Every finding on record at Continental Home Health Care, Inc

A Medicare revisit survey was conducted by the Michigan Department of Licensing and Regulatory Affairs on 10/13/2021 at: Continental Home Health Care 24381 Orchard Lake Rd. suite 2 Farmington Hills, MI 48334 This agency has no extension sites. For this survey 6 records, 3 active and 3 discharged, were reviewed. At the survey's conclusion, the agency was found to be in substantial compliance with the requirements for participation in Medicare/Medicaid at 42 CFR §484.22, Emergency Preparedness.

A Medicare revisit survey was conducted by the Michigan Department of Licensing and Regulatory Affairs on 10/13/2021 at: Continental Home Health Care 24381 Orchard Lake Rd. suite 2 Farmington Hills, MI 48334 This agency has no extension sites. For this survey 6 records, 3 active and 3 discharged, were reviewed. At the conclusion of the survey the agency was found to be out of compliance, at the standard level, with the conditions of participation for home health agencies at: 42 CFR Part 484.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status based on past medical history that included dates of onset, exacerbations, treatments and outcomes, and history of events leading to current home care needs; and fails to reflect the patient's current health status in 2 of 6 records (MR#s 1, 2), from a total of 6 records reviewed, resulting in incomplete clinical information to aide in determining the needs of the patient. Findings included: MR #1: The SOC was dated 10/2/21. The Plan of Care (POC) identified the diagnoses of pain in left leg, peripheral vascular disease (PVD), hypertension (HTN). A review of the Comprehensive Assessment (OASIS) on 10/13/21, showed that under the category of (M1021): "Patient Diagnoses", the only information provided was a list of 6 diagnoses. There was no information about the onset, exacerbations, prior treatments and outcomes, or history of how the above illnesses/events led to the need for the current home care admission. No further information was provided under each diagnoses' OASIS system section. MR #2: The SOC was dated 9/16/21. The POC identified the diagnoses of HTN, edema, weakness and heart failure. A review of the Comprehensive Assessment (OASIS) on 10/13/21, showed that under the category of (M1021): "Patient Diagnoses", the only information provided was a list of 6 diagnoses. There was no information about the onset, exacerbations, prior treatments and outcomes, or history of how the above illnesses/events led to the need for the current home care admission. No further information was provided under each diagnoses' OASIS system section. During an interview on 10/13/21 at 3:30 p.m., the administrator (Adm#1), acknowledged the above findings.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to promptly alert the physician in 3 of 3 records reviewed (MR#s 1, 2 and 3), from a total sample of 6 records reviewed, resulting in the potential for poor patient outcomes. Findings include: MR #1: The start of care (SOC) was dated 10/2/21. The Plan of Care (POC) identified the diagnoses of pain in left leg, peripheral vascular disease (PVD), hypertension (HTN). The POC also documented parameters for notifying the physician. The systolic blood pressure parameters are 160, notify physician. The diastolic blood pressure parameters are 95, notify physician. During review of the SOC assessment on 10/13/21, it was discovered that a blood pressure of 153/98 was documented under the vital signs section. There was no documented evidence that the physician was notified regarding the patient's elevated blood pressure. MR #2: The SOC was dated 9/16/21. The POC identified the diagnoses of HTN, edema, weakness and heart failure. The POC also documented parameters for notifying the physician. The systolic blood pressure parameters are 160, notify physician. The diastolic blood pressure parameters are 95, notify physician. During review of the SOC assessment on 10/13/21, it was discovered that a blood pressure of 162/92 was documented under the vital signs section. A skilled nurse visit note dated 9/24/21 had a documented blood pressure of 165/86. There was no documented evidence that the physician was notified regarding the patient's elevated blood pressure. MR #3: The SOC was dated 9/20/21. The POC identified the diagnoses of HTN, myalgia and low back pain. The POC also documented parameters for notifying the physician. The systolic blood pressure parameters are 160, notify physician. The diastolic blood pressure parameters are 95, notify physician. During review of the SOC assessment on 10/13/21, it was discovered that a blood pressure of 146/96 was documented under the vital signs section. A skilled nurse visit note dated 9/29/21 had a documented blood pressure of 172/93, and a physical therapy visit note dated 9/21/21 had a documented blood pressure of 165/104. There was no documented evidence that the physician was notified regarding the patient's elevated blood pressure. These findings were reviewed and acknowledged during an interview with the Administrator (ADM#1) on 10/13/21 at 3:30 p.m.

On July 27, 2021 through July 30, 2021, an Emergency Preparedness survey was conducted by the Michigan Department of Licensing and Regulatory Affairs. At the survey, Continental Home Health Care was found to be not in substantial compliance with the requirements for participation in Medicare at 42 CFR 484.102 Emergency Preparedness. 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 and maintain an emergency preparedness program that includes an emergency plan, policies, procedures, communication plan, training, and testing. These deficient practices could affect all 30 of the agency's current patients. The cumulative effect of these systemic problems resulted in the agency's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR 484.102, Emergency Preparedness. Findings include: 1. The agency did not develop an emergency preparedness plan that must be reviewed and updated at least every 2 years and include guidance for Emerging Infectious Diseases. (See E0004) 2. The agency did not ensure their emergency preparedness plan was based on a documented facility and community-based risk assessment from an all-hazards approach, including strategies for emerging infectious diseases. (See E0006) 3. The agency did not ensure their emergency plan includes a process for cooperation and collaboration with local, regional, State and Federal emergency preparedness officials to maintain an integrated response during a disaster or emergency. (See E0009) 4. The agency did not ensure the emergency preparedness policies and procedures included a process for informing State and local emergency preparedness officials of patients needing evacuation from their residence at any time due to an emergency. (See E0019) 5. The agency did not develop Emergency Preparedness policies and procedures that addressed the use of volunteers or other emergency staffing strategies during an emergency. (See E0024) 6. The agency did not 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. (See E0029) 7. The agency did not develop and maintain an Emergency Preparedness communication plan that includes the names and contact information for all entities as required in this standard. (See E0030) 8. The agency did not develop and maintain an emergency preparedness communication plan that is reviewed and updated at least every 2 years and includes contact information for Federal, State, regional, local emergency preparedness staff, and other sources of assistance. (See E0031) 9. The agency did not develop and maintain an emergency preparedness communication plan that includes primary and alternate means for communicating with staff, Federal, State, tribal, regional, and local emergency preparedness officials. (See E0032) 10. The agency did not develop and maintain an Emergency Preparedness training and testing program that is based on the emergency plan, risk assessment, policies, procedures, and the communication plan. (See E0036)

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 must be reviewed and updated at least every 2 years and include guidance for Emerging Infectious Diseases, resulting in lack of direction for agency personnel in the event of an actual emergency or disaster. This deficient practice could affect the health and safety of all 30 patients currently serviced by the agency. Findings include: On 7/29/21, the Administrator (Adm #1) submitted for review the agency's Emergency Preparedness documentation. During the review, it was noted that the agency had no documented evidence that their emergency preparedness plan had been reviewed and updated in the past 2 years. The agency's "Emergency Management Policy" (number B-400, not dated) failed to include guidance regarding COVID-19 or other Emerging Infectious Diseases. The findings were reviewed with and confirmed by the Administrator during an interview on 7/29/21 at 2:00 p.m.

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 their emergency preparedness plan was based on documented facility and community-based risk assessments from an all-hazards approach, including strategies for emerging infectious diseases, resulting in the lack of direction or framework for agency personnel in the event of an actual emergency or disaster. This deficient practice could affect the health and safety of all 30 patients currently serviced by the agency. Findings include: On 7/29/21 at 2:00 p.m., the agency's Emergency Preparedness Plan documents were reviewed with the Administrator (Adm #1). During the review, it was noted that there was no documented facility and community-based risk assessments utilizing an all-hazards approach. There was no evidence the agency's emergency plan included strategies for addressing emergency events identified by the risk assessments. These findings were reviewed with and confirmed by Adm #1 at the time of discovery.

Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years (annually for LTC facilities). The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure their emergency plan includes a process for cooperation and collaboration with local, regional, State, and Federal emergency preparedness officials to maintain an integrated response during a disaster or emergency, resulting in a potential lack of coordination with emergency officials in the event of an actual emergency or disaster. This deficient practice could affect the health and safety of all 30 patients currently serviced by the agency. Findings include: On 7/29/21 at 2:00 p.m., the agency's Emergency Preparedness Plan documents were reviewed with the Administrator (Adm #1). During the review, it was noted that there was no evidence the agency had a process to cooperate and collaborate with local, regional, State, and Federal emergency preparedness officials. These findings were reviewed with and confirmed by Adm #1 at the time of discovery.

Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the emergency preparedness policies and procedures included a process for informing State and local emergency preparedness officials of patients needing evacuation from their residence at any time due to an emergency, resulting in a potential lack of coordination with emergency officials in the event of an actual emergency or disaster. This deficient practice could affect the health and safety of all 30 patients currently serviced by the agency. Findings include: The agency's Emergency Preparedness Plan documents were reviewed with the Administrator (Adm #1) during an interview on 7/29/21 at 2:00 p.m. During the review, it was noted there was no documented evidence of policies or procedures to notify officials of patients in need of evacuation from their residences at any time due to an emergency based on the patient's triage prioritization category (agency utilizes Categories 1-4 based on the patient's medical condition). These findings were reviewed with and confirmed by Adm #1 at the time of discovery.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to develop Emergency Preparedness policies and procedures that addressed the use of volunteers or other emergency staffing strategies during an emergency, resulting in the potential for the interruption in care and services for the agency's 30 current patients. Findings include: The agency's Emergency Preparedness Plan was reviewed on 7/29/21. During the review, it was noted that there was no documented evidence of policies or procedures that detailed a process for the integration or use of volunteers or other emergency staffing strategies during an emergency. These findings were reviewed with and acknowledged by the Administrator during an interview on 7/29/21 at 2:00 p.m.

Development of Communication Plan CFR(s): 484.102(c) (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). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to 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. Resulting in the agency's inability to ensure the coordination of patient care in the event of an actual emergency. These practices could negatively affect the health and safety of the agency's 30 current patients. Findings include: The agency's Emergency Preparedness Plan was reviewed on 7/29/21. During the review, it was noted that there was no documented evidence of a communication plan the agency would utilize during an emergency. The communication plan failed to indicate how the agency would interact and coordinate with staff, patients, and emergency management agencies to protect patient health and safety in the event of a disaster. These findings were reviewed with and acknowledged by the Administrator during an interview on 7/29/21 at 2:00 p.m.

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, the agency failed to develop and maintain an Emergency Preparedness communication plan that includes the names and contact information for staff, entities providing services under arrangement, patient's physicians, and volunteers, resulting in a lack of effective communication in the event of an actual emergency. This deficient practice has the potential to negatively affect the health and safety of the agency's 30 current patients. Findings include: The agency's Emergency Preparedness Plan was reviewed on 7/29/21 at 2:00 p.m.. During the review, it was noted there was no documented evidence of a communication plan that included the names and contact information for staff, entities providing services under arrangement, patient's physicians, and volunteers. The findings were reviewed with and acknowledged by the Administrator at the time of discovery.

Emergency Officials Contact Information CFR(s): 484.102(c)(2) [(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: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to develop and maintain an emergency preparedness communication plan that is reviewed and updated at least every 2 years and includes contact information for Federal, State, regional, local emergency preparedness staff, and other sources of assistance, resulting in a lack of effective communication and coordination in the event of an actual emergency. This deficient practice could affect the health and safety of the agency's 30 current patients in the event of an actual emergency. Findings include: The agency's Emergency Preparedness Plan was reviewed on 7/29/21 at 2:00 p.m. During the review, it was noted that there was no documented evidence of a communication plan that includes the contact information for Federal, State, regional, local emergency preparedness staff, and other sources of assistance. There was no documentation to indicate the agency's communication plan was reviewed and updated at least every 2 years. The findings were reviewed with and acknowledged by the Administrator at the time of discovery.

Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) [(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: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to develop and maintain an emergency preparedness communication plan that includes primary and alternate means for communicating with staff, Federal, State, tribal, regional, and local emergency preparedness officials, resulting in a lack of a framework to coordinate a response during an emergency. This deficient practice could affect the health and safety of the agency's 30 current patients in the event of an actual emergency. Findings include: The agency's Emergency Preparedness Plan was reviewed on 7/29/21 at 2:00 p.m. During the review, it was noted that there was no documented evidence of a communication plan that includes primary and alternate means for communicating with staff, Federal, State, tribal, regional, and local emergency preparedness officials. There was no documentation to indicate the agency's communication plan was reviewed and updated at least every 2 years. The findings were reviewed with and acknowledged by the Administrator at the time of discovery.

EP Training and Testing CFR(s): 484.102(d) *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to develop and maintain an Emergency Preparedness training and testing program that is based on the emergency plan, risk assessment, policies, procedures, and the communication plan. The training and testing program must be reviewed and updated at least every 2 years. Resulting in the agency's inability to ensure staff actions align with the emergency plan. These practices could negatively affect the health and safety of the agency's 30 current patients in the event of an agency-based emergency or community disaster. Findings include: The agency's Emergency Preparedness Plan was reviewed with the Administrator (Adm #1) on 7/29/21 at 2:00 p.m. During the review, it was noted that there was no documented evidence that the agency had developed a training and testing program to guide personnel and agency actions during an emergent situation that was based on the Emergency Preparedness plan. There was no documentation to indicate the agency's training and testing program was reviewed and updated at least every 2 years. Adm#1 stated the agency reviews the emergency plan each year and conducts a fire drill. Adm #1 presented sign-in logs for in-service meetings dated 1/5/18, 1/4/19, 4/3/20, 1/4/21, and 3/3/21. There was no documentation to support that the in-services covered training and testing of the agency's Emergency Preparedness Plan. There was no documentation of an agency-based fire drill and no documentation of the agency's efforts during the COVID-19 pandemic. The agency had developed policies related to COVID-19 however, those policies included a 3-page document titled, "COVID-19 Home Care Agency Checklist 2020," (dated 3/16/20). The document detailed steps to take during the COVID-19 pandemic along with boxes to be checked off or filled in. The document was blank and failed to detail the agency's efforts during the pandemic. The findings were reviewed with and acknowledged by Adm #1 at the time of discovery.

The following Condition and Standard deficiencies were identified at a Medicare authorized Re-Certification survey conducted by the Department of Licensing and Regulatory Affairs on 7/27/21 through 7/30/21 at: Continental Home Health Care 24381 Orchard Lake Rd., Suite 2 Farmington Hills, MI 48336 This agency had no additional branch locations. Records reviewed: 3 records with home visits; 4 records without home visits (including 2 discharged records), for a total of 7 records reviewed. The following Condition level deficiencies were identified: 42 CFR §484.55: Comprehensive Assessments of Patients. 42 CFR §484.60: Care Planning, Coordination of Services, and Quality of Care. 42 CFR §484.65: Quality Assessment Performance Improvement. 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 document review and interview, the agency failed to ensure the comprehensive assessment accurately reflected the patient's current health status and needs for 4 (MR's #1, 2, 3, 4) records, from a total of 7 sampled records reviewed,resulting in incomplete clinical information towards determining the needs of these patients (G528); failed to ensure that the comprehensive assessment was updated and revised in 1 (MR #4) of 1 record in which the patient was transferred and admitted to an inpatient facility related to unknown causes, resulting in the lack of information in determining the care and support needs of the patient (G544); failed to ensure that the comprehensive assessment was updated and revised in 1 (MR #4) of 2 records in which the patient was discharged from the agency's services, resulting in the lack of information in determining the continuing needs of the patient (G550). The cumulative effect of these systemic problems resulted in the 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.

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 accurately reflected the patient's current health status and needs for 4 (MR's #1, 2, 3, 4) records, from a total of 7 sampled records reviewed,resulting in incomplete clinical information towards determining the needs of these patients. Findings include: MR #1: The patient's start of care (SOC) was 6/10/21 with diagnoses that included Diabetes Mellitus, hypertension and Monoplegia lower limbs. The clinical record review was conducted on 7/28/21 at 10:30 a.m. The Initial Comprehensive Assessment dated 6/10/21, completed by the Registered Nurse, revealed the following: Sections 1021/1023 titled (Primary/Other Diagnoses) failed to include dates of onset or exacerbation. Additionally, there was no information as to whether the mentioned diagnoses were resolved or required continued care. The assessment failed to paint a clear clinical picture of the patient's health status at the time of admission. These findings were reviewed with and acknowledged by the Administrator (Adm #1) during an interview on 7/29/21 at 3:52 p.m. MR #2: The patient's SOC was 7/28/21 with diagnoses that included Venous insufficiency, Polyneuropathy and cellulitis left lower leg. The clinical record review was conducted on 7/28/21 at 1:10 p.m. The Initial Comprehensive Assessment dated 7/28/21, completed by the Registered Nurse, revealed the following: Sections 1021/1023 titled (Primary/Other Diagnoses) failed to include dates of onset or exacerbation. Additionally, there was no information as to whether the mentioned diagnoses were resolved or required continued care. The assessment failed to paint a clear clinical picture of the patient's health status at the time of admission. These findings were reviewed with and acknowledged by Adm #1 during an interview on 7/29/21 at 3:54 p.m. MR #3: The patient's SOC was 7/10/21 with diagnoses that included Traumatic Spondylopathy, low back pain and hypertension. The clinical record review was conducted on 7/28/21 at 1:10 p.m. The Initial Comprehensive Assessment dated 7/10/21, completed by the Registered Nurse, revealed the following: Sections 1021/1023 titled (Primary/Other Diagnoses) failed to include dates of onset or exacerbation. Additionally, there was no information as to whether the mentioned diagnoses were resolved or required continued care. The assessment failed to paint a clear clinical picture of the patient's health status at the time of admission. These findings were reviewed with and acknowledged by Adm #1 during an interview on 7/29/21 at 3:56 p.m. MR #4: The patient's SOC was 11/26/20 with diagnoses that included Hypertension, abnormal weight loss and anorexia. The clinical record review was conducted on 7/29/21 at 1:00 p.m. The Initial Comprehensive Assessment dated 11/26/20, completed by the Registered Nurse, revealed the following: Sections 1021/1023 titled (Primary/Other Diagnoses) listed diagnoses with the dates of 11/26/20. There was no indication of whether they were new diagnoses or in an exacerbated state. Additionally, there was no information as to whether the mentioned diagnoses were resolved or required continued care. The assessment failed to paint a clear clinical picture of the patient's health status at the time of admission along with continuing needs. These findings were reviewed with and acknowledged by Adm #1 during an interview on 7/29/21 at 4:15 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 and interview, the Agency failed to ensure that the comprehensive assessment was updated and revised in 1 (MR #4) of 1 record in which the patient was transferred and admitted to an inpatient facility related to unknown causes, resulting in the lack of information in determining the care and support needs of the patient. Findings include: MR #4: The patient's Start of Care (SOC) was 11/26/20 with diagnoses that included Hypertension, abnormal weight loss and Anorexia. On 7/29/21 at 1:00 p.m., during the clinical record review, it was noted that the patient was transferred to the hospital on 12/11/20. No reason had been documented in the clinical record as to why the patient was transferred out. No Transfer Oasis/Assessment had been completed at the time of this review. On 7/29/21 at 10:10 a.m., the Administrator (Adm #1) was queried about the reason for the patient's transfer yet expressed no knowledge. Adm #1 was also asked why the Comprehensive Assessment had not been updated to reflect the patient's transfer, yet again, was unable to explain. The Agency failed to ensure that the Comprehensive Assessment was updated and revised to reflect the patient's transfer to an inpatient facility. These findings were discussed with and acknowledged by Adm #1 during the interview.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure that the comprehensive assessment was updated and revised in 1 (MR #4) of 2 records in which the patient was discharged from the agency's services, resulting in the lack of information in determining the continuing needs of the patient. Findings include: MR #4: The patient's Start of Care (SOC) was 11/26/20 with diagnoses that included Hypertension, abnormal weight loss and Anorexia. On 7/29/21 at 1:00 p.m., during the clinical record review, it was noted that the patient was discharged from the agency on 12/11/20. No reason had been documented in the clinical record as to why the patient was transferred out. No Discharge Oasis/Assessment had been completed at the time of this review. On 7/29/21 at 10:10 a.m., the Administrator (Adm #1) was queried about why the Discharge Comprehensive Assessment had not been updated to reflect the discharge from the agency, yet again, was unable to explain. The Agency failed to ensure that the Comprehensive Assessment was updated and revised to reflect the patient's discharge from the agency's services. These findings were discussed with and acknowledged by Adm #1 during the interview.

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: MR#5: The patient's SOC was 9/16/20 with diagnoses of pressure ulcers and cellulitis. The 9/16/20 POC ordered weekly skilled nursing and physical therapy services. During clinical record review on 7/28/21, it was noted that the nurse documented that she performed weekly wound care however, the POC failed to include interventions or goals related to the patient's pressure ulcers. The care plan listed the same vague/non-specific goals as detailed above. MR#6: The patient's SOC was 7/9/21 with diagnoses of diabetes, and high blood pressure. The 7/9/21 POC ordered weekly skilled nursing and physical therapy services. During clinical record review on 7/29/21, it was noted that the POC failed to include interventions and measurable goals pertinent to the patient's diabetes and high blood pressure. The care plan listed the same vague/non-specific goals as detailed above. MR#7: The patient's SOC was 7/9/21 with diagnoses of thyrotoxicosis (excess thyroid hormone) with goiter and arrhythmia (irregular heartbeat). The 7/9/21 POC ordered weekly skilled nursing and physical therapy services. During clinical record review on 7/29/21, it was noted that the POC failed to include interventions and measurable goals pertinent to the patient's diagnoses. The care plan listed the same vague/non-specific goals as detailed above. The findings were reviewed with and acknowledged by Adm #1 during an interview on 7/29/21 at 3:30 p.m. Based on observation, record review and interview, the agency failed to ensure the plan of care covered all pertinent interventions with reportable parameters, safety precautions and objectively measurable goals specific to the needs of the patient for 6 (MR's # 1, 3, 4, 5, 6, 7) records, from a total of 7 sampled records reviewed, resulting in patients not receiving care specific to their individual needs and the potential for poor patient outcomes. Findings include: MR #1: The patient's start of care (SOC) was 6/10/21 with diagnoses that included Diabetes Mellitus, coronary Artery disease and essential hypertension. During the clinical record review on 7/28/21 at 10:30 a.m., it was noted that the plan of care (POC) ordered Skilled Nursing (SN) and Physical Therapy (PT) services to be provided. The POC was bare and was void of any SN or PT interventions or goals. The Plan of Care failed to include all the required elements, as per this requirement, in order to meet the individualized needs of the patient. MR #3: The patient's SOC was 7/10/21 with diagnoses that included Traumatic spondylopathy, low back pain and hypertension. During the clinical record review on 7/28/21 at 2:20 p.m., it was noted that the POC ordered SN, PT and Home Health Aide (HHa) services to be provided. The POC was void of any SN, HHa or PT interventions or goals. The Plan of Care failed to include all the required elements, as per this requirement, in order to meet the individualized needs of the patient. MR #4: The patient's SOC was 11/26/20 with diagnoses that included Hypertension, Abnormal weight loss, anorexia and anemia. During the clinical record review on 7/29/21 at 1:00 p.m., it was noted that the POC ordered SN and PT services to be provided. It was further noted that the patient was discharged from the agency's services on 12/11/20. The POC was void of any SN or PT interventions or goals. The Plan of Care failed to include all the required elements, as per this requirement, in order to meet the individualized needs of the patient. Each of the above care plans contained the following vague/non-specific documentation: "Goals/Rehabilitation Potential/Discharge Plans/Referral Plan/Other Notes - - Patient - - Representative - - Patient - - Representative - - Agreed their personal goals were realistic based on the patient's health status. - - Agreed their personal goals needed to be modified based on the patient's health status. - - Agreed to and identified actions/interventions the patient is willing to safely implement, so the patient will be able to meet their goals by the anticipated discharge date. - - Patient helped write a measurable goals, understandable to all stakeholders. - - Representative helped write a measurable goals, understandable to all stakeholders. - - Patient was informed, appeared to understand and agreed the personal goals would be added to the patient's individualized plan of care and submitted to the physician responsible for reviewing and signing the plan of care.. - - Representative was informed, appeared to understand and agreed the personal goals would be added to the patient's individualized plan of care and submitted to the physician responsible for reviewing and signing the plan of care." There were no individualized plans in place to meet the needs of the patient. The above records were reviewed with and acknowledged by the Administrator (Adm #1) during an interview on 7/29/21 at 3:56 p.m., who reported, "We can fix this. The interventions and goals are in a separate document." When asked if the "separate document" for each of the above records was sent to the Physician for review, approval and signature, Adm #1 responded, "No."

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure treatments were provided only as ordered by the physician in 1 of 1 (MR# 5) records reviewed in which wound care was provided, resulting in the potential to negatively affect the health and well-being of this patient. Findings include: MR#5: This 82-year-old patient was admitted to home care on 9/16/20 with diagnoses of two stage 2 pressure ulcers on the posterior right thigh, a stage 3 pressure ulcer on the posterior left thigh, and cellulitis. The skilled nurse (SN) documented 8 weekly visits were provided from 9/16/20 through 10/30/20. The SN provided the following wound care during each visit: wash with water, apply Mupirocin (antibiotic) ointment, cover with 4x4 gauze. During record review on 7/28/21, it was noted that there were no physician orders to direct the care provided to this patient's wounds. The findings were reviewed with and confirmed by Adm #1 (administrator/registered nurse) during an interview on 7/29/21 at 3:30 p.m.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the physician was promptly notified of elevated blood pressure readings outside of the reportable parameters for 1 of 7 (MR #5) records reviewed, resulting in the potential to negatively affect the health and well-being of this patient. Findings include: MR #5: This 82-year-old patient was admitted to home care on 9/16/20 with diagnoses of two stage 2 pressure ulcers on the posterior right thigh, a stage 3 pressure ulcer on the posterior left thigh, and cellulitis. The 9/16/20 plan of care ordered the physician to be notified regarding the following parameters for the patient's blood pressure (BP): systolic 160 and diastolic 95. During record review on 7/28/21, it was noted that the skilled nurse (SN) documented that the patients BP was outside reportable parameters on 4 of 8 home visits. On 9/25/20 the patient's BP was 150/96, on 10/16/20 it was 148/100, on 10/24/20 it was 152/98, and on 10/30/20 the day of discharge from nursing services it was 170/102. There was no documented evidence in the clinical record that the physician was promptly alerted regarding the patient's elevated blood pressure readings outside of the reportable parameters as ordered in the plan of care. These findings were reviewed with and acknowledged by the Administrator during an interview on 7/29/2`1 at 3:30 p.m.

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on interview and record review, it was determined the Agency failed to provide evidence of its efforts to measure, track and analyze it's quality indicators in order to assess processes of care and services, resulting in the inability to determine the scope of services provided and the potential unmet care needs for all 30 patients currently serviced by this agency (G642); failed to develop Performance Improvement activities, as part of the Agency's Quality Assessment Performance Improvement program, in order to track and trend adverse patient events, analyze the cause and implement preventive interventions, resulting in the potential for the rendering of substandard care and unmet care needs (G654); failed to develop a Quality Assessment Performance Improvement program that documented the quality improvement projects, the reasons for conducting these projects with measurable progress achieved on these projects for 2018, 2019 and 2021, resulting in the Agency's inability to improve in patient care, health outcomes, patient safety, quality of care and the agency's performance (G658); the Governing Body failed to ensure the Agency had an active and functioning Quality Assessment and Performance Improvement program that addressed priorities for improved quality of care and patient safety and was evaluated for effectiveness, resulting in the potential to negatively affect the quality of care to all 30 patients currently receiving services (G660). The cumulative effect of these systemic problems resulted in the agency's inability to ensure the provision of quality health care in a safe environment for the condition of participation of 42 CFR §484.65 Quality Assessment and Performance Improvement (QAPI).

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on interview and record review, it was determined the Agency failed to provide evidence of its efforts to measure, track and analyze it's quality indicators in order to assess processes of care and services, resulting in the inability to determine the scope of services provided and the potential unmet care needs for all 30 patients currently serviced by this agency. Findings include: On 7/29/21 at 3:16 p.m., during an interview, the Administrator (Adm #1) was asked for permission to review the Agency's QAPI (Quality Assessment Performance Improvement) program documentation. Adm #1 provided documents titled "Accident/Incident Report" and "Ethical Concerns/Complaints Reports." Upon review of the submitted data with Adm #1, it was noted that no specific data had been collected for the calendar years 2018 2019 and 2021 that showed the agency's efforts to measure, track and analyze indicators in order to determine if care and services have been provided safely and appropriately. These findings were reviewed with and confirmed by Adm #1 at the time of review.

Track adverse patient events CFR(s): 484.65(c)(2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. This STANDARD is not met as evidenced by: Based on interview and record review, it was determined the Agency failed to develop Performance Improvement activities, as part of the Agency's Quality Assessment Performance Improvement program, in order to track and trend adverse patient events, analyze the cause and implement preventive interventions, resulting in the potential for the rendering of substandard care and unmet care needs. Findings include: On 7/29/21 at 3:16 p.m., during an interview, the Administrator (Adm #1) was asked for permission to review the Agency's QAPI (Quality Assessment Performance Improvement) program documentation. Adm #1 provided documents titled "Accident/Incident Report" and "Ethical Concerns/Complaints Reports." Upon review of the submitted data with Adm #1, it was noted that no specific data had been collected for the calendar years 2018 2019 and 2021 that showed the agency's efforts to measure, track and analyze indicators in order to determine if care and services have been provided safely and appropriately. These findings were reviewed with and confirmed by Adm #1 at the time of review.

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on interview, it was determined the Agency failed to develop a Quality Assessment Performance Improvement program that documented the quality improvement projects, the reasons for conducting these projects with measurable progress achieved on these projects for 2018, 2019 and 2021, resulting in the Agency's inability to improve in patient care, health outcomes, patient safety, quality of care and the agency's performance. Findings include: During an interview on 7/29/21 at 3:16 p.m., a request was submitted to the Administrator (Adm #1), to review the agency's QAPI (Quality Assessment Performance Improvement) projects for the 2018, 2019 and 2021 calendar years but was unable to do so. There was no evidence that the agency had developed a QAPI program that documented the quality improvement projects, the reasons for conducting these projects and the measurable progress achieved on these projects. These findings were reviewed with and acknowledged by Adm #1 at the time of discovery.

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on record review and interview, it was determined the Governing Body failed to ensure the Agency had an active and functioning Quality Assessment and Performance Improvement program that addressed priorities for improved quality of care and patient safety and was evaluated for effectiveness, resulting in the potential to negatively affect the quality of care to all 30 patients currently receiving services. Findings include: During an interview on 7/29/21 at 3:19 p.m., the Administrator (Adm #1) was asked for permission to review the agency's Quality Assessment Performance Improvement (QAPI) report and Governing Body meeting minutes for the 2018, 2019 and 2021 calendar years. Adm #1 submitted 2 documents: 1) "Governing body Meeting Minutes" dated February 28, 2018 that included topics: "Looking for new accountant, Prepare for CHAP survey and Implementation of Emergency Preparedness." 2) 'Meeting Minutes" dated June 4, 2021 that included topics: "Review Oasis and charts and Review cases exposure to Covid [sic]." There were no Governing Body or QAPI data made available for review that determined or affirmed the Governing Body's oversight of the agency's QAPI program.

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 the nurse documented weekly wound measurement assessments of the patient's wounds and failed to ensure the registered nurse assessed the patient before discharge from skilled nursing for 1 of 1 (MR #5) records reviewed in which the patient had pressure ulcers, resulting in the potential to negatively affect the health and well-being of this patient. Findings include: MR#5: This 82-year-old patient was admitted to home care on 9/16/20 with diagnoses of two stage 2 pressure ulcers on the posterior right thigh, a stage 3 pressure ulcer on the posterior left thigh, and cellulitis. The 9/16/20 plan of care ordered 2 skilled nursing visits in week one and then one visit each week for 6 weeks, for a total of 8 nursing visits. During record review on 7/28/21, the following was noted: On the 9/16/20 comprehensive assessment, the registered nurse (RN) documents the patient has 2 stage 2 pressure ulcers on the posterior right thigh that measured 1 centimeter (cm) x 2 cm and 2 cm x 1.5 cm. The patient has a stage 3 pressure ulcer on the posterior left thigh that measured 2 cm x 2 cm. 9/19/20, the licensed practical nurse (LPN) documents, "Patient has three stage to (sic) pressure ulcer's (sic) and posterior gluteal region and lower thighs with one stage III pressure ulcer right lower posterior thigh measuring 2 x 2 cm." It is unclear whether the LPN was describing a new wound to the "posterior gluteal region" since this was a new descriptive term that was not used by the RN. It is unclear how many wounds the LPN is describing. It could be anywhere from 3 to 7 wounds. 9/25/20, the LPN documents the same, "Patient has three stage to (sic) pressure ulcer's (sic) and posterior gluteal region and lower thighs with one stage III pressure ulcer right lower posterior thigh measuring 2 x 2 cm." Only 1 of 3 wounds were measured. It is unclear how many wounds the LPN is describing. It could be anywhere from 3 to 7 wounds. 10/3/20, the LPN documents, "Patient has pressure ulcer's (sic) stage 3 right lower thigh posterior and stage 2 to left gluteal and thigh with healing of right upper thigh." There were no documented wound measurements. 10/9/20, the LPN documents, "Patient has improved skin with 2 pressure ulcers healed and continued stage 3 right lower thigh and stage 2 left gluteal." There were no documented wound measurements. 10/16/20, the LPN documents, "Patient has improved skin with one pressure ulcer still to right lower thigh with slightly yellow tissue at center however depth decreasing and size decreased." There were no documented wound measurements. 10/24/20, the LPN documents, "Patient has improved skin with 1 pressure ulcer still to right lower thigh with red healing tissue at center and depth decreasing and size decreased." There were no documented wound measurements. 10/30/20, the LPN documents, "Patient has improved skin with 1 pressure ulcer still to right ischium with red healing tissue at center and depth decreasing and size decreased and stage 2 ulcer to left lower thigh with decreased size." It was unclear whether the LPN was describing a new wound to the "right ischium" since this was a new descriptive term used by LPN. There were no documented wound measurements for the past 5 weeks. The patient was then discharged that day from nursing services by the LPN. There was no documented assessment by the registered nurse at the time of discharge from nursing services. The findings were reviewed with and confirmed by Adm #1 (administrator/registered nurse) during an interview on 7/29/21 at 3:30 p.m. Adm #1 stated that the agency does not have a wound care policy however, wounds are to be measured weekly, and that the registered nurse should have assessed the patient at the time of discharge from nursing services.

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, it was determined that the Agency failed to ensure Physical Therapy services were provided for 1 (MR #4) of 7 records with Physical Therapy services ordered; and failed to ensure the Registered Nurse assessed a patient's Oxygen levels as ordered in 1 (MR #3) 1 patient who experienced shortness of breath, from a total of 7 records review, resulting in the potential for physical decline, and unmet care needs. Findings include: MR #3: The patient's start of care (SOC) was 7/10/21 with diagnoses that included Traumatic Spondylopathy and COPD (Chronic Obstructive Pulmonary Disease). The clinical record review was conducted on 7/28/21 at 2:20 p.m. During the review, it was noted that the Initial Comprehensive Assessment, dated 7/10/21 documented, "He is displaying increase shortness of breath with moderate exertion and with occasional productive cough. Bilateral wheezing noted on posterior aspects of lungs. Patient also experienced easy fatigue..., Exacerbation of COPD..., Instructed to use breathing medication as ordered..., Wheezing noted today on his bilateral upper/lower posterior area and he experienced shortness of breath after walking for 25 feet. Patient with COPD..., Experiencing shortness of breath that can affect her activities/mobilities..., check SPO2 (Oxygen) every visit by SN (Skilled Nurse)." A review of the SN visit notes dated 7/13/21, 7/16/21 and 7/22/21 was conducted. During the SN visit on 7/13/21, the nurse documented, "Wheezing noted today on his bilateral upper lobe and he experienced shortness of breath after walking 25 feet. There was no documented evidence that the SN assessed the patient's oxygen level as indicated. During the 7/16/21 SN visit, the nurse documented, "He still experienced shortness of breath especially when he needed to use bathroom right away due to urinary frequency." There was no documented evidence that the SN assessed the patient's oxygen level. These findings were reviewed with and acknowledged by the Administrator (Adm #1) on 7/29/21 at 3:56 p.m. MR #4: The patient's SOC was 11/26/20 with diagnoses that included Hypertension, Abnormal weight loss and Anorexia. During the clinical record review on 7/29/1:00 p.m., it was noted that the patient was ordered to received SN services at a frequency of 1w5. Physical Therapy (PT) services were ordered to Evaluate and Treat. At the time of this clinical record review, no PT evaluation had been conducted and no PT services had been provided. Further, there was no documented evidence in the clinical record that the patient had declined services. These findings were reviewed with and acknowledged by Adm #1 during an interview on 7/29/21 at 4:10 p.m.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on 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 1 (MR# 3) of 1 record in which Home Health Aide services were ordered, from a total of 7 sampled records reviewed, resulting in no guidance on what services to provide, the potential for the provision of unsafe care and unmet care needs. Findings include: Policy: "Home Health Aides Competency, Supervision and Assignment" dated 8/5/17 stated, "The Registered Nurse or other appropriate professional makes the Initial Assessment visit to the patient evaluates the care needed, develops the plan of care and aide assignment form and instructs the aide prior to the aide's first visit." MR #3: The patient's start of care (SOC) was 7/10/21 with diagnoses that included Traumatic Spondylopathy, lumbar region, hypertension and COPD (Chronic Obstructive Pulmonary Disease). The Plan of Care (POC) instructed Home Health Aide (HHa) services to be provided at a frequency of 1x/wk. x 6 wks. At the time of this clinical record review on 7/28/21 at 2:20 p.m., no Aide Care Plan had been completed. These findings were reviewed with and acknowledged by the Administrator (Adm #1) during an interview on 7/29/21 at 3:56 p.m. who reported, "It (HHa Care Plan) should have been there."

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, resulting in the potential for interruption in continuity of care and unmet care needs. Findings include: On 7/27/21 at 9:30 a.m., during the entrance conference, the Administrator (Adm #1) was asked what services were currently provided by the agency and reported, "We offer Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), Medical Social Work (MSW), Speech Therapy (ST), and Home Health Aide (HHa) services." When asked if they utilized contract personnel, Adm #1 said "Yes." When asked which services were provided by the contract agency, Adm #1 stated, "We contract PT, MSW, SN, PT, OT and ST. A couple are independent contractors." When asked to clarify which service was directly provided by the Agency, Adm #1 reported, "Skilled Nursing." Upon further review, it was noted that the agency also contracted Skilled Nursing services. The agency failed to ensure that at least one qualifying service was provided directly by agency employees. Adm #1 was unable to locate the requested contracts at the time of the survey. These findings were discussed with and acknowledged by Adm #1 at the time of discovery.

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: MR#5: This 82-year-old patient was admitted to home care on 9/16/20 with diagnoses of two stage 2 pressure ulcers on the posterior right thigh, a stage 3 pressure ulcer on the posterior left thigh, and cellulitis. The 9/16/20 plan of care ordered weekly skilled nursing and physical therapy services. The patient was discharged from the agency on 11/5/20 by the physical therapist. There was no documented evidence the discharge summary completed by the physical therapist was sent to the physician within 5 business days of the patient's discharge from the agency. The findings were reviewed with and acknowledged by Adm #1 during an interview on 7/29/21 at 3:30 p.m. 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 (MR# 4, 5) 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: MR #4: The patient's Start of Care (SOC) was 11/26/20 with diagnoses that included Hypertension, abnormal weight loss and Anorexia. On 7/29/21 at 1:00 p.m., during the clinical record review, it was noted that the patient was transferred to the hospital on 12/11/20. No reason had been documented in the clinical record as to why the patient was transferred out. No Transfer Summary had been completed at the time of this review. Additionally, the Agency documented that the patient was subsequently discharged from the Agency on the same date of 12/11/20. No discharge summary had been completed at the time of this review. On 7/29/21 at 10:10 a.m., the Administrator (Adm #1) was queried about the reason for the patient's transfer, yet expressed no knowledge. Adm #1 was also asked why the Comprehensive Assessment had not been updated to reflect the patient's transfer, yet again, was unable to explain. The Agency failed to ensure that a Transfer Summary was completed and sent to the receiving facility within 2 days of the patient's transfer to an inpatient facility, and failed to ensure a discharge summary was completed and sent to the Physician within 5 days of the patient's discharge from the agency. These findings were discussed with and acknowledged by Adm #1 during the interview.