Every finding on record at Fine Home Health Care, LLC

A Medicare authorized complaint investigation was conducted for intake #2702006 by the Michigan Department of Licensing and Regulatory Affairs on 2/10/26 through 2/11/26 at: Parc Home Care 33060 Northwestern Hwy, Suite 210 West Bloomfield, MI 48322 This Agency had no additional multi-sites. At the conclusion of the investigation, the Agency was found to be not in compliance with the requirements of 42 CFR 484, Conditions of Participation for Home Health. 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).

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure visit frequencies were provided only as ordered by the physician for 1 (P-1) of 3 records reviewed, resulting in the potential for the provision of inappropriate care and services. Findings include: Patient #1’s (P-1) Start of Care (SOC) was dated 9/16/25. The Plan of Care (POC) identified diagnoses of Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Congestive Heart Failure, Diabetes Type 2. During record review on 2/11/26, it was noted that Skilled Nursing (SN) completed a recertification comprehensive assessment dated 11/11/25 with no ordered frequency. The SN then completed a discharge non-visit on 11/14/25 stating, “Other: Patient’s daughter called Agency and informed office, patient did not need SN visits from Agency.” On 11/18/25, the Clinical Manager (Staff B) sent a text message to SN (Staff C) questioning, “Did you see P-1 yesterday (11/17/25)? Staff C responded, “Yes I did”. On 2/11/26 at 10:52 am, Staff B stated, “Staff C visited P-1 on 11/17/25 but it was not completed (visit note).” The Clinical Manger (Staff B) reviewed and acknowledged the findings listed above in an interview on 2/11/26 at 10:55 am. The SN completed a visit on 11/17/25, 3 days after the documented discharge of 11/14/25, without a physician’s order. A review of the agency policy occurred on 2/11/26 titled "Physician Orders - Verbal Orders" (Revised March 2018). The policy states, "Policy: Drugs and treatments are administered by the Agency staff only as ordered by the physician. Only authorized staff receives and record verbal orders. Verbal orders are put in writing and signed and dated by the RN or qualified therapists responsible for furnishing or supervising the care. Orders are obtained prior to the provision of any care, including changes in the plan of care.”

Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure the clinical record was complete and included all clinical notes for 1 (P-1) of 3 records reviewed (see G1012); and failed to ensure a discharge summary was forwarded to the physician within 5 days of discharge in 1 (P-1) of 2 closed records (see G1022). 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§484.110 Clinical Records.

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 was complete and included all clinical notes for 1 (P-1) of 3 records reviewed, resulting in the potential to negatively affect the health and well-being of these patients. Findings include: Patient #1’s (P-1) Start of Care (SOC) was dated 9/16/25. The Plan of Care (POC) identified diagnoses of Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Congestive Heart Failure, Diabetes Type 2. During record review on 2/11/26, it was documented in the Electronic Medical Record (EMR) that the Skilled Nurse (Staff C) completed a recertification visit on 11/11/25. On 2/10/25 at 3:15pm, Staff C was questioned regarding completing the prior weekly visits on Mondays (9/29/25, 10/6/25, 10/13/25, 10/20/25, 10/27/25 and 11/3/25) for medication set up and then completing the recertification on Tuesday, 11/11/25 and stated, “I went out on Mondays to fill the med boxes, the 11/11/25 date must be wrong.” Review of the handwritten notes of Staff C confirmed that the recertification visit was completed on 11/10/25. Furthermore, on 11/18/25, Staff B sent a text message to Staff C questioning, “Did you see P-1 yesterday (11/17/25)? Staff C responded, “Yes I did”. On 2/11/26 at 10:52 am, Staff B stated, “Staff C visited P-1 on 11/17/25 but it was not completed (visit note).” There was no evidence of a completed visit and medication set up by Staff C in the EMR on 11/17/25, 3 days after the documented discharge of 11/14/25. The agency failed to accurately date the recertification visit and document a completed visit within the EMR. A review of the agency policy occurred on 2/11/26 titled "Medical Record Content" (Revised March 2018). The policy states, "Policy: The Agency will provide an accurate and current medical record for every patient seen by the Agency.” The Clinical Manger (Staff B) reviewed and acknowledged the findings listed above in an interview on 2/11/26 at 10:55 am.

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 forwarded to the physician within 5 days of discharge in 1 (P-1) of 2 closed records, resulting in the potential for unidentified continuing health care concerns and unmet care needs. Findings include: Patient #1’s (P-1) Start of Care (SOC) was dated 9/16/25. The Plan of Care (POC) identified diagnoses of Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Congestive Heart Failure, Diabetes Type 2. During record review on 2/11/26, it was noted that the Skilled Nurse (SN) completed a discharge on 11/14/25. The Electronic Medical Record (EMR) contained no evidence that the discharge summary was sent to the physician within 5 business days of the patient's discharge. Furthermore, Staff D (Ordering Nurse Practitioner) confirmed that a discharge summary was not received during an interview on 2/12/26 at 9:30 am. The Clinical Manger (Staff B) reviewed and acknowledged the findings listed above in an interview on 2/11/26 at 10:55 am.

A Medicare authorized complaint investigation was conducted for intake #116969 by the Michigan Department of Licensing and Regulatory Affairs on 7/24/25 through 7/25/25 at: Parc Home Care 33060 Northwestern Hwy, Suite 210 West Bloomfield, MI 48322 This Agency had no additional multi-sites. At the conclusion of the investigation, the Agency was found to be in substantial compliance with the requirements of 42 CFR 484, Conditions of Participation for Home Health.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure visit frequencies were provided only as ordered by the physician for 1 (P-1) of 3 records reviewed, resulting in the potential for the provision of inappropriate care and services. Findings include: This patient (P-1) was admitted to the home care agency on 6/6/25 with diagnoses of Hypokalemia, Acute Respiratory Failure and Schizoaffective Disorder. During record review on 7/24/25, it was noted that the Physical Therapist (PT) completed a comprehensive assessment on 6/6/25. The Plan of Care (POC) ordered PT services at a frequency of 1w1 (1 time a week for 1 week), 2w5. Physical Therapy Assistant (PTA) #1 completed a visit on 6/10/25. On 6/11/25, Speech Therapy documented a missed visit form stating, “Reason: Patient Hospitalized.” On 6/16/25, PTA #1 documented a “Missed Visit Form” stating, “Reason: Patient Hospitalized. Comments: pt (patient) hospitalized.” On 6/18/25, PTA #1 documented a “Missed Visit Form” stating, “Reason: No Answer to Phone Call. Comments: Unable to reach patient since recent hospitalization.” PTA #1 completed a visit the following week on 6/26/25. The next day, on 6/27/25 PTA #1 documented a “Missed Visit Form” stating, “Reason: Cancellation of Care. Comments: pt cancelled apt d/t (due to) not feeling well.” The following week, on 7/2/25 PT #1 documented a “Missed Visit Form (PT Re-evaluation)” stating, “Reason: No Answer to Locked Door.” The PT Re-evaluation was completed on 7/10/25. There was no attempt to complete the visit frequency as ordered. A review of the agency policy occurred on 7/25/25 titled "Plan of Care – CMS #485 and Physician Orders" (Revised March 2019). The policy states, "Procedure: 2. …The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment … 4. The individualized plan of care must include the following: … The frequency and duration of visits to be made …” The Clinical Manager (CM #1) reviewed and acknowledged the findings listed above in an interview on 7/25/25 at 12:25 pm.

The following deficiencies were identified during a Medicare authorized Emergency Preparedness survey conducted by the Michigan Department of Licensing and Regulatory Affairs on 4/8/25 through 4/11/25 at: Parc Home Health Care33060 Northwestern Hwy., Suite 210West Bloomfield, MI 48322This agency offered no additional locations. At the conclusion of the survey, this agency was determined to be non-compliant with the Conditions of Participation at 42 CFR 484.102 Emergency Preparedness.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to develop an Emergency Preparedness Plan that had been reviewed and updated at least every 2 years, resulting in lack of guidance and direction for agency personnel in the event of an actual emergency or disaster. This deficient practice could potentially affect the health and safety of all directly employed staff, regularly utilized contracted staff and all patients actively serviced by this agency in the event of a crisis. Findings include: On 4/8/25 at 10:55 a.m., during a review of the agency's Emergency Preparedness documents, it was noted that the agency's "Covid-19 Vaccination Policy", included under the tab "EPP Policy" was dated 1/16/22. The document titled "Emergency Operations Plan and Policies" was noted to have a revised date of January 2020. There was no documented evidence that the agency's Emergency Preparedness Plan had been reviewed and updated at least every 2 years as per this requirement. These findings were reviewed with and acknowledged by the Clinical Manager during an interview on 4/10/25 at 1:45 p.m. who inquired, "Would it be alright to submit Governing Body meeting minutes to show that the Plan had been updated if we added that information?" No additional information had been provided by the survey's end. The agency failed to ensure its Emergency Preparedness Plan had been reviewed and updated at least every 2 years.

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 develop and establish written Emergency Preparedness policies and procedures that were based on the Emergency Preparedness plan, risk assessment and communication plan that had been reviewed and updated at least every 2 years, resulting in the agency’s inability to implement appropriate emergency actions and the potential for poor outcomes for all staff and patients serviced by this agency in the event of a disaster. Findings include: On 4/8/25 at 10:55 a.m., the agency's Emergency Preparedness documents were reviewed. A document titled "Emergency Operations Plan and Policies" was noted to have a revised date of January 2020. There was no documented evidence that the agency's Emergency Preparedness policies had been reviewed and updated at least every 2 years as per this requirement. These findings were reviewed with and acknowledged by the Clinical Manager during an interview on 4/10/25 at 1:45 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 a testing and training program that had been reviewed and updated at least every 2 years as per this requirement, resulting in staff being ill-prepared in the event of an actual disaster. This deficiency could potentially affect staff and all patients currently serviced by this agency. Findings include: On 4/8/25 at 10:55 a.m., during a review of the agency's Emergency Preparedness documents, it was noted that the agency's "Emergency Operations Plan and Policies" including documentation regarding testing and training, was noted to have a revised date of January 2020. There was no documented evidence that the agency's Emergency Preparedness Testing and Training program had been reviewed and updated at least every 2 years as per this requirement. These findings were reviewed with and acknowledged by the Clinical Manager during an interview on 4/10/25 at 1:45 p.m.

A Medicare Authorized Recertification Survey was conducted on 4/8/25 through 4/11/25 by the Michigan Department of Licensing and Regulatory Affairs at: PARC Home Care 33060 Northwestern Highway, Suite 210 West Bloomfield, MI 48322 At the time of the survey, the Agency did not have any branch offices or subunits. The services the Agency provides are: Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), Speech Therapy (ST), Medical Social Work (MSW), and Home Health Aide (HHa). Clinical records reviewed for this survey included: 5 records with home visits, 7 records without home visits, and 7 discharged records for a total of 19 records reviewed. At the conclusion of the survey, the Agency was found to be out of compliance with standard level deficiencies for the conditions of participation for home health agencies at: 42 CFR Part 484.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure that 2 (P-5, P-8) of 5 patients observed during home visits, from a total of 19 sampled records reviewed, were included in the overall planning of care including informing the patient/caregiver in advance of the days in which services would be provided, resulting lack of inclusion in planning, the potential for missed visits and unmet care needs. Findings include: P-5: The patient's start of care was 3/29/25 with diagnoses that included Rt. Hip Replacement, Osteoarthritis and Urinary Retention. During the record review on 4/8/25 at 1:30 p.m., it was noted that the Plan of Care ordered Skilled Nursing (SN), Physical Therapy (PT) and Occupational Therapy (OT) services to be provided. On 4/9/25 at 12:00 p.m., a scheduled home survey visit was conducted with the Skilled Nurse (RN #1). With the patient's permission to review the admission packet, it was noted that the calendar of proposed visits had not been completed. During the visit the patient expressed concerns that “PT hasn’t called to schedule any visits since his initial visit." (PT initial eval conducted on 4/7/25.) The patient continued, "OT came out once (on 4/5/25) and I haven’t heard from him since. He (OT) showed up at my door yesterday ($/8/25) at 1:30 p.m. and said he was here for a visit, but I couldn’t do it because I had my virtual appt. with my doctor. He then claimed he tried to call me but didn’t get an answer, but I didn't get any calls. And, if he called and didn’t get an answer, why wouldn’t he leave a message? I don't want to get anyone in trouble but, I mean if they’re gonna [sic] come, then come.” The agency failed to ensure its disciplines included the patient in the overall planning of his care. These findings were reviewed with and acknowledged by the Clinical Manager during an interview on 4/10/25 at 12:52 p.m. P-8: The Start of Care (SOC) was dated 4/2/2025. The Plan of Care for the certification period 4/2/2025 to 5/31/2025 identified diagnoses of Aftercare following joint replacement surgery, Presence of left artificial knee joint, Long-term use of aspirin, Long-term use of opiate analgesic. The patient was receiving Physical Therapy (PT) Services 2 times a week for 1 week and 3 times a week for 1 week. During a survey home visit on April 9th, 2025, at 2:15 p.m., conducted with the Physical Therapy Assistant it was observed while reviewing the patient's home care packet provided by the agency, that the home health visit calendar was completely blank. After the visit, the Physical Therapy Assistant was queried regarding the blank calendar and was asked how the client would be aware of the times and dates of future home visits? The response was, "oh, I call them the day/night before my planned visit to let them know what time I will be coming for their visits, the patient is home bound and doesn't go anywhere anyway except for Doctor appointments." When asked what happens if the patient has other appointments or conflicts such as Doctor appointments, the Pta stated, "we will just reschedule to another date and time." The agency failed to document Physical Therapy visits in the patient's HHA calendar in advance of providing services to ensure the times and dates of visits are agreeable to the patient resulting in lack of patient inclusion and choices in planning future visits. These findings were reviewed with and acknowledged by the Clinical Manager during an interview on 4/10/25 at 3:45 p.m. P-8: The Start of Care (SOC) was dated 4/2/2025. The Plan of Care for the certification period 4/2/2025 to 5/31/2025 identified diagnoses of Aftercare following joint replacement surgery, Presence of left artificial knee joint, Long-term use of aspirin, Long-term use of opiate analgesic. The patient was receiving Physical Therapy (PT) Services 2 times a week for 1 week and 3 times a week for 1 week. During a survey home visit on April 9th, 2025, at 2:15 p.m., conducted with the Physical Therapy Assistant it was observed while reviewing the patient's home care packet provided by the agency, that the home health visit calendar was completely blank. After the visit, the Physical Therapy Assistant was queried regarding the blank calendar and was asked how the client would be aware of the times and dates of future home visits? The response was, "oh, I call them the day/night before my planned visit to let them know what time I will be coming for their visits, the patient is home bound and doesn't go anywhere anyway except for Doctor appointments." When asked what happens if the patient has other appointments or conflicts such as Doctor appointments, the Pta stated, "we will just reschedule to another date and time." The agency failed to document Physical Therapy visits in the patient's HHA calendar in advance of providing services to ensure the times and dates of visits are agreeable to the patient resulting in lack of patient inclusion and choices in planning future visits. These findings were reviewed with and acknowledged by the Clinical Manager during an interview on 4/10/25 at 3:45 p.m. P-5: The patient's start of care was 3/29/25 with diagnoses that included Rt. Hip Replacement, Osteoarthritis and Urinary Retention. During the record review on 4/8/25 at 1:30 p.m., it was noted that the Plan of Care ordered Skilled Nursing (SN), Physical Therapy (PT) and Occupational Therapy (OT) services to be provided. On 4/9/25 at 12:00 p.m., a scheduled home survey visit was conducted with the Skilled Nurse (RN #1). With the patient's permission to review the admission packet, it was noted that the calendar of proposed visits had not been completed. During the visit the patient expressed concerns that “PT hasn’t called to schedule any visits since his initial visit." (PT initial eval conducted on 4/7/25.) The patient continued, "OT came out once (on 4/5/25) and I haven’t heard from him since. He (OT) showed up at my door yesterday ($/8/25) at 1:30 p.m. and said he was here for a visit, but I couldn’t do it because I had my virtual appt. with my doctor. He then claimed he tried to call me but didn’t get an answer, but I didn't get any calls. And, if he called and didn’t get an answer, why wouldn’t he leave a message? I don't want to get anyone in trouble but, I mean if they’re gonna [sic] come, then come.” The agency failed to ensure its disciplines included the patient in the overall planning of his care. These findings were reviewed with and acknowledged by the Clinical Manager during an interview on 4/10/25 at 12:52 p.m.

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient received proper written notice/Notice of Medicare Provider Non-Coverage, in advance of the agency terminating on-going care for 5 (P-6, P-1, P-3, P-16, P-19) of 7 discharged records, from a total of 19 sampled records reviewed, resulting in the patient being denied the right to appeal the decision to end covered services. Findings include: P-16: The SOC date to home care was 3/7/24, with diagnoses that included systolic congestive heart failure, acute kidney failure, and pulmonary hypertension. Record review on 4/10/25 noted that P-16 was discharged from the Agency on 4/16/24 by PT (Physical Therapy) services. Occupational Therapy (OT) and Skilled Nursing (SN) services discharged the patient by discipline on 3/14/24 and 3/29/24 respectively. Further record review found no documented evidence that the patient was provided with the Notice of Non-Coverage prior to terminating any of the above services. The findings above were reviewed and acknowledged by the Clinical Manager (CM#1) and Administrator (Adm#1) during an interview on 4/11/25 at 9:33 AM. P-1: This patient was admitted to home care on 9/24/24 with diagnoses of sacral pressure ulcer stage 4, sepsis, and pneumonia. During record review on 4/8/25, it was noted that the plan of care ordered skilled nursing, physical therapy (PT), occupational therapy, and aide services to be provided. The patient was discharged from agency services by the PT on 11/15/24. At the time of this review, there was no documented evidence that the patient was provided with the Notice of Non-Coverage prior to terminating services. These findings were reviewed with and acknowledged by the Clinical Manager (CM#1), the Administrator (Adm#1), and the Clinical Supervisor (CS#1) during an interview on 4/11/25 at 10:15 a.m. CM#1 explained that the Notice of Non-Coverage was kept separate from the medical record and she would make them available. At the time of exit on 4/11/25 at 2:30 p.m., there was no evidence the patient received proper written Notice of Medicare Non-Coverage. The agency failed to follow its own policy titled, Medicare Notice of Non-Coverage (NOMNC) (revised 10/2017), which states, the NOMNC must be given to the patient or representative at least 2 calendar days before the end of agency discharge... include date coverage ends...must be signed and dated by the beneficiary or their representative to confirm receipt. P-3: This patient was admitted to home care on 9/9/24 with diagnoses of Parkinson's disease and type 2 diabetes. During record review on 4/10/25, it was noted that the plan of care ordered skilled nursing, physical therapy (PT), and occupational therapy services to be provided. The patient was discharged from agency services by the PT on 11/1/24. At the time of this review, there was no documented evidence that the patient was provided with the Notice of Non-Coverage prior to terminating services. P-19: This patient was admitted to home care on 12/27/23 with diagnoses of cellulitis right lower extremity and hypertensive heart disease. During record review on 4/10/25, it was noted that the 2/25/24 plan of care ordered physical therapy (PT) services to be provided. The patient was discharged from agency services by the PT on 4/24/24. At the time of this review, there was no documented evidence that the patient was provided with the Notice of Non-Coverage prior to terminating services. P-6: The patient's start of care was 1/15/25 with diagnoses that included Myocardial Infarction, Heart Failure and Debility. During the record review on 4/9/25 at 2:55 p.m., it was noted that the Plan of Care ordered Skilled Nursing (SN), Home Health Aide (HHa), Physical Therapy (PT) and Occupational Therapy (OT) services to be provided. The patient was discharged from the agency's services on 2/5/25. At the time of this review, there was no documented evidence that the patient was provided with the Notice of Non-Coverage prior to terminating services. These findings were reviewed with and acknowledged by the Clinical Manager during an interview on 4/10/25 at 1:10 p.m.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: (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 complete an accurate Initial Comprehensive Assessment during the start of care in 5 (P-8, P-9, P-10, P-13, P-14) of 19 total sampled records, resulting in the potential for unmet patient needs and poor clinical outcomes. Findings include: P-8: The Start of Care (SOC) was dated 4/2/2025. The Plan of Care for the certification period 4/2/2025 to 5/31/2025 identified diagnoses of Aftercare following joint replacement surgery, Presence of left artificial knee joint, Long-term use of aspirin, Long-term use of opiate analgesic. The patient was receiving Physical Therapy (PT) Services 2 times a week for 1 week and 3 times a week for 1 week resulting from surgery for a total knee replacement. Upon review of the Comprehensive Assessment under the Category of "Safety/Sanitation Hazards affecting patient", the Physical Therapist documented "no hazards identified". However, the patient was admitted to the Home Care agency after surgery for a total knee replacement with a left artificial knee joint requiring the patient to use crutches and canes for support during ambulation while healing. Under the category of Musculoskeletal, the Physical Therapist documented "weakness, ambulation difficulty, limited Mobility/ROM Left Knee, Joint Pain/stiffness Left knee, Poor balance, and Assistive Device, Rolling Walker. During a survey home visit on 4/9/2025, it was observed a steep staircase without safety handrails leading to the upstairs bedrooms. The patient had a bandaged knee that was immobilized for healing. Physical Therapy was ordered for strengthening exercises to improve the patient's stability with ambulation. It was noted upon reviewing the comprehensive assessment that the Physical Therapist documented "no hazards identified" under the category of "Safety/Sanitation Hazards affecting the patient" and failed to document "stairs" which would be a hazard for a patient using canes and crutches while ambulating with an immobilized knee. The agency failed to perform an accurate Comprehensive Assessment to ensure the safety of the patient while healing from a total knee replacement surgery. In addition, the Physical Therapist documented 2+ edema in the left lower extremity without using an objective measurement such as a tape measure to use as a baseline for further edema measurement results to determine if the edema was improving or worsening. However further review of the record found that there was no further documentation or follow-up of the patient's edema status to determine if the Left Lower extremity was improving or worsening. P-9: The Start of Care was dated 8/19/2024. The Plan of Care for the certification period 8/19/2024 to 10/17/2024 identified diagnoses of Urinary tract infection, Klebsiella pneumoniae, Multiple Sclerosis, Hypertensive chronic kidney disease, Epilepsy, without status epilepticus, Coronary Artery Disease, Ataxia, and Depression This patient was receiving Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), and Home Health aide (HHa) services. Upon review of the record, it was noted the mood assessment on the Comprehensive Assessment was incomplete. There was no documentation of the patient's mood assessment questions from C through I. All these areas were blank. P-10: The Start of Care was dated 3/12/2025. The Plan of Care for the certification period 3/12/25 to 5/10/25 identified diagnoses of Unspecified cirrhosis of the liver, Diabetes Type 2 with diabetic polyneuropathy and diabetic retinopathy with macular edema, Muscle Weakness, Hypertension, Hyperlipidemia, Vitamin D deficiency, Gastro-esophageal reflux, Long-term use of insulin, Long-term use of oral hypoglycemic drugs. Skilled Nursing, Physical Therapy, Occupational Therapy, Medical Social Work, and Home Health aide services. Upon review of the Start of Care OASIS, under the category of safety measures, it was noted that sharps safety was not included as a safety measure, nor was the patient instructed on the use of the sharps container. These findings were reviewed with and acknowledged by the Clinical Manager during an interview on 4/10/25 at 3:45 p.m. P-13: This patient was admitted to the Agency’s home care on 3/31/25, with diagnoses which included acute respiratory failure with hypoxia (low blood oxygen), heart disease with congestive heart failure, and dysphagia-unspecified. On 4/9/25, review of the referral for home care revealed documentation dated 3/7/25, that P-13 had a large hiatal hernia (when part of the stomach protrudes through the diaphragm and into the chest cavity) and was a "high risk for aspiration (breathing in liquid or food into the lungs). Also, the referral had a ST (speech therapy) session on 3/13/2025 that documented P-13 was on aspiration precautions and that P-13 needed to "Sit upright; Small bites/sips; Go slow (when eating/drinking); Choose soft foods; Alternate solids and liquids. ST documented P-13 met only 3/13 ST goals. There was no evidence found that indicated Skilled Nursing (SN) had acknowledged this finding in the comprehensive assessment, subsequently none of the five interventions noted above (sit upright, small bites/sips etc.) were incorporated to meet the needs of the patient. The findings above were reviewed and acknowledged by the Clinical Manager (CM#1) and Administrator (Adm#1) during an interview on 4/11/25 at 8:52 AM. P-14: This 68-year-old female patient was admitted to the Agency on 2/24/25, with diagnoses that included bipolar disorder, hypertension, and chronic pain. On 4/9/25, review of the referral for home care documentation noted the following medication precautions: "Continue to monitor lithium level and kidney function while patient is taking lithium with ACE/ARB (high blood pressure medications) and celecoxib (NSAID medication). We recommend tapering celecoxib when able given interactions between lithium and NSAIDs (anti-inflammatory medications)." No evidence was found that Skilled Nursing (SN) who performed the initial comprehensive assessment, included this information in the assessment and potentially mitigate lithium drug toxicity (life-threatening condition that may cause intestinal, neurological symptoms and kidney damage). In addition, the home care referral noted P-14 had active depression with anxiety related to her primary diagnosis of bipolar disorder and was admitted to Adult Psychiatry Services for Bipolar disorder on 2/7/25. The physician home care referral documented "Social Work: Community Resource Referral, Counseling, Evaluation, Financial Assist, Long Term Planning." However, review of the comprehensive assessment performed by SN documented under M1100 that P-14 did not have Social Work needs and subsequently had no Social Work services provided by the home care Agency. In addition, relevant mental status screening tools such as "BPRS (Brief Psychiatric Rating Scale); GDS (Geriatric Depression Scale); and HAM-A (Hamilton Anxiety Scale) were all listed as "Not indicated this visit" and subsequently were not assessed during the comprehensive assessment. These findings were reviewed and acknowledged by CM#1 and Adm#1 during an interview on 4/11/25 at 9:02 AM. Both acknowledged findings from P-13 and P-14 did not meet Agency expectations or its policy referenced below. Agency Policy: "Initial Assessments/Comprehensive Assessments" 9.6.1 (revised 1/2020) stated, "The comprehensive assessment will identify the patient's need for home care and meet the patient's need for: Medical, Rehabilitative, Nursing, Social, Discharge Planning."

Patient's needs CFR(s): 484.55(c)(4) The patient's medical, nursing, rehabilitative, social, and discharge planning needs; This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure the patient's Activity of Daily Living needs were adequately met in the patient's home for 2 (P-4, P-6) patients who required assistance with grooming, dressing and toileting, and failed to include a relevant service to meet the psycho-social needs in 1 (P-14) of 1 record reviewed with primary psychiatric needs, from a total of 19 sampled records reviewed, resulting in the potential for poor grooming, psychological decline and unmet care needs. Findings include: P-4: The patient's start of care (SOC) was 11/25/24. The certification period of review was 3/25/25 through 4/11/25 with diagnoses that included Stage IV Sacral Pressure Ulcer, Effusion Rt. Hip and Dysphagia following Cerebral Infarction. During the clinical record review on 4/8/25 at 11:40 a.m., it was noted that the Plan of Care (POC) ordered Skilled Nursing (SN) at a frequency of 1w9 and Home Health Aide (HHa) services to be provided at a frequency of 2w4 through 4/19/25; 1w5 through 5/23/25. A Physician's Order dated 3/28/25 changed the HHa frequency to reflect services were to be provided 1w8. Section M1800 of the Recertification Comprehensive Assessment dated 3/21/25 revealed the "patient depends entirely upon someone else for grooming needs, dressing, bathing, toileting, bedfast, unable to transfer and is unable to turn and position self, unable to ambulate or be up in a chair..." On 4/8/25 at 2:00 p.m. a scheduled joint survey home visit was conducted with HHa #1. During the visit, the patient's responsible party expressed concerns that HHa services had been reduced from 2x/wk. to 1x/wk. and stated, "I really need the help." There was no documented rationale for the decrease in the provision of HHa services. These findings were discussed with the Clinical Manager (CM #1) during an interview on 4/10/25 at 12:39 p.m. When queried about the reduction of HHa services, CM #1 stated, "I would have to look into the reasons for the reduction in frequency as it may be insurance related." No additional information had been provided by the survey's end. The agency failed to ensure the patient's (Activity of Daily Living) ADL needs were adequately met in the patient's home. P-6: The patient's SOC was 1/15/25 with diagnoses that included Myocardial Infarction, Heart Failure and Chest Pain. During the record review on 4/9/25 at 2:55 p.m., it was noted that the POC ordered HHa services to be provided at a frequency of 1x/wk. x 4 wks. beginning 1/15/25. Section M1800 of the Initial Comprehensive Assessment dated 1/15/25 documented someone must assist with grooming, dressing, transfers and toileting. During the review, it was noted that the HHa made no visits to the patient's home during the first week of care. Additionally, the HHa missed the schedule home visit during the second week of care on 1/23/25. There were no further HHa visits made to the patient's home throughout the course of care. The agency failed to ensure the patient's ADL needs were adequately met in the patient's home. These findings were reviewed with and acknowledged by CM #1 during an interview on 4/10/25 at 1:10 p.m. P-14: This 68-year-old female patient was admitted to the Agency on 2/24/25, with diagnoses that included bipolar disorder, hypertension, and chronic pain. On 4/9/25, review of the referral for home care noted P-14 had active depression with anxiety related to her primary diagnosis of bipolar disorder and was admitted to Adult Psychiatry Services for Bipolar disorder on 2/7/25. The physician home care referral documented the need for the following services: Skilled Nursing-provided by Agency, Physical Therapy-provided by Agency, Occupational Therapy-provided by Agency, and "Social Work (not provided by Agency): Community Resource Referral, Counseling, Evaluation, Financial Assist, Long Term Planning." In addition, review of the comprehensive assessment performed by SN documented under M1100 that P-14 did not have Social Work needs and subsequently had no Social Work services provided by the home care Agency despite extensive psycho-social needs outlined by the physician in the referral. No evidence was found in the medical record that P-14 had to opportunity to accept and participate or refuse Social Work services. These findings were reviewed and acknowledged by CM#1 and Adm#1 during an interview on 4/11/25 at 9:02 AM. CM#1 acknowledged that based off the findings, Social Work services should have been added to P-14's Plan of Care.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure its procedure to perform a comprehensive review was sufficient within accepted standards of professional practice in determining any potential adverse medication effects such as: side effects, drug interactions, and duplicate drug therapy in 1 (P-14) of 1 record reviewed with advance medication safety warnings, out of a total sample of 19 records reviewed, resulting in the potential for unrecognized adverse effects due to significant medication interactions and duplications that could negatively affect all 609 current patients. Findings include: P-14: This patient was admitted to the Agency on 2/24/25, with diagnoses that included bipolar disorder, hypertension, and chronic pain. On 4/9/25, record review of the Comprehensive Assessment under "Drug Regimen Review" documented, "No issues found during review" and "Medication Follow-up" was left blank. Subsequent review of the 25 medications listed on P-14's Plan of Care noted several high-risk classifications (narcotic, CNS (central nervous system) depressants, and anti-psychotics) all together which has a high potential to create significant drug to drug interactions at the highest level (severe/major). Verification of potential significant interactions was performed through a professional on-line pharmaceutical resource "Drugs.com" which noted the following: 21 severe/major level drug to drug interactions, 65 moderate interactions, and 8 therapeutic duplications. Additional review of the referral for home care documentation noted the following medication precautions: "Continue to monitor lithium level and kidney function while patient is taking lithium with ACE/ARB (high blood pressure medications) and celecoxib (NSAID medication). We recommend tapering celecoxib when able given interactions between lithium and NSAIDs (anti-inflammatory medications)." No evidence this information was captured during the comprehensive assessment medication review performed by the RN and no monitoring interventions were noted to prevent potential lithium drug toxicity on P-14's plan of care. Even though a documented drug review took place, it was determined the Agency's procedure for capturing severe drug interactions was insufficient (0 of 21 severe) and posed a potential risk for poor outcomes concerning optimal patient care. No physician notification as of 4/11/25 was found in the medical record concerning the above findings. The findings above were reviewed with and acknowledged by the Clinical Manager and Administrator during an interview on 4/10/25 at 4:38 PM. The Agency failed to ensure its EMR captured (even at a partial level) severe drug interactions, failed in noting pertinent drug information in the home care referral by the RN, and failed to alert the physician as referenced by Agency policy below. Agency Policy: "Medication Reconciliation" (revised 5/2022) pg.1 stated, "Medication interactions report will be completed by an RN using the EMR (electronic medical record) interactions check. The EMR uses three different levels of interaction; Intervention required (severe), Review suggested (moderate), and Potential interaction risk (mild). Significant drug interaction alerts in EMR as an Intervention required interaction. The RN will call and notify patients physician of this significant interaction."

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 observation, record review and interview, the agency failed to ensure the plan of care covered all pertinent interventions with reportable parameters, safety precautions and objectively measurable goals specific to the needs of the patient for 8 (P-5, P-6, P-7, P-10, P-11, P-13, P-14, P-17) records, from a total of 19 sampled records reviewed, resulting in patients not receiving care specific to their individual needs and the potential for poor patient outcomes. Findings include: P-5: The patient’s start of care (SOC) was 3/29/25 with diagnoses that included Hip/Joint Replacement, Osteoarthritis and Urinary Retention. During the record review on 4/8/25 at 1:30 p.m., it was noted that the Plan of Care (POC) ordered Skilled Nursing (SN) at a frequency of 1w1, 2w1, 1w2 to provide the following services: instruct on importance of pain management, instruction on precautions for high-risk medication, instruct on disease, instruct on signs/symptoms of UTI to report, instruct on proper catheter care, instruct on diabetic foot care. A Urology note dated 3/18/25 documented, “Urinary Retention-S/P (status post) surgery – will start bladder training 4 hours on/4 hours off for example @ (at) breakfast – clamp for 4 hours, unclamp @ lunch then reclamp @ dinner then open before bed- Do this for 5 days – remove catheter Tuesday morning!“ A scheduled survey home visit was conducted with the Registered Nurse (RN #1) on 4/9/25 at 12:00 p.m. During the visit, RN #1 asked the patient if he had been clamping his Foley (indwelling urinary collection) catheter to which he responded, “Yes. I’ve been clamping it every 4 hours. I just clamped it at noon.” RN #1 then asked, “You’re leaving it free draining at night, right?” To which the patient replied, “They (doctor’s office) told me to clamp every 4 hours so that’s what I’ve been doing.” RN #1 reported, “I’m pretty sure you’re supposed to have it free draining at night. I’ll have to call them (doctor’s office) to clarify.” RN #1 was unable to refer to the POC for guidance as the Urology orders/instruction/Clamping guidelines had not been added to the POC. Additionally, it was noted that the POC was void of reportable pain parameters in which to notify the Physician and all 13 listed diagnoses were reported as having exacerbated on the date of admission (3/29/25). There were no interventions, reportable parameters or associated measurable goals that the addressed the exacerbated diagnoses. The agency failed to ensure the Plan of Care included all orders, interventions, reportable parameters and goals to meet the individualized needs of the patient. These findings were reviewed with and acknowledged by the Clinical Manager (CM #1) during an interview on 4/10/25 at 12:52 p.m. P-6: The patient’s SOC was 1/15/25 with diagnoses that included Myocardial Infarction, Hypertensive Heart Disease with Heart Failure, Acute on Chronic Congestive Heart Failure (CHF) and Chest Pain. The POC ordered SN, Physical Therapy (PT), Occupational Therapy (OT) and Home Health Aide (HHa) services to be provided. On 4/9/25 at 2:55 p.m., during the clinical record review, it was noted that the POC listed the patient’s 6 diagnoses as having exacerbated on the date of admission (1/15/25). There were no reportable pain parameters, no CHF goals, and no goals that addressed the identified exacerbated diagnoses. These findings were reviewed with and acknowledged by CM #1 during an interview on 4/10/25 at 1:10 p.m. who reported, “I do see that the pain parameters were not added.” P-7: The patient’s SOC was 2/12/25 with diagnoses that included Displaced Tri-Malleolar Fracture and Falls. The POC ordered SN and OT services to be provided. There was no OT frequency provided. During the record review on 4/10/25 at 10:25 a.m., it was noted that the POC listed the patient’s 16 diagnoses with an exacerbation date of 2/12/25 (date of admission), however, there were no interventions, reportable parameters or associated measurable goals to address the identified exacerbated diagnoses. All other goals were noted to be vague in nature such as, “Patient will verbalize 3 s/s and 2 ways to manager [sic] HTN” but gave no evidence as to how this would be attained. Additional interventions vague such as, “instruct on methods to prevent pressure ulcer and instruct on s/s that necessitate calling 911 yet gave no guidance on how to achieve these goals. The POC did not address the identified needs of the patient. These findings were reviewed with and acknowledged by CM #1 during an interview on 4/10/25 1:45 p.m. P-10: The Start of Care was dated 3/12/2025. The Plan of Care (POC) for the certification period 3/12/25 to 5/10/25 identified diagnoses of Unspecified cirrhosis of the liver, Diabetes Type 2 with diabetic polyneuropathy and diabetic retinopathy with macular edema, Muscle Weakness, Hypertension, Hyperlipidemia, Vitamin D deficiency, Gastro-esophageal reflux, Long-term use of insulin, Long-term use of oral hypoglycemic drugs. The patient was receiving Skilled Nursing, Physical Therapy, Occupational Therapy, Medical Social Work, and Home Health aide services. Upon review of the Plan of Care, it was noted diabetic precautions were not included as a safety measure. In addition, the POC was absent of diabetic DME and Supplies such as a sharps container, alcohol pads, syringes, and needles. P-11: The Start of Care was dated 3/26/2024. The Plan of Care for the Certification Period 3/26/2024 to 5/24/2024 identified diagnoses of Hypertensive Heart Disease with Heart Failure, Chronic Systolic Congestive Heart Failure, Atrial Fibrillation, Muscle Weakness, Coronary Artery Disease, Chronic Obstructive Pulmonary Disease, Hearing Loss, History of Covid-19, Presence of aortocoronary bypass graft, Long-term use of anticoagulants, Long-term use of opiate analgesic. The patient was receiving Physical Therapy, Occupational Therapy, and Home Health aide services. Upon review of the Plan of Care, it was noted there were no weight parameters on the Plan of Care for this patient diagnosed with Chronic Congestive Heart Failure. These findings were reviewed with and acknowledged by the Clinical Manager during an interview on 4/10/25 at 3:45 p.m. P-13: This patient was admitted to the Agency’s home care on 3/31/25, with diagnoses which included acute respiratory failure with hypoxia (low blood oxygen), heart disease with congestive heart failure, and dysphagia-unspecified. On 4/9/25, review of the referral for home care revealed documentation dated 3/7/25, that P-13 had a large hiatal hernia (when part of the stomach protrudes through the diaphragm and into the chest cavity) and was a "high risk for aspiration (breathing in liquid or food into the lungs). Also, the referral had a ST (speech therapy) session on 3/13/2025 that documented P-13 was on aspiration precautions and that P-13 needed to "Sit upright; Small bites/sips; Go slow (when eating/drinking); Choose soft foods; Alternate solids and liquids. ST documented P-13 met only 3/13 ST goals. There was no evidence found that P-13's POC included aspiration precautions, or any of the five interventions noted above (sit upright, small bites/sips etc.) to mitigate the risk of aspiration. In addition, P-13 was on supplemental oxygen (2 Liters/minute as needed) and that the physician was to be notified when O2 (oxygen) was less than 90% saturation. The POC failed to clarify what the reference level was to notify; was it at room air, or when oxygen was being administered at 2, 3, or 3.5 Liters/minute, all of which had documentation being administered during skilled visits performed by nursing (SN), physical therapy (PT), and occupational therapy (OT). The findings above were reviewed and acknowledged by the Clinical Manager (CM#1) and Administrator (Adm#1) during an interview on 4/11/25 at 8:52 AM. P-14: This patient was admitted to the Agency on 2/24/25, with diagnoses that included bipolar disorder, hypertension, and chronic pain. On 4/9/25, record review of P-14's POC found PT services were to evaluate and treat for mobility in the first week of being admitted to home care. However, the POC failed to include any PT interventions or goals with no updates to the POC since 2/24/25. This finding was reviewed and acknowledged by CM#1 and Adm#1 during an interview on 4/11/25 at 9:02 AM. P-17: The start of care date to home care was 2/10/25, with diagnoses which included pneumonia, chronic obstructive pulmonary disease, and heart disease with congestive heart failure. On 4/10/25, review of the POC noted P-17 was on supplemental oxygen (2 Liters/minute continuously) and that the physician was to be notified when O2 was less than 90% saturation. The POC failed to clarify what the reference level was to notify; was it at room air, or when oxygen was being administered at 2 (ordered amount) or 4 Liters/minute, which had documentation being administered at 4 L/min. by PT (on 2/14/25 visit) and OT (on 2/26/25 visit). Further, the POC failed to include any oxygen safety precautions. These findings above were reviewed and acknowledged by the Clinical Manager (CM#1) and Administrator (Adm#1) during an interview on 4/11/25 at 9:54 AM.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure services were provided only as ordered by the physician in 2 (P-13, P-17) of 2 records reviewed with supplemental oxygen, out of a total sample of 19 records, resulting in the potential to negatively affect all 609 patients currently serviced by the Agency. Findings include: P-13: This patient was admitted to the Agency’s home care on 3/31/25, with diagnoses which included acute respiratory failure with hypoxia (low blood oxygen), heart disease with congestive heart failure, and dysphagia-unspecified. On 4/9/25, review of P-13’s Plan of Care (POC) noted an order for oxygen to be administered at 2 Liters per minute via nasal cannula as needed for shortness of breath. Further review of visit notes by PT (Physical Therapy), OT (Occupational Therapy), and SN (Skilled Nursing) revealed all three disciplines were administering oxygen at unprescribed levels. For example, PT on 4/3/25 documented oxygen being administered at 3 L/minute throughout the visit, OT on 4/4/25 also documented oxygen being administered at 3 L/minute during the visit, and SN documented on 4/8/25 oxygen was being administered at 3.5 L/minute with a 98% oxygen level reading. No explanation was found in the medical record why each discipline above was not following the physician order of 2 Liters per minute as needed when short of breath. No physician communication or new orders were found in the medical record authorizing oxygen to be administered at 3.0 to 3.5 L/minute at any time. These findings were reviewed and acknowledged by the Clinical Manager (CM#1) and Administrator (ADM#1) during an interview on 4/11/25 at 8:46 AM. P-17: The start of care date to home care was 2/10/25, with diagnoses which included pneumonia, chronic obstructive pulmonary disease, and heart disease with congestive heart failure. On 4/10/25, review of P-17’s POC noted an order for oxygen to be administered at 2 L/min. via nasal cannula continuously. Further review of visit notes by PT and OT revealed both disciplines were administering oxygen at unprescribed levels. For example, PT on 2/11/25 and 2/14/25 documented oxygen being administered at 4 L/minute throughout the visit, and OT on 2/26/25 also documented oxygen being administered at 4 L/minute during the visit. No explanation was found in the medical record why each discipline above was not following the physician order of 2 Liters per minute when short of breath. No physician communication or new orders were found in the medical record authorizing oxygen to be administered at 4.0 L/min. at any time. These findings were reviewed and acknowledged by the Clinical Manager (CM#1) and Administrator (ADM#1) during an interview on 4/11/25 at 9:51 AM. The Agency failed to adhere to its policy referenced below. Agency Policy: “Physician Orders-Verbal Orders” 11.9.1 (revised 3/2018) stated, “Drugs and treatments are administered by the Agency staff only as ordered by the physician.”

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Physician was promptly notified of a significant change in condition for 1 (P-6) of 4 records reviewed of a patient who complained of intractable itching, from a total of 19 sampled records, resulting in unrelieved, untreated health conditions and unmet care needs. Findings include: P-6: The patient's start of care was 1/15/25 with diagnoses that included Myocardial infarction, Shortness of Breath and Chest Pain. During the record review on 4/9/25 at 2:55 p.m., it was noted that the Plan of Care ordered Skilled Nursing (SN), Home Health Aide (HHa), Physical Therapy (PT) and Occupational Therapy (OT) services to be provided. A review of the SN visit note dated 1/20/25 revealed, "Patient complains of persistent flanks rash, trying several OTC (over the counter) topical treatments..." There was no documented evidence that the SN promptly notified the Physician of the patient's complaints. A SN visit note dated 1/23/25 revealed the patient contacted the Physician himself regarding treatment for unrelieved itching. An OT visit note dated 1/24/25 documented, "Pt (patient) back home but suffering from intractable itchiness impacting attention and quality of life since returning from hospital..." The patient was subsequently transferred to an inpatient facility on 1/27/25 due to uncontrolled itching and resumed under the agency's care on 2/3/25. The SN failed to promptly notify the Physician regarding the patient's initial complaints of intractable itching. These findings were reviewed with and acknowledged by the Clinical Manager during an interview on 4/10/25 at 1:10 p.m.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure its Home Health Aide followed Infection Control Standards of Practice during the provision of care for 1 (P-4) of 2 patients observed during a home visit, from a total of 19 sampled records reviewed, resulting in the potential for the development and spread of infection. Findings include: P-4: The patient's start of care was 11/25/24. The certification period of review was 3/25/25 through 4/11/25 with diagnoses that included Stage IV Sacral Pressure Ulcer, Effusion Rt. Hip and Dysphagia following Cerebral Infarction. During the clinical record review on 4/8/25 at 11:40 a.m., it was noted that the Plan of Care ordered Home Health Aide (HHa) services to be provided at a frequency of 2w4 through 4/19/25; 1w5 through 5/23/25. A Physician's Order dated 3/28/25 changed the HHa frequency to reflect services were to be provided 1w8. On 4/8/25 at 2:00 p.m. a scheduled joint survey home visit was conducted with HHa #1. During the visit, HHa #1 provided a complete bed bath for the patient. During the observation, HHa #1 bathed the patient's torso, vagina, legs and feet. HHa #1 never changed the water before proceeding to bath the patient's back and buttocks. The patient had a bowel movement prior to care. HHa #1 used disposable wipes to clean the patient's anal area, however, was observed wiping the stool upward towards the patient's sacral wound. The HHa failed to utilize Infection Control standards of practice during the provision of care. These findings were reviewed with and acknowledged by HHa #1 upon completion of the visit and acknowledged by the Clinical Manager during an interview on 4/10/25 at 12:39 p.m.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure its skilled discipline performed baseline assessments for 1 (P-5) patient observed during a home visit with bilateral lower extremity edema, from a total of 17 sampled records reviewed, resulting in the potential for unidentified untreated health conditions and decline in physical functioning. Findings include: P-5: The patient's start of care was 3/29/25 with diagnoses that included Rt. Hip Replacement, Osteoarthritis and Urinary Retention. On 4/8/25 at 1:30 p.m. during the record review, it was noted that the patient was ordered to have Skilled Nursing (SN) services provided at a frequency of 1w1, 2w1, 1w2. On 4/9/25 at 12:00 p.m., a scheduled joint survey home visit was conducted with the Registered Nurse (RN #1). During the visit, the patient’s bilateral lower extremities were noticeably swollen with bruising noted to his left anterior leg. RN #1 stated, “Your legs look more swollen to me than before.” Patient (Pt.) replied, “My ankles are swollen more than normal. I thought it was because I was walking around in my apartment yesterday.” RN #1 reported, “Yea, I don’t like it.” RN #1 made no further assessments of the patient’s legs and did not establish baseline measurements to report to the Physician. Upon completion of the visit, RN #1 was queried and reported, “I meant to do that (measure).” These findings were reviewed with and acknowledged by the Clinical Manager during an interview on 4/10/25 at 12:52 p.m.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure that the clinical record notes were written in a manner for reader understanding in 1 of 17 (P-9) records reviewed in which documentation in the record included undefined abbreviations and misspelled words. Examples included: P-9: The Start of Care was dated 8/19/2024. The Plan of Care for the certification period 8/19/2024 to 10/17/2024 identified diagnoses of Urinary tract infection, Klebsiella pneumoniae, Multiple Sclerosis, Hypertensive chronic kidney disease, Epilepsy, without status epilepticus, Coronary Artery Disease, Ataxia, and Depression This patient was receiving Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), and Home Health aide (HHa) services. Upon review of the record, it was noted that the Physical Therapy Assistant (PTa) used undefined abbreviations in the visit notes. Examples included: "decreased DF L foot and knee flexion with max VC's"; Posture intervention mod VCs TC to back ES muscles and upper chest. Tactile cues TC to back ES muscles and upper chest. Plan for visit GT. Pt will ambulate 200 with SPC single point cane. The abbreviations were undefined in the record making it difficult to understand the status of the patient during the physical therapy visit. These findings were reviewed with and acknowledged by the Clinical Manager during an interview on 4/10/25 at 3:45 p.m.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on observation, interview and record review, it was determined the Agency failed to ensure the Skilled Nurse prepared clear written patient care instructions for the home health aide regarding client needs, that included safety precautions, prior to the provision of care in 3 (P-4, P-6, P-1) of 5 records in which Home Health Aide services were ordered, from a total of 19 sampled records reviewed, resulting in the potential for omission of care, the provision of unsafe care and unmet care needs. Findings include: P-1: This patient was admitted to home care on 9/24/24 with diagnoses of sacral pressure ulcer stage 4, sepsis, and pneumonia. During record review on 4/8/25, it was noted that the 9/24/24 plan of care contained the following under the area for orders and treatments: Patient is currently bedbound with a trach (tracheostomy is a tube surgically inserted into the windpipe to allow the patient to breathe), stage three pressure ulcer on his backside and uses a condom catheter because of incontinence. Under the area for nursing interventions the documentation notes that the patient has a PEG tube (feeding tube inserted through the stomach wall) with continuous tube feedings. The 9/24/24 aide care plan instructed the aide to do the following every visit: turn or position the patient, provide a partial sponge bath, shampoo hair, shave, and dress the patient. The aide care plan notifies the aide that the patient has a trach and is on a ventilator but fails to alert the aide regarding the presence of a condom catheter, the wound vac to the sacral area, and the continuous PEG tube feedings. There were no instructions or precautions for the aide regarding the patient's trach, PEG tube, condom catheter, or wound vac. The findings were reviewed with and acknowledged by Adm#1 (administrator) and CM#1 (clinical manager) during an interview on 4/11/25 at 10:15 a.m. P-4: The patient’s start of care (SOC) was 11/25/24. The certification period of review was 3/25/25 through 4/11/25 with diagnoses that included Stage IV Sacral Pressure Ulcer with scheduled wound dressing changes, Dysphagia and Effusion Rt. Hip. During the record review on 4/8/25 at 11:40 a.m., it was noted that the Plan of Care (POC) ordered Home Health Aide (HHa) services to be provided. The POC indicated the following precautions, safety measures and functional limitations: keep siderails up, neutropenic precautions, show position change, anticoagulant precautions, seizure precautions, fall precautions, enteral nutrition (Continuous Tube Feeding), dyspnea, Hoyer Lift. The Aide Care Plan dated 3/25/25 was void of any of the aforementioned safety precautions. Additionally, there was no instruction on what to do if the patient’s sacral dressing should become soiled or dislodged and no instructions to keep the patient’s head of bed elevated due to the patient’s continuous tube feeding. These findings were reviewed with and acknowledged by the Clinical manager (CM #1) during an interview on 4/10/25 at 12:39 p.m. P-6: The patient’s SOC was 1/15/25 with diagnoses that included Myocardial Infarction and Heart Failure. The POC ordered HHa services effective 1/15/25 to be provided at a frequency of 1w4 and indicated the following safety precautions: impaired judgement, support during transfer and ambulation and fall precautions. The Aide Care Plan 1/23/25 was void of any of the aforementioned precautions. Additionally, though HHa services were to begin 1/15/25, no HHa Care Plan had been generated that would guide the course of care provided until 1/23/25. These findings were reviewed with and acknowledged by CM #1 during an interview on 4/10/25 at 1:10 p.m.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure the Home Health Aide provided care and services as ordered in the Plan of Care for 1 (P-4) of 5 patients observed during home visits, from a total of 19 sampled records reviewed, resulting in the patient not receiving services based on her identified needs. Findings include: P-4: The patient's start of care was 11/25/24. The period of review was 3/25/25 through 4/11/25 with diagnoses that included Stage 4 Sacral Pressure Ulcer, Effusion Right Hip and Metabolic Encephalopathy. During the record review on 4/8/25 at 11:40 a.m., it was noted that the Plan of Care ordered Home Health Aide (HHa) services to be provided at a frequency of 1x/wk. x 8 wks. The "Aide Care Plan" ordered the following tasks to be performed: Complete bath, foot care, pericare, skin care, oral hygiene/Denture care and Comb hair. On 4/8/25 at 2:00 p.m., a scheduled joint survey home visit was conducted with HHa #1. During the visit, HHa #1 gave the patient a bed bath as indicated in the Aide Care Plan. Upon completion of the bath, HHa #1 applied lotion to her hands and proceeded to massage the patient's back which resulted in the patient crying out in pain. The back rub/massage was not ordered in the Aide Care Plan. Once care was completed, HHa #1 proceeded to exit the patient's home. HHa #1 failed to comb the patient's hair and provide oral hygiene/denture care as ordered in the Aide Care Plan. HHa #1 was queried as to why she failed to perform the ordered tasks, and why she rendered services that had not been ordered in the Plan of Care yet offered no response. These findings were reviewed with and acknowledged by the Clinical Manager during an interview on 4/10/25 at 12:39 p.m.

Goals in the patient's plans of care CFR(s): 484.110(a)(3) Goals in the patient's plans of care and the patient's progress toward achieving them; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to include objectively measurable goals in the Plan of Care to determine the patient's progress towards obtaining the goals in 4 of 17 records reviewed (P-8, P-9, P-10, P-11) resulting in the inability to determine the patient progress towards attaining the goals. Examples included: P-8: The Start of Care (SOC) was dated 4/2/2025. The Plan of Care for the certification period 4/2/2025 to 5/31/2025 identified diagnoses of Aftercare following joint replacement surgery, Presence of left artificial knee joint, Long-term use of aspirin, Long-term use of opiate analgesic. The patient was receiving Physical Therapy (PT) Services. Upon review of the Plan of Care, it was noted the goals were not objectively measurable. Examples included: "Patient/caregiver will demonstrate/verbalize understanding of post-op surgical instructions related to left Total Knee Arthroplasty (TKA)."; "Patient/caregiver will demonstrate/verbalize understanding of post-op surgical instructions related to left TKA." These goals are not objectively measurable to determine the patient's progress towards achieving the goals. P-9: The Start of Care was dated 8/19/2024. The Plan of Care for the certification period 8/19/2024 to 10/17/2024 identified diagnoses of Urinary tract infection, Klebsiella pneumoniae, Multiple Sclerosis, Hypertensive chronic kidney disease, Epilepsy, without status epilepticus, Coronary Artery Disease, Ataxia, and Depression This patient was receiving Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), and Home Health aide (HHa) services. Upon review of the Plan of Care it was noted the goals on the Plan of Care were not objectively measurable. Examples included: "Teach and instruct on depression, high risk medications and pressure ulcer prevention"; "PT to instruct patient/caregiver on pressure ulcer prevention techniques; Patient will verbalize understanding of high-risk medications prescribed. These goals are not objectively measurable to determine the patient's progress towards achieving the goals. P-10: The Start of Care was dated 3/12/2025. The Plan of Care for the certification period 3/12/25 to 5/10/25 identified diagnoses of Unspecified cirrhosis of the liver, Diabetes Type 2 with diabetic polyneuropathy and diabetic retinopathy with macular edema, Muscle Weakness, Hypertension, Hyperlipidemia, Vitamin D deficiency, Gastro-esophageal reflux, Long-term use of insulin, Long-term use of oral hypoglycemic drugs. Skilled Nursing, Physical Therapy, Occupational Therapy, Medical Social Work, and Home Health aide services were ordered by the physician. Upon review of the record, it was noted the goals on the Plan of Care were not objectively measurable to determine the patient's progress towards obtaining the goals. Examples included: For PT: "Patient/Caregiver will verbalize understanding of when to call agency vs. MD VS go to ER." However, there were no goals found in the record for Skilled Nursing, Occupational Therapy, Medical Social Work, or Home Health aide services. P-11: The Start of Care was dated 3/26/2024. The Plan of Care for the Certification Period 3/26/2024 to 5/24/2024 identified diagnoses of Hypertensive Heart Disease with Heart Failure, Atrial Fibrillation, Muscle Weakness, Coronary Artery Disease, Chronic Obstructive Pulmonary Disease, Hear Loss, History of Covid-19, Presence of aortocoronary bypass graft, Long-term use of anticoagulants, Long-term use of opiate analgesic. The patient was receiving Physical Therapy, Occupational Therapy, and Home Health aide services. Upon review of the record, it was noted the goals on the Plan of Care were not objectively measurable to determine the patient's progress towards obtaining the goals. Examples included: "Patient will be independent with bed mobility in order to safely get in and out of bed; Patient will perform transfers at an independent level in order to return to prior level of function; Patient/Caregiver will be independent with HEP (home exercise program) in order to better self-manage condition." These goals are not objectively measurable to determine the patient's progress towards obtaining the goals. These findings were reviewed with and acknowledged by the Clinical Manager during an interview on 4/10/25 at 3:45 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 transfer summaries were sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after transfer from the HHA within 48 hours of transfer in 3 (P-6, P-9, P-15) of 4 records reviewed with transfers; and failed to send a discharge summary within 5 business days of the patient's discharge from the agency in 7 (P-3, P-6, P-11, P-14, P-15, P-16, P-17) of 11 records reviewed with discharge by discipline, from a total sample of 19 records reviewed, resulting in the potential for unidentified continuing health care concerns and unmet care needs. Findings include: P-3: This patient was admitted to home care on 9/9/24 with diagnoses of Parkinson's disease and diabetes type 2. During record review on 4/10//25, it was noted that the patient was discharged from agency services on 11/01/24. There was no evidence that a detailed discharge summary report was sent to the physician within 5 days of the patient’s discharge. The findings were reviewed with and acknowledged by Adm#1 and CM-1 during an interview on 4/11/25 at 10:15 a.m. P-9: The Start of Care was dated 8/19/2024. The Plan of Care for the certification period 8/19/2024 to 10/17/2024 identified diagnoses of Urinary tract infection, Klebsiella pneumoniae, Multiple Sclerosis, Hypertensive chronic kidney disease, Epilepsy, without status epilepticus, Coronary Artery Disease, Ataxia, and Depression This patient was receiving Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), and Home Health aide (HHa) services. Upon review of the record, it was noted the patient was transferred to the hospital and discharged from the agency on September 18, 2024, by the Physical Therapist with 9 unmet goals for "other than above reasons." {sic} However, there was no information found in the record that revealed the reason for the hospitalization or the name of the hospital in which the patient was transferred for further health care. There was no information stating whether the physician that referred the patient for home care was notified of the transfer, or if the other services providing care by the home health care agency were notified. P-11: The Start of Care was dated 3/26/2024. The Plan of Care for the Certification Period 3/26/2024 to 5/24/2024 identified diagnoses of Hypertensive Heart Disease with Heart Failure, Atrial Fibrillation, Muscle Weakness, Coronary Artery Disease, Chronic Obstructive Pulmonary Disease, Hear Loss, History of Covid-19, Presence of aortocoronary bypass graft, Long-term use of anticoagulants, Long-term use of opiate analgesic. The patient was receiving Physical Therapy, Occupational Therapy, and Home Health aide services. Upon review of the record, it was noted the patient was discharged from the agency on May 1, 2024, with "condition improved, max potential reached, improved knowledge of self-care management". However, there was no indication documented in the record that the Discharge Summary was sent within 5 business days of patient discharge to the primary care practitioner or whether the other health care professionals who were responsible for providing care and services to the patient were notified. The agency documented, "Physician notified of discharge summary availability." These findings were reviewed with and acknowledged by the Clinical Manager during an interview on 4/10/25 at 3:45 p.m. P-6: The patient’s start of care was 1/15/25 with diagnoses that included Myocardial Infarction and Heart Failure. During the clinical record review on 4/9/25 at 2:55 p.m., it was noted that the Plan of Care ordered Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT) and Home Health Aide (HHa) services to be provided. The record revealed that the patient was transferred to an inpatient facility on 1/27/25 due to uncontrolled itching. There was no documented evidence that the Transfer summary had been sent to the receiving facility within 2 days as per this requirement. Additionally, there was no evidence that the Physician had been notified of the transfer. Upon further review, the patient was resumed under the agency’s care on 1/27/25 and was discharged from the agency’s services on 2/5/25. There was no documented evidence that an OT, SN or PT discharge summary had been completed and/or forwarded to the Physician within 5 days of the date of discharge, as per this requirement. These findings were reviewed with and acknowledged by the Clinical Manager during an interview on 4/10/25 at 1:10 p.m. P-14: This patient was admitted to the Agency on 2/24/25, with diagnoses that included bipolar disorder, hypertension, and chronic pain. On 4/9/25, record review noted OT (Occupational Therapy) performed an evaluation on 2/25/25 with no further visits needed. Further review found no evidence that OT services had ever sent an OT discharge summary to the physician for review. P-15: The start of care (SOC) date to home care was 2/18/25, with diagnoses which included hypertensive heart disease, diabetes type-2, and chronic kidney disease-stage 3. On 4/10/25, record review revealed P-15 was transferred to the hospital on 4/1/25. However, the "OASIS-E1 Transfer" and "Transfer Summary" forms both dated 4/1/25, had been documented as "Not Started" as of 4/10/25. This was well past the 48-hour requirement to send the Transfer Summary to the receiving provider responsible for meeting the patient's needs with the most up to date and accurate information available. In addition, OT had scheduled visits on 2/5/25 (evaluation performed), 2/12/25-missed visit due to no answer at the door, 2/19/25-missed visit due to no answer at the door, and 2/26/25-missed visit due to no answer at the door, with no further visits made. No evidence was found in the medical record that OT services had sent out a discharge summary as required within 5 days of discharge. P-16: The SOC date to home care was 3/7/24, with diagnoses that included systolic congestive heart failure, acute kidney failure, and pulmonary hypertension. Record review on 4/10/25 noted the following disciplines that provided patient care services without evidence of sending out a discipline discharge summary: Skilled Nursing (SN) provided a visit frequency of 1W4 (once a week x four weeks) and a SN discharge on 3/29/24; Physical Therapy (PT) provided a visit frequency of 1W1, 2W2, 1W2 with a discharge from PT services on 4/16/24; and OT provided an evaluation on 3/14/24 with no further visits needed. The Agency failed to provide evidence that a discharge summary was sent out for physician review within the required timeframe for the three disciplines noted above. P-17: The SOC date to home care was 2/10/25, with diagnoses which included pneumonia, chronic obstructive pulmonary disease, and heart disease with congestive heart failure. Record review on 4/10/25 noted the following disciplines that provided patient care services without evidence of sending out a discipline discharge summary: SN provided a visit frequency of 1W5 (visits on 2/10/25; start of care evaluation and 2/25/25; resumption of care after hospitalization) with no further SN visits made. OT had an ordered visit frequency of 1W4 and provided visits on 2/26/25: OT evaluation, 3/8/25: approved missed visit, 3/13/25: home visit performed, and 3/18/25: OT discharge. The Agency failed to provide evidence that a discharge summary was sent out for physician review within the required timeframe for the two disciplines noted above. The findings above concerning records P-14, P-15, P-16, and P-17 were reviewed with and acknowledged by the Clinical Manager (CM#1) and Administrator (Adm #1) during an interview on 4/11/25 at 9:03 through 9:54 AM. respectively. CM#1 stated the Agency does not perform a comprehensive discharge summary that includes all disciplines but rather performs a separate discharge summary by discipline instead.

The following Condition level deficiency was identified at an Emergency Preparedness Survey conducted by the Michigan Department of Licensing and Regulatory Affairs on 5/2/22 through 5/5/22 at: Parc Home Health 33060 Northwestern Hwy #210 West Bloomfield Township, MI 48322 At the time of the survey, Parc Home Health was found to be non-compliant with the requirements for the Conditions of Participation at: 42 CFR §484.102, Emergency Preparedness.

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, §485.625, §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 ensure an Emergency Preparedness Plan existed that was based on a documented facility and community-based risk assessment from an all-hazards approach, resulting in the potential for lack of preparedness and poor patient and staff outcomes, in the event of an actual emergency (E0006); failed to develop and maintain an emergency preparedness communication plan that included contact information for all current staff, patient's physicians, and volunteers, as appropriate, which had the potential to negatively affect the health and safety of the 25 patients currently serviced by this agency, resulting in the lack of effective communication in the event of an actual emergency (E0030); failed to ensure all staff including contracted staff received initial and ongoing training in the Agency's Emergency Preparedness policies and procedures, resulting in staff being ill-prepared in the event of an actual disaster or emergency. This deficient practice could potentially negatively affect all staff employed by this agency, and all 25 patients currently serviced by this Agency (E0037); failed to provide documentation for the required annual tabletop and community based full-scale exercises and failed to provide documentation of an actual event that would qualify as a test of the emergency plan, resulting in staff being unprepared in the event of an actual emergency. This deficient practice could negatively affect all 25 patients currently serviced by this Agency (E0039). The cumulative effect of these systemic problems could potentially have a negative effect on all patients currently serviced by this Agency in the event of an actual emergency/disaster for the Condition of Participation: 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), §485.625(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 ensure an Emergency Preparedness Plan existed that was based on a documented facility and community-based risk assessment from an all-hazards approach, resulting in the potential for lack of preparedness and poor patient and staff outcomes, in the event of an actual emergency. Findings include: On 5/4/22 at 1:30 p.m., the agency's Emergency Preparedness documents were reviewed. The Risk Assessment document was undated and noted to be void of the Covid-19 global pandemic. The Risk assessment had not been updated as per this requirement. These findings were reviewed with and confirmed by the Clinical Manager and Assistant Clinical Manager at the time of discovery.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.625(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, it was determined that the facility failed to develop and maintain an emergency preparedness communication plan that included contact information for all current staff, patient's physicians, and volunteers, as appropriate, which had the potential to negatively affect the health and safety of the 25 patients currently serviced by this agency, resulting in the lack of effective communication in the event of an actual emergency. Findings include: During a review of the agency's Emergency Preparedness documents on 5/4/22, it was noted that there was no contact information for all current staff, patient's Physicians, or volunteers as appropriate. These findings were reviewed with and confirmed by the Clinical Manager and Assistant Clinical Manager during an interview on 5/4/22 at 2:48 p.m.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on record review and interview, the Agency failed to ensure all staff including contracted staff received initial and ongoing training in the Agency's Emergency Preparedness policies and procedures, resulting in staff being ill-prepared in the event of an actual disaster or emergency. This deficient practice could potentially negatively affect all staff employed by this agency, and all 25 patients currently serviced by this Agency. Findings include: On 5/4/22 at 1:30 p.m., the Agency's Emergency Preparedness documents were reviewed with the Clinical Manager and Assistant Clinical Manager. A request was made to review the staff's, including contracted staff, initial and ongoing training in Emergency Preparedness. The Clinical Manager reported, "I usually go to a Region 2 North table top session." No evidence of staff training had been provided by the survey's conclusion. There was no documented evidence that all Agency staff, including contracted staff received initial or ongoing training in Emergency Preparedness. These findings were reviewed with and acknowledged by the Clinical manager and Assistant Clinical Manager at the time of discovery.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.625(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, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on record review and interview, the Agency failed to provide documentation for the required annual tabletop and community based full-scale exercises and failed to provide documentation of an actual event that would qualify as a test of the emergency plan, resulting in staff being unprepared in the event of an actual emergency. This deficient practice could negatively affect all 25 patients currently serviced by this Agency. Findings include: During a review of the Agency's Emergency Preparedness documents on 5/4/22 at 1:30 p.m. with the Clinical Manager and Assistant Clinical Manager, it was noted that there was no evidence the Agency had conducted any trainings or exercises to test the agencies emergency plan. Further, there was no documentation of an actual event that would qualify as an emergency, no community based full-scale exercise, no second full-scale exercise or a table-top exercise. The Agency failed to provide documented evidence that the required trainings had been conducted. The Clinical Manager reported, "I usually go to a Region 2 North table top session." There was no evidence of any table top sessions having taken place.

A Medicare Authorized Recertification Survey was conducted May 2nd through May 5th, 2022 by the Michigan Department of Licensing and Regulatory Affairs at: PARC Home Care 33060 Northwestern Highway, Suite 210 West Bloomfield, MI 48322 At the time of the survey, the agency did not have any branch offices or subunits. The services the agency provides are: Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), Speech Therapy (ST), Medical Social Work (MSW), and Home Health Aide (HHa). Clinical records reviewed for this survey included: 7 records with home visits, 5 records without home visits, and 5 discharged records for a total of 17 records reviewed. The following condition level citations were identified during the survey: 42 CFR§ 484.55: Comprehensive Assessment of Patient 42 CFR§ 484.60: Care Planning, Coordination, Quality of Care 42 CFR§ 484.65: Quality Assessment and Performance Improvement 42 CFR§ 484.75: Skilled Professional Services 42 CFR§ 484.102 Emergency Preparedness In addition, the following Immediate Jeopardy level deficiencies were identified during the survey: 42 CFR§ 484.60 (b): Conformance with physician orders. 42 CFR§ 484.75(b)(3): Skilled Professional Services. On 5/4/22 at 2:54 p.m. an Immediate Jeopardy was approved due to the Agency's failure to conform with physician orders for baseline assessments and re-assessments, and notify the physician that monitoring was not performed due to lack of required equipment, thus failing to deliver care as ordered, resulting in deterioration of the patient's health condition and resulting in an emergency hospitalization. The Skilled Nurse failed to provide services in the Plan of Care as ordered. The Agency's Administrator and Chief Operations Officer were notified of the Immediate Jeopardy on 5/4/22 at 3:18 p.m. The Immediate Jeopardy was removed at 5:14 p.m. on 5/4/22 after the review and approval of the Agency's immediacy Plan of Correction. The Agency was found to be in compliance with staff vaccination requirements. 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 §484.36 (a)(2)(i).

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure that 4 (MR's #5, 6, 7, and 9) of 7 patients observed during home visits, from a total of 17 sampled records reviewed, and 2 (MR's# 11 and 17) of 17 patients were included in their overall planning of care including informing the patient/caregiver in advance of the days in which services would be provided and disciplines that will furnish care, resulting in a lack of inclusion in planning, lack of informed consent, the potential for missed visits and unmet care needs. Findings include: MR #7: The patient's start of care (SOC) was 4/20/22 with diagnoses that included Stroke, Hemiplegia and Hypertension. During the clinical record review on 5/3/22, it was noted that Physical Therapy (PT) and Occupational Therapy (OT) services were ordered to be provided. On 5/3/22 at 1:30 p.m., a home visit was conducted with the Physical Therapist (PT #1). During a review of the patient's admission packet, it was noted that there was no calendar of proposed visits to be made by the PT or OT. MR #9: The patient's SOC was 4/20/22 with diagnoses that included Multiple fracture of ribs and left radius, Diabetes Mellitus and End Stage Renal Disease. During the record review on 5/3/22 at 9:45 a.m., it was noted that Skilled Nursing (SN), Home Health aide (HHa) and PT services were ordered to be provided. On 5/3/22 at 3:30 p.m. during a scheduled home visit with the Physical Therapy Assistant (PTA #1), it was noted that the patient's admission packet was void of a calendar of proposed visits. The agency failed to ensure a calendar of proposed visits had been provided at the SOC to assist the patient with participating in planning his/her care and daily routine. These findings were reviewed with and acknowledged by the Clinical Manager and the Assistant Clinical Manager during an interview on 5/4/22 at 10:37 a.m. MR#11: The Start of Care (SOC) was dated 3/11/22. The Plan of Care (POC) identified diagnoses of Aftercare Following Surgical Amputation, Diabetes Type 2 and Congestive Heart Failure (CHF). During record review on 5/4/22, it was noted that a Skilled Nursing (SN) communication note dated 3/30/22 documented, “Additional Disciplines Needed: PT, OT, HHA, MSW.” There was no documentation that the patient declined HHA services. The agency failed to provide HHA services as referred. MR#17: The Start of Care (SOC) was dated 3/31/22. The Plan of Care (POC) identified diagnoses of Diabetes Type 2, Hypertension and Chronic Obstructive Pulmonary Disease. During record review on 5/2/22, it was noted that a SN communication note dated 3/31/22 documented, “Additional Comments: Patient states she needs help with a shower weekly.” Additionally, the comprehensive assessment completed on 3/31/22 stated, “All providers involved in care (including NP/PA): SN, PT, OT, HHA, MD.” There was no documentation that the patient declined HHA services. The agency failed to provide HHA services as referred. MR#5: The Start of Care was dated 5/4/2022. The Plan of Care for the Certification Period of 4/15/2022 to 6/13/2022 identified diagnoses of Normal Pressure Hydrocephalus, Chronic Kidney Disease, Coronary Artery Disease, and history of Transient Ischemic Attack (TIA). The patient was receiving Skilled Nursing and Speech Therapy Services. During a joint survey home visit on May 4th at 11:00 a.m. with the Speech Therapist (ST#20), it was noted that the Patient Admission packet failed to have a calendar with proposed visit dates for the RN and Speech Therapist. MR#6: The Start of Care was dated 4/19/2022. The Plan of Care for the certification period 4/19/2022 identified diagnoses of Gastro-esophageal reflux disease, Chronic Kidney Disease, Dementia, Coronary Artery Disease, and Atrial Fibrillation. The patient was receiving Skilled Nursing, Physical Therapy, and Occupational Services. A joint survey home visit was conducted on May 3rd at 23:30 p.m. with the Physical Therapist During the visit the Patient's Admission Packet was reviewed. It was noted that there was no Calendar found in the packet to record proposed visit dates for the Skilled Nurse, Physical Therapist or Occupational Therapist. These findings were reviewed and acknowledged by the Clinical Manager and Alternate Clinical Manager during an interview 0n 5/5/2021 at 2:30 p.m.

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the patient received proper written notice (Notice of Medicare Provider Non-Coverage) in advance of the agency terminating on-going care for 1 (MR# 8) of 5 discharged records, resulting in the patient being denied the right to appeal the decision to end Medicare covered services. Findings include: MR #8: The patient's start of care was 2/1/22 with diagnoses that included Hypertensive Heart Disease and Acute on Chronic Diastolic Heart Failure. The record review conducted on 5/3/22 at 11:00 a.m. revealed the following: The plan of care (POC) ordered Skilled Nursing (SN), Physical Therapy (PT) and Home Health Aide (HHa) services to be provided. The patient was discharged from the Agency's services on 2/23/22. There was no documented evidence that the patient was provided the "Notice of Medicare Provider Non-Coverage" prior to being discharged from the agency. The Agency failed to ensure the patient received proper written Notice of Medicare Provider Non-Coverage in advance of the agency terminating on-going care. These findings were reviewed with and acknowledged by the Clinical Manager and Assistant Clinical Manager during an interview on 5/4/22 at 10:59 a.m.

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to provide documented evidence of the existence of complaints received, details of the investigation and the resolution of the complaints, as per this requirement, resulting in the potential for unaddressed patient/family concerns, inability to exercise one's rights and unmet care needs. Findings include: On 5/4/22 at 10:16 a.m., the Clinical Manager was asked for permission to review the agency's complaint log. Shortly after, the Clinical Manager acknowledged having received complaints for the calendar year 2021, however was unable to produce the requested documentation. The Agency failed to ensure that all complaints, investigative measures and the resolutions, as appropriate, were documented as per this requirement. These findings were reviewed with and acknowledged by the Clinical Manager at the time of discovery.

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 Record Review, and Interview, the agency failed to conduct the Start of Care Assessment within 48 hours of the physician referral (See G-514); failed to conduct a patient-specific comprehensive assessment that accurately reflected the patient's current health status based on past medical history that included dates of onset, exacerbations, treatments, and outcomes, and history of events leading to current home care needs (See G-528); Failed to ensure the registered nurse reviewed patient medications for possible side effects and possible drug interactions (See G-530); failed to ensure the patient's Activities of Daily Living and Medical Social Work needs were adequately met in the patient's home (See G-534); and failed to complete a medication reconciliation to the referral (See G- ). This deficient practice results in the potential for unrecognized medication side effects and drug interactions that could affect all 25 current patients serviced by the agency (G-536). The cumulative effect of these systemic problems resulted in the home health agency's inability to ensure the provision of quality health care in a safe environment for the agency's 25 current active patients at the condition of participation at 42 CFR 484.55: Comprehensive Assessment of Patients.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on Record Review and Interview, the agency failed to conduct the Start of Care Assessment within 48 hours of the physician referral in 1 of 17 records reviewed (MR#1), resulting in a delay of needed care. Findings included: MR#1: The patient was admitted on 12/29/2021. The Comprehensive Assessment for the Certification period 12/29/21 to 2/26/22 identified diagnoses of Hypertensive Heart Disease (HF), Congestive Heart Failure (CHF), Abnormal Gait, Coronary Artery Disease (CAD), and Diabetes Type 2 (DM2). There was no Plan of Care (POC) found in the electronic record. A request was made to the clinical manager to provide a copy of the Plan of Care, who confirmed that no Plan of Care had been created for the certification period 12/29/2021 to 2/26/2022 for this patient. Upon further review of the record on 5/2/2022 , it was noted a faxed referral for home health care services was documented and sent by "Ascension Michigan" and signed by the patient's physician. The FAX documented the date sent to the Home Care Agency was dated 12/21/2021. The date of the Start of Care Comprehensive Assessment was documented as 12/29/2021. A review of the Comprehensive Assessment under the category of "MO104: Date of Referral was blank. Further review of the record failed to include any physician orders authorizing a delay of the Start of Care, or documentation of the patient requesting a delay of the Start of Care Assessment date. The agency failed to provide services to the patient within 48 hours of referral. These findings were reviewed with and acknowledged by the Clinical Manager and the Assistant Clinical Manager during an interview on 5/5/22 at 2:30 p.m.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on record review, and interview, the Agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status based on past medical history that included dates of onset, exacerbations, treatments and outcomes, and history of events leading to current home care needs in 6 of 17 records reviewed (MR#s 1, 2, 3, 4, 5, and 6) resulting in incomplete clinical information to aide in determining the needs of the patient. Findings included: MR#1: The Start of Care (SOC) was dated 12/29/2021. The Plan of Care (POC) for the certification period 12/29/2021 to 2/26/2022 identified diagnoses of Hypertensive Heart Disease (HF), Congestive Heart Failure (CHF), Abnormal Gait, Coronary Artery Disease (CAD), and Diabetes Mellitus Type 2 (DM2). Upon review of the record on 5/2/2022 it was noted that the Comprehensive Assessment dated 12/29/21, completed by PT#11, that there was no history of how long the patient had any of above diseases/conditions, or when and how the diseases occurred. There was no history of the status of the above diseases including treatments for past medical problems and outcomes of those treatments. Three of the disease had documented the same date of onset as 12/29/2021, and fourteen documented the same date of onset as 1/1/2022. There was no documented evidence of an assessment of the events that led to the home care referral, no date for the referral, and no assessment of the patient's specific current home care needs. MR#2: The Start of Care was dated 3/21/2022. The patient was admitted to the agency after a hospital stay with a diagnosis of cerebral infarction. The patient's past medical history included Myocardial Infarction (MI), Coronary Artery Disease (CAD), Uterine Cancer, Osteoarthritis, Cerebral Vascular Accident (CVA), and Hemiplegia. A review of the record on 5/2/2022 revealed that there was no history of how long the patient had any of above diseases/conditions, or when and how the diseases occurred. There was no history of the status of the above diseases including treatments for past medical problems and outcomes of those treatments. The Comprehensive Assessment dated 3/21/2022 documented under "Primary Diagnosis and Other Diagnoses, 24 Diagnoses. All 24 diagnoses that had the same dates of onset and exacerbation documented as 3/21/2022. There was no documentation of prior treatments, outcomes, or history of how these diagnoses led to the need for home care. MR#3: The SOC was dated 11/7/2021. The Plan of Care for the certification period 11/7/21 to 1/5/21 identified diagnoses of Emphysema, Chronic diastolic heart failure (CHF), Diabetes type 2 (DM2), Chronic Kidney Disease (CKD), Atrial Fibrillation (A-fib), and Irritable Bowel Syndrome. During record review on 5/3/2022, it was noted that there was no history of how long the patient had any of above diseases/conditions, or when and how the diseases occurred. There was no history of the status of the above diseases including treatments for past medical problems and outcomes of those treatments. Also, it was noted that the SOC Comprehensive Assessment dated 11/07/2021 documented under "Primary Diagnosis and Other Diagnoses" 25 different diseases. All 25 diagnoses had the same date of onset and exacerbation documented 25 as 11/07/2021. There was no documentation of prior treatments, outcomes, or history of how these diagnoses led to the need for current home care services. MR#4: The SOC was dated 9/24/2021. The Plan of Care for the certification period 3/23/22 to 5/21/22 included diagnoses of Diabetes type 2 (DM2) with foot ulcer, Chronic Diastolic Congestive Heart Failure (CHF), Atrial fibrillation (A-Fib), and Coronary Artery Disease (CAD). During record review on 5/4/2022, it was noted that there was no history of how long the patient had any of above diseases/conditions, or when and how the diseases occurred. There was no history of the status of the above diseases including treatments for past medical problems and outcomes of those treatments. Further review of the record revealed that the SOC Comprehensive Assessment dated 9/24/21 documented under "Primary Diagnosis and Other Diagnoses" 25 diagnoses. All 25 diagnoses had the same date of onset and exacerbation documented as 9/24/2021. There was no documentation of prior treatments, outcomes, or history of how these diagnoses led to the need for home care. MR#5: The SOC was dated 4/15/2022. The Plan of Care for the certification period 4/15/2022 to 6/13/2022 identified diagnoses of Normal Pressure Hydrocephalus,, Chronic Kidney Disease (CKD), Coronary Artery Disease (CAD), Gastrointestinal Reflux, and history of Transient Ischemic Attack (TIA). During record review on 5/3/2022, it was noted that there was no history of how long the patient had any of above diseases/conditions, or when and how the diseases occurred. There was no history of the status of the above diseases including treatments for past medical problems and outcomes of those treatments. Further review of the record revealed that the SOC Comprehensive Assessment dated 4/15/2022 documented under "Primary Diagnosis and Other Diagnoses" 13 diagnoses. Three of the diagnoses (Idiopathic normal pressure hydrocephalus, Hypertensive Chronic Kidney Disease, and Chronic Kidney Disease) had the same date of onset of 4/15/2022 which was the same date as the Start of Care Assessment. Ten of the diagnoses had the same date of onset of 1/1/2022. There was no documentation of prior treatments, outcomes, or history of how these diagnoses led to the need for home care. MR#6: The SOC was dated 4/19/2022. The POC for the certification period 4/19/2022 to 6/17/2022 identified diagnoses of Gastro-esophageal reflux disease, Chronic Kidney Disease stage 3 (CKD3), Atrial Fibrillation (A-Fib), Coronary Artery Disease (CAD), and dementia. During record review on 5/5/2022, it was noted that there was no history of how long the patient had any of above diseases/conditions, or when and how the diseases occurred. There was no history of the status of the above diseases including treatments for past medical problems and outcomes of those treatments. Further review of the record revealed that the SOC Comprehensive Assessment dated 4/19/2022 documented under "Primary Diagnosis and Other Diagnoses" 11 diagnoses. One diagnosis (the Primary Diagnosis of Gastro-esophageal reflux disease without esophagitis) had a date of onset of 4/19/2022. The 10 "other diagnoses" had the same dates of onset of 1/1/2022. There was no documentation of prior treatments, outcomes, or history of how these diagnoses led to the need for home care. These findings were reviewed with and acknowledged by the Clinical Manager and the Assistant Clinical Manager during an interview on 5/5/22 at 2:30 p.m.

Strengths, goals, and care preferences CFR(s): 484.55(c)(2) The patient's strengths, goals, and care preferences, including information that may be used to demonstrate the patient's progress toward achievement of the goals identified by the patient and the measurable outcomes identified by the HHA; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to include patient specific measurable baseline health information and data on the initial comprehensive assessment to determine the patient's progress toward achieving goals in 1 (MR#s 1) records reviewed out of a total of 17 records reviewed resulting in lack of information to determine the patient's progress towards goals during the course of care. Findings included: MR#1: The Start of Care (SOC) was dated 12/29/2021. The Plan of Care (POC) for the certification period 12/29/2021 to 2/26/2022 identified diagnoses of Hypertensive Heart Disease (HF), Congestive Heart Failure (CHF), Abnormal Gait, Coronary Artery Disease (CAD), and Diabetes Mellitus Type 2 (DM2). Upon review of the comprehensive assessment on 5/2/2022, it was noted that the patient was an insulin dependent diabetic currently prescribed subcutaneous injectable insulin (Novolog as directed per sliding scale, and Lantus 12 units every morning). Upon further review of the comprehensive assessment, the Physical Therapist (PT11) failed to document the patient's normal blood sugar ranges to use as a measure to alert the physical therapist of out of range blood sugar results during future assessments. In addition, the patient has a primary diagnosis of Hypertensive Heart Disease and Congestive Heart Failure, yet under Cardiac Status PT11 documented "WNL" and under comments, "Patient has history of Hypertension, Congestive Heart Failure, and Coronary Artery Disease." There was no assessment of lower extremity edema, pitting edema, heart sounds, neck vein distention, peripheral pulses, or capillary refill to use as a baseline for future assessments. All these areas were blank. Under Elimination Status, PT11 documented within normal limits (WNL): incontinence, but no description of the urine. Under Digestive P11 documented WNL and the rest of the area was blank. No documentation of bowel sounds or last BM. Under Physician's orders or diet requirements, PT11 documented 188 Calorie ADA Diet, and Heart Healthy, but failed to include "No Concentrated Sweets" for this patient diagnosed with insulin dependent diabetes. Also under the category of "Mobility" the following categories were blank: (Q): Does patient use wheelchair and/or scooter? (R): Wheel 50 feet with two turns? (RR1): Indicate the type of wheelchair or scooter used; (S): Wheel 150 feet? All these areas on the Comprehensive were Blank. The patient does use a walker and wheelchair for mobility, and this information is used to measure the patient's performance at the Start of Care, Resumption of Care and Discharge to ascertain the patient's progress toward stated goals. The Agency failed to use measurable data to determine the patient's progress toward obtaining the patient's individualized goals.

Patient's needs CFR(s): 484.55(c)(4) The patient's medical, nursing, rehabilitative, social, and discharge planning needs; This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the patient's Activities of Daily Living and Medical Social Work needs were adequately met in the patient's home in 3 (MR's #8, 9, 10) of 3 records reviewed of patients who required these services, from a total of 17 sampled records reviewed, resulting in the potential for lack of needed grooming, loss of self-esteem, lack of assistance with financial resources, and unmet care needs. Findings include: MR #8: The patient's start of care (SOC) was 2/1/22 with diagnoses that included Hypertensive Heart Disease and Acute on Chronic Diastolic Congestive Heart Failure. During the clinical record review on 5/3/22 at 11:00 a.m., it was noted that the Initial Comprehensive Assessment (ICA) dated 2/1/22 completed by the Registered Nurse (RN) documented, "Patient needs financial assistance, MSW (Medical Social Work) ordered - No." Additionally, Home Health Aide services were ordered at a frequency of 1x/wk. x 4 wks. At the time of this review, no MSW or HHa services had been provided. The Agency failed to ensure the patient's Medical Social Work and Activity of Daily Living (ADL) needs were adequately met in the patient's home. MR #9: The patient's SOC was 4/20/22 with diagnoses that included Multiple fractures of ribs and left forearm and Diabetes Mellitus. During the record review on 5/3/22 at 9:45 a.m., it was noted that the referral for home care ordered Skilled Nursing (SN), Home Health Aide (HHa), Physical Therapy (PT) and Occupational Therapy (OT) services to be provided. At the time of this review, No HHa services had been provided. Additionally, there was no evidence that the patient refused services or that the Physician had been notified. MR #10: The patient's SOC was 4/7/22 with diagnoses that included Hypertensive Heart Disease and Chronic Systolic Congestive Heart Failure. During the clinical record review on 5/4/22 at 12:15 p.m., it was noted that the ICA dated 4/7/22, completed by the RN documented, "Patient needs financial assistance, MSW ordered - No." Additionally, section M1800 (Grooming) documented, "Patient needs assistance with grooming/dressing/toileting..." At the time of this record review, no MSW or HHa services had been provided or offered. These findings were reviewed with and acknowledged by the Clinical Manager and Assistant Clinical Manager on 5/4/22 at 10:37 a.m. The above findings were reviewed with and acknowledged by the Assistant Clinical Manager during an interview on 5/4/22 at 1:25 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 registered nurse reviewed patient medications for possible side effects and possible drug interactions for 13 of 17 (MR#s 1, 2, 3, 4, 7, 10, 11, 12, 13, 14, 15, 16, 17) records reviewed, and failed to complete a medication reconciliation to the referral for 3 of 17 (MR#s 12, 15, 17) records reviewed. This deficient practice results in the potential for unrecognized medication side effects and drug interactions that could affect all 25 current patients serviced by the agency Findings included: MR #7: The patient's start of care (SOC) was 4/20/22 with diagnoses that included Stroke and Hemiplegia. During the clinical record review on 5/3/22, it was noted that the Plan of Care (POC) ordered the patient to receive Physical Therapy (PT) and Occupational Therapy (OT) services. Section M2001 of the Initial Comprehensive Assessment (ICA) dated 4/20/22 completed by the Physical Therapist documented "No issues found during review. There was no documented evidence of the actual review that had been conducted. The section of the "Patient Medication Record" dated 4/20/22 that required "Nurse Signature and Title" was digitally signed by the Physical Therapist (PT #1). The Registered Nurse (RN) failed to review and co-sign the review process conducted by PT #1 in accordance with this requirement. These findings were reviewed with and acknowledged by the Clinical Manager and Assistant Clinical Manager during an interview on 5/3/22 at 11:15 a.m. MR #10: The patient's SOC was 4/7/22 with diagnoses that included Hypertensive Heart Disease and Congestive Heart Failure. During the record review on 5/4/22 at 12:15 p.m., it was noted that section M2001 of the ICA dated 4/7/22 completed by the RN documented "No issues found during the review." Upon further review, there was no documentation of the findings of the drug review process and no evidence that a drug review had been conducted. Additionally, there was no Patient Medication Record that listed the patient's medications. On 5/4/22 at 1:25 p.m., during an interview, the Assistant Clinical Manager was queried about the drug review process and reported, "The Nurse didn't complete the drug review process." MR#11: The Start of Care (SOC) was dated 3/11/22. The Plan of Care (POC) identified diagnoses of Aftercare Following Surgical Amputation, Diabetes Type 2 and Congestive Heart Failure (CHF). During record review on 5/4/22, a medication interaction report was completed in the EMR (Electronic Medical Record) and noted 3 duplicate therapy medications: Amlodipine Besylate, Lasix and Aldactone. There was no documented evidence, during the 5/4/22 clinical record review, that a drug interaction review had in fact been conducted to identify any adverse reactions or effects, or documented evidence that the physician had been notified of the above findings. MR#12: The Start of Care (SOC) was dated 3/29/22. The Plan of Care (POC) identified diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Falls and Congestive Heart Failure (CHF). During record review on 5/3/22, it was noted that the hospital discharge referral dated 3/26/22, contained 21 medications and the EMR medication profile had 13 medications documented. The missing medications from the referral were: Duoneb, Mylanta, Aspirin, Lipitor, Colace, Flonase, Advair, Mucinex and Zofran. Additionally, the medication profile contained Protonix, which was not on the hospital referral. There is no documented medication reconciliation completed with the physician to determine an accurate home medication regimen. MR#13: The Start of Care (SOC) was dated 3/23/22. The Plan of Care (POC) identified diagnoses of Left Radius Fracture and Congestive Heart Failure (CHF). During record review on 5/3/22, a medication interaction report was completed in the EMR and noted 1 duplicate therapy medications: Metoprolol and Lisinopril. There was no documented evidence, during the 5/2/22 clinical record review, that a drug interaction review had in fact been conducted to identify any adverse reactions or effects, or documented evidence that the physician had been notified of the above findings. MR#14: The Start of Care (SOC) was dated 4/29/22. The Plan of Care (POC) identified diagnoses of Right Hip Replacement and Congestive Heart Failure (CHF). During record review on 5/4/22, a medication interaction report was completed in the EMR and noted 1 duplicate therapy medications: Tramadol HCL and Norco. Additionally, 7 drug to drug interactions were noted. There was no documented evidence, during the 5/4/22 clinical record review, that a drug interaction review had in fact been conducted to identify any adverse reactions or effects, or documented evidence that the physician had been notified of the above findings. MR#15: The Start of Care (SOC) was dated 11/22/21. The Plan of Care (POC) identified diagnoses of Diabetes Type 2 and Stage 2 Pressure Right Buttock. During record review on 5/2/22, a medication interaction report was completed in the EMR and noted 2 duplicate therapy medications: Divalproex Sodium and Depakote, then Lantus and Humulin R. Additionally, 2 drug to drug interactions were noted. There was no documented evidence, during the 5/2/22 clinical record review, that a drug interaction review had in fact been conducted to identify any adverse reactions or effects, or documented evidence that the physician had been notified of the above findings. Furthermore, on 12/8/21, 16 days after the SOC, the Skilled Nurse (SN) documented, “Physician Contacted Re: Sliding scale, Novolog dose.” The medication profile was not updated with a sliding scale. The agency failed to complete a medication reconciliation with the physician at the SOC to determine an accurate medication regimen. MR#16: The Start of Care (SOC) was dated 1/7/22. The Plan of Care (POC) identified diagnoses of Rheumatoid Arthritis, Hypertension and A-Fib. During record review on 5/2/22, a medication interaction report was completed in the EMR and noted 1 drug to drug interactions. There was no documented evidence, during the 5/2/22 clinical record review, that a drug interaction review had in fact been conducted to identify any adverse reactions or effects, or documented evidence that the physician had been notified of the above findings. Additionally, the medication profile was completed at discharge on 3/4/22 by a Physical Therapist. The agency failed to complete a medication reconciliation with the physician at the SOC to determine an accurate medication regimen. MR#17: The Start of Care (SOC) was dated 3/31/22. The Plan of Care (POC) identified diagnoses of Diabetes Type 2, Hypertension and Chronic Obstructive Pulmonary Disease. During record review on 5/2/22, a medication interaction report was completed in the EMR and noted 2 duplicate therapy medications: Oxycodone HCI and Tramadol, then Norvasc and Hydralazine. Additionally, 2 drug to drug interactions were noted. There was no documented evidence, during the 5/4/22 clinical record review, that a drug interaction review had in fact been conducted to identify any adverse reactions or effects, or documented evidence that the physician had been notified of the above findings. Additionally, it was noted that the hospital discharge referral dated 3/30/22, contained 22 medications and the EMR medication profile had 12 medications documented. The missing medications from the referral were: Keflex, Zetia, Medrol Dosepak, Crestor, Cymbalta, Advair Diskus, Albuterol, Qvar inhaler, Coreg, Plavix, Glucotrol XL, Lantus, Zestril, Antivert, Lyrica, Tiotropium inhaler, Trulicity and Tylenol/Codeine #4. Additionally, the medication profile contained the following 8 medications that were not on the referral: Simvastatin, Oxycodene, Metformin, Hydrochlorothiazide, Colace, Xanax and Tylenol. There is no documented medication reconciliation completed with the physician to determine an accurate home medication regimen. These findings were reviewed with and acknowledged by the Administrator (Adm#1), Alternate Clinical Manager (ACM3) during an interview on 5/5/22 at 11:55 am. MR#1: The Start of Care (SOC) was dated 12/29/2021. The Plan of Care (POC) for the certification period 12/29/2021 to 2/26/2022 identified diagnoses of Hypertensive Heart Disease (HF), Congestive Heart Failure (CHF), Abnormal Gait, Coronary Artery Disease (CAD), and Diabetes Mellitus Type 2 (DM2). Upon review of the Comprehensive Assessment dated 12/29/2021 under the Category of (M2001: Drug Regimen Review), the Physical Therapist (PT# 11) documented "No issues found during review." However, a review of the patient's current medications via drugs.com identified 2 major drug interactions as follows: 1) The concurrent use of Methotrexate and Aspirin can result in nausea, vomiting, diarrhea, sore throat, chills, rash, fever, bruising, bleeding and dark urine; 2) The use of methotrexate together with esomeprozole magnesium increases blood levels and side effects of methotrexate. There was no evidence found in the record that these interactions were reported to the physician. The HHA failed to ensure the comprehensive assessment included an accurate and complete review of all medications used by the patient that identified significant adverse effects and were reported to the physician. MR#2: The Start of Care was dated 3/21/2022. The patient was admitted to the agency after a hospital stay with a diagnosis of cerebral infarction. The patient's past medical history included Myocardial infarction (MI, Coronary Artery Disease (CAD), Uterine Cancer, Osteoarthritis, Cerebral Vascular Accident (CVA), and Hemiplegia. Upon review of the Comprehensive Assessment dated 12/29/2021 under the Category of (M2001: Drug Regimen Review), the Physical Therapist (PT# 13) documented "Yes, issues found during review." A review of the patient's current medication via drugs.com, identified 3 major drug interactions as follows: 1) The concurrent use of ciprofloxacin and glipizide can sometimes affect blood glucose levels. Both hyperglycemia (high blood glucose) and less frequently, hypoglycemia (low blood glucose) have been reported. Severe cases of hypoglycemia have resulted in coma and even death. 2) The combination of clopidogrel together with omeprazole may reduce the effectiveness of clopidogrel in preventing heart attack or stroke. This patient was recently hospitalized due to stroke, and has a medical history of Myocardial infarction. 3) The concurrent use of trazodone and sertraline can increase the risk of "serotonin syndrome" which includes symptoms such as confusion, hallucination, seizure, extreme changes in blood pressure, increased heart rate, fever, excessive sweating, shivering or shaking, blurred vision, muscle spasm or stiffness, tremor, incoordination, stomach cramp, nausea, vomiting, and diarrhea. Severe cases may result in coma and even death. The PT documented under (M:2003) Medication Follow-up: "No" to the question "Did the agency contact a physician by midnight of the next calendar day and complete prescribed/recommended actions in response to the identified potential clinically significant medication issues. The agency failed to identify a medicine regimen that could cause harm to the patient, and failed to notify the physician of these findings. MR#3: The SOC was dated 11/7/21. The Plan of Care for the certification period of 11/7/21 to 1/5/22 identified diagnoses of Emphysema, Chronic diastolic heart failure (CHF), Diabetes type 2 (DM2), Chronic Kidney Disease (CKD), Atria Fibrillation (A-Fib), and Irritable Bowel Syndrome. Upon review of the Start of Care Comprehensive Assessment dated 11/7/2021 under the Category of (M2001: Drug Regimen Review), the Registered Nurse (RN# 6) documented, "no issues found." However, during a review of the patient's current medications via Drugs.Com, a major interaction was identified between two of the patient's current medications as follows: "The concurrent use of oxycodone and quetiapine can lead to serious side effects including respiratory distress, coma, and even death." The patient 's current primary diagnosis is emphysema. The HHA failed to ensure the comprehensive assessment included an accurate and complete review of all medications used by the patient that identified significant adverse effects and were reported to the physician. MR#4: The SOC was dated 9/24/2021. The Plan of Care for the certification period 3/23/22 to 5/21/22 included diagnoses of Diabetes type 2 (DM2) with foot ulcer, Chronic Congestive Heart Failure (CHF), Atrial Fibrillation (A-Fib), and Coronary Artery Disease (CAD). Upon review of the Comprehensive Assessment dated 9/24/21, it was noted under the Category of (M2001: Drug Regimen Review), the Registered Nurse (RN# 7), documented, "no issues found." However, during a review of the patient's current medications via Drugs.Com, seven (7) major interactions were identified with the use of the patient's current medications as follows: 1) The use of apixaban together with aspirin may increase the risk of bleeding, including severe and sometimes fatal hemorrhage. 2) The concurrent use of tramadol together with pregabalin can lead to serious side effects including respiratory distress, coma, and even death. 3) Using Hydrocodone together with pregabalin can result serious side effects including respiratory distress, coma, and even death. 4) The combined use of Alprazolam together with Hydrocodone can lead to respiratory distress, coma, and even death. 5) The use of Alprazolam together with tramadol can result in respiratory distress, coma, and even death. 6) Using Hydrocodone together with tramadol can lead to serious side effects including seizures, respiratory distress, coma, and even death. 7) The use of Effexor XR and tramadol can increase the risk of a serious condition called the serotonin syndrome which includes symptoms such as confusion, hallucination, seizure, extreme changes in blood pressure, increased heart rate, fever, excessive sweating, blurred vision, muscle spasm or stiffness, tremor, stomach cramp, nausea, vomiting, and diarrhea. Severe cases may result in coma and even death. Documentation under the category of "(M:2003): Medication Follow-up", was blank. There was no evidence that RN#7 had completed a drug regimen review for this patient, and no evidence the physician had been notified of these 7 serious drug interactions with the use of the patient's currently prescribed medications.

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, Policy Review, and Interview, the agency failed to conduct the Start of Care Assessment within 48 hours of the physician referral (See G-514); failed to conduct a patient-specific comprehensive assessment that accurately reflected the patient's current health status based on past medical history that included dates of onset, exacerbations, treatments, and outcomes, and history of events leading to current home care needs (See G-528); Failed to ensure the registered nurse reviewed patient medications for possible side effects and possible drug interactions (See G-530); failed to ensure the patient's Activities of Daily Living and Medical Social Work needs were adequately met in the patient's home (See G-534); and failed to complete a medication reconciliation to the referral (See G- ). This deficient practice results in the potential for unrecognized medication side effects and drug interactions that could affect all 25 current patients serviced by the agency (G-536). Based on record review and interview, the agency failed to ensure the plan of care included patient specific objectively measurable goals and outcomes (See G-572); failed to ensure the Plan of Care included objectively measurable and individualized goals to determine the patient's progress towards goals (See G-574); failed to ensure skilled nursing provided assessments and interventions as ordered by the physician (See G-578); failed to ensure the skilled disciplines promptly notified the Physician of changes in the patient's health condition (See (G-590); failed to provide a Medication Profile that included the names, dosages, frequencies and side effects of the patient's prescribed medications, in plain language, resulting in lack of direction for medication administration and the potential for improper use of medications (See G-616). The cumulative effect of these systemic problems resulted in the home health agency's inability to ensure the provision of quality health care in a safe environment for the condition of participation of 42 CFR 484.60, Care Planning, Coordination, and Quality of Care.

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 or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner 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 ensure the plan of care included patient specific objectively measurable goals and outcomes in 1 of a total of 17 sampled records reviewed (MR#s: 1), resulting in difficulty determining the patient's progress toward the achievement of goals. Findings included: MR#1: There was no Plan of Care (POC) found in the electronic record for this patient. During an interview with the Clinical Manager (CM#2) on 5/3/22 at 9:00 a.m., CM#2 was advised that this surveyor could not find this patient's Plan of Care in the Electronic Medical record (Kinnser). A request was made to the CM2 to provide a copy of the Plan of Care for this patient. The CM2 followed up on the request and confirmed that no Plan of Care had been created for the certification period 12/29/2021 to 2/26/2022 for this patient. The Agency failed to create a Plan of Care for this patient. .

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, policy review, and interview, the agency failed to ensure the Plan of Care included objectively measurable and individualized goals to determine the patient's progress towards goals in 6 of 17 records reviewed. Findings included: MR#1: The Start of Care (SOC) was dated 12/29/2021. The Plan of Care (POC) for the certification period 12/29/2021 to 2/26/2022 identified diagnoses of Hypertensive Heart Disease (HF), Congestive Heart Failure (CHF), Abnormal Gait, Coronary Artery Disease (CAD), and Diabetes Mellitus Type 2 (DM2). Upon review of the record on 5/2/2022 it was noted the goals were not individualized or objectively measurable to determine the patient's progress towards goals. Examples include: "Patient will demonstrate independence with written HEP for strengthening; PT to instruct patient caregiver on ulcer prevention techniques such as" {sic}; Patient and/or Caregiver will verbalize an understanding of the signs and symptoms of COVID-19." These goals are not objectively measurable to determine the patient's progress towards goals. MR#2: The Start of Care was dated 3/21/2022. The patient was admitted to the agency after a hospital stay with a diagnosis of cerebral infarction. The patient's past medical history included Myocardial Infarction (MI), Coronary Artery Disease (CAD), Uterine Cancer, Osteoarthritis, Cerebral Vascular Accident (CVA), and Hemiplegia. Upon review of the record, there was no Plan of Care found in the electronic record to use as a resource in determining goals, or how to measure the patient's progress towards goals MR#3: The SOC was dated 11/7/2021. The Plan of Care for the certification period 11/7/21 to 1/5/21 identified diagnoses of Emphysema, Chronic diastolic heart failure (CHF), Diabetes type 2 (DM2), Chronic Kidney Disease (CKD), Atrial Fibrillation (A-fib), and Irritable Bowel Syndrome. During record review on 5/3/2022, it was noted the goals were not individualized or objectively measurable to determine the patient's progress towards goals. Examples include: "Patient will achieve a reduction in pain score and patient and caregiver will verbalize understanding of pain medication; The caregiver will verbalize understanding of individualized emergency plan by Target Date 11-7-21"; Patient will verbalize understanding of CHF Management {sic}". These goals are not objectively measurable to determine the patient's progress towards goals. MR#4: The SOC was dated 9/24/2021. The Plan of Care for the certification period 3/23/22 to 5/21/22 included diagnoses of Diabetes type 2 (DM2) with foot ulcer, Chronic Diastolic Congestive Heart Failure (CHF), Atrial fibrillation (A-Fib), and Coronary Artery Disease (CAD). During record review on 5/4/2022, it was noted the goals were not individualized or objectively measurable to determine the patient's progress towards goals. Examples include: During record review on 5/3/2022, it was noted the goals were not individualized or objectively measurable to determine the patient's progress towards goals. Examples include: "Patient wounds will heal without complications; The patient will verbalize and demonstrate edema-relieving measures; Patient will experience a reduction in Shortness of breath." These goals are not objectively measurable to determine the patient's progress towards goals. MR#5: The SOC was dated 4/15/2022. The Plan of Care for the certification period 4/15/2022 to 6/13/2022 identified diagnoses of Normal Pressure Hydrocephalus,, Chronic Kidney Disease (CKD), Coronary Artery Disease (CAD), Gastrointestinal Reflux, and history of Transient Ischemic Attack (TIA). During record review on 5/4/2022, it was noted the goals were not individualized or objectively measurable to determine the patient's progress towards goals. Examples include: "Patient will verbalize understanding of mediation {sic} regimen, dose, route, frequency, indications, and side effects; Patient will remain free of aspiration and reduce the risk of recurrence; The patient will verbalize understanding of individualized emergency plan." These goals are not objectively measurable to determine the patient's progress towards goals. MR#6: The SOC was dated 4/19/2022. The POC for the certification period 4/19/2022 to 6/17/2022 identified diagnoses of Gastro-esophageal reflux disease, Chronic Kidney Disease stage 3 (CKD3), Atrial Fibrillation (A-Fib), Coronary Artery Disease (CAD), and dementia. it was noted the goals were not individualized or objectively measurable to determine the patient's progress towards goals. Examples include: "Patient will be able to verbalize understanding of GERD, pancreatitis; Patient will verbalize understanding of mediation {sic} regimen, dose, route, frequency, indications, and side effects; Patient/Caregiver can verbalize or demonstrate dementia precaution measures by discharge date." These goals are not objectively measurable to determine the patient's progress towards goals. These findings were reviewed and acknowledged by the Clinical Manager and Alternate Clinical Manager during an interview on May 5th 2022 at 2:30 p.m.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review, and interview, the agency failed to ensure skilled nursing provided assessments and interventions as ordered by the physician for 1 of 17 (MR# 4) records reviewed, resulting in a lack of assessments needed to determine the patient's health status and poor patient outcomes for the patient. Findings included: MR#4: The SOC was dated 9/24/2021. The Plan of Care for the certification period 3/23/22 to 5/21/22 included diagnoses of Diabetes type 2 (DM2) with foot ulcer, Chronic Diastolic Congestive Heart Failure (CHF), Atrial fibrillation (A-Fib), and Coronary Artery Disease (CAD). The patient was receiving Physical Therapy Services. The plan of care for the certification period of 3/23/22 to 5/21/2022 included orders to 1) monitor random and fasting blood sugars and report readings that are outside the ordered parameters of blood sugars greater than 350 or less than 70 to the physician; and 2) weigh patient every visit and report a 3 pound per day or 5 pound per week weight gain to the physician. The patient was prescribed injectable Novolin Insulin 1 unit per sliding scale, and Lantus Solarstar 40 units nightly. The Physical Therapist (PT#11) failed to follow these orders to monitor the patient's blood sugar results, or monitor the patient's daily weights. There were no weights or blood sugar results documented in the patient's record. As a result of the lack of monitoring the patient's weights and blood sugars, EMS was called on 4/8/2022 for blood sugars greater than 350 and the patient was treated at her home with IV fluids and insulin by emergency services. On 4/11/2022 EMS was called again for uncontrolled blood sugars greater that 350 and the patient was transferred to the hospital for an inpatient admission due to out of control blood sugars. Further review of the record revealed the patient did not have a glucometer to monitor blood sugars, or scales to obtain daily weights. The PT had not notified the physician that ordered interventions were not provided or that the patient did not have the equipment to obtain weights or blood sugars. An immediate Jeopardy was enforced due to the situation. On 5/4/22 at 2:54 an Immediate Jeopardy was approved due to the Agency's failure to conform with physician orders for baseline assessments and re-assessments; and failure to notify the physician that monitoring the patients health condition was not performed due to lack of required equipment, thus failing to deliver care and services as ordered in the Plan of Care. The Agency's Administrator, Clinical Director were notified of the Immediate Jeopardy on 5/4/22 at 3:18/22 at 3:18 p.m. The Immediate Jeopardy was removed at 5:14 p.m. on 5/4/22 after the review and approval of the Agency's Immediacy Plan of Correction.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the Agency failed to ensure its skilled disciplines promptly notified the Physician of 1 (MR #8) of 1 patient who experienced a 6-pound unplanned weight loss, and 1 (MR #9) of 1 patient observed during a home visit with an elevated blood sugar and decreased blood pressure, from a total of 17 sampled records reviewed, resulting in the potential unidentified, untreated health conditions and unmet care needs. Findings include: MR #8: The patient’s start of care (SOC) was 2/1/22 with diagnoses that included Hypertensive Heart Disease and Acute on Chronic Congestive Heart Failure. During the record review on 5/3/22 at 11:00 a.m., it was noted that the Skilled Nurse (SN) documented a “stated” weight of 103.6 pounds in the Initial Comprehensive Assessment at the start of care (2/1/22). The SN failed to document the patient’s weight during the SN visit on 2/4/22. The next visit made by the SN was 2/17/22 in which the SN documented the patient’s weight as 97 pounds. This reflected a 6-pound weight loss. Further review of the clinical record revealed no documented evidence that the SN promptly notified the Physician of the patient’s unplanned weight loss of 6 pounds. MR #9: The patient’s SOC was 4/20/22 with diagnoses that included Multiple fractures to ribs and left forearm and Diabetes Mellitus, End Stage Renal Disease and Orthostatic Hypotension. On 5/3/22 at 3:30 p.m., a scheduled home visit was conducted with the Physical Therapy Assistant (PTA #1). During the visit the patient’s blood pressure was noted to be 81/54. The reportable parameters in which to notify the Physician were listed on the Plan of Care (POC) as: Systolic BP less than 90. PTA #1 did not promptly notify the Physician of the patient’s low blood pressure reading. Additionally, during the visit, the patient became unstable while standing. The patient’s sister assisted with checking the patient’s blood sugar to reveal a reading of 482. The reportable parameters in which to notify the Physician stated, Random blood sugar (>) greater than 350. Additional review of the clinical record was conducted on 5/4/22. There was no documented evidence that the Physician had been notified of the findings observed during the in-home visit. PTA #1 failed to promptly notify the Physician of the patient’s elevated blood sugar reading as instructed in the POC. These findings from the above records were reviewed with and acknowledged by the Clinical Manager and Assistant Clinical Manager during an interview on 5/4/22 at 10:59 a.m.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, it was determined that the agency failed to provide 2 (MR's #7, 9) of 2 patients observed during a home visit, with a Medication Profile that included the names, dosages, frequencies and side effects of the patient's prescribed medications, in plain language, from a total of 17 sampled records reviewed, resulting in lack of direction for medication administration and the potential for improper use of medications. Findings include: MR #7: The patient's start of care (SOC) was 4/20/22 with diagnoses that included Stroke, Hemiplegia and Hypertension. During the clinical record review on 5/3/22, it was noted that Physical Therapy (PT) and Occupational Therapy (OT) services were ordered to be provided. On 5/3/22 at 1:30 p.m., a home visit was conducted with the Physical Therapist (PT #1). During the visit, it was noted that the patient's admission packet was void of a Medication Profile/Schedule to direct the patient/caregiver on the use of the prescribed medications and to ensure the patient was aware of any potential side effects. MR #9: The patient's SOC was 4/20/22 with diagnoses that included Multiple fracture of ribs and left radius, Diabetes Mellitus and End Stage Renal Disease. During the record review on 5/3/22 at 9:45 a.m., it was noted that Skilled Nursing (SN), Home Health aide (HHa) and PT services were ordered to be provided. On 5/3/22 at 3:30 p.m. during the visit, it was noted that the patient's admission packet was void of a Medication Profile/Schedule to direct the patient/caregiver on the use of the prescribed medications and to ensure the patient was aware of any potential side effects. The Agency failed to provide the patient with a Medication Profile that included the names, dosages, frequencies and side effects of the patient's prescribed medications as per this requirement. These findings were reviewed with and acknowledged by the Clinical Manager and the Assistant Clinical Manager during an interview on 5/4/22 at 10:37 a.m.

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to maintain compliance with this condition of participation. The agency failed to develop, implement, evaluate, and maintain an agency-wide, data driven Quality Assessment and Performance Improvement program in 2020, 2021, and 2022 (See G 642); failed to collect and utilize quality indicator data and other relevant agency data in the design of its quality assessment and performance improvement program (See G 644); failed to ensure to conduct performance improvement projects in 2020, 2021, and 2022 (See G 658); and the governing body failed to ensure the agency developed, implemented, and maintain an agency-wide, data driven Quality Assessment and Performance Improvement program in 2020, 2021, and 2022 (See G660). The cumulative effect of these systemic problems resulted in the home health agency's inability to ensure the provision of quality health care in a safe environment for the condition of participation of 42 CFR 484.65, Quality Assessment and Performance Improvement.

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, the agency failed to develop, implement, evaluate, and maintain an agency-wide, data driven Quality Assessment and Performance Improvement program in 2020, 2021, and 2022. Resulting in no documented evidence of the agency's efforts to monitor agency processes and improve patient outcomes for the 1249 patients admitted to the agency in the past 12 months. Findings include: On 5/5/22, the agency provided for review, a binder titled Quality Assessment and Performance Improvement (QAPI). Review of the documentation indicates the agency has not had an active QAPI program since the third quarter of 2019. There was no documented evidence of the agency's efforts to develop, implement, evaluate, and maintain an effective, ongoing, agency wide, data driven QAPI program in 2020, 2021, and 2022. During an interview on 5/5/22 at 10:40 a.m., the Administrator ( ADM#1) and the alternate clinical manager (ACM#3) reviewed and acknowledged the findings. ADM#1 explained that the agency is maintaining a QAPI program, but they have failed to document their daily discussions and efforts regarding QAPI. The agency failed to follow its own policy titled, Quality Assessment and Performance Improvement (QAPI) Plan and Program (revised February 2021) which states, "The agency will establish an on-going, Agency-wide, data-driven program of quality assessment and performance improvement and maintain documentary evidence of its program."

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 utilize quality indicator data and other relevant agency data in the design of its quality assessment and performance improvement program, resulting in the potential for poor quality outcomes for the 1249 patients admitted to the agency in the past 12 months. Findings include: On 5/5/22, the agency provided for review, a binder titled Quality Assessment and Performance Improvement (QAPI). Review of the documentation indicates the agency has not had an active QAPI program since the third quarter of 2019. There was no documented evidence of the agency's efforts in 2020 and 2021 to collect and utilize quality indicator data including data derived from OASIS (outcome and assessment information set) to track and trend the quality of care. During an interview on 5/5/22 at 10:40 a.m., the alternate clinical manager (ACM#3) explained that the agency is currently utilizing the software in their electronic medical record (EMR) system to collect data regarding hospital re-admissions in 2022. A printout of the hospital re-admission data was reviewed, and ACM#3 was unable to explain what data was being collected by the EMR system and how the data would be utilized to monitor the effectiveness and safety of services and quality of care. There was no documented evidence the agency was utilizing quality indicator data from OASIS in 2020 through 5/5/2022.

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, the agency failed to ensure to conduct performance improvement projects in 2020, 2021, and 2022, resulting in no coordinated efforts to improve patient outcomes for the 1249 patients admitted to the agency in the past 12 months. Findings include: On 5/5/22, the agency provided for review, a binder titled Quality Assessment and Performance Improvement (QAPI). Review of the documentation indicates the agency has not had an active QAPI program since the third quarter of 2019. There was no documented evidence of the agency's performance improvement projects (PIPs) in 2020 and 2021. During an interview on 5/5/22 at 10:40 a.m., the alternate clinical manager (ACM#3) was queried regarding the agency's PIPs in 2022. ACM#3 explained that the agency is currently utilizing the software in their electronic medical record (EMR) system to collect data regarding hospital re-admissions in 2022. A printout of the hospital re-admission data was reviewed, and ACM#3 was unable to explain what data was being collected by the EMR system and how the data would be utilized. There was no documentation to indicate the reasons for conducting this project, what data would be collected, how long data would be collected and analyzed, and any measurable progress toward improved patient outcomes.

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, the governing body failed to ensure the agency developed, implemented, and maintain an agency-wide, data driven Quality Assessment and Performance Improvement program in 2020, 2021, and 2022. Resulting in a lack of oversight by the governing body to ensure patient safety and quality of care improvements for the 1249 patients admitted to the agency in the past 12 months. Findings include: On 5/5/22, the agency provided two binders for review, one binder titled Quality Assessment and Performance Improvement (QAPI) and the other titled GB (governing body) Meetings. Review of the documentation indicates the agency has not had an active QAPI program since the third quarter of 2019 and there were no documented Governing Body meeting minutes since 12/06/2019. During an interview on 5/5/22 at 10:40 a.m., the Administrator ( ADM#1) and the alternate clinical manager (ACM#3) reviewed and acknowledged the findings. ADM#1 explained that the governing body is maintaining oversight of the QAPI program, but they have failed to document their daily discussions and efforts regarding QAPI. The agency failed to follow its own policy titled, Quality Assessment and Performance Improvement (QAPI) Plan and Program (revised February 2021) which states, "The Governing Body is ultimately responsible for an ongoing QAPI and patient safety program that is defined, implemented, and maintained."

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 coordinate an agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases as a part of their Quality Assessment Performance Improvement program in 2020, 2021, and 2022, resulting in the potential development and spread of infections between staff and the agency's 25 current patients. Findings include: On 5/5/22, the agency provided for review, a binder titled Quality Assessment and Performance Improvement (QAPI). Review of the documentation indicates the agency has not had an active QAPI program since the third quarter of 2019. There was no documented evidence the agency maintained an agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases as a part of their Quality Assessment Performance Improvement program in 2020, 2021, and 2022. The findings were reviewed with and acknowledged by the Administrator (ADM#1) and the alternate clinical manager (ACM#3) during an interview on 5/5/22 at 10:40 a.m.

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: Based on observation, interview and record review, the Physical Therapist failed to utilize professional standards of practice during the provision of Therapeutic exercises for 1 (MR #7) of 2 patients observed during a home visit, from a total of 17 sampled records reviewed, resulting in the potential for injury (G704); failed to ensure Occupational/Physical Therapy services were provided as ordered for 3 (MR's #7, 9, 10); and failed to ensure the Registered Nurse followed the plan of care, including obtaining weights for 1 (MR #8) of 7 patients with diagnoses that included Congestive Heart failure, from a total of 17 sampled records review, resulting in the potential for decline in health status, decline in physical functioning, and unmet care needs (G710); failed to ensure its Skilled Disciplines provided education regarding medication usage to both the patient and caregiver for 1 (MR #9) of 1 patient observed during a home visit who experience a drop in blood pressure, from a total of 17 sampled records reviewed, resulting in the potential for elevated blood pressures, additional health concerns and unmet care needs (G714). The cumulative effect of these systemic problems resulted in the Home Health agency's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR 484.75: Skilled Professional Services.

Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This STANDARD is not met as evidenced by: Based on observation, interview and record review, the Physical Therapist failed to utilize professional standards of practice during the provision of Therapeutic exercises for 1 (MR #7) of 2 patients observed during a home visit, from a total of 17 sampled records reviewed, resulting in the potential for injury. Findings include: MR #7: The patient’s SOC was 4/20/22 with diagnoses hat included Stroke, Hemiplegia, Hypertension and Falls. On 5/3/22 at 1:30 p.m., a schedule home visit was conducted with the Physical Therapist (PT #1). Upon arrival, the patient was noted have an unsteady gait and required the use of a 4-point walker to assist with ambulation. During the visit, PT #1 assisted the patient with lower extremity exercises as the patient was in a seated position. PT #1 then instructed the patient on ambulation to the dining room and back. While ambulating to the dining room the patient became unsteady and had to be assisted to a nearby chair. It was further observed that PT #1 failed to utilize a gait belt (Used during ambulation to prevent falls) to support the patient during ambulation. Upon completion of the visit, PT #1 was queried as to why she failed to use the required gait belt to support the patient during ambulation and reported, “It just slipped my mind.” These findings were reviewed with and acknowledged by the Clinical Manager and Assistant Clinical Manager during an inter on 5/4/22 at 11:15 a.m.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, it was determined that the Agency failed to ensure Occupational/Physical Therapy services were provided as ordered for 6 (MR's #7, 9, 10, 15, 16, 17); and failed to ensure the Registered Nurse followed the plan of care, including obtaining weights for 4 (MR #8, 11, 12, 13) of 7 patients with diagnoses that included Congestive Heart failure, from a total of 17 sampled records review, resulting in the potential for decline in health status, decline in physical functioning, and unmet care needs. Findings include: MR #7: The patient's start of care (SOC) was 4/20/22 with diagnoses that included Stroke and Hemiplegia. During the record review on 5/3/22, it was noted that the Plan of Care (POC) ordered the patient to receive Occupational Therapy (OT) services at a frequency of 2x/wk. x 4 wks. Upon further review, OT did not conduct the initial evaluation until 4/27/22. This was 7 days/1 week after the start of care. Additionally, there was no documented rationale for the delay in needed services and no evidence that the Physician had been informed of the delay. These findings were reviewed with and acknowledged by the Assistant Clinical Manager during an interview on 5/4/22 at 1:20 p.m. MR #8: The patient's SOC was 2/1/22 with diagnoses that included Hypertensive Heart Disease and Acute on Chronic Diastolic Heart Failure. The POC ordered Skilled Nursing (SN) at a frequency of 2x/wk. x 1 wk., 1x/wk. x 3 wks. to assess patient's weight every visit. Upon review of the clinical record on 5/3/22 at 11:00 a.m., it was noted that the SN did not check the patient's weight during the visit on 2/4/22. The SN missed the visit on 2/10/22. The SN failed to follow the POC and check the patient's weights each visit as ordered. These findings were reviewed with and acknowledged by the Clinical Manager and Assistant Clinical Manager during an interview on 5/4/22 at 10:59 a.m. MR #9: The patient's SOC was 4/20/22 with diagnoses that included Multiple Fractures to rib and left forearm and Diabetes Mellitus. During the record review on 5/3/22 at 9:45 a.m., it was noted that the referral for home care dated 4/19/22 ordered SN, Home Health Aide, Physical Therapy and Occupational Therapy services to be provided. At the time of this review, No OT services had been provided. Additionally, there was no documented evidence that the patient refused the ordered services or that the Physician had been notified. These findings were reviewed with and acknowledged by the Assistant Clinical Manager during an interview on 5/4/22 at 10:37 a.m. MR #10: The patient's SOC was 4/7/22 with diagnoses that included Hypertensive Heart Disease and Congestive Heart Failure. During the clinical record review on 5/4/22 at 12:15 p.m., it was noted that the referral for home care services ordered SN, PT and OT services to be provided. The PT evaluation was conducted on 4/9/22. At the time of this review, no further PT visits had been made. Additionally, OT attempted services 11 days after the start of care, at which time, the patient declined services. The Agency failed to ensure that PT and OT services were provided as ordered and failed to notify the Physician that services had not been provided. These findings were reviewed with and acknowledged by the Assistant Clinical Manager during an interview on 5/4/22 at 1:25 p.m. MR#11: The Start of Care (SOC) was dated 3/11/22. The Plan of Care (POC) identified diagnoses of Aftercare Following Surgical Amputation, Diabetes Type 2 and Congestive Heart Failure (CHF). During record review on 5/4/22, it was noted the Skilled Nurse (SN) failed to document the patient's weight on: 3/14/22, 3/16/22, 3/18/22, 3/23/22, 4/4/22, 4/13/22, 4/18/22 and 4/22/22. 8 of the 8 SN visits completed failed to document weights for this CHF patient every visit. MR#12: The Start of Care (SOC) was dated 3/29/22. The Plan of Care (POC) identified diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Falls and Congestive Heart Failure (CHF). During record review on 5/3/22, it was noted the Skilled Nurse (SN) failed to document the patient's weight on 4/3/22, 4/8/22 and 4/14/22. 3 of the 3 SN visits completed failed to document weights for this CHF patient every visit. MR#13: The Start of Care (SOC) was dated 3/23/22. The Plan of Care (POC) identified diagnoses of Left Radius Fracture and Congestive Heart Failure (CHF). During record review on 5/3/22, it was noted that SN failed to document the patient's weight on 3/23/22, 3/28/22 and 4/6/22. 3 of the 3 SN visits completed failed to document weights for this CHF patient every visit. MR#15: The Start of Care (SOC) was dated 11/22/21. The Plan of Care (POC) identified diagnoses of Diabetes Type 2 and Stage 2 Pressure Ulcer Right Buttock. During record review on 5/2/22, it was noted that the POC dated 11/22/21 ordered "Occupational Therapy (OT): Evaluate and Treat." The OT evaluation dated 11/29/21 was late by 7 days from the SN Comprehensive Assessment dated 11/22/21. The agency failed to evaluate the patient within 48 hours. Furthermore, the SN failed to document the patient's blood sugars on: 6/5/21, 6/12/21, 6/26/21, 7/3/21, 7/22/21, 7/24/21, 7/29/21, 8/5/21 and 8/7/21. 9 of the 20 SN visits completed failed to document blood sugar for this diabetic patient every visit. MR#16: The Start of Care (SOC) was dated 1/7/22. The Plan of Care (POC) identified diagnoses of Rheumatoid Arthritis, Hypertension and A-Fib. During record review on 5/2/22, it was noted that the POC dated 1/7/22 ordered "Physical Therapy (PT): Evaluate and Treat. OT: Eval and Treat" The PT evaluation dated 1/14/22 was late by 7 days from the SN Comprehensive Assessment dated 1/7/22. Additionally, the OT evaluation dated 1/11/22 was late by 4 days. The agency failed to evaluate the patient within 48 hours. MR#17: The Start of Care (SOC) was dated 3/31/22. The Plan of Care (POC) identified diagnoses of Diabetes Type 2, Hypertension and Chronic Obstructive Pulmonary Disease. During record review on 5/2/22, it was noted that the POC dated 3/31/22 ordered "Occupational Therapy (OT): Evaluate and Treat." The OT evaluation dated 4/11/22 was late by 11 days from the SN Comprehensive Assessment dated 3/31/22. The agency failed to evaluate the patient within 48 hours. Furthermore, the OT was ordered at a frequency of 2w3 (2 times a week for 3 weeks). The OT completed the first three of six ordered visits on 4/11/22, 4/15/22 and 4/20/20. There is no order or communication note on why the reaming three visits were not completed. The Agency failed to ensure that OT services were provided as ordered These findings were reviewed with and acknowledged by the Administrator (Adm#1), Alternate Clinical Manager (ACM3) during an interview on 5/5/22 at 12:45 pm.

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the Agency failed to ensure its Skilled Disciplines provided education regarding medication usage to both the patient and caregiver for 1 (MR #9) of 1 patient observed during a home visit who experience a drop in blood pressure, from a total of 17 sampled records reviewed, resulting in the potential for elevated blood pressures, additional health concerns and unmet care needs. Findings include: MR #9: The patient’s SOC was 4/20/22 with diagnoses that included Multiple fractures to ribs and left forearm, Diabetes Mellitus, End Stage Renal Disease and Orthostatic Hypotension. On 5/3/22 at 3:30 p.m., a scheduled home visit was conducted with the Physical Therapy Assistant (PTA #1). Prior to the session, PTA #1 checked the patient's blood pressure which revealed a reading of 120/66. During the therapy session, the patient became lightheaded and unsteady. PTA #1 assisted the patient to a seated position and rechecked her blood pressure. The patient’s blood pressure was noted to be 81/54 (below the reportable parameters). The patient’s sister retrieved a bottle of medication (Midodrine HCL 10mg TID w/meals/used for low blood pressure). The patient's sister proceeded to give the patient one tablet by mouth and stated, "The nurse told us to give her a dose whenever her blood pressure was low." The instructions on the medication bottle were to take one tablet 3 times/day with meals. There was no medication profile in the patient's admission packet to refer to for instructions or indications for use. According to "Drugs.com" (online pharmaceutical encyclopedia), increased use of Midodrine may cause "increased blood pressure (flushing, headache, pounding heartbeat, blurred vision)." The Agency failed to provide patient and caregiver education regarding proper medication usage. These findings were reviewed with and acknowledged by the Clinical Manager and Assistant Clinical Manager during an interview on 5/4/22 at 10:59 a.m.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the Skilled Nurse prepared clear written patient care instructions for the Home Health Aide regarding client needs, and safety precautions prior to the provision of care in 2 (MR's #8, 9) of 4 records in which Home Health Aide services were ordered, from a total of 17 sampled records reviewed, resulting in the potential for the provision of unsafe care and unmet care needs. Findings include: MR #8: The patient's start of care (SOC) was 2/1/22 with diagnoses that included Hypertensive Heart Disease. During the record review on 5/3/22 at 11:00 a.m., it was noted that the Plan of Care (POC) ordered Home Health Aide (HHa) services to be provided at a frequency of 1x/wk. x 4 wks. The POC listed the following precautions and equipment: Cane, elevated toilet seat, tub/shower bench, walker, slow position change, support during transfer/ambulation, anticoagulant (bleeding) precautions, proper position during meals, fall precautions. The Aide Care Plan dated 2/1/22 failed to include a visit frequency and all of the above safety precautions and equipment. These findings were reviewed with and acknowledged by the Clinical Manager and Assistant Clinical Manager during an interview on 5/4/22 at 10:59 a.m. MR #9: The patient's SOC was 4/20/22 with diagnoses that included Multiple fractures to rib and left forearm and Diabetes Mellitus. During the record review on 5/3/22 at 9:45 a.m., it was noted that the POC listed the following equipment and precautions: wheelchair, elevated toilet seat, keep side rails up, slow position change, support during transfer/ambulation, proper position during meals, fall precautions, diabetic precautions, prone to skin breakdown precautions. The Aide Care Plan was dated 5/2/22 and failed to include a visit frequency and all of the above safety precautions and equipment. The findings from the above records was reviewed with and acknowledged by the Clinical Manager and Assistant Clinical Manager during an interview on 5/4/22 at 10:59 a.m.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure clinical notes were accurate for 2 of 17 (MR# 11 and 15) records reviewed, resulting in the potential to negatively affect the health and well-being of these patients. Findings include: MR#11: The Start of Care (SOC) was dated 3/11/22. The Plan of Care (POC) identified diagnoses of Aftercare Following Surgical Amputation, Diabetes Type 2 and Congestive Heart Failure (CHF). During record review on 5/4/22, it was noted that the referral dated 3/9/22 stated, “Please change right foot dry dressing every other day and apply Iodosorb to the wound.” The Skilled Nurse (SN) completed a comprehensive assessment on 3/11/22 and documented wound measurements. There were no wound measurements completed for the second and third weeks of visits which were dated: 3/14/22, 3/16/22, 3/18/22, 3/21/22 and 3/23/22. The patient was transferred to the hospital on 3/24/22 for “Difficulty in breathing and Pneumonia.” On 3/30/22 the SN completed a resumption of care assessment that documented the surgical wound status as “Closed, present on admission.” On 4/13/22, the SN documented, “Patient called nurse early to home due to new pressure sore on left buttocks. Small dime sized area noted, stage two pressure sore…Contacted pcp (primary care physician). The SN added a new intervention order that stated, “Left buttocks: cleanse with wound wash. Apply zinc oxide cream to wound. Cover with gauze bandage. To be changed daily or when soiled.” There is no wound documentation for the following 2 weeks, with SN visits of: 4/18/22, 4/22/22 and 4/29/22. During an observation visit with the SN on 5/4/22, she was questioned on how often wound measurements are completed and stated, “Weekly wound measurements are documented within the EMR (Electronic Medical Record).” Clinical Manager (CM2) was questioned on 5/4/22 at 3:45 pm regarding wound care documentation and stated, "There is no wound care documentation for this patient. Wound measurements are to be done weekly." The agency failed to ensure that the medical record was complete and accurate. MR#15: The Start of Care (SOC) was dated 11/22/21. The Plan of Care (POC) identified diagnoses of Diabetes Type 2 and Stage 2 Pressure Ulcer Right Buttock. During record review on 5/2/22, it was noted that the referral dated 11/20/21 documented, “Comment: Visiting nurse for wound care, lab draws, diabetic education, glucose monitoring. Consult PT/PT.” The Skilled Nurse (SN) completed a comprehensive assessment on 11/22/21 and documented a Stage 2 Pressure Ulcer to the Right Buttock that measured “Size: Length: 1cm, Width: 1cm…. Treatment: NA wound care consulted.” The POC ordered SN: 1w4 (1 time a week for 4 weeks), then an additional order was completed on 12/12/21 for 1w3. The SN failed to document wound measurements for weeks 2-7, which included the visits of: 11/30/21, 12/8/21, 12/15/21, 12/23/21, missed visit on 12/29/21 and discharge 1/11/22. The agency failed to ensure that the medical record was complete and accurate. These findings were reviewed with and acknowledged by the Administrator (Adm#1), Alternate Clinical Manager (ACM3) during an interview on 5/5/22 at 12:35 pm.

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 complete, provided the patient's current health status at the time of discharge, progress toward goals, and forwarded to the physician within 5 days of discharge in 3 (MR#'s 1, 15 and 16), of 5 closed records, from a total of 17 records reviewed, resulting in the potential for unidentified continuing health care concerns and unmet care needs. Findings include: MR#15: The Start of Care (SOC) was dated 11/22/21. The Plan of Care (POC) identified diagnoses of Diabetes Type 2 and Stage 2 Pressure Right Buttock. During record review on 5/2/22, it was noted that the Skilled Nursing discharge dated 1/11/22 stated, "Care Summary (care given, progress, regress including therapies): VSS (vital signs stable), physical assessment completed." The discharge summary failed to detail the course of care provided, responses to treatment, any potential continuing needs, and failed to document the patient's health status at the time of discharge in measurable terms. MR#16: The Start of Care (SOC) was dated 1/7/22. The Plan of Care (POC) identified diagnoses of Rheumatoid Arthritis, Hypertension and A-Fib. During record review on 5/2/22, it was noted that the Skilled Nursing discharge dated 1/16/22 stated, "Care Summary (care given, progress, regress including therapies): VSS (vital signs stable), physical assessment completed and skin intact. Pending venous duplex." The discharge summary failed to detail the course of care provided, responses to treatment, any potential continuing needs, and failed to document the patient's health status at the time of discharge in measurable terms. These findings were reviewed with and acknowledged by the Administrator (Adm#1), Alternate Clinical Manager (ACM3) during an interview on 5/5/22 at 12:15 pm. MR#1: The Start of Care (SOC) was dated 12/29/2021. The Plan of Care (POC) for the certification period 12/29/2021 to 2/26/2022 identified diagnoses of Hypertensive Heart Disease (HF), Congestive Heart Failure (CHF), Abnormal Gait, Coronary Artery Disease (CAD), and Diabetes Mellitus Type 2 (DM2). The patient was discharged on 2/1/22 per patient/family request. Upon review of the discharge summary, it was noted, the Physical Therapist (PT#11) documented "Physician notified of discharge summary." However, there was no documentation found in the record to ensure a discharge summary was sent to the physician within 5 business days of the patient's discharge. The agency failed to ensure the physician was aware of the patient's health status at the time of discharge including summary of the care received and the health status at the time of discharge, resulting in the physician not having knowledge of the patient's health status at the time of discharge, including and a summary of the care received which has the potential to negatively affect the patient.