Every finding on record at Care First Homecare, LLC

A recertification survey for Emergency Preparedness was conducted by the Michigan Department of Licensing and Regulatory Affairs, on 4/1/24 through 4/4/24 at: Axiom Home Care 12815 Northline Rd. Southgate, MI 48195 At the time of the survey, the agency did not operate any branch offices or subunits. At the survey's conclusion, the agency was found to be in substantial compliance (standard citation) with the requirements for participation in Medicare/Medicaid at 42 CFR §484.102, Emergency Preparedness.

A Medicare recertification survey was conducted by the Michigan Department of Licensing and Regulatory Affairs from 4/1/24 through 4/4/24 at: Axiom Home Care 12815 Northline Rd. Southgate, MI 48195 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.

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment was completed within 5 calendar days of the start of care in 1 (P-9) of 17 records reviewed, resulting in a delay in determining the immediate care and support needs for this patient. P-9: This 91-year-old patient was admitted to home care on 2/17/24 with diagnoses of pressure ulcer and type 2 diabetes. During record review on 4/3/24, it was noted that the physician order for home care, dated 2/21/24, ordered OT (occupational therapy) and PT (physical therapy) evaluation and treatment. PT evaluated the patient on 2/18/24. OT evaluated the patient on 2/24/24, eight days after the start of care. This finding was reviewed and acknowledged by the clinical director (Staff B) and assistant administrator (Staff C) during an interview on 4/4/24 at 11:50 a.m.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient’s clinical record documented all medications, failed to ensure the comprehensive assessment included a review of all medications to determine any potential adverse effects, and failed to ensure the physician was notified of potential drug interactions for 5 (P-1, 2, 6, 9, 12) of 17 records reviewed. This deficient practice results in the potential for unrecognized medication side effects and drug interactions that could affect all patients serviced by the agency. Findings included: **Agency policy "Medication Reconciliation" (Medications Implemented 2023) stated, "Policy: The Agency will reconcile patient’s medications at time of admission and on an ongoing basis. Standards and Guidelines 1. At time of admission, the admitting RN, PT, or SLP will create and document a complete list of medications that the patient is taking at home, including dose, route, and frequency.” P-12: The Start of Care (SOC) was dated 3/1/24. The Plan of Care (POC) identified diagnoses of Sarcopenia, Muscle Weakness and Hypertension. During record review on 4/2/24, it was noted that the medical record failed to contain a documented list of the patient’s medications, thus potentially having poor patient outcomes. These findings were reviewed with and acknowledged by the Staff-B (Clinical Director) and Staff-C (Assistant Administrator) during an interview on 4/4/24 at 10:00 am. Agency Policy: Assessments: Initial Comprehensive (dated 2023). Drug Regimen Review: Each patient’s comprehensive assessment includes a review of all medications the patient is currently taking…to identify side effects, drug interactions, noncompliance with medications, duplicate therapy, ineffective therapy, potential adverse effects, medication reactions, significant medication issues, omissions, dosage errors, management of oral and injectable medications. Medication Reconciliation must be completed and for all major drug interactions must include documentation of physician notification. P-1: This 70-year-old patient was admitted to home care on 7/8/23 with diagnoses of hypertensive heart disease with congestive heart failure and type 2 diabetes. During record review on 4/1/24, it was noted that the record failed to include evidence a medication reconciliation was completed. P-2: This 84-year-old patient was admitted to home care on 6/28/23 with diagnoses of type 2 diabetes and toxic encephalopathy. During record review on 4/1/24, it was noted that the record failed to include evidence a medication reconciliation was completed. P-6: This 89-year-old patient was admitted to home care on 1/24/24 with diagnoses of orthopedic aftercare and femur fracture. During record review on 4/2/24, it was noted that the start of care assessment dated 1/24/24 stated no issues found during drug regimen review (Section M2001) and the patient medication record stated there were no discrepancies and no interactions. A medication interaction report was generated using the agency’s electronic medical record (EMR) software that indicated the patient is taking furosamide and there was a drug/allergy check as patient is allergic to Zonegran (a sulfanomide). There was no evidence the physician was notified. P-9: This 91-year-old patient was admitted to home care on 2/17/24 with diagnoses of pressure ulcer and type 2 diabetes. During record review on 4/3/24, it was noted that the start of care assessment dated 3/1/24 stated no issues found during drug regimen review (Section M2001) and the patient medication record stated there were no discrepancies and no interactions. A medication interaction report was generated using the agency’s EMR software that indicated “intervention required” for diltiazem and simvastatin. There was no evidence the physician was notified. These findings were reviewed and acknowledged by the clinical director (Staff B) and assistant administrator (Staff C) during an interview on 4/4/24 at 11:50 a.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 the plan of care included appropriate interventions with objectively measurable goals specific to the individualized needs of the patient in 15 (P-1, 2, 4, 5, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17) of 17 records reviewed, resulting in the potential for poor patient outcomes and unmet care needs for these patients. Findings include: P-10: The Start of Care (SOC) was dated 2/15/24. The Plan of Care (POC) identified diagnoses of Chronic Respiratory Failure and Congestive Heart Failure. During record review on 4/3/24, it was noted that the goals on the POC were not measurable, for example the Skilled Nursing goals stated, "Patient will remain free from chest pain, or chest pain will be relieved with nitroglycerin, during the episode. The patient will be free from injury during the certification period." There was no evidence of how these goals could be quantitatively measured. P-11: The Start of Care (SOC) was dated 1/14/24. The Plan of Care (POC) identified diagnoses of Atrial Fibrillation, Congestive Heart Failure and Chronic Kidney Disease. During record review on 4/3/24, it was noted that the goals on the POC were not measurable, for example the Skilled Nursing goals stated, "Patient and caregiver will verbalized understanding of all medications 01/20/2024. Cardiac program: for CHF, cardiomyopathies." There was no evidence of how these goals could be quantitatively measured. P-12: The Start of Care (SOC) was dated 3/1/24. The Plan of Care (POC) identified diagnoses of Sarcopenia, Muscle Weakness and Hypertension. During record review on 4/2/24, it was noted that the goals on the POC were not measurable, for example the Skilled Nursing goals stated, "The patient will be free from injury during the certification period. Patient’s blood pressure will remain within established parameters during the episode, SN will instruct patient/caregiver on Cardiac Diet as prescribed by MD." There was no evidence of how these goals could be quantitatively measured. P-13: The Start of Care (SOC) was dated 11/22/23. The Plan of Care (POC) identified diagnoses of Cellulitis of Left Lower Limb, Muscle Weakness and Hypertension. During record review on 4/3/24, it was noted that the goals on the POC were not measurable, for example the Skilled Nursing goals stated, "Patient/caregiver will have clear understanding of each medication being taken/utilized. Patient’s skin will remain intact throughout episode." There was no evidence of how these goals could be quantitatively measured. P-14: The Start of Care (SOC) was dated 2/13/24. The Plan of Care (POC) identified diagnoses of Spondylosis, Parkinson’s and Hypertension. During record review on 4/3/24, it was noted that the goals on the POC were not measurable, for example the Skilled Nursing goals stated, "Patient will verbalize understanding of proper use of pain medication by end of cert. Patient skin integrity will remain intact during this episode." There was no evidence of how these goals could be quantitatively measured. P-15: The Start of Care (SOC) was dated 3/27/24. The Plan of Care (POC) identified diagnoses of Traumatic Brain Injury and Pelvic Fracture. During record review on 4/3/24, it was noted that the goals on the POC were not measurable, for example the Skilled Nursing goals stated, "The patient will verbalize understanding of symptoms of cardiac complications and when to call 911. Patient will verbalize understanding of all medications by discharge." There was no evidence of how these goals could be quantitatively measured. P-16: The Start of Care (SOC) was dated 5/17/23. The Plan of Care (POC) identified diagnoses of Diabetes Type 2, Chronic Obstructive Pulmonary Disease and Paraplegic. During record review on 4/1/24, it was noted that the goals on the POC were not measurable, for example the Skilled Nursing goals stated, "Patient/caregiver will remove all clutter from patient’s path, such as clothes, books, shoes, electrical cords, and other items that may cause patient to trip by end of cert. Patient will verbalize understanding of positive coping skills related to anxiety and/or depression." There was no evidence of how these goals could be quantitatively measured. P-17: The Start of Care (SOC) was dated 6/15/23. The Plan of Care (POC) identified diagnoses of Cerebral Infraction, Hypertension and Diabetes Type 2. During record review on 4/1/24, it was noted that the goals on the POC were not measurable, for example the Skilled Nursing goals stated, "Patient and caregiver will verbalize understanding of medication regimen, dose, route, frequency, indications, and side effects by 08/13/2023. Patient will be able to identify signs and symptoms of worsening symptoms of CVA." There was no evidence of how these goals could be quantitatively measured. These findings were reviewed with and acknowledged by the Staff-B (Clinical Director) and Staff-C (Assistant Administrator) during an interview on 4/4/24 at 10:00 am. P-1: This 70-year-old patient was admitted to home care on 7/8/23 with diagnoses of hypertensive heart disease with congestive heart failure and type 2 diabetes. During record review on 4/1/24, it was noted that the plan of care failed to include measurable nursing goals that are individualized to address patient needs. The plan of care contained the following goals, patient/caregiver will verbalize understanding of meds, side effects, uses, routes and patient/caregiver will verbalize understanding of seizure precautions. There was no evidence of how these goals could be objectively measured to determine progress toward meeting the goals. P-2: This 84-year-old patient was admitted to home care on 6/28/23 with diagnoses of type 2 diabetes and toxic encephalopathy. During record review on 4/1/24, it was noted that the plan of care failed to include measurable nursing goals that are individualized to address patient needs. The plan of care contained the following goals, patient/caregiver will be able to verbalize understanding of symptoms of cardiac complications and when to call 911 and the patient and caregiver will verbalize understanding of proper diabetic foot care. There was no evidence of how these goals could be objectively measured to determine progress toward meeting the goals. P-4: This 89-year-old patient was admitted to home care on 3/20/24 with diagnoses of hypertensive heart disease with congestive heart failure and chronic kidney disease. During record review on 4/2/24, it was noted that the plan of care failed to include measurable nursing goals that are individualized to address patient needs. The plan of care contained the following goals, improve patient safety and cardiac program for CHF, cardiomyopathies. There was no evidence of how these goals could be objectively measured to determine progress toward meeting the goals. P-5: This 81-year-old patient was admitted to home care on 3/23/24 with diagnoses of orthopedic aftercare and femur fracture. During record review on 4/2/24, it was noted that the plan of care failed to include measurable nursing goals that are individualized to address patient needs. The plan of care contained the following goals, patient/caregiver will be able to verbalize understanding of symptoms of cardiac complications and when to call 911 and patient and caregiver will verbalize understanding of all medications. There was no evidence of how these goals could be objectively measured to determine progress toward meeting the goals. P-7: This 82-year-old patient was admitted to home care on 3/1/24 with a diagnosis of hypertensive heart disease with congestive heart failure. During record review on 4/3/24, it was noted that the plan of care failed to include measurable nursing goals that are individualized to address patient needs. The plan of care contained the following goals, patient/caregiver will verbalize understanding of med safety, uses, indications, and side effects and caregiver will verbalize understanding of proper orientation techniques to use when patient becomes disoriented. There was no evidence of how these goals could be objectively measured to determine progress toward meeting the goals. P-8: This 61-year-old patient was admitted to home care on 3/13/24 with diagnoses of chronic obstructive pulmonary disease, shortness of breath, and type 2 diabetes. During record review on 4/3/24, it was noted that the plan of care failed to include measurable nursing goals that are individualized to address patient needs. The plan of care contained the following goals, patient and caregiver will verbalize an understanding of factors that contribute to shortness of breath and patient will verbalize an understanding of energy conserving measures. There was no evidence of how these goals could be objectively measured to determine progress toward meeting the goals. P-9: This 91-year-old patient was admitted to home care on 2/17/24 with diagnoses of pressure ulcer and type 2 diabetes. During record review on 4/3/24, it was noted that the plan of care failed to include measurable nursing goals that are individualized to address patient needs. The plan of care contained the following goals, caregiver will verbalize understanding of medication dose, route, indication, interactions, frequency, and side effects and patient and caregiver will verbalize an understanding of factors that contribute to shortness of breath. There was no evidence of how these goals could be objectively measured to determine progress toward meeting the goals. These findings were reviewed and acknowledged by the clinical director (Staff B) and assistant administrator (Staff C) during an interview on 4/4/24 at 11:50 a.m. P-1: This 70-year-old patient was admitted to home care on 7/8/23 with diagnoses of hypertensive heart disease with congestive heart failure and type 2 diabetes. During record review on 4/1/24, it was noted that the plan of care failed to include measurable nursing goals that are individualized to address patient needs. The plan of care contained the following goals, patient/caregiver will verbalize understanding of meds, side effects, uses, routes and patient/caregiver will verbalize understanding of seizure precautions. There was no evidence of how these goals could be objectively measured to determine progress toward meeting the goals. P-2: This 84-year-old patient was admitted to home care on 6/28/23 with diagnoses of type 2 diabetes and toxic encephalopathy. During record review on 4/1/24, it was noted that the plan of care failed to include measurable nursing goals that are individualized to address patient needs. The plan of care contained the following goals, patient/caregiver will be able to verbalize understanding of symptoms of cardiac complications and when to call 911 and the patient and caregiver will verbalize understanding of proper diabetic foot care. There was no evidence of how these goals could be objectively measured to determine progress toward meeting the goals. P-4: This 89-year-old patient was admitted to home care on 3/20/24 with diagnoses of hypertensive heart disease with congestive heart failure and chronic kidney disease. During record review on 4/2/24, it was noted that the plan of care failed to include measurable nursing goals that are individualized to address patient needs. The plan of care contained the following goals, improve patient safety and cardiac program for CHF, cardiomyopathies. There was no evidence of how these goals could be objectively measured to determine progress toward meeting the goals. P-5: This 81-year-old patient was admitted to home care on 3/23/24 with diagnoses of orthopedic aftercare and femur fracture. During record review on 4/2/24, it was noted that the plan of care failed to include measurable nursing goals that are individualized to address patient needs. The plan of care contained the following goals, patient/caregiver will be able to verbalize understanding of symptoms of cardiac complications and when to call 911 and patient and caregiver will verbalize understanding of all medications. There was no evidence of how these goals could be objectively measured to determine progress toward meeting the goals. P-7: This 82-year-old patient was admitted to home care on 3/1/24 with a diagnosis of hypertensive heart disease with congestive heart failure. During record review on 4/3/24, it was noted that the plan of care failed to include measurable nursing goals that are individualized to address patient needs. The plan of care contained the following goals, patient/caregiver will verbalize understanding of med safety, uses, indications, and side effects and caregiver will verbalize understanding of proper orientation techniques to use when patient becomes disoriented. There was no evidence of how these goals could be objectively measured to determine progress toward meeting the goals. P-8: This 61-year-old patient was admitted to home care on 3/13/24 with diagnoses of chronic obstructive pulmonary disease, shortness of breath, and type 2 diabetes. During record review on 4/3/24, it was noted that the plan of care failed to include measurable nursing goals that are individualized to address patient needs. The plan of care contained the following goals, patient and caregiver will verbalize an understanding of factors that contribute to shortness of breath and patient will verbalize an understanding of energy conserving measures. There was no evidence of how these goals could be objectively measured to determine progress toward meeting the goals. P-9: This 91-year-old patient was admitted to home care on 2/17/24 with diagnoses of pressure ulcer and type 2 diabetes. During record review on 4/3/24, it was noted that the plan of care failed to include measurable nursing goals that are individualized to address patient needs. The plan of care contained the following goals, caregiver will verbalize understanding of medication dose, route, indication, interactions, frequency, and side effects and patient and caregiver will verbalize an understanding of factors that contribute to shortness of breath. There was no evidence of how these goals could be objectively measured to determine progress toward meeting the goals. These findings were reviewed and acknowledged by the clinical director (Staff B) and assistant administrator (Staff C) during an interview on 4/4/24 at 11:50 a.m. P-10: The Start of Care (SOC) was dated 2/15/24. The Plan of Care (POC) identified diagnoses of Chronic Respiratory Failure and Congestive Heart Failure. During record review on 4/3/24, it was noted that the goals on the POC were not measurable, for example the Skilled Nursing goals stated, "Patient will remain free from chest pain, or chest pain will be relieved with nitroglycerin, during the episode. The patient will be free from injury during the certification period." There was no evidence of how these goals could be quantitatively measured. P-11: The Start of Care (SOC) was dated 1/14/24. The Plan of Care (POC) identified diagnoses of Atrial Fibrillation, Congestive Heart Failure and Chronic Kidney Disease. During record review on 4/3/24, it was noted that the goals on the POC were not measurable, for example the Skilled Nursing goals stated, "Patient and caregiver will verbalized understanding of all medications 01/20/2024. Cardiac program: for CHF, cardiomyopathies." There was no evidence of how these goals could be quantitatively measured. P-12: The Start of Care (SOC) was dated 3/1/24. The Plan of Care (POC) identified diagnoses of Sarcopenia, Muscle Weakness and Hypertension. During record review on 4/2/24, it was noted that the goals on the POC were not measurable, for example the Skilled Nursing goals stated, "The patient will be free from injury during the certification period. Patient’s blood pressure will remain within established parameters during the episode, SN will instruct patient/caregiver on Cardiac Diet as prescribed by MD." There was no evidence of how these goals could be quantitatively measured. P-13: The Start of Care (SOC) was dated 11/22/23. The Plan of Care (POC) identified diagnoses of Cellulitis of Left Lower Limb, Muscle Weakness and Hypertension. During record review on 4/3/24, it was noted that the goals on the POC were not measurable, for example the Skilled Nursing goals stated, "Patient/caregiver will have clear understanding of each medication being taken/utilized. Patient’s skin will remain intact throughout episode." There was no evidence of how these goals could be quantitatively measured. P-14: The Start of Care (SOC) was dated 2/13/24. The Plan of Care (POC) identified diagnoses of Spondylosis, Parkinson’s and Hypertension. During record review on 4/3/24, it was noted that the goals on the POC were not measurable, for example the Skilled Nursing goals stated, "Patient will verbalize understanding of proper use of pain medication by end of cert. Patient skin integrity will remain intact during this episode." There was no evidence of how these goals could be quantitatively measured. P-15: The Start of Care (SOC) was dated 3/27/24. The Plan of Care (POC) identified diagnoses of Traumatic Brain Injury and Pelvic Fracture. During record review on 4/3/24, it was noted that the goals on the POC were not measurable, for example the Skilled Nursing goals stated, "The patient will verbalize understanding of symptoms of cardiac complications and when to call 911. Patient will verbalize understanding of all medications by discharge." There was no evidence of how these goals could be quantitatively measured. P-16: The Start of Care (SOC) was dated 5/17/23. The Plan of Care (POC) identified diagnoses of Diabetes Type 2, Chronic Obstructive Pulmonary Disease and Paraplegic. During record review on 4/1/24, it was noted that the goals on the POC were not measurable, for example the Skilled Nursing goals stated, "Patient/caregiver will remove all clutter from patient’s path, such as clothes, books, shoes, electrical cords, and other items that may cause patient to trip by end of cert. Patient will verbalize understanding of positive coping skills related to anxiety and/or depression." There was no evidence of how these goals could be quantitatively measured. P-17: The Start of Care (SOC) was dated 6/15/23. The Plan of Care (POC) identified diagnoses of Cerebral Infraction, Hypertension and Diabetes Type 2. During record review on 4/1/24, it was noted that the goals on the POC were not measurable, for example the Skilled Nursing goals stated, "Patient and caregiver will verbalize understanding of medication regimen, dose, route, frequency, indications, and side effects by 08/13/2023. Patient will be able to identify signs and symptoms of worsening symptoms of CVA." There was no evidence of how these goals could be quantitatively measured. These findings were reviewed with and acknowledged by the Staff-B (Clinical Director) and Staff-C (Assistant Administrator) during an interview on 4/4/24 at 10:00 am.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure visit frequencies were provided only as ordered by the physician for 1 (P-17) of 17 records reviewed, resulting in the potential for the provision of inappropriate care and services. Findings include: **Agency Policy: "Plan of Care (485) and Physician/NPP Orders," (Clinical Implemented 2023). The policy states, "The Plan of Care is established in writing by the physician or NPP, Agency staff, the patient and members of the patient’s family based on an evaluation of the patient’s immediate and long term needs. The Plan of Care is developed with the patient’s participation and includes: …Frequency of visits and duration.” P-17: The Start of Care (SOC) was dated 6/15/23. The Plan of Care (POC) identified diagnoses of Cerebral Infraction, Hypertension and Diabetes Type 2. During record review on 4/1/24, the Occupational Therapist (OT) completed an evaluation visit on 6/20/23 with an order frequency and duration stating, “2w2 (Two visits per week for two week), 1w3.” No further OT visits were completed, and no physician order or notification was documented. The OT failed to provide the services and frequency as ordered by the physician. These findings were reviewed with and acknowledged by the Staff-B (Clinical Director) and Staff-C (Assistant Administrator) during an interview on 4/4/24 at 10:00 am.

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, it was determined the Agency had failed to promptly notify the Physician concerning weight change outside of vital sign parameters for 1 (P-11) of 5 patients with congestive heart failure, resulting in a potential poor clinical outcome. Findings include: P-11: The Start of Care (SOC) was dated 1/14/24. The Plan of Care (POC) identified diagnoses of Atrial Fibrillation, Congestive Heart Failure and Chronic Kidney Disease. During record review on 4/3/24, it was noted that the POC ordered Skilled Nursing (SN) at a frequency of 2w2 (two times a week for 2 weeks), 1w3. The POC had orders to notify the physician with a “Weight greater than (>) 142 lbs or less than ( These findings were reviewed with and acknowledged by the Staff-B (Clinical Director) and Staff-C (Assistant Administrator) during an interview on 4/4/24 at 10:00 am.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure skilled professionals provided services as ordered by the physician in the plan of care for 3 (P-1, 4, 7) of 17 records reviewed, resulting in the potential for poor patient outcomes for these patients. Findings include: P-1: This 70-year-old patient was admitted to home care on 7/8/23 with diagnoses of hypertensive heart disease with congestive heart failure and type 2 diabetes. During record review on 4/1/24, it was noted that the start of care assessment, dated 7/8/23, failed to include a baseline blood sugar level. Skilled nursing visits on 7/19/23 and 7/20/23 failed to include a weight to monitor potential worsening of congestive heart failure. The skilled nursing visit on 7/25/23 failed to include a weight or blood sugar level and the nurse documented “n/a.” P-4: This 89-year-old patient was admitted to home care on 3/20/24 with diagnoses of hypertensive heart disease with congestive heart failure and chronic kidney disease. During record review on 4/2/24, it was noted that the plan of care ordered nursing to assess the patient’s weight log every visit and report any significant changes to the physician. The skilled nursing visit on 3/28/24 failed to include a weight to monitor potential worsening of congestive heart failure. P-7: This 82-year-old patient was admitted to home care on 3/1/24 with a diagnosis of hypertensive heart disease with congestive heart failure. During record review on 4/3/24, it was noted that it was noted that the plan of care ordered nursing to assess the patient’s weight log every visit and report any significant changes to the physician. The skilled nursing visits on 3/13/24, 3/21/24, and 3/27/24 failed to include weights to monitor potential worsening of congestive heart failure. These findings were reviewed and acknowledged by the clinical director (Staff B) and assistant administrator (Staff C) during an interview on 4/4/24 at 11:50 a.m.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on record review and interview, it was determined the Agency failed to ensure the Registered Nurse prepared complete written instructions for patient safety needs in 5 (P-1, 4, 5, 10 and 14) of 5 records in which aide services were provided, resulting in the potential for unsafe, substandard care and unmet care needs. Findings include: **Agency Policy: "Care Planning Process," (Clinical Implemented 2023). The policy states, "3. The patient care plan for the Home Health Aide will be: The assignment sheet/plan of care will include: Safety measures including use of specific equipment.” P-10: The Start of Care (SOC) was dated 2/15/24. The Plan of Care (POC) identified diagnoses of Chronic Respiratory Failure and Congestive Heart Failure. The POC ordered Home Health Aide (HHa) services at a frequency of 1w4 (1 time a week for 4 weeks) with the following safety measures: Keep pathway clear, instructed on disaster/emergency plan, instructed on mobility safety, emergency plan developed, instructed on safety measures, fall precautions, use of assistive devices, standard precautions/infection control. During record review on 4/3/24, the "Aide Care Plan" dated 2/15/24 completed by the Registered Nurse (RN) contained no safety precautions. The HHa care plan failed to include the necessary safety measure and precautions to alert the aide of the patient's health concerns. P-14: The Start of Care (SOC) was dated 2/13/24. The Plan of Care (POC) identified diagnoses of Spondylosis, Parkinson’s and Hypertension. The POC ordered HHa services at a frequency of 1w4 (1 time a week for 4 weeks) with the following safety measures: Keep pathway clear, instructed on disaster/emergency plan, keep side rails up, slow position change, instructed on mobility safety, support during transfer and ambulation, emergency plan developed, anticoagulant precautions, safety in ADLs, instructed on safety measures, sharps safety, fall precautions, use of assistive devices, standard precautions/infection control. During record review on 4/3/24, the "Aide Care Plan" dated 2/24 completed by the RN contained no safety precautions. The HHa care plan failed to include the necessary safety measure and precautions to alert the aide of the patient's health concerns. These findings were reviewed with and acknowledged by the Staff-B (Clinical Director) and Staff-C (Assistant Administrator) during an interview on 4/4/24 at 10:00 am. P-1: This 70-year-old patient was admitted to home care on 7/8/23 with diagnoses of hypertensive heart disease with congestive heart failure and type 2 diabetes. The Plan of Care (POC) ordered Home Health Aide (HHa) services at a frequency of 2W2 (twice a week for 2 weeks) then 1W2 (once a week for 2 weeks). The POC included the following safety measures: keep path clear, disaster/emergency plan, DME (durable medical equipment) & electrical safety, slow position change, mobility safety, support during transfer and ambulation, emergency plan, safe utilities management, anticoagulant precautions, safety in ADLs (activities of daily living), safety measures, fall precautions, use of assistive devices, standard precautions/infection control. During record review on 4/1/24, it was noted that the Aide care plan dated 7/8/23 completed by the Registered Nurse (RN), failed to include safety precautions. P-4: This 89-year-old patient was admitted to home care on 3/20/24 with diagnoses of hypertensive heart disease with congestive heart failure and chronic kidney disease. The POC HHa services at a frequency of 1W1 (once a week for 1 week) then 2W2 (twice a week for 2 weeks). The POC included the following safety measures: anticoagulant precautions, disaster/emergency plan, slow position change, mobility safety, support during transfer and ambulation, emergency plan, safety in ADLs, safety measures, proper position during meals, fall precautions, use of assistive devices, standard precautions/infection control. During record review on 4/2/24, it was noted that the Aide care plan dated 3/20/24 completed by the RN, failed to include safety precautions. P-5: This 81-year-old patient was admitted to home care on 3/23/24 with diagnoses of orthopedic aftercare and femur fracture. The POC HHa services at a frequency of 2W3 (twice a week for 3 weeks). The POC included the following safety measures: keep path clear, disaster/emergency plan, mobility safety, support during transfer and ambulation, emergency plan, safe utilities management, safety in ADLs, safety measures, fall precautions, use of assistive devices, standard precautions/infection control. During record review on 4/2/24, it was noted that the Aide care dated 3/23/24 completed by the RN, plan failed to include safety precautions. These findings were reviewed and acknowledged by the clinical director (Staff B) and assistant administrator (Staff C) during an interview on 4/4/24 at 11:50 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 3 (P-8, 13 and 17) of 17 records reviewed, resulting in the potential to negatively affect the health and well-being of these patients. Findings include: **Agency Policy: "Medical Record Protection and Retention," (Administration Implemented 2023). The policy states, "Clinical Records: Agency must maintain a clinical record containing past and current information for every patient accepted by the agency and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards…” P-13: The Start of Care (SOC) was dated 11/22/23. The Plan of Care (POC) identified diagnoses of Cellulitis of Left Lower Limb, Muscle Weakness and Hypertension. During record review on 4/3/24, it was noted that the Registered Nurse (RN) completed a recertification on 1/19/24 and 3/18/24. The section under “Skilled Intervention” titled “Assessment/Instruction/Performance” contained the same exact wording for both recertification visits. The agency failed to maintain a current and accurate clinical record. P-17: The Start of Care (SOC) was dated 6/15/23. The Plan of Care (POC) identified diagnoses of Cerebral Infraction, Hypertension and Diabetes Type 2. During record review on 4/1/24, it was noted that the Physical Therapist (PT) completed an PT Evaluation on 6/20/23 and a 30-day PT Evaluation on 7/11/23. The section titled “Clinical Statement of Assessment Finding and Recommendations” contained the same exact wording for both evaluation visits. The agency failed to maintain a current and accurate clinical record. These findings were reviewed with and acknowledged by the Staff-B (Clinical Director) and Staff-C (Assistant Administrator) during an interview on 4/4/24 at 10:00 am. P-8: This 61-year-old patient was admitted to home care on 3/13/24 with diagnoses of chronic obstructive pulmonary disease, shortness of breath, and type 2 diabetes. During record review on 4/3/24, it was noted that the skilled nursing visit notes from 3/27/24 are “not started.” This finding was reviewed and acknowledged by the clinical director (Staff B) and assistant administrator (Staff C) during an interview on 4/4/24 at 11:50 a.m. During the entrance interview on 4/1/24 at 9:40 a.m., Staff B stated visit notes are to be completed within 72 hours. Staff B stated this clinician has been sent a request to finish charting.

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 discharge summary was complete, provided the patient's current health status at the time of discharge and progress toward goals in 3 (P-1, 16 and 17) of 5 closed records, resulting in the potential for unidentified continuing health care concerns and unmet care needs. Findings include: **Agency Policy: "Discharge Summary," (Clinical Implemented 2023). The policy states, "Standards and guidelines: 1. Skilled Nurse, Medical Social Worker and/or Therapist will complete Discharge Summary form. The Discharge Summary will include, but is not limited to: Discharge date, Reason for discharge, Status of problems identified throughout the course of care, patient’s overall status, and Summary of care and services provided." P-16: The Start of Care (SOC) was dated 5/17/23. The Plan of Care (POC) identified diagnoses of Diabetes Type 2, Chronic Obstructive Pulmonary Disease and Paraplegic. During record review on 4/1/24, it was noted that the Skilled Nursing discharge dated 6/7/23 stated, "Care Summary (care given, progress, regress including therapies): MD (Doctor of Medicine) referral with 2 recent hospitalizations and having trouble coping with current living situation. Unable to get in for DC visit." The discharge 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 discharge in measurable terms. P-17: The Start of Care (SOC) was dated 6/15/23. The Plan of Care (POC) identified diagnoses of Cerebral Infraction, Hypertension and Diabetes Type 2. During record review on 4/1/24, it was noted that the Skilled Nursing discharge dated 6/23/23 stated, "Care Summary (care given, progress, regress including therapies): Blank." The discharge 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 discharge in measurable terms. These findings were reviewed with and acknowledged by the Staff-B (Clinical Director) and Staff-C (Assistant Administrator) during an interview on 4/4/24 at 10:00 am. P-1: This 70-year-old patient was admitted to home care on 7/8/23 with diagnoses of hypertensive heart disease with congestive heart failure and type 2 diabetes. During record review on 4/1/24, it was noted that the last skilled nursing visit occurred on 7/25/23 and there were missed visits documented for the following five weeks until the patient was discharged from the agency on 9/5/23. There was no documented evidence that a detailed discharge summary report was sent to the physician within 5 days of the patient’s discharge. This finding was reviewed and acknowledged by the clinical director (Staff B) and assistant administrator (Staff C) during an interview on 4/4/24 at 11:50 a.m.