Every finding on record at Helping Hand Home Healthcare, LLC

A recertification survey for Emergency Preparedness was conducted by the Michigan Department of Licensing and Regulatory Affairs, on 4/25/23 through 4/28/23 at: Hope at Home Health Care 24225 West 9 Mile Rd. Suite 120 Southfield, MI 48033 At the time of the survey, the agency did not operate any branch offices or subunits. At the survey's conclusion, the agency was found to be in substantial compliance (standard citation) with the requirements for participation in Medicare/Medicaid at 42 CFR §484.102, Emergency Preparedness.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on document review and interview, it was determined that the Agency ailed to provide documentation for the required annual tabletop and community based full-scale exercises nor any documentation of an actual event that would qualify as a test of the emergency plan, resulting in the potential to affect all patients and staff, in the event staff is not properly prepared for an emergency. Findings include: On 4/28/23 at 2:15 pm, the Administrator (Staff A) was queried about annual staff emergency preparedness drills and tabletop exercises and stated, "We have not done the annual drills.” The Agency failed to document the needed exercises designed for the preparation of emergency situations within the Agency and surrounding community.

A Medicare authorized Home Health recertification survey was conducted April 25th through April 28th, 2023, at: Hope at Home Health Care 24225 West 9 Mile Rd. Suite 120 Southfield, MI 48033 During the survey, 17 records were reviewed including 7 active records with home visits, 5 active records without home visits, and 5 discharged records. At the conclusion of the survey, the following Condition Level citation was cited: CFR 484.60 Care Planning, Coordination, Quality of Care.

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 (MR's# 11 and 15) of 17 patients were included in their overall planning of care including informing the patient/caregiver in advance of the days in which services would be provided and disciplines that will furnish care, resulting in a lack of inclusion in planning, lack of informed consent, the potential for missed visits and unmet care needs. Findings include: MR#11: The Start of Care (SOC) was dated 4/13/23. The Plan of Care (POC) identified diagnoses of Cervical Spinal Surgery, Diabetes Type 2 and Chronic Obstructive Pulmonary Disease. During record review on 4/27/23, it was noted that the referral ordered, “Physical Therapy and Occupational Therapy (OT).” The consent signed by the patient on 4/13/23 and the comprehensive assessment completed by the Physical Therapist on 4/13/23 were blank under the OT section and there was no documentation of the patient refusing OT. MR#15: The Start of Care (SOC) was dated 2/10/23. The Plan of Care (POC) identified diagnoses of Stage 4 Pressure Ulcer, Paraplegia and Osteomyelitis. During record review on 4/26/23, it was noted that the referral ordered, “SN (Skilled Nursing), OT (Occupational Therapy) and PT (Physical Therapy).” The consent signed by the patient on 2/10/23 and the comprehensive assessment completed by the SN on 2/10/23 were blank under the OT section and there was no documentation of the patient refusing OT. These findings were reviewed with and acknowledged by the Administrator (Staff A) during an interview on 4/28/23 at 2:35 pm.

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: Based on document review, record review and interview, the agency failed to inform the patient/caregiver before care was initiated of the extent to which payment for home health agency services may be expected from Medicare or other insurance sources and the extent to which payment may be required from the patient in 9 of 17 sampled records reviewed (MR#s 3, 7, 11, 12, 13, 14, 15, 16 and 17), resulting in the potential for undisclosed charges. Findings included: **Agency Policy: "Bill of Rights: Patient," (Undated) The policy states, "The Agency protects and promotes the rights of each individual. In advance of furnishing care to the patient or during the initial evaluation visit before the initiation of treatment, the patient is informed both verbally and in writing of all rights including: - Be advised of the extent to which payment for services may be expected from Medicare, Medicaid, or any other federally funded or federal aid program known to the organization; - Be advised of the charges for services that may not be covered by Medicare, Medicaid, or any other federally funded or federal aid program known to the organization; - Be advised of the charges the individual may have to pay before care in initiated;…” MR#11: The Start of Care (SOC) was dated 4/13/23. The Plan of Care (POC) identified diagnoses of Cervical Spinal Surgery, Diabetes Type 2 and Chronic Obstructive Pulmonary Disease. During record review on 4/27/23, it was noted that the Admission Consent failed to include the amount the patient would be responsible to pay for services from the agency. The area under "Assignment of Benefits" was blank in the area to document the possible Co-pay for which the patient may be responsible for. The home health agency failed to advise the patient, in writing, of the possible charges they may be responsible for paying before care was initiated. MR#12: The Start of Care (SOC) was dated 3/27/23. The Plan of Care (POC) identified diagnoses of Post Left Hip Replacement, Wound Infection, Diabetes Type 2 and Congestive Heart Failure. During record review on 4/27/23, it was noted that the Admission Consent failed to include the amount the patient would be responsible to pay for services from the agency. The area under "Assignment of Benefits" was blank in the area to document the possible Co-pay for which the patient may be responsible for. The home health agency failed to advise the patient, in writing, of the possible charges they may be responsible for paying before care was initiated. MR#13: The Start of Care (SOC) was dated 3/22/23. The Plan of Care (POC) identified diagnoses of Post Kidney Transplant, Diabetes Type 2 and Congestive Heart Failure. During record review on 4/26/23, it was noted that the Admission Consent failed to include the amount the patient would be responsible to pay for services from the agency. The area under "Assignment of Benefits" was blank in the area to document the possible Co-pay for which the patient may be responsible for. The home health agency failed to advise the patient, in writing, of the possible charges they may be responsible for paying before care was initiated. MR#14: The Start of Care (SOC) was dated 1/14/23. The Plan of Care (POC) identified diagnoses of Diabetes Type 2, Infection of Amputation Stump and Chronic Kidney Disease. During record review on 4/26/23, it was noted that the Admission Consent failed to include the amount the patient would be responsible to pay for services from the agency. The area under "Assignment of Benefits" was blank in the area to document the possible Co-pay for which the patient may be responsible for. The home health agency failed to advise the patient, in writing, of the possible charges they may be responsible for paying before care was initiated. MR#15: The Start of Care (SOC) was dated 2/10/23. The Plan of Care (POC) identified diagnoses of Stage 4 Pressure Ulcer, Paraplegia and Osteomyelitis. During record review on 4/26/23, it was noted that the Admission Consent failed to include the amount the patient would be responsible to pay for services from the agency. The area under "Assignment of Benefits" was blank in the area to document the possible Co-pay for which the patient may be responsible for. The home health agency failed to advise the patient, in writing, of the possible charges they may be responsible for paying before care was initiated. MR#16: The Start of Care (SOC) was dated 12/22/22. The Plan of Care (POC) identified diagnoses of Right Femur Fracture, Alzheimer’s and Congestive Heart Failure. During record review on 4/25/23, it was noted that the Admission Consent failed to include the amount the patient would be responsible to pay for services from the agency. The area under "Assignment of Benefits" was blank in the area to document the possible Co-pay for which the patient may be responsible for. The home health agency failed to advise the patient, in writing, of the possible charges they may be responsible for paying before care was initiated. MR#17: The Start of Care (SOC) was dated 12/16/22. The Plan of Care (POC) identified diagnoses of Transient Ischemic Attack, Dysphagia and Hypertension. During record review on 4/25/23, it was noted that the Admission Consent failed to include the amount the patient would be responsible to pay for services from the agency. The area under "Assignment of Benefits" was blank in the area to document the possible Co-pay for which the patient may be responsible for. The home health agency failed to advise the patient, in writing, of the possible charges they may be responsible for paying before care was initiated. These findings were reviewed with and acknowledged by the Administrator (Staff A) during an interview on 4/28/23 at 2:40 pm. **Agency Policy: "Admission Criteria-Patient, dated 2018. The policy states, "During the initial visit, the admitting professional will explain the patient's liability for payment of services. Give the patient in writing his/her expected payment responsibility." MR#3: The Start of Care (SOC) was dated 2/20/2023. The Plan of Care (POC) for the certification period 2/20/23 to 4/20/23 identified diagnoses of Hemiplegia following Cerebral Infarction (CVA) affecting right dominant side, Dysphasia following cerebral infarction, dysphagia following cerebral infarction, atrial fibrillation (A-fib), Hypertension (HTN), and Gastro-esophageal reflux. Upon review of the patient's Home Care Consent and Service Agreement, it was noted that the document failed to include the amount the patient would be responsible to pay for services from the agency. The area under "Assignment of Benefits" was completely blank in the area to document the possible Co-pay for which the patient may be responsible. The home health agency failed to advise the patient, in writing, of the charges they may be responsible to pay for Home Health Care services. MR#7: The SOC was dated 3/8/2023. The POC for the certification period 3/8/23 to 5/6/23 identified diagnoses of Open Wound of Left Breast, Malignant Neoplasm, Malignant neoplasm of left breast, Atrial Fibrillation (A-fib), Major Depressive disorder. Upon review of the patient's Home Care Consent and Service Agreement, it was noted the document was completely blank except for the date, Patient Name, Signatures of the Patient and Registered Nurse, and frequency and duration for Skilled Nursing, Physical Therapy, and Home Health aide services. The area under "Assignment of Benefits" was completely blank in the area to document the possible Co-pay for which the patient may be responsible to pay. The home health agency failed to advise the patient, in writing, of the charges they may be responsible to pay for Home Health Care services. These findings were reviewed and acknowledged by the Administrator (Staff A) during an interview on 4/28/23 at 4:00 p.m.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status based on past medical history that included dates of onset, exacerbations, treatments and outcomes, and baseline data for 13 of 17 records (MR#s 1, 3, 4, 5, 6,10, 11, 12, 13, 14, 15, 16 and 17) from a total of 17 records reviewed, resulting in incomplete clinical information to aide in determining the needs of the patient. Findings included: MR#11: The Start of Care (SOC) was dated 4/13/23. The Plan of Care (POC) identified diagnoses of Cervical Spinal Surgery, Diabetes Type 2 and Chronic Obstructive Pulmonary Disease. During record review on 4/27/23, it was noted that the SOC comprehensive assessment dated 4/13/23, documented under "Primary Diagnosis and Other Diagnoses", all 15 diagnoses were blank under onset/exacerbation and date of the onset/exacerbation. No exacerbation, prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. MR#12: The Start of Care (SOC) was dated 3/27/23. The Plan of Care (POC) identified diagnoses of Post Left Hip Replacement, Wound Infection, Diabetes Type 2 and Congestive Heart Failure. During record review on 4/27/23, it was noted that the SOC comprehensive assessment dated 3/27/23, documented under "Primary Diagnosis and Other Diagnoses", all 22 diagnoses had a date of 3/27/23. No onset, exacerbation, prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. MR#13: The Start of Care (SOC) was dated 3/22/23. The Plan of Care (POC) identified diagnoses of Post Kidney Transplant, Diabetes Type 2 and Congestive Heart Failure. During record review on 4/26/23, it was noted that the SOC comprehensive assessment dated 3/22/23, documented under "Primary Diagnosis and Other Diagnoses", all 25 diagnoses had a date of 3/22/23. No onset, exacerbation, prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. MR#14: The Start of Care (SOC) was dated 1/14/23. The Plan of Care (POC) identified diagnoses of Diabetes Type 2, Infection of Amputation Stump and Chronic Kidney Disease. During record review on 4/26/23, it was noted that the SOC comprehensive assessment dated 1/14/23, documented under "Primary Diagnosis and Other Diagnoses", all 19 diagnoses had a date of 1/14/23. No onset, exacerbation, prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. MR#15: The Start of Care (SOC) was dated 2/10/23. The Plan of Care (POC) identified diagnoses of Stage 4 Pressure Ulcer, Paraplegia and Osteomyelitis. During record review on 4/26/23, it was noted that the SOC comprehensive assessment dated 2/10/23, documented under "Primary Diagnosis and Other Diagnoses", all 22 diagnoses had a date of 2/10/23. No onset, exacerbation, prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. MR#16: The Start of Care (SOC) was dated 12/22/22. The Plan of Care (POC) identified diagnoses of Right Femur Fracture, Alzheimer’s and Congestive Heart Failure. During record review on 4/25/23, it was noted that the SOC comprehensive assessment dated 12/22/22, documented under "Primary Diagnosis and Other Diagnoses", all 16 diagnoses had a date of 12/22/22. No onset, exacerbation, prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. MR#17: The Start of Care (SOC) was dated 12/16/22. The Plan of Care (POC) identified diagnoses of Transient Ischemic Attack, Dysphagia and Hypertension. During record review on 4/25/23, it was noted that the SOC comprehensive assessment dated 12/16/22, documented under "Primary Diagnosis and Other Diagnoses", all 13 diagnoses had a date of 12/16/22. No onset, exacerbation, prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. These findings were reviewed with and acknowledged by the Administrator (Staff A) during an interview on 4/28/23 at 2:30 pm. MR#10: The SOC was dated 4/8/23. The Plan of Care identified diagnoses of hypertension (HTN), surgical aftercare, chronic kidney disease and congestive heart failure. A review of the Comprehensive Assessment on 4/27/23 noted under the vital signs category: "Stated weight of 132 pounds." The patient had a diagnosis of congestive heart failure and parameters for when to call the physician for changes in weight. A stated weight does not provide an objective baseline weight to compare future weights. During an interview on 4/28/23 at 3:25 p.m., the administrator (Staff-A) acknowledged the above findings. **Agency Policy: "Assessments: Initial Assessment", dated 2018. The policy states, "Each patient admitted will receive a comprehensive OASIS assessment. The assessment will reflect the patient's current health status and include information to demonstrate the patient's progress toward achievement of desired outcomes." MR#1: The Start of Care (SOC) was dated 2/18/23. The Plan of Care (POC) for the certification period 2/18/23 to 4/18/23 identified diagnoses of Hypertensive heart and chronic kidney disease with heart failure; Congestive Heart Failure (CHF); Diabetes Type 2 (DM2); Chronic Kidney Disease stage 3 (CKD3), Atrial Fibrillation (A-fib); and Coronary Artery Disease (CAD). During record review on 4/26/23, it was noted that the SOC comprehensive assessment dated 2/18/23, documented under "Primary Diagnosis and Other Diagnoses", that all 25 diagnoses had dates of onset of 2/18/23. There was no specific onset date documented for each diagnosis, and no dates of exacerbations, prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. In addition, the patient had a diagnosis of congestive heart failure on the list of diagnoses, yet the Registered Nurse documented a stated weight on the Start of Care Comprehensive Assessment rather than documenting an actual weight as an accurate baseline to assess future weights for weight loss or weight gain. MR#3: The Start of Care (SOC) was dated 2/20/2023. The Plan of Care (POC) for the certification period 2/20/23 to 4/20/23 identified diagnoses of Hemiplegia following Cerebral Infarction (CVA) affecting right dominant side, Dysphasia following cerebral infarction, dysphagia following cerebral infarction, atrial fibrillation (A-fib), Hypertension (HTN), and Gastro-esophageal reflux. During record review on 4/26/23, it was noted that the SOC comprehensive assessment dated 2/20/23, documented under "Primary Diagnosis and Other Diagnoses", that all 25 diagnoses had a date of onset of 2/18/23. There were no documented dates of exacerbation, prior treatments, outcomes, or history of how these diagnoses led to the need for home care were services. MR#4: The Start of Care (SOC) was dated 12/07/22. The Plan of Care for the certification period 12/7/22 to 2/4/23 identified diagnoses of Diabetes Type 2 (DM2), Hypertension (HTN), Hyperlipidemia (HLD), and personal history of COVID-19. During record review under the category of Primary Diagnosis and Other Diagnoses there were 6 diagnoses listed as follows: Diabetes type 2, Hypertension, Hyperlipidemia, Personal History of COVID-19, Long-term use of oral hypoglycemic drugs, and Long-term use of insulin, however there were no dates of onset for any of the diagnoses, nor was there any information regarding any exacerbations, prior treatments, outcomes, or history of how these diagnoses led to the need for home care were services. MR 5: The Start of Care (SOC) was dated 3/21/23. The Plan of Care (POC) for the certification period 3/21/23 to 5/19/23 identified diagnoses of Diabetes type 2 (DM2), Neuromuscular dysfunction of bladder, Atrial Fibrillation (A-fib), Osteoarthritis, Hypertension (HTN), and Coronary Artery Disease (CAD). During record review on 4/27/23, it was noted that the SOC comprehensive assessment dated 3/21/23, documented under "Primary Diagnosis and Other Diagnoses", that all 16 diagnoses had a date of onset of 3/21/23. There were no individualized documented dates of onset, exacerbation, prior treatments, outcomes, or history of how these diagnoses led to the need for home care were services. MR 6) The SOC was dated 4/19/23. The POC for the certification period 4/19/23 to 6/17/23 identified diagnoses of non-ST elevation myocardial infarction (NSTEMI), Coronary Artery Disease (CAD), Congestive Heart Failure (CHF), Chronic Kidney Disease (CKD), Respiratory Failure, and Alzheimer's Disease. Upon record review on 4/28/23, it was noted that the SOC comprehensive assessment dated 4/19/23, documented under "Primary Diagnosis and Other Diagnoses", that all 16 diagnoses had the same date of onset of 4/19/23. There were no individualized documented dates of onset, exacerbation, prior treatments, outcomes, or history of how these diagnoses led to the need for home care were services.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the registered nurse reviewed patient medications for possible side effects and possible drug interactions for 1 of 1 (MR# 11) Physical Therapy records reviewed. This deficient practice results in the potential for unrecognized medication side effects and drug interactions that could affect all patients serviced by the agency. Findings included: MR#11: The Start of Care (SOC) was dated 4/13/23. The Plan of Care (POC) identified diagnoses of Cervical Spinal Surgery, Diabetes Type 2 and Chronic Obstructive Pulmonary Disease. During record review on 4/27/23, section M2001 of the "Comprehensive Assessment" dated 2/10/21, completed by the Physical Therapist (PT), documented "No issues found during review." The medication profile was signed by the PT. There was no documented evidence that the patient's medications had been reviewed by a registered nurse for possible drug interactions and duplicate drug therapy. These findings were reviewed with and acknowledged by the Administrator (Staff A) during an interview on 4/28/23 at 2:30 pm.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on record review and interviews, the agency failed to ensure the Start of Care Assessment was completed within 48 hours of the patient's referral for home care services in 1 of 17 (MR#3) records reviewed, resulting in care not provided in a timely manner. Findings included: **Agency Policy: Assessments: Initial Comprehensive, dated 2018. The policy states, "The Initial Assessment and Time Frame: A Registered Nurse, Physical Therapist, or Speech and Language Therapist must conduct the initial assessment visit within 48 hours of referral, within 48 hours of the patients return home or on the physician-ordered start of care date." MR#3: The Start of Care (SOC) was dated 2/20/2023. The Plan of Care (POC) for the certification period 2/20/23 to 4/20/23 identified diagnoses of Hemiplegia following Cerebral Infarction (CVA) affecting right dominant side, Dysphasia following cerebral infarction, dysphagia following cerebral infarction, atrial fibrillation (A-fib), Hypertension (HTN), and Gastro-esophageal reflux. This patient was discharged from the Hospital on 2/16/2023. The Start of Care occurred 4 days after the patient's discharge from the hospital. There were no physician orders found in the record to delay the start of care, nor was there any documentation of a request from the patient to delay the Start of Care Comprehensive Assessment. These findings were reviewed and acknowledged by the Administrator (Staff A) during an interview on 4/28/23 at 4:00 p.m.

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: Based on record review and interviews, the agency failed to include required information and notifications upon transfer to the hospital in 1 of 2 records (MR#1) reviewed in which the patient was transferred to the hospital, resulting in incomplete information being provided for the receiving facility's' information. Findings included: **Agency Policy, "Transfer Criteria", dated 2018. The policy states, "Patients are to be transferred or referred to alternative care situations when specifically defined conditions exist. The patient/family and physician will be involved in the transfer and referral decisions as appropriate. A written transfer summary concerning the Agency's involvement with the patient (summary of care/services provided, patient's current physical and psychosocial status, instructions/referrals provided to patient, current reconciled medication list, advance directives, any continuing symptom management needs, reasons for transfer or referral.) The Transfer Summary will be provided to receiving organization within two (2) business days of transfer when Agency is actively involved in the transfer process. MR#1: The Start of Care (SOC) was dated 2/18/23. The Plan of Care (POC) for the certification period 2/18/23 to 4/18/23 identified diagnoses of Hypertensive heart and chronic kidney disease with heart failure; Congestive Heart Failure (CHF); Diabetes Type 2 (DM2); Chronic Kidney Disease stage 3 (CKD3), Atrial Fibrillation (A-fib); and Coronary Artery Disease (CAD). This patient was transferred to the hospital via the hospital emergency department and was admitted on 3/13/2023 for "other heart disease", however, the agency failed to document the name of the hospital the patient was transferred to and failed to notify the physician of the patient's transfer and admission to the hospital. These findings were reviewed and acknowledged by the Administrator (Staff A) during an interview on 4/28/23 at 4:00 p.m.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on record review and interview, it was determined that the Agency failed to include objectively measurable goals to determine the patient's progress towards achieving the goals in 16 of (MR#s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 16 and 17) of 17 records reviewed (G574); failed to provide services as ordered in the Plan of Care in 1 (MR#2) of 16 records (G578), and failed to promptly notify the Physician concerning significant weight gain and increased lower leg edema for 1 (MR #7) of 4 patients with congestive heart failure, resulting in a poor clinical outcome (G590). The cumulative effect of these systemic problems resulted in the home health agency's inability to ensure the provision of quality health care for the condition of participation of 42 CFR 484.60: Care Planning, Coordination of Services, and Quality of Care.

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 Plan of Care failed to include objectively measurable goals to determine the patient's progress towards achieving the goals in 16 of 17 records (MR#s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 16 and 17). Findings included: **Agency Policy: "Plan of Care (485) and Physician's Orders," no date. The policy states, "The Plan of Care is established in writing by the physician, Agency staff, the patient and members of the patient's family based on an evaluation of the patient's immediate and long-term needs. The Plan of Care includes frequency of visits and duration, equipment and supplies required, instructions for timely discharge or referral, expected goals or outcomes to be achieved, safety measures to protect against injury, discharge plan. Orders for therapy services include the specific procedures and modalities to be used and the amount, frequency and duration." MR#8: The SOC was dated 1/7/23. The Plan of Care identified diagnoses of sacral pressure ulcer and right buttock pressure ulcer. A review of the Plan of Care on 4/27/23 revealed wound measurements were ordered to be done every visit. Skilled nursing visits on 3/14 and 3/30 documented wound care was completed. No wound measurements were documented for either of the visits. MR#9: The SOC was dated 3/3/23. The Plan of Care identified diagnoses of hypertension (HTN), surgical aftercare, chronic kidney disease and congestive heart failure. A review of the Plan of Care on 4/27/23 revealed the nursing goals were not measurable. One goal stated, "The patient/caregiver will verbalize understanding of individualized emergency plan by 4/29/23." Another stated, "Patient/caregiver will demonstrate steps to protect oneself and others from COVID-19 infection by end of certification period." The goals are not objectively measurable to determine the patients progress toward attaining the stated goals. MR#10: The SOC was dated 4/8/23. The Plan of Care identified diagnoses of hypertension (HTN), surgical aftercare, chronic kidney disease, atrial septal defect and congestive heart failure. A review of the Plan of Care on 4/27/23 revealed the nursing goals were not measurable. One goal stated, "The patient/caregiver will verbalize and demonstrate edema relieving measures by 5/27/23." Another stated, "Patient/caregiver will verbalize understanding of symptoms of cardiac complications and when to call 911 by 5/27/23." The goals are not objectively measurable to determine the patients progress toward attaining the stated goals. During an interview on 4/28/23 at 3:25 p.m., the administrator (Staff-A) acknowledged the above findings. MR#11: The Start of Care (SOC) was dated 4/13/23. The Plan of Care (POC) identified diagnoses of Cervical Spinal Surgery, Diabetes Type 2 and Chronic Obstructive Pulmonary Disease. During record review on 4/27/23, it was noted that the goal within the POC was not measurable for Skilled Nursing (SN). The goal stated, Nursing Goals: Patient will demonstrate knowledge of diabetes self-care measures.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. MR#12: The Start of Care (SOC) was dated 3/27/23. The Plan of Care (POC) identified diagnoses of Post Left Hip Replacement, Wound Infection, Diabetes Type 2 and Congestive Heart Failure. During record review on 4/27/23, it was noted that the goals within the POC were not measurable. For example, one goal stated, “Patient will exhibit stable vital signs as evidenced by the following throughout the certification period.” Additionally, another goal stated, “Patient/caregiver will demonstrate proper infection precautions and prevent the spread of infection within the care episode.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. MR#13: The Start of Care (SOC) was dated 3/22/23. The Plan of Care (POC) identified diagnoses of Post Kidney Transplant, Diabetes Type 2 and Congestive Heart Failure. During record review on 4/26/23, it was noted that the goals within the POC were not measurable. For example, one goal stated, “Patient/caregiver will demonstrate steps to protect oneself and others from COVID-19 infection by end of certification period.” Additionally, another goal stated, “Patient and caregiver will verbalize an understanding of factors that contribute to shortness of breath by 05/06/2023.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. MR#15: The Start of Care (SOC) was dated 2/10/23. The Plan of Care (POC) identified diagnoses of Stage 4 Pressure Ulcer, Paraplegia and Osteomyelitis. During record review on 4/26/23, it was noted that the goals within the POC were not measurable. For example, one goal stated, “Patient/caregiver will demonstrate proper infection precautions and prevent the spread of infection within the care episode.” Additionally, another goal stated, “Patient/caregiver will demonstrate steps to protect oneself and others from COVID-19 infection by end of certification period.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. MR#16: The Start of Care (SOC) was dated 12/22/22. The Plan of Care (POC) identified diagnoses of Right Femur Fracture, Alzheimer’s and Congestive Heart Failure. During record review on 4/25/23, it was noted that the goals within the POC were not measurable. For example, one goal stated, “Wound(s) will be free from signs and symptoms of infection during 60-day episode.” Additionally, another goal stated, “Patient's respiratory rate will remain within established parameters during the episode.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. MR#17: The Start of Care (SOC) was dated 12/16/22. The Plan of Care (POC) identified diagnoses of Transient Ischemic Attack, Dysphagia and Hypertension. During record review on 4/25/23, it was noted that the goals within the POC were not measurable. For example, one goal stated, “The Patient/PCG will verbalize understanding and will be able to recognize signs of heart attack that necessitate calling 911 by 01/24/2023.” Additionally, another goal stated, “Skin integrity will be maintained throughout the care episode and patient/caregiver will demonstrate measures to prevent skin breakdown by 12/24/2022.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. These findings were reviewed with and acknowledged by the Administrator (Staff A) during an interview on 4/28/23 at 2:45 pm. MR#1: The Start of Care (SOC) was dated 2/18/23. The Plan of Care (POC) for the certification period 2/18/23 to 4/18/23 identified diagnoses of Hypertensive heart and chronic kidney disease with heart failure; Congestive Heart Failure (CHF); Diabetes Type 2 (DM2); Chronic Kidney Disease stage 3 (CKD3), Atrial Fibrillation (A-fib); and Coronary Artery Disease (CAD). The patient had been hospitalized for repeated falls at home. Upon review of the Plan of Care, it was noted the goals were not objectively measurable to determine the patient's progress towards attaining the goals. Examples included: 1). "A plan of care will be established that meets all patient's nursing needs and countersigned by physician." This goal is not measurable or specific to the patient's identified needs. 2)."The Patient/Caregiver will verbalize understanding of individualized emergency plan by 3/18/23." This goal is not objectively measurable. 3)."Patient will verbalize an understanding of energy conserving measures." This goal is not objectively measurable. 4)."Patient's ADL/IADL needs will be met with assistance of home health aide." These goals are not individualized or objectively measurable to determine the patients progress toward attaining the stated goals. MR#2: The Start of Care (SOC) was dated 2/26/23. The Plan of Care (POC) for the certification period 2/26/23 to 4/26/23 identified diagnoses of Diabetes type 2 (DM2), Hypertension (HTN), Hyperlipidemia, Tinnitus, Morbid Obesity, Dependence on Oxygen. Upon review of the plan of care, it was noted the goals were not objectively measurable to determine the patient's progress toward attaining goals. Examples include: 1). "A plan of care will be established that meets all patient's needs and countersigned by physician." This goal is not individualized to the patient's identified home health needs, nor is this goal measurable. 2). "Patient will verbalize understanding of emergency measures and signs and symptoms that need immediate attention." This goal is not objectively measurable. 3). "Patient and caregiver will verbalize understanding of Type 2 diabetes mellites with diabetic neuropathy, its causes, risk factors, signs and symptoms of hypo/hyperglycemia that needs to be recognized and reported to MD, complications by 4/8/2023 {sic}". This goal is not objectively measurable to determine the patient's progress towards attaining the goal. MR#3: The Start of Care (SOC) was dated 2/20/2023. The Plan of Care (POC) for the certification period 2/20/23 to 4/20/23 identified diagnoses of Hemiplegia following Cerebral Infarction (CVA) affecting right dominant side, Dysphasia following cerebral infarction, dysphagia following cerebral infarction, atrial fibrillation (A-fib), Hypertension (HTN), and Gastro-esophageal reflux. Upon review, the goals on the POC were not objectively measurable to determine the patient's progress towards goals. Examples include: 1). "The patient will verbalize understanding of individualized emergency plan by stating what actions to take in case of emergency by 3/4/23." This goal is not measurable to determine the patient's progress towards attaining the goal. 2). "Patient will verbalize an understanding of energy conserving measures by 3/11/23." This goal is not measurable to determine the patient's progress towards goals. 3). "The patient/PCG will verbalize understanding and will be able to recognize signs of heart attack that necessitate calling 911 by 3/4/2023." This goal is not objectively measurable to determine the patient's progress towards goals. MR#4: The Start of Care (SOC) was dated 12/07/22. The Plan of Care for the certification period 12/7/22 to 2/4/23 identified diagnoses of Diabetes Type 2 (DM2), Hypertension (HTN), Hyperlipidemia (HLD), and personal history of COVID-19. Upon review of the record, it was noted the goals on the POC were not objectively measurable. Example included: 1) "A plan of care will be established that meets all patient's nursing needs and countersigned by physician." This goal is beyond the patient's control and is not objectively measurable or specific to the patient's individual needs. 2). "Patient will verbalize understanding of emergency measures and signs and symptoms that need immediate attention." This goal is not specific to the patient's needs, nor is it objectively measurable. 3). "The patient will be free of adverse medication reactions during the episode." This goal is not objectively measurable and is beyond control of the patient's actions. MR 5: The Start of Care (SOC) was dated 3/21/23. The Plan of Care (POC) for the certification period 3/21/23 to 5/19/23 identified diagnoses of Diabetes type 2 (DM2), Neuromuscular dysfunction of bladder, Atrial Fibrillation (A-fib), Osteoarthritis, Hypertension (HTN), and Coronary Artery Disease (CAD). Upon review of the record, it was noted the goals on the POC were not objectively measurable to determine the patient's progress towards goals. Examples included: 1). "A plan of care will be established that meets all patient's nursing needs and countersigned by physician." This goal is beyond the patient's control, nor is it specific to the patient's identified health needs. 2) "The patient will have no hospitalizations during the certification period." This goal is beyond the patient's control, nor is it specific to the patient's identified health care needs. 3) "Patient will be able to institute high risk medication precaution to prevent adverse effects by end of certification". This goal is not within control of the patient, nor is it objectively measurable. MR 6) The SOC was dated 4/19/23. The POC for the certification period 4/19/23 to 6/17/23 identified diagnoses of non-ST elevation myocardial infarction (NSTEMI), Coronary Artery Disease (CAD), Congestive Heart Failure (CHF), Chronic Kidney Disease (CKD), Respiratory Failure, and Alzheimer's Disease. Upon review of the record, it was noted that the goals on the Plan of Care were not objectively measurable to determine the patient's progress towards attaining the goals. Examples include: 1). "A plan of Care will be established that meets all patient's nursing needs and countersigned by the physician." This goal is beyond the patient's control and beyond the control of the patient." 2). "Patient will be able to institute high medication precaution to prevent adverse effects by 5/13/23. This goal is not objectively measurable to determine progress towards achieving the goal. 3). "The patient will be free from injury during the certification period." This goal cannot be controlled by the patient given the many health issues of the patient and the goal is not objectively measurable. MR#7: The SOC was dated 3/8/2023. The POC for the certification period 3/8/23 to 5/6/23 identified diagnoses of Open Wound of Left Breast, Malignant Neoplasm, Malignant neoplasm of left breast, Atrial Fibrillation (A-fib), Major Depressive disorder. Upon review of the record, it was noted the goals on the POC were not objectively measurable to determine the patient progress toward attainment of goals. Examples included: 1). "Patient will be able to enumerate and demonstrate non-pharmacological pain management measures within the care episode." This goal is not specific or measurable to determine the patient's progress towards achieving the goals". 2). "Wound will heal without complications". This goal is not measurable to determine the progress towards achieving the goal". 3). Patient will verbalize understanding and patient will exhibit compliance with prescribed diet throughout the episode of care." This goal is not objectively measurable to determine the patient's progress towards achieving the goal. MR#8: The SOC was dated 1/7/23. The POC for the certification 1/7/23 to 3/7/23 identified diagnoses of Pressure Ulcer Stage 4 of Sacral Region, Pressure Ulcer of Right and Left Buttock Stage 4, Diabetes type 2 (DM2), Osteomyelitis of vertebra, sacral and sacrococcygeal region, Cerebral Palsy (CP), Hypertension (HTN), and Asthma. Upon review of the record, it was noted the goals on the POC were not objectively measurable to determine the patient's progress towards achieving the goals. Examples included: 1). "The patient will be able to enumerate and demonstrate pharmacologic and non-pharmacologic pain management measures." This goal is not objectively measurable. 2). "Suprapubic tube will remain patent during this episode and patient will be free of signs and symptoms of Urinary Tract Infection." This goal is not objectively measurable, and not controllable by the patient." These findings were reviewed and acknowledged by the Administrator (Staff A) during an interview on 4/28/23 at 4:00 p.m.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review and interview, the skilled nurse failed to provide services as ordered in the Plan of Care in 1 (MR#2) of 16 records in which Skilled Nursing provided services. Findings included: **Agency Policy: "Plan of Care and Physician Orders", dated 2018. The policy states, "Skilled nursing and other home health services will be in accordance with a Plan of Care based on the patient's diagnosis and assessment of immediate and long-range needs and resources." MR#2: The Start of Care (SOC) was dated 2/26/23. The Plan of Care (POC) for the certification period 2/26/23 to 4/26/23 identified a primary diagnosis of Diabetes type 2 (DM2); and secondary diagnoses of Hypertension (HTN), Hyperlipidemia, Tinnitus, Morbid Obesity, Dependence on Oxygen. The Plan of Care included the following order: "Notify physician of: Fasting blood sugar greater than 150 or less than 90. Random Blood sugar greater than 150 or less than 90. Further review of the Skilled Nurse visit notes revealed no blood sugar results recorded in any of the 4 visit notes documented by the LPN dated 3/8/23, 3/10/23, 3/15/23, and 3/18/23. The visit note dated 3/8/23 included a remark from the patient that the "blood glucose levels had been between 150 to 160 in the morning before breakfast". There was no indication found in the record that the LPN attempted to get an on-site blood sugar reading while assessing the patient during the visits to determine the patient's trend in blood sugar results as ordered by the physician on the Plan of Care. These findings were reviewed and acknowledged by the Administrator (Staff A) during an interview on 4/28/23 at 4:00 p.m.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, it was determined the Agency had failed to promptly notify the Physician concerning significant weight gain and increased lower leg edema for 1 (MR #7) of 4 patients with congestive heart failure, resulting in a poor clinical outcome. Findings include: MR#13: The Start of Care (SOC) was dated 3/22/23. The Plan of Care (POC) identified diagnoses of Post Kidney Transplant, Diabetes Type 2 and Congestive Heart Failure. During record review on 4/26/23, it was noted that the comprehensive assessment completed by the Registered Nurse (RN) on 3/22/23 stated, “Weight 118.5. Actual...No edema.” The following RN visit on 3/25/23, 3 days after the SOC, stated, “Weight: 128.4… Edema: Lower limbs 1+. Comments: Pitting edema +1 both lower limbs. Patient has gained 2 pounds over 2 days…Assessment/Instruction/Performance: Patient came down the stairs A/Ox3 (alert and oriented). Physical examination revealed mild SOB (shortness of breath) but the patient did not complain of SOB…Coordination Plan – Physician Contacted Re: Blank.” The patient had gained 9.9 pounds in three days, increased edema from SOC and noted SOB. The patient was transferred and admitted to the hospital on 3/28/23 with “Heart Failure”. The RN failed to notify the physician of weight gain, thus leading to the hospitalization of the patient. These findings were reviewed with and acknowledged by the Administrator (Staff A) during an interview on 4/28/23 at 3:30 pm.

Other pertinent instructions CFR(s): 484.60(e)(4) Any other pertinent instruction related to the patient's care and treatments that the HHA will provide, specific to the patient's care needs. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the physical therapists failed to provide a written exercise program and instructions for the patient to use between scheduled Physical Therapy visits in 1 of 2 records MR#7 in which Physical Therapy (PT) was assigned and provided a joint surveyor home visit in the patient's home resulting in patients' not having the tools necessary to maintain their therapy achievements. Findings included: MR#7: The SOC was dated 3/8/2023. The POC for the certification period 3/8/23 to 5/6/23 identified diagnoses of Open Wound of Left Breast, Malignant neoplasm of left breast, Atrial Fibrillation (A-fib), Major Depressive disorder. The patient was receiving Skilled Nursing, Physical Therapy, and Occupational Therapy services. During a joint survey home visit on April 27th, 2023, at 10:00 a.m., with the Physical Therapist, it was observed during the home visit, that the Physical Therapist led the patient through an exercise program by demonstrating the exercises first and then counting the number of repetitions as the patient performed. After the exercise regimen was completed, another appointment was scheduled for the following week. During an interview with the patient, the patient was asked if a written copy of the prescribed exercises had been provided to use in between physical therapy visits. The response was, "no". The Physical Therapist failed to provide the patient with a written copy of the prescribed exercise program to use on days when the physical therapy was not providing services.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the Agency failed to ensure the personnel followed accepted Infection Control standards of practice during the provision of care and services for 1 of 6 patients (MR #13) observed home visits, from a total of 17 sampled records reviewed, resulting in the potential for the transmission and development of infection. Findings include: MR#13: The Start of Care (SOC) was dated 3/22/23. The Plan of Care (POC) identified diagnoses of Post Kidney Transplant, Diabetes Type 2 and Congestive Heart Failure. During record review on 4/26/23, the plan of care documented, "SN (Skilled Nurse) to perform IV (Intravenous)/PICC (Peripherally Inserted Central Catheter) site care every week..." On 4/26/23 at 1:15 p.m., a scheduled home visit was conducted with the Registered Nurse (Administrator (Staff A)). During the visit, the following was observed: Staff A, after donning sterile gloves, pulled up both left and right sleeves, thus contaminating both sterile gloves. The patient was sitting at an awkward angle, thus when Staff A cleaned the PICC site with Chloraprep, the patient’s shirt would rest on cleaned area, therefore contaminating the cleaned area. Lastly, the PICC dressing change kit failed to have a Statlock (Stabilization device). This was not recognized by Staff A until after removing the old Statlock and cleaning the PICC site with Chloraprep. Staff A then removed contaminated sterile gloves, then found an extra Statlock, re-donned contaminated sterile gloves and placed Statlock and covered PICC dressing. Staff A failed follow accepted Infection Control standards of practice during the provision of care. These findings were reviewed with and acknowledged by the Administrator (Staff A) during an interview on 4/26/23 at 3:15 pm.

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 policy review, the agency failed to provide services as ordered on the Plan of Care in 1 of 17 records reviewed (MR#7) that ordered Occupational Therapy Services, resulting in the patient not receiving ordered services needed by the patient to assist in improving the patient's safety and health condition. Findings included: MR#7: The Start Of Care was dated 3/8/2023. The Plan of Care (POC) for the certification period 3/8/23 to 5/6/23 identified diagnoses of Open Wound of Left Breast, Malignant Neoplasm, Malignant neoplasm of left breast, Atrial Fibrillation (A-fib), Major Depressive disorder. The POC included orders for Skilled Nursing (SN), Physical Therapy (PT), and Occupational Therapy (OT) services. Upon review of the record, there were no Occupational Therapy visit notes found in the record. There were no further orders or documentation that the order for Occupational Therapy services had been denied by the patient or cancelled. The agency failed to provide OT services as ordered. During an interview with the Administrator (Staff A) on 4/28/23, Staff A was queried whether the patient had received OT services or if the services had been refused by the patient. After a brief review of the record, the response was "no, I could not find any information that the ordered was cancelled or the patient refused". The agency failed to provide OT services as ordered by the physician.

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 ensure the Registered Nurse (RN) prepared complete written instructions for patient safety needs in 2 of 9 records in which aide services were provided, from a total of 17 records reviewed, (MR's 15, and 16) resulting in the potential for unsafe, substandard care and unmet care needs. Findings include: MR#15: The Start of Care (SOC) was dated 2/10/23. The Plan of Care (POC) identified diagnoses of Stage 4 Pressure Ulcer, Paraplegia and Osteomyelitis. The POC ordered Home Health Aide (HHa) services at a frequency of 1w4 (1 time a week for 4 weeks) with the following safety measures: Instructed on disaster/emergency plan. Keep Side Rails Up. Instructed on DME & electrical safety. Instructed on mobility safety. Support During Transfer and Ambulation. Emergency Plan Developed. Safety in ADLs. Instructed on safety measures. Proper Position During Meals. Fall Precautions. Use of Assistive Devices. Instructed on proper handling of biohazard waste. Standard Precautions/Infection Control. During record review on 4/26/23, the "Aide Care Plan" dated 2/10/23 completed by the Registered Nurse (RN) contained no safety precautions. The HHa care plan failed to include the necessary safety measure and precautions to alert the aide of the patient's health concerns. MR#16: The Start of Care (SOC) was dated 12/22/22. The Plan of Care (POC) identified diagnoses of Right Femur Fracture, Alzheimer’s and Congestive Heart Failure. The POC ordered Home Health Aide (HHa) services at a frequency of 1w6 with the following safety measures: Keep Pathway Clear. Instructed on disaster/emergency plan. Keep Side Rails Up. Instructed on DME &electrical safety. Instructed on medical gas. Slow Position Change. O2 Precautions. Instructed on mobility safety. Support During Transfer and Ambulation. Emergency Plan Developed. Instructed on safe utilities management. Safety in ADLs. Seizure Precautions. Instructed on safety measures. Proper Position During Meals. Fall Precautions. Use of Assistive Devices. Standard Precautions/Infection Control. During record review on 4/25/23, the "Aide Care Plan" dated 12/22/22 completed by the Registered Nurse (RN) contained no safety precautions. The HHa care plan failed to include the necessary safety measure and precautions to alert the aide of the patient's health concerns. These findings were reviewed with and acknowledged by the Administrator (Staff A) during an interview on 4/28/23 at 2:50 pm.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure clinical notes were accurate for 3 of 17 (MR# 12, 13 and 16) records reviewed, resulting in the potential to negatively affect the health and well-being of these patients. Findings include: MR#12: The Start of Care (SOC) was dated 3/27/23. The Plan of Care (POC) identified diagnoses of Post Left Hip Replacement, Wound Infection, Diabetes Type 2 and Congestive Heart Failure. During record review on 4/27/23, it was noted that the POC ordered Skilled Nursing (SN) at a frequency of 3w6 (3 times a week for 6 weeks). The comprehensive assessment dated 3/27/23 documented a weight of 295. The following 12 SN visits contained no weight recordings: 3/28, 3/29, 4/3, 4/5, 4/6, 4/10, 4/12, 4/14, 4/17, 4/20, 4/22 and 4/24. Additionally, on 4/5/23 and 4/6/23, the Licensed Practical Nurse (LPN) documented the same “Skilled Intervention” as the Registered Nurse (RN) on 4/20/23 which stated, “…Today IV antibiotics completed last dose. RN pulled the PICC line under aseptic precautions as ordered. PICC line removed with tip intact…” (SIC) The agency failed to ensure that the medical record was complete and accurate. MR#13: The Start of Care (SOC) was dated 3/22/23. The Plan of Care (POC) identified diagnoses of Post Kidney Transplant, Diabetes Type 2 and Congestive Heart Failure. During record review on 4/26/23, it was noted that the RN completed a resumption of care assessment on 4/8/23 with an ordered SN frequency of 1w6. The following 2 SN visits failed to document a weight, 4/12/23 and 4/19/23. The agency failed to ensure that the medical record was complete and accurate. MR#16: The Start of Care (SOC) was dated 12/22/22. The Plan of Care (POC) identified diagnoses of Right Femur Fracture, Alzheimer’s and Congestive Heart Failure. During record review on 4/25/23, it was noted that the POC ordered SN at a frequency of 1w7. The comprehensive assessment dated 12/22/22 documented a weight of 130. The following 6 SN visits contained no weight recordings: 12/26/22, 1/2/23, 1/11/23, 1/18/23, 1/24/23 and discharge 1/29/23. The agency failed to ensure that the medical record was complete and accurate. These findings were reviewed with and acknowledged by the Administrator (Staff A) during an interview on 4/28/23 at 3:05 pm.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review, policy review, and interview, the Agency failed to ensure a transfer or discharge summary was completed, provided the patient's current health status at the time of transfer or discharge; progress toward goals; and Transfer Summary is sent to the receiving agency and physician within 2 days; and Discharge Summary sent to the physician within 5 days in 8 (MR# 1, 2, 3, 4, 13, 15, 16, 17) of 7 records with a transfer or discharge, resulting in the potential for unidentified continuing health care concerns and unmet care needs. Findings include: **Agency Policy: "Transfer Criteria" dated 2018. The policy states, "Patients are transferred or referred to alternate care situations when ...the medical condition or treatment warrants a different level of care. Appropriate Parties will be informed immediately as the need for transfer becomes evident. A written Transfer Summary concerning the Agency's involvement with a summary of care/services provided, patient's current physical and psychosocial status, instructions/referrals provided to patient, current reconciled medication list, advance directives, any continuing symptom management needs, pain and reasons for transfer or referral will be forwarded to the new health care provider., Transfer Summary will be provided to receiving organization within two business days of transfer when Agency is actively involved in the transfer process." **Agency Policy: "Discharge Summary dated 2018." The Policy states, "A discharge summary will be completed for all patients discharged from the Agency. The discharge Summary will include, but is not limited to: Discharge date, reason for discharge, status of problems identified throughout the course of care, Patient's overall status. Summary of care and services provided." "The original Discharge Summary form from each service will be filed in the medical record. The physician will be notified regarding discharge and copy of the Discharge Summary will be sent to the physician or medical care provider within five business days." MR#13: The Start of Care (SOC) was dated 3/22/23. The Plan of Care (POC) identified diagnoses of Post Kidney Transplant, Diabetes Type 2 and Congestive Heart Failure. During record review on 4/26/23, it was noted that the Skilled Nursing transfer dated 3/28/23 stated, "Summary of Care: Referred to home care for IV antibiotic infusion, weekly PICC dressing change and labs related to bacteremia." The transfer summary failed to detail the course of care provided, responses to treatment, any potential continuing needs, and failed to document the patient's health status at the time of discharge in measurable terms. MR#15: The Start of Care (SOC) was dated 2/10/23. The Plan of Care (POC) identified diagnoses of Stage 4 Pressure Ulcer, Paraplegia and Osteomyelitis. During record review on 4/26/23, it was noted that the Skilled Nursing transfer dated 3/28/23 stated, "Summary of Care: Home care services focused on wound care to multiple sites, foley catheter management." The transfer summary failed to detail the course of care provided, responses to treatment, any potential continuing needs, and failed to document the patient's health status at the time of discharge in measurable terms. MR#16: The Start of Care (SOC) was dated 12/22/22. The Plan of Care (POC) identified diagnoses of Right Femur Fracture, Alzheimer’s and Congestive Heart Failure. During record review on 4/25/23, it was noted that the Skilled Nursing discharge dated 1/29/23 stated, "Care Summary (care given, progress, regress including therapies): SN (Skilled Nurse) educated patient/caregiver on wound care, pain management, pressure ulcer prevention, safety measures, medications and side effects; patient's overall status stable, vitals wnl (within normal limits), surgical incisions healed and staples removed, pain well controlled at acceptable levels through medications and hep tool, increased knowledge related to disease process, diets and medications and independence improved." The discharge summary failed to detail the course of care provided, responses to treatment, any potential continuing needs, and failed to document the patient's health status at the time of discharge in measurable terms. MR#17: The Start of Care (SOC) was dated 12/16/22. The Plan of Care (POC) identified diagnoses of Transient Ischemic Attack, Dysphagia and Hypertension. During record review on 4/25/23, it was noted that the Occupational Therapy discharge dated 2/3/23 stated, "Care Summary (care given, progress, regress including therapies): thera exe of bues self care training transfer tech bed mobility tech pressure relief tech." (SIC) The discharge summary failed to detail the course of care provided, responses to treatment, any potential continuing needs, and failed to document the patient's health status at the time of discharge in measurable terms. These findings were reviewed with and acknowledged by the Administrator (Staff A) during an interview on 4/28/23 at 3:00 pm. MR#1: The Start of Care (SOC) was dated 2/18/23. The Plan of Care (POC) for the certification period 2/18/23 to 4/18/23 identified diagnoses of Hypertensive heart and chronic kidney disease with heart failure; Congestive Heart Failure (CHF); Diabetes Type 2 (DM2); Chronic Kidney Disease stage 3 (CKD3), Atrial Fibrillation (A-fib); and Coronary Artery Disease (CAD). The patient was receiving Skilled Nursing, Physical Therapy, Occupational Therapy, and Home Health Aide services. The patient was transferred to the hospital on 3/13/2023 due to complaints of weakness. A list of the patient's medication was included on the Transfer Summary, however, the transfer summary failed to detail the course of care provided, responses to treatment, any potential continuing needs, and failed to document the patient's health status at the time of transfer. In addition, there was no documentation found in the record that indicated the physician had been notified of the patient's transfer to the hospital. MR#2: The Start of Care (SOC) was dated 12/07/22. The Plan of Care (POC) for the certification period 12/7/22 to 2/5/23 identified diagnoses of Diabetes type 2 (DM2), Hypertension (HTN), Hyperlipidemia, Tinnitus, Morbid Obesity, Dependence on Oxygen. The patient was discharged from services on 1/11/23 due to no longer homebound. All services were notified and discontinued. The discharge summary failed to detail the course of care provided, responses to treatment, any potential continuing needs, and failed to document the patient's health status at the time of discharge. The physician was notified of discharge prior to the discharge date and all services were notified and discontinued. The record documented the physician was notified of discharge summary availability, however there was no evidence found in the record that the discharge summary had been sent to the physician per agency policy. MR#3: The Start of Care (SOC) was dated 2/20/2023. The Plan of Care (POC) for the certification period 2/20/23 to 4/16/23 identified diagnoses of Type 2 Diabetes, Hypertension HTN Cerebral Infarction (CVA) affecting right dominant side, Dysphasia following cerebral infarction, dysphagia following cerebral infarction, atrial fibrillation (A-fib), Hypertension (HTN), and Gastro-esophageal reflux. This patient was discharged from services on 4/16/2023 due to "Goals Met/maximum potential reached" The patient was provided discharge instructions, however, the discharge summary failed to detail the course of care provided, responses to treatment, any potential continuing needs, and failed to document the patient's health status at the time of discharge. The physician was notified of discharge prior to the discharge date and all services notified and discontinued. The record documented the physician was notified of discharge summary availability, however there was no evidence found in the record that the discharge summary had been sent to the physician per agency policy. MR#4: The Start of Care (SOC) was dated 12/07/22. The Plan of Care for the certification period 12/07/22 to 2/4/23 identified diagnoses of Diabetes Type 2 (DM2), Hypertension (HTN), Hyperlipidemia (HLD), and personal history of COVID-19. This patient was Transferred to the hospital emergency department on 1/11/23 due to Hypoglycemia with BS of 70, and diabetes out of control. The patient was discharged from the Home Health Agency on 1/11/23 because the patient was no longer homebound." The patient was provided discharge instructions, however, there was no discharge summary found in the record. The agency failed to detail the course of care provided, responses to treatment, any potential continuing needs, and failed to document the patient's health status at the time of discharge. The Scheduler was notified. The physician was notified of discharge prior to the discharge date and all services notified and discontinued. The record documented the physician was notified of discharge summary availability, however there was no evidence found in the record that the discharge summary had been sent to the physician per agency policy. These findings were reviewed and acknowledged by the Administrator (Staff A) during an interview on 4/28/23 at 4:00 p.m.

The following Standard level deficiency was identified at a Medicare Authorized complaint investigation (MI000121706/22758) conducted by the Michigan Department of Licensing and Regulatory Affairs on 9/8/21 at: Home at Home Health Care2 Corporate Drive, suite 100Southfield, MI 48076During the onsite investigation, 1 active record and 2 discharged records were reviewed, for a total of 3 records review. At the conclusion of the investigation, this Agency was determined to non-compliant, at a Standard level, with the Conditions of Participation at sub part 42 CFR Home Health Services Patient Rights.

Treatment or care CFR(s): 484.50(e)(1)(i)(A) (i)(A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; and This ELEMENT is not met as evidenced by: Based on interview and record review, it was determined that the Agency failed to ensure staff provided care and services in a manner of dignity and respect for 1 (MR #1) 1 patient exposed to inappropriate language during a home visit, from a total of 3 sampled records reviewed, resulting in the discontinuation of needed services and the potential for psychological and physical decline. Findings include: A complaint received, reported that agency staff failed to treat the patient with dignity and respect. MR #1: The patient was admitted to the Agency on 7/29/21 with a diagnosis of status post (s/p) left knee replacement and additional diagnoses that included fibromyalgia and chronic pain syndrome. During the record review on 9/8/21 at 11:14 a.m., it was noted that the Plan of Care (POC) ordered Skilled Nursing (SN) and Physical Therapy (PT) to be provided. On 9/8/21 at 12:36 p.m., during a telephone interview, the patient reported, "The Staff (Staff #1) came to my home for the initial visit on the same day I was released from the hospital (7/29/21). He was inquiring about my medications and I told him I have Hydrocodone (narcotic pain relief) 10 milligram (mg) and 15 mg tablets. He then stated, "Oh, I see they gave you the good shit." I was offended and surprised at the same time that he would feel comfortable using that language with me. He (Staff #1) used that same language a few more times during the visit. Later, he said, "Make sure you call your doctor to have them (medications) refilled. You don't wanna be without your dope [sic]." I became more and more uncomfortable so I called my nephew to come into the room with me. Staff #1 left the room when I started calling for my nephew. He (Staff #1) called me the following week to set up a visit but I declined any further services." On 9/8/21 at 1:24 p.m., a telephone interview was conducted with Staff #1. When queried about his practices during home visits, Staff #1 reported, "I'm very thorough. I assess the patient and I check all the patient's medications while I'm in the home." When asked if he ever used inappropriate language during visits in the patient's homes, Staff #1 replied, "Well, I'm not going to lie to you, the words "Shit" and "Damn" do come out of my mouth often. It's not in a mean way. I just say it." When asked if he felt that using such language with the patient's was appropriate, Staff #1 replied, "No. I know it's not." These findings were reviewed with the Administrator (Adm #1) (via telephone conference), Assistant Administrator (Adm #2), Human Resources Manager (HR #1) and Compliance Officer (CO #1) during the exit interview on 9/8/21. Adm #1 reported, "I'm shocked. This is unacceptable."