and acknowledged by the Administrator during an interview on 4/17/24 at 2:00 p.m.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, it was determined that the Agency failed to ensure services were provided as ordered in the Plan of Care for 1 (P-2) of 1 patient observed during a home visit, who required cardiovascular and diabetic monitoring, and 2 patients (P#'s 1, 3) who required Occupational Therapy services, from a total of 7 sampled records reviewed, resulting in the potential for unidentified health concerns, physiological decline and unmet care needs. Findings include: P-2: The patient's start of care (SOC) was 2/29/24 with diagnoses that included Surgical Aftercare (Pacemaker implant) Congestive Heart Failure and Diabetes Mellitus. The Plan of Care (POC) ordered Skilled Nursing (SN) services to assess skin for breakdown every visit, perform finger stick for fasting blood sugar/random blood sugar during visit if it has not been done, perform inspection of patient's lower extremities every visit and report any alteration in skin integrity to Physician, instruct patient on daily weight self-monitoring. On 4/16/24 a scheduled survey home visit was conducted with the Skilled Nurse (RN #1). During the visit, RN #1 failed to perform any of the above ordered assessments. After the visit, the patient stated that he hasn't checked his blood sugars. When asked to clarify, the patient stated he has not checked, nor had his blood sugars checked since being a patient with this agency. During the visit, RN #1 asked the patient if he weighed himself, to which the patient responded, "Yes." The nurse did not inquire of the patient's weight or assess any possible weight log to determine the patient's health status. Additionally, RN #1 did not assess the patient's left chest wall pacemaker surgical site or lower extremities for possible edema. The nurse failed to provide care and services in accordance with the POC and Physician's orders. Upon completion of the visit, RN #1 was queried about not following the POC with regard to skin assessment, blood sugars and weights and replied, "That falls on me..." These findings were reviewed with and acknowledged by the Administrator during an interview on 4/16/24 at 12:00 p.m. who responded, "I'll have to review it and see where we went wrong. It's expected that all disciplines follow the plan of care." P-1: The patient's SOC was 12/7/23 with diagnoses that included Neck and Rib Fracture and Impaired Mobility. The referral for home care dated 12/6/23 ordered Occupational Therapy (OT) services to be provided. On 4/15/24 during the Entrance Conference, the Administrator reported that disciplines are expected to see the patient within 48 hours of the date of the referral, unless the patients decline services, or request a different date of service. At the time of the record review on 4/15/24, it was noted that the Occupational Therapist did not conduct the initial evaluation until the 3rd week of services. There was no acceptable, documented rationale for the delay in needed services. The OT did not provide care and services in accordance with the POC. These findings were reviewed and confirmed by the Administrator during an interview on 4/17/24 at 3:11 p.m., and again on 4/18/24 at 11:33 a.m. P-3: The patient's SOC was 3/13/24 with diagnoses that included Repeated Falls and Sarcopenia. The referral for home care was dated 3/13/24 and ordered SN, OT and Physical Therapy (PT) services to be provided. During the clinical record review on 4/16/24 at 2:30 pm., it was noted that OT did not conduct the initial evaluation until the 2nd week of services, 8 days after the date of the referral. There was no documented rationale for delay in needed services. The OT did not provide care and services in accordance with the POC. These findings were reviewed with and acknowledged by the Administrator during an interview on 4/17/24 at 3:40 p.m. and 4/18/24 at 11:46 a.m.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a completed discharge summary was sent to the physician within 5 days of the patient's date of discharge in 3 (P#'s 7, 1, 3) records in which the patient was discharged from the agency, resulting in a lack of health information available to the physician for continuity of care. Findings include: Policy: DISCHARGE SUMMARY, undated stated, "A discharge Summary will be completed for all patients discharged from the Agency. The Skilled Nurse, Medical Social worker and/or Therapist will complete Discharge Summary form for all patients." [sic] P-1: The patient's start of care (SOC) was 12/7/23 with diagnoses that included Fractured Neck and Rib and Impaired Mobility. During the clinical record review on 4/15/24, it was noted that the Plan of Care (POC) ordered Skilled Nursing (SN), Physical therapy (PT) and Occupational Therapy (OT) services to be provide. The patient was discharged from SN services on 12/13/23. The SN summary documented "Physician notified of discharge summary availability." There was no documented evidence that the summary was sent to the Physician within 5 days of the date of discharge. The patient was discharged from OT services on 12/20/23 and discharged from PT and the agency's services on 1/16/24. There was no documented evidence that either summary was sent to the Physician within 5 days of the date of discharge. These findings were reviewed with the Administrator during an interview on 4/17/24 at 3:11 p.m. who reported, "We created this process where we created a log so whenever the summaries are sent to the Physician, we put an initial." The Administrator presented a log of typed patient names and dates of when discharge summaries were reportedly sent to the Physician. The typed list was void of this patient's name. There was no documented evidence that the discharge summaries were forwarded to the Physician within 5 days of the dates of discharge. P-3: The patient's SOC was 3/13/24 with diagnoses that included Repeated Falls and Sarcopenia. The POC ordered SN, PT and OT services to be provided. On 4/16/24 at 3:30 p.m., during a review of the clinical record it was noted that the patient was discharged from SN services on 4/2/24. The SN Discharge Summary dated 4/2/24 was void of a summary which detailed the course of care provided with responses and the health status of the patient at the time of discharge. The section titled "Care Summary" was left blank. Further, there was no documented evidence that the summary had been forwarded to the Physician within 5 days of the date of discharge. On 4/17/24 at 3:40 p.m., the Administrator provided a document with typed patient names and stated this is the system used to document if the discharge summaries had been forwarded to the Physician. After review, it was noted that this patient's name was in fact on the list, however, there were no entries to support that the summary was sent to the Physician. These findings were again reviewed with and acknowledged by the Administrator during an interview on 4/18/24 at 11:46 a.m. Agency policy titled “Discharge Summary” (undated), was reviewed on 4/18/24. On the one-page policy, it stated “A Discharge Summary will be completed for all patients discharged from the Agency… The original Discharge Summary form from each service will be filed in the medical record. The physician or health care practitioner will be sent a copy of the Discharge Summary within 5 days of discharge.” P-7: This 68-year-old was admitted to agency on 8/8/23 with diagnoses of Type 2 Diabetes with foot ulcer; chronic ulcer to left foot; and diabetic polyneuropathy (nerve damage that occurs from being diabetic). The medical record was reviewed on 4/15/24. Physical Therapy (PT) made scheduled visits to the patient as ordered beginning 8/15/23 and completed a discharge Outcome and Assessment Information Set (OASIS) on 9/25/23. There was no document titled “Discharge Summary” found in the medical record. There was no documented evidence in the medical record that a discharge summary had been sent to the physician. During interview on 4/18/24 at 12:35 p.m., the Administrator (Staff A) was queried as to whether a completed discharge summary was sent to the physician within 5 days of the discharge. Staff A stated that the agency either sends or hands the discharge summary to the physician, and the agency kept track of this with a home-made tracking tool. The tracking tool provided did not show discharges from 2023. Staff A was queried about where the discharge summary was in the medical record. Staff A stated that the OASIS included a section called “Discharge Summary” and that data was sent/handed to the physician but was not able to identify the exact sections that were provided to the physician, and was unable to provide evidence that the information was sent/handed to the physician within 5 days of discharge. Agency policy titled “Discharge Summary” (undated), was reviewed on 4/18/24. On the one-page policy, it stated “A Discharge Summary will be completed for all patients discharged from the Agency… The original Discharge Summary form from each service will be filed in the medical record. The physician or health care practitioner will be sent a copy of the Discharge Summary within 5 days of discharge.” P-7: This 68-year-old was admitted to agency on 8/8/23 with diagnoses of Type 2 Diabetes with foot ulcer; chronic ulcer to left foot; and diabetic polyneuropathy (nerve damage that occurs from being diabetic). The medical record was reviewed on 4/15/24. Physical Therapy (PT) made scheduled visits to the patient as ordered beginning 8/15/23 and completed a discharge Outcome and Assessment Information Set (OASIS) on 9/25/23. There was no document titled “Discharge Summary” found in the medical record. There was no documented evidence in the medical record that a discharge summary had been sent to the physician. During interview on 4/18/24 at 12:35 p.m., the Administrator (Staff A) was queried as to whether a completed discharge summary was sent to the physician within 5 days of the discharge. Staff A stated that the agency either sends or hands the discharge summary to the physician, and the agency kept track of this with a home-made tracking tool. The tracking tool provided did not show discharges from 2023. Staff A was queried about where the discharge summary was in the medical record. Staff A stated that the OASIS included a section called “Discharge Summary” and that data was sent/handed to the physician but was not able to identify the exact sections that were provided to the physician, and was unable to provide evidence that the information was sent/handed to the physician within 5 days of discharge. Policy: DISCHARGE SUMMARY, undated stated, "A discharge Summary will be completed for all patients discharged from the Agency. The Skilled Nurse, Medical Social worker and/or Therapist will complete Discharge Summary form for all patients." [sic] P-1: The patient's start of care (SOC) was 12/7/23 with diagnoses that included Fractured Neck and Rib and Impaired Mobility. During the clinical record review on 4/15/24, it was noted that the Plan of Care (POC) ordered Skilled Nursing (SN), Physical therapy (PT) and Occupational Therapy (OT) services to be provide. The patient was discharged from SN services on 12/13/23. The SN summary documented "Physician notified of discharge summary availability." There was no documented evidence that the summary was sent to the Physician within 5 days of the date of discharge. The patient was discharged from OT services on 12/20/23 and discharged from PT and the agency's services on 1/16/24. There was no documented evidence that either summary was sent to the Physician within 5 days of the date of discharge. These findings were reviewed with the Administrator during an interview on 4/17/24 at 3:11 p.m. who reported, "We created this process where we created a log so whenever the summaries are sent to the Physician, we put an initial." The Administrator presented a log of typed patient names and dates of when discharge summaries were reportedly sent to the Physician. The typed list was void of this patient's name. There was no documented evidence that the discharge summaries were forwarded to the Physician within 5 days of the dates of discharge. P-3: The patient's SOC was 3/13/24 with diagnoses that included Repeated Falls and Sarcopenia. The POC ordered SN, PT and OT services to be provided. On 4/16/24 at 3:30 p.m., during a review of the clinical record it was noted that the patient was discharged from SN services on 4/2/24. The SN Discharge Summary dated 4/2/24 was void of a summary which detailed the course of care provided with responses and the health status of the patient at the time of discharge. The section titled "Care Summary" was left blank. Further, there was no documented evidence that the summary had been forwarded to the Physician within 5 days of the date of discharge. On 4/17/24 at 3:40 p.m., the Administrator provided a document with typed patient names and stated this is the system used to document if the discharge summaries had been forwarded to the Physician. After review, it was noted that this patient's name was in fact on the list, however, there were no entries to support that the summary was sent to the Physician. These findings were again reviewed with and acknowledged by the Administrator during an interview on 4/18/24 at 11:46 a.m.

On 4/20/21 through 4/23/21, an Emergency Preparedness Survey was conducted by the Michigan Department of Licensing and Regulatory Affairs. At the survey, Care First Home Health Services was found in substantial compliance with the requirements for participation in Medicare/Medicaid at 42 CFR 484.102, Emergency Preparedness.

The following standard and condition level deficiencies were identified during an authorized Medicare recertification survey concurrent with a Focused Infection Control Covid-19 survey conducted on 4/20/2021 through 4/23/2021 by the Michigan Department of Licensing and Regulatory Affairs at: Care First Home Health Services 1000 John R Rd, Suite 205 Troy, MI 48083 At the time of the survey, the agency did not operate any branch locations. The services the agency provides are: Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), Medical Social Work (MSW) Dietician (RD) and Speech Therapy (ST). Clinical records reviewed for this survey included: 3 records with home visits and 4 records without home visits, for a total of 7 records reviewed. Condition level deficiencies were identified at: 42 CFR§484.75 Skilled Professional Services 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).

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 to determine the immediate care needs of the patient, including homebound status for 1 of 4 (MR#4) records reviewed in which both skilled nursing and therapy services were ordered, resulting in the potential for unmet nursing care needs. Findings include: MR#4: This patient was admitted to the agency on 2/27/21. The patient was discharged from the hospital on 2/22/21 after undergoing a surgical revision of a dialysis fistula on the left arm with post-operative complications of low blood pressure, chest pain, and hemorrhagic anemia. During record review on 4/21/21, it was noted that the hospital referral for home care instructed the agency to provide nursing, physical therapy, and occupational therapy for this patient. The clinical record also contained a physician order dated 2/22/21 that stated, Ref (referral) to home health care evaluate for nursing care and PT (physical therapy) evaluate and care...status post revision of fistula left arm. The initial assessment visit was conducted by PT-D (physical therapist) on 2/27/21. The agency's policy titled, Plan of Care (revised 2018) states, the initial assessment is to be made by a registered nurse or qualified physical therapist...In certain circumstances, when the patient's physician has ordered only therapy services, the appropriate therapist...may perform the initial assessment. Record review indicates the hospital referral instructed the agency to provide nursing care and the physician ordered nursing care and PT evaluations of this patient. The registered nurse should have conducted the initial assessment visit and not the physical therapist. The findings were reviewed with Admin-A (administrator/occupational therapist) during an interview on 4/21/21 at 1:30 p.m. Admin-A reviewed the medical record and stated the patient had declined nursing services. There was no documented evidence the patient declined nursing services and no documentation to indicate the physician was informed that nursing services were not provided as ordered.

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 ensure the comprehensive assessment accurately reflected the patient's current health status for 4 of 7 (MR# 4, 5, 6, and 7) records reviewed, resulting in incomplete clinical information to aid in determining the needs of this patient and for measuring the patient's progress toward goals/outcomes. Findings include: MR#4: This patient was admitted to the agency on 2/27/21. The patient was discharged from the hospital on 2/22/21 after undergoing a surgical revision of a dialysis fistula on the left arm with post-operative complications of low blood pressure, chest pain, and hemorrhagic anemia. During record review on 4/21/21, it was noted that the comprehensive assessment completed by PT-D (physical therapist) on 2/27/21 failed to document the status of the patient's fistula revision on the left arm. There was no documentation to indicate whether the surgical revision was located on the upper or lower left arm. There was no documentation to indicate if the wound was healed or if there was a dressing. There were no wound care orders. There was no documented assessment of the patient's left arm fistula revision. The agency failed to follow its own policy titled, Admission Policy (revised 2018) which states, the physical assessment will include client's current complaints, past, and present health status. PT-D failed to document an assessment of the current status of the patient's left arm fistula revision. These findings were reviewed with and acknowledged by Admin-A during an interview on 4/21/21 at 1:30 p.m. MR#5: The Start of Care (SOC) was dated 8/31/20. The Plan of Care (POC) identified diagnoses of Congestive Heart Failure (CHF), Diabetes Type 2, and Respiratory Failure. During record review on 4/21/21, it was noted that the SOC comprehensive assessment dated 8/31/20, documented under "Primary Diagnosis and Other Diagnoses", all 17 diagnoses had the same date of exacerbation documented, 8/31/20. No onset, prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. Furthermore, Diabetes Type 2 documented a "symptom control" of 3 which states, "Symptoms poorly controlled; patient needs frequent adjustment in treatment and dose monitoring." Under the "Endocrine" section of the comprehensive assessment, the SN documented, "pt (patient) is stable with diet and exercise, no oral medications or insulin, pt is not required to check blood glucose levels, physician monitors with blood draws." The agency failed to accurately document symptom severity. MR#6: The Start of Care (SOC) was dated 3/11/21. The Plan of Care (POC) identified diagnoses of Spondylosis of Lumbar Region, Osteoarthritis, and Falls. During record review on 4/21/21, it was noted that the SOC comprehensive assessment dated 3/11/21, documented under "Primary Diagnosis and Other Diagnoses", all 18 diagnoses had the same date of exacerbation documented, 3/11/21. No onset, prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. MR#7: The Start of Care (SOC) was dated 10/22/20. The Plan of Care (POC) identified diagnoses of Spinal Stenosis and Chronic Kidney Disease (CKD). During record review on 4/20/21, it was noted that the SOC comprehensive assessment dated 10/22/20, documented under "Primary Diagnosis and Other Diagnoses", all 13 diagnoses had the same date of exacerbation documented, 10/22/20 No onset, prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. The Admin-A was questioned on 4/23/21 at 9:45 am and confirmed the findings stating, "We use an outside coding company, I will have to talk with them regarding the diagnoses."

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 a registered nurse conducted a review of the patient's medications for any potential adverse effects such as: side effects, drug interactions, and duplicate drug therapy for 2 of 4 (MR# 2, 4) records reviewed with therapy only services. This deficient practice results in the potential for unrecognized adverse effects due to medications that could negatively affect all 14 current patients. Findings include: MR#2: This patient was admitted to the agency on 3/2/21 with diagnoses of pleural effusion (excess fluid surrounding the lungs), weakness, and heart disease. The comprehensive assessment was conducted by PT-E (physical therapist) on 3/2/21. Record review on 4/20/21, indicates the patient's record contained a "Drug Interaction Report" (Drugs.com) acknowledged and signed by Admin-A (Administrator/occupational therapist) on 3/2/21. During an interview on 4/20/21 at 4:00 p.m., Admin-A explained that he had run the Drugs.com interaction report and that he informed the physician of the one major drug interaction noted in the report. There was no documented evidence that the patient's medications had been reviewed by a registered nurse (RN). Admin-A confirmed that the list of medications were not reviewed by an RN. MR#4: This patient was admitted to the agency on 2/27/21 with diagnoses of low blood pressure and end stage renal disease. The comprehensive assessment was completed by PT-D (physical therapist) on 2/27/21. Record review on 4/21/21, indicates the patient's record contained a "Drug Interaction Report" (Drugs.com) acknowledged and signed by Admin-A on 2/27/21. During an interview on 4/21/21 at 1:30 p.m., Admin-A explained that he had run the Drugs.com interaction report and that he informed the physician of the one major drug interaction noted in the report. Admin-A confirmed that the list of medications were not reviewed by an RN. The agency's policy titled, Clinical Records (revised 2018) states, Review of Medications: The staff reviews all medications the patient is currently using...For therapy only cases, the therapist submits a list of medications, which he/she collects during the comprehensive assessment to an agency nurse for review. There was no documented evidence that the patient's medications had been reviewed by a registered nurse. The physical therapist and Admin-A failed to follow agency policy and ensure the patient's medications were reviewed by an RN.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, it was determined that the Agency failed to provide care and services in accordance with the plan of care in 1 (MR's #5) of 7 records reviewed, resulting in unmet care needs and an increase in wound size. Findings include: Policy: "Plan of Care" Undated stated, "Plan of Care Contents. 5. The frequency and duration of visits to be made." MR#5: The Start of Care (SOC) was dated 8/31/20. The Plan of Care (POC) identified diagnoses of Congestive Heart Failure (CHF), Diabetes Type 2, and Respiratory Failure. The POC ordered Skilled Nursing (SN) 1w8 (1 time a week for 8 weeks). The recertification on 10/30/20 ordered SN 1w6 and later ordered to extend through the certification period and recertify. Furthermore, the recertifications on 12/29/20 and 2/27/21 ordered SN 1w9 and 1w8. During record review on 4/21/21, it was noted that the SN missed visits on 9/17/20, 10/16/20, 11/11/20, 3/11/21 and 4/1/21. Following the missed visit on 10/16/20, the SN documented, "New wound identified to patients left posterior lower leg. Nurse educated patient on how wounds form and how to treat. Nurse cleansed both wounds with wound cleanser, applied calmoseptine and applied border gauze." On 11/6/20, the SN documented, "Left buttock 0.7 x 0.6 x 0.1." (centimeters). The following week, on Wednesday, 11/11/20 the SN documented a "missed visit" order stating, "Unable to coordinate care, patient refused times available." On 11/20/20, 9 days after the missed visit, the SN documented, "Left buttock 1.2 x 1.0 x 0.1." (centimeters). This surveyor calculated the wound surface area, and it went from 0.42cm on 11/6/20 to 1.2cm on 11/20/20, more than doubling the wounds surface area. There were no documented attempts made to honor the ordered visit frequencies and the patients wound deteriorated subsequently. The Agency failed to provide care and services in accordance with the plan of care. The Admin-A was questioned on 4/23/21 at 9:45 am and confirmed the findings stating, "The visit frequency was not met as ordered."

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the plan of care included all pertinent diagnoses, patient-specific safety measures, interventions, and education for 1 of 7 (MR# 4) records reviewed, resulting in the potential for a poor patient outcome. Findings include: MR#4: This 82-year-old patient was admitted to the agency on 2/27/21. The patient was discharged from the hospital on 2/22/21 after undergoing a surgical revision of a dialysis fistula on the left arm with post-operative complications of low blood pressure, chest pain, and hemorrhagic anemia. During record review on 4/21/21, it was noted that the plan of care (POC) failed to include the patient's fistula revision as a pertinent diagnosis and failed to note the date of the surgical procedure. The POC failed to include safety measures regarding the patient's dialysis fistula. Basic safety measures include no blood pressure readings or blood draws on the dialysis access arm. The POC failed to include any interventions regarding the fistula such as monitoring the blood flow through the fistula by touch ("thrill" sensation) and sound (listen for "bruit" with stethoscope). The patient resides in an assisted living facility. The POC failed to include education for the patient and caregivers at the facility. The findings were reviewed with and acknowledged by Admin-A (administrator) during an interview on 4/21/21 at 1:30 p.m.

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: Based on document review and interview, it was determined that the Agency failed to ensure the Registered Nurse followed accepted standards of practice in assuming responsibility for the care of 1 (MR #5) of 1 patient who required wound care management, from a total of 7 sampled patient records reviewed (see G704); failed to document weights for a Congestive Heart Failure patient and notify the physician of elevated edema and pain levels in 1 record, from a total of 7 sampled records reviewed (MR's #5) (see G710); and failed to ensure the caregiver were provided wound care teaching/instructions for 1 of 1 record reviewed (MR's #5) with wound care (see G714). The cumulative effect of these systemic failures resulted in a hospitalization for unidentified patient needs; the possibility for decline in physical functioning and unmet care needs; and the physician not having a complete clinical picture of the patient's health status during the period of care.

Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This STANDARD is not met as evidenced by: Based on record review and interview, it was determined that the Agency failed to ensure the Registered Nurse followed accepted standards of practice in assuming responsibility for the care of 1 (MR #5) of 1 patient who required wound care management, from a total of 7 sampled patient records reviewed, resulting in interruption in needed care and services and a poor patient outcome. Findings include: Policy: "Registered Nurse", undated, stated, "Provides skilled nursing care in accordance with the patient's plan of treatment, including comprehensive health and psychosocial evaluation, monitoring of the patient's condition, health promotion and prevention, coordination of service, teaching and training activities, provision of direct nursing care, and planning for patient's needs or service requests." MR#5: The Start of Care (SOC) was dated 8/31/20. The Plan of Care (POC) identified diagnoses of Congestive Heart Failure (CHF), Diabetes Type 2, and Respiratory Failure. The POC ordered Skilled Nursing (SN) at a frequency of 1w9 (1 time a week for 9 weeks). During record review on 4/21/21, it was noted that the Comprehensive Assessment completed by the SN on 8/31/20 documented, "+1 BLE (bilateral lower extremity) edema. The following weeks the RN documented BLE edema as 9/9/20 +2, 9/25/20 +3, 9/29/20 +3, 10/9/20 +3 and 10/23/20 +3. The RN documented two missed visits for 9/17/20 stating, "Patient refused visit this week" and 10/16/20 stating, "Patient refused visit this week, wants to wait until next week." On 10/23/20, the SN documented, "+3 BLE edema ...New wound identified to patients left posterior lower leg .... Nurse cleansed both wounds with wound cleanser, applied calmoseptine and applied bordered gauze." Additionally, the Comprehensive Assessment was the only visit with a documented weight. During the entrance interview on 4/20/21 at 10:30 am, Admin-A was questioned regarding CHF and stated, "We document weights for CHF patients every visit." The agency failed to document weights for CHF patients every visit. There was no documented coordination with the physician regarding the patients increased BLE edema prior to the documented new wound on 10/23/20. Additionally, there was no measurements of the two wounds, the left posterior lower leg wound or where the second wound was located. The patient was recertified on 10/29/20 with a SN frequency of 1w6 and primary diagnosis of Stage 2 Pressure Ulcer and wound care order stating, "Left leg and left buttock: Clean wound with normal saline or wound cleanser; apply calmoseptine ointment and cover with border dressing each visit." The SN documented, "left buttock ... 1.0x0.7x0.1 ...left post. (posterior) leg ... 1.0x1.0x0.1." The SN documented on the following visit on 11/6/20, "left buttock ... 0.7x0.6x0.1 ... left post. leg ... 0.3x0.3x0.1." On Wednesday 11/11/20, the SN documented a missed visit stating, "Unable to coordinate care patient refused times available." There were no documented attempts to complete the ordered visit the rest of the week. The following SN visit on 11/20/20 the left buttock wound was documented, "1.2x1.0x0.1 .... wound was not covered when nurse assessed." The wound increased in surface area of 0.42 on 11/6/20 to 1.2 on 11/20/20, nearly 3 times increase in size. Furthermore, under the "Intervention" section of the recertification assessment completed on 10/29/20, there is no checkmark for "SN to instruct Patient/Caregiver on wound care as follows:" for this patient that resides in an assisted living facility. The facility failed to notify the physician regarding the increase in BLE edema which resulted in a new lower leg wound, educate the assisted living facility staff in wound care to prevent an increase in the left buttock wound due to a missed visit that was not attempted to be completed. The Admin-A was questioned on 4/23/21 at 10:15 am and confirmed the findings stating, "Yes, the left buttock wound did increase from the week prior to the missed visit to the week after. The nurse should have contacted the physician regarding the increase in edema and weigh the patient every visit."

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 document weights for a Congestive Heart Failure patient and notify the physician of elevated edema and pain levels in 1 record, from a total of 7 sampled records reviewed (MR's #5), resulting in the physician not having a clear and concise clinical picture of the patient's health status, progression towards goals, unmet needs and a poor outcome. Findings include: MR#5: The Start of Care (SOC) was dated 8/31/20. The Plan of Care (POC) identified diagnoses of Congestive Heart Failure (CHF), Diabetes Type 2, and Respiratory Failure. The POC ordered Skilled Nursing (SN) at a frequency of 1w9 (1 time a week for 9 weeks). During record review on 4/21/21, it was noted that the Comprehensive Assessment completed by the SN on 8/31/20 documented, "+1 BLE (bilateral lower extremity) edema. The following weeks the RN documented BLE edema as 9/9/20 +2, 9/25/20 +3, 9/29/20 +3, 10/9/20 +3 and 10/23/20 +3. The RN documented two missed visits for 9/17/20 stating, "Patient refused visit this week" and 10/16/20 stating, "Patient refused visit this week, wants to wait until next week." On 10/23/20, the SN documented, "+3 BLE edema ...New wound identified to patients left posterior lower leg .... Nurse cleansed both wounds with wound cleanser, applied calmoseptine and applied bordered gauze." Additionally, it was noted the SN failed to document the patient's weight on 9/9/20, 9/25/20, 9/29/20, 10/9/20, 10/23/20, recertification on 10/29/20, 11/6/20, 11/20/20, 11/25/20, 12/4/20, 12/10/20, 12/17/20, recertification on 12/28/20, 1/7/21, 1/14/21, 1/21/21, 1/28/21, 2/4/21, 2/11/21, 2/16/21, 3/4/21, 3/16/21, 3/25/21, 4/8/21, and 4/15/21. During the entrance interview on 4/20/21 at 10:30 am, Admin-A was questioned regarding CHF and stated, "We document weights for CHF patients every visit." The agency failed to document weights for CHF patients every visit. Furthermore, it was noted the POC ordered, "Call Orders: SN to notify physician of findings outside of agency standard vital sign parameters: ...Pain level >8 ..." On 11/6/20, 11/20/20 and 1/21/21, the Skilled Nurse (SN) documented 9 under "Pain Intensity." The section regarding "Physician Contact Re:" was blank for all three visits. There was no documented evidence the SN notified the Physician as ordered in the POC. These findings were reviewed with and acknowledged by Admin-A during an interview on 4/23/21 at 10:20 am.

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient and caregiver were provided wound care teaching/instructions for 1 of 1 record reviewed (MR's #5) with wound care, for a potential of improper wound care and unmet care needs. Findings include: MR#5: The Start of Care (SOC) was dated 8/31/20. The Plan of Care (POC) identified diagnoses of Congestive Heart Failure (CHF), Diabetes Type 2, and Respiratory Failure. During record review on 4/21/21, it was noted that the patient was recertified on 10/29/20 with a SN frequency of 1w6 and primary diagnosis of Stage 2 Pressure Ulcer and wound care order stating, "Left leg and left buttock: Clean wound with normal saline or wound cleanser; apply calmoseptine ointment and cover with border dressing each visit." Under the "Intervention" section of the recertification assessment completed on 10/29/20, there is no checkmark for "SN to instruct Patient/Caregiver on wound care as follows:" for this patient that resides in an assisted living facility. On 10/29/20, the SN documented, "left buttock ... 1.0x0.7x0.1 ...left post. (posterior) leg ... 1.0x1.0x0.1." The SN documented on the following visit on 11/6/20, "left buttock ... 0.7x0.6x0.1 ... left post. leg ... 0.3x0.3x0.1." On Wednesday 11/11/20, the SN documented a missed visit stating, "Unable to coordinate care patient refused times available." There were no documented attempts to complete the ordered visit the rest of the week. The following SN visit on 11/20/20 the left buttock wound was documented, "1.2x1.0x0.1 .... wound was not covered when nurse assessed." The agency failed to educate the caregivers on order wound care if the nurse was unable to complete the ordered visit schedule. These findings were reviewed with and acknowledged by Admin-A during an interview on 4/23/21 at 10:20 am.

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 record review and interview, the agency failed to ensure clinical notes were accurate for 2 of 7 (MR#4 and 5) records reviewed, resulting in the potential to negatively affect the health and well-being of these patients. Findings include: MR#4: This patient was admitted to the agency on 2/27/21. The patient was discharged from the hospital on 2/22/21 after undergoing a surgical revision of a dialysis fistula on the left arm with post-operative complications of low blood pressure, chest pain, and hemorrhagic anemia. During record review on 4/21/21, it was noted that PT-D (physical therapist) documented on 8 of 9 clinical notes (dated 2/27/21 through 4/13/21) that blood pressure (BP) readings were measured on the patient's left arm, the arm with the recently revised dialysis fistula. PT-D documented in 6 of 9 clinical notes (dated 3/6/21 through 4/13/21) that BP readings were measured on the left arm twice each visit, once prior to treatment and once post treatment. This practice is not advised as a course of treatment or procedure. Basic safety measures indicate no blood pressure readings or blood draws on the dialysis access arm. These findings were reviewed with Admin-A (administrator) during an interview on 4/21/21 at 1:30 p.m. Admin-A acknowledged that BP readings are not to be obtained on this patient's left arm. A joint phone interview was conducted with Admin-A and PT-D on 4/21/21 at 2:05 p.m. PT-D states that he always takes the BP readings on the right arm for this patient due to the fistula and that he must have made errors in the documentation. A phone interview was conducted with MR#4 on 4/22/21 at 11:15 a.m. MR#4 states that PT-D does BP readings on her right arm only and she will not let anyone touch her left arm because of the dialysis fistula. PT-D failed to accurately document BP readings in 8 of 9 clinical notes. MR#5: The Start of Care (SOC) was dated 8/31/20. The Plan of Care (POC) identified diagnoses of Congestive Heart Failure (CHF), Diabetes Type 2, and Respiratory Failure. During record review on 4/21/21, it was noted the Skilled Nurse (SN) failed to document the patient's weight on 9/9/20, 9/25/20, 9/29/20, 10/9/20, 10/23/20, recertification on 10/29/20, 11/6/20, 11/20/20, 11/25/20, 12/4/20, 12/10/20, 12/17/20, recertification on 12/28/20, 1/7/21, 1/14/21, 1/21/21, 1/28/21, 2/4/21, 2/11/21, 2/16/21, 3/4/21, 3/16/21, 3/25/21, 4/8/21, and 4/15/21. During the entrance interview on 4/20/21 at 10:30 am, Admin-A was questioned regarding CHF and stated, "We document weights for CHF patients every visit." The agency failed to document weights for CHF patients every visit.