Every finding on record at First Stop Home Care, Inc

A recertification survey for Emergency Preparedness was conducted by the Michigan Department of Licensing and Regulatory Affairs from 9/16/24-9/19/24. EPIC Home Care 15443 Middlebelt Rd Livonia, MI 48154 At the survey's conclusion, the agency was found to be in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR §484.102, Emergency Preparedness.

A recertification survey was conducted by the Michigan Department of Licensing and Regulatory Affairs from 9/16/24-9/19/24. EPIC Home Care 15443 Middlebelt Rd Livonia, MI 48154 The agency had no other locations at the time of survey. At the survey's conclusion, the agency was found to be out of compliance with the requirements for participation in Medicare/Medicaid at 42 CFR §484., Home Health.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment included an accurate review of all medications to determine potential adverse effects or duplicate drug therapy in 3 of 7 (P-1, 2, 3) records reviewed, resulting in the potential for harmful medication effects for all patients serviced by this agency. Findings include: Agency policy: Medication Profile; Policies and Procedures Manual (Revised March 2018) 11.8.1 states, "The comprehensive assessment performed at time of admission includes a review of all medications that 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, duplicative drug therapy and non-compliance with drug therapy. P-1: The start of care (SOC) was dated 11/17/23, with diagnoses of hypertensive heart disease with heart failure. During record review on 9/16/24, it was noted that the medication profile and the plan of care (POC) dated 11/17/23, documented Eliquis/Apixaban (Anticoagulant) oral 5 MG 1-tab 4X/day, and another order for Eliquis oral 5 MG 1-tab 2X/day. Albuterol Sulfate inhalation (2.5 MG/3ML) 0.083% HHN Q 4-6 ML as needed anti-asthmatic and bronchodilator, and another order for Albuterol Sulfate HFA inhalation 108 (90 Base) MCG/ACT 1-2 puffs every 4 hours as needed for chronic obstructive pulmonary disease (COPD) anti-asthmatic and bronchodilator. Pravastatin Sodium oral 10 MG 1 tab twice daily, and Pravastatin Sodium oral 10 MG 1 tab at bedtime. There was no documented clarification in the record as to which of these duplicate orders the patient should be taking. The medication profile signed by registered nurse (Staff C) also documented there were no discrepancies or interactions. P-2: The SOC was dated 9/6/24 with diagnoses of osteoarthritis, weakness, and unsteady. During record review on 9/17/24, it was noted that the medication profile and the plan of care (POC) dated 9/6/24, documented Trelegy Ellipta inhalation 100-62.5-25 MCG/INH 1 puff daily listed twice. Pantoprazole Sodium oral 40 MG 1 tab daily was listed twice. Metoprolol Succinate ER oral 50 MG 1 tab daily, and Metoprolol Succinate ER oral 25 MG 1 tab daily. Atorvastatin Calcium oral 40 MG 1 tab daily at bedtime, and Atorvastatin Calcium oral 40 MG 1 tab daily. Amiodarone HCL oral 200 MG 1-tab oral daily was listed twice. Furosemide 40 MG oral 1 tab daily was listed twice. Eliquis/Apixaban (Anticoagulant) oral 5 MG 1 tab oral daily, Eliquis oral 5 MG 1 tab twice daily and Eliquis oral 2.5 MG 2 tabs patient to take one tablet twice daily orally. 3 separate orders for Eliquis were documented on the medication profile. The medication profile also documented Clopidogrel Bisulfate (Another anticoagulant) oral 75 MG 1 tab oral daily. There was no documented clarification in the record as to which of these duplicate orders the patient should be taking. The medication profile signed by registered nurse (Staff C) also documented there were no discrepancies or interactions. During an interview on 9/19/24 at 1:30 p.m., the alternate administrator (Staff B), the clinical manager/registered nurse (Staff C), and the administrative assistant (Staff E) acknowledged the above findings. P-3: This 78-year-old patient was admitted to home care on 2/29/24 with diagnoses of wound on the toe, varicose veins, and peripheral vascular disease. During record review on 9/16/24, it was noted that the plan of care dated 2/29/24 contained multiple duplicate medications. For example, Xarelto 20mg was listed four times; 21 medications (vitamin E 1000U, vitamin C 500mg, fluconazole 100mg, melatonin 5mg, Claritin 10mg, hydrocodone 10/325mg, gabapentin 300mg, fenofibrate 200mg, esomeprazole 40mg, doxycycline 100mg, furosemide 20mg, digoxin 125 mcg, ropinirole 0.5mg, cilostazol 100mg, cholestyramine 4gm, cholecalciferol 10mg, Cartia XT 180mg, biotin 1000mcg, atorvastatin 10mg, allopurinol 100mg, and Synthroid 50mcg) were listed twice; and two medications (duloxetine 30mg and silver sulfadiazine 400gm) were listed once. This finding was reviewed and acknowledged by the alternate administrator (Staff B), the clinical manager (Staff C), and administrative support (Staff E) during an interview on 9/19/24 at 9:40 a.m. Staff B and Staff E stated they were unsure of why medications were populating multiple times on the plan of care while the medication profile listed medications once, and will be following up with the electronic medical record company. Agency policy: Medication Profile; Policies and Procedures Manual (Revised March 2018) 11.8.1 states, "The comprehensive assessment performed at time of admission includes a review of all medications that 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, duplicative drug therapy and non-compliance with drug therapy. P-1: The start of care (SOC) was dated 11/17/23, with diagnoses of hypertensive heart disease with heart failure. During record review on 9/16/24, it was noted that the medication profile and the plan of care (POC) dated 11/17/23, documented Eliquis/Apixaban (Anticoagulant) oral 5 MG 1-tab 4X/day, and another order for Eliquis oral 5 MG 1-tab 2X/day. Albuterol Sulfate inhalation (2.5 MG/3ML) 0.083% HHN Q 4-6 ML as needed anti-asthmatic and bronchodilator, and another order for Albuterol Sulfate HFA inhalation 108 (90 Base) MCG/ACT 1-2 puffs every 4 hours as needed for chronic obstructive pulmonary disease (COPD) anti-asthmatic and bronchodilator. Pravastatin Sodium oral 10 MG 1 tab twice daily, and Pravastatin Sodium oral 10 MG 1 tab at bedtime. There was no documented clarification in the record as to which of these duplicate orders the patient should be taking. The medication profile signed by registered nurse (Staff C) also documented there were no discrepancies or interactions. P-2: The SOC was dated 9/6/24 with diagnoses of osteoarthritis, weakness, and unsteady. During record review on 9/17/24, it was noted that the medication profile and the plan of care (POC) dated 9/6/24, documented Trelegy Ellipta inhalation 100-62.5-25 MCG/INH 1 puff daily listed twice. Pantoprazole Sodium oral 40 MG 1 tab daily was listed twice. Metoprolol Succinate ER oral 50 MG 1 tab daily, and Metoprolol Succinate ER oral 25 MG 1 tab daily. Atorvastatin Calcium oral 40 MG 1 tab daily at bedtime, and Atorvastatin Calcium oral 40 MG 1 tab daily. Amiodarone HCL oral 200 MG 1-tab oral daily was listed twice. Furosemide 40 MG oral 1 tab daily was listed twice. Eliquis/Apixaban (Anticoagulant) oral 5 MG 1 tab oral daily, Eliquis oral 5 MG 1 tab twice daily and Eliquis oral 2.5 MG 2 tabs patient to take one tablet twice daily orally. 3 separate orders for Eliquis were documented on the medication profile. The medication profile also documented Clopidogrel Bisulfate (Another anticoagulant) oral 75 MG 1 tab oral daily. There was no documented clarification in the record as to which of these duplicate orders the patient should be taking. The medication profile signed by registered nurse (Staff C) also documented there were no discrepancies or interactions. During an interview on 9/19/24 at 1:30 p.m., the alternate administrator (Staff B), the clinical manager/registered nurse (Staff C), and the administrative assistant (Staff E) acknowledged the above findings. P-3: This 78-year-old patient was admitted to home care on 2/29/24 with diagnoses of wound on the toe, varicose veins, and peripheral vascular disease. During record review on 9/16/24, it was noted that the plan of care dated 2/29/24 contained multiple duplicate medications. For example, Xarelto 20mg was listed four times; 21 medications (vitamin E 1000U, vitamin C 500mg, fluconazole 100mg, melatonin 5mg, Claritin 10mg, hydrocodone 10/325mg, gabapentin 300mg, fenofibrate 200mg, esomeprazole 40mg, doxycycline 100mg, furosemide 20mg, digoxin 125 mcg, ropinirole 0.5mg, cilostazol 100mg, cholestyramine 4gm, cholecalciferol 10mg, Cartia XT 180mg, biotin 1000mcg, atorvastatin 10mg, allopurinol 100mg, and Synthroid 50mcg) were listed twice; and two medications (duloxetine 30mg and silver sulfadiazine 400gm) were listed once. This finding was reviewed and acknowledged by the alternate administrator (Staff B), the clinical manager (Staff C), and administrative support (Staff E) during an interview on 9/19/24 at 9:40 a.m. Staff B and Staff E stated they were unsure of why medications were populating multiple times on the plan of care while the medication profile listed medications once, and will be following up with the electronic medical record company.

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 interventions with objectively measurable goals specific to the individualized needs of the patient in 1 (P-5) of 7 records reviewed, resulting in the potential for poor patient outcomes and unmet care needs for this patient. Findings include: P-5: This 82-year-old patient was admitted to home care on 8/3/24, with diagnoses of hypertensive heart disease and chronic kidney disease. During record review on 9/17/24, it was noted that the plan of care failed to include measurable nursing goals that are individualized to address patient needs. For example, one goal stated, “patient will verbalize understanding of proper use of pain medication.” Another goal stated, “patient will verbalize an understanding of energy conserving measures.” There was no evidence of how these goals could be objectively measured to determine progress toward meeting the goals. This finding was reviewed and acknowledged by the alternate administrator (Staff B), the clinical manager (Staff C), and administrative support (Staff E) during an interview on 9/19/24 at 9:40 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 record review and interview, the agency failed to ensure the clinical record contained accurate clinical notes for 1 (P-3) of 7 records reviewed, resulting in the potential for poor patient outcomes and a lack of information for all agency staff caring for the patient. Findings include: P-3: This 78-year-old patient was admitted to home care on 2/29/24 with diagnoses of wound on the toe, varicose veins, and peripheral vascular disease. During record review on 9/16/24, it was noted that the nursing notes from 3/13/24, 3/20/24, and 3/25/24 contained identical comments for all three visit notes. For example, cardiovascular comments stated, “Patient has dried right leg venous ulcer, healed, concerns for very large bruise to right thigh, leg, increase in swelling and pain.” Musculoskeletal comments stated, “Patient reports walking exacerbates pain, in wheelchair today, concern for pressure to right back of thigh, instruct to shift weight, elevate legs through the day.” Psychosocial comments stated, “patient anxious about bruise to whole right upper thing in pain with lump of unknown cause, patient agitated.” Pain comments stated, “Patient reports taking Norco to help with pain in knees, and right hip.” Digestive nutrition comments stated, “encouraged to eat 3 meals a day and to incorporate protein into diet to promote wound healing. Encouraged not to skip meals, eating hardboiled egg.” These findings were reviewed and acknowledged by the alternate administrator (Staff B), the clinical manager (Staff C), and administrative support (Staff E) during an interview on 9/19/24 at 9:40 a.m. Staff B stated nursing notes are prefilled with prior comments to assist with continuity of care and stated staff should be updating the comments.

On 8/24/21 through 8/27/21, a recertification survey was conducted by the Michigan Department of Licensing and Regulatory Affairs at EPIC Home Care. This was a standard survey. The requirements for participation in Medicare at 42 CFR 484.102 Emergency Preparedness were not reviewed.

A Medicare recertification survey and a COVID-19 focused infection control survey were conducted by the Michigan Department of Licensing and Regulatory Affairs from 8/24/2021 through 8/27/21 at: EPIC Home Care 15443 Middlebelt Road Livonia, MI 48154 This agency has no branch sites. Records Reviewed: 3 records with home visits; 4 records without home visits, for a total of 7 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.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the initial assessment visit was conducted within 48 hours of referral for 2 of 7 (MR# 5, 6) records reviewed, resulting in a delay in determining the immediate care and support needs for these patients. Findings include: MR#5: This patient was admitted to home care on 4/12/21 with diagnoses of cellulitis (bacterial skin infection), congestive heart failure, and respiratory failure. Record review on 8/25/21 indicates by fax stamp that the agency received the referral for home care services on 4/5/21. The initial assessment was conducted by the registered nurse 7 days later on 4/12/21. There was no documentation to indicate the patient had delayed the initial assessment visit and no documentation to indicate the physician was informed of and approved the delay in home care services. MR#6: This patient was admitted to the agency on 9/8/20 with diagnoses of right sided weakness following a stroke, high blood pressure, and muscle weakness. Record review on 8/25/21 indicates by fax stamp that the agency received the referral for home care services on 9/4/21 at 1:08 p.m. The initial assessment was conducted by the registered nurse 4 days later on 9/8/20. There was no documentation to indicate the patient had delayed the initial assessment visit and no documentation to indicate the physician was informed of and approved the delay in home care services. The above findings were reviewed with and acknowledged by Alt-A (alternate administrator) and CM-B (clinical manager) during an interview on 8/27/21 at 10:00 a.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 4 of 7 records reviewed (MR#s 1, 2, 3, 4), resulting in incomplete clinical information to aid in determining the needs of the patient and determining progress towards goals. Findings included: MR#1: The Start of Care (SOC) was dated 8/26/20. The Plan of Care (POC) identified diagnoses of Congestive Heart Failure (CHF) and Diabetes Type 2. During record review on 8/24/21, it was noted that the SOC comprehensive assessment dated 8/26/20, documented under "Primary Diagnosis and Other Diagnoses", all 11 diagnoses had no exacerbation and onset documented. No prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. MR#2: The Start of Care (SOC) was dated 6/29/21. The Plan of Care (POC) identified diagnoses of Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease (COPD), and Spinal Stenosis. During record review on 8/25/21, it was noted that the SOC comprehensive assessment dated 6/29/21, documented under "Primary Diagnosis and Other Diagnoses", all 13 diagnoses had the same date of exacerbation, 6/29/21. No prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. MR#3: The Start of Care (SOC) was dated 7/29/21. The Plan of Care (POC) identified diagnoses of Spondylosis and Muscle Weakness. During record review on 8/25/21, it was noted that the SOC comprehensive assessment dated 7/29/21, documented under "Primary Diagnosis and Other Diagnoses", all 8 diagnoses had the same date of exacerbation, 7/29/21. No prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. MR#4: The Start of Care (SOC) was dated 8/2/21. The Plan of Care (POC) identified diagnoses of Chronic Kidney Disease and Hemiplegia. During record review on 8/26/21, it was noted that the SOC comprehensive assessment dated 8/2/21, documented under "Primary Diagnosis and Other Diagnoses", all 12 diagnoses had the same date of exacerbation documented, 8/2/21. No prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. The Alt-A (alternate administrator) was questioned on 8/27/21 at 9:50 am and confirmed the findings.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure plans of care included all treatments, and measurable outcomes and goals for 5 of 7 (MR#1, 2, 4, 5, 6) records reviewed, resulting in the potential for poor patient outcomes. Findings include: MR#5: This patient was admitted to home care on 4/12/21 with diagnoses of cellulitis (bacterial skin infection), congestive heart failure, and respiratory failure. The 4/12/21 plan of care (POC) ordered skilled nursing, physical therapy, occupational therapy, and aide services for this patient. Review of the patient's record on 8/25/21, indicates the registered nurse (RN) documented on the start of care assessment (dated 4/12/21) that there is swelling, weeping, and stasis ulcers on both of the patient's lower legs. The RN documents that the patient's lower legs were cleansed with wound cleanser, soap, and water; medicated ointment was applied; Unna boots were applied (a special gauze bandage) and wrapped with kerlix. The RN provided 2 visits each week for the next 4 weeks and documented that wound care was provided and that Unna boots were applied. The 4/12/21 plan of care (POC) failed to include the wound care treatments the RN provided to the patient's lower legs. There was no indication how often wound care was to be provided. The POC included the following skilled nursing goal: Patient weight will be maintained between 285 pounds and 294 pounds during the episode. The RN documented the patient's weight at the start of care at 246 pounds and at the recertification on 6/8/21 the patient's weight was 244 pounds. It was unclear why the nurse would expect the patient to gain approximately 40 pounds during this episode of care. The goals were not individualized to the patient's needs and were perhaps cut and pasted from another care plan. MR#6: This patient was admitted to the agency on 9/8/20 with diagnoses of right sided weakness following a stroke, high blood pressure, and muscle weakness. During record review on 8/25/21, it was noted that the 9/8/20 POC included the following skilled nursing goals: home exercise program will be established by occupational therapist (this is not a nursing goal, it is a goal for the occupational therapist), home exercise program will be established by the physical therapist (this is not a nursing goal, it is a goal for the physical therapist), and patient will maintain heart healthy, high fiber diet, mechanical soft diet compliance during the episode. There was no indication how the nurse would measure the patient's progress toward the goal of maintaining a heart healthy, high fiber, mechanical soft diet. The above findings were reviewed with and acknowledged by Alt-A (alternate administrator) and CM-B (clinical manager) during an interview on 8/27/21 at 10:00 a.m. MR#1: The Start of Care (SOC) was dated 8/26/20. The Plan of Care (POC) identified diagnoses of Congestive Heart Failure (CHF) and Diabetes Type 2. During record review on 8/24/21, it was noted that the goals on the POC were not measurable, for example the Skilled Nursing (SN) stated, "Patient and caregiver will verbalize an understanding of factors that contribute to shortness of breath by 8/31/2020. Patient will verbalize and demonstrate edema relieving measures by 8/31/2020." There was no evidence of how these goals could be quantitatively measured. MR#2: The Start of Care (SOC) was dated 6/29/21. The Plan of Care (POC) identified diagnoses of Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease (COPD), and Spinal Stenosis. During record review on 8/25/21, it was noted that the goals on the POC were not measurable, for example the SN stated, "The patient and caregiver will verbalize understanding of symptoms of cardiac complications and when to call 911 by 7/10/21. Patient and caregiver will verbalize an understanding of factors that contribute to shortness of breath by 7/10/2021." There was no evidence of how these goals could be quantitatively measured. MR#4: The Start of Care (SOC) was dated 8/2/21. The Plan of Care (POC) identified diagnoses of Chronic Kidney Disease and Hemiplegia. During record review on 8/26/21, it was noted that the goals on the POC were not measurable, for example the SN stated, "Patient will be without signs or symptoms of UTI. The patient and caregiver will verbalize understanding of symptoms of cardiac complications and when to call 911 by 8/28/2021. Patient skin integrity will remain intact during this episode." There was no evidence of how these goals could be quantitatively measured. The Alt-A (alternate administrator) was questioned on 8/27/21 at 9:35 am and confirmed the findings.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the plan of care contained all patient care orders for 1 of 1 (MR#5) records reviewed with wound care orders, resulting in the potential for a poor patient outcome for this patient. Findings include: MR#5: This patient was admitted to home care on 4/12/21 with diagnoses of cellulitis (bacterial skin infection), congestive heart failure, and respiratory failure. Record review on 8/25/21 indicates there were no wound care orders on the plan of care for this patient with cellulitis. Review of the patient's record on 8/25/21, indicates the registered nurse (RN) documented on the start of care assessment (dated 4/12/21) that there is swelling, weeping, and stasis ulcers on both of the patient's lower legs. The RN documents that the patient's lower legs were cleansed with wound cleanser, soap, and water; medicated ointment was applied; Unna boots were applied (a special gauze bandage) and wrapped with kerlix. A physician order dated 4/12/21 orders the skilled nurse to cleanse the wound with wound cleanser/soap and water, apply Triamcinolone (corticosteroid used to treat inflammation) ointment, and wrap Unna boot, Kerlix, and Unna boot. There was no documentation on the 4/12/21 plan of care to indicate this physician order dated the same day was incorporated into the patient's plan of care. The findings were reviewed with and acknowledged by Alt-A (alternate administrator) during an interview on 8/27/21 at 10:00 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 registered nurse prepared appropriate patient care instructions for the aide in 3 of 5 (MR #2, 4, 5) records reviewed with aide services, resulting in the potential for a poor patient outcome for this patient. Findings include: MR#5: This patient was admitted to home care on 4/12/21 with diagnoses of cellulitis (bacterial skin infection), congestive heart failure, and respiratory failure. The 4/12/21 plan of care (POC) ordered skilled nursing, physical therapy, occupational therapy, and aide services for this patient. Review of the patient's record on 8/25/21, indicates the registered nurse (RN) documented on the start of care assessment (dated 4/12/21) that there is swelling, weeping, and stasis ulcers on both of the patient's lower legs. The RN documents that the patient's lower legs were cleansed with wound cleanser, soap, and water; medicated ointment was applied; Unna boots were applied (a special gauze bandage) and wrapped with kerlix. The RN provided 2 visits each week for the next 4 weeks and documented that wound care was provided and that Unna boots were applied. The aide care plan prepared by the RN on 4/12/21 ordered the aide to provide 1 visit each week for four weeks and to provide a shower during each visit. The aide care plan failed to provide any guidance or instructions for the aide regarding the patient's Unna boots during the shower. It was unclear if the aide was supposed to give the patient a shower with the gauze boots on, remove the Unna boots before the shower, or wrap the patient's legs in plastic to prevent the gauze boots from getting wet. The findings were reviewed with and acknowledged by Alt-A (alternate administrator) during an interview on 8/27/21 at 10:00 a.m. MR#2: The Start of Care (SOC) was dated 6/29/21. The Plan of Care (POC) identified diagnoses of Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease (COPD), and Spinal Stenosis. The POC ordered HHa services at a frequency of 1w4 (1 time a week for 4 weeks) with the following safety precautions: Keep pathway clear. Instructed on disaster/emergency plan. Instructed on DME & electrical safety. Slow position change. Instructed on mobility safety. Support during transfer and ambulation. Emergency plan developed. Instructed on safe utilities management. Anticoagulant precautions. Safety in ADLs. Instructed on safety measures. Fall precautions. Use of assistive devices. Standard precautions/infections control. During record review on 8/25/21, the "Aide Care Plan" dated 7/7/21 completed by the Registered Nurse (RN) contained the following safety precaution, "Universal Precautions." The HHa care plan failed to include the necessary safety measure and precautions to alert the aide of the patient's health concerns. MR#4: The Start of Care (SOC) was dated 8/2/21. The Plan of Care (POC) identified diagnoses of Chronic Kidney Disease and Hemiplegia. The POC ordered HHa services at a frequency of 2w2, 1w2 effective 8/22/21 with the following safety precautions: Keep pathway clear. Instructed on disaster/emergency plan. Instructed on mobility safety. Support during transfer and ambulation. Emergency plan developed. Instructed on safe utilities management. Safety in ADLs. Instructed on safety measures. Proper position during meals. Fall precautions. Use of assistive devices. Instructed on proper handling of biohazard waste. Standard precautions/infections control. During record review on 8/26/21, the "Aide Care Plan" dated 8/22/21 completed by the RN contained the following safety precaution, "Right sided weakness, history of stroke, dependent upon walker, assistance in transfers, universal precautions." The HHa care plan failed to include the necessary safety measure and precautions to alert the aide of the patient's health concerns. The Alt-A (alternate administrator) was questioned on 8/27/21 at 9:40 am and confirmed the findings.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a discharge summary was sent to the physician within 5 business days of discharge for 1 of 2 (MR#6) discharge records reviewed, and failed to ensure the discharge summary was complete, provided the patient's current health status at the time of discharge, and documented progress toward goals for 1 of 2 (MR#1) discharge records reviewed, resulting in the physician not having knowledge of the patient's health status at the time of discharge. Findings include: MR#6: This patient was admitted to the agency on 9/8/20 with diagnoses of right sided weakness following a stroke, high blood pressure, and muscle weakness. During record review on 8/25/21, it was noted that the patient decided to seek outpatient treatment and was discharged from the agency on 9/12/21. The discharge summary was faxed to the physician 13 days later on 9/25/21. The above findings were reviewed with and acknowledged by Alt-A (alternate administrator) and CM-B (clinical manager) during an interview on 8/27/21 at 10:00 a.m. MR#1: The Start of Care (SOC) was dated 8/26/20. The Plan of Care (POC) identified diagnoses of Congestive Heart Failure (CHF) and Diabetes Type 2. During record review of the EMR on 8/24/21 noted a "SN Discharge Summary" was completed on 9/9/20. The discharge summary stated, "Care Summary (care given, progress, regress including therapies): SN (Skilled Nurse) conducted a prescreening assessment of covid-19 via phone with pt (patient) before visit, no covid symptoms noted. Pt sitting on couch, alert oriented times 3 with forgetfulness. Pt said I thought I said I didn’t need a nurse but now that you are here you can stay. SN thoroughly went through all medications and interactions and appropriate times medications should be given with pt. instructed on factors that contribute to sob (shortness of breath) including avoiding outdoors on poor air quality days. Avoiding leaving windows open when outside temperature is above 80 degrees. SN instructed on symptoms that could be sign of heart attack and when to call 911. Instructed on wound prevention and inspecting feet daily for any injuries. Pt verbalized understanding. (sic) 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. The Alt-A (alternate administrator) was questioned on 8/27/21 at 9:45 am and confirmed the findings stating, "The discharge summary is incomplete."