Every finding on record at Centerwell Certified Healthcare Corp

A Medicare authorized survey was conducted by the Michigan Department of Licensing and Regulatory Affairs on 10/3/23 through 10/6/23 at: CenterWell Home Health 5148 Lovers Lane STE 210 Portage, MI 49002 At the conclusion of the survey, the agency was found in substantial compliance with the requirements for participation in Medicare/Medicaid at 42 CFR§484.102, Emergency Preparedness.

A Medicare recertification survey was conducted by the Michigan Department of Licensing and Regulatory Affairs from 10/3/23 through 10/6/23 at: CenterWell Home Health 5148 Lovers Lane STE 210 Portage, MI 49002 This agency has no branches or sub-units. Clinical records reviewed for this survey included 7 records with home visits, 5 records without home visits, and 5 discharged records. At the conclusion of the survey the agency was found to be out of compliance with standard level deficiencies for the conditions of participation for home health agencies at: 42 CFR Part 484.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the Agency failed to ensure that 4 (P-1, P-4, P-5 and P-7) of 4 patients observed during home visits, were included in the overall planning of care including informing the patient/caregiver in advance of the days in which services would be provided, from a total of 17 sampled records reviewed, resulting lack of inclusion in planning, the potential for missed visits and unmet care needs. Findings include: P-1: The patient's start of care (SOC) was 5/19/23. The certification period of review began 9/16/23 with diagnoses that included Pressure Ulcer Left Heel, Heart Failure and Diabetes Mellitus. During the record review, it was noted that the patient was ordered to receive Skilled Nursing (SN) and Medical Social Work (MSW) services to be provided. On 10/3/23 at 4:00 p.m., during a scheduled survey home visit with the Registered Nurse (RN #1), it was noted that the patient's admission packet was void of a calendar of proposed visits to be made by the RN. The agency failed to ensure a calendar of proposed visits had been provided at the SOC to assist the patient with participating in planning his care and daily routine. These findings were reviewed with and acknowledged by the Administrator (Adm #1) during an interview on 10/5/23 at 11:30 a.m. P-4: The patient's SOC was 7/18/23. The certification period of review began 9/16/23 with diagnoses that included Diabetes Mellites, Hypertension and Low Back Pain. During the record review on 10/4/23 at 3:55 p.m., it was noted that the patient was ordered to receive SN and Home Health Aide services. On 10/4/23 at 11:00 a.m., during a scheduled survey home visit with the Home Health Aide (HHa #1), it was noted that the patient's admission packet was void of a calendar of proposed visits to be made by the SN and HHa. The agency failed to ensure a calendar of proposed visits had been provided at the SOC to assist the patient with participating in planning his care and daily routine. These findings were reviewed with and acknowledged by the Administrator (Adm #1) during an interview on 10/5/23 at 12:25 p.m. P-5: The patient's SOC was 8/26/23 with diagnoses that included Left knee Replacement and Hypertension. During the record review on 10/3/23 at 2:30 p.m., it was noted that the patient was ordered to receive Physical Therapy services. On 10/4/23 at 9:00 a.m., during a scheduled survey home visit with the Physical Therapist (PT #1), it was noted that the patient's admission packet was void of a calendar of proposed visits to be made by the PT. The agency failed to ensure a calendar of proposed visits had been provided at the SOC to assist the patient with participating in planning his care and daily routine. These findings were reviewed with and acknowledged by the Administrator (Adm #1) during an interview on 10/5/23 at 12:36 p.m. P-7: The Start of Care was dated 9/12//2023. The Plan of Care identified diagnoses of Multiple fracture of ribs, emphysema, Fracture of 7th cervical vertebrae, Traumatic Hemopneumothorax, Cancer of the Lung, Anxiety Disorder, and history of falls. The patient was receiving Skilled Nursing (SN), Physical Therapy (PT), and Occupational Therapy (OT) services. During a survey home visit with the occupational therapist on 10/4/23 at 10:00am, it was observed at the end of the visit, the OT arranging for scheduling of the next visit. The OT stated, "why don't I just give you a call next week to schedule your visit." A discussion occurred between this surveyor, the patient, and the patient's spouse, as the OT listened. The Spouse stated during the discussion that "I still work a full-time job, and would appreciate knowing in advance the date and time of the visit so I can schedule to attend the visit to know where my wife is in the process of healing and to learn the exercises she is required to do between visits so I can assist". The patient agreed and stated, "I guess I would like to know when you will be here so I can be prepared." The agency's Admission Packet was nowhere to be found, so there was no calendar available to document date and time of proposed visits. The agency failed to ensure a calendar of proposed visits had been provided to assist the patient and family with participating in planning OT visits. These findings were reviewed and acknowledged by the Administrator (Adm #1) during an interview on 10/4/23 at 4:00 p.m.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient’s current health status based on past medical history that included dates of onset, exacerbations, treatments and outcomes, and history of events leading to current home care needs in 13 records (P#’s 2, 5, 6, 8, 9, 10, 11, 12, 13, 14, 15, 16, and 17), from a total of 17 records reviewed, resulting in incomplete clinical information to aide in determining the needs of the patient. Findings included: P-13: The Start of Care (SOC) was dated 8/24/23. The Plan of Care (POC) identified diagnoses of Urinary Tract Infection, Diabetes Type 2 and Sepsis. During record review on 10/4/23, it was noted that the SOC comprehensive assessment dated 8/24/23, documented under "Primary Diagnosis and Other Diagnoses", all 30 diagnoses had an exacerbation or onset date of 8/24/23. No prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. P-14: The Start of Care (SOC) was dated 7/15/23. The Plan of Care (POC) identified diagnoses of Surgical Wound, Diabetes Type 2 and Chronic Kidney Disease. During record review on 10/4/23, it was noted that the SOC comprehensive assessment dated 7/15/23, documented under "Primary Diagnosis and Other Diagnoses", all 29 diagnoses had an exacerbation or onset date of 7/15/23. No prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. P-15: The Start of Care (SOC) was dated 3/7/23. The Plan of Care (POC) identified diagnoses of Diabetes Type 2, Chronic Kidney Disease and Chronic Obstructive Pulmonary Disease. During record review on 10/4/23, it was noted that the SOC comprehensive assessment dated 3/7/23, documented under "Primary Diagnosis and Other Diagnoses", all 29 diagnoses had an onset date of 3/7/23. No exacerbation, prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. P-16: The Start of Care (SOC) was dated 7/13/23. The Plan of Care (POC) identified diagnoses of Diabetes Type 2, Foot Ulcer and Congestive Heart Failure. During record review on 10/5/23, it was noted that the SOC comprehensive assessment dated 7/13/23, documented under "Primary Diagnosis and Other Diagnoses", all 25 diagnoses had an onset date of 7/13/23. No exacerbation, prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. P-17: The Start of Care (SOC) was dated 8/20/23. The Plan of Care (POC) identified diagnoses of Sacral Pressure Ulcer, End Stage Renal Disease and Diabetes Type 2. During record review on 10/5/23, it was noted that the SOC comprehensive assessment dated 8/20/23, documented under "Primary Diagnosis and Other Diagnoses", all 30 diagnoses had an exacerbation or onset date of 8/20/23. No prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. These findings were reviewed with and acknowledged by the Adm #1 (Administrator) during an interview on 10/6/23 at 10:45 am. P-2: The patient's Start of Care (SOC) was 12/9/22 with diagnoses that included Congestive Heart Failure, Diabetes and Chronic Kidney Disease. During the clinical record review on 10/5/23 at 9:00 a.m., it was noted that sections M1021 and M1023 of the Initial Comprehensive Assessment "Primary/Other Diagnoses" had the same date of 12/9/22 for all listed diagnoses. There was no documented history or current status of the mentioned diagnoses and no indication as to whether these diagnoses led to the need for home care services. These findings were reviewed with and acknowledged by the Administrator (Adm #1) during an interview on 10/5/23 at 11:53 a.m. P-5: The patient's SOC was 8/26/23 with diagnoses that included Left Knee Replacement. During the clinical record review on 10/5/23 at 9:00 a.m., it was noted that sections M1021 and M1023 of the Initial Comprehensive Assessment "Primary/Other Diagnoses" had the same date of 8/26/23 for all listed diagnoses. There was no documented history or current status of the mentioned diagnoses and no indication as to whether these diagnoses led to the need for home care services. These findings were reviewed with and acknowledged by the Adm #1 during an interview on 10/5/23 at 12:36 p.m. P-6: The patient's SOC was 9/24/23 with diagnoses that included Fractured Neck of Femur, Prosthetic Hip and Hypertension. During the clinical record review on 10/5/23 at 10:45 a.m., it was noted that sections M1021 and M1023 of the Initial Comprehensive Assessment "Primary/Other Diagnoses" had the same date of 9/24/23 for all listed diagnoses. There was no documented history or current status of the mentioned diagnoses and no indication as to whether these diagnoses led to the need for home care services. These findings were reviewed with and acknowledged by the Adm #1 during an interview on 10/5/23 at 12:45 p.m. P-8: The Start of Care was dated 9/27/2022. The Plan of Care identified diagnoses of Diabetes Type 2 (DM2), Congestive Heart Failure (CHF), End State Renal Disease, Hemiplegia of Left side following Cerebral Infarction, and Coronary Artery Disease (CAD). Upon review of the Comprehensive Assessment dated 9/27/22, under the category of "Primary Diagnosis and Other Diagnoses, there were 6 diagnoses with the same date of onset of 9/26/27, and 18 diagnoses with onset date of 9/27/22. There was no documentation of prior treatments, outcomes, or history of how these diagnoses led to the need for home care services. P-9: The Start of Care was dated 1/9/2023. The Plan of Care identified diagnoses of Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD), Anemia, Atrial Fibrillation (A-fib), Respiratory Failure, Hearing Loss, and Morbid Obesity. Upon review of the Comprehensive Assessment, dated 1/9/2023, under the category of Primary Diagnosis and Other Diagnoses, there were 2 diagnoses with the same date of onset of 12/27/22, and 22 diagnoses with the same date of onset of 1/9/23. There was no documentation of prior treatments, outcomes, or history of how these diagnoses led to the need for home care services. P-10: The Start of Care was dated 11/1/2022. The Plan of Care for the certification period of 11/1/22 to 12/30/22 identified diagnoses of Hemiplegia following Cerebral Infarction affecting Right Dominant Side, Aphasia, Hypertension (HTN), Diabetes type 2 (DM2), and Chronic Obstructive Pulmonary Disease (COPD). Upon review of the Comprehensive Assessment dated 11/1/2022, under the category of "Primary Diagnoses and Other Diagnoses, there were 21 diagnoses with the same date of onset documented as 11/1/22. There was no documentation of prior treatments, outcomes, or history of how these diagnoses led to the need for home care services. P-11: The SOC was dated 9/13/23. The Plan of Care for the certification period 9/13/23 to 11/11/23 identified diagnoses of Stage 5 Chronic Kidney Disease (CKD), Congestive Heart Failure (CHF), Diabetes Type 2 (DM2), Pneumonia, Osteoporosis, and Hypothyroidism. Upon review of the Comprehensive Assessment dated 9/13/23, under the category of "Primary Diagnoses and Other Diagnoses, there were 31 diagnoses with the same date of onset documented as 9/13/23. There was no documentation of prior treatments, outcomes, or history of how these diagnoses led to the need for home care services. P-12: The SOC was dated 8/7/23. The POC identified diagnoses of Atrial Fibrillation, Contusion of Left Lower Leg, Peripheral Vascular Disease (PVD), Chronic Kidney Disease (CKD), Chronic Diastolic Congestive Heart Failure, Bilateral Hearing Loss, and Right Artificial Knee Joint. Upon review of the Comprehensive Assessment dated 8/7/23, under the category of "Primary Diagnoses and Other Diagnoses, there were 21 diagnoses with the same date of onset documented as 8/07/23. There was no documentation of prior treatments, outcomes, or history of how these diagnoses led to the need for home care services. These findings were reviewed with and acknowledged by the Administrator (ADM#1) on 10/6/23 at 1:30 p.m.

Patient's needs CFR(s): 484.55(c)(4) The patient's medical, nursing, rehabilitative, social, and discharge planning needs; This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the Agency failed to ensure the patient's Activity of Daily Living needs were adequately met in the patient's home for 1 (P-1) of 1 patient observed during a Home Health Aide visit of a patient who required assistance with grooming and toileting, from a total of 17 sampled records reviewed, resulting in poor grooming and the potential for low self-esteem and unmet care needs. Findings include: P-1: The patient's start of care was 5/19/23. The certification period of review began 9/16/23 with diagnoses that included Pressure Ulcer Left Heel, Heart Failure and Diabetes Mellitus. During the clinical record review on 10/3/23 at 1:30 p.m., it was noted that the patient was ordered to receive Skilled Nursing (SN ) and Medical Social Work (MSW) services. On 10/3/23 at 4:00 p.m., a survey home visit was conducted with the Registered Nurse (RN #1). Upon arrival, the patient was noted to be seated in a wheelchair and had on bilateral knee braces. During the visit, the patient expressed that he manages to perform self grooming. The patient further stated that a female aide was coming out but he (patient) preferred a male aide. RN #1 interjected and stated, "He (patient) didn't want a female looking at him." The patient further stated that a male aide came out but he (aide) had scheduling issues. "I never knew when he was coming. He would show up during meal times, then he just stopped coming. I have to learn to do it (grooming) myself. Since I had my Spinal fusion, sometimes I can't tell when I have to have a bowel movement so I have to clean myself." The above observations were discussed with the Administrator (Adm #1) during an interview on 10/5/23 at 11:30 a.m. who said, "I'll have to look into this and get back to you." During a subsequent interview, Adm #1 reported, "I called the patient and he confirmed that there were scheduling issues with the male aide." The Agency failed to ensure the patient's ADL/grooming needs were adequately met in the patient's home.

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 was patient specific and individualized to the patient's identified needs, covered all pertinent interventions with reportable parameters for 3 of 17 records reviewed (P#'s 14, 16 and 17), and failed to ensure the goals on the Plan of Care were objectively measurable to determine the patient's progress towards achieving the goals in 6 of 17 (P#'s 7, 8, 9, 10, 11, and 12), resulting in patients not receiving care specific to their needs and the potential for poor patient outcomes. Findings included: P-14: The Start of Care (SOC) was dated 7/15/23. The Plan of Care (POC) identified diagnoses of Surgical Wound, Diabetes Type 2 and Chronic Kidney Disease. During record review on 10/4/23, it was noted that the comprehensive assessment completed on 7/15/23 stated, “Dysphagia, Oropharyngeal Phase.” Additionally, in the patients History and Physical, the Speech Therapist documented, “Recommendation details: …aspiration precautions…” on 7/13/23. Additionally, the POC failed to contain parameters to notify the physician of blood sugar irregularities. The POC failed to contain aspiration precautions and blood sugar parameters to notify the physician. P-16: The Start of Care (SOC) was dated 7/13/23. The Plan of Care (POC) identified diagnoses of Diabetes Type 2, Foot Ulcer and Congestive Heart Failure. During record review on 10/5/23, the POC failed to contain parameters to notify the physician of blood sugar irregularities. The POC failed to contain the blood sugar parameters to notify the physician. P-17: The Start of Care (SOC) was dated 8/20/23. The Plan of Care (POC) identified diagnoses of Sacral Pressure Ulcer, End Stage Renal Disease and Diabetes Type 2. During record review on 10/5/23, the comprehensive assessment dated 8/20/23 stated, “… maintain hydration within fluid restriction of 1500 ML per day.” The POC failed to contain the fluid restriction of 1500 ML per day within the nutritional requirements. These findings were reviewed with and acknowledged by the Adm #1 (Administrator) during an interview on 10/6/23 at 10:45 am. P-7: The Start of Care was dated 9/27/2023. The Plan of Care (POC) identified diagnoses of Multiple fracture of ribs, emphysema, Fracture of 7th cervical vertebrae, Traumatic Hemopneumothorax, Cancer of the Lung, Anxiety Disorder, and history of falls. Upon review of the record, it was noted the goals were not objectively measurable to determine the patient's progress towards achieving the goals. Examples include: "A Plan of Care will be established that meets the patient's nursing needs and countersigned by the physician; Changes in pain status/management are identified promptly and reported to Physician." These goals are not objectively measurable to determine the patient's progress towards achieving the goals. P-8: The Start of Care was dated 9/27/2022. The Plan of Care identified diagnoses of Diabetes Type 2 (DM2), Congestive Heart Failure (CHF), End State Renal Disease, Hemiplegia of Left side following Cerebral Infarction, and Coronary Artery Disease (CAD). Upon review of the record, it was noted the goals on the POC were not objectively measurable to determine the patient's progress towards achieving the goals. Examples included: "A Plan of Care will be established that meets the patient's nursing needs and countersigned by the physician; Cardiovascular exacerbations are identified promptly, and interventions initiated to minimize risks; Changes in pain status/management are identified promptly and reported to physician; Patient adheres to medication regimen." These goals are not objectively measurable to determine the patient's progress toward achieving the goals. P-9: The Start of Care was dated 1/9/2023. The Plan of Care identified diagnoses of Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD), Anemia, Atrial Fibrillation (A-fib), Respiratory Failure, Hearing Loss, and Morbid Obesity. Upon review of the record, it was noted the goals on the POC were not objectively measurable to determine the patient's progress towards achieving the goals. Examples included: "A Plan of care will be established that meets the patient's needs and countersigned by physician; Patient adheres to medication regimen; PRN visits will be performed timely as indicated." These goals are not patient specific or measurable to determine the patient's progress towards achieving the goals. P-10: The Start of Care was dated 11/1/2022. The Plan of Care for the certification period of 11/1/22 to 12/30/22 identified diagnoses of Hemiplegia following Cerebral Infarction affecting Right Dominant Side, Aphasia, Hypertension (HTN), Diabetes type 2 (DM2), and Chronic Obstructive Pulmonary Disease (COPD). Upon review of the record, it was noted the goals on the Plan of Care were not objectively measurable to determine the patient's progress towards achieving the goals. Examples included: "A Plan of Care will be established that meets the patient's needs and countersigned by the physician; Patient adheres to medication regimen; PRN visit will be performed timely as indicated; A Physical Therapy Evaluation will be completed and a Plan of Care to increase functional independence will be established for the physician's review and signature." These goals are not objectively measurable to determine the patient's progress towards achieving goals. P-11: The SOC was dated 9/13/23. The Plan of Care for the certification period 9/13/23 to 11/11/23 identified diagnoses of Stage 5 Chronic Kidney Disease (CKD), Congestive Heart Failure (CHF), Diabetes Type 2 (DM2), Pneumonia, Osteoporosis, and Hypothyroidism. Upon review of the record, it was noted the goals on the POC were not objectively measurable to determine the patient's progress towards achieving the goals. Examples include: "Changes in pain status/management are identified promptly and reported to physician; A Medical Social Services evaluation will be completed, and a Plan of Care will be established for the physician's signature for the enhancement of the patient's social and emotional factors, need for care, response to treatment, and adjustment to care, to foster independent living at home." These goals are not objectively measurable to determine the patient's progress toward achieving goals. P-12: The SOC was dated 8/7/23. The POC identified diagnoses of Atrial Fibrillation, Contusion of Left Lower Leg, Peripheral Vascular Disease (PVD), Chronic Kidney Disease (CKD), Chronic Diastolic Congestive Heart Failure, Bilateral Hearing Loss, and Right Artificial Knee Joint. Upon review of the record, it was determined the goals were not objectively measurable to determine the patient's progress towards achieving the goals. Examples include: " A Plan of Care will be established that meets the patient's nursing needs and countersigned by the physician; PRN visits will be performed timely as indicated." These goals are not objectively measurable to determine the patient's progress towards achieving goals.

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 medications and services were provided only as ordered by the physician for 2 (P-14, P-4) records of patients who were recertified for continuing services, from a total of 17 records reviewed, resulting in the potential for the provision of inappropriate care and services. Findings include: P-14: The Start of Care (SOC) was dated 7/15/23. The Plan of Care (POC) identified diagnoses of Surgical Wound, Diabetes Type 2 and Chronic Kidney Disease. During record review on 10/4/23, it was noted that a “Medication Issues Communication/Order” was completed and sent to the physician on 9/14/23. On 9/15/23, the physician signed and returned the “Medication Issues Communication/Order”, and stated, “Patient is not taking Amiodarone, Oxycodone.” The agency failed to update the medication list to reflect the order from the physician. This finding was reviewed with and acknowledged by the Adm #1 (Administrator) during an interview on 10/6/23 at 10:45 am. P-4: The patient's start of care was 7/18/23. The certification period of review began 9/16/23 with diagnoses that included Diabetes Mellitus, Hypertension, Low Back Pain and Epilepsy. During the clinical record review on 10/4/23 at 3:55 p.m., there was no Physician's orders or any documented evidence that the Physician had approved recertification for continuation of services. These findings were reviewed discussed with the Administrator during an interview on 10/5/23 at 12:25 p.m. who initially reported that the plan of care serves as the approval for recertification. The Administrator later reported, "We couldn't find anything in our system, but we found a telephone encounter with Physician's triage nurse who approved the recertification. Upon review of the presented document, it stated, "Nurse triage approved standing order for home care services..." There was no signed Physician's orders that approved the continuation of services.

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 2 of 17 (P-8 and P-15) records reviewed, resulting in the potential to negatively affect the health and well-being of these patients. Findings include: P-15: The Start of Care (SOC) was dated 3/7/23. The Plan of Care (POC) identified diagnoses of Diabetes Type 2, Hypertensive Heart and Chronic Kidney Disease with Heart Failure and with Stage 5 Chronic Kidney Disease. During record review on 10/4/23, it was noted that the POC ordered Skilled Nursing (SN) 1w5 (1 time a week for 5 weeks), 1q2w4 (1 time every other week for 4 weeks). The comprehensive assessment dated 3/7/23 documented a weight of 250. The following 6 SN visits contained no weight recordings: 3/16/23, 3/21/23, 3/30/23, 4/6/23, 4/18/23, and SN Discharge 5/2/23. The agency failed to ensure that the medical record was complete and accurate. These findings were reviewed with and acknowledged by the Adm #1 (Administrator) during an interview on 10/6/23 at 10:45 am. P-8: The Start of Care was dated 9/27/2022. The Plan of Care identified diagnoses of Diabetes Type 2 (DM2), Congestive Heart Failure (CHF), End State Renal Disease, Hemiplegia of Left side following Cerebral Infarction, and Coronary Artery Disease (CAD). The Plan of Care included the following order: "Skilled Nurse to assess/evaluate co-morbid conditions including CKD, Gout, Obesity, Epilepsy, Hypertension, Heart Failure, CVA, PVD, Pneumonia, Hypoglycemia, and other conditions that present themselves during the course of this episode to identify changes and intervene to minimize complications." {sic} During a review of the record, it was noted there was only 1 blood sugar result documented dated 10/6/22, a random test with result of 130. The nurse failed to follow the order to assess and evaluate the patient's diagnosis of hypoglycemia. In addition, for this patient with a diagnosis of Congestive Heart Failure, the Skilled Nurse failed to follow the order to assess or evaluate the status of the patient's Heart Failure status. Upon reviewing the patient's record, the only documented weight was at the Start of Care; and there were only 2 ankle measurements, 1 on 10/4/22 with the following results: Right 29cm/Left30.5cm; and 1 on 10/1/22: Right 31.5cm/Left 32.5cm. This resulted in a 2.5cm increase in 7 days for the right ankle, and 2.5cm increase for the left ankle. There was no documentation in the record that the physician had been notified of the increase in the measurement of the patient's bilateral ankles. Also, there was an error in the record under the category of "Surgical History" in the Comprehensive Assessment. This female patient was referred as a male in the following documentation. "Upon exam, he is resting comfortably on his chair and is pleasant and cooperative." The agency failed to ensure that the medical record was complete and accurate. These findings were reviewed with and acknowledged by the Adm #1 (Administrator) during an interview on 10/6/23 at 2:00 pm.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the discharge summary was completed and detailed the health status of the patient at the time of discharge for 1 (P-2) of 2 discharge records reviewed, of 5 total discharge records, from a total of 17 sampled records reviewed, resulting in the potential for unidentified health concerns and unmet continuing care needs. Findings include: Policy: Transfer/Discharge Summaries, 03-25, 4/2023 stated, "A copy of the Home Health agency transfer/discharge summary will be sent to the receiving healthcare provider responsible for ongoing patient care and will include the following information: Reason for admission to home health, Disciplines and frequency of services provided, Discharge instructions provided to the patient, Patient's condition at the time of discharge..." P-2: The patient's start of care was 12/9/22 with diagnoses that included Congestive Heart Failure, Diabetes Mellitus with Diabetic Chronic Kidney Disease and Low Back Pain. The plan of care ordered Skilled Nursing (SN), Physical Therapy (PT) and Occupational Therapy (OT) services to be provided. During the record review on 10/5/23 at 9:00 a.m., it was noted that the patient was discharged from OT services on 2/3/23. The patient was discharged from PT services on 1/23/23. The PT Discharge Summary was sent to the Physician on 2/7/23, which was 15 days after the date of discharge. The patient was discharged from SN services on 2/7/23. The SN Discharge Summary was void of the patient's weight, Blood Sugar and pain levels at the time of discharge. These findings were reviewed with and acknowledged by the Administrator during an interview on 10/5/23 at 11:53 a.m.