Every finding on record at Cns Homecare, Inc

On 4/25/23 through 4/27/23, the Michigan Department of Licensing and Regulatory Affairs conducted a recertification survey at CNS Home Care. This was a standard survey. The requirements for participation in Medicare at 42 CFR 484.102 Emergency Preparedness were not reviewed.

On 4/25/23 through 4/27/23, the Michigan Department of Licensing and Regulatory Affairs conducted a recertification survey concurrent with a vaccine mandate review at: CNS Home Care 1920 Livernois Troy, MI 48083 The agency has no branch locations. Records reviewed: 4 records with home visits; 6 records without home visits; for a total of 10 records reviewed. The agency was determined to be in compliance with the Covid-19 Vaccine requirement for Home Health Agencies. At the conclusion of the survey the agency was found not in 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 (MR's #3 and 4) of 2 patients observed during a home visit, was 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 10 sampled records reviewed, resulting lack of inclusion in planning, the potential for missed visits and unmet care needs. Findings include: MR #3: The patient's start of care (SOC) was 12/13/19. The period of review was 3/27/23 through 4/27/23 with diagnoses that included Exacerbation of Multiple Sclerosis and Cystostomy. During the clinical record review on 4/26/23 at 8:4110:00 a.m., it was noted that Skilled Nursing (SN), Occupational Therapy (OT) and Home Health Aide (HHa) services were ordered to be provided. On 4/26/23 at 8:00 a.m., a home visit was conducted with the Home Health Aide. During the visit, a request was made to review the patient's admission packet, to which he (patient) responded, "I have no idea where it is." Upon completion of the visit, the Home Health Aide informed the patient, "I'll probably be back out on Friday. I'll call first." There was no documented evidence that agency staff informed the patient, in advance, of proposed visits to be conducted to ensure the patient was included in the overall planning of his care. MR #4: The patient's SOC was 4/13/23 with diagnoses that included Right hip Replacement. During the clinical record review on 4/26/23 at 1:15 p.m., it was noted that Skilled Nursing (SN) and Physical Therapy (PT) services were ordered to be provided. On 4/26/23 at 11:30 a.m., a scheduled home visit was conducted with the Physical Therapist. During a review of the patient's admission packet, it was noted that there was no calendar of proposed visits to be made by the SN or PT. The above findings were reviewed with and acknowledged by the Director of Operations and Alternate Clinical Manager during an interview on 4/26/23 at 2:30 p.m.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to inform all patients that they could voice concerns/complaints at any time by calling the State of Michigan's toll-free hotline number, resulting in misleading information to enable patients or caregivers to voice complaints or ask questions. This deficient practice has the potential to negatively affect the health and well-being of all 448 patients admitted to the agency in the past 12 months. Findings include: On 4/25/23, the agency's start of care booklet titled, Home Health Admission Booklet, was reviewed. On pages 9 and 10 of the booklets, the complaint procedure is explained to patients as follows: "If you have a concern (complaint), please submit the concern verbally to the nurse...if not resolved...contact the Clinical Manager...if not resolved...notify the Administrator...complete the "Client Concern" form...return the completed form to the Supervising Nurse...if not resolved...You may also contact the state's toll-free home care hotline..." The patient with a concern (complaint) is instructed to go through many steps with the agency before contacting the state's toll-free hotline. A patient with a complaint is not required to go through steps with the agency. The patient is free at any time to contact the state's toll-free hotline number to voice concerns or complaints. On page 10 of the booklet, the patient is instructed to also contact the CHAP (Community Health Accreditation Partner) hotline phone number. The agency's deemed status with CHAP was withdrawn on 3/30/23 and CHAP no longer has oversight regarding patient complaints. The findings were reviewed with and acknowledged by the director of operations (Staff-B) during an interview on 4/25/23 at 11:15 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 comprehensive assessment included a thorough review of the patient’s medications to identify any potential adverse effects such as: side effects, drug interactions, and duplicate drug therapy; failed to ensure the physician was notified if indicated; and failed to ensure a registered nurse conducted a review of the patient’s medications for 6 of 10 (MR# 6, 8, 10, 1, 4, 5) records reviewed. This deficient practice results in the potential for unrecognized adverse effects due to medications that could negatively affect these patients. Findings include: MR#6: This 81-year-old patient was admitted to home care on 3/13/23 with diagnoses of hemiplegia (weakness or paralysis) of the dominant side and vascular dementia. The comprehensive assessment was conducted by the physical therapist on 3/13/23. Record review on 4/27/23, indicates the patient's medical record contains a "Patient Medication Record" that lists the patient's medications and a medication review acknowledgement signed by the physical therapist on 3/13/23. There was no documented evidence that the patient's medications had been reviewed by a registered nurse (RN). During an interview on 4/27/23 at 1:35 p.m., the clinical manager (Staff-D) looked over the findings and confirmed that the medications were not reviewed by an RN. MR#8: This 88-year-old patient was admitted to home care on 3/10/23 with diagnoses of spondylosis thoracolumbar region (a type of arthritis in the mid to lower spine) and disc degeneration. The comprehensive assessment was conducted by the physical therapist on 3/10/23. Record review on 4/27/23, indicates the patient's medical record contains a "Patient Medication Record" that lists the patient's medications and a medication review acknowledgement signed by the physical therapist on 3/10/23. There was no documented evidence that the patient's medications had been reviewed by an RN. MR#10: This 86-year-old patient was admitted to home care on 6/24/22 with diagnoses of a left femur fracture, Alzheimer's disease, and dementia. Record review on 4/25/23, indicates the comprehensive assessment was conducted by the RN on 6/24/22. Section M2001 Drug Regimen Review of the comprehensive assessment indicates that no issues were found during the review. The Patient Medication Record dated 6/24/22, notes that the physician was not contacted regarding medication discrepancies and not notified of severe medication interactions. On 4/26/23, Staff-E (RN) provided documentation of a medication interaction report generated utilizing the agency's medical record software. The interactions report indicates duplicate drug therapy for Atenolol +Vasotec +Hydralazine + Lasix. The report also indicates a review is suggested for 4 medications and that there are potential interaction risks for 6 of the patient's medications. There was no documentation to indicate the physician was informed of the duplicate drug therapies and the potential interaction risks. The agency failed to follow its own patient care policy titled, Medications (Section 4 page 16, not dated) which states, "All prescribed and over the counter drugs that the patient is currently taking is inputted into the Agency's point of care system. The clinician will use the point of care system to reconcile the medication list for drug reactions, duplicate therapy, drug interactions, and drug adverse effects...Any significant issues identified will be immediately brought to the physician's attention." During an interview on 4/27/23 at 1:35 p.m., the clinical manager (Staff-D) looked over the medical record and acknowledged the findings. MR #1: The patient's start of care (SOC) was 3/28/23 with diagnoses that included Hypertensive Heart Disease and Congestive Heart Failure. During the record review on 4/25/23 at 11:55 a.m., it was noted that section M2001 of the Initial Comprehensive Assessment, completed by the Registered Nurse (RN) documented "No issues found during review." There was no drug interaction report to reference to support the findings of no issues found. On 4/26/23 at 3:20 p.m., during an interview, the Alternate Clinical Manager was asked to provide evidence of the drug review conducted at the SOC, however, was unable to do so. A drug interaction report dated 4/26/23 was submitted which reflected positive drug to drug interactions and duplicate drugs. In light of these findings, it was determined that the agency failed to ensure the comprehensive assessment included a thorough review of all the patient's medication in order to determine the presence of any untoward findings. These findings were reviewed with and acknowledged by the Director of Operations and Alternate Clinical Manager at the time of discovery. MR #4: The patient's SOC was Right Hip Replacement. During the record review on 4/26/23 at 1:15 p.m., it was noted that section M2001 of the Initial Comprehensive Assessment completed by the RN documented, "No issues found during review." Further review revealed no documented evidence to support the findings of no identified issues. The patient's 10 prescribed medications were entered in "Drugs.com" (online drug interaction checker) and revealed 2 major drug to drug interactions; 12 moderate drug to drug interactions, 5 drug to food interactions; 2 duplicate drugs; 1 major drug to food interaction. Additionally, during a home visit on 4/26/23 at 11:30 a.m., it was noted that a medication (Meloxicam) had not been included in the drug review process. The agency failed to ensure that a comprehensive drug review was conducted that included all the patient's prescribed medications. These findings were reviewed with and acknowledged by the Director of Operations and Alternate Clinical Manager during an interview on 4/26/23 at 2:30 p.m. MR #5: The patient's SOC was 4/20/23 with diagnoses that included Hypertensive Chronic Kidney Disease and Ataxia. During the record review on 4/27/23 at 11:10 a.m., it was noted that section M2001 of the Initial Comprehensive Assessment, completed by the Physical Therapist, documented "No issues found during review." Further review revealed that the Registered Nurse had not provided oversight of the drug review process in accordance with this requirement. Additionally, the patient's 13 prescribed medications were entered in Drugs.com and revealed 1 major drug to drug interaction, 12 moderate drug to drug interactions and 4 duplicate drugs. There was no documented evidence that a comprehensive drug review had been conducted in accordance with this requirement. These findings were reviewed with and acknowledged by the Director of Operations during an interview on 4/27/23.

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 covered all pertinent interventions with reportable parameters, and objectively measurable goals specific to the needs of the patient for 5 (MR's #7, 8, 2, 3, 4) records, from a total of 10 sampled records reviewed, resulting in patients not receiving care specific to their individual needs and the potential for poor patient outcomes. Findings include: MR#7: This 91-year-old patient was admitted to home care on 3/18/23 with diagnoses of pressure ulcers of the back, buttock, and hip. The 3 /18/23 plan of care ordered weekly skilled nursing care. On the 3/18/23 start of care comprehensive assessment, the nurse documents the patient's pain intensity to the lower back and both shoulders is rated at 10 (scale 0 no pain to 10 worst pain). On the next visit on 3/22/23, the patient rated her pain at a 10 severe all the time to both shoulders and back. During record review on 4/27/23, it was noted that the plan of care failed to include a reportable parameter for pain to aid in determining when the physician should be contacted. This is a patient that reports severe pain and is prescribed Tramadol, Acetaminophen, and Lidocaine patches to shoulders to help manage pain. The findings were reviewed with and acknowledged by Staff-D (clinical manager) during an interview on 4/27/23 at 1:35 p.m. MR#8: This 88-year-old patient was admitted to home care on 3/10/23 with diagnoses of spondylosis thoracolumbar region (a type of arthritis in the mid to lower spine) and disc degeneration. The 3 /10/23 plan of care ordered weekly physical therapy (PT) care. On the 3/10/23 start of care comprehensive assessment, the PT documents the patient's pain intensity to the lower back is rated at 7 (scale 0 no pain to 10 worst pain). During record review on 4/27/23, it was noted that the plan of care failed to include a reportable parameter for pain to aid in determining when the physician should be contacted. This is a patient that reports a pain intensity of 7 and is prescribed Acetaminophen with Codeine (300-30 milligrams) every 6 hours as needed to help manage pain. The findings were reviewed with and acknowledged by Staff-D during an interview on 4/27/23 at 1:35 p.m. MR #2: The patient's start of care (SOC) was 3/2/23 with diagnoses that included Hypertensive & Chronic Kidney Disease with Heart Failure and Congestive Heart Failure, Diabetes and Pressure Ulcer Left buttock. During the clinical record review on 4/25/23 at 1:25 p.m., it was noted that the POC failed to include interventions, reportable parameters and associated measurable goals that addressed the above diagnoses. There were no pain parameters in which to notify the Physician and no reportable weight parameters. Additionally, there was no instruction on the frequency in which to monitor the patient's blood sugars and no wound care orders. The POC was void of the required elements in order to meet the needs of the patient, in accordance with this requirement. These findings were reviewed with and acknowledged by the Director of Operations and Alternate Clinical Manager during an interview on 4/26/23. MR #3: The patient's SOC was 12/13/19. The period of review was 3/27/23 through 4/27/23 with diagnoses that included Exacerbation of Multiple Sclerosis and Cystostomy. during the record review on 4/26/23 at 10:00 a.m., it was noted that the POC was void of interventions, reportable parameters and associated measurable goals that addressed the identified diagnoses. There were no interventions to monitor and assess pain with reportable parameters. During the review, it was noted that the patient suffered with constipation which required manual extraction of feces. This information was not included in the POC. The patient was identified as high risk for falls, however, there were no interventions to prevent falls and no associated goals. These findings were reviewed with and acknowledged by the Director of Operations and Alternate Clinical Manager during an interview on 4/26/23 at 2:50 p.m. MR #4: The patient's SOC was 4/13/23 with diagnoses that included Right Hip Replacement. During the clinical record review on 4/26/23 at 1:15 p.m., it was noted that the POC was void of interventions to monitor pain with reportable parameters in which to notify the Physician. There was no mention of the patient's fresh surgical incision with interventions to monitor for signs of infection. Additionally, there were no associated goals with regard to the above diagnosis. These findings were reviewed with and acknowledged by the Director of Operations and Alternate Clinical Manager during an interview on 4/26/23 at 2:55 p.m.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, it was determined that the agency failed to provide 2 (MR's 3 and 4) of 2 patients observed during home visits, with a Medication Profile that included the names, dosages and frequencies of the patient's prescribed medications, in plain language, from a total of 10 sampled records reviewed, resulting in lack of direction for medication administration and the potential for improper use of medications. Findings include: MR #3: The patient's start of care (SOC) was 12/13/19. The period of review was 3/27/23 through 4/27/23 with diagnoses that included Exacerbation of Multiple Sclerosis and Cystostomy. During the clinical record review on 4/26/23 at 8:4110:00 a.m., it was noted that Skilled Nursing (SN), Occupational Therapy (OT) and Home Health Aide (HHa) services were ordered to be provided. On 4/26/23 at 8:00 a.m., a joint home visit was conducted with the Home Health Aide. During a review of the patient's admission packet, it was noted that there was no Medication Profile available for review. The patient was queried regarding the whereabouts of the required document and expressed no knowledge. MR #4: The patient's SOC was 4/13/23 with diagnoses that included Right hip Replacement. During the clinical record review on 4/26/23 at 1:15 p.m., it was noted that Skilled Nursing (SN) and Physical Therapy (PT) services were ordered to be provided. On 4/26/23 at 11:30 a.m., a scheduled home visit was conducted with the Physical Therapist. During a review of the patient's admission packet, it was noted that there was no Medication Profile in the patient's admission packet that listed the patient's prescribed medications, dosages, and side effects. The patient was queried and expressed no knowledge of ever having a Medication list provided by the Agency. The above findings were reviewed with and acknowledged by the Director of Operations and Alternate Clinical Manager during an interview on 4/26/23 at 2:30 p.m.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure the patient was provided written information with the correct name and contact information for the agency's clinical manager for 1 of 2 (MR#8) joint survey home visits, resulting in a lack of information to enable patients to contact the clinical manager. this deficient practice has the potential to negatively affect the agency's 82 current patients. Findings include: The agency's start of care folder was reviewed on 4/25/23 at 11:00 a.m. During review of the booklet titled, Home Health Admission Booklet, it was noted that the back page of the booklet listed the name, email, and phone number for Staff-C (former clinical manager). An interview was conducted with Staff-B (director of operations) on 4/25/23 at 11:15 a.m. Staff-B explained that Staff-C was the clinical manager but had left the agency about 5 months ago. Staff-B acknowledged that the information in the booklet had not been updated to reflect Staff-D as the current clinical manager along with contact information for Staff-D. MR#8: During a joint survey home visit with the physical therapist on 4/26/23 at 10:00 a.m., it was observed that the agency's Admission Booklet listed the name and contact information for Staff-C. The information had not been updated to reflect the name and contact information for Staff-D.

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 record review and interview, the agency failed to ensure occupational therapy performed an assessment of the patient's health status and needs in 1 of 2 (MR# 10) records reviewed with occupational therapy services, resulting in the potential for unidentified health concerns, decline in physical functioning, and poor patient outcomes. Findings include: MR#10: This 86-year-old patient was admitted to home care on 6/24/22 with diagnoses of a left femur fracture, Alzheimer's disease, and dementia. The 6/24/22 plan of care orders occupational therapy (OT) to evaluate and treat this patient. During record review on 4/25/23, it was noted that OT evaluated this patient on 7/7/22, which is 13 days after the patient was admitted to home care. There was no documented evidence the patient had delayed the OT assessment and no documentation that the physician was informed of the delay in OT services. During an interview on 4/27/23 at 1:35 p.m., the clinical manager (Staff-D) looked over the findings and Staff-B (director of operations) explained that the patient should have been evaluated by OT within 2 to 3 days after the physician's order.

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 the physical therapist provided services as ordered by the physician in the plan of care for 1 of 2 (MR# 6) records reviewed with physical therapy only services, resulting in the potential for poor patient outcomes for this patient. Findings include: MR#6: This 81-year-old patient was admitted to home care on 3/13/23 with diagnoses of hemiplegia (weakness or paralysis) of the dominant side and vascular dementia. The 3/13/23 plan of care orders the physical therapist (PT) to provide two visits each week for six weeks. During record review on 4/27/23, it was noted that the PT failed to provide visits in weeks five and six. The last visit documented by PT was on 4/7/23. There was no documented evidence to indicate the patient had declined visits and no evidence the physician was informed that visits had not been provided in weeks 5 & 6. During an interview on 4/27/23 at 1:35 p.m., the clinical manager (Staff-D) looked over the findings and confirmed that the PT had not provided visits in weeks 5 & 6. Staff-D acknowledged that visit notes are due within 48 hours after the provision of care.

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 observation, interview and record review, it was determined the Agency failed to ensure Skilled Nursing prepared clear written patient care instructions for the home health aide regarding client needs, and safety precautions prior to the provision of care in 3 (MR#'s 1, 3, 5) of 4 records in which Home Health Aide services were ordered, from a total of 10 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 3/28/23 with diagnoses that included Hypertensive Heart Disease and Congestive Heart Failure. The plan of care (POC) ordered Home Health Aide services to be provided at a frequency of 1x/wk. x 4 wks. During a review of the Aide Care Plan on 4/25/23 at 11:55 a.m., it was noted that the plan was void of the following safety precautions and durable medical equipment as indicated in the POC/485: Slow Position Change, O2 precautions, Support during transfer and ambulation, Fall precautions, Diabetic precautions, Pacemaker precautions, Dyspnea with moderate exertion, Impaired vision, Pressure ulcers, bleeding precautions; Nebulizer. These findings were reviewed with and acknowledged by the Director of Operations and Alternate Clinical Manager during an interview on 4/26/23 at 3:20 p.m. MR #3: The patient's SOC was 12/13/19. The period of review was 3/27/23 through 4/27/23 with diagnoses that included Exacerbation of Multiple Sclerosis and Cystostomy. On 4/26/23 at 8:00 a.m., during a scheduled home visit with the Home Health Aide, it was noted that the patient was bedbound and totally dependent on staff for all areas of mobility and required a mechanical lift (Hoyer Lift) to aid in transfers, and bilateral bed siderails to prevent falls. During the home visit, the patient demonstrated muscle spasms of his upper and lower extremities. Upon completion of the visit, the Aide left the right siderail down. When asked if she would be leaving it down, the Aide responded, "Yes." The Aide care plan failed to include siderails as a needed precaution. On 4/26/23 at 10:00 a.m., during a review of the POC/485, the following precautions/equipment were noted: Motorized wheelchair, Dyspnea with moderate exertion, High risk for falls. None of the aforementioned precautions had been included in the Aide plan of care. These findings were reviewed with and acknowledged by the Director of Operations and Alternate Clinical Manager during an interview on 4/26/23 at 2:50 p.m. MR #5: The patient's SOC was 4/20/23 with diagnoses that included Hypertensive Chronic Kidney Disease and Ataxia. During the clinical record review on 4/27/23 at 11:10 a.m., it was noted that the POC indicated the following: "Safety Measures: Support during transfer and ambulation, Anticoagulant/Bleeding precautions, Fall Precautions..., Functional limitations: bowel/bladder incontinence, dyspnea (difficulty breathing) ..., Activities: Cane." During the review, the Aide Care Plan failed to include the aforementioned precautions. These findings were reviewed with and acknowledged by the Director of Operations and Alternate Clinical Manger during an interview on 4/27/23.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the home health aide provided care in accordance with the plan of care for 3 of 4 (MR's #10, 1, 3) patients in which aide services were provided, resulting in the potential for a poor patient outcome. Findings include: MR#10: This 86-year-old patient was admitted to home care on 6/24/22 with diagnoses of a left femur fracture, Alzheimer's disease, and dementia. The 6/24/22 plan of care orders the aide to provide one visit each week for three weeks. The aide care plan dated 6/24/22, instructs the aide to weigh the patient once a week. The aide provided three visits dated 6/30/22, 7/8/22, and 7/15/22. During record review on 4/25/23, it was noted that the aide failed to weigh the patient once each week as instructed by the registered nurse. During an interview on 4/27/23 at 1:35 p.m., the clinical manager (Staff-D) looked over the findings and confirmed that the aide had not weighed the patient as instructed. MR #1: The patient's start of care (SOC) was 3/28/23 with diagnoses that included Hypertensive Heart Disease with Heart Failure and Congestive Heart Failure. During the record review on 4/25/23 at 11:55 a.m., it was noted that the "Aide Care Plan" instructed the Aide to weigh the patient every visit. A review of the Aide visit notes dated 3/30/23, 4/5/23, 4/11/23 and 4/20/23 revealed that the Aide failed to obtain the patient's weight in accordance with the plan of care. These findings were reviewed with and acknowledged by the Director of Operations and Alternate Clinical Manager during an interview on 4/26/23 at 3:20 p.m. MR #3: The patient's SOC was 12/13/19. The period of review was 3/27/23 through 4/27/23 with diagnoses that included Exacerbation of Multiple Sclerosis and Cystostomy. The Aide Care Plan instructed the Aide to check the patient's blood pressure, pulse, respiration and temperature every visit. During the visit, the Aide failed to check the patient's temperature. The Care Plan also instructed the Aide to transfer the patient to chair via Hoyer lift (mechanical lift) every visit. Upon completion of the visit, the Aide was queried as to why she failed to follow the plan of care and transfer the patient with use of the Hoyer lift and responded, "I usually just put "refused" because I never do that." The Aide failed to provide care in accordance with the Aide Care Plan. These findings were reviewed with and acknowledged by the Director of Operations and Alternate Clinical Manager during an interview on 4/26/23 at 2:50 p.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 record review and interview, the agency failed to ensure the clinical record contained clinical notes for 1 of 2 (MR# 6) records reviewed with physical therapy only services, resulting in a lack of information for the physician and all agency staff caring for this patient. Findings include: MR#6: This 81-year-old patient was admitted to home care on 3/13/23 with diagnoses of hemiplegia (weakness or paralysis) of the dominant side and vascular dementia. The 3/13/23 plan of care orders the physical therapist (PT) to provide two visits each week for six weeks. During record review on 4/27/23, it was noted that the PT failed to document clinical notes in weeks five and six. The last clinical note documented by PT was on 4/7/23. There was no documented evidence to indicate the patient had declined visits in weeks 5 & 6. During an interview on 4/27/23 at 1:35 p.m., the clinical manager (Staff-D) looked over the findings and confirmed that the PT had not documented clinical notes in weeks 5 & 6. Staff-D acknowledged that notes are due within 48 hours after the provision of care.

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 detailed discharge summary was sent to the physician within 5 business days of discharge for 2 of 3 (MR's #9, 2) records of patients discharged from agency services, resulting in a lack of information to ensure continuity of care and the potential for unmet care needs. Findings include: MR#9: This patient was admitted to the agency on 5/26/22. During record review on 4/25/23, it was noted that the patient was discharged from the agency by the physical therapist on 7/20/22. There was no documented evidence that a detailed discharge summary was sent to the physician within 5 business days of discharge. The agency's policy titled, Discharge Documents (section 4 page 6, not dated) states, "If requested, the physician will receive a copy of a discharge summary." The agency's policy fails to align with federal regulations that require a discharge summary to be sent to the primary care practitioner or health care professional who will be responsible for providing care and services to the patient after discharge from the home health agency within 5 business days of the patient's discharge. The findings were reviewed with the clinical manager (Staff-D) during an interview on 4/27/23 at 1:35 p.m. Staff-D reviewed the medical record and noted that the discharge summary was sent to the physician on 8/4/22, which is 15 days after the patient was discharged from the agency. MR #2: The patient's start of care (SOC) was 3/2/23 with diagnoses that included Hypertensive Chronic Kidney Disease, congestive Heart Failure and Pressure Ulcer Left buttock. During the clinical record review on 4/25/23 at 1:25 p.m., it was noted that the Plan of Care ordered Skilled Nursing (SN), Physical Therapy (PT) and Occupational Therapy (OT) services to be provided. The patient was discharged from PT services on 4/4/23 and discharged from OT services on 4/5/23. There was no documented evidence that the discharge summaries had been forwarded to the Physician within 5 days of the date of discharge from the ordered services. These findings were reviewed with and acknowledged by the Director of Operations and Alternate Clinical Manager during an interview on 4/26/23.