Every finding on record at Dynamic Home Care, Inc

The following Condition level deficiencies were identified during a Medicare authorized Emergency Preparedness survey conducted by the Michigan Department of Licensing and Regulatory Affairs on 12/19/23 at: Dynamic Home Care, Inc. 24001 Southfield Rd, Suite 205 Southfield, MI 48075 At the conclusion of the survey, the following Conditions were identified: 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).

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 maintain an emergency preparedness plan centered on both agency-based and community-based risk assessments (See E0006); failed to maintain, review, and update written emergency preparedness policies and procedures that were based on an emergency preparedness plan, risk assessment, and communication plan (See E0013); failed to maintain, review, and update written emergency preparedness policies and procedures to follow up with on-duty staff and patients to determine needed services (See E0021); failed to maintain, review, and update written emergency preparedness communication plan (See E0030); failed to develop and maintain an Emergency Preparedness training and testing program that is based on the emergency plan, risk assessment, policies, procedures, and communication plan (See E0036), and failed to conduct exercises to test the emergency plan (See E0039). This deficient practice has the potential to negatively affect the health and safety of all patients serviced by this agency. 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.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(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 Hospices at §418.113(a):] 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. *[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. 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):] 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. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to maintain an emergency preparedness plan centered on both agency-based and community-based risk assessments, resulting in a lack of direction and duties for agency personnel in the event of an actual disaster. This deficient practice has the potential to negatively affect the health and safety of all patients serviced by this agency. Findings include: On 12/19/23, the agency’s Emergency Preparedness binder was reviewed. There was no documentation to indicate the agency had conducted a risk assessment since April 2020. The administrator (ADM-1) acknowledged the findings during an interview on 12/19/23 at 3:25 p.m.

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [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. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility 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 annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization 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 address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility 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. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to maintain, review, or update the written emergency preparedness policies and procedures that were based on an emergency preparedness plan, risk assessment, and communication plan, resulting in the agency's inability to implement appropriate emergency actions. This deficient practice has the potential to negatively affect the health and safety of all patients serviced by this agency. Findings include: On 12/19/23, the agency’s Emergency Preparedness binder was reviewed. There was no documentation to indicate the agency had reviewed or updated the policies and procedures in the past two years. The administrator (ADM-1) acknowledged the findings during an interview on 12/19/23 at 3:25 p.m.

HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA 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:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to maintain, review, and update written emergency preparedness policies and procedures to follow up with on-duty staff and patients to determine needed services, in the event there is an interruption in services during or due to an emergency, resulting in the agency's inability to implement appropriate emergency actions. This deficient practice has the potential to negatively affect the health and safety of all patients serviced by this agency. Findings include: On 12/19/23, the agency’s Emergency Preparedness binder was reviewed. There was no documentation to indicate the agency had reviewed or updated the policies and procedures in the past two years. The administrator (ADM-1) acknowledged the findings during an interview on 12/19/23 at 3:25 p.m.

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 maintain, review, and update written emergency preparedness communication plan, resulting in the agency's inability to implement appropriate emergency actions. This deficient practice has the potential to negatively affect the health and safety of all patients serviced by this agency. Findings include: On 12/19/23, the agency’s Emergency Preparedness binder was reviewed. There was no documentation to indicate the agency had reviewed or updated the communication plan in the past two years. The administrator (ADM-1) acknowledged the findings during an interview on 12/19/23 at 3:25 p.m.

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(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, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and 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 facilities 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 communication plan, resulting in the agency’s inability to ensure staff actions align with the emergency plan. This deficient practice has the potential to negatively affect the health and safety of all patients serviced by this agency. Findings include: On 12/19/23, the agency's Emergency Preparedness documentation was reviewed. The agencies Training & Testing policy (no date) states the Emergency Preparedness plan will be reviewed and updated at least annually. There was no documentation to indicate staff participated in drills or education in the past two years. The administrator (ADM-1) acknowledged the findings during an interview on 12/19/23 at 3:25 p.m.

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 conduct exercises to test the emergency plan, resulting in the agency's inability to implement appropriate emergency actions. This deficient practice has the potential to negatively affect the health and safety of all patients serviced by this agency. Findings include: On 12/19/23, the agency’s Emergency Preparedness binder was reviewed. It was noted, there was documentation of a mock drill on 4/17/20. There was no documentation to indicate the agency had conducted a community-based, facility-based, or table-top exercise to test the emergency plan in the past three years. The administrator (ADM-1) acknowledged the findings during an interview on 12/19/23 at 3:25 p.m.

The following Condition and Standard level deficiencies were identified during a Medicare authorized recertification survey, concurrent with an Emergency Preparedness survey, conducted by the Michigan Department of Regulatory Affairs on 12/19/23 at: Dynamic Home Care, Inc. 24001 Southfield Rd, Suite 205 Southfield, MI 48075 This Agency had no additional locations. Clinical records reviewed for this survey included 4 discharge records with no home visits. The agency had no active patients. At the conclusion of the survey, the following Condition level deficiencies were identified: 42 CFR §484.65, Quality Assessment and Performance Improvement. 42 CFR §484.70, Infection Control. 42 CFR § 484.102, Emergency preparedness. 42 CFR § 484.105, Organization and Administration of Services. 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).

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment accurately reflected the patient's current health status at the time of admission to home care for 2 of 4 (P-3, 4) records reviewed, resulting in incomplete clinical information to aide in determining the needs of the patient and for measuring progress toward goals/outcomes. Findings include: P-3: This 85-year-old patient was admitted to home care on 5/28/21 with diagnoses of chronic obstructive pulmonary disease, essential hypertension, and osteoarthritis. During record review on 12/19/23, it was noted that the start of care assessment (SOC) dated 5/28/21, documented under “Primary Diagnosis & Other Diagnoses,” all 8 other diagnoses list the same date of onset, 5/28/21. A few of the other diagnoses listed include bilateral osteoarthritis of the knees, spondylosis of the lumbar region, unspecified hearing loss, and dependence on supplemental oxygen. These diagnoses are indicative of long-term, chronic health issues. There was no information found in the record to indicate that these other 8 diagnoses were all new as of 5/28/21 or that the patient had experienced exacerbations. P-4: This 79-year-old patient was admitted to home care on 4/5/21 with diagnoses of osteoarthritis of the knee, difficulty walking, and abnormal gait. During record review on 12/19/23, it was noted that the start of care assessment (SOC) dated 4/5/21, documented under “Primary Diagnosis & Other Diagnoses,” all 7 other diagnoses list the same date of onset, 4/5/21. A few of the other diagnoses listed include long term use of oral hypoglycemic drugs, chronic obstructive pulmonary disease, and essential hypertension. These diagnoses are indicative of long-term, chronic health issues. There was no information found in the record to indicate that these other 7 diagnoses were all new as of 4/5/21 or that the patient had experienced exacerbations. These findings were reviewed and acknowledged by the administrator (ADM-1) during an interview on 12/19/23 at 3:25 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 an accurate review of all medications to determine any duplicate therapy or adverse effects, and failed to ensure the physician was notified of potential drug interactions or duplicate therapy in 2 of 4 (P-1, 3) records reviewed, resulting in the potential for harmful medication effects for all patients serviced by this agency. Findings include: P-3: This 85-year-old patient was admitted to home care on 5/28/21 with diagnoses of chronic obstructive pulmonary disease, essential hypertension, and osteoarthritis. During record review on 12/19/23, it was noted that the start of care assessment dated 5/28/21 stated no issues were found during drug regimen review (Section M2001). A medication interaction report was generated through the electronic medical record software that indicated 3 duplicate therapies between metoprolol and carvedilol, Mucinex and Robitussin, and metoprolol and losartan. There was no evidence that the physician was notified of the duplicate therapies. This finding was reviewed and acknowledged by the administrator (ADM-1) during an interview on 12/19/23 at 3:25 p.m. P-1: The patient was admitted to home care on 6/2/21, with diagnoses of diabetes mellitus, essential hypertension, and osteoarthritis. During record review on 12/19/23, it was noted that no medication reconciliation was documented in the record. A drug reconciliation was performed on 12/19/23 and found 5 major, 60 moderate, 3 minor drug to drug interactions, multiple food to drug interactions and multiple duplicate drug therapies. There was no evidence the physician was notified of the interactions and duplicate therapies. During an interview on 12/19/23 at 3:10 p.m., ADM-1 acknowledged the above findings.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the plan of care included appropriate interventions with objectively measurable goals specific to the individualized needs of the patient in 1 of 4 (P-3) records reviewed, resulting in the potential for poor patient outcomes and unmet care needs. Findings include: P-3: This 85-year-old patient was admitted to home care on 5/28/21 with diagnoses of chronic obstructive pulmonary disease, essential hypertension, and osteoarthritis. During record review on 12/19/23, it was noted that the plan of care failed to include measurable skilled nursing goals and outcomes. For example, one goal stated, “patient will be independent with medication management.” There was no indication how this goal would be measured to determine the patient's progress towards discharge. This finding was reviewed and acknowledged by the administrator (ADM-1) during an interview on 12/19/23 at 3:25 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 record review and interview, it was determined the home health agency failed to develop a Quality Assessment and Performance Improvement (QAPI) program that measures, tracks and analyzes it's quality indicators in order to assess the processes of care and services provided by the agency, resulting in the inability to improve patient care with positive outcomes (refer to G 0642); the agency failed to collect and monitor data for the Quality Assessment and Performance Improvement (QAPI) program, to ensure the effectiveness and safety of services and quality of care to the patients and to identify opportunities for improvement, and there was no documented evidence the governing body approved the QAPI frequency and data collection process (refer to G0644); failed to initiate any performance improvement activities within their Quality Assessment Performance Improvement (QAPI) program that focused on high risk, high volume or problem prone areas (See G0648); failed to initiate any performance improvement activities within their Quality Assessment Performance Improvement (QAPI) program that considered incidence, prevalence, and severity of problems in identified areas of focus (See G0650); failed to track adverse patient events, analyze their causes, and implement preventative actions within their Quality Assessment Performance Improvement (QAPI) program (See G0654); failed to conduct any performance improvement projects within their Quality Assessment Performance Improvement (QAPI) program (See G0658); 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, that addressed priorities for improved quality of care and patient safety and was evaluated for effectiveness (See G0660). 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 record review and interview, it was determined the agency failed to provide evidence of its efforts to measure, track and analyze its 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 for unmet care needs. Findings include: On 12/19/23, the administrator (ADM-1) was asked to provide documentation of the agency's Quality Assessment/Performance Improvement program. Adm#1 said they have not done any QAPI activities. No documentation of the agency's QAPI program, except policies, for 2021, 2022, and 2023 were available for review. There was no documented evidence the agency had measured, tracked and analyzed any quality indicators in the QAPI program for 2021, 2022, or 2023. All agency patients could be impacted by the agency's failure to measure, track and analyze quality indicators. During an interview on 12/19/23 at 3:10 p.m., ADM-1 acknowledged the above findings.

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 collect and monitor data for the Quality Assessment and Performance Improvement (QAPI) program, to ensure the effectiveness and safety of services and quality of care to the patients and to identify opportunities for improvement, resulting in the potential for ineffective, unsafe and unmet care needs. Findings include: On 12/19/23, the administrator (ADM-1) was asked to provide documentation of the agency's Quality Assessment/Performance Improvement program. Adm#1 said they have not done any QAPI activities since 3/20/21. No documentation of the agency's QAPI program, except policies, for 2021, 2022, and 2023 were available for review. There was no documented evidence the agency had collected and monitored data, in the QAPI program for 2021, 2022, or 2023. All agency patients could be impacted by the agency's failure to collect and monitor data. During an interview on 12/19/23 at 3:10 p.m., ADM-1 acknowledged the above findings.

Program activities CFR(s): 484.65(c) Standard: Program activities. The HHA's performance improvement activities must-- This STANDARD is not met as evidenced by: Based on record review and interview, it was determined the Agency (HHA) failed to initiate any performance improvement activities within their Quality Assessment Performance Improvement (QAPI) program, resulting in the potential for the rendering of substandard care and unmet care needs. Findings include: On 12/19/23 at 1:30 p.m., the administrator (ADM-1) was asked to provide documentation of the agency's Quality Assessment/Performance Improvement program. Adm#1 said they have not done any QAPI activities since 3/20/21. No documentation of the agency's QAPI program, except policies, for 2021, 2022, and 2023 were available for review. There was no documented evidence the agency initiated any performance improvement activities in the QAPI program for 2021, 2022, or 2023. All agency patients could be impacted by the agency's failure to initiate any performance improvement activities. During an interview on 12/19/23 at 3:10 p.m., ADM-1 acknowledged the above findings.

High risk, high volume, or problem-prone area CFR(s): 484.65(c)(1)(i) (i) Focus on high risk, high volume, or problem-prone areas; This ELEMENT is not met as evidenced by: Based on record review and interview, it was determined the Agency (HHA) failed to initiate any performance improvement activities within their Quality Assessment Performance Improvement (QAPI) program that focused on high risk, high volume or problem prone areas, resulting in the potential for agency issues to go unresolved in high risk, high volume or problem prone areas that could affect all patients served by the agency. Findings include: On 12/19/23 at 1:30 p.m., the administrator (ADM-1) was asked to provide documentation of the agency's Quality Assessment/Performance Improvement program. ADM-1 said they have not done any QAPI activities since 3/20/21. No documentation of the agency's QAPI program, except policies, for 2021, 2022, and 2023 were available for review. There was no documented evidence the agency initiated any performance improvement activities that focused on high risk, high volume or problem prone areas in the QAPI program for 2021, 2022, or 2023. All agency patients could be impacted by the agency's failure to initiate any performance improvement activities that focused on high risk, high volume or problem prone areas. During an interview on 12/19/23 at 3:10 p.m., ADM-1 acknowledged the above findings.

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 the Agency (HHA) failed to track adverse patient events, analyze their causes, and implement preventative actions within their Quality Assessment Performance Improvement (QAPI) program, resulting in the potential for patient issues to go unresolved and affect all patients served by the agency. Findings include: On 12/19/23 at 1:30 p.m., the administrator (ADM-1) was asked to provide documentation of the agency's Quality Assessment/Performance Improvement program. ADM-1 said they have not done any QAPI activities since 3/20/21. No documentation of the agency's QAPI program, except policies, for 2021, 2022, and 2023 were available for review. There was no documented evidence the agency tracked adverse patient events, analyzed their causes, or implemented preventative actions within their QAPI program for 2020, 2021, or 2022. All agency patients could be impacted by the agency's failure to track adverse patient events, analyze their causes, and implement preventative actions. During an interview on 12/19/23 at 3:10 p.m., ADM-1 acknowledged the above findings.

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 record review and interview, it was determined the Agency (HHA) failed to conduct any performance improvement projects within their Quality Assessment Performance Improvement (QAPI) program, resulting in the potential for patient and agency issues to go unresolved and affect all patients served by the agency. Findings include: On 12/19/23 at 1:30 p.m., the administrator (ADM-1) was asked to provide documentation of the agency's Quality Assessment/Performance Improvement program (QAPI). ADM-1 said they have not done any QAPI activities since 3/20/21. No documentation of the agency's QAPI program, except policies, for 2021, 2022, and 2023 were available for review. There was no documented evidence the agency conducted performance improvement projects within their QAPI program for 2021, 2022, or 2023. All agency patients could be impacted by the agency's failure to conduct performance improvement projects. During an interview on 12/19/23 at 3:10 p.m., ADM-1 acknowledged the above findings.

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, that 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 patients receiving services. Findings include: On 12/19/23 at 1:30 p.m., the administrator (ADM-1) was asked to provide documentation of the agency's Quality Assessment/Performance Improvement program (QAPI). ADM-1 said they have not done any QAPI activities since 3/20/21. No documentation of the agency's QAPI program, except policies, for 2021, 2022, and 2023 were available for review. There was no documented evidence the agency's governing body ensured the agency had an active and functioning QAPI program for 2021, 2022, and 2023. All agency patients could be impacted by the agency's failure to have an active and functioning QAPI program. During an interview on 12/19/23 at 3:10 p.m., ADM-1 acknowledged the above findings.

Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This CONDITION is not met as evidenced by: Based on record review and interview, it was determined the agency failed to ensure effective infection prevention and control measures were utilized (G-682); and failed to document any infection control meeting minutes for 2021, 2022, or 2023 (G-684); resulting in the potential for the development and spread of infections to staff and all patients serviced by this agency. Findings include: 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§484.70 Infection Control.

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 record review and interview, the agency failed to maintain a coordinated agency-wide program for the surveillance, identification, and prevention of infections, resulting in the potential development and spread of infections between agency staff and the agency's patients. Findings include: On 12/19/23 at 1:30 p.m., the administrator (ADM-1) was asked to provide documentation of the agency's Quality Assessment/Performance Improvement program (QAPI). ADM-1 said they have not done any QAPI activities since 3/20/21. No documentation of the agency's QAPI program, except policies, for 2021, 2022, and 2023 were available for review. There was no documented evidence the agency maintained a coordinated agency-wide program for the surveillance, identification, and prevention of infections, for 2021, 2022, and 2023. All agency patients could be impacted by the agency's deficient practice. During an interview on 12/19/23 at 3:10 p.m., ADM-1 acknowledged the above findings.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to maintain an agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases as a part of the agency's Quality Assessment Performance Improvement (QAPI) program, resulting in the potential spread of infections between patient care staff and the agency's patients. Findings include: On 12/19/23 at 1:30 p.m., the administrator (ADM-1) was asked to provide documentation of the agency's Quality Assessment/Performance Improvement program (QAPI). ADM-1 said they have not done any QAPI activities since 3/20/21. No documentation of the agency's QAPI program, except policies, for 2021, 2022, and 2023 were available for review. There was no documented evidence the agency maintained a coordinated agency-wide program for the surveillance, identification, and prevention of infections as part of the agency's (QAPI) program for 2021, 2022, and 2023. All agency patients could be impacted by the agency's deficient practice. During an interview on 12/19/23 at 3:10 p.m., ADM-1 acknowledged the above findings.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure a governing body assumed responsibility for the operation of the agency, the provision of all home health services and its quality assessment and performance improvement program, resulting in a lack of overall leadership in the agency's provision of home health services (See G942). The systemic effects of the above deficiencies had the potential to affect all agency patients, resulting in the provision of substandard care, patients not receiving needed services and the potential for poor patient outcomes.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on record review and interview, it was determined the home health agency failed to have an active Governing Body that met at least annually, and assumed full legal authority and responsibility for the agency's overall management and operations, all services provided, the fiscal operations, review of the agency's budget and operations plans, and it's quality assessment and performance improvement program (QAPI), since 3/20/21, resulting in the potential to adversely affect the quality of care to all patients receiving services. Findings include: On 12/19/23 at 1:30 p.m., the administrator (ADM-1) was asked to provide documentation of the agency's Quality Assessment/Performance Improvement program (QAPI). ADM-1 said they have not done any QAPI activities since 3/20/21. No documentation of the agency's QAPI program, except policies, for 2020, 2021 or 2022 were available for review. There was no documented evidence that an active Governing Body met at least annually and assumed full legal authority and responsibility for the agency's overall management and operations, all services provided, the fiscal operations, review of the agency's budget, and operations plans and it's QAPI program, since 3/20/21. During an interview on 12/19/23 at 3:10 p.m., ADM-1 acknowledged the above findings.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the clinical record contained completed assessments for 1 of 4 (P-3) records reviewed, resulting in the potential for poor patient outcomes and a lack of information for all agency staff caring for the patient. Findings include: P-3: This 85-year-old patient was admitted to home care on 5/28/21 with diagnoses of chronic obstructive pulmonary disease, essential hypertension, and osteoarthritis. During record review on 12/19/23, it was noted that the start of care assessment dated 5/28/21, failed to include a fire assessment for patients with oxygen, stating “patient not using oxygen.” However, the plan of care included under medications, oxygen at 3 liters per nasal cannula as needed as well as safety measures for oxygen precautions. This finding was reviewed and acknowledged by the administrator (ADM-1) during an interview on 12/19/23 at 3:25 p.m.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a detailed discharge summary was sent to the physician within 5 business days of discharge for 2 of 4 (P-2, 4) discharge records reviewed, resulting in a lack of information to ensure continuity of care. Findings include: P-4: This 79-year-old patient was admitted to home care on 4/5/21 with diagnoses of osteoarthritis of the knee, difficulty walking, and abnormal gait. During record review on 12/19/23, it was noted that the patient was discharged from agency services on 5/19/21. There was no documented evidence that a detailed discharge summary report was sent to the physician within 5 days of the patient’s discharge. The administrator (ADM-1) acknowledged that no discharge summary was sent during an interview on 12/19/23 at 3:25 p.m. P-2: This patient was admitted to home care on 6/20/21, with diagnoses of Poly-osteoarthritis, spondylosis, and diabetes mellitus. During record review on 12/19/23, it was noted that the patient was discharged from agency services on 8/12/21. There was no documented evidence that a detailed discharge summary report was sent to the physician within 5 days of the patient’s discharge. During an interview on 12/19/23 at 3:10 p.m., ADM-1 acknowledged the above findings.

On 1/4/21 through 1/7/21, an Emergency Preparedness survey was conducted by the Michigan Department of Licensing and Regulatory Affairs. At the survey, Dynamic Home 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 standard level deficiency was identified.

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 1 patient currently serviced by the agency. Findings include: The agency's Emergency Preparedness Plan was reviewed on 1/6/21. 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 (Admin-A) and the Alternate Clinical Manager (RN-D) during an interview on 1/6/21 at 10:30 a.m.

On 1/4/21 to 1/7/21, the Michigan Department of Licensing and Regulatory Affairs conducted a Medicare authorized recertification survey along with a focused infection control survey at: Dynamic Home Care 24001 Southfield Road, Suite 205 Southfield, MI 48075 Records reviewed: 6 discharged records and 1 record with a home visit, for a total of 7 records reviewed. The agency had 1 active patient at the time of the survey. The agency has no branch sites. At the conclusion of the survey the agency was found to be in compliance for the conditions of participation for Home Health Agency at: 42 CFR Part §484.70 Infection Prevention and Control. The following condition level deficiencies were identified during the survey: 42 CFR §484.55 Comprehensive assessment of patients. 42 CFR §484.60 Care planning, coordination of services, and quality of care. 42 CFR §484.75 Skilled professional services 42 CFR §484.80 Home health aide services 42 CFR §484.105 Organization and administration of services As a result of the Condition level noncompliance on 1/7/21, 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 observation, record review, and interview, the agency failed to ensure the comprehensive assessment was an accurate reflection of the patient's health status and included a review of all medications. These practices impacted 4 of 7 (MR# 1, 2, 3, 4) patients from a total sample of 7 records reviewed. The cumulative effect of these systemic problems resulted in the agency's inability to ensure the provision of quality health care. Findings include: 1. The agency failed to ensure the comprehensive assessment included baseline information detailing the status of the patient's wound at the time of admission. (See G528) 2. The agency failed to ensure the comprehensive assessment included a review of all medications to identify any potential adverse effects, drug reactions, or interactions. (See G536)

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 observation, record review, and interview, the agency failed to ensure the comprehensive assessment included baseline information detailing the status of the patient's wound at the time of admission for 2 of 4 (MR#1, 4) records reviewed in which the patient had a wound, resulting in the potential for poor patient outcomes for these wound care patients. Findings include: MR#1: This 68-year-old patient was admitted to home care on 12/29/20 with diagnoses of polyosteoarthritis, high blood pressure and colostomy. The patient had a hysterectomy on 5/20/20 that resulted in a colostomy. The patient was then transferred to a rehab facility to recover from the surgery and generalized weakness before returning home. The clinical record was reviewed on 1/4/21. During review of the 12/29/20 comprehensive assessment, it was noted that RN-C (registered nurse) documented the patient has two wounds. Wound 1 is located mid abdomen, the wound is closed with no drainage, wound size is documented as 0 cm (centimeters) length x 0 cm width x 0 cm depth and "area cleansed with n/s (normal saline), covered with gauze and taped." It is unclear why a closed wound would require wound care and a dressing. Wound 2 no location is noted, the wound is closed, and wound size is documented as 0 cm x 0 cm x 0 cm. During a joint surveyor home visit with RN-C on 1/5/21 at 10:30 a.m., it was observed that the patient's mid abdomen wound is approximately 3 inches in diameter and the dressing that was removed showed a scant amount of serosanguinous drainage. The second wound is located below or inferior to wound 1 and the size is approximately 3 cm in length x 2 cm wide with a scant amount of serosanguinous drainage. RN-C is observed providing wound care and redressing the wounds. RN-C was queried regarding wound measurements and she replied that she does not have a tape measure. The comprehensive assessment failed to include an accurate baseline description of the patient's wounds to assist the agency in developing the patient's plan of care. An accurate baseline description of the wound along with measurements (if possible) is essential in determining whether a wound is healing or deteriorating. The findings were reviewed with Admin-A (administrator) and RN-D (registered nurse, alternate clinical manager) during an interview on 1/6/21 at 2:00 p.m. RN-D stated the nurse should document wound measurements during the comprehensive assessment and then at least weekly thereafter. M.R. #4: This patient was admitted to the agency on 6/13/2020 with the diagnoses of, "Open Wound to left lower extremity and right lower extremity and Hypertension." The "Start of Care (SOC) Assessment" signed by RN-D (Registered Nurse/Alternate Clinical Manager) and dated 6/13/2020 documented, "Past Medical History: LLE Wound (left lower extremity wound). Multiple surgeries on legs from accident at work and non-healing leg wound." The Primary Diagnosis was "Exacerbation of Open Wound of Right Lower Leg." And the other diagnosis was "Exacerbation of Open Wound Left Lower Leg. Wound Care Worksheet: Wounds addressed on this visit: LLE, Status: Open, Present on Admission, Type-Traumatic, Size: Length 0 cm., Width 0 cm., Depth 0 cm, Wound Bed: Red, Edges: Attached, Drainage: Serosangenous, Amount: Large, Surrounding Tissue: Excoriated/Fragile, Treatment: Cleanse with NS (normal saline), apply wet to dry, cover with 4X4, ABD and wrap with Kerlix daily & PRN-Patient able to do own dressing change, SN (skilled nurse) did today & patient tolerated well." It is unclear why a closed wound would require wound care and a dressing. The comprehensive assessment failed to include a baseline description of the patient's right lower leg wound to assist the agency in developing the patient's plan of care. The findings were reviewed with Admin-A and RN-D during an interview on 01/05/2021 at 10:10 AM, RN-D stated, "I don't think the patient had a wound on both legs." Admin.-A stated, "Yes, I remember this patient I was the therapist (physical therapy), he did have wounds on both lower legs." RN-D stated, "I don't know how I missed it. I didn't document anything on the right leg, it should be documented on the SOC assessment."

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 identify any potential adverse effects, drug reactions, or interactions for 2 of 7 (MR# 2, 3) records reviewed, resulting in the potential for harmful medication effects for these patients. Findings include: MR#2: This patient was admitted to the agency on 10/22/20 with diagnoses of left sided paralysis following a stroke and cerebral palsy. The comprehensive assessment was completed by Admin-A (administrator, physical therapist) on 10/22/20. The 1/4/21 review of the comprehensive assessment indicates for (M2001) drug regimen review that issues were found during the review and that the physician was contacted. Under the area for care coordination, Admin-A documents that the physician was contacted regarding the plan of care and the frequency. There was no indication of the issues found during the drug review. There was no evidence that Admin-A completed a "Patient Medication Record" that lists the patient's medications, dosage, frequency, and the reason for the drug therapy. The findings were reviewed with Admin-A and RN-D (alternate clinical manager) during an interview on 1/6/21 at 2:15 p.m. RN-D reviewed the electronic medical record and acknowledged there was no evidence that the comprehensive assessment included a review of the patient's medications to identify any potential adverse effects and drug reactions. MR#3: This patient was admitted to the agency on 7/30/20 with diagnoses of pressure ulcer left heel and major depressive disorder. The comprehensive assessment was completed by CM-B (clinical manager, registered nurse) on 7/30/20. The 1/4/21 review of the comprehensive assessment indicates for (M2001) drug regimen review that issues were found during the review and that the physician was contacted. Under the area for skilled intervention, CM-B documented that she conferenced with the physician and the response was "yes." There was no indication of the issues found during the drug review and no explanation of the physician's "yes" response. That same date, 7/30/20, CM-B documented opposing findings on the patient medication record that there were no medication discrepancies, no action was taken, and the physician was not notified. It was unable to be determined if the comprehensive assessment included a review of the patient's medications to identify any potential adverse effects and drug reactions. The agency failed to follow its own policy titled, Medication Reconciliation (2018) which states, "At the time of admission, the admitting RN (registered nurse), PT (physical therapist) or SLP (speech therapist) will create and document a complete list of medications that patient is taking at home, including dose, route, frequency. A RN will reconcile any discrepancies with the patient's physician. Discrepancies include duplications, omissions, changes, contraindications and/or unclear information." The findings were reviewed with and acknowledged by Admin-A and RN-D during an interview on 1/6/21 at 2:15 p.m.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to provide services as ordered in the plan of care, ensure wound care orders were included on the plan of care, provide services only as ordered by the physician, alert the physician to changes in the patient's condition, coordinate the delivery of care services, and provide education and training to ensure the patient is proficient at wound care. These practices impacted 5 of 7 (MR# 1, 3, 4, 6, 7) patients from a total sample of 7 records reviewed. The cumulative effect of these systemic problems resulted in the agency's inability to ensure the provision of quality health care. Findings include: 1. Physical therapy, medical social work, and aide services were not provided as ordered. (See G572) 2. There were no wound care orders on the plan of care (See G574). 3. The skilled nurse and social worker provided services without an order from the physician. (See G580) 4. The skilled nurse did not alert the physician to changes in the patient's respiratory status. (See G590) 5. Physical therapy, medical social work, and aide services were not coordinated to meet the patient's needs. (See 608) 6. Documentation indicates patient was 50% proficient at wound care before being discharged. (See G610)

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to provide services as ordered in the plan of care for 4 of 7 (MR# 1, 3, 4 and 6) records reviewed, resulting in the potential for poor patient outcomes, decline in physical functioning, and unmet personal care needs for these two patients. Findings include: MR#1: This 68-year-old patient was admitted to home care on 12/29/20 with diagnoses of polyosteoarthritis, high blood pressure and colostomy. The patient had a hysterectomy on 5/20/20 that resulted in a colostomy. The patient was then transferred to a rehab facility to recover from the surgery and generalized weakness before returning home. The plan of care dated 12/29/20 orders weekly skilled nursing (SN) and aide services along with physical therapy (PT) and medical social worker (MSW) to evaluate and treat the patient. The clinical record also contains a physician order dated 12/29/20 which orders SN, PT, MSW and aide services for this patient. During an interview on 1/4/21 at 10:10 a.m., Admin-A (administrator, PT) states the agency has 2-5 days after the start of care to get other disciplines out to see the patient and complete their evaluations. Record review on 1/4/21, indicates there is no documented evidence that aide services were provided and no evidence that PT and MSW have evaluated and treated the patient in the past 7 days since the patient was admitted to home care. During a joint survey home visit with RN-C (registered nurse) on 1/5/21 at 10:30 a.m., the patient and caregiver/spouse were asked about PT, MSW, and aide services. The patient stated that she's not had any contact regarding PT, MSW or aide services and that the services have not been declined or delayed due to patient request. The findings were reviewed with Admin-A and RN-D (alternate clinical manager, registered nurse) during an interview on 1/6/21 at 2:00 p.m. RN-D states the agency is waiting on an order from the physician for aide services. The clinical record is reviewed with Admin-A and RN-D to point out that the 12/29/20 plan of care and a 12/29/20 physician order both document orders for PT, MSW, and aide services for this patient. MR#3: This 60-year-old patient was admitted to the agency on 7/30/20 with diagnoses of stage 3 pressure ulcer on the left sole, a skin lesion on the left lateral (side) foot, and major depressive disorder. The 7/30/20 plan of care ordered skilled nursing (SN) services to be provided once a week for one week, two visits per week for two weeks, one visit per week for five weeks, and two as needed visits. Record review on 1/4/21 indicates the SN documented a visit on 8/10/20 but failed to provide a second visit that same week. There was no documentation to indicate the patient had declined or delayed the second visit and no evidence the physician was informed of the change in visit frequency. SN services were not provided at the frequency ordered in the plan of care. The findings were reviewed with and confirmed by Admin-A and RN-D during an interview on 1/6/21 at 2:15 p.m. M.R. #4: This patient was admitted to the agency on 6/13/320 with the diagnoses of, "Open Wound LLE & RLE (left lower extremity and right lower extremity) and Hypertension." The Plan of Care ordered SN (skilled nurse) services once a week for seven weeks. The 01/04/2021 record review noted the SN documented a visit on 6/13/20, 6/20/20, 6/26/20, 7/8/20, 7/15/20 and 7/22/20. The SN documented one visit per week for the first three weeks, there was no documented SN visit for week four. The SN documented a missed visit on 7/3/20, there was no documented evidence the SN made any attempts to reschedule the visit and to provide wound care. There was no documented evidence the patient and/or caregiver refused any other visits this fourth week, and no documented evidence the SN notified the physician of the change in visit frequency. M.R. #6: This patient was admitted to the agency on 10/23/20 with the diagnoses of, "Dementia without Behavior Disturbance, Fracture Right Femur and Unsteadiness on Feet." The Plan of Care ordered OT (occupational therapy) services, evaluate, and treat. The OT-E's evaluation was signed and dated 10/28/20. The OT's visit frequency was documented as once a week for four weeks. The OT-E documented a visit once a week for 10/28/20 and 11/4/20. The OT-E documented a missed visit for week three dated 11/13/20. There was no documented evidence OT-E made any attempts to reschedule the visit and no notification to the physician of the change in visit frequency. The above findings were reviewed and acknowledged by Administrator-A/Physical Therapy and RN-D (Alternate Clinical Manager/Registered Nurse), during an interview on 01/05/2021 at 1 PM.

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 may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure wound care orders were included on the plan of care for 3 of 4 (M.R. #4, 6, and 7) records reviewed with diagnoses of wounds, resulting in the potential for unhealed wounds for all patients with wounds resulting in a possible negative outcome. Findings include: M.R. #4: This patient was admitted to the agency on 6/13/2020 with the diagnoses of, "Open Wound to left lower extremity and right lower extremity and Essential Hypertension." The plan of care documented, "Assessment of patient with unspecified open wound, right lower leg unspecified encntr. (encounter), unspecified open wound left lower leg." The Start of Care Assessment signed by RN-D/Alternate Clinical Manager documented, "Wound 1: LLE (left lower extremity), open, present on admission. Large amount of serosangenous drainage. Treatment-Cleanse with normal saline, apply wet to dry, cover with 4X4, ABD and wrap with Kerlix daily and prn (as needed)." At the time of the record review on 01/04/2021, there was no documented wound care orders on the plan of care, to direct the nursing care of the patient's wounds. The SN (skilled nurse) documented on visit notes dated 6/20/20, 6/26/20, and 7/15/20, "Wound on bilateral lower extremities, dressing done." The agency failed to include specific wound care orders on the plan of care. M.R. #6: This patient was admitted to the agency on 10/23/2020 with the diagnoses of, Dementia without Behavior Disturbance, Right Fractured Femur and Coronary Angioplasty Implant & Graft." The Start of Care assessment dated 10/23/2020 documented Incision Right Femur. One Surgical incision, two lines the upper line with 12 staples and the lower line with 37 staples, dressing changed." At the time of the 01/05/2021 record review, there was no documented wound care orders on the plan of care, to direct the nursing care of the patient's incisions. The agency failed to include specific wound care orders on the plan of care. M.R. #7: This patient was admitted to the agency on 6/5/2020 with the diagnoses of, "Stage III Sacral Pressure Ulcer, Multiple Sclerosis and Essential Hypertension." The plan of care, for the recertification period beginning 10/3/2020, signed by RN-C and dated 9/30/2020 documented, "Assessment of patient with Pressure Ulcer of Sacral region, stage 3." At the time of the record review on 01/04/2021, there was no documented wound care orders on the plan of care, to direct the nursing care of the patient's wound. The recertification assessment dated 9/30/2020 and SN visit notes dated to 10/13/2020 wound care was documented as "Cleanse with normal saline, pack with Aqua Cel dressing, cover with gauze and tape." The SN visit notes 10/19/2020 to 11/12/2020 documented the following wound care: Aloe Vera Wound Wash, Dakins Solution to gauze inserted to wound, gauze and tape." None of the above wound care directions were documented on the plan of care dated 9/30/2020. The agency failed to include specific wound care orders on the plan of care.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure services were provided only as ordered by the physician in 2 of 7 (MR# 3, 4) records reviewed, resulting in the potential to negatively affect these two patients. Findings include: MR#3: This 60-year-old patient was admitted to the agency on 7/30/20 with diagnoses of stage 3 pressure ulcer on the left sole, a skin lesion on the left lateral (side) foot, and major depressive disorder. The 7/30/20 plan of care ordered skilled nursing (SN) services to be provided once a week for one week, two visits per week for two weeks, one visit per week for five weeks, and two as needed visits (without criteria to direct the need for the 2 visits). Clinical record review on 1/4/21, indicates the SN provided three additional visits (9/18/20, 9/22/20, and 9/26/20) without a physician order. The SN failed to follow the agency's policy titled, Plan of Care (485) and Physician Orders (2018) which states, "Skilled nursing and other home health services will be in accordance with a Plan of Care..." The findings were reviewed with and confirmed by Admin-A (administrator) and RN-D (alternate clinical manager, registered nurse) during an interview on 1/6/21 at 2:15 p.m. M.R. #4: M.R. #4: This patient was admitted to the agency on 6/13/320 with the diagnoses of, "Open Wound LLE & RLE (left lower extremity and right lower extremity) and Hypertension." The Plan of Care ordered SN (skilled nurse) and PT (physical therapy) services. At the time of the 01/04/2021 record review, it was noted a MSW (medical social worker) evaluation signed by MSW-G and dated 7/10/20. At the time of the record review on 01/04/2021, there was no physician order for social work services and no documented evidence the SN or the PT notified the physician of the need for social work services for this patient. During an interview on 01/05/2021 at 10:07 AM when queried if the agency had a physician order for MSW services Administrator-A (Administrator /Physical Therapy) replied, "We did not get an order. What happened was we discussed and agreed that the patient needed to see an MSW. We had a hard time getting someone to go to that location, it was too far. It took a while; I had an independent MSW to go there. But no, we did not get an order."

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(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 registered nurse failed to promptly alert the physician to changes in the patient's condition for 1 of 6 records reviewed (M.R. #6) with skilled nursing services, for unmet medical needs which could negatively affect all 44 patients. Findings include: M.R. #6: This patient was admitted to the agency on 10/23/2020 with the diagnoses of, Dementia without Behavior Disturbance, Right Fractured Femur and Coronary Angioplasty Implant & Graft." The patient was hospitalized for repair of Right Femur Fracture on 10/15/2020 and discharged from hospital to home on 10/22/2020. The Start of Care Assessment signed by RN-C (registered nurse) and dated 10/23/2020 documented, "Respiratory Rate: 16-WNL (within normal limits), Lung Sounds: Wheezes and Crackles, patient is not short of breath." The visit note dated 10/27/2020, signed by RN-C documented, "Respiratory Status: WNL, Lung Sounds: Wheezes-Chest." The visit note dated 11/3/2020, signed by RN-C documented, "Respiratory Status: WNL, Lung Sounds: CTA (clear to auscultation). Pt. (patient) is still unable to spit out sputum when he coughs. Therapy is having trouble getting him OOB (out of bed) to bathroom." The visit note dated 11/10/2020, signed by RN-C documented, "Respiratory Status: CTA. He still has rattle in his throat and can't spit out mucous when he coughs." There was no documented evidence on any of the four SN (skilled nurse) visit notes that the physician was promptly alerted to the presence of shortness of breath, wheezes in the patient's chest and his inability to cough up and expectorate the mucous. During the clinical record review on 01/07/2021, a Transfer Summary Note dated 11/16/2020 signed by RN-C documented, "Transferred to hospital with shortness of breath and fever, died 3 days later." During an interview on 01/7/2021 at 1 PM, it was queried to explain this patient's case. The Administrator-A (Administrator/Physical Therapy) stated, "The daughter called over the weekend and stated family members had came to visit and the patient beginning not feeling well. They think he got COVID-19 from a family visitor. They transferred him to the hospital, and he died 3 days later." It was queried to provide documentation of communication between RN-C and the physician regarding the changes in the patient's condition, the chest wheezes and the inability to cough up and spit out the mucous, RN-D (Alternate Clinical Manager/RN-D) replied,"He should've notified the physician and documented it."

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to coordinate the delivery of physical therapy, social work, and aide services for 1 of 6 (MR#1) records reviewed in which more than one discipline was ordered to provide care. This practice results in the potential for unmet personal care needs for this patient and the potential for decline in physical functioning. Findings include: MR#1: This 68-year-old patient was admitted to home care on 12/29/20 with diagnoses of polyosteoarthritis, high blood pressure and colostomy. The 12/29/20 plan of care ordered the agency to provide skilled nursing, physical therapy (PT), medical social work (MSW), and aide services to this patient. During record review on 1/4/21, it was noted there was no documented evidence that PT, MSW, or aide services had been provided or that services had been declined or delayed by the patient. During an interview on 1/4/21 at 10:10 a.m., Admin-A (administrator, PT) states the agency has 2-5 days after the start of care to get other disciplines out to see the patient and complete their evaluations. During a joint survey home visit with RN-C (registered nurse) on 1/5/21 at 10:30 a.m., the patient and caregiver/spouse were asked about PT, MSW, and aide services. The patient states that she has not had any contact regarding PT, MSW or aide services and that the services have not been declined or delayed due to patient request. The findings were reviewed with Admin-A and RN-D (alternate clinical manager, registered nurse) during an interview on 1/6/21 at 2:00 p.m. RN-D states the agency is waiting on an order from the physician for aide services. The clinical record is reviewed with Admin-A and RN-D to point out that the 12/29/20 plan of care and a 12/29/20 physician order both document orders for PT, MSW, and aide services for this patient. There was no documentation to indicate RN-C or the agency had corresponded with PT, MSW, or the aide to coordinate these services as ordered by the physician.

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient was proficient at wound care before being discharged from the agency for 1 of 4 (MR#3) records reviewed in which the patient had a wound, resulting in the potential for a poor outcome for this wound care patient. Findings include: MR#3: This 60-year-old patient was admitted to the agency on 7/30/20 with diagnoses of stage 3 pressure ulcer on the left sole, a skin lesion on the left lateral (side) foot, and major depressive disorder. This clinical record was reviewed on 1/4/21. The 7/30/20 plan of care ordered skilled nursing services to be provided once a week for one week, two visits per week for two weeks, one visit per week for five weeks, and two as needed visits. On the 7/30/20 comprehensive assessment, CM-B (clinical manager, registered nurse) documented the size of the pressure ulcer on the sole of the left foot as 2.2 cm (centimeter) x 1.6 x 0.2 (length x width x depth in cm) and the size of the lesion on the left lateral foot was documented as 0.5 x 0.3 x 0.1 with scant serosanguinous drainage. CM-B documented weekly visits, wound care and weekly wound measurements. On 9/26/20, CM-B documented the decreasing size of the pressure ulcer on the left sole which was now 0.8 x 0.5 x 01. The skin lesion on the left lateral foot had been increasing in size throughout the episode of care and on 9/26/20 it now measured 4 x 3 x 0.3 with a moderate amount of serous drainage. The size of the wound and the amount of drainage had both increased, yet CM-B discharged the patient during the visit that day on 9/26/20. CM-B documented the reason for the discharge was because the patient was able to do wound care. On 9/18/20 and 9/22/20, the goal progress summaries indicates the patient's progress was 50% for wound care: Clean wound on left foot with wound cleanser, dry and apply Santyl cream, cover with 4x4 and wrap with Kerlix and Ace bandage. On the date of discharge, 9/26/20, the goal progress summary documented "unchanged" for wound care indicating the patient remained at 50% progress in performing his own wound care. There was no documentation to indicate that a caregiver or anyone else was proficient at wound care for this patient. It was unclear why this patient was discharged on 9/26/20 without demonstrating greater that 50% progress in wound care. The findings were reviewed with and confirmed by Admin-A (administrator, PT) and RN-D (alternate clinical manager, registered nurse) during an interview on 1/6/21 at 2:15 p.m. CM-B failed to ensure the patient was proficient at wound care before being discharged from the agency.

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 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 record review and interview, the agency failed to ensure interdisciplinary assessments of the patient, development of plans of care, and provide services ordered in the plan of care. These practices impacted 1 of 7 patients (MR# 1) from a total sample of 7 records reviewed. The cumulative effect of these systemic problems resulted in the agency's inability to ensure the provision of quality health care. Findings include: 1. The physical therapist and the medical social worker failed to perform initial assessments of the patient's functional status and needs. (See G706) 2. The physical therapist and the medical social worker failed to develop plans of care. (G708) 3. Physical therapy and medical social work services were provided (G710)

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 physical therapist and the medical social worker performed initial assessments of the patient's functional status and needs for 1 of 6 (MR# 1) records reviewed in which more than one discipline was ordered to provide care, resulting in a potential decline in physical functioning and a delay in accessing community resources for this patient. Findings include: MR#1: This 68-year-old patient was admitted to home care on 12/29/20 with diagnoses of polyosteoarthritis, high blood pressure and colostomy. The patient had a hysterectomy on 5/20/20 that resulted in a colostomy. The patient was then transferred to a rehab facility to recover from the surgery and generalized weakness before returning home. The plan of care dated 12/29/20 orders weekly skilled nursing and aide services along with orders for physical therapy (PT) and medical social worker (MSW) to evaluate and treat the patient. The clinical record also contains a physician order dated 12/29/20 which orders PT and MSW to evaluate and treat this patient. During an interview on 1/4/21 at 10:10 a.m., Admin-A (administrator, PT) states the agency has 2-5 days after the start of care to get other disciplines out to see the patient and complete their evaluations. Record review on 1/4/21, indicates there is no documented evidence that PT and MSW have evaluated and treated the patient in the past 7 days since the patient was admitted to home care. There is no documentation to indicate the patient or caregiver have declined or delayed PT or MSW services. During a joint survey home visit with RN-C (registered nurse) on 1/5/21 at 10:30 a.m., the patient and caregiver/spouse were asked about PT and MSW services. The patient stated that she has not had any contact regarding PT or MSW services and that the services have not been declined or delayed due to patient request. The findings were reviewed with and confirmed by Admin-A and RN-D (alternate clinical manager, registered nurse) during an interview on 1/6/21 at 2:00 p.m.

Development and evaluation of plan of care CFR(s): 484.75(b)(2) Development and evaluation of the plan of care in partnership with the patient, representative (if any), and caregiver(s); This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the physical therapist and the medical social worker developed plans of care for 1 of 6 (MR# 1) records reviewed in which more than one discipline was ordered to provide care, resulting in a potential decline in physical functioning and a delay in accessing community resources for this patient. Findings include: MR#1: This patient was admitted to home care on 12/29/20 with diagnoses of polyosteoarthritis, high blood pressure and colostomy. The plan of care dated 12/29/20 orders weekly skilled nursing and aide services along with orders for physical therapy (PT) and medical social worker (MSW) to evaluate and treat the patient. The clinical record also contains a physician order dated 12/29/20 which orders PT and MSW to evaluate and treat this patient. Admin-A (administrator, PT) states during an interview on 1/4/21 at 10:10 a.m., the agency has 2-5 days after the start of care to get other disciplines out to see the patient and complete their evaluations. Record review on 1/4/21, indicates there is no documented evidence that PT and MSW have evaluated the patient and developed plans of care in the past 7 days since the patient was admitted to home care. There is no documented evidence the patient or caregiver have declined or delayed PT or MSW services. During a joint survey home visit with RN-C (registered nurse) on 1/5/21 at 10:30 a.m., the patient and caregiver/spouse were asked about PT and MSW services. The patient stated that she has not had any contact regarding PT or MSW services and that the services have not been declined or delayed due to patient request. The findings were reviewed with and confirmed by Admin-A and RN-D (alternate clinical manager, registered nurse) during an interview on 1/6/21 at 2:00 p.m.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure that physical therapy and medical social work services were provided for 1 of 6 (MR#1) records reviewed in which these services were ordered, resulting in a potential decline in physical functioning and a delay in accessing community resources for this patient. Findings include: MR#1: This patient was admitted to home care on 12/29/20 with diagnoses of polyosteoarthritis, high blood pressure and colostomy. The plan of care dated 12/29/20 orders weekly skilled nursing and aide services along with orders for physical therapy (PT) and medical social worker (MSW) to evaluate and treat the patient. There was also a physician order dated 12/29/20 which orders PT and MSW to evaluate and treat this patient. At the time of clinical record review on 1/4/21, PT and MSW services had not been provided as ordered by the physician. There is no documented evidence the patient or caregiver have declined or delayed PT or MSW services. The findings were reviewed with and confirmed by Admin-A (administrator, PT) and RN-D (alternate clinical manager, registered nurse) during an interview on 1/6/21 at 2:00 p.m.

Home health aide services CFR(s): 484.80 Condition of participation: Home health aide services. All home health aide services must be provided by individuals who meet the personnel requirements specified in paragraph (a) of this section. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure the home health aide's competency evaluation addressed each of the subjects listed in paragraph (b)(3)(1), (iii), (ix), (x), and (xi) of this section and completed through observation, the aide's performance of each task, with a patient by a registered nurse prior to being deemed competent as described in this section (Refer to G 768), failed to ensure the home health aide received 12 hours of in-service training during the year 2020 (Refer to G 774), failed to ensure the aide provided services at the frequency ordered in the plan of care (Refer to G 800), and failed to make an annual on-site supervisory visit to the location where the patient was receiving care along with the home health aide to observe and assess the aide while performing care (Refer to G 812), resulting in the potential of substandard aide services that could negatively affect all patients receiving aide services. The cumulative effect of these systemic problems resulted in the agency's inability to ensure the provision of safe and quality services by competent home health aides, for all patients receiving aide services, for the Condition of Participation of 42 CFR §484.80, Home Health Aide Services.

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the home health aide (HHA competency evaluation addressed each of the subjects listed in paragraph (b)(3)(1), (iii), (ix), (x), and (xi) of this section and completed through observation, the aide's performance of each task, with a patient by a registered nurse prior to being deemed competent as described in this section for 1 of 1 aide (Aide-F) from a total sample of 1 home health aide personnel file reviewed, resulting in the potential of substandard aide services that could negatively affect all patients receiving aide services. Findings include: Agency Policy, "Competency Program" dated 2018 stated, "Patient care staff will be competency assessed at defined intervals. Competency evaluations are performed at time of hire and annually... The Agency has established competency criteria for each job category. Qualified peer individuals will observe the employee during competency evaluation." The competency evaluation checklist will be completed and retained in the employee's record." During the home health aide personnel file review on 01/06/2021 the following was noted: HHa-F (Home Health Aide): Date of hire was 10/01/2019. There was no documented evidence a registered nurse completed all the aide's competencies prior to performing aide services. The 2019 Competency Checklist for the Home Health Aide documented "discussed" in the section for the following tasks: Reading and Recording T, P, R (temperature, pulse, and respiration). There was a check mark for the other tasks. There was no documentation to determine what procedure was used to deem the aide competent to perform the other tasks (e.g. Observed, discussed, tested, etc.), or the location the task was performed (e.g., patient home, classroom, etc.). The registered nurse (Clinical Manager #1) documented, "Home Health Aide Competent to Provide Care "No." There was no follow-up documentation to indicate Aide-F had been deemed competent to provide aide services from 10/01/2019 to 10/10/2020. The next skills competency was dated 10/10/2020 to 11/3/2020. During an interview on 01/06/2020 at 1 PM a review of the aide's competency Evaluations for 2019 and 2020 were reviewed with the Alternate Clinical Manager (Registered Nurse/RN-D) she stated, "I know, the aide has to perform each task and the competency evaluation has to be completed before the aide starts giving service. I do not know what happened in 2019 I did not do that one, I did the competency for 2020. I know I did not document the location where the tasks were performed, and I did not know each task had to be completed. This is an old form; it need to be revised." There was no documentation to identify the location of where the competencies were performed (e.g., patient's home, lab, etc.) and no documentation to identify which task were completed with which patient. The RN-D stated, "I did not know I needed to document that information, but that makes sense." There was no documentation on the competency form that the following skills were performed with a patient: Sponge Bath, Tub Bath, Shower Bath, Hair Shampooing in Sink, Hair shampooing in the tub and Hair shampooing in the bed, Skin Care, Nail Care, Toileting and Elimination. And, for the multiple choice tasks on the form, there was no specific documentation to identify which skill was performed, and no date to identify what day(s) the skill(s) were performed on (e.g. Nail and Skin Care, Bath: Sponge bath, tub bath or shower bath, Hair Shampooing: sink, tub and bed, Toileting and Elimination). The 2020 form was signed by the Alternate Clinical Manager (Registered Nurse/RN-D) The agency failed to complete a competency evaluation for HHa-F (home health aide) at time of hire in 2019, prior to the aide providing service and annually in 2020, as indicated in the above policy.

12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the home health aide received 12 hours of in-service training during the year 2020 for 1 of 1 home health aide (Aide-F) providing service, for a potential of an unprepared aide providing services that could negatively affect all patients receiving aide services. Findings include: During a review of the home health aide (Aide-F) personnel file review on 01/06/2021 it was noted there were no in-service training records to review for 2020, in the file. A request was submitted to review all of the aide's in-service records for 2020. The Office Manager #1 submitted the employees' Training Manual for 2020. After a brief review of the manual, it noted documented in-service training forms dated from 1-10-2020 to 8-11-2020, that totaled 8.0 hrs., for Aide-F. There were other in-service forms in the manual that failed to include the dates for the in-service, and the the hours for the in-service training. During a review of the in-service records with the Alternate Clinical Manager on 01/06/2021 at 1 PM it was queried why the forms were not dated, and what were the hours for the in-service review and tests, and if a registered nurse had reviewed/corrected the tests and was a registered nurse involved in the training she stated, "I see, the forms were not completed. I know, the dates should be documented on each form and the training hours should also be on the form."

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the aide provided services at the frequency ordered in the plan of care for 1 of 1 (MR#1) record reviewed in which aide services were ordered, resulting in the potential for unmet personal care needs for this patient. Findings include: MR#1: This 68-year-old patient was admitted to home care on 12/29/20 with diagnoses of polyosteoarthritis, high blood pressure and colostomy. The 12/29/20 plan of care ordered the aide to provide services twice a week for five weeks and then once a week for two weeks. During an interview on 1/4/21 at 10:10 a.m., Admin-A (administrator) states the agency has 2-5 days after the start of care to get other disciplines out to see the patient. Record review on 1/4/21, indicates there was no documented evidence that aide services had been provided in the past 6 days since the start of care. During a joint survey home visit with RN-C (registered nurse) on 1/5/21 at 10:30 a.m., the patient and caregiver/spouse were asked about aide services. The patient states that she has not had any contact regarding aide services and that the services have not been declined or delayed due to patient request. The findings were reviewed with Admin-A and RN-D (alternate clinical manager, registered nurse) during an interview on 1/6/21 at 2:00 p.m. RN-D states the agency is waiting on an order from the physician for aide services. The clinical record is reviewed with Admin-A and RN-D to point out that the 12/29/20 plan of care and a 12/29/20 physician order both document orders for aide services for this patient. There was no documentation to indicate the aide provided services at the frequency ordered by the physician.

Direct observation every 12 months CFR(s): 484.80(h)(1)(iii) A registered nurse or other appropriate skilled professional must make an annual on-site visit to the location where a patient is receiving care in order to observe and assess each aide while he or she is performing care. This ELEMENT is not met as evidenced by: Based on record review and interview, the registered nurse failed to make an annual on-site supervisory visit to the location where the patient was receiving care along with the home health aide to observe and assess the aide while performing care for 1 of 1 home health aide providing care (Aide-F), for a potential of an unqualified aide providing services that could negatively affect all patients receiving aide services. Findings include: During the personnel file review on 01/06/2021, the following information was noted: HHa-F (Home Health Aide): Date of hire was 10/01/2019. During the Entrance Conference conducted on 01/04/2021 at 10:10 AM, it was queried to identify the location of the documented Aide's Supervision for every 14 days and the annual supervisory visit, the Registered Nurse-D/Alternate Clinical Manager (RN-D) replied, "You will find it documented on the visit note or in the aide's personnel file." During the home health aide personnel file review on 01/06/2021 there was no documented annual onsite supervisory visit for 2020. And, during the clinical record review from 01/04/2021 to 01/07/2021 there was no documented evidence a registered nurse completed an annual aide supervisory visit for 2020. During an interview on 01/06/2021 at 1 PM, it was queried if the 2020 annual aide's supervisory visit was kept in another location the RN-D replied, "It should be filed in her personnel file." After a brief review of the file she replied, "It's not there. It was not done last year; we had so much going on with the COVID-19 pandemic. We will get it done this year."

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on record review and interview, the Clinical Manager failed to ensure the coordination of patient care services, wound care needs were continually assessed, and the development and implementation of plans of care. These practices impacted 2 of 7 (MR# 1, 3) patients from a total sample of 7 records reviewed. The cumulative effect of these systemic problems resulted in the agency's inability to ensure the provision of quality health care. Findings include: 1. The Clinical Manager failed to ensure the coordination of physical therapy, medical social work, and aide services. (See G962) 2. The Clinical Manager failed to ensure the patient's wounds were continually assessed and addressed before being discharged. (See G966) 3. The Clinical Manager failed to ensure the development and implementation of plans of care for physical therapy, medical social work, and aide services. (See 968)

Coordinate patient care CFR(s): 484.105(c)(2) Coordinating patient care, This ELEMENT is not met as evidenced by: Based on record review and interview, the Clinical Manager failed to ensure the coordination of patient care services for 1 of 7 (MR#1) records reviewed, resulting in a potential decline in physical functioning, a delay in accessing community resources, and a lack of assistance with personal care needs for this patient. Findings include: MR#1: This 68-year-old patient was admitted to home care on 12/29/20 with diagnoses of polyosteoarthritis, high blood pressure and colostomy. The 12/29/20 plan of care orders physical therapy (PT), medical social worker (MSW), and aide services for this patient. The clinical record also contains a physician order dated 12/29/20 which orders PT, MSW, and aide services. The clinical record was reviewed on 1/4/21 and there was no evidence that PT, MSW, or the aide had seen or contacted the patient since care started on 12/29/20. There was no documentation to indicate the patient or caregiver had declined PT, MSW, or aide services. There was no evidence to indicate the Clinical Manager provided oversight and coordinated PT, MSW, or aide services for this patient. The findings were reviewed with and confirmed by Admin-A (administrator, PT) and RN-D (alternate clinical manager, registered nurse) during an interview on 1/6/21 at 2:00 p.m.

Assure patient needs are continually assessed CFR(s): 484.105(c)(4) Assuring that patient needs are continually assessed, and This ELEMENT is not met as evidenced by: Based on record review and interview, the Clinical Manager failed to ensure the patient's wound care needs were continually assessed for 1 of 4 (MR#3) records reviewed in which the patient had a wound, resulting in the potential for a poor outcome for this wound care patient. Findings include: MR#3: This 60-year-old patient was admitted to the agency on 7/30/20 with diagnoses of stage 3 pressure ulcer on the left sole, a skin lesion on the left lateral (side) foot, and major depressive disorder. This clinical record was reviewed on 1/4/21. The 7/30/20 plan of care ordered skilled nursing services to be provided once a week for one week, two visits per week for two weeks, one visit per week for five weeks, and two as needed visits. On the 7/30/20 comprehensive assessment, CM-B (clinical manager, registered nurse) documented the size of the pressure ulcer on the sole of the left foot as 2.2 cm (centimeter) x 1.6 x 0.2 (length x width x depth in cm) and the size of the lesion on the left lateral foot was documented as 0.5 x 0.3 x 0.1 with scant serosanguinous drainage. CM-B documented weekly visits, wound care and weekly wound measurements. On 9/26/20, CM-B documented the decreasing size of the pressure ulcer on the left sole which was now 0.8 x 0.5 x 01. The skin lesion on the left lateral foot increased in size and drainage throughout the episode of care. On 9/26/20 the lesion measured 4 x 3 x 0.3 with moderate serous drainage. CM-B discharged the patient during the visit on 9/26/20. CM-B documented the reason for the discharge was because the patient was able to do wound care. The goal established in the plan of care was that the "wound(s) will decrease in size by 0 by 9/27." Neither of the wounds had decreased to "0" at the time of discharge. The goal summary on the discharge assessment states wound(s) will decrease in size by 0 by 9/27 and CM-B documented that this goal was "met." The goal clearly was not met. It was unclear why the patient would be discharged from home care when the size of the lateral lesion was increasing throughout the episode of care. The orders for wound care had remained the same throughout the episode of care: clean wound with wound cleanser, dry, and apply Santyl cream, cover with 4x4 and wrap in Kerlix and Ace bandage. The lateral wound was not responding positively to the wound care regimen and was increasing in size, yet there were no changes to the wound care regimen and no change to the frequency of nursing visits to monitor the wound more often. CM-B failed to ensure the patients wound care needs were continually assessed. The findings were reviewed with and confirmed by Admin-A (administrator, PT) and RN-D (alternate clinical manager, registered nurse) during an interview on 1/6/21 at 2:15 p.m.

Assure implementation of plan of care CFR(s): 484.105(c)(5) Assuring the development, implementation, and updates of the individualized plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the Clinical Manager failed to ensure the development and implementation of plans of care for 1 of 7 (MR#1) records reviewed, resulting in a potential decline in physical functioning, a delay in accessing community resources, and a lack of assistance with personal care needs for this one patient. Findings include: MR#1: This 68-year-old patient was admitted to home care on 12/29/20 with diagnoses of polyosteoarthritis, high blood pressure and colostomy. The 12/29/20 plan of care orders physical therapy (PT), medical social worker (MSW), and aide services for this patient. The clinical record also contains a physician order dated 12/29/20 which orders PT, MSW, and aide services. The clinical record was reviewed on 1/4/21 and there was no evidence that PT or MSW had developed plans of care and no evidence that the nurse had developed an aide care plan pertinent to the patient's personal care needs. There was no documentation to indicate the patient or caregiver had declined PT, MSW, or aide services. There was no evidence to indicate the Clinical Manager provided oversight and ensured the development and implementation of plans of care for PT, MSW, or aide services. The findings were reviewed with and confirmed by Admin-A (administrator, physical therapist) and RN-D (alternate clinical manager, registered nurse) during an interview on 1/6/21 at 2:00 p.m.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a discharge summary was sent to the physician within 5 business days of the patient's discharge for 6 of 6 (MR# 2, 3, 4, 5, 6, and 7) records reviewed in which the patient was discharged from the agency, and failed to ensure a transfer summary was sent to the hospital within 2 business days of becoming aware of an unplanned transfer for 1 of 1 (MR #6) records reviewed in which the patient was transferred to the hospital, resulting in the physician not having knowledge of the patient's health status at the time of discharge/transfer and a summary of the care received which has the potential to negatively affect the 44 patients discharged in the past twelve months. Findings include: MR#2: This patient was admitted to the agency on 1/4/21 and a discharge OASIS (outcome and assessment information set) was completed by Admin-A (administrator, physical therapist) on 12/5/20. Record review on 1/4/21 indicates there was no documented evidence a discharge summary was sent to the physician within 5 business days of the patient's discharge. MR#3: This patient was admitted to the agency on 7/30/20 and a discharge OASIS was completed by CM-B (clinical manager, registered nurse) on 9/26/20. Record review on 1/4/21 indicates there was no documented evidence a discharge summary was sent to the physician within 5 business days of the patient's discharge. The agency's policy titled, Discharge Criteria (2018), states the physician and other care providers will be informed and knowledgeable of discharge. The policy failed to reflect the regulatory language which requires the discharge summary to be sent to the physician or other healthcare professional within 5 days of the patient's discharge. The above findings were reviewed with Admin-A and RN-D (registered nurse, alternate clinical manager) during an interview on 1/6/21 at 2:15 p.m. M.R. #4: This patient was admitted to the agency on 6/13/2020 with the diagnoses of, "Open Wound to left lower extremity and right lower extremity and Hypertension." The Discharge OASIS was completed and signed by Administrator-A/Physical Therapy (Admin. A/PT) on 7/25/2020. During the record review on 01/04/2021 it was noted there was no documented evidence a discharge summary was sent to the physician within 5 business days of the patient's discharge from the agency. M.R. #5: This patient was admitted to the agency on 4/15/2020 with the diagnoses of, "Cerebrovascular Disease, Urinary Tract Infection and Hypertension." The Discharge OASIS was completed and signed by Clinical Manager-B/Registered Nurse (CM-B/RN) on 6/11/2020. During the record review on 01/04/2021 it was noted there was no documented evidence a discharge summary was sent to the physician within 5 business days of the patient's discharge from the agency. M.R. #6: This patient was admitted to the agency on 10/23/2020 with the diagnoses of, Dementia without Behavior Disturbance, Right Fractured Femur and Coronary Angioplasty Implant & Graft." During the 01/05/2021 record review, it was noted Administrator-A/Physical Therapy (Admin. A/PT) completed and signed a Transfer OASIS dated 11/16/2020 that documented, "Transfer to hospital-Respiratory Infection." There was no documented evidence a transfer summary was sent to the receiving hospital within 2 business days of becoming aware of the unplanned transfer. During an interview on 01/05/2021 at 10:30 AM, it was queried if the PT made a visit to the patient's home on 11/16/2020 he replied, "No. The patient's daughter called the office, and they were informed the patient had been taken to the hospital over the weekend. They think he caught the COVID-19 from family that visited over the weekend." M.R. #7: This patient was admitted to the agency on 6/5/2020 with the diagnoses of, "Stage III Sacral Pressure Ulcer, Multiple Sclerosis and Essential Hypertension." The Discharge OASIS was completed and signed by Registered Nurse-C (RN-C) on 11/26/2020. During the record review on 01/06/2021 it was noted there was no documented evidence a discharge summary was sent to the physician within 5 business days of the patient's discharge from the agency.