Every finding on record at Diversity Home Care Services, LLC

Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] 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: * (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: Based on record review and interview, the Agency failed to develop an emergency preparedness plan that had been updated as per this requirement and included the agency's current and correct address and personnel, 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 directly employed staff, regularly utilized contracted staff and all patients actively serviced by this Agency in the event of a facility emergency or disaster (E0004); failed to develop and maintain an emergency preparedness communication plan that included contact information for all current staff, patient's physicians, and volunteers, as appropriate, which had the potential to negatively affect the health and safety of all patients currently serviced by this agency, resulting in the lack of effective communication in the event of an actual emergency (E0030); failed to provide evidence of initial and ongoing training in emergency preparedness policies and procedures to all new and existing staff, including contract employees and volunteers, and failed to maintain documentation of training's, resulting in the potential for inappropriate, unprepared responses to emergencies and interruption in the provision of needed patient care and services (E0037); and, failed to provide documentation for the required community/facility based full-scale exercises and failed to provide documentation of an actual event that would qualify as a test of the emergency plan, resulting in staff being ill-prepared in the event of an actual emergency. This deficient practice could negatively affect staff and all patients currently serviced by this Agency (E0039). The cumulative effect of these systemic problems could potentially have a negative effect on all patients cared for by the home health agency in the event staff is not properly prepared for an emergency for the Condition of Participation of 42 CFR §485.102, Emergency Preparedness.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(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 had been updated as per this requirement and included the agency's current and correct address and personnel, 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 directly employed staff, regularly utilized contracted staff and all patients actively serviced by this Agency in the event of a facility emergency or disaster. Findings include: On 3/10/23 at 3:27 p.m., the agency's Emergency Preparedness documents were reviewed. During the review, it was noted that the policy/plan indicated the agency's address was located at 2021 Monroe Street, Suite 104, Dearborn, MI 48126 and not the agency's current address, located at 1213 Monroe Street, Suite 5 Dearborn MI 48124. During the review, the Administrator (Adm #1) was queried as to where staff was to meet in the event of an emergency, to which he replied, "Originally, it was to be in the parking lot, but we have to update that information because that was the old address." The Agency failed to ensure the Emergency Plan had been updated as per this requirement and as needed to ensure staff received accurate information on emergency protocol in the event of a crisis. These findings were reviewed with and acknowledged by Adm #1 at the time of discovery.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(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 facilities]. 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 included contact information for all current staff, patient's physicians, and volunteers, as appropriate, which had the potential to negatively affect the health and safety of all patients currently serviced by this agency, resulting in the lack of effective communication in the event of an actual emergency. Findings include: During a review of the agency's emergency preparedness documents on 8/10/23 at 3:27 pm., it was noted that there was no contact information for all current staff, patient's physicians, or volunteers as appropriate. These findings were reviewed with and acknowledged by the Administrator at the time of discovery.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on record review and interview, it was determined the Agency failed to provide evidence of initial and ongoing training in emergency preparedness policies and procedures to all new and existing staff, including contract employees and volunteers, and failed to maintain documentation of training's, resulting in the potential for inappropriate, unprepared responses to emergencies and interruption in the provision of needed patient care and services. Findings include: On 8/10/23 at 3:27 p.m., during a review of the agency's Emergency Prepared documents, it was noted that there was no evidence of initial and ongoing training in the agency's Emergency Preparedness policies and procedures as per this requirement. During the review, the Administrator (Adm #1) reported, "We used to keep the documentation but then we just started them (Staff) sign off on the checklist. We had a consultant, so I will admit I didn't provide the training." The Agency failed to provide documented evidence that initial and going training had been provided to new and existing staff, including contract employees as per this requirement. These findings were reviewed with and acknowledged by Adm #1 at the time of discovery.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on record review and interview, the Agency failed to provide documentation for the required community/facility based full-scale exercises and failed to provide documentation of an actual event that would qualify as a test of the emergency plan, resulting in staff being ill-prepared in the event of an actual emergency. This deficient practice could negatively affect staff and all patients currently serviced by this Agency. Findings include: During review of the agency's Emergency Preparedness documents on 8/10/23 at 3:27 p.m., with the Administrator (Adm #1) it was noted that there was no evidence the agency had conducted any training or exercises to test the agencies emergency plan since 2019. Further, there was no documentation of an actual event that would qualify as an emergency, no community based full-scale exercise, no second full-scale exercise. Adm #1 provided a copy of a table-top exercise that was dated 4/25/19. There was no list of attendees, and no additional information was provided on any drills that would satisfy this requirement. These finding were reviewed with and acknowledged by Adm #1 at the time of this review.

The following Condition and Standard level deficiencies were identified at a Medicare authorized Recertification and Emergency Preparedness survey conducted by the Michigan Department of Licensing and Regulatory Affairs on 8/8/23 through 8/11/23 at: 1213 Monroe St, Suite 5 Dearborn, MI 48124 This Agency had no additional locations. Records reviewed: 3 records with home visits; 2 discharged records; 2 active records without home visits, for a total of 7 records reviewed. The following Conditions were identified: CFR§484.65 Quality Assessment and Performance Improvement. 42 CFR §484.75 Skilled Professional Services. 42 CFR §485.102 Emergency Preparedness. At the conclusion of the survey, this agency was determined to be out of compliance with the conditions of Participation at Sub-Part CFR 484 Home Health Agencies.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure that 3 (P's #1, 2, 3) of 3 patients observed during home visits, were included in the overall planning of care including informing the patient/caregiver in advance of the days in which services would be provided and disciplines that will furnish care, from a total of 7 sampled records reviewed, resulting in a lack of inclusion in planning, lack of informed consent, the potential for missed visits and unmet care needs. Findings include: P-1: The patient's start of care (SOC) was 7/14/23 with diagnoses that included Hypertensive Heart Disease with Heart Failure. The plan of care (POC) ordered skilled nursing (SN), Home Health Aide (HHa) and Physical Therapy services to be provided. On 8/10/23 at 10:00 a.m., during a scheduled home visit with the Registered Nurse (RN #1), it was noted that the patient's admission packet was void of a completed calendar of proposed visits to be made by the ordered disciplines. These finding were reviewed with and acknowledged by the Administrator (Adm #1) during an interview on 8/10/23 at 11:46 a.m. P-2: The patient's SOC was 7/13/23 with diagnoses that included Subdural Hematoma, Falls and Syncope. The POC ordered SN, HHa, PT, OT and speech therapy (ST) services to be provided. On 8/9/23 at 11:00 a.m., during a scheduled home visit with the HHa, it was noted that the patient's admission packed was void of a completed calendar of proposed visits to be made by the ordered disciplines. These findings were reviewed with and acknowledged by Adm #1 during an interview on 8/10/23 at 12:20 p.m. P-3: The patient's SOC was 7/12/23 with diagnoses that included Diabetes Mellitus and Peripheral Vascular Disease. The POC ordered SN, PT and OT services to be provided. On 8/9/23 at 12:45 p.m., during a scheduled home visit with the PT (Adm #1), it was noted that the patient's admission packed was void of a completed calendar of proposed visits to be made by the ordered disciplines. These findings were reviewed with and acknowledged by Adm #1 during an interview on 8/10/23 at 12:55 p.m.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment included a review of all medications to determine any adverse effects; failed to provide documented evidence of the drug regime review: failed to ensure the Registered Nurse provided oversight of the review process, and failed to ensure the physician was notified of potential drug interactions in 3 (P#'s 3, 4, 6) of 7 sampled records reviewed, resulting in the potential for harmful medication effects for all patients currently serviced by this Agency. Findings include: P-3: The patient's start of care (SOC) was 7/12/23 with diagnoses that included Sarcopenia, Peripheral Vascular Disease, Diabetes Mellitus and Swelling of Lower Extremities. Section M2001 of the Initial Comprehensive Assessment documented, was completed by the Physical Therapist (PT) and documented "No issues found during review." There was no drug interaction report available for review. During the record review on 8/8/23 at 2:10 p.m., there was no documented evidence that the Registered Nurse (RN) conducted the drug review as per this requirement. The agency failed to ensure the comprehensive assessment included an accurate review of the patient's medications conducted by an RN. These findings were reviewed with and acknowledged by the Administrator (Adm #1) during an interview on 8/10/23 at 12:55 p.m. P-4: The patient's SOC was 6/14/22 with diagnoses that included Sprain Right Knee and Pain bilateral Knees. Section M2001 of the Initial Comprehensive Assessment documented, completed by the PT documented "No issues found during review." There was no drug interaction report available for review. During the record review on 8/8/23 at 3:15 p.m., there was no documented evidence that the RN conducted the drug review as per this requirement. The agency failed to ensure the comprehensive assessment included an accurate review of the patient's medications conducted by an RN. These findings were reviewed with and acknowledged by Adm #1 during an interview on 8/10/23 at 1:35 p.m. P-6: The patient's SOC was 8/3/23 with diagnoses that included Hypertensive Heart Disease and Chronic Kidney Disease with Heart Failure. Section M2001 of the Initial Comprehensive Assessment documented, completed by the PT documented "Yes - issues found during review." There was no drug interaction report available for review. During the record review on 8/8/23 at 4:00 p.m., there was no documented evidence that the RN conducted the drug review as per this requirement. or that the Physician had been notified of the identified interactions. The agency failed to ensure the comprehensive assessment included an accurate review of the patient's medications conducted by an RN. These findings were reviewed with and acknowledged by Adm #1 during an interview on 8/10/23 at 2:30 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 observation, record review and interview, the agency failed to ensure the comprehensive assessment had been updated to reflect 1 (P-3) of 1 patient observed during a home visit who sustained a fall with injury, from a total of 7 sampled records reviewed, resulting in the potential for the patient not receiving care and services based on his individualized needs. Finsings include: P-3: The patient's SOC was 7/12/23 with diagnoses that included Sarcopenia, Swelling of Lower Extremities and Diabetes Mellitus. On 8/8/23 at 2:10 p.m., during the record review, it was noted that the patient experienced a fall on7/18/23. There was no documented evidence of injury. On 8/9/23 at 12:45 p.m., during a scheduled home visit with the Physical Therapist (Adm #1/PT #1), the patient was observed to have bruising to the right side of his face. The patient's wife stated the patient fell again on 7/24/23 and hurt his head and face and went to the Emergency Room. Upon further review of the clinical record, there was no evidence that the Comprehensive Assessment had been updated to reflect the patient's significant change in condition. These findings were reviewed with and acknowledged by the Administrator (Adm #1) during an interview on 8/10/23 at 12:55 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 observation, interview and record review, the Agency failed to ensure the Physician was promptly notified of the patient's change in condition for 1 (P-1) patient who experienced significant weight loss and 1 (P-3) patient who experienced a fall with injury, from a total of 7 sampled records reviewed, resulting in the potential for unidentified, unaddressed health concerns and unmet health care needs. Findings include: P-1: The patient's start of care (SOC) was 7/14/23 with diagnoses that included Hypertensive Heart Disease with Heart Failure. The plan of care (POC) ordered Skilled Nursing (SN), Home Health Aide (HHa) and Physical therapy (PT) services to be provided and indicated the following parameters: "Report wt. gain of 3 lbs. in one day. 5 lbs. in one week." The POC further ordered, "Report sudden weight gain, swelling." During the clinical record review on 8/8/3 at 11:45 a.m., it was noted that the Initial Comprehensive Assessment dated 7/14/23, completed by the Registered Nurse, documented a stated weight of 260 pounds (lbs.). On 7/27/23, the SN documented a weight of 238.8 pounds (lbs.). On 8/4/23, the SN documented a weight of 163 lbs. This reflected a loss of 75.8 lbs. in 8 days. Further review revealed no documented evidence that the Physician had been notified of the patient's significant change in condition. These findings were reviewed with and acknowledged by Adm #1 during an interview on 8/10/23 at 11:46 a.m. who reported, "Our QA (Quality Assurance) should have caught it." P-3: The patient's SOC was 7/12/23 with diagnoses that included Sarcopenia, Swelling of Lower Extremities and Diabetes Mellitus. On 8/8/23 at 2:10 p.m., during the record review, it was noted that the patient experienced a fall on7/18/23. There was no documented evidence of injury. On 8/9/23 at 12:45 p.m., during a scheduled home visit with the Physical Therapist (Adm #1/PT #1), the patient was observed to have bruising to the right side of his face. The patient's wife stated the patient fell again on 7/24/23 and hurt his head and face and went to the Emergency Room. The patient's wife went on to report that she informed the Physical Therapy Assistant (PTA #1). There was no documented evidence that PTA #1 promptly notified the Physician. On 8/10/23 at 12:55 p.m., during an interview with Adm #1, it was reported that "It was actually the Occupational Therapist (OT #1) who was aware of the patient's fall and informed PTA #1." When asked if OT #1 informed the Physician of the patient's fall, Adm #1 stated, "No." The Agency failed to ensure the Physician was promptly notified of the patient's fall with injury and resultant Emergency Room visit.

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 include contact information for the Home Health Agency's Clinical Manager in the Patient Admission/Orientation Packet, resulting in the potential for unaddressed patient concerns. Findings include: On 8/8/23 the Agency's Admission packet was reviewed. The packet included a consent form, admission agreement, Beneficiary notice and patient rights and responsibilities forms and Emergency Preparedness documents. Upon review, it was noted that there was no contact information for the Agency's Clinical Manager. These findings were reviewed with and confirmed by the Administrator (Adm #1) during an interview on 8/10/23 at 11:59 a.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 patients currently serviced by this agency (G642); failed to ensure that the collected data was used to monitor the effectiveness and safety of services provided with opportunities for improvement; and failed to ensure the Governing Body approved the program's frequency and detail of data collection, resulting in the potential for poor patient outcomes for all 13 patients currently serviced and the Agency's 116 patients admitted in the past year (G644); failed to track and analyze adverse events in order to implement preventative actions, which had the potential to negatively affect all 116 patients serviced by the agency in the past 12 months, resulting in the potential for failing to prevent future adverse events (G654); failed to ensure the Agency had an active and functioning Quality Assessment and Performance Improvement (QAPI) program that fulfilled all the regulatory requirements of this section, addressed priorities for improved quality of care and patient safety and was evaluated for effectiveness, resulting in the potential to adversely affect the quality of care to all 13 patients currently receiving services and all 116 patients admitted over the past year (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 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 patients currently serviced by this agency. Findings include: On 8/11/23 at 12:40 p.m., during a review of the agency's Quality Assessment Performance Improvement (QAPI) data with the Administrator (Adm #1), it was noted that there was no data to review for the calendar years 2022 and 2023 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 acknowledged by Adm #1 at the time of discovery.

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure that the collected data was used to monitor the effectiveness and safety of services provided with opportunities for improvement; and failed to ensure the Governing Body approved the program's frequency and detail of data collection, resulting in the potential for poor patient outcomes for all 13 patients currently serviced and the Agency's 116 patients admitted in the past year. Findings include: On 8/11/23 at 12:40 p.m., during a review of the agency's Quality Assessment Performance Improvement (QAPI) data, it was noted that there was no evidence that the agency collected and analyzed QAPI data in order to monitor the quality, effectiveness and safety of services and care to their patients, and to identify opportunities for improvement. Additionally, there was no evidence the agency's Governing Body approved the frequency and detail of the QAPI data to be collected. These findings were reviewed with and acknowledged by the Administrator (Adm #1) at the time of discovery.

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 record review and interview, it was determined that the agency failed to track and analyze adverse events in order to implement preventative actions, which had the potential to negatively affect all 116 patients serviced by the agency in the past 12 months, resulting in the potential for failing to prevent future adverse events. Findings include: On 8/11/23 at 12:40 p.m., during a review of the agency's Quality Assessment Performance Improvement (QAPI) data, it was noted that there was no tracking, analyzing or implementation of preventive actions to decrease the number of adverse patient events and improve the quality and safety of patient care and outcomes. These findings were reviewed with and acknowledged by the Administrator (Adm #1) at the time of discovery who reported, "We used to do this, but we stopped."

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 (QAPI) program that fulfilled all the regulatory requirements of this section, addressed priorities for improved quality of care and patient safety and was evaluated for effectiveness, resulting in the potential to adversely affect the quality of care to all 13 patients currently receiving services and all 116 patients admitted over the past year. Findings include: On 8/11/23 at 12:40 p.m., during a review of the agency's Quality Assessment Performance Improvement (QAPI) documents and Governing Board meeting minutes, with the Administrator (Adm #1), it was noted that there was no indication that the Governing Board provided oversight of the data collection, performance improvement projects or addressed improved quality of care and patient safety. These findings were reviewed with and acknowledged by Adm #1 at the time of discovery.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, interview and record review, the Agency failed to ensure its disciplines utilized Infection Control standards of practice during the provision of care and services for 1 (P-2)) of 1 patient observed during a home health aide visit, from a total of 7 sampled records reviewed, resulting in the potential for the development and spread of infection. Findings include: P-2: The patient's start of care (SOC) was 7/13/23 with diagnoses that included Subdural Hematoma, Intercranial Bleed, Syncope and Falls. On 8/9/23 at 11:00 a.m., during a scheduled home visit with the Home Health Aide (HHa #1) the HHa was observed performing a bed bath for the patient, who was totally dependent on others for activities of daily living. During the visit, HHa #1 washed the patient's face and upper torso. HHa #1 then repositioned the patient to his right side and proceeded to cleanse the patient's genitals, anal area and buttocks. HHa #1 wiped the patient's anus and buttocks then used one continuous motion upward toward the patient's back and neck. This action was repeated by the HHa. Upon completion of the bed bath, HHa #1 placed the towel used to dry the patient, over her left arm which made contact with her uniform. HHa #1 then emptied the basin of water and concluded the visit. During the observation, it was noted that HHa #1 used the same washcloth to cleanse the patient's entire body, and failed to change the water in the basin during the provision of care. These findings were discussed with and confirmed by HHa #1 during an interview after completion of the visit and by the Administrator (Adm #1) during an interview on 8/10/23 at 12:20 p.m.

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: Based on observation and interview, the Skilled disciplines failed to implement appropriate seizure precautions for 1 (P-2) of 1 patient diagnosed with seizures and failed to utilize professional standards of practice during the provision of care and services for 1 (P-3) of 1 patient observed during a Physical Therapy home visit, from a total of 7 sampled records reviewed, resulting in the potential for injury, unidentified, unassessed patient concerns, decline in physical functioning and unmet care needs (G704); 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 Heart Failure, from a total of 7 sampled records reviewed, resulting in the potential for unidentified health concerns, decline in physical functioning, and poor patient outcomes (G706); and, failed to ensure the clinical record was completed and included detailed Skilled Nursing notes for 1 (P's #3) record with the ordered services, from a total of 7 sampled records reviewed, resulting in the potential for lack of continuity of care, undocumented, unidentified health concerns, and unmet patient needs (G716). Findings include: The cumulative effects of this systemic problem resulted in the Home Health Agency's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR 484.75 Skilled Professional Services.

Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This STANDARD is not met as evidenced by: Based on observation and interview, the Skilled disciplines failed to implement appropriate seizure precautions for 1 (P-2) of 1 patient diagnosed with seizures and failed to utilize professional standards of practice during the provision of care and services for 1 (P-3) of 1 patient observed during a Physical Therapy home visit, from a total of 7 sampled records reviewed, resulting in the potential for injury, unidentified, unassessed patient concerns, decline in physical functioning and unmet care needs. Findings include: P-2: The patient's start of care was 7/13/23 with diagnoses that included Subdural Hematoma, Falls, Intercranial Bleed and Syncope. The plan of care (POC) ordered Skilled Nursing (SN), Home Health Aide (HHa), Physical Therapy (PT), Occupational Therapy (OT) and Speech Therapy (ST) services to be provided. During the record review on 8/8/23 at 1:05 p.m., it was noted that the plan of care (POC) specified "Seizure Precautions." On 8/9/23 at 11:00 a.m., during a scheduled home visit with the Home Health Aide (HHa #1) there were no seizure precautions put in place by any of the ordered disciplines. These findings were reviewed with and acknowledged by the Administrator (Adm #1) during an interview on 8/10/23 at 12:20 p.m. P-3: The patient's SOC was 7/12/23 with diagnoses that included Sarcopenia, Peripheral Vascular Disease, Swelling Lower Extremities and Diabetes Mellites. On 8/9/23 at 12:45 p.m. during a scheduled PT visit with the Administrator (Adm #1/PT #1). During the visit, the following was observed: Upon arrival, the patient was seated in a recliner and was noted to have bruising to the right side of his face. PT #1 assessed the patient's blood pressure and revealed a reading of 98/52. PT #1 then stated, "It's very low." PT #1 did not recheck the patient's blood pressure prior to initiating exercises. Additionally, PT #1 did not check the patient's oxygen level. During the therapy session, the patient was noted to be visibly fatigued as evidenced by rapid breathing. PT #1 did not reassess the patient's blood pressure or oxygen saturation. PT #1 instructed on the continuation of therapy exercises with use of his walker and again, was visibly fatigued and reported being tired. PT #1 instructed the patient to sit down and then passed him (patient) a cup of water. Upon completion of the session, PT #1 checked the patient's blood pressure and revealed a reading of 122/80. PT #1 did not check the patient's oxygen saturation or respiratory rate. This writer observed the patient's respiratory rate which revealed a rate of 28 breaths per minute. (Reportable parameters were report respirations greater than 24). These findings were reviewed with and acknowledged by Adm #1 upon completion of the onsite visit and again during an interview on 8/10/23 at 12:55 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 observation, record review and interview, 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 Heart Failure, 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 included: P-1: The patient's start of care (SOC) was 7/14/23 with diagnoses that included Hypertensive Heart Disease with Heart Failure. The plan of care (POC) ordered Skilled Nursing (SN), Home Health Aide (HHa) and Physical therapy (PT) services to be provided and indicated the following parameters: "Report wt. gain of 3 lbs. in one day. 5 lbs. in one week." The POC further ordered, "Report sudden weight gain, swelling." During the clinical record review on 8/8/3 at 11:45 a.m., it was noted that the Initial Comprehensive Assessment dated 7/14/23, completed by the Registered Nurse, documented a stated weight of 260 pounds (lbs.). There was no baseline measurement of edema. The patient's "Internal Medical History and Physical report dated 7/7/23 documented, "Review of systems: Significant for fatigue, leg swelling and history of falls." Further review of the clinical record revealed no measurement of the patient's weights or edema had been assessed on 7/20/23, no measurement of edema on 7/27/23, no measurement of edema on 8/4/23. Additionally, during a scheduled home visit with the Registered Nurse (RN #1) on 8/10/23 at 10:00 a.m., RN #1 looked at the patient's bilateral lower extremities and was noted to touch both legs with her (RN #1) palms and stated, "They are more swollen." RN #1 did not measure the patient's bilateral lower extremity edema. RN #1 failed to perform baseline and on-going assessments of the patient's health status. These findings were reviewed with and acknowledged by the Administrator (Adm #1) during an interview on 8/10/23 at 11:46 a.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's #3) record with the ordered services, from a total of 7 sampled records reviewed, resulting in the potential for lack of continuity of care, undocumented, unidentified health concerns, and unmet patient needs. Findings include: P-3: The patient's start of care (SOC) was 7/12/23 with diagnoses that included Sarcopenia, Peripheral Vascular Disease, Diabetes Mellitus and Swelling Lower Extremities. During the record review on 8/8/23 at 2:10 p.m., it was noted that Skilled Nursing (SN) was ordered at a frequency of 1w1, 2w3 and 2 prn (as needed). During a review of the clinical record, it was noted that there were no SN visit notes after 7/28/23. There were 3 SN visits plotted (scheduled) for 8/1/23, 8/3/23 and 8/8/23. No SN visit notes had been input by the end of the survey. These findings were reviewed with and acknowledged by the Administrator (Adm #1) during an interview on 8/10/23 at 12:55 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 2 (P#'s 1, 2) of 2 records reviewed in which Home Health Aide services were ordered, from a total of 7 sampled records reviewed, resulting in the potential for the provision of unsafe care and unmet care needs. Findings include: P-1: The patient's start of care (SOC) was 7/14/23 with diagnoses that included Acute/Chronic Combined Systolic/Diastolic Heart Failure. The 485/plan of care (POC) indicated the following: "Functional limitations: Bowel/Bladder Incontinence, Dyspnea; Safety Measures: Anticoagulant (bleeding) precautions, support during transfer, fall precautions, use of assistive devices; Activities: Cane, Walker, Wheelchair." During the record review on 8/8/23 at 11:45 a.m., it was noted that the "Aide Care Plan" failed to include all the above noted precautions. These findings were reviewed with and acknowledged by the Administrator (Adm #1) during an interview on 8/10/23 at 11:46 a.m. P-2: The patient's SOC was 7/13/23 with diagnoses that included Subdural Hematoma, Syncope and Falls. The POC listed the following: Forgetful, Seizures, Tremors, Cane, Hospital Bed, Slow position change, support during transfer, Bowel/Bladder Incontinence, Endurance. On 8/8/23 at 1:05 p.m., during the record review, it was noted that the Aide Care Plan failed to include all the above noted precautions. The findings were reviewed with and acknowledged by Adm #1 during an interview on 8/10/23 at 12:20 p.m.