Every finding on record at Great Lakes Home Health Care Agency, Inc

From 2/12/24 through 2/15/24, the Michigan Department of Licensing and Regulatory Affairs conducted a recertification survey at The Care Team. 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 was conducted by the Michigan Department of Licensing and Regulatory Affairs from 2/12/24 through 2/15/24 at: The Care Team 3226 Fashion Square Blvd Saginaw, MI 48603 This agency has no branches. Clinical records reviewed for this survey included 7 records with home visits, 5 active records without home visits, and 5 discharged records. 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.

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure patients were informed of the Administrator's name and contact information to receive complaints for 6 of 7 (P-4, 5, 7, 11, 16, 17) joint surveyor home visits, resulting in the potential for patient complaints or concerns to go unaddressed which could negatively affect the quality of care for the agency's 370 current patients. Findings include: P-11: A joint surveyor home visit with the physical therapist was conducted on 2/14/24 at 3:00 p.m. During the visit the agency's start of care folder was reviewed. It was observed that on the inside page of the front cover of the booklet there was a dedicated space to write the Administrator's name and contact information. This area was blank of information regarding the Administrator's name and contact information. The findings were reviewed with Staff-1 (Administrator) during an interview on 2/15/24 at 12:30 p.m. Staff-1 stated that the agency had conducted a mock survey two weeks ago and are in the process of fixing this matter. P-16: A joint surveyor home visit with the physical therapy assistant was conducted on 2/14/24 at 12 noon. During the visit the agency's start of care folder was reviewed. It was observed that on the inside page of the front cover of the booklet there was a dedicated space to write the Administrator's name and contact information. This area was blank of information regarding the Administrator's name and contact information. P-17: A joint surveyor home visit with the physical therapist was conducted on 2/13/24 at 2:30 p.m. During the visit the agency's start of care folder was reviewed. It was observed that on the inside page of the front cover of the booklet there was a dedicated space to write the Administrator's name and contact information. This area was blank of information regarding the Administrator's name and contact information. P-4: The Start of Care (SOC) was dated 1/26/24. The Plan of Care (POC) identified diagnoses of Right Knee Effusion, Osteoarthritis of Right Knee and Left Hip, and History of Falls. A joint surveyor home visit with the Occupation Therapist was conducted on 2/13/24 at 10:00 am. During review of the start of care folder provided by the agency, it was noted that the designated section on the inside cover to write the Administrators name and contact information in case of the need to lodge a complaint, was left blank. P-5: The Start of Care (SOC) was dated 1/20/24. The Plan of Care (POC) identified diagnoses of Chronic Obstructive Pulmonary Disease, Bronchitis and Pneumonia. A joint surveyor home visit with the Registered Nurse was conducted on 2/14/24 at 9:30 am. During review of the start of care folder provided by the agency, it was noted that the designated section on the inside cover to write the Administrators name and contact information in case of the need to lodge a complaint, was left blank. P-7: The Start of Care (SOC) was dated 1/12/24. The Plan of Care (POC) identified diagnoses of Fracture of 5Th Cervical Vertebrae, COVID-19 and Hyponatremia. A joint surveyor home visit with the Registered Nurse was conducted on 2/15/24 at 9:00 am. During review of the start of care folder provided by the agency, it was noted that the designated section on the inside cover to write the Administrators name and contact information in case of the need to lodge a complaint, was left blank. These findings were reviewed with and acknowledged by the Staff-A (Administrator) and Staff-B (Clinical Manager) during an interview on 2/15/24 at 1:15 pm. P-4: The Start of Care (SOC) was dated 1/26/24. The Plan of Care (POC) identified diagnoses of Right Knee Effusion, Osteoarthritis of Right Knee and Left Hip, and History of Falls. A joint surveyor home visit with the Occupation Therapist was conducted on 2/13/24 at 10:00 am. During review of the start of care folder provided by the agency, it was noted that the designated section on the inside cover to write the Administrators name and contact information in case of the need to lodge a complaint, was left blank. P-5: The Start of Care (SOC) was dated 1/20/24. The Plan of Care (POC) identified diagnoses of Chronic Obstructive Pulmonary Disease, Bronchitis and Pneumonia. A joint surveyor home visit with the Registered Nurse was conducted on 2/14/24 at 9:30 am. During review of the start of care folder provided by the agency, it was noted that the designated section on the inside cover to write the Administrators name and contact information in case of the need to lodge a complaint, was left blank. P-7: The Start of Care (SOC) was dated 1/12/24. The Plan of Care (POC) identified diagnoses of Fracture of 5Th Cervical Vertebrae, COVID-19 and Hyponatremia. A joint surveyor home visit with the Registered Nurse was conducted on 2/15/24 at 9:00 am. During review of the start of care folder provided by the agency, it was noted that the designated section on the inside cover to write the Administrators name and contact information in case of the need to lodge a complaint, was left blank. These findings were reviewed with and acknowledged by the Staff-A (Administrator) and Staff-B (Clinical Manager) during an interview on 2/15/24 at 1:15 pm. P-11: A joint surveyor home visit with the physical therapist was conducted on 2/14/24 at 3:00 p.m. During the visit the agency's start of care folder was reviewed. It was observed that on the inside page of the front cover of the booklet there was a dedicated space to write the Administrator's name and contact information. This area was blank of information regarding the Administrator's name and contact information. The findings were reviewed with Staff-1 (Administrator) during an interview on 2/15/24 at 12:30 p.m. Staff-1 stated that the agency had conducted a mock survey two weeks ago and are in the process of fixing this matter. P-16: A joint surveyor home visit with the physical therapy assistant was conducted on 2/14/24 at 12 noon. During the visit the agency's start of care folder was reviewed. It was observed that on the inside page of the front cover of the booklet there was a dedicated space to write the Administrator's name and contact information. This area was blank of information regarding the Administrator's name and contact information. P-17: A joint surveyor home visit with the physical therapist was conducted on 2/13/24 at 2:30 p.m. During the visit the agency's start of care folder was reviewed. It was observed that on the inside page of the front cover of the booklet there was a dedicated space to write the Administrator's name and contact information. This area was blank of information regarding the Administrator's name and contact information.

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 record review and interview, the agency failed to ensure that 2 (P-1 and 3) 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: P-1: The Start of Care (SOC) was dated 11/7/23. The Plan of Care (POC) identified diagnoses of Right Hip Fracture, Diabetes Type 2, Falls and Congestive Heart Failure. During record review on 2/12/24, it was noted that the referral stated, “Discharge with the Agency on 11/2/23 with PT (Physical Therapy)/OT (Occupational Therapy), Nursing, CNA (Certified Nursing Assistant/Home Health Aide) and SW (Medical Social Worker).” The consent signed by the patient on 11/7/23 was blank under MSW and documented “N/A” under Home Health Aide. The comprehensive assessment completed by Registered Nurse on 11/7/23 stated, “SN (Skilled Nurse) 1w6 (1 time a week for 6 weeks), PT/OT eval and treat.” There was no documentation of the patient refusing Home Health Aide or Medical Social Worker. P-3: The Start of Care (SOC) was dated 8/22/23. The Plan of Care (POC) identified diagnoses of Congestive Heart Failure, Atrial Fibrillation, and Atherosclerosis Heart Disease. During record review on 2/12/24, it was noted that the referral stated, “Resident to discharge home with Nurse, Wound Care, Aide (Home Health Aide), PT (Physical Therapy), OT (Occupational Therapy), and Social Worker.” The comprehensive assessment completed by Registered Nurse on 8/22/23 stated, “SN (Skilled Nurse) 1w4, PT/OT eval, HHA 1w1, 2w3, 1w3.” There was no documentation of the patient refusing Medical Social Worker. These findings were reviewed with and acknowledged by the Staff-A (Administrator) and Staff-B (Clinical Manager) during an interview on 2/15/24 at 1:00 pm.

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 written patient care instructions that included safety parameters and skin care instructions for 2 of 8 (P-12, 15) records reviewed in which aide services were provided, resulting in a lack of direction regarding the needs of these patients. Findings include: P-12: This patient was admitted to home care on 4/3/23 with diagnoses of stage 2 sacral pressure ulcer, type 2 diabetes with polyneuropathy, and urinary tract infection. The 4/3/23 plan of care ordered skilled nursing, physical therapy, and occupational therapy services. Aide services were added the week of 4/16/23. During record review on 2/14/24, it was noted that the aide care plan failed to include the following safety precautions that were on the plan of care: diabetic precautions, fall precautions, pressure ulcer prevention, and wound precautions. The plan of care instructed the skilled nurse to perform/teach pressure ulcer care to stage 2 sacral pressure ulcer: cleanse with wound cleanser, pat dry with gauze, apply nickel thick layer of Santyl ointment to wound bed using cotton tipped applicator, cover with Optifoam dressing using clean/aseptic technique, change dressing every other day and as needed if soiled or dislodged by skilled nursing or trained caregiver. The aide care plan instructed the aide to provide a bath/shower each weekly visit. The skilled nurse failed to include instructions for the aide regarding the care of the sacral ulcer during the bath/shower. The findings were reviewed with and acknowledged by Staff-1 (Administrator) during an interview on 2/15/24 at 12:30 p.m. P-15: This patient was admitted to home care on 12/4/23 with diagnoses of poly osteoarthritis and hypertensive heart disease with heart failure. The 12/4/23 plan of care ordered skilled nursing, physical therapy, occupational therapy, and aide services. During record review on 2/13/24, it was noted that the 12/5/23 aide care plan failed to include the following safety precautions that were on the plan of care: bleeding precautions, diabetic precautions, fall precautions, pressure ulcer prevention, infection precautions, and wound precautions.

A Medicare authorized Re-Certification survey was conducted by the Michigan Department of Licensing and Regulatory Affairs from 2/9/21 through 2/12/21 at: The Care Team 3232 Fashion Square Blvd. Saginaw, MI 48603 This agency has no extension sites. Services provided: Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), Speech Therapy (ST), Medical Social Work (MSW), Home Health Aide (HHa). Records Reviewed: 7 records with home visits; 10 records without home visits, for a total of 17 records reviewed. From 2/10/20 through 2/13/20, a recertification survey was conducted by the Michigan Department of Licensing and Regulatory Affairs at: This was a standard survey. The requirements for participation in Medicare at 42 CFR 484.102 Emergency Preparedness were not reviewed.

The following standard level deficiencies were identified at a Medicare authorized Re-Certification survey, conducted by the Michigan Department of Licensing and Regulatory Affairs on 2/9/21 through 2/12/21 at: The Care Team 3232 Fashion Square Blvd. Saginaw, MI 48603 Services provided: Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), Speech Therapy (ST), Medical Social Work (MSW), Home Health Aide (HHa). The agency does not maintain any branch locations. Records Reviewed: 7 records with home visits; 10 records without home visits, for a total of 17 records reviewed.

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 observation, 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, measurable data to use as a baseline for future assessments, and history of events leading to current home care needs for 17 of 17 sampled records reviewed (MR#s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17), resulting in incomplete clinical information to aid in determining the current and future care needs of the patient. Findings included: **Agency Policy PC2.7: "Comprehensive Assessment, revised 10/2018. The policy states, "The Comprehensive Assessment will include information to establish and monitor a plan of care; the patient's current health status which includes all active health and medical problems; Relevant past medical history. MR #11: The Start of Care (SOC) was dated 9/26/20. The Plan of Care (POC) for the certification period 9/26/20 to 11/24/20 identified diagnoses of Zoster without complications, Dysphagia, Hypertension (HTN), and malaise. The patient was receiving Skilled Nursing (SN), Home Health aide (HHa), Physical Therapy (PT), Occupational Therapy (OT), Speech Therapy (ST), and Medical Social Services (MSW). Upon review of the SOC Comprehensive Assessment on 2/11/2021, it was noted the SN used check marks to indicate the patient had a history of Hypertension, headaches, dizziness/vertigo, constipation, urinary incontinence, vision problems and glaucoma. However, there was no information regarding the current and past disease processes that included dates of onset, current status of the diseases, exacerbations or current treatments/conditions that warranted admission to the agency. MR#12: The SOC was dated 8/12/2020. The POC for the certification period of 8/12/2020 to 10/10/2020 identified diagnoses of Malignant neoplasm of left bronchus of lung and bone, dysphagia, emphysema, Coronary Artery Disease (CAD), and hypertension (HTN). The patient was receiving SN, HHa, PT, OT, ST, and MSW services. The patient also suffers from failure to thrive (FTT). Upon review of the SOC Comprehensive Assessment on 2/11/2021, it was noted the SN used check marks to indicate the patient had a past history of Metastatic Lung Cancer; Divicula of the Esophagus; and GERD. However, there was no information regarding the current and past disease processes that included dates of onset, current status of the diseases, exacerbations or current treatments/conditions that warranted admission to the agency. MR#13: The SOC was dated 3/9/2020. The POC for the certification period 3/9/2020 to 5/7/2020 identified diagnoses of Encounter for orthopedic aftercare, Spondylosis, acute posthemorrhagic anemia, heart failure, Diabetes type 2 (DM2), chronic obstructive pulmonary disease (COPD), and atrial fibrillation (A-fib). The patient was receiving SN, PT, OT, and MSW services. Upon review of the SOC Comprehensive Assessment on 2/11/2021, it was noted the SN used check marks to indicate the patient had a past history of CHF, CAD, Cancer of the Prostate, Osteoarthritis, DM2, COPD, Asthma, Urinary Incontinence, Dorsalgia, chronic pain, vascular myelopathies, shortness of breath. However, there was no information regarding the above mentioned past and current disease processes that included dates of onset, current status of the diseases, exacerbations or current treatments/conditions that warranted admission to the agency. MR#14: The SOC was dated 11/13/2020. The POC for the certification period 11/13/20 to 1/11/2021 identified diagnoses of Alzheimers disease, dementia, schizophrenia, HTN, Coronary Artery Disease (CAD) and hearing loss. SN, PT,and MSW services. Upon review of the SOC Comprehensive Assessment on 2/12/2021, it was noted the SN used check marks to indicate the patient had a history of Myocardial Infarction (MI), CAD, HTN, Cerebral Vascular Accident (CVA), depression, dementia, Alzheimer's, mental disorder of schizophrenia, renal failure, thyroid problems, vision problems, hearing loss, dislipidemia, GERD, actinic keratois, and past surgical history of pacemaker. However, there was no information regarding the above mentioned past and current disease processes that included dates of onset, current status of the diseases, exacerbations or current treatments/conditions that warranted admission to the agency. MR#15: The SOC was dated 12/20/20. The POC identified diagnoses of cirrhosis of the liver, DM2, COPD, HTN, and Hypersplenism. The patient was receiving SN, PT, OT, MSW, and HHa Services. Upon review of the SOC Comprehensive Assessment on 2/12/2021, it was noted the SN used check marks to indicate the patient had a history of Anemia, diabetes, COPD, cirrhosis of liver, acute hypoxic respiratory distress secondary to hepatopulmonary syndrome, bilateral hydronephrosis r/t stones, Acute Kidney Injury (AKI). However, there was no information regarding the above mentioned past and current disease processes that included dates of onset, current status of the diseases, exacerbations or current treatments/conditions that warranted admission to the agency. MR#16: The SOC was dated 11/10/2020. The POC identified diagnoses of COVID-19, pneumonia, frontotemporal dementia, HTN, and dysphagia. The patient was receiving SN, PT, and OT services. Upon review of the SOC Comprehensive Assessment on 2/12/2021, it was noted the SN used check marks to indicate the patient had a history of hyperkalemia, hypercholesterolemia, dysphagia, hypernatremia, and dyspnea. However, there was no information regarding the above mentioned past and current disease processes that included dates of onset, current status of the diseases, exacerbations or current treatments/conditions that warranted admission to the agency. MR#17: The SOC was dated 1/7/2021. The POC identified diagnoses of disorganized schizophrenia, anxiety disorder, unspecified mental disorder, and HTN. The patient was receiving SN and MSW services. Upon review of the POC it was noted the goals were not objectively measurable. Upon review of the SOC Comprehensive Assessment on 2/12/2021, it was noted the SN used check marks to indicate the patient had a history of HTN, osteoarthritis, gait problems, fractures, falls, anxiety, mental disorders including schizophrenia with hallucinations and self-talk, COPD, Vitamin D deficiency and essential tremor. However, there was no information regarding the above mentioned past and current disease processes that included dates of onset, current status of the diseases, exacerbations or current treatments/conditions that warranted admission to the agency. These findings were reviewed and acknowledged during an interview on February 12, 2021 at 3:00 p.m. with the Clinical Manager (CM#1). MR #1: The Start of Care (SOC) was dated 10/16/20. The patient was receiving Skilled Nursing (SN), Physical Therapy (PT) and Occupational Therapy (OT). Upon review of the SOC Comprehensive Assessment on 2/9/2021, it was noted the SN used check marks to indicate the patient had a history of congestive heart failure (CHF), cancer, hypertension (HTN), anemia and atrial fibrillation. However, there was no information regarding the current disease processes that included dates of onset, current status of the diseases, exacerbations or current treatments/conditions that warranted admission to the agency. MR #2: The SOC was dated 6/11/20. The patient was receiving SN, Home Health aide (HHa), PT, OT, Speech Therapy (ST) and Medical Social Worker (MSW) services. Upon review of the SOC Comprehensive Assessment on 2/9/2021, it was noted the SN used check marks to indicate the patient had a history of heart failure, chronic kidney disease (CKD) and anemia. However, there was no information regarding the current disease processes that included dates of onset, current status of the diseases, exacerbations or current treatments/conditions that warranted admission to the agency. MR #3: The SOC was dated 1/15/21. The patient was receiving SN, PT, OT and MSW services. Upon review of the SOC Comprehensive Assessment on 2/11/2021, it was noted the SN used check marks to indicate the patient had a history of heart failure, CKD and type 2 diabetes. However, there was no information regarding the current disease processes that included dates of onset, current status of the diseases, exacerbations or current treatments/conditions that warranted admission to the agency. MR #4: The SOC was dated 1/28/21. The patient was receiving SN, HHa, PT and OT services. Upon review of the SOC Comprehensive Assessment on 2/11/2021, it was noted the SN used check marks to indicate the patient had a history of heart failure, CKD and major depressive disorder. However, there was no information regarding the current disease processes that included dates of onset, current status of the diseases, exacerbations or current treatments/conditions that warranted admission to the agency. MR #5: The SOC was dated 1/23/21. The patient was receiving SN services. Upon review of the SOC Comprehensive Assessment on 2/11/2021, it was noted the SN used check marks to indicate the patient had a history of atrial fibrillation, wound and type 2 diabetes. However, there was no information regarding the current disease processes that included dates of onset, current status of the diseases, exacerbations or current treatments/conditions that warranted admission to the agency. MR #6: The SOC was dated 1/18/21. The patient was receiving SN services. Upon review of the SOC Comprehensive Assessment on 2/11/2021, it was noted the SN used check marks to indicate the patient had a history of Parkinson's disease, urinary tract infection, osteoarthritis and atrial fibrillation. However, there was no information regarding the current disease processes that included dates of onset, current status of the diseases, exacerbations or current treatments/conditions that warranted admission to the agency. MR #7: The SOC was dated 10/30/20. The patient was receiving SN, PT, OT and ST services. Upon review of the SOC Comprehensive Assessment on 2/11/2021, it was noted the SN used check marks to indicate the patient had a history of atrial fibrillation, pneumonia and CKD. However, there was no information regarding the current disease processes that included dates of onset, current status of the diseases, exacerbations or current treatments/conditions that warranted admission to the agency. MR #8: The SOC was dated 1/29/21. The patient was receiving SN, PT and OT services. Upon review of the SOC Comprehensive Assessment on 2/11/2021, it was noted the SN used check marks to indicate the patient had a history of atrial fibrillation, demyelinating polyneuritis and CKD. However, there was no information regarding the current disease processes that included dates of onset, current status of the diseases, exacerbations or current treatments/conditions that warranted admission to the agency. MR #9: The SOC was dated 1/12/21. The patient was receiving SN, PT and OT services. Upon review of the SOC Comprehensive Assessment on 2/11/2021, it was noted the SN used check marks to indicate the patient had a history of atrial fibrillation, demyelinating polyneuritis and CKD. However, there was no information regarding the current disease processes that included dates of onset, current status of the diseases, exacerbations or current treatments/conditions that warranted admission to the agency. MR #10: The SOC was dated 1/16/21. The POC for the certification period 1/16/21-3/16/21 identified diagnoses of lymphedema, atrial fibrillation and dementia. The patient was receiving SN, HHa, PT, OT and MSW services. Upon review of the SOC Comprehensive Assessment on 2/11/2021, it was noted the SN used check marks to indicate the patient had a history of lymphedema, atrial fibrillation and dementia. However, there was no information regarding the current disease processes that included dates of onset, current status of the diseases, exacerbations or current treatments/conditions that warranted admission to the agency. These findings were reviewed and acknowledged during an interview on February 12, 2021 at 3:00 p.m with the Clinical Manager (CM#1).

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by:

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the plan of care covered all pertinent interventions with reportable safety parameters, and objectively measurable goals specific to the needs of the patient for 15 records (MR#s 1, 2, 3, 4, 5, 7, 8, 10, 11, 12, 13, 14, 15, 16, and 17) from a total sample of 17 records reviewed, resulting in patients not receiving care specific to their individual needs and the potential for poor patient outcomes. Findings included: **Agency Policy #PC2.21: "Physician Plan of Care," revised 3/2/21. The policy states, "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 agency anticipates will occur as a result of implementing and coordinating the plan of care. Services must be furnished in accordance with accepted standards of practice and includeSafety measures to protect against injury." MR #11: The Start of Care (SOC) was dated 9/26/20. The Plan of Care (POC) for the certification period 9/26/20 to 11/24/20 identified diagnoses of Zoster without complications, Dysphagia, Hypertension (HTN), and malaise. The patient was receiving Skilled Nursing (SN), Home Health aide (HHa), Physical Therapy (PT), Occupational Therapy (OT), Speech Therapy (ST), and Medical Social Services (MSW). Upon review of the POC it was noted the goals were not objectively measurable. Examples included: "Patient/Caregiver will verbalize understanding of individualized emergency plan by 9/26/20; Patient skin integrity will remain intact during this episode; Patient and/or caregiver will verbalize an understanding of COVID-19, necessary precautions and when to get immediate medical attention." In addition, the POC failed to include swallowing or aspiration precautions as a safety measure related to the patient's diagnosis of dysphagia. MR#12: The SOC was dated 8/12/2020. The POC for the certification period of 8/12/2020 to 10/10/2020 identified diagnoses of Malignant neoplasm of left bronchus of lung and bone, dysphagia, emphysema, Coronary Artery Disease (CAD), and hypertention (HTN). The patient was receiving SN, HHa, PT, OT, ST, and MSW services. The patient also suffers from failure to thrive (FTT). Upon review of the POC, it was noted the goals were not objectively measurable. Examples included: "Patient will demonstrate proper pursed lip breathing techniques by 9/11/2020; Patient will demonstrate proper pursed lip breathing techniques by 9/11/2020; Home Exercise Program will be established by the Physical Therapist/Occupational Therapist; Patient/Caregiver will remove all clutter from patient's path, such as clothes, books, shoes, electrical cord, and other items that may cause patient to trip by 9/11/2020." In addition, the POC failed to include swallowing or aspiration precautions as a safety measure related to the patient's diagnosis of dysphagia. MR#13: The SOC was dated 3/9/2020. The POC for the certification period 3/9/2020 to 5/7/2020 identified diagnoses of Encounter for orthopedic aftercare, Spondylosis, acute posthemorrhagic anemia, heart failure, Diabetes type 2 (DM2), chronic obstructive pulmonary disease (COPD), and atrial fibrillation (A-fib). The patient was receiving SN, PT, OT, and MSW services. Upon review of the plan of care, it was noted the goals were not objectively measurable. Examples included: "Patient will verbalize understanding of proper use of pain medication by 4/4/20; Patient will maintain heart healthy, low carbohydrate diet compliance during the episode; Home exercise program will be established by physical therapist; 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 by 4/18/20." In addition, the POC failed to include sharps or diabetic precautions as a safety measure to address the patients diagnosis of diabetes type 2. Also, the POC failed to include reportable weight parameters to report to the physician to address the patient's current diagnosis of Congestive Heart Failure. MR#14: The SOC was dated 11/13/2020. The POC for the certification period 11/13/20 to 1/11/2021 identified diagnoses of Alzheimer's disease, dementia, schizophrenia, HTN, Coronary Artery Disease (CAD) and hearing loss. SN, PT,and MSW services. Upon review of the POC, it was noted that the goals on the POC were not objectively measurable. Examples included: ""The patient/Caregiver will verbalize understanding of the individualized Emergency Plan by 11/13/20; The patient will verbalize understanding of proper use of pain medication by 1/9/21; Home Exercise Program will be established by the Physical Therapist." MR#15: The SOC was dated 12/20/2020. The POC for the certification period 12/20/2020 to 2/17/2020 identified diagnoses of Cirrhosis of the liver, DM2, COPD, Portal HTN, and hypersplenism. The patient was receiving SN, PT, OT, HHa, and MSW services. Upon review of the POC, it was noted that the goals on the POC were not objectively measurable. Examples included: "Patient will verbalize understanding of signs and symptoms of COVID-19, necessary precautions and when to get immediate attention; Patient demonstrates stable physiological diabetic status within the patient normal limits, patient verbalized understanding of diabetes and self-care management; Patient will not have signs or symptoms of cirrhosis, ascites, liver failure." In addition, the POC failed to include reportable parameters to address the patient's diagnosis of "reportable paramaters. The POC included the following order: "Patient demonstrates stable physiological diabetic status within the patient's normal limits." There was no numerical description for Blood Sugar results that were "normal" for this patient. MR#16: The SOC was dated 11/10/2020. The POC identified diagnoses of COVID-19, pneumonia, frontotemporal dementia, HTN, and dysphagia. The patient was receiving SN, PT, and OT services. Upon review of the POC it was noted that the goals on the POC were not objectively measurable. Examples included: "Patient demonstrates stable physiological pulmonary status within the patient's normal limits; COVID to resolve; Patient and Caregiver verbalizes understanding of pneumonia and self-care management." In addition, the POC failed to include swallowing or aspiration precautions as a safety measure related to the patient's diagnosis of dysphagia. MR#17: The SOC was dated 1/7/2021. The POC identified diagnoses of disorganized schizophrenia, anxiety disorder, unspecified mental disorder, and HTN. Upon review of the POC it was noted the goals were not objectively measurable. Examples included: "Patient achieves optimal level of function within the community related to their psycho-emotional stability; SN will administer the injection as prescribed; Patient demonstrates stable physiological integumentary status within the patient's normal limits. The above goals for MR#11 through MR#17 were vague and not objectively measurable to determine the patient's progress towards goals. Patient's diagnosed with dysphagia did not include swallowing/aspiration precautions. as a safety measure; and patients diagnosed with diabetes did not include diabetic or sharps precautions as a safety measure. These findings were reviewed and acknowledged during an interview on February 12, 2021 at 3:00 p.m. with the Clinical Manager (CM#1). MR #1: The Start of Care (SOC) was dated 10/16/20. The Plan of Care (POC) for the certification period 10/16/20-12/14/20 identified diagnoses of heart failure, chronic kidney disease (CKD) and hypertension (HTN). The patient was receiving Skilled Nursing (SN), Physical Therapy (PT) and Occupational Therapy (OT) services. Upon review of the POC it was noted the goals were not objectively measurable. Examples included: "Patient/Caregiver will verbalize understanding of individualized emergency plan by 10/30/20; Patient skin integrity will remain intact during this episode; Caregiver will verbalize undertanding of proper orientation techniques to use when patient becomes disoriented." MR #2: The SOC was dated 6/11/20. The POC for the certification period 6/11/20-8/9/20 identified diagnoses of heart failure, chronic kidney disease and anemia. The patient was receiving SN, Home Health aide (HHa), PT, OT, Speech Therapy (ST) and Medical Social Worker (MSW) services. Upon review of the POC it was noted the goals were not objectively measurable. Examples included: "Patient/Caregiver will verbalize understanding of individualized emergency plan by 10/30/20; Patient skin integrity will remain intact during this episode; Patient will verbalize and understanding of energy conserving measures by 6/28/20." MR #3: The SOC was dated 1/15/21. The POC for the certification period 1/15/21-3/15/21 identified diagnoses of heart failure, chronic kidney disease and type 2 diabetes. The patient was receiving SN, PT, OT and MSW services. Upon review of the POC it was noted the goals were not objectively measurable. Examples included: "Patient/Caregiver will verbalize understanding of individualized emergency plan by 10/30/20; Patient will verbalize understanding of signs and symptoms of COVID-19, necessary precautions and when to get immediate attention by 3/13/21." MR #4: The SOC was dated 1/28/21. The POC for the certification period 1/28/21-3/28/21 identified diagnoses of heart failure, chronic kidney disease and major depressive disorder. The patient was receiving SN, HHa, PT and OT services. Upon review of the POC it was noted the goals were not objectively measurable. Examples included: "Patient/Caregiver will verbalize heart healthy diet by end of episode; Patient will verbalize understanding of signs and symptoms of COVID-19, necessary precautions and when to get immediate attention by 3/26/21." MR #5: The SOC was dated 1/23/21. The POC for the certification period 1/23/21-3/23/21 identified diagnoses of atrial fibrillation, wound and type 2 diabetes. The patient was receiving SN services. Upon review of the POC it was noted the goals were not objectively measurable. Examples included: "Patient/Caregiver will verbalize heart healthy diet by end of episode; Patient will verbalize understanding of signs and symptoms of COVID-19, necessary precautions and when to get immediate attention by 3/26/21; Patient's skin integrity will remain intact during this episode." MR #7: The SOC was dated 10/30/20. The POC for the certification period 10/30/20-12/28/20 identified diagnoses of atrial fibrillation, pneumonia and CKD. The patient was receiving SN, PT, OT and ST services. Upon review of the POC it was noted the goals were not objectively measurable. Examples included: "Patient/Caregiver will verbalize an understanding of factors that contribute to shortness of breath by 11/28/20; Patient will verbalize understanding of signs and symptoms of COVID-19, necessary precautions and when to get immediate attention by 3/26/21; Patient's skin integrity will remain intact during this episode." MR #8: The SOC was dated 1/29/21. The POC for the certification period 1/29/21-3/29/21 identified diagnoses of atrial fibrillation, demyelinating polyneuritis and CKD. The patient was receiving SN, PT and OT services. Upon review of the POC it was noted the goals were not objectively measurable. Examples included: "Patient will verbalize understanding of signs and symptoms of COVID-19, necessary precautions and when to get immediate attention by 3/26/21; Patient to understand healthy heart and low cholesterol diet by 3/19/21." MR #10: The SOC was dated 1/16/21. The POC for the certification period 1/16/21-3/16/21 identified diagnoses of lymphedema, atrial fibrillation and dementia. The patient was receiving SN, HHa, PT, OT and MSW services. Upon review of the POC it was noted the goals were not objectively measurable. Examples included: "Patient will verbalize understanding of signs and symptoms of COVID-19, necessary precautions and when to get immediate attention by 3/26/21; Patient and caregiver demonstrates compliance with interventions to prevent pressure injury by 3/16/21." These findings were reviewed and acknowledged during an interview on February 12, 2021 at 1:20 p.m. with the Clinical Manager (CM#1)

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on record review and interview, it was determined that the agency failed to ensure the registered nurse performed complete assessments and re-assessments of the patient's health status and needs in 2 of 7 records reviewed in which nursing services were provided out of a total sample of 17 records reviewed (MR#s 12 and 13), which resulted in the potential for unidentified patient needs. Findings included: MR#12: The SOC was dated 8/12/2020. The POC for the certification period of 8/12/2020 to 10/10/2020 identified diagnoses of Malignant neoplasm of left bronchus of lung and bone, dysphagia, emphysema, Coronary Artery Disease (CAD), and hypertention (HTN). The patient was receiving SN, HHa, PT, OT, ST, and MSW services.The patient was receiving Skilled Nursing (SN) once a week for 5 weeks. Additionally, the patient was receiving Home Health aide (HHa), Physical Therapy (PT), Occupational Therapy (OT), Speech Therapy (ST), and Medical Social Services (MSW). Upon review of the SOC OASIS, it was noted the patient's documented weight was 73 pounds with a weight loss of 10 pounds or more in the past 12 months. It was noted during the record review that there was no documented weight for this patient in 2 (8/17/20 and 8/31/20) of 5 SN home visits. These findings were reviewed and acknowledged with Clinical Manager (CM#1) during an interview on 2/12/21 at 3:00 p.m. CM#1 stated, "the nurse should have obtained the patient's weight every visit. MR#13: The SOC was dated 3/9/2020. The POC for the certification period 3/9/2020 to 5/7/2020 identified diagnoses of Encounter for orthopedic aftercare, Spondylosis, acute posthemorrhagic anemia, heart failure, Diabetes type 2 (DM2), chronic obstructive pulmonary disease (COPD), and atrial fibrillation (A-fib). The patient was receiving SN, PT, OT, and MSW services. The POC included a reportable parameter for the patient's diabetes as follows: "Report Fasting Blood Sugars greater than 250 or less than 60; Report Random Blood Sugars greater than 300 and less than 60." Upon review of the 6 SN home visits, it was noted the SN failed to obtain blood sugar results in 1 of 6 home visits (3/23/21). This finding was reviewed and acknowledged with CM#1 on 2/12/21 at 3:00 pm. CM#1 stated, "the blood sugar should have been obtained every visit as ordered." In addition, for this patient diagnosed with Congestive Heart Failure, the SN was using subjective measurements rather than objective measurements to assess the patient's lower extremity edema status. The SN was using 2+, 3+, 4+ measurements rather than utilizing a tape measure to obtain objective measurements to determine the patient's CHF status. Also, the SN obtained an actual weight of 200 pounds on the initial visit, however, the SN failed to evaluate the patient's weight in all 5 of the SN follow-up visits to determine the status of the patient's CHF. These findings were reviewed and acknowledged by the Clinical Manager (CM#1) during an interview on 2/12/21 at 3:00 p.m. CM#1 stated, "the nurse is new to our agency, we will need to provide some teaching regarding our expectations for CHF patients." .

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, it was determined the agency failed to prepare clearly written patient care instructions and include safety precautions on the aide's care plan, in 4 of 6 records in which Home Health Aide (HHa) services were provided (MR#s 2, 4, 10 and 12) from a total of 17 records reviewed, resulting in the potential for the provision of unsafe care and unmet care needs. Findings included: ***Agency policy: Home Health Aide Service, No PC2.52, pg 3 of 6 and dated 4/2018: Appropriate and safe techniques in performing personal hygiene and grooming tasks that include: (A) Bed bath. (B) Sponge, tub, and shower bath. (C) Hair shampooing in sink, tub, and bed. (D) Nail and skin care. (E) Oral hygiene. (F) Toileting and elimination. MR #2: The Plan of Care (POC) dated, 4/27/18 documented the following diagnoses, "Atrial fibrillation, chronic kidney disease and Essential Hypertension." During review of the HHa POC dated 6/11/2020, the POC failed to include any safety precations, including bleeding precautions for a patient on Eliquis (anticoagulant) and the HHa was ordered to perform nail care. MR #4: The POC for the certification period 1/28/21-3/28/21 identified diagnoses of heart failure, chronic kidney disease and major depressive disorder. The patient was receiving SN, HHa, PT and OT services. Upon review of the HHa POC dated 1/28/21, there were no documented safety precautions found. MR #10: The POC for the certification period 1/16/21-3/16/21 identified diagnoses of lymphedema, atrial fibrillation and dementia. The patient was receiving SN, HHa, PT, OT and MSW services. Upon review of the HHa POC dated 1/16/21, there were no documented safety precations found. During an interview on 2/12/21 at 1:00 PM, after a review of the aide's care plan, the Clinical Manager (CM#1) stated, "I agree, the safety precautions should be on the aide's care plans." MR#12: The SOC was dated 8/12/2020. The POC for the certification period of 8/12/2020 to 10/10/2020 identified diagnoses of Malignant neoplasm of left bronchus of lung and bone, dysphagia, emphysema, Coronary Artery Disease (CAD), and hypertension (HTN). The patient was receiving SN, HHa, PT, OT, ST, and MSW services. The POC included the following safety measures: "Keep pathways clear, slow position changes, Support during transfer and Ambulation, anticoagulant precautions, Safety in ADL's, Fall Precautions, Use of Assistive devices, and infection control. The Home Health aide Care Plan dated 8/12/2020 ordered HHa frequency and duration of visits once a week for 3 weeks, however, RN#1 failed to include safety precautions on the Home Health aide care plan to ensure the patient's safety and avoidance of injury during care. These findings were reviewed and acknowledged during an interview with the Clinical Manager (CM#1) on 2/12/2021 at 3:00 p.m. CM#1 stated, the electronic medical record does not include the ability to transfer the safety precautions from the Plan of Care to the Home Health aide care plan. I will need to contact my electronic record provider."

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a discharge summary was sent to the physician within 5 business days of the patient's discharge for 5 of 17 (MR#s 1, 2, 11, 12, and 13) records reviewed in which the patient was discharged from the agency, resulting in the physician not having knowledge of the patient's health status at the time of discharge. Findings included: **Agency Policy: "Discharge Summaries", no date. The policy states, "Discharge and transfer summaries are equired to be sent to the primary care practitioner or other health care professional who will be responsible for providing care & services to the patient after discharge from home care...Sent within five (5) business days of the patient's discharge; therefore discharges must be submitted timely. Faxed to physician's office by office staff. MR#11: The Start of Care (SOC) was dated 9/26/20. The Plan of Care (POC) for the certification period 9/26/20 to 11/24/20 identified diagnoses of Zoster without complications, Dysphagia, Hypertension (HTN), and malaise. The patient was receiving Skilled Nursing (SN), Home Health aide (HHa), Physical Therapy (PT), Occupational Therapy (OT), Speech Therapy (ST), and Medical Social Services (MSW). The SN Discharge Summary was dated 10/27/2020; The OT Discharge summary was dated 10/22/2020; The ST Discharge Summary was dated 10/19/2020; The PT's last visit was dated 11/05/2020 and the PT's Discharge Summary and Discharge OASIS was dated 11/05/2020. There was no documented evidence the Discharge OASIS or summaries were sent to the physician within 5 business days of the patient's discharge from services. MR#12: The SOC was dated 8/12/2020. The POC for the certification period of 8/12/2020 to 10/10/2020 identified diagnoses of Malignant neoplasm of left bronchus of lung and bone, dysphagia, emphysema, Coronary Artery Disease (CAD), and hypertention (HTN). The patient was receiving SN, HHa, PT, OT, ST, and MSW services. The SN 's last visit was dated 9/09/2020. The Discharge Summary was dated 9/09/2020. There was no documented evidence the Discharge OASIS or summaries were sent to the physician within 5 business days of the patient's discharge. MR#13: The SOC was dated 3/9/2020. The POC for the certification period 3/9/2020 to 5/7/2020 identified diagnoses of Encounter for orthopedic aftercare, Spondylosis, acute posthemorrhagic anemia, heart failure, Diabetes type 2 (DM2), chronic obstructive pul,onary disease (COPD), and atrial fibrillation (A-fib). SN, PT, OT, and MSW services. Thje final visit by the PT was 4/1/20; The last visit for the OT was dated 3/9/20. The SN 's last visit was dated 4/20/2020. The Discharge Summary was dated 4/20//2020. There was no documented evidence the Discharge OASIS summary was sent to the physician within 5 business days of the patient's discharge. These findings were reviewed and acknowledged by the Clinical Manager (CM#1) during an interview on 2/12/21 at 3:00 p.m. The Clinical Manager stated, "we fax them to the physician, but do not have proof that they were faxed." MR #1: The Start of Care (SOC) was dated 10/16/20. The Plan of Care (POC) for the certification period 10/16/20-12/14/20 identified diagnoses of heart failure, chronic kidney disease (CKD) and hypertension (HTN). The patient was receiving Skilled Nursing (SN), Physical Therapy (PT) and Occupational Therapy (OT) services. Upon review of the record on 2/12/21, there was no documented evidence of a discharge summary or that a discharge summary had been sent to the doctor. During an interview on 2/12/21 at 1:20 p.m., the clinical manager (CM#1) was asked about the discharge summary and stated, "There is not a discharge summary for this patient, so one was not sent to the doctor." MR #2: The SOC was dated 6/11/20. The POC for the certification period 6/11/20-8/9/20 identified diagnoses of heart failure, chronic kidney disease and anemia. The patient was receiving SN, Home Health aide (HHa), PT, OT, Speech Therapy (ST) and Medical Social Worker (MSW) services. Upon review of the record on 2/12/21, there was no documented evidence of a discharge summary or that a discharge summary had been sent to the doctor. During an interview on 2/12/21 at 1:20 p.m., CM#1 was asked about the discharge summary and stated, "We do not do a discharge summary or send a discharge summary if a patient transfers and does not return." These findings were reviewed and acknowledged by CM#1 during an interview on 2/12/21 at 1:20 p.m.