Every finding on record at Heartland Home Care, LLC

A Medicare Re-certification survey was conducted on 03/09/2021 through 03/17/2021 by the Michigan Department of Licensing and Regulatory Affairs at: Promedica Home Health Care 100 Powell Dr., Suite #1 and #3 Dundee, MI 48131 The requirements for participation in Medicare at 42 CFR 484.102 Emergency Preparedness were not reviewed.

A Medicare Re-certification survey was conducted on 03/09/2021 through 03/17/2021 by the Michigan Department of Licensing and Regulatory Affairs at: Promedica Home Health Care 100 Powell Dr., Suite #1 and #3 Dundee, MI 48131 At the time of the survey, the agency did not operate any branch offices or subunits. The services the agency provides are: Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), Speech Therapy (ST), Medical Social Work (MSW), and Home Health Aide (HHa). Clinical records reviewed for this survey included: 7 records with home visits; 5 records without home visits; and 5 discharged records, for a total of 17 records reviewed.

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to advise their patients of the names, addresses and telephone numbers of the federally and state funded entities that serve the area in which each patient resides, resulting in the potential for unmet patient care needs for all patients currently serviced by the agency, with a potential to negatively affect all 411 active patients. Findings included: During the review of the agency's patient admission packet on 03/09/2021 it was noted the information for the Federally and State funded patient resource entities (Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center and Quality Improvement Organization) had not been included for the two counties the agency serves. During an interview on 03/09/2021 at 2 PM Administrator #1 (Adm. #1) was queried regarding the counties the agency serves, Adm. #1 replied, "Monroe and Lenawee counties." During the review of the patient admission packet, it was noted the "Admission Supplement" booklet documented the phone numbers for the following community resource agencies: Social Service agency, Medicare, Area Office on Aging, Survey office, Abuse Hotline, Accreditation Commission for Health Care, and the State Complaint hotline," there were no addresses documented for these agencies. The booklet failed to include the names, addresses and phone numbers for the following federally and state funded entities for Monroe and Lenawee counties: Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center and the Quality Improvement Organization. During the Exit Conference on 03/17/2021 at 4 PM and after a review of both, the Patient Information Handbook and the Admission Supplement booklet Administrator #1 acknowledged both booklets failed to include the names, addresses, and telephone numbers of the federally and state community entities for both Monroe and Lenawee counties.

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 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 7 of 17 records reviewed (MR# 4, 10, 11, 13, 15, 16, and 17), in incomplete clinical information to aid in determining the current and future care needs of the patient, with a potential to negatively affect all patient. Findings included: M.R. #10: The Plan of Care (POC) dated 3/3/2021 documented the patient's diagnoses as, "Aftercare following Joint Replacement Surgery, Difficulty in Walking, Essential Hypertension and Multiple Myeloma." The SN (skilled nurse) documented on the Start of Care assessment dated 3/3/2021, "Edema-Lower left____, non-pitting." There was no documented location of the specific area of the edema (e.g., knee, calf, ankle, foot, etc.) and no documented measurements. There were no documented measurements to indicate the baseline data to monitor the progression of the edema for improvement or deterioration. M.R. #11: The Plan of Care (POC) dated 2/23/2021 documented the patient's diagnoses as, "Cerebral Infarction, Hemiplegia following Cerebral Infarction-Affecting left nondominant side, Essential Hypertension, and Hypertensive Chronic Kidney Disease-Stage 1." The SN (skilled nurse) documented on the Start of Care assessment dated 2/25/2021, "Edema, lower right__, lower left__ 2+, 2+." There was no documented location of the specific area of the edema (e.g., knee, calf, ankle, foot, etc.) and no documented measurements. There were no documented measurements to indicate the baseline data to monitor the progression of the edema for improvement or deteriation. The patient's weight was documented as 261 pounds, no documentation if the weight was a stated or an actual weight to monitor possible fluid retention and kidney fuction. M.R. #13: The Plan of Care (POC) dated 3/11/2020 documented the patient's diagnoses as, "Cellulitis Left Lower Limb, Lymphedema, Hypertensive Heart Disease, Heart Failure and Congestive Heart Failure." The SN (skilled nurse) documented on the Start of Care assessment dated 3/11/2020, "Edema, lower right___, lower left___, 2+, 2+." There was no documented location of the specific area of the edema (e.g., knee, calf, ankle, foot, etc.) and no documented measurements or weights. There were no documented measurements or weights to indicate the baseline data to monitor the progression of the edema for improvement or deterioration. M.R. #15: The Plan of Care (POC) dated 2/21/2020 documented the patient's diagnoses as, "Hemiplegia following CVA (Cerebrovascular Accident-Stroke), Dysphagia, Essential Hypertension, Epilepsy, Pressure Ulcer of Left Heel and Type 2 Diabetes Mellitus." The SN (skilled nurse) failed to complete a patient specific Start of Care assessment, dated 2/21/2020. The SN documented, "Significant Past History-Seizures: there was no documentation of the patient's last seizure, is the seizure controlled with medication or the frequency of the seizure. The SN documented Cardiovascular Assessment: Edema 2+ lower right and left, there was no location for the area of the edema (e.g., knee, calf, ankle, foot etc.), there were no measurements or weights to document the baseline data to monitor the progression of the edema for improvement or deterioration. The Endocrine Assessment: No blood sugars were documented, frequency of monitoring, history of diabetes, no documentation if the diabetes was controlled or the patient's knowledge of the diabetes. After a brief review of the above assessments Administrator #1 stated, "The nurse should have been more specific with her documentation." M.R. #16: The Plan of Care (POC) dated 1/27/2021 documented the patient's diagnoses as, "Type 2 Diabetes Mellitus with Foot Ulcer-Left Foot, Chronic Ulcer of left foot with fat layer exposed and Chronic Pain Syndrome." The SN (skilled nurse) documented on the Start of Care Assessment: Endocrine Assessment-There was no documentation of the patient's history of the foot ulcer, how it occurred, the past treatments and the effectiveness, and the duration of the ulcer. M.R. #17: The Plan of Care (POC) dated 1/29/2021 documented the patient's diagnoses as, "Acute Systolic (Congestive) Heart Failure, Atrial Fibrillation and Acute Kidney Failure." The SN (skilled nurse) documented on the Start of Care assessment dated 1/29/2021: " Edema 1+, 2+, right and left," there were no measurements or weights to document the baseline data to monitor the progression of the edema for improvement or deterioration. During an interview on 3/12/2021 at 2 PM it was queried to explain the expectations for monitoring the patient's edema Administrator #1 replied, "Yes, I agree, the location of the edema should be included in the assessments, and measurements should be taken and documented at start of care and at least once a week." M.R. #4: The Plan of Care, dated for the period of 12-26-20 to 2-23-21, the patient was admitted for nursing services with diagnoses that included abscess of left foot, chronic obstructive pulmonary disease and heart failure. The SN (skilled nurse) documented on the Start of Care assessment dated 12-26-20, "Edema (Lower left): 3+, Edema (Lower right: 3+." There was no documented location of the specific area of the edema (e.g., knee, calf, ankle, foot, etc.) and no documented measurements. There were no documented measurements to indicate the baseline data to objectively monitor the progression of the edema for improvement or deterioration.

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 services as ordered in the plan of care for 1 of 17 (MR#15) records reviewed, resulting in the potential for poor patient outcomes, decline in physical functioning, and unmet personal care needs, and a negative outcome for all patients receiving therapy services and social services. Findings include: M.R. #15: This patient was admitted to the agency on 2/21/2020 with the diagnoses of, "Hemiplegia following Cerebrovascular Accident (CVA-Stroke), Dysphagia, Essential Hypertension, Type 2 Diabetes Mellitus and Pressure Ulcer of Left Heel." The patient was hospitalized from 3/11/2020 to 3/13/2020 with a diagnosis of "Chronic Obstructive Pulmonary Disease with (acute) exacerbation." The "Resumption of Care (ROC) orders, signed by the physician and dated 3/14/2020 ordered the following services: "SN (skilled nurse) effective 3/8/2020, PT (physical therapy) effective 3/15/2020, OT (occupational therapy) effective 3/15/2020, ST (speech therapy) effective 3/15/2020 and HHA (home health aide) effective 3/15/2020. At the time of the 3/16/2021 record review it was noted the SN Resumption of Care Assessment was dated 3/14/2020, there was no documented evidence an evaluation had been completed by the PT, OT, ST or the MSW during the week of 3/15/2020 (3/15/2020 to 3/21/2020), as ordered by the physician, to re-evaluate the patient's needs after hospitalization. There was no documented evidence to explain the reason why the above evaluations had not been completed as ordered. During an interview on 3/16/2021 at 11 AM it was queried to explain why the above evaluations had not been completed as ordered Administrator #1 replied, "I don't know, I will have to check." At the time of the Exit Conference on 3/17/2021 no other documentation had been submitted for review.

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, it was determined the agency failed to ensure the plan of care included complete and pertinent orders and measurable goals in 10 of 17 records reviewed out of a total of 17 records reviewed (MR #1, 3, 4, 5, 6, 7, 9, 10, 11, and 12), resulting in incomplete care for the patient and potential for unidentified goals. Findings include: Findings include: MR #1: The plan of care, dated for the period of 2-19-21 to 4-19-21, stated the patient was admitted for nursing, physical therapy and occupational therapy services with diagnoses that included, fracture around hip replacement prosthesis, hypertension (high blood pressure), polyneuropathy (nerve pain), asthma (difficulty breathing), and obesity. The plan of care included goals such as: "Patient/Caregiver will verbalize understanding of the ability to properly manage co-morbid conditions."; "Patient will report pain at their acceptable level by end of episode."; and "Wound status will improve as evidenced by healing by end of episode." The goals on the plan of care were not objectively measurable. MR #3: The plan of care, dated for the period of 2-28-21 to 4-28-21, stated the patient was admitted for nursing and physical therapy services with diagnoses that included, aftercare following joint replacement (knee), abnormal gait, weakness and hypertension. The plan of care included goals such as: "Patient/Caregiver will verbalize understanding of the ability to properly manage co-morbid conditions."; "Patient will report pain at their acceptable level by end of episode."; and "Additional orders will be received from alternate physician in a timely manner." The goals on the plan of care were not objectively measurable. The plan of care included an order for "Skilled Nurse to notify physician of reported pain exceeding parameters." There were no reportable parameters identified on the plan of care for the nurse to use in carrying out the above order. MR #4: The plan of care, dated for the period of 12-26-20 to 2-23-21, stated the patient was admitted for nursing services with diagnoses that included abscess of left foot (wound), chronic obstructive pulmonary disease (difficulty breathing), gangrene (infection causing death of skin and underlying tissues), heart failure (weak heart), encounter for dressing change and dependence on supplemental oxygen. The plan of care included goals such as: "Patient/Caregiver will verbalize understanding of the ability to properly manage co-morbid conditions."; "Patient will report pain at their acceptable level AEB (as evidenced by) reporting by end of episode."; "Wound status will improve as evidenced by end of episode."; "Patient will remain safe within home environment."; and "Patient/Caregiver will verbalize/Demonstrate the ability to manage self care for altered cardiovascular status by the end of the episode." The goals on the plan of care were not objectively measurable. MR #5: The plan of care, dated for the period of 2-7-21 to 4-7-21, stated the patient was admitted for nursing, physical therapy, occupational therapy, speech therapy, social work and aide services with diagnoses that included cystitis with hematuria (urinary bladder infection/inflammation with blood in the urine), cerebral infarct (stroke), hemilplegia (paralysis in half of the body), hypertension, pressure ulcers of the right and left heels. The plan of care included goals such as: "Patient/Caregiver will verbalize / demonstrate understanding of depression self management , medication compliance and measures to manage depression by end of episode."; and "Patient will report pain at their acceptable level by end of episode."; "The goals on the plan of care were not objectively measurable. The plan of care also included the goal of " Patient/Caregiver will verbalize/demonstrate disease self management for diabetes by end of episode. The plan of care did not include any diagnoses that suggested the patient had diabetes. MR #6: The plan of care, dated for the period of 12-18-20 to 2-15-21, stated the patient was admitted for nursing, physical therapy, occupational therapy, social work and aide services with diagnoses that included vertebral fracture (broken back), osteoporosis (soft bones), polyosteoarthritis (arthritis), hypertension, major depression, age-related debility and weakness. The plan of care included goals such as: "Patient/Caregiver will verbalize understanding of the ability to properly manage co-morbid conditions."; "Wound will improve by end of episode."; and "Patient/Caregiver will demonstrate/verbalize self management for falls prevention and safety hazards. Patient will remain safe within home environment." The goals on the plan of care were not objectively measurable. MR #7: The plan of care, dated for the period of 12-29-20 to 2-26-21, stated the patient was admitted for nursing, physical therapy, and occupational therapy services with diagnoses that included COVID-19, heart attack, kidney failure, urinary catheter, heart failure, and diabetes. The plan of care included goals such as: "Patient/Caregiver will verbalize understanding of the ability to properly manage co-morbid conditions."; "Abnormal O2 (oxygen) saturation levels will be promptly reported to physician."; and "Patient will receive assessment and support to ensure goals of care are met." The goals on the plan of care were not objectively measurable. M.R. #9: The Plan of Care (POC), for the recertification period 01/12/2021-3/12/2021 documented the patient's diagnoses as, "Cellulitis of Left Lower Limb, Contusion of Left Lower Leg, COVID-19 and Difficulty in Walking." The goals on the POC included examples as; "Patient/Caregiver will verbalize/demonstrate self management of Hypertension by the end of episode...Patient will demonstrate improved wound status and self management by end of episode...Patient will exhibit minimal distress due to infection...Patient will report pain at their acceptable level by end of episode." The goals on the plan of care were not objectively measurable. M.R. #10: The Plan of Care (POC) dated 3/3/2021 documented the patient's diagnoses as, "Aftercare following Joint Replacement Surgery, Difficulty in Walking, Essential Hypertension and Multiple Myeloma." The goals on the POC included examples as; "Patient will report pain at their acceptable level by end of episode...Patient/Caregiver will verbalize/demonstrate self management of wound care wound status will improve as evidenced by end of episode...Patient/Caregiver will demonstrate/verbalize self management for falls prevention and safety hazards, patient will remain safe within home environment...Patient/Caregiver will verbalize/demonstrate the ability to manage self care for altered Cardiovascular status by the end of the episode...Patient will exhibit minimal distress due to infection." The goals on the plan of care were not objectively measurable. Also, the Hospital Discharge Orders dated 3/3/2021 documented, "Total Hip Arthroplasty-Exercise left hip, weight bearing as tolerated, no left hip adduction, flexion greater than 90 degrees, Internal rotation 6 post-operative weeks. Elevate surgical leg above heart while sitting. Wear TED hose: on in the morning, and off at night. Not to bend your hip post 90 degrees or more than an "L" position. No kneeling, no pillow under the knee. Continuous ice bag to operative site. Apply ice to affected area anytime you have swelling or pain, after or doing exercises. May shower after initial dressing is removed. Let the water run over the incisions. Do not soak or immerse the wounds, using separate wash cloth to wash incision. Pat dry. No lotion to incision until healed. Keep initial dressing on for 5 days, Hibiclens incision daily. Removal aqua cel post-op day 5, Leave open. ABD, gauze dressing PRN (as needed)." There was no mention of the above post-op the left hip safety precautions/instructions on the plan of care to guide the care of the disciplines. M.R. #11: The Plan of Care (POC) dated 2/23/2021 documented the patient's diagnoses as, "Cerebral Infarction, Hemiplegia following Cerebral Infarction-Affecting left nondominant side, Essential Hypertension, and Hypertensive Chronic Kidney Disease-Stage 1." The goals on the POC included examples as; "Patient/Caregiver will verbalize understanding of the ability to properly manage co-morbid conditions...Patient/Caregiver will verbalize/demonstrate the ability to manage self care for altered Cardiovascular status by the end of the episode...Patient/Caregiver will demonstrate/verbalize self management for falls prevention and safety hazards...Patient/Caregiver will verbalize/understanding of CVA Disease process by end of episode....Patient/Caregiver will verbalize/demonstrate disease self management for Diabetes by end of episode...Patient/Caregiver will report pain at their acceptable level by end of episode." The goals on the plan of care were not objectively measurable. M.R. #12: The Plan of Care (POC) dated 2/25/2021 documented the patient's diagnoses as, "Acute Cystitis without hematuria, Atrial Fibrillation, Chronic Obstructive Pulmonary Disease and Weakness." The goals on the POC included examples as; "Patient/Caregiver will verbalize understanding of the ability to properly manage co-morbid conditions...Patient/Caregiver will verbalize/demonstrate the ability to manage self care for altered Cardiovascular status by the end of the episode...Patient/Caregiver will verbalize/demonstrate the ability to manage self care for altered Integumentary status and measures to promote skin integrity and prevent injury...Patient will report pain at their acceptable level AEB (as evidence by) end of episode." The goals on the plan of care were not objectively measurable. The above information was reviewed and acknowledged by Administrator #1 during the record review period on 3/17/2021 at 3:30 PM.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure that all drugs, care and services were provided only in accordance with Physician's orders for 2 (MR #1 and #6) of 17 records, from a total of 17 records reviewed, resulting in the potential for the provision of unsafe, unauthorized care and unmet care needs. Findings include: MR #1: The plan of care, dated for the period of 2-19-21 to 4-19-21, stated the patient was admitted for nursing, physical therapy and occupational therapy with diagnoses that included bone fracture around the hip replacement prosthesis, hypertension (high blood pressure), nerve pain, asthma and obesity. On the nursing visit note, dated 2-26-21, the nurse documented the patient's blood was drawn for a CRP (c-reactive protein). There was no evidence in the record of a physician's order for the nurse to draw the patient's blood. During an interview on 3-17-21 at 3:00 PM, Adm #1 and DCS #1 agreed with the above findings. MR #6: The plan of care, dated for the period of 12-18-20 to 2-15-21, stated the patient was admitted for nursing, aide, physical therapy, occupational therapy and social work services with diagnoses that included fractured vertebra (broken back), polyosteoarthritis (arthritis), hypertension, and major depression. On the nursing visit note, dated 12-21-20, the nurse documented, "Patient reluctant to take pain medication due to causing drowsiness, SN (skilled nurse) suggested taking half Norco (pain medication) and a Tylenol instead 3 x (times) daily. Has small blister that opened from reaction to adhesive, SN instructed may have son or daughter apply neosporin/cortisone for pain and itching." There was no evidence of a physician's order for the patient to take half of a dose of Norco with Tylenol 3 times per day and no order for the use neosporin/cortisone creams/ointments on the new open area in the skin. On the nursing visit note, dated 12-31-20, the nurse documented, "Right posterior back blister turned into rash. States itches. PCP (primary care physician) seen on Tuesday, recommended vitamin AD ointment. No cortisone or triple antibiotic ointment." There was no evidence of a physician's order for the patient to use A&D ointment on the new rash. During an interview on 3-17-21 at 8:50 AM, ADM #1 and DCS #1 both confirmed the above findings.

Development and evaluation of plan of care CFR(s): 484.75(b)(2) Development and evaluation of the plan of care in partnership with the patient, representative (if any), and caregiver(s); This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the physical therapist and the medical social worker developed plans of care for 1 of 17 (MR# ) records reviewed in which more than one discipline was ordered to provide care, resulting in a potential decline in physical functioning and a delay in accessing community resources for this patient, with a potential to negatively affect all 411 patients. Findings include: M.R. #15: This patient was admitted to the agency on 2/21/2020 with the diagnoses of, "Hemiplegia following Cerebrovascular Accident (CVA-Stroke), Dysphagia, Essential Hypertension, Type 2 Diabetes Mellitus and Pressure Ulcer of Left Heel." The patient was hospitalized from 3/11/2020 to 3/13/2020 with a diagnosis of "Chronic Obstructive Pulmonary Disease with (acute) exacerbation." The "Resumption of Care (ROC) orders, signed by the physician and dated 3/14/2020 ordered the following services: "SN (skilled nurse) effective 3/8/2020, PT (physical therapy) effective 3/15/2020, OT (occupational therapy) effective 3/15/2020, ST (speech therapy) effective 3/15/2020 and HHA (home health aide) effective 3/15/2020. At the time of the 3/16/2021 record review it was noted the SN Resumption of Care Assessment was dated 3/14/2020, there was no documented evidence an evaluation had been completed by the PT, OT, ST or the MSW during the week of 3/15/2020 (3/15/2020 to 3/21/2020), as ordered by the physician, to re-evaluate the patient's needs after hospitalization. There was no documented evidence to explain the reason why the above evaluations had not been completed as ordered. During an interview on 3/16/2021 at 11 AM it was queried to explain why the above evaluations had not been completed as ordered Administrator #1 replied, "I don't know, I will have to check." At the time of the Exit Conference on 3/17/2021 no other documentation had been submitted for review.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health aide failed to provide services as ordered on the plan of care, for 3 of 6 records reviewed with home health aide services (M.R. #12, 14 and 15), for a potential of unmet care needs, for a potential to negatively affect all patients receiving home health aide services. Findings include: M.R. #12: The Plan of Care (POC) dated 2/25/2021 documented the patient's diagnoses as, "Acute Cystitis without hematuria, Atrial Fibrillation, Chronic Obstructive Pulmonary Disease and Weakness." The POC ordered, "HHA (home health aide) effective 2/28/2021 1WK4 (once a week for four weeks)." During the 3/12/2021 record review it was noted there were no documented HHA visits for week two (2/28/2021 go 3/6/2021. The first aide visit was documented on 3/10/2021. There was a communication note in the EMR (electronic medical record) signed by LPN #1 (licensed practical nurse) and dated 3/3/2021 that documented, "HHA missed visit on 3/3/21 reason: shower done by OT (occupational therapy)-case manager notified." There was no documented evidence the HHA completed or attempted a visit during this week (3/4/21 to 3/6/21), or that the patient refused a visit by the aide during this week. During an interview on 3/12/2021 at 1:30 PM it was queried what were the agency's expectation for the aide to complete a visit this week Administrator #1 agreed the aide should have completed a visit from 3/4/21 to 3/6/21 of this week. M.R #14: The Plan of Care (POC) dated 6/9/2020 documented the patient's diagnoses as, "Spondylopathy (disorders of the vertebrae), Apaxia (a neurological disorder characterized by the inability to perform learned movements on command), COPD (Chronic Obsructive Pulmonary Disease) and Localized Edema." The POC ordered, "HHA (home health aide) effective 1WK1 (once a week for one week), and 2W3 (twice a week for three weeks)." During the 3/16/2021 record review it was noted there was no documented HHA visit for week one (6/9/2020 to 6/13/2020). The PT (physical therapy) documented on the Start of Care assessment dated 6/9/2020, "There is no willing or able caregiver to provide for hygiene needs." There was no documented evidence the home health aide provided services the first week of the certification period from 6/9/2020 to 6/13/2020. There was no documented evidence the patient refused aide services the first week of service. M.R. #15: The Plan of Care (POC) dated 2/21/2020 documented the patient's diagnoses as, "Hemiplegia following CVA (Cerebravascular Accident-Stroke), Dysphagia, Essential Hypertension, Epilepsy, Pressure Ulcer of Left Heel and Type 2 Diabetes Mellitus." The patient was hospitalized 3/11/2020 to 3/13/2020 with Acute COPD (Chronic Obstructive Pulmonary Disease). The Resumption of Care orders dated 3/13/2020 ordered HHA (home health aide) effective 3/15/2020: 2WK2 (twice a week for two weeks), and 1WK1 (once a week for one week). During the 3/16/2021 record review it was noted the home health aide documented one visit on 3/17/2020 (for week one 3/15-20 to 3/21/20), there should be two visits this week. There was no documented evidence the patient refused a second home health aide visit this week.