Every finding on record at Central Home Health Care, Inc.

A Medicare recertification survey was conducted by the Michigan Department of Licensing and Regulatory Affairs from 1/8/2023 through 1/11/2023 at: Central Home Health Care 20245 West 12 Mile Rd. suite 100 Southfield, MI 48076 This was a standard survey, the conditions of participation for Emergency Preparedness were not reviewed.

A Medicare recertification survey was conducted by the Michigan Department of Licensing and Regulatory Affairs from 1/8/2023 through 1/11/2023 at: Central Home Health Care 20245 West 12 Mile Rd. suite 100 Southfield, MI 48076 For this survey 3 home visits with record reviews, 2 active records without a home visit and 2 discharged records were 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.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure that 2 (P's #2, 3) patients observed during home visits, were included in the overall planning of their care including informing the patient/caregiver in advance of the days in which services would be provided, from a total of 7 sampled records reviewed, resulting in a lack of inclusion in planning, lack of informed consent, the potential for missed visits and unmet care needs. Findings include: P-2: The patient's start of care (SOC) was 1/1/24 with diagnoses that included Anterior Cervical Decompression with fusion. During the record review on 1/9/24 at 2:00 p.m., it was noted that the plan of care (POC) ordered Skilled Nursing (SN), Physical Therapy (PT) and Occupational Therapy (OT) services to be provide. On 1/9/24, during a scheduled survey home visit with the Skilled Nurse (RN #1), it was noted that the patient's admission packet was void of a completed calendar of proposed visits to be made by the nurse or any of the other ordered disciplines. During the visit, the patient questioned, "Are you coming back to see me? RN #1 stated a day in which to report, however the patient stated, "No. That won't work due to plans." RN #1 then stated, "Well, I can come back Thursday around 9." The patient reported, "No. That's too early." RN #1 then changed the time to later in the day. During the visit, the nurse stepped away to dispose of items. During that time, the patient reported, "They (staff) come out whenever they want to, and my husband doesn't like it." These findings were reviewed with and acknowledged by the Administrator (Adm #1) and Alternate Administrator (Adm #2) during an interview on 1/10/24 at 2:50 p.m. P-3: The patient's SOC was 12/29/23 with diagnoses that included Lumbar Radiculopathy and Greater Trochanter Bursitis. The POC ordered PT services to be provided. On 1/9/24, during a scheduled survey home visit with PT #1, it was noted that the patient's admission packet was void of a completed calendar of proposed visits to be made by the PT. During the visit, the patient asked PT #1 when he would be coming back for the next PT visit as it had not been noted on the provided calendar. These findings were reviewed with and acknowledged by Adm #1 and Adm #2 during an interview on 1/10/24 at 3:15 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 ensure the Initial Comprehensive Assessment accurately reflected the patient's condition at the time of admission and documented the events that lead to the need for home care for 4 (P#'s 4, 5, 6, 7) patients admitted to this agency, from a total of 7 sampled records reviewed, resulting in the potential for unidentified health concerns and unmet care needs. Findings include: P-4: The patient's start of care (SOC) was 8/24/23, with diagnoses that included diabetes mellitus, cerebral infarct, and heart disease. On 1/8/24, during the clinical record review, it was noted that the initial Comprehensive Assessment listed all diagnoses with an onset date of 8/24/23. There were no documented diagnoses history, onset, or previous treatments in the SOC assessment. Under each body system section of the SOC assessment, there was a lack of information documented to ascertain home care needs. P-5: The patient's start of care (SOC) was 11/20/23, with diagnoses that included orthopedic aftercare, spondylosis, and spinal stenosis. On 1/9/24, during the clinical record review, it was noted that the initial Comprehensive Assessment listed all diagnoses with an onset date of 11/20/23. There were no documented diagnoses history, onset, or previous treatments in the SOC assessment. Under each body system section of the SOC assessment, there was a lack of information documented to ascertain home care needs. P-6: The patient's start of care (SOC) was 9/13/23, with diagnoses that included lumbar fusion, and spinal stenosis. On 1/9/24, during the clinical record review, it was noted that the initial Comprehensive Assessment listed all diagnoses with an onset date of 9/13/23. There were no documented diagnoses history, onset, or previous treatments in the SOC assessment. Under each body system section of the SOC assessment, there was a lack of information documented to ascertain home care needs. P-7: The patient's start of care (SOC) was 12/29/23, with diagnoses that included multiple fracture of ribs, and acute pain. On 1/10/24, during the clinical record review, it was noted that the initial Comprehensive Assessment listed all diagnoses with an onset date of 12/29/23. There were no documented diagnoses history, onset, or previous treatments in the SOC assessment. Under each body system section of the SOC assessment, there was a lack of information documented to ascertain home care needs. During an interview on 1/11/24 at 10:10 a.m., the administrator (Adm#1) and the alternate administrator (Adm#2) acknowledged the above findings.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment included an accurate review of all medications to determine potential adverse effects or duplicate drug therapy in 1 of 7 (P- 6) records reviewed, resulting in the potential for harmful medication effects for all patients serviced by this agency. Findings include: P-6: The patient's start of care (SOC) was 9/13/23, with diagnoses that included lumbar fusion, and spinal stenosis. On 1/9/24, during the clinical record review, it was noted that the initial medication profile dated 9/13/23, was signed by the physical therapist (PT), had no medication reconciliation attached, and documented no interactions or adverse reactions found. A registered nurse cosigned the original medication profile on 9/21/23, 8 days later, and had a medication reconciliation attached that documented major interactions found. The physical therapist missed the major interactions that the RN found 8 days later. During an interview on 1/11/23 at 10:10 a.m., the administrator (Adm#1) and the alternate administrator (Adm#2) acknowledged the above findings.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, it was determined the agency failed to ensure the plan of care included all safety measures to prevent injury in 1 of 7 records reviewed (P-7). resulting in the potential for a poor patient outcome. Findings include: P-7: The SOC was dated 12/29/23, with diagnoses that included multiple fracture of ribs and acute pain. During review of the Plan of Care (POC) on 1/9/24, it was documented that the patient had Plavix (Anticoagulant) ordered. No bleeding or anticoagulant precautions were documented on the POC. During an interview on 1/11/24 at 10:10 p.m., the administrator (Adm#1) acknowledged the findings and said the precautions should have been on the POC.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review and interview, it was determined the home health agency failed to ensure the physician orders were followed in 1 of 7 records (P-6) from a total of 7 records reviewed, resulting in the potential for unmet care needs for agency patients. Findings include: P-6: The start of care (SOC) was dated 9/13/23. The plan of care (POC) dated 9/13/23, identified the diagnoses of lumbar fusion and spinal stenosis. The POC documented physical therapy (PT) services ordered at a visit frequency of 2w2 and 1w7. During review of the record on 1/9/24, it was discovered that PT had a missed visit between 9/23/23 and 10/6/23. There was no documentation in the record explaining the missed visit. During an interview on 1/9/24 at 10:10 p.m., the administrator (Adm#1) acknowledged the findings.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure the skilled nurse performed ongoing assessments of the patient's surgical site for 1 (P-2) patient who underwent surgery and reported feeling a lump near the surgical site, from a total of 7 sampled records reviewed, resulting in the potential for worsening of condition, development and spread of infection and unmet care needs. Findings include: P-2: The patient's start of care was 1/1/24 with diagnoses that included Anterior Cervical Decompression surgery with Fusion. On 1/9/24 during a scheduled survey home visit with the Registered Nurse (RN #1), the patient was observed with a horizonal incision to her anterior neck. During the visit, the patient reported, "I feel a lump above my incision and some itching." RN #1 glanced at the patient's neck yet took no additional action. The plan of care instructed, "Assessment of Cervical surgical area for palpable edema..." RN #1 failed to follow the plan of care and assess/palpate the surgical area for edema. These findings were reviewed with and acknowledged by RN #1 upon completion of the visit and discussed with the Administrator and Alternate Administrator during an interview on 1/10/24 at 2:50 p.m. On 1/11/24, the Administrator approached this writer and stated, “I spoke with the nurse (RN #1), and she acknowledged that she didn’t assess the patient’s surgical incision. We’re sending her back out there to do another assessment.”

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 Occupational Therapy services were provided as ordered for 1 (P-2) patient who underwent cervical surgery, and 1 (P-6) patient with lumbar surgery, from a total of 7 sampled records reviewed, resulting in the potential for decline in physical functioning and unmet care needs. Findings include: P-2: The patient's start of care was 1/1/24 with diagnoses that included Cervical Disc Disorder and Anterior Cervical Decompression with Fusion. On 1/9/24 at 2:00 p.m., during the clinical record review, it was noted that the referral for home care services dated 12/28/23, ordered Skilled Nursing (SN), Physical Therapy (PT) and Occupational Therapy (OT) services to be provided. At the time of this review, OT services had not been provided. These findings were reviewed with and acknowledged by the Administrator (Adm #1) during an interview on 1/10/24 at 2:50 p.m. who reviewed the record and reported, "I don't think the nurse offered the services (OT) to the patient." No OT services had been provided by the survey's exit. P-6: The patient's start of care was 9/13/23, with diagnoses that included spinal stenosis with spinal fusion. During record review on 1/9/24, it was noted that the home care referral dated 9/6/23, had occupational therapy (OT) services ordered. There was no documentation in the record of any OT services being provided to the patient. These findings were acknowledged by the administrator (Adm #1) and the alternate administrator (Adm#2) during an interview on 1/11/24 at 10:10 a.m. Adm#1 said it looks like OT never went out to the patient.

The following condition level deficiencies were identified during an Emergency Preparedness Survey conducted by the Michigan Department of Licensing and Regulatory Affairs on 1/4/21 through 1/7/21 at: Central Home Health Care, Inc. 20245 W. 12 Mile Rd., Suite 100 Southfield, MI 48076 This agency had no additional branch locations The following condition level deficiency was identified: 42 CFR §484.102 Emergency Preparedness.

Establishment of the Emergency Program (EP) CFR(s): 484.102 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must 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: *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: Based on record review and interview, the Agency failed to develop an emergency preparedness plan that was clear, accessible, and included guidance for the Covid-19 pandemic, resulting in lack of direction for Agency personnel in the event of an actual emergency or disaster and unsafe, unmet care needs for all 26 patients actively serviced by this agency (E0004); failed to ensure an emergency plan existed that was based on a documented facility and community based risk assessment from an all hazards approach, including strategies for the Covid-19 global pandemic, resulting in the potential for lack of preparedness and poor patient and staff outcomes, in the event of an actual emergency (E0006); failed to develop and maintain an emergency preparedness communication plan that included contact information for patient's physicians, volunteers and entities under arrangement, which had the potential to negatively affect the health and safety of the 26 patients currently serviced by this agency, resulting in the lack of communication in the event of an actual emergency (E0030); failed to ensure all staff received initial and annual training in the Agency's emergency preparedness program, including training on the Covid-19 pandemic, resulting in staff being ill-prepared in the event of an actual disaster or emergency. This deficient practice could potentially affect the 33 direct and contracted staff employed by this agency, and all 26 patients currently serviced by this Agency (E0037). The cumulative effect of these systemic problems could potentially have a negative effect on all patients cared for by the home health agency in the event staff is not properly prepared for an emergency for the Condition of Participation of 42 CFR §485.102, Emergency Preparedness.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(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 was clear, accessible and included guidance for the Covid-19 pandemic, resulting in lack of direction for Agency personnel in the event of an actual emergency or disaster and unsafe, unmet care needs for all 26 patients actively serviced by this agency. Findings include: On 1/6/21 at 4:00 p.m., the agency's Emergency Preparedness documents were requested for review. The Administrator (Adm #1) provided a large binder titled "Emergency Preparedness." Upon review, it was noted that the binder contained multiple copies of documents printed from the Center for Disease Control (CDC) website. There was no Emergency Preparedness Plan enclosed. On 1/7/21 at 10:10 a.m., Adm #1 was asked of the whereabouts of the agency's Emergency Preparedness Plan was and reported, "I'll have to look for it." Adm #1 began searching in her computer for the documents, yet was unable to access them in her files. The Assistant Administrator (Adm #2) was called in to assist with locating the documents and reported, "There should be another binder." Adm #2 left to retrieve the requested documents. Upon return, Adm #2 placed a binder containing disheveled papers on the desk and began looking through them. Adm #2 then retrieved a document titled, "Agency Policy, Emergency Preparedness Plan" with a Revision date 1/2/20. The document had an organizational chart on it with no names to establish a clear delineation of duties. Adm #2 continued to search the binder for "the remainder of the plan...", stating "There are pages missing." Adm #2 left the office multiple times in search for additional pages to the Emergency Plan. The agency failed to have an Emergency Preparedness Plan in place that was accessible and organized with clearly established duties, in the midst of an actual emergency. Additionally, there was no language included in the Emergency Preparedness plan that addressed the Covid-19 global pandemic. Adm #1 then asked, "Can we just put our "Infection Control" documents in with our Emergency Preparedness documents, because it includes Covid-19. We will add everything to the plan. We've just been focusing everything on Covid-19. Everything is Covid." This finding was reviewed with and acknowledged by the Administrator and Assistant Administrator at the time of discovery.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) [(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 the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. *[For LTC facilities at §483.73(a)(1):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a)(1):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a)(2):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. This STANDARD is not met as evidenced by: Based on record review and interview, the Agency failed to ensure an emergency plan existed that was based on a documented facility and community based risk assessment from an all hazards approach, including strategies for the Covid-19 global pandemic, resulting in the potential for lack of preparedness and poor patient and staff outcomes, in the event of an actual emergency. Findings include: On 1/7/21 at 10:10 a.m., the agency's Emergency Preparedness documents were reviewed with the Administrator (Adm #1) and Assistant Administrator (Adm #2). The Risk Assessment, dated 3/3/20, was reviewed and noted to have identified Community based risks. Additionally, there was no mention of the Covid-19 global pandemic in the agency's Risk Assessment. Further, the agency's Emergency Preparedness Plan failed to include strategies to address the Covid-19 global pandemic. These findings were reviewed with and confirmed by Adm #1 and Adm #2 at the time of discovery.

Names and Contact Information CFR(s): 484.102(c)(1) [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years (annually for LTC).] The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on record review and interview, it was determined that the facility failed to develop and maintain an emergency preparedness communication plan that included contact information for patient's physicians, volunteers and entities under arrangement, which had the potential to negatively affect the health and safety of the 26 patients currently serviced by this agency, resulting in the lack of communication in the event of an actual emergency. Findings include: During a review of the agency's emergency preparedness documents with the Administrator (Adm #1) and Assistant Administrator (Adm #2), it was noted that there was no contact information for patient's physicians, volunteers, and other contract entities who provide services. These findings were reviewed with and confirmed by Adm #1 and Adm #2 at the time of discovery.

EP Training Program CFR(s): 484.102(d)(1) *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on interview, the Agency failed to ensure all staff received initial and annual training in the Agency's emergency preparedness program, including training on the Covid-19 pandemic, resulting in staff being ill-prepared in the event of an actual disaster or emergency. This deficient practice could potentially affect the 33 direct and contracted staff employed by this agency, and all 26 patients currently serviced by this Agency. Findings include: On 1/7/21 at 10:10 a.m., the agency's Emergency Preparedness documentation was reviewed with the Administrator (Adm #1) and the Assistant Administrator (Adm #2). A request was made to review the staff's initial training in emergency preparedness that included the topic of Covid-19, as well as annual training. No evidence of staff training had been provided by the survey's conclusion. There was no documented evidence that all Agency staff had received initial or annual training in emergency preparedness. These findings were reviewed with and acknowledged by Adm #1 and Adm #2 at the time of discovery.

The following standard and condition level deficiencies were identified during the Medicare recertification survey conducted on 1/4/21 through 1/7/21 by the Michigan Department of Licensing and Regulatory Affairs at: Central Home Health Care, Inc. 20245 W. 12 Mile Rd., Suite 100 Southfield, MI 48076 At the time of the survey, the agency did not operate any branch offices or subunits. The services the agency provides are: Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), Medical Social Work (MSW), Speech Therapy, and Home Health Aide (HHa) Clinical records reviewed for this survey: 3 records with home visits and 4 records without home visits for a total of 7 records reviewed. At the conclusion of the survey, (Central Home Health Care, Inc.) was found to be not in compliance with 42 CFR Part 484, requirements for Home Health Agencies. Condition level deficiencies were noted at: 42 CFR §484.55 Comprehensive Assessment of Patients. 42 CFR §484.102 Emergency Preparedness. 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).

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure the initial comprehensive assessment visit was completed by a registered nurse in 1 of 7 (MR# 1) records reviewed (See G514); failed to ensure the comprehensive assessment included baseline information that detailed the patient's current health at the time of admission for 1 of 7 (MR# 5) records reviewed (See G528); and failed to ensure the registered nurse conducted a comprehensive review of the patient's medications for any potential adverse effects such as: side effects, drug interactions, and duplicate drug therapy for 1 of 7 (MR# 7) records and failed to ensure the registered nurse performed a review of the patient's medication list in which therapy only services were ordered in 1 of 7 records (MR# 6) (See G536). The cumulative effect of these systemic problems resulted in the home health agency's inability to ensure the provision of quality health care in a safe environment for the condition of participation of 42 CFR §484.55, Comprehensive Assessment of Patients.

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- 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 performed the initial start of care comprehensive assessment for 1 (MR# 1) record in which both Nursing and Physical Therapy services were ordered, from a total sample of 7 records reviewed, resulting in the potential for unmet care needs. Findings include: MR #1: The patient's start of care (SOC) was 11/10/20 with diagnoses that included Rheumatoid Arthritis, Diabetes Mellitus and Urinary Tract Infection. A Physician's order for home care dated 11/6/20 ordered "SN (skilled nurse) for disease process management, OA, DM, UTI, Nocturia, Pain medication mgt, s/s infection, home safety, diet/hydration, fall precautions; PT Eval and treat, Rt Knee pain mgt, strengthening, improve transfers, standing balance, endurance, gait training, fall prevention." On 1/4/21 at 3:34 p.m., during a review of the clinical record, it was noted that the Physical Therapist conducted the initial assessment of the patient on 11/10/20. These findings were reviewed with and acknowledged by the Administrator (Adm #1) and the Assistant Administrator (Adm #2) during an interview on 1/6/21 at 2:56 p.m. Adm #1 reported, "The Nurse (RN #1) requested me to send the PT in first and she would go in after. The nurses are burned out. We made a special exception for her and I didn't have any other nurse at the time."

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 document review and interview, the agency failed to ensure the comprehensive assessment included baseline information that detailed the patient's current health at the time of admission for 1 of 7 (MR# 5) records reviewed, resulting in incomplete clinical information to assist in determining the needs of the patient which resulted in a poor outcome. Findings include: **Agency Policy: "Staff Competence-Employees" #2092 (revised 8/13/2019) stated, "Physical Therapy/Occupational Therapy-Rehab staff will demonstrate competency on Hands on assessment including hands on assessment, evaluation of respiratory status with auscultation and pulse-Ox if needed... will be performed at initial visit and all required re-evaluations." MR #5: The patient's start of care (SOC) was 9/26/20 with diagnoses that included acute congestive heart failure, dyspnea (difficulty in breathing), pleural effusion (excess fluid around the lungs), and acute kidney failure. The referral for home care dated 9/25/20, was from Providence hospital which ordered physical therapy (PT) services only. The two listed patient diagnoses on the referral were dyspnea and pleural effusion. During record review of the comprehensive assessment on 1/6/21, it was noted that under section M1400, PT documented the patient was short of breath with minimal exertion (eating or talking). However, PT failed to document the assessment of the patient's respiratory status (lungs sounds, oxygen saturation, or history). Review of a transfer summary dated 9/28/20 (2 days after admission), revealed the patient was re-admitted to the hospital for "fatigue, running fever 99, difficulty breathing." (sic). The agency failed to ensure PT had performed a comprehensive assessment at the SOC to potentially identify any respiratory concerns to alert the physician or skilled nursing. The administrator (Adm. #1) acknowledged the above findings during an interview on 1/6/21 at 11:40 am. Adm. #1 stated, "We will have an in-service to make sure this doesn't happen again. Physical therapy needs to do a much better job of assessing and documenting when opening a case."

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 document review and interview, the agency failed to ensure the comprehensive assessment included a review of all medications to identify any potential adverse effects and drug reactions for 1 of 7 (MR# 7) records reviewed, and failed to ensure a registered nurse performed a review of the patient's medication list in which therapy only services were ordered in 1 of 7 records (MR# 6) reviewed, resulting in the potential for harmful medication effects for all 156 patients serviced by this agency in the last 12 months. Findings include: **Agency Policy: "Plan of Care (485)" #0280 (revised 2/1/2018) stated, "Agency staff check all medications a patient may be taking to identify interactions & possible ineffective drug therapy or adverse reactions, significant side effects, drug allergies, and contraindicated medications, and promptly report any problems to the physician." MR #7: The admission date for this patient was 6/30/2020 with diagnoses which included quadriplegia, constipation due to neurogenic bowel, and DVT (deep vein thrombosis). The patient was re-certified 12/27/20 through 2/24/21. On 1/5/2021, review of the patient's medication reconciliation for re-certification noted the "Review" section was blank. Additionally, review of the previous medication reconciliation dated 10/27/2020 again by skilled nursing documented, "No changes have been made, and no major drug interactions." However, when the patient's 19 prescribed medications were entered "Drugs.com" (online pharmaceutical encyclopedia which provides drug information to healthcare professionals), it revealed 7 major/severe, 18 moderate interactions, and one duplication. No evidence was found in the clinical record that indicated communication with the physician regarding the above noted interactions had occurred. These findings were reviewed with and acknowledged by the Administrator (Adm. #1) during an interview on 1/6/21 at 1:10 PM. Adm. #1 stated, "I thought our system would catch these, we used to actually use something like Drugs.com. We'll have to look into that again until we can get this resolved with Devero (electronic medical records company). The Agency failed to notify the physician of any potential harmful effects from the patient's drug regimen as stipulated by the referenced policy above. MR #6: The patient's start of care (SOC) was 12/24/2020, with diagnoses that included: gangrene of left leg, hemiplegia (paralysis affecting one side of the body), left above the knee amputation, and repeated falls. The plan of care dated 12/24/20 ordered one discipline, physical therapy (PT) to evaluate and treat the patient. During review of the clinical record on 1/5/21, it was documented that the patient's medication review at the SOC was performed by PT#1. No evidence of a subsequent review by a registered nurse (RN) was found in the medical record. During an interview on 1/6/21 at 11:55 a.m., the Administrator (Adm. #1) was asked if she was aware of the CMS regulation that an RN is to perform a medication review in cases when therapy is the only discipline assigned. Adm. #1 stated, "Yes, normally we make sure this has been done."

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, it was determined that the Agency failed to ensure that Speech Therapy services were provided for 1 (MR #3) of 1 record with Speech Therapy services ordered, resulting in the potential for physical decline, and unmet care needs. Findings include: MR #3: The patient's start of care (SOC) was 12/15/20 with diagnoses that included Right sided hemiplegia (paralysis) following stroke, Aphasia (loss of ability to understand or express speech), Dysphagia (Difficulty swallowing) and Atrial Fibrillation. The clinical record review was conducted on 1/5/21 at 1:30 p.m. During the review, it was noted that a referral for home care services, dated 12/11/20, ordered "Physical Therapy (PT), Occupational Therapy (OT), Speech Therapy (ST), Social Work (MSW) and Home Health Aide (HHa)" services to be provided. At the time of the clinical record review, Speech Therapy services had not been provided. These findings were reviewed with and acknowledged by the Administrator (Adm #1) during an interview on 1/6/21 at 3:55 p.m., who reported, "We just did not want to overwhelm the patient. I'll call her (ST) to find out when she's going to see the patient." The Agency failed to provide Speech Therapy Services as ordered.

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on observation, documents reviewed, and interview, it was determined the Home Health Agency failed to perform training/evaluation prior to the aide providing services for 1 of 4 home health aide records reviewed (MR #7), out of a total of 7 records, resulting in the potential for having an unqualified aide providing personal care to patients. Findings include: **Agency Policy, "Home Health Aide Certification" #2076 (revised 1/27/20) stated, "Demonstrate competency in bed/bath/showering, transfer skills, ambulation skills, and any special skills as ROM, use of any special DMEs (durable medical equipment)/orthotics." MR #7: The admission date for this patient was 6/30/2020 with diagnoses which included quadriplegia, constipation due to neurogenic bowel, and DVT (deep vein thrombosis). The Plan of Care ordered aide services weekly for 9 weeks. During a skilled nursing home visit on 1/4/21, it was observed the patient had a specialized mechanical lift system engineered to enable the patient to be transferred from a motorized wheelchair to the bed using a suspended railing system. After the visit, the aide care plan was reviewed for instructions detailing how to transfer the patient using the mechanical lift system. No instructions were noted within the aide care plan. Review of the personnel file for Aide#1 revealed no documentation of training or evaluation concerning safe and appropriate use of the patient's specialized lift system. During an interview on 1/6/21 at 1:10 PM., the Administrator acknowledged the above findings. The agency failed to perform a competency testing/evaluation for Aide#1, prior to providing services, per the above agency policy.

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 Physical Therapy and Skilled Nursing prepared clear written patient care instructions for the home health aide regarding client needs, and safety precautions prior to providing care in 2 (MR#'s 1 and 7) of 4 records in which Home Health Aide services were ordered, from a total of 7 sampled records reviewed, resulting in the potential for the provision of unsafe care and unmet care needs. Findings include: MR #1: The patient's start of care (SOC) was 11/10/20 with diagnoses that included Rheumatoid Arthritis, Diabetes Mellitus and Urinary Tract Infection. hypertension, COPD (chronic obstructive pulmonary disease) and knee pain. The plan of care (POC) indicated the following: "Functional limitations: Poor endurance, unsteady gait, weakness..." The "HHA (Home Health Aide) Plan of Care" dated 11/27/20 documented the following assigned tasks: Bath: Tub, Shower: Use shower chair Assist with dressing, Assist with ambulation..." A Physician's Order dated 11/24/20 ordered "HHa starting 11/27/20 1w7 ... Aide to assist with personal care per care plan and tidy up bed & bathroom each visit, change linen PRN." During a review of the clinical record on 1/4/21 at 3:34 p.m., it was noted that the "HHA Plan of Care Plan" failed to include all the above-mentioned safety precautions, failed to indicate a frequency in which services and tasks were to be provided, failed to provide clear instruction on whether a bath or shower was to be provided and failed to include instructions to Tidy/Clean bathroom, bedroom and change bed linen as ordered. These findings were reviewed with and confirmed by the Administrator (Adm #1) during an interview on 1/6/21 at 3:18 p.m. MR #7: The admission date for this patient was 6/30/2020 with diagnoses which included quadriplegia, constipation due to neurogenic bowel, and DVT (deep vein thrombosis). The Plan of Care (POC) ordered aide services weekly for 9 weeks. During review of the POC/485 on 1/6/21, the following DME (durable medical equipment) and safety precautions were noted: "Motorized Hoyer lift, Overbed table with standing frame, Motorized wheelchair, Anticoagulant (bleeding) and Cardiac precautions, Frequent position change." Subsequent review of the Home Health Aide care plan failed to include any of the above DME, or safety precautions listed on the POC/485. These findings were reviewed with and confirmed by the Administrator (Adm #1) during an interview on 1/6/21 at 1:10 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 document review and interview, the agency failed to ensure transfer summaries were sent within 2 business days to the receiving facility/physician for 1 of 1 (MR# 5) record reviewed in which the patient was transferred from a total sample of 7 records, resulting in the potential to negatively affect all patients transferred from the agency in the past 12 months. Findings include: Agency Policy: "Discharge/Transfer" #0440, (Revised 10/1/2019), failed to contain language which stipulated required timeframes for both discharge and transfer summaries. MR #5: The patient's start of care (SOC) was 9/26/20 with diagnoses that included acute congestive heart failure, dyspnea (difficulty in breathing), pleural effusion (excess fluid around the lungs), and acute kidney failure. During record review on 1/6/21, it was noted that the patient was transferred to the hospital on 9/28/2020 through 10/5/20 due to difficulty in breathing. No documentation was found that indicated the hospital had received a transfer summary which reflected the patient's current medical condition. Further, records show the transfer summary was sent to the physician on 10/13/2020 (14 days late) at 11:01 AM. No documentation was found as to why the transfer summary was sent late. The Administrator acknowledged and agreed with the above findings during an interview on 1/6/21 at 12:50 PM. The Administrator stated, "We'll update our policy to include the needed timeframes and make sure we send out our summaries timely."