Every finding on record at Compassionate Home Health Services, Inc

On 6/13/23 through 6/15/23, the Michigan Department of Licensing and Regulatory Affairs conducted a recertification survey at Compassionate Home Health Services. This was a standard survey. The requirements for participation in Medicare at 42 CFR 484.102 Emergency Preparedness were not reviewed.

A recertification survey was conducted by the Michigan Department of Licensing and Regulatory Affairs from 6/13/23 through 6/15/23 at: Compassionate Home Health Services 35 S. Johnson St. suite 3B Pontiac, MI 48341 The agency had no additional locations at the time of survey. 7 records were reviewed which included 3 active records with home visits, 2 active records with no home visits and 2 discharge records. At the conclusion of the survey the agency was found to be out of compliance at the standard level with the conditions of participation at 42 CFR Part 484, home health agencies.

Written notice of patient's rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient's rights and responsibilities under this rule, and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure patients received written notice of the agency's transfer and discharge policies, resulting in a lack of information regarding discharge and transfer rights for all 53 patients admitted to the agency in the past 12 months. Findings include: The agency provides a start of care booklet to each new patient. The booklet was reviewed on 6/13/23. During the review, it was noted that the booklet failed to include written notice of the agency's transfer and discharge policies. The findings were reviewed with and acknowledged by the Administrator (Admin-A) during an interview on 6/15/23 at 1:55 p.m.

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure patients were informed of the Administrator's business address, resulting in the potential for patient complaints or concerns to go unaddressed which could negatively affect the quality of care for the agency's 23 current patients. Findings include: During review of the agency's start of care booklet on 6/13/23, it was noted that the back page of the booklet indicated the address of the agency was in Oak Park, Michigan. On page 14, patients and caregivers are directed to contact the agency at the same address in Oak Park. The agency is currently located at a different address in Pontiac, Michigan. During an interview on 6/15/23 at 1:55 p.m., the Administrator (Admin-A) explained that the agency had moved to the current address in Pontiac in January of 2023. Admin-A acknowledged that the patient booklet had not been updated to reflect the Administrator's current business address.

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, record review, and interview, the agency failed to ensure the patient participated in care planning and was informed of the time and frequency of visits for 1 of 7 (P-7) records reviewed, resulting in anxiety and frustration for this patient. Findings include: P-7: This patient was admitted to homecare on 6/8/23 with diagnoses of sepsis, pneumonia, and chronic obstructive pulmonary disease. The 6/8/23 plan of care ordered nursing and physical therapy (PT) services for this patient. The nurse provides one visit each week for 5 weeks and the PT provides two visits each week for 5 weeks. During a joint survey home visit with the nurse on 6/14/23 at 10:00 a.m., the patient expressed surprise at the nurse showing up for a visit and stated he was expecting the nurse tomorrow, on Thursday. The patient also expressed that he has been waiting for his visit with the PT since 8:00 a.m. this morning. The PT has not shown up for the visit and has not called and informed the patient of the delay in care. The patient verbalized that he was upset and frustrated with PT services this morning. The agency provides each patient with a start of care booklet that contains 2 pages for calendar entries for staff to utilize to coordinate and schedule care with the patient. The patient's calendar was blank and was not being utilized by agency staff. The patient had 2 personal calendars in the home and those were observed to also be blank of information regarding nursing or PT visits. Record review on 6/14/23 indicates that the PT provided a visit on 6/12/23 at 7:30 a.m. and that the visit on 6/14/23 was provided at 4:40 p.m. and not at 8:00 a.m. as expected by the patient. The findings were reviewed with and acknowledged by the Administrator (Admin-A) during an interview on 6/15/23 at 1:55 p.m.

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on record review, the Agency failed to ensure the patient received proper written Notice of Medicare Provider Non-Coverage in advance of the Agency terminating on-going care for 1 (P-1) of 2 discharged records, resulting in the patient being denied the right to appeal the decision to end Medicare covered services. Findings include: P-1: The patient's start of care was 12/22/22 with diagnoses that included Hypertensive Heart disease with Heart Failure. During the clinical record review on 6/13/23 at 1:15 p.m., it was noted that the patient was discharged from the Agency's services on 1/18/23. The Notice of Medicare Provider Non-Coverage was provided to and signed by the patient on the same day of discharge (1/18/23). This resulted in the patient being ill-advised, within the required time, of his rights to appeal the decision to end services. The Agency failed to ensure the patient received proper written Notice of Medicare Provider Non-Coverage no later than 48 hours prior to the end of covered services, as per this requirement.

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to advise patients of the names, addresses and telephone numbers of Federally funded and State funded entities that serve the areas where the patients reside, resulting in a lack of information regarding available resources which has the potential to negatively affect the quality of care for the agency's 23 current patients. Findings include: On 6/13/23, the contents of the agency's start of care booklet were reviewed. The booklet failed to include documentation of the names, addresses and phone numbers for the following Federally funded and State funded agencies: Center for Independent Living, Protection and Advocacy Agency, and Aging and Disability Resource Center. The findings were reviewed with and confirmed by the Administrator (Admin-A) during an interview on 6/15/23 at 1:55 p.m.

Access to auxiliary aids and language service CFR(s): 484.50(c)(12) Be informed of the right to access auxiliary aids and language services as described in paragraph (f) of this section, and how to access these services. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure patients were informed of their right to access auxiliary aids and language services and how to access these services, resulting in a lack of information and resources for all patients with disabilities or limited English proficiency. Findings include: On 6/13/23, the contents of the agency's start of care booklet were reviewed. The booklet failed to include documentation of the patient's right to access auxiliary aids for persons with disabilities and access to language services for patients with limited English proficiency. The booklet also failed to provide information for patients regarding how to access these services. The findings were reviewed with and acknowledged by the Administrator (Admin-A) during an interview on 6/15/23 at 1:55 p.m.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the initial assessment visit was conducted within 48 hours of referral for 2 of 7 (P#'s 6, 1) records reviewed, resulting in a delay in determining the immediate care and support needs for these patients. Findings include: P-1: The patient's start of care (SOC) was 12/22/22 with diagnoses that included Hypertensive Heart Disease with Heart Failure. During the clinical record review on 6/13/23 at 1:15 p.m., it was noted that the referral for home care dated and faxed to the Agency on 12/16/22, ordered Skilled Nursing (SN) and Medical Social Work (MSW) services to be provided. Upon further review, it was noted that services were started on 12/22/22. This was 6 days after the date of the referral. The Agency failed to ensure the SN conducted the SOC assessment within 48 hours of the date of the referral. P-6: This 84-year-old patient was admitted to home care on 3/16/23 with diagnoses of metabolic encephalopathy (chemical imbalance in the blood that affects the brain) and gastric ulcer with hemorrhage. During record review on 6/14/23, it was noted that the referral for home care services was faxed from the skilled facility to the agency on 3/10/23. The fax stated the patient would be discharged from the skilled facility to home on 3/12/23 and the patient would need skilled nursing, physical therapy, occupational therapy, and aide services. The start of care comprehensive assessment was conducted by the nurse on 3/16/23, which is 6 days after the referral and 4 days after the patient was discharged from the skilled facility. There was no documentation to indicate the patient's discharge from the skilled facility was delayed and no documentation to indicate the patient had requested a delay in home care services. The findings were reviewed with the administrator (Admin-A), the clinical manager (CM-B), and the consultant (Consultant-C) during an interview on 6/15/23 at 1:55 p.m. Consultant-C reviewed the medical record and explained that care was delayed due to authorization for home care services from the patient's medical insurance provider. There was no documentation to indicate the physician was informed of the delay in home care.

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, the Agency failed to ensure the comprehensive assessment accurately reflected the patient's condition at the start of care for 1 (P-1) of 2 discharged records, from a total of 7 sampled records reviewed, resulting in the potential for unidentified continuing health needs and poor patient outcomes. Findings include: P-1: The patient's start of care (SOC) was 12/22/22 with diagnoses that included Hypertensive Heart Disease with Heart Failure. During the clinical record review on 6/13/23 at 1:15 p.m., it was noted that the plan of care (POC) ordered Skilled Nursing (SN) and Medical Social Work (MSW) services to be provided. Section M1021 of the Initial Comprehensive Assessment dated 12/22/22, listed multiple diagnoses. There were no associated dates of onset or exacerbation for any of the listed diagnoses. There was no information provided to determine if the listed diagnoses were resolved or required continued monitoring and care. Additionally, there was no documented weight, actual or stated in order to establish a baseline in which to monitor due to the patient's diagnosis of heart failure. Section M2001 (Medication Review) documented, "No issues found during review." However, during the record review, it was noted that drug interactions had been identified. The Agency failed to ensure the Comprehensive Assessment accurately reflected the patient's health condition at the start of care.

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 review of all medications to determine any adverse effects and duplicate drug therapy in 1 (P-5) record, from a total of 7 sampled records reviewed, resulting in the potential for harmful medication side effects or interactions. Findings include: P-5: This 67-year-old patient was admitted to home care on 5/24/23 with diagnoses of atherosclerotic heart disease, non-stemi myocardial infarction, and congestive heart failure. During record review on 6/14/23 at 2:00 p.m., it was noted that the plan of care failed to list Diclofenac as one of the patient’s medications. There is no evidence that Diclofenac had been included in the review by RN-A for possible adverse effects or drug interactions. The findings were reviewed and acknowledged with the administrator (Admin-A), the clinical manager (CM-B), and the consultant (Consultant-C) during an interview on 6/15/23 at 2:15 p.m.

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on record review, the Agency failed to ensure the comprehensive assessment was updated and revised in 1 (P-1) of 1 record in which the patient was transferred to an inpatient facility related to elevated blood glucose levels, from a total of 7 sampled records reviewed, resulting in lack of information in determining the care and support needs of the patient. Findings include: P-1: The patient's start of care (SOC) was 12/22/22 with diagnoses that included Hypertensive Heart Disease with Heart Failure. During the record review on 6/13/23 at 1:15 p.m., it was noted that the patient was transferred to the hospital on 1/4/23 due to elevated blood glucose levels. A Skilled Nursing (SN) visit noted dated 1/4/23 documented, "BS (blood sugar) emergent at 524..., Patient seen for SN visit. Vitals stable, bs (blood sugar) log checked and blood sugar today was 501 and 524. Rechecked and meter read "high." Caregiver called and ambulance called." According to the Centers for disease control (CDC) "A fasting blood sugar level of 99 mg/dL or lower is normal, 100 to 125 mg/dL indicates you have prediabetes, and 126 mg/dL or higher indicates you have diabetes." Further review of the clinical record revealed that no Transfer Oasis/Comprehensive Assessment had been completed and updated to reflect the patient's current health crisis. The Agency failed to ensure the comprehensive assessment was updated and revised in accordance with this requirement.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on record review the Agency failed to ensure the Comprehensive Assessment was updated and completed at the time of discharge from the agency's services in 1 (P-1) of 2 discharged records, from a total of 7 sampled records reviewed, resulting in no indication of the patient’s progression towards their identified goals and the potential for unmet continuing care needs. Findings include: P-1: The patient's start of care (SOC) was 12/22/22 with diagnoses that included Hypertensive Heart Disease with Heart Failure. During the record review on 6/13/23 at 1:15 p.m., it was noted that the plan of care ordered Skilled Nursing (SN) and Medical Social Work (MSW) services to be provided. The patient was discharged from the Agency's services on 1/18/23. Upon review, the Discharge Comprehensive Assessment (Oasis) was noted to be incomplete/inaccurate, such as: the section titled integumentary Status documented "No problems identified", however, during the record review, the SN identified small lesions to the patient's skin that were questioned to be bed bug associated; Cardiac Status documented "No problems identified, however the patient was noted to have experienced weakness throughout the course of care, according to the SN visit notes. The section titled Discharge Readiness was left blank. The Agency failed to ensure the discharge comprehensive assessment was updated/accurate/completed to reflect the patient's condition at the time of discharge.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the plan of care included appropriate interventions with reportable parameters, safety measures and objectively measurable goals specific to the individualized needs of the patient in 6 (P-1, P-3, P-4, P-5, P-6, P-7) records, from a total of 7 sampled records reviewed, resulting in the potential for poor patient outcomes and unmet care needs. Findings include: P-3: The start of care (SOC) was dated 6/7/23. The POC identified diagnoses of hypertensive chronic kidney disease with stage 1-4 renal failure. During record review on 6/15/23, it was found that the goals on the POC were not measurable, for example, one goal stated, "Patient and caregiver will be able to recognize fall risk factors by 3 weeks." Another stated, "Patient/Caregiver demonstrate [sic] ability to effectively manage medication regimen by 3 weeks." There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-4: The SOC was dated 2/17/23. The POC identified diagnoses of chronic hypertensive heart disease with heart failure. During record review on 6/14/23, it was found that the goals on the POC were not measurable, for example, one goal stated, "Patient will demonstrate return to stable gastrointestinal status regarding GERD and verbalize improvement to heartburn by DC." Another stated, "Patient will receive safe and effective personal care during this episode of care." There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. The POC also failed to document anticoagulant/bleeding precautions for a patient taking Plavix. The findings were reviewed with and acknowledged by the Administrator (Admin-A) during an interview on 6/15/23 at 2:30 p.m. P-1: The patient's start of care was 12/22/22 with diagnoses that included Hypertensive Heart Disease with Heart Failure. During the clinical record review on 6/13/23 at 1:15 p.m., it was noted that the plan of care (POC) ordered Skilled Nursing (SN) and Medical Social Work (MSW) services to be provided. Upon review of the POC, it was noted that there were no interventions to manage the diagnosis of Heart Failure, such as, monitoring of the patient's weight and edema, with reportable parameters in which to notify the Physician. Additionally, there were no associated goals regarding this diagnosis. The POC was void of the required elements to meet the individualized needs of the patient. P-6: This 84-year-old patient was admitted to home care on 3/16/23 with diagnoses of metabolic encephalopathy and gastric ulcer with hemorrhage. During record review on 6/14/23, it was noted that the nursing goals in the 3/16/23 plan of care were not measurable. The following goals are from the plan of care: patient/caregiver demonstrate ability to effectively manage medication regimen by end of this episode; patient will receive safe and effective personal care; and patient will demonstrate return to stable gastrointestinal status regarding hemorrhagic gastric ulcers and verbalize improvement by discharge. There was no indication as to how each of these goals would be measured to determine readiness for discharge from skilled nursing care. The findings were reviewed with the administrator (Admin-A), the clinical manager (CM-B), and the consultant (Consultant-C) during an interview on 6/15/23 at 1:55 p.m. P-7: This patient was admitted to home care on 6/8/23 with diagnoses of sepsis, pneumonia, and chronic obstructive pulmonary disease. During record review on 6/13/23, it was noted that the nursing goals in the 6/8/23 plan of care were not measurable. The following goals are from the plan of care: patient/caregiver will demonstrate compliance with prescribed treatment regimen regarding hypertension including adherence to cardiac regimen/program within 30 days; patient will have optimal bowel evacuation throughout this episode of care; and patient's home will be equipped with adequate lighting within 30 days. There was no indication as to how each of these goals would be measured to determine readiness for discharge from skilled nursing care. The findings were reviewed with Admin-A, CM-B, and Consultant-C during an interview on 6/15/23 at 1:55 p.m. P-5: This 67-year-old patient was admitted to home care on 5/24/23 with diagnoses of atherosclerotic heart disease, non-stemi myocardial infarction, and congestive heart failure. During record review on 6/14/23 at 2:00 p.m., it was noted that the patient was on Plavix (anti-platelet) and Eliquis (anticoagulant). These medications put the patient at risk for bleeding and hemorrhage. These safety precautions failed to be included in the plan of care. In addition, Albuterol and Diclofenac were not included in the plan of care. The findings were reviewed and acknowledged with the administrator (Admin-A), the clinical manager (CM-B), and the consultant (Consultant-C) during an interview on 6/15/23 at 2:15 p.m.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure physician orders were signed for 2 of 3 (P-4, P-6) discharge records reviewed, resulting in a lack of physician authentication for patient care orders for this patient. Findings include: P-6: This 84-year-old patient was admitted to home care on 3/16/23 with diagnoses of metabolic encephalopathy and gastric ulcer with hemorrhage. The patient was discharged from the agency on 4/20/23. During record review on 6/14/23, it was noted that the 3/16/23 plan of care was not signed by the physician. Almost 2 months have passed since the patient was discharged. There was no documentation to indicate the physician had authorized the agency to provide home care services to this patient. The findings were reviewed with the administrator (Admin-A), the clinical manager (CM-B), and the consultant (Consultant-C) during an interview on 6/15/23 at 1:55 p.m. Admin-A acknowledged the findings and explained that the agency has no timeframe for physician signature of orders and the agency has no policy to guide the agency's practices regarding signatures for physician orders. P-4: The start of care (SOC) was 2/17/23 with diagnoses of hypertensive heart disease with heart failure. The patient was discharged from the agency on 4/12/23. During record review on 6/14/23, it was noted that the 2/17/23 plan of care was not signed by the physician. Over 2 months have passed since the patient was discharged. There was no documentation to indicate the physician had authorized the agency to provide home care services to this patient. The findings were reviewed with the administrator (Admin-A), the clinical manager (CM-B), and the consultant (Consultant-C) during an interview on 6/15/23 at 2:30 p.m. Admin-A acknowledged the findings and explained that the agency has no timeframe for physician signature of orders and the agency has no policy to guide the agency's practices regarding signatures for physician orders.

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 record review and interview, the agency failed to ensure written information was provided to patients that detailed the name and contact information for the agency's clinical manager, resulting in a lack of information to enable the agency's 23 current patients to contact the clinical manager. Findings include: During review of the agency's start of care booklet on 6/13/23, it was noted that there was no documented evidence that patients were informed of the name and contact information for the clinical manager. The findings were reviewed with and acknowledged by the Administrator (Admin-A) during an interview on 6/15/23 at 1:55 p.m.

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, the Agency failed to ensure the Registered Nurse performed baseline assessments and re-assessments of the patient's health status and needs in 1 (P-1) record of a patient with a diagnosis of Hypertensive Heart Disease, from a total of 7 sampled records reviewed, resulting in the potential for unidentified health concerns, decline in physical functioning, and poor patient outcomes. Findings include: P-1: The patient's start of care (SOC) was 12/22/22 with diagnoses that included Hypertensive Heart Disease with Heart Failure. During the clinical record review on 6/13/23 at 1:15 p.m., it was noted that the plan of care (POC) ordered Skilled Nursing (SN) and Medical Social Work (MSW) services to be provided. The Initial Comprehensive Assessment was void of a baseline weight and assessment of edema. It was documented that the patient declined to be physically weighed at the time of admission due to pain. There was no documented evidence of the patient's refusal of care and services throughout the remaining course of care. Further, a review of the SN visit notes revealed the following: 12/28/22 - no assessment of weight or edema. "On oral diabetic medication, not taking blood sugars daily." There was no evidence that the SN assessed the patient's blood sugar during the onsite visit and no further attempts to obtain an accurate patient weight as well as an assessment of edema; 1/4/23 no measurement of edema or assessment of the patient's weight; 1/11/23 there was no assessment of weight or edema; 1/18/23 there was no assessment of the patient's weight or edema. The SN failed to perform baseline and ongoing assessments of the patient's health status in accordance with this requirement.

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 medical social worker and skilled nursing provided services as ordered by the physician in the plan of care for 1 (P-5) record, from a total of 7 sampled records reviewed, resulting in the potential for poor patient outcomes for this patient. Findings include: P-5: This 67-year-old patient was admitted to home care on 5/24/23 with diagnoses of atherosclerotic heart disease, non-stemi myocardial infarction, and congestive heart failure. The plan of care orders skilled nursing to provide visits twice a week for three weeks and the medical social worker (MSW) to provide one visit per week for two weeks. During record review on 6/14/23 at 2:00 p.m., it was noted that skilled nursing failed to provide a second visit in week three and MSW failed to provide a second visit in week two. There was no documented evidence to indicate the patient had declined these visits and no evidence the physician was informed that visits had not been provided as ordered. The findings were reviewed with the administrator (Admin-A), the clinical manager (CM-B), and the consultant (Consultant-C) during an interview on 6/15/23 at 2:15 p.m.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the clinical record was completed and included detailed Skilled Nursing notes for 1 (P-1) of 1 record of a patient who was transferred to the hospital due to elevated blood glucose levels, from a total of 7 sampled records reviewed, resulting in the potential for undocumented, unidentified health concerns, and unmet patient care needs. Findings include: P-1: The patient's start of care (SOC) was 12/22/22 with diagnoses that included Hypertensive Heart Disease with Heart Failure. During the clinical record review on 6/13/23 at 1:15 p.m., it was noted that the patient was transferred to the hospital on 1/4/23 due to elevated blood glucose levels greater than 500. (Normal 70 - 120). Upon further review of the clinical record, there was no additional documentation regarding the health status of the patient after hospitalization. On 6/13/23 at 3:10 p.m., during an interview, the Agency's consultant was queried regarding communication notes regarding the status of the patient to which he replied, "There are no communication notes." The Agency failed to ensure the clinical record was complete and painted a clear clinical picture of the status of the patient.

Services under arrangement CFR(s): 484.105(e)(1) The HHA must ensure that all services furnished under arrangement provided by other entities or individuals meet the requirements of this part and the requirements of section 1861(w) of the Act (42 U.S.C. 1395x (w)). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure 1 of 1 contract (Contractor-1) met the requirements of section 1861(w) of the Act (42 U.S.C. 1395x(w)), resulting in the potential to adversely affect the finances of all patients that receive contracted services. Findings include: Contractor-1: On 6/15/23, the contract with Contractor-1 dated January 1, 2023, was reviewed. The contract was to provide skilled nursing, physical therapy, occupational therapy, speech therapy, aide, social work, licensed practical nursing, and physical therapy assistant services. During review of the contract it was noted that the contract failed to include the regulatory language of section 1861(w) of the Act (42 U.S.C 1395x(w)), which states, "...receipt of payment by the...home health agency...with respect to services for which an individual is entitled to have payment made under this title, discharges the liability of such individual or any other person to pay for the services." The regulatory language ensures that both the contract agency and the home health agency would not simultaneously charge patients for covered services and items. The finding was reviewed with and acknowledged by the Administrator (Admin-A) during an interview on 6/15/23 at 1:55 p.m.

Must have a written agreement CFR(s): 484.105(e)(2)(i-iv) An HHA must have a written agreement with another agency, with an organization, or with an individual when that entity or individual furnishes services under arrangement to the HHA's patients. The HHA must maintain overall responsibility for the services provided under arrangement, as well as the manner in which they are furnished. The agency, organization, or individual providing services under arrangement may not have been: (i) Denied Medicare or Medicaid enrollment; (ii) Been excluded or terminated from any federal health care program or Medicaid; (iii) Had its Medicare or Medicaid billing privileges revoked; or (iv) Been debarred from participating in any government program. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a contract for services indicated the agency maintains overall responsibility for the services provided under arrangement for 1 of 1 (Contractor-1) contract reviewed, resulting in a lack of overall responsibility by the agency for the services provided under arrangement. Findings include: On 6/15/23 the contract with Contractor-1 was reviewed. Contract-1 (dated 1/1/23) provides the following services: skilled nursing, physical therapy, occupational therapy, speech therapy, aide, social work, licensed practical nursing, and physical therapy assistant services under arrangement. It was noted that the contract failed to indicate that the home health agency maintains the overall responsibility for the services provided under arrangement and the way in which they are furnished. The agency failed to follow its own policy entitled, Contracts Policy (rev 02/11) which states, the written contract includes all of the following features: notation that patients are admitted and discharged by the home health agency; specification of the scope and type of services to be provided by the contractor; confirmation that the contractor will conform to all applicable agency policies and procedures, including personnel qualifications, as well as compliance with professional standards; clarification of the manner in which services will be controlled, coordinated, and evaluated by the home health agency and identification of parties responsible for supervising contract personnel; and mechanism for orienting contracting parties to the organization's policies, procedures, and function. The finding was reviewed with and acknowledged by the Administrator (Admin-A) during an interview on 6/15/23 at 1:55 p.m.

Skilled services furnished CFR(s): 484.105(f) Standard: Services furnished. Skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis, in a place of residence used as a patient's home. An HHA must provide at least one of the services described in this subsection directly, but may provide the second service and additional services under arrangement with another agency or organization. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure that at least one qualifying service was provided directly by agency employees for 1 of 1 (Contractor-1) contract reviewed, resulting in the agency contracting for all patient services. This deficient practice has the potential to negatively affect the health and well-being of all 53 patients admitted to the agency in the past year. Findings include: On 6/15/23 the contract with Contractor-1 was reviewed. Contract-1 (dated 1/1/23) indicates that Contractor-1 provides the following services for the agency: skilled nursing (RN), physical therapy (PT), occupational therapy, speech therapy, aide, social work, licensed practical nursing, and physical therapy assistant (PTA) services under arrangement. The staff list provided by the Administrator (Admin-A) indicates the agency has 3 field staff that work for the agency consisting of one RN, one PT, and one PTA. The other 25 employees provide contracted services to the agency. Record review of P-1, P-5, P-6, and P-7 indicate that all services were provided by contracted employees. The findings were reviewed with the administrator (Admin-A), the clinical manager (CM-B), and the consultant (Consultant-C and Contractor-1) during an interview on 6/15/23 at 1:55 p.m. Admin-A explained that the agency could not afford to employ all the staff required to care for patients in the various counties that the agency serves. Admin-A also acknowledged that all intake services are provided by Contractor-1. There was no documented evidence that the agency provides at least one qualifying service directly by agency employees.

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 transfer/discharge summaries were complete, provided the patient's current health status at the time of transfer/discharge, progress toward goals, and forwarded to the receiving facility and the Physician in 2 (P-1, P-4) of 2 records in which the patient was discharged/transferred from the agency's services, from a total of 7 records reviewed, resulting in the potential for unidentified continuing health care concerns and unmet care needs. Findings include: P-4: The start of care was dated 2/17/23 with diagnoses of chronic respiratory failure with hypoxia. During record review on 6/15/23, it was found that the discharge summary dated 3/23/23 failed to address progress of goals. The goals met, goals not met, and goals partially met boxes were not checked. It is unclear how the patient progressed toward achieving their goals. The findings were reviewed with and acknowledged by the Administrator (Admin-A) during an interview on 6/15/23 at 2:30 p.m. P-1: The patient's start of care (SOC) was 12/22/22 with diagnoses that included Hypertensive Heart Disease with Heart Failure. During the clinical record review on 6/13/23 at 1:15 p.m., it was noted that the plan of care (POC) ordered Skilled Nursing (SN) and Medical Social Work (MSW) services to be provided. During the review, it was the noted that the patient was transferred to the hospital on 1/4/23 due to elevated blood glucose levels. The SN failed to complete a transfer summary which detailed the events that transpired resulting in transfer to the hospital. The patient was discharged from MSW services on 1/14/23. The MSW Discharge Summary dated 1/14/23 had not been forwarded to the Physician until 1/27/23. This was 13 days after the date of discharge. The patient was discharged from SN on 1/18/23. The SN Discharge Summary was void of the required summary of care that detailed the course of care provided with patient responses and the status of the patient at the time of discharge along with which goals were met versus not met. The Discharge Summary was not forwarded to the Physician; however, the Discharge Oasis was sent to the Physician on 1/27/23. This was 9 days after the date of discharge. The Agency failed to ensure a Transfer and Summary had been completed and forwarded to the receiving facility and to the Physician within 2 days (transfer summary) and within 5 days of the date of discharge from the Agency's services, as per this requirement.