Every finding on record at Golden Plus Home Health Care, L L C

On 3/18/24 through 3/20/24, the Michigan Department of Licensing and Regulatory Affairs conducted a recertification survey at Golden Plus Home Health Care. This was a standard survey. The requirements for participation in Medicare at 42 CFR 484.102 Emergency Preparedness were not reviewed.

The Michigan Department of Licensing and Regulatory Affairs conducted a Medicare Authorized Home Health Care Recertification Survey 3/18/24 through 3/20/24 at: Golden Plus Home Health Care 27301 Dequindre Road, Suite 214 Madison Heights, Mi 48071 The agency has no branch sites. Clinical records reviewed for this survey: 1 record with a home visit (only 1 home visit was available) and 6 records without home visits for a total of 7 records reviewed. At the conclusion of the survey, the agency was found in noncompliance at the standard level for the conditions of participation for Home Health Agencies at: 42 CFR Part §484.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to inform patients of the appropriate phone number for the State of Michigan's toll-free hotline for 7 of 7 (P-1, P-2, P-3, P-4, P-5, P-6, P-7) records reviewed, resulting in a lack of required information to enable patients or caregivers to voice complaints or ask questions. This deficient practice has the potential to negatively affect the health and well-being of all 14 patients admitted to the agency in the past 12 months. Findings include: During the survey from 3/18/24 to 3/20/24, record review of admission documents for the above patients noted the wrong number for the State of Michigan's toll-free hotline. On 3/18/24, review of the agency's admission packet which were given to all patients upon the start of care, were directed to call 1-800-242-2873 for lodging a complaint to the State. However, when the number was called at 12:24 PM., it revealed the State of Michigan Attorney General's fraud hotline. In addition, another number (855-967-6900) listed on the cover of the admission packet to contact the agency for any concerns was found to be disconnected when called at 12:27 PM. These findings were reviewed with and acknowledged by the Administrator (Staff A) and Clinical Manager (Staff B) during an interview on 3/18/24 at 13:15 PM. The agency failed to provide patients with the correct information to lodge a complaint or concern and failed to adhere to its policy referenced below. Agency Policy: "Patient Privacy & Bill of Rights" pg.5 (undated) stated, "Right to be advised when you are accepted for treatment or care and be informed of the FREE STATE HOTLINE NUMBER... available 24 hours/day, 7 days/week and may be reached by dialing: 1-800-882-6002, toll free."

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 (SOC) assessment within 48 hours of the referral in 3 (P-2, P-5, and P-7) of 7 records reviewed, resulting in the delay of patient care and the potential for poor clinical outcomes. Findings included: P-2: The Start of Care (SOC) was dated 2/1/24. The Plan of Care (POC) for the Certification Period 2/1/2024 to 3/3/2024 identified diagnoses of Diabetes type 2 (DM2), Chronic Obstructive Pulmonary Disease (COPD), Morbid Obesity (BMI 500-599), Essential Hypertension (HTN), and Hyperlipidemia. Upon review of the record, it was noted a Skilled Nursing Facility sent the referral to the Home Care Agency on 1/23/2024 at 4:49 p.m. The Start of Care Assessment was conducted on 02/02/2024, 7 days after the referral. These findings were acknowledged by the Administrator and Clinical Manager during an interview on 3/20/24 at 3:30 p.m. P-5: The SOC was dated 12/22/23 with diagnoses which included osteo-arthritis, low back pain, and hypertension. On 3/19/24, record review noted the referral for home care was dated 12/10/23 at 12:53 PM. The SOC initial assessment occurred 12 days after the referral. No orders or communication notes were evidenced within the clinical record which authorized or explained why the agency failed to follow this CMS (Centers for Medicare & Medicaid Services) requirement of providing the SOC comprehensive assessment within 48 hours of receiving the referral. These findings were reviewed with and acknowledged by the Administrator (Staff-A) and Clinical Manager (Staff-B) during an interview on 3/20/24 at 10:50 AM. P-7: The SOC date was 1/30/24 with diagnoses which included chronic pain, muscle weakness, hypertension, and diabetes-type 2. On 3/19/24, record review noted the referral for home care was received (dated fax stamp) on 1/25/24. The SOC initial assessment above occurred 5 days after the referral. No orders to authorize or communication note(s) that explained for the delay were evidenced in the clinical record. These findings were reviewed with and acknowledged by Staff-A and Staff-B during an interview on 3/20/24 at 11:05 AM.

Content of the comprehensive assessment CFR(s): 484.55(c) 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: This STANDARD 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, past medical history, history of events leading to home care, baseline data for future assessments, and ascertained the patient's immediate care needs in 1 (P-7) of 7 records reviewed, out of a total of 7 records reviewed, resulting in the potential for unmet care needs. Findings included: P-7: The SOC date was 1/30/24, with diagnoses which included chronic pain, muscle weakness, hypertension, and diabetes-type 2. On 3/19/24, review of P-7's SOC comprehensive assessment performed by Physical Therapy (PT-only case) found an insufficient assessment of the patient's past medical history that included dates of onset, exacerbations, past medical treatments and outcomes, measurable data to use as a baseline for future assessments or a history of events leading to the need for the current home care admission. For example, the comprehensive assessment failed to acknowledge the physician's referral for home care notes which documented under "Assessment/Plan" the following: "Fasting (morning blood sugar) currently 80-110. Needs to be in 130's, so will decrease Lantus (insulin blood sugar medication)." Also, the physician increased to patient's blood pressure medication (amlodipine) that day due to increased readings experienced in the office that day. PT also documented 8 of 8 listed diagnoses had exacerbation (worsening) dates of 1/30/24, which in found to be inaccurate when compared to the physician referral. Further, the comprehensive assessment included misleading and inaccurate information concerning P-7's clinical needs. For example, the PT documented P-7 needed seizure precautions and neutropenic (specific infection control measures) when there was no history found in the physician's referral. Under "Past Medical History", PT documented P-7 had CHF (congestive heart failure), cancer of the right breast that was active (not in remission), and COPD (chronic obstructive pulmonary disease). Corroboration of these findings was not found in the physician's referral signed on 1/25/24. The findings above were reviewed with and acknowledged by the Administrator (Staff-A) and Clinical Manager (Staff-B) during an interview on 3/20/24 at 11:05 AM. Both agreed it was the agency's expectation that all clinicians performing a SOC assessment had thoroughly reviewed the physician referral when opening a case and failed to adhere to agency policy below. Agency Policy: "Comprehensive Client Assessment" pg. 1 (undated) stated, "A thorough, well-organized comprehensive and accurate assessment, consistent with the client's immediate needs... To increase clarity in measurement."

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 incorporated a review of all medications the patient is currently prescribed, and to determine interactions, adverse effects, or duplicate drug therapy in 2 (P-1, P-7) of 7 records reviewed, and failed to review for any potential medication changes in 1 (P-7) of 1 home visit observations, out of a total sample of 7 records reviewed, resulting in the potential for harmful medication effects for the patients. Findings include: P-1: The Start of Care (SOC) was dated 12/15/2023. The Plan of Care for the certification period 12/15/2023 to 2/12/2024 identified diagnoses of Arthritis of right hip, unilateral primary osteoarthritis of right hip, muscle weakness, difficulty walking, Chronic Obstructive Pulmonary Disease, Hypertension, and Type 2 Diabetes with neuropathy. Upon review of the record, it was noted the patient was currently prescribed the following medications: Polyethylene Glycol, Norco, Doxycycline, Magnesium Oxide, Methocarbamol, Humulin-R, Gabapentin, Albuterol Sulfate, Lidocaine External, Tylenol, Atorvastatin, Banophen, Fenofibrate, Farxiga, Isosorbide Mononitrate, hydrochlorothiazide, metoprolol Succinate, Trulicity, Levothyroxine, Folic Acid, Amlodipine, and oxygen. A drug review of the concurrent use of these medications results in the following major interactions: The concurrent use of methocarbamol and hydrocodone results in central nervous system depression; The concurrent use of Atorvastatin and Fenofibrate results in side effects of liver damage, and rhabdomyolysis (breakdown of skeletal muscle); and the concurrent use of Hydrocodone and Gabapentin can result in respiratory distress, kidney damage, and death. These findings were reviewed with and acknowledged by the Administrator (Staff A) and Clinical Manager (Staff B) on 3/20/2024 at 3:30 p.m. P-7: The start of care (SOC) date was 1/30/24 with diagnoses which included chronic pain, muscle weakness, hypertension, and diabetes-type 2. On 3/19/24, record review noted on the referral for home care under "Medications" that P-7 was on Humalog Tempo (diabetic insulin medication) sliding scale to be used timely when blood sugars are too high. However, when reviewing the SOC medication reconciliation list, there was no sliding scale insulin listed with blood sugar ranges to be used to administer the correct dosage. In addition, during a joint home visit with Physical Therapy (PT) on 3/19/24, P-7's medication bottles were compared the agency's current medication list which found the following discrepancies: Atorvastatin (for high cholesterol) bottle was 40 mg. daily vs. the listed 20 mg. daily; Potassium Chloride (for low potassium levels) was discontinued vs. the listed 10 mg. daily; Aspirin 81 mg. and Naproxen 250 mg. (pain reliever) were both discontinued vs. listed as being active. The findings above were reviewed with and acknowledged by the Administrator (Staff-A) and Clinical Manager (Staff-B) during an interview on 3/20/24 at 11:10 AM. Both agreed it was the agency's expectation that all clinicians performing a SOC assessment had thoroughly reviewed the physician referral when opening a case and failed to adhere to agency policy below. Agency Policy: "Medication Profile & Reconciliation" pg. 2 (undated) stated, "The case manager (visiting clinician) will assess for medication changes, updates, or discontinued medications at every visit." Agency Policy: "Physician/Medication Orders" pg. 1 (undated) stated, "Sliding scale orders for insulin type drugs must have type of mediation, how often, blood sugar ranges, route and what dosages based on blood sugar ranges." P-7: The start of care (SOC) date was 1/30/24 with diagnoses which included chronic pain, muscle weakness, hypertension, and diabetes-type 2. On 3/19/24, record review noted on the referral for home care under "Medications" that P-7 was on Humalog Tempo (diabetic insulin medication) sliding scale to be used timely when blood sugars are too high. However, when reviewing the SOC medication reconciliation list, there was no sliding scale insulin listed with blood sugar ranges to be used to administer the correct dosage. In addition, during a joint home visit with Physical Therapy (PT) on 3/19/24, P-7's medication bottles were compared the agency's current medication list which found the following discrepancies: Atorvastatin (for high cholesterol) bottle was 40 mg. daily vs. the listed 20 mg. daily; Potassium Chloride (for low potassium levels) was discontinued vs. the listed 10 mg. daily; Aspirin 81 mg. and Naproxen 250 mg. (pain reliever) were both discontinued vs. listed as being active. The findings above were reviewed with and acknowledged by the Administrator (Staff-A) and Clinical Manager (Staff-B) during an interview on 3/20/24 at 11:10 AM. Both agreed it was the agency's expectation that all clinicians performing a SOC assessment had thoroughly reviewed the physician referral when opening a case and failed to adhere to agency policy below. Agency Policy: "Medication Profile & Reconciliation" pg. 2 (undated) stated, "The case manager (visiting clinician) will assess for medication changes, updates, or discontinued medications at every visit." Agency Policy: "Physician/Medication Orders" pg. 1 (undated) stated, "Sliding scale orders for insulin type drugs must have type of mediation, how often, blood sugar ranges, route and what dosages based on blood sugar ranges." P-1: The Start of Care (SOC) was dated 12/15/2023. The Plan of Care for the certification period 12/15/2023 to 2/12/2024 identified diagnoses of Arthritis of right hip, unilateral primary osteoarthritis of right hip, muscle weakness, difficulty walking, Chronic Obstructive Pulmonary Disease, Hypertension, and Type 2 Diabetes with neuropathy. Upon review of the record, it was noted the patient was currently prescribed the following medications: Polyethylene Glycol, Norco, Doxycycline, Magnesium Oxide, Methocarbamol, Humulin-R, Gabapentin, Albuterol Sulfate, Lidocaine External, Tylenol, Atorvastatin, Banophen, Fenofibrate, Farxiga, Isosorbide Mononitrate, hydrochlorothiazide, metoprolol Succinate, Trulicity, Levothyroxine, Folic Acid, Amlodipine, and oxygen. A drug review of the concurrent use of these medications results in the following major interactions: The concurrent use of methocarbamol and hydrocodone results in central nervous system depression; The concurrent use of Atorvastatin and Fenofibrate results in side effects of liver damage, and rhabdomyolysis (breakdown of skeletal muscle); and the concurrent use of Hydrocodone and Gabapentin can result in respiratory distress, kidney damage, and death. These findings were reviewed with and acknowledged by the Administrator (Staff A) and Clinical Manager (Staff B) on 3/20/2024 at 3:30 p.m.

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 provide skilled nursing (SN) and physical therapy (PT) services as ordered in the plan of care for 1 (P-6) of 7 records reviewed, out of a total sample of 7 records reviewed. This practice results in the potential for unmet patient care needs for all 14 patients that received SN and PT services in the last year. Findings include: P-6: This patient was admitted on 11/14/2023, with diagnoses which included hemiplegia (paralysis of one side of the body) following stroke affecting left side, hypertension, acute pain due to trauma, and history of falls. On 3/19/24, review of the Plan of Care (POC) dated 11/14/23, ordered SN services to begin the week of 11/12/23 at a frequency of 1W4 (one visit weekly times four weeks) and PT services the starting the week of 11/12/23 at a frequency of 1W1 and 2W4. Further review noted after the initial first week, 4 of 4 scheduled visits (1 by SN and 3 by PT) were missed. Even though the physician had been seen notification of the missed visits, no documentation of further attempts to provide visits as ordered were evidenced in the clinical record. In addition, the missed visit notes documented by SN and PT revealed the following concerns: SN (11/22/23): "Requested to be seen next week after the holiday." SN (11/29/23): "Transfer to hospital due to increased weakness." PT (11/21/23): "The patient's son stated, "My mom does not feel like doing therapy today." PT (11/24/23): "The patient's son stated, "My mom said she is not feeling well and does not want therapy today." PT (11/27/23): "The patient/caregiver did not answer to phone call. The therapist writer will follow-up on Friday this week to confirm appointment." On 11/30/23, SN documented in the Discharge Summary under "Condition at Discharge" that the patient "was unresponsive and was brought to the nearest hospital as per cg. (caregiver) MD notified." These findings were reviewed with and acknowledged by the Administrator (Staff-A) and Clinical Manager (Staff-B) during an interview on 3/20/24 at 10:45 AM. Both agreed more urgency was warranted to make up for the missed visits by either discipline despite documentation indicating the physician was informed of the above findings.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the goals on the Plan of Care (POC) were objectively measurable to determine the patient's progress towards meeting pre-established goals in 5 (P-1, P-2, P-3, P-4, P-6) of 7 records; and failed to include reportable parameters concerning abnormal blood sugar readings in 2 (P-1, P-7) of 3 records with diabetes, out of a total sample of 7 records reviewed. Findings included: P-1: The Start of Care (SOC) was dated 12/15/2023. The Plan of Care (POC) for the certification period 12/15/2023 to 2/12/2024 identified diagnoses of Arthritis of right hip, Unilateral Primary Osteoarthritis of right hip, Muscle Weakness, Difficulty Walking, Chronic Obstructive Pulmonary Disease (COPD), Hypertension (HTN), and Type 2 Diabetes (DM2) with neuropathy. Upon review of the POC, it was noted the goals were not objectively measurable to determine the patient's progress towards achieving the goals. Examples include: "Patient will verbalize and understanding of energy conserving measures by 12/29/2023; The Patient/Caregiver will verbalize an understanding of skin conditions that must be reported to SN or physician immediately; The Patient/Caregiver will verbalize understanding of symptoms of cardiac complications and when to call 911." There were no goals to address the patient's diagnosis of Type 2 Diabetes. These goals are not objectively measurable to determine the patient's progress towards achieving the goals. In addition, the Plan of Care included reportable parameters to address the patient's diagnosis of Type 2 diabetes, however there were no orders for the frequency and duration of Diabetic Testing. P-2: The Start of Care (SOC) was dated 2/1/24. The Plan of Care (POC) for the Certification Period 2/1/2024 to 3/3/2024 identified diagnoses of Diabetes type 2 (DM2), Chronic Obstructive Pulmonary Disease (COPD), Morbid Obesity (BMI 500-599), Essential Hypertension (HTN), and Hyperlipidemia. Upon review of the POC, it was noted the goals on the POC were not objectively measurable to determine the patient's progress toward achieving the goals. Examples included: "Patient will verbalize understanding of proper use of pain medication by 02/09/24; The patient will be independent with safety education, fall precautions, body mechanics, and energy conservation to maintain physical conditions; The patient will demonstrate an effective and safe gait pattern." These goals are not objectively measurable to determine the patient's progress towards obtaining the goals. In addition, the POC failed to include interventions and goals to address the patient's diagnosis of Diabetes type 2. The POC did include reportable parameters, however there were no orders for frequency of diabetic testing. P-3: The Start of Care (SOC) was dated 11/11/2023. The Plan of Care (POC) for the certification period 11/11/2023 to 1/09/2024 identified diagnoses of Bilateral Osteoarthritis of Knee, Chronic Pain Syndrome, Fibromyalgia, Bilateral Temporomandibular Joint Disorder, Primary Hypertension (HTN), Hyperlipidemia, and Gastro-esophageal Reflux. Upon review of the POC, it was noted the goals were not objectively measurable to determine the patient's progress towards achieving goals. Examples included: "Patient will verbalize understanding of proper use of pain medication; The patient/caregiver will remove all clutter from patient's path, such as clothes, books, shoes, electrical cords, and other items, that may cause patient to trip." These goals are not objectively measurable to determine the patient's progress towards achieving the goals. P-4: The Start of Care was dated 9/7/22. The Plan of Care for the Certification Period 9/7/22 to 11/5/22 identified diagnoses of Encounter for surgical aftercare, Spinal Stenosis of Lumbar Region, Sciatica of Right and Left side, Hypertension (HTN), Diabetes type 2 (DM2), Coronary Heart Disease (CAD), and muscle weakness. Upon review of the Plan of Care (POC), it was noted the goals on the Plan of Care were not objectively measurable to determine the patient's progress towards achieving the goals. Examples included: "Patient will verbalize understanding of proper use of pain medication; The patient will demonstrate an increase of independence in performing ADLs (Activities of Daily Living) and Functional Mobility safely and without pain; Patient will demonstrate an effective muscles strength to improve balance, ambulation and ADLs. These goals are not objectively measurable to determine the patient's progress towards achieving the goals. These findings were reviewed and acknowledged by the Administrator and Clinical Manager during an interview on 3/20/2024. P-6: This patient was admitted on 11/14/2023, with diagnoses which included hemiplegia (paralysis of one side of the body) following stroke affecting left side, hypertension, acute pain due to trauma, and history of falls. On 3/19/24, review of P-6's POC revealed 16 of 16 listed goals listed by skilled nursing (SN) were not measurable. For example, "The patient will be free from falls during the certification period; The patient will be free from injury during the certification period; Patient will remain free from increased confusion during the episode..." Subsequently, no determination of P-6's clinical progress or lack of was evidenced throughout the certification period. These findings were reviewed with and acknowledged by the Administrator (Staff-A) and Clinical Manager (Staff-B) during an interview on 3/20/24 at 10:45 AM. P-7: The start of care (SOC) date was 1/30/24 with diagnoses which included chronic pain, muscle weakness, hypertension, and diabetes-type 2. On 3/19/24, record review noted on the referral for home care under "Medications" that P-7 was on two different types of insulin to help control abnormal blood sugar readings. However, when reviewing the POC, no evidence was found of any safety parameters concerning abnormal blood sugar readings. Ordered safety parameters are essential to direct the clinicians or the patient if a significantly abnormal reading is obtained. The findings above were reviewed with and acknowledged by the Administrator (Staff-A) and Clinical Manager (Staff-B) during an interview on 3/20/24 at 11:10 AM. Both agreed the POC's failed to meet agency expectations and its policy referenced below. Agency Policy: "Care Plans" pg. 1 (undated) stated, "Each client will have a care plan on file that outline care and services necessary to meet the patient specific needs... and the agency's plan to respond to those needs. This plan is developed with the client and family, as indicated, and is based on services needed to achieve specific measurable goals."

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, the agency failed to provide services as ordered in the Plan of Care in 2 (P-2, P-6) of 7 records reviewed out of a total sample of 7 records, resulting in the patient not receiving interventions needed to evaluate the patient's current healthcare status. Findings included: Based on record review, observation and interview it was determined that the agency failed to ensure the professional staff provided ongoing objective measurements of the patient's Diabetes including monitoring daily blood sugar results in 1 of 2 records (MR# 2) in which the patient had diabetes, out of a total of 7 records reviewed, which resulted in the potential for unidentified patient needs. Findings include: P-2: The Start of Care (SOC) was dated 2/1/24. The Plan of Care (POC) for the Certification Period 2/1/2024 to 3/3/2024 identified diagnoses of Diabetes type 2 (DM2), Chronic Obstructive Pulmonary Disease (COPD), Morbid Obesity (BMI 500-599), Essential Hypertension (HTN), and Hyperlipidemia. The Plan of Care included an order for reportable parameters for the patient's diabetes as follows: "Notify the physician of: Fasting blood sugar greater than 250 or Less than 70; Random blood sugar greater than 350 or less than 70." A review of the 5 physical therapy visit notes failed to include any documentation of the patient's blood sugar results. These findings were reviewed and acknowledged by the Administrator and Clinical Manager during an interview on 3/20/2024 at 3:30 p.m. P-6: This patient was admitted on 11/14/2023, with diagnoses which included hemiplegia (paralysis of one side of the body) following stroke affecting left side, hypertension, acute pain due to trauma, and history of falls. On 3/19/24, review of the referral for home (11/1/23) noted the following documentation by the physician: "The patient needs Occupational Therapy (OT) to: Strengthen Fine Motor Skills." However, additional review of P-6's Plan of Care (POC) found no evidence of providing the needed services. Documentation of patient refusal or orders explaining why OT services were no longer warranted were not found in the medical record. These findings were reviewed with and acknowledged by the Administrator (Staff-A) and Clinical Manager (Staff-B) during an interview on 3/20/24 at 10:45 AM. Both agreed OT services should have been provided or have documentation explaining why they were not provided. The agency failed to ensure services were provided in the POC to meet the specified needs of the patient.

Contents of clinical record CFR(s): 484.110(a) Standard: Contents of clinical record. The record must include: This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to define abbreviations documented in the clinical record in 1 (P-1) of 7 records reviewed and failed to maintain required elements of the clinical record in 1 (P-7) of 7 records out of a total sample of 7 records reviewed, resulting in documentation that is missing and may be misunderstood in the patient's health care record. Findings included: P-1: The Start of Care (SOC) was dated 12/15/2023. The Plan of Care (POC) for the certification period 12/15/2023 to 2/12/2024 identified diagnoses of Arthritis of right hip, Unilateral Primary Osteoarthritis of right hip, Muscle Weakness, Difficulty Walking, Chronic Obstructive Pulmonary Disease (COPD), Hypertension (HTN), and Type 2 Diabetes (DM2) with neuropathy. Upon review of the record, it was noted the Plan of Care included the following order: "SN to assist patient to obtain "ERS" button." There was no definition regarding the meaning of "ERS" found in the record. These findings were reviewed and acknowledged by the Administrator and Clinical Manager during an interview on 3/20/24 at 3:30 p.m. P-7: The start of care (SOC) date was 1/30/24 with diagnoses which included chronic pain, muscle weakness, hypertension, and diabetes-type 2. On 3/19/24, record review of the Physical Therapist (PT) notes for services provided on 3/4/24 under "Status-Completed" revealed the entire visit note was blank or void of any information even though it was signed off by the PT on 3/4/24. The ordered visit frequency was 1W4 (once weekly times four weeks). No information concerning P-7's therapy was noted from 2/27/24 through 3/11/24 (13 days) in the medical record. This finding was reviewed with and acknowledged by the Administrator (Staff-A) and Clinical Manager (Staff-B) during an interview on 3/20/24 at 11:15 AM. Both had no knowledge how a signed off completed record could be entirely blank. The agency failed to ensure it adhered to its policy referenced below. Agency Policy: "Clinical Record & Contents" pg. 1 (undated) stated, "Every record should contain accurate, comprehensive and up to date information. Every medical record documentation will provide care/treatments, etc. given."

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 after the patient was discharged from the agency in 3 (P-1, P-3, P-4) of 6 records reviewed in which the patient was discharged, and failed to produce evidence of a discharge summary in the patient's medical record in 1 (P-5) of 6 discharged records out of a total sample of 7 records reviewed, resulting in the physician not having knowledge of the patient's course of care during services provided by the home care agency or the patient's health status at the time of discharge. Findings included: P-1: The Start of Care (SOC) was dated 12/15/2023. The Plan of Care (POC) for the certification period 12/15/2023 to 2/12/2024 identified diagnoses of Arthritis of right hip, Unilateral Primary Osteoarthritis of right hip, Muscle Weakness, Difficulty Walking, Chronic Obstructive Pulmonary Disease (COPD), Hypertension (HTN), and Type 2 Diabetes (DM2) with neuropathy. Upon review of the record, it was noted that this patient was discharged from the agency on 1/4/2024, however, it was noted the agency documented that the Physican had been notified of the discharge, yet there was no indication or documentation that the discharge summary had been sent to the physician as required resulting in the physician not having knowledge of the services provided by the agency during the course of care or the patient's health status at the time of discharge. P-3: The Start of Care (SOC) was dated 11/11/2023. The Plan of Care (POC) for the certification period 11/11/2023 to 1/09/2024 identified diagnoses of Bilateral Osteoarthritis of Knee, Chronic Pain Syndrome, Fibromyalgia, Bilateral Temporomandibular Joint Disorder, Primary Hypertension (HTN), Hyperlipidemia, and Gastro-esophageal Reflux. Upon review of the record, it was noted that this patient was discharged from the agency on 12/24/2023, however, it was noted the agency documented that the Physican had been notified of the discharge, yet there was no indication or documentation that the discharge summary had been sent to the physician as required resulting in the physician not having knowledge of the services provided by the agency during the course of care or the patient's health status at the time of discharge. P-4: The Start of Care (SOC) was dated 9/7/2022. The Plan of Care for the Certification Period 9/7/2022 to 11/5/2022 identified diagnoses of Surgical Aftercare, Lumbar Spinal Stenosis, Intervertebral Disc Degeneration, Hypertension, Diabetes Type 2, Coronary Artery Disease (CAD), Presence of Coronary Angioplasty Implant and Graft. Upon review of the record, it was noted that this patient was discharged from the agency on 11/03/2022, however, it was noted the agency notified the physician of the discharge, yet there was no indication or documentation that the discharge summary had been sent to the physician as required resulting in the physician not having knowledge of the services provided by the agency during the course of care or the patient's health status at the time of discharge. These findings were reviewed and acknowledged during an interview with the Administrator and Clinical Director on 3/20/2024 at 3:30 p.m. P-5: The SOC was dated 12/22/23 with diagnoses which included osteo-arthritis, low back pain, and hypertension. On 3/19/24, record review noted the patient was discharged on 2/9/24. Further review failed to note any documentation of a discharge summary in the clinical record. Instead, an OASIS (Outcome and Assessment Information Set) Discharge was completed by Physical Therapy (lone discipline assigned). No summary of the patient's progression throughout the episode was evidenced. Instead, documentation was entered into the Discharge OASIS which was unrealistic. For example, the Plan of Care had goals of the patient's ambulation increasing from 20 feet to 250 feet by end of episode. Record review showed the patient's ambulation on 12/22/23 as being 20 feet, and slowly progressing to 90 feet on 1/16/24. On 1/19/24 and 1/23/24, the patient ambulated 100 feet for both visits. The following visit on 1/31/24, ambulation was 110 feet. No visits were made until discharge on 2/9/24. Review of PT's discharge documentation noted the patient did not remain stable of ambulating around 100 to 110 feet, but instead suddenly increased to 250 feet without any therapy since 1/31/24. No evidence was found in the medical record that this information was made available for physician review. These findings were reviewed with and acknowledged by the Administrator (Staff-A) and Clinical Manager (Staff-B) during an interview on 3/20/24 at 10:50 AM. Both offered no answer when queried how the patient would progress 140 feet in 9 days with no therapy vs. 90 feet in 40 days with therapy and why this was not included in the OASIS discharge. The agency failed to follow its discharge policy noted below. Agency Policy: "Discharge Policy & Summary" pg.1 (undated) stated, "In all cases, a discharge OASIS and Summary will be completed by all disciplines... To record a summary of care received by the client from the start of care through discharge."