Every finding on record at Honest Home Care, Inc

On 2/12/24 through 2/15/24, the Michigan Department of Licensing and Regulatory Affairs conducted a recertification survey at Honest Home Care. This was a standard survey. The requirements for participation in Medicare at 42 CFR 484.102 Emergency Preparedness were not reviewed.

A Medicare recertification survey was conducted by the Michigan Department of Licensing and Regulatory Affairs on 2/12/24 through 2/15/24 at: Honest Home Care 1681 E Auburn Rd., Suite B Rochester Hills, MI 48307 Clinical records reviewed for this survey: 3 records with home visits and 4 records without home visits for a total of 7 records reviewed. The agency has no branch sites. At the conclusion of the survey, the agency was found to be in non-compliance with standard level citations for the conditions of participation for Home Health Agency at: 42 CFR Part §484.

Content of the comprehensive assessment CFR(s): 484.55(c) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status, past medical history, history of events leading to home care, baseline data for future assessments, and ascertained the patient's immediate care needs in 2 records (P-2, P-7) from a total of 7 records reviewed, resulting in the potential for unmet care needs for all 14 patients currently receiving services. Findings include: P-2: The start of care (SOC) date for this patient was 11/22/2023, with diagnoses which included diabetes-type 2, osteo-arthritis, and hypertension. The referral for home care (11/22/23) noted under "Chief Complaint" that P-2 "complains of blurred vision and retinopathy... Blood sugars will run up to 300's at night and she will frequently take another dose of insulin at that time." On 2/13/24, review of the SOC comprehensive assessment performed by skilled nursing (SN) on 11/22/23, had revealed the following concerns. Under "Endocrine" (used for assessing diabetes), SN had checked ten interventions which were to be performed that day (SN discharged P-2 on 11/22/23) from SN service. In addition, SN documented goals for P-2's blood sugar readings were to be between 70 mg/dl. and 350 mg/dl. during the certification period. SN also documented under "Conclusions" that "Skilled Intervention" and "Skilled Instruction" were needed. However, no documentation was found within the initial assessment of SN ever performing any of the 10 interventions listed for diabetes. Further, under "Skilled Intervention" the entire narrative section that details what SN performed during the initial assessment was void of any diabetic information. Under "Plan for Next Visit", SN documented, "Teach about Diabetes Mellitus-the risk factors and treatment." No evidence was found in the medical record this occurred while P-2 was admitted by the agency. These findings were reviewed with and confirmed by the Administrator (Staff A) and Clinical Manager (Staff B) during an interview on 2/14/24 at 4:05 PM. Both agreed this did not meet agency expectations or its policy referenced below. Agency Policy: "Comprehensive Client Assessment" (undated) stated, "The depth and frequency on ongoing assessments will depend on client needs, goals, and the care treatment and services provided... Reassessments are conducted based on client needs, physician orders..." P-7: The SOC date for this patient was 11/30/2023, with diagnoses which included osteo-arthritis, congestive heart failure (CHF), urinary tract infection (UTI), and bacterial pneumonia. The referral for home care (11/29/23) documented P-7's weight was 125 pounds on 11/27/23 at 11:51 AM. Under Assessment/Plan, the physician documented "daily walking program, daily weight check, pt. needs visiting nurse." In addition, under "Problems" the referral listed 25 diagnoses including 10 different onset dates, such as CHF/fluid overload occurring on 2/27/2020, 9/9/2023, and again on 10/19/23. However, the SOC comprehensive assessment performed by skilled nursing (SN) on 11/22/23, had documented only 8 diagnoses, all with dates of onset being 11/30/23. P-2 also had an active UTI and bacterial pneumonia listed under the referral's "Assessment/Plan" on 11/29/23. On 2/14/24, review of the SOC comprehensive assessment performed by skilled nursing (SN) on 11/22/23, had documented a "stated" weight of 130 pounds. SN under "Notify Physician of:" left then section concerning weight greater (>) or less than ( These findings were reviewed with and confirmed by the Administrator (Staff A) and Clinical Manager (Staff B) during an interview on 2/14/24 at 4:35 PM. Both agreed this did not meet agency expectations or its policy referenced above.

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 (POC) met the needs of the patient in 3 (P-2, P-3, and P-7) of 7 records, out of a total sample of 7 records reviewed, resulting in the potential for negative patient outcomes for all 14 patients currently receiving services. Findings include: P-2: The start of care (SOC) date for this patient was 11/22/2023, with diagnoses which included diabetes-type 2, osteo-arthritis, and hypertension. The referral for home care (11/22/23) noted under "Chief Complaint" that P-2 "complains of blurred vision and retinopathy... Blood sugars (BS) will run up to 300's at night and she will frequently take another dose of insulin at that time." On 2/13/24, review of the POC revealed no orders to assess and document P-2's BS readings. Subsequently, 6 of 6 visits (11.24.23 to 12.13.23) made by the lone discipline of physical therapy failed to document any aspects concerning P-2's diabetes throughout admission. These findings were reviewed with and confirmed by the Administrator (Staff A) and Clinical Manager (Staff B) during an interview on 2/14/24 at 3:50 PM. Both agreed this did not meet agency expectations or its policy referenced below. Agency Policy: "Care Plans" (undated) pg. 1 stated, "Each client will have a care plan on file that outline care and services necessary to meet the patient specific needs identified..." P-3: The SOC date for this patient was 1/18/23, with diagnoses which included diabetes-type 2, hypertensive heart disease with congestive heart failure (CHF), and chronic kidney disease. On 2/13/24, review of the initial SOC assessment found P-3's blood sugar (BS) was 312 mg/dL. (normal is 74-106). The next visit on 1/25/23, skilled nursing (SN) had documented the following: "SN checked the BS level, first reading was 529 mg/dL., patient/cg stated she just ate breakfast, she had cereal with milk and some coffee. SN administered Victoza (medication for blood sugar control) 6 units and the re-checked BS after 30 minutes and went down to 429 mg/dL. SN instructed patient/cg to take the patient to the hospital, but patient and cg refused." When the Plan of Care (POC) for P-3 was reviewed, an order for Victoza was noted for a subcutaneous injection of 6 units daily. However, no sliding-scale insulin coverage was found in P-3's POC, and no order was found which authorized SN to administer any amount of Victoza PRN (as needed) under any circumstances. These findings were reviewed with and confirmed by the Administrator (Staff A) and Clinical Manager (Staff B) during an interview on 2/14/24 at 4:10 PM. Both agreed the POC should have included an order for sliding-scale insulin coverage prior to the 1/25/23 visit given P-3's previous diabetic history. The POC failed to include patient specific treatments/interventions to meet the needs of the patient. P-7: The SOC date for this patient was 11/30/2023, with diagnoses which included osteo-arthritis, congestive heart failure (CHF), urinary tract infection (UTI), and bacterial pneumonia. The referral for home care (11/29/23) documented P-7's weight was 125 pounds on 11/27/23 at 11:51 AM. The SOC assessment documented the patient's weight increased to 130 pounds. The referral's "Assessment/Plan" noted the physician documented for "daily walking program, daily weight check, pt. needs visiting nurse." In addition, under "Problems" the referral noted significant history of CHF/fluid overload occurring on 2/27/2020, 9/9/2023, and again on 10/19/23. On 2/14/24, review of P-7's plan of care (POC) failed to have any detailed patient specific treatments/interventions for CHF. Subsequently no other weight assessments were performed until 1/26/24, when P-2 was being recertified for another episode by physical therapy (PT) services. PT documented P-2's "stated" weight as 158 pounds (gain of 33-pounds since 11/27/23). Further, after the SOC assessment by skilled nursing (SN) on 11/30/24, the POC failed to incorporate any further SN visits to help meet the patient's needs as noted by the physician referral above. These findings were reviewed with and confirmed by the Administrator (Staff A) and Clinical Manager (Staff B) during an interview on 2/14/24 at 4:35 PM. Both agreed the POC for P-7 did not meet agency expectations or its policy referenced above.

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 services were provided only as ordered by the physician in 1 (P-3) of 7 total records reviewed, resulting in the potential to negatively affect all 14 patients currently serviced by the agency. Findings include: P-3: The start of care (SOC) date for this patient was 1/18/23, with diagnoses which included diabetes-type 2, hypertensive heart disease with congestive heart failure (CHF), and chronic kidney disease. On 2/13/24, review of the initial SOC assessment found P-3's blood sugar (BS) was 312 mg/dL. (normal is 74-106). The next visit on 1/25/23, skilled nursing (SN) had documented the following: "SN checked the BS level, first reading was 529 mg/dL., patient/cg stated she just ate breakfast, she had cereal with milk and some coffee. SN administered Victoza (medication for blood sugar control) 6 units and the re-checked BS after 30 minutes and went down to 429 mg/dL. SN instructed patient/cg to take the patient to the hospital, but patient and cg refused." It was unclear from the 1/25/23 note if P-3 had already taken the daily dose of Victoza prior to SN's administration. Further review of the SN notes on 1/25/23 found the physician's office was contacted concerning the "elevated blood sugar" but no documentation of subsequent orders or physician response was found in the medical record. When the Plan of Care (POC) for P-3 was reviewed, an order for Victoza was noted for a subcutaneous injection of 6 units daily. However, no sliding-scale insulin coverage was found in P-3's POC, and no order was found which authorized SN to administer any amount of Victoza PRN (as needed) under any circumstances. These findings were reviewed with and confirmed by the Administrator (Staff A) and Clinical Manager (Staff B) during an interview on 2/14/24 at 4:10 PM. Both agreed SN should not have administered Victoza and should have obtained an order for sliding-scale insulin coverage prior to the 1/25/23 visit given P-3's previous diabetic history.

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, the agency failed to ensure the physician was notified of changes in the patient's condition in 1 (P-7) of 7 records reviewed from a total sample of 7 records, resulting in the potential for poor clinical outcomes for all 14 patients currently receiving services. Findings include: P-7: The SOC date for this patient was 11/30/2023, with diagnoses which included osteo-arthritis, congestive heart failure (CHF), urinary tract infection (UTI), and bacterial pneumonia. The referral for home care (11/29/23) documented P-7's weight was 125 pounds on 11/27/23 at 11:51 AM. In addition, the referral noted the primary diagnosis as CHF/fluid overload, with occurrences on 2/27/2020, 9/9/2023, and again on 10/19/23. The referral's "Assessment/Plan" section documented daily weight checks were warranted to monitor for fluid overload. On 2/14/24, review of the SOC comprehensive assessment performed by skilled nursing (SN) on 11/22/23, had documented a "stated" weight of 130 pounds. No other weight assessments were performed until 1/26/24, when P-2 was being recertified for another episode by physical therapy (PT) services. PT documented P-2's "stated" weight as 158 pounds (gain of 33-pounds since 11/27/23), indicating the potential for fluid overload with subsequent hospitalization as evidenced from the three previous occurrences noted above. No evidence was found which indicated PT was aware of the significance of this weight gain, and no physician notification was found in the medical record. These findings were reviewed with and confirmed by the Administrator (Staff A) and Clinical Manager (Staff B) during an interview on 2/14/24 at 4:35 PM. Even though the recertification assessment on 1/26/24 showed no cardiovascular or respiratory concerns, both agreed the PT should have notified the physician once an actual weight was obtained.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview, it was determined that the agency failed to provide documentation that a discharge summary had been sent to the physician for review as required in 3 (P-2, P-3, and P-6) of 3 discharge records, out of a total sample of 7 records reviewed, resulting in the potential for unmet post-discharge needs. Findings include: P-2: This patient was admitted to the agency on 11/22/2023, with diagnoses which included diabetes-type 2, osteo-arthritis, and hypertension. The referral for home care (11/22/23) noted under "Chief Complaint" that P-2 "complains of blurred vision and retinopathy... Blood sugars will run up to 300's at night and she will frequently take another dose of insulin at that time." On 2/13/24, record review noted skilled nursing (SN) had performed a discharge from SN services on 11/22/23, the same day P-2 was admitted. Physical therapy (PT) had discharged the patient from the agency on 12/13/23. However, evidence of a discharge summary from the agency was not found in the medical record. No summary of findings concerning P-2's diabetes management was provided to the physician for review. These findings were reviewed with and confirmed by the Administrator (Staff A) and Clinical Manager (Staff B) during an interview on 2/14/24 at 3:45 PM. Both agreed this did not meet agency expectations or its policy referenced below. Agency Policy: "Discharge Policy & Summary" (undated) stated, "The discharge summary shall include, but not limited to: Services provided; Status upon admission; Status at time of discharge, Patient response to treatment..." The policy further stated, "When a client is discharged from the agency, a discharge summary and/or OASIS (Outcome and Assessment Information Set) form shall be completed... A copy of the discharge summary will be sent to the physician..." P-3: The admit date for this patient was 1/18/23, with diagnoses which included diabetes-type 2, hypertensive heart disease with congestive heart failure (CHF), and chronic kidney disease. The referral for home care (1/18/23) documented that P-2 had 13 diagnoses concerning: "Uncontrolled systolic blood pressure around 185... acute diastolic CHF exacerbation, discharged from the hospital 8/8 cont bumex (diuretic medication) ..." (SIC) and being an insulin-dependent diabetic. On 2/13/24, record review found the patient had been hospitalized on 2/15/23 due to uncontrolled blood sugars greater than 500 (normal is 74-106). Further review noted SN discharged the patient from the agency on 3/16/23. SN utilized the OASIS discharge form which included a "Discharge Summary" that failed to summarize any of the medical concerns above with clinical data obtained throughout the certification period, response to intervention/treatments, and progress made towards set goals. These findings were reviewed with and confirmed by the Administrator (Staff A) and Clinical Manager (Staff B) during an interview on 2/14/24 at 4:00 PM. Both agreed this did not meet agency expectations or its policy referenced above. P-6: The admit date for this patient was 7/11/23, with diagnoses which included cerebral infarction (stroke in the brain), dysphagia (difficulty swallowing), and low back pain. On 2/14/24, record review noted PT (lone discipline ordered) discharged the patient from the agency on 8/2/23. Additional review found no evidence of a discharge summary in the medical record. These findings were reviewed with and confirmed by the Administrator (Staff A) and Clinical Manager (Staff B) during an interview on 2/14/24 at 4:15 PM. Both agreed this did not meet agency expectations or its policy referenced above.

On 2/9/21 through 2/11/21, an Emergency Preparedness survey was conducted by the Michigan Department of Licensing and Regulatory Affairs. At the survey, Honest Home Care was found to be not in compliance with the standard requirements for participation in Medicare at 42 CFR 484.102 Emergency Preparedness.

EP Training Program CFR(s): 484.102(d)(1) *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on record review, it was determined that the agency failed to ensure initial training in emergency preparedness policies and procedures was provided to all employees. Findings include: **Agency policy "Training & Testing" (dated 2020) stated, "Initial training in emergency preparedness policies and procedures to all new and exiting staff, individuals providing services under arrangement consistent with their expected roles...Documentation of training shall be maintained...Staff knowledge of emergency preparedness shall be demonstrated..." During a review of the agency's emergency preparedness training binder on 2/11/21 it was noted that there was no documented initial Emergency preparedness training for employees. Review of employee records documented initial emergency preparedness training by a check mark on the orientation form. There was no evidence the employees were trained initially in the emergency preparedness policy and procedures. During an interview on 2/11/21 at 1630 hours Admin-A (administrator) and DON-A (director of nursing) acknowledged the above findings.

On 2/9/21 to 2/11/21, the Michigan Department of Licensing and Regulatory Affairs conducted a Medicare authorized recertification survey along with a focused infection control survey at: Honest Home Care 1681 E Auburn Rd., Suite B Rochester Hills, MI 48307 Clinical records reviewed for this survey: 3 records with home visits and 4 records without home visits for a total of 7 records reviewed. The agency has no branch sites. The following condition level deficiency was identified during the survey: 42 CFR §484.60 Care planning, coordination of services, and quality of care. 42 CFR §484.65 Quality Assessment/Performance Improvement 42 CFR §484.80 Home Health Aide Services. At the conclusion of the survey the agency was found to be in compliance for the conditions of participation for Home Health Agency at: 42 CFR Part §484.70 Infection Prevention and Control. As a result of the Condition level noncompliance on 2/11/21, the Agency is prohibited for 2 years from offering a Home Health Aide training and competency evaluation or a competency evaluation program as specified in 42 CFR §484.80(f)(3).

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment included a review of all medications to identify any potential adverse effects, drug reactions, or interactions for 5 of 7 (MR# 3, 4, 5, 6, 7) records reviewed, resulting in the potential for harmful medication effects for these patients. Findings include: MR#4: This patient was admitted to the agency on 1/14/21 with diagnoses of osteoarthritis of bilateral knees, hypertension, and prostatic hyperplasia. The comprehensive assessment was completed by PT-A (physical therapist) on 1/14/21. The 2/9/21 review of the comprehensive assessment indicates for (M2001) drug regimen review that, "Yes issues were found during review." Documented was that the physician had been contacted regarding potential clinically significant medication issues, (M2003) was checked yes. There was no evidence that a medication review had been completed by PT-A for this patient. During review on 2/9/21 of the "Patient Medication Record" found in the written patient record, the drug review had been completed by DON-A (director of nursing) that was dated 1/18/21 and that the physician had been faxed on 1/18/21 stating, "PT notified MD of high-risk RX, Duplicate RX: Finasteride & Tamsulosin, Pulmicort, Advair & Ventolin." A Drug/Allergy Checks sheet was attached with the date completed 2/9/21 blacked out with drug interactions and duplicate therapy found. During an interview at 18:30 hours on 2/11/21, DON-A stated, "I did the drug review after you requested the patient's record, none had been completed prior to 2/9/21." MR#5: This patient was admitted to the agency on 1/14/21 with diagnoses of osteoarthritis of bilateral knees, spondylosis of lumbar region, and type 2 diabetes mellitus. The comprehensive assessment was completed by RN-A (registered nurse) on 1/14/21. The 2/10/21 review of the comprehensive assessment indicates for (M2001) drug regimen review that, "Yes issues were found during review." Documented was that the physician had been contacted regarding potential clinically significant medication issues, (M2003) was checked yes. There was no evidence that a medication review had been completed by RN-A for this patient. During review on 2/10/21 of the "Patient Medication Record" found in the written patient record the drug review had been completed by DON-A (director of nursing) that was dated 1/18/21 and that the physician had been faxed on 1/18/21 stating, "PT notified MD of high-risk RX, Duplicate RX: Insulin Glargine & Lispro & Metformin." A Drug/Allergy Checks sheet was attached with the date completed 2/9/21 blacked out with drug interactions and duplicate therapy found. During an interview at 18:30 hours on 2/11/21, DON-A stated, "I did the drug review after you requested the patient's record, none had been completed prior to 2/9/21." MR#6: This patient was admitted to the agency on 10/27/20 with diagnoses of hypertension, osteoarthritis of bilateral hips, and osteoarthritis of bilateral knees. The comprehensive assessment was completed by RN-B (registered nurse) on 10/27/20. The 2/10/21 review of the comprehensive assessment indicates for (M2001) drug regimen review that, "No issues were found during review." The physician had been contacted regarding potential clinically significant medication issues, (M2003) was not checked yes or no. There was no evidence that a medication review had been completed by RN-B for this patient. Additionally, the plan of care failed to include the following medications ordered on the referral dated 10/26/20: Lamotrigine (for bipolar depression), Atorvastatin (lowers cholesterol), and metoprolol (treats high blood pressure). There was no documentation by RN-B that the physician was notified regarding these patient medications. MR#7: This patient was admitted to the agency on 3/13/20 with diagnoses of heart failure, chronic kidney disease, and type 2 diabetes mellitus. The comprehensive assessment was completed by RN-A (registered nurse) on 3/13/20. The 2/11/21 review of the comprehensive assessment indicates for (M2001) drug regimen review that, "No issues were found during review." The physician had been contacted regarding potential clinically significant medication issues (M2003) was not checked yes or no. There was no evidence that a medication review had been completed by RN-A for this patient. A drug interaction report at Drugs.com completed on 2/11/21 indicated a major interaction between Colchicine (anti-inflammatory) and Atorvastatin (cholesterol lowering), a major food interaction between Colchicine and grapefruit juice, and therapeutic duplication with anticholinergics/antispasmodics- Oxybutynin/Dicyclomine. The skilled nurse failed to identify and report to the physician the drug interactions for the 21 medications the patient was taking at the time of service. The findings were reviewed with and acknowledged by Admin-A (administrator) and DON-A (director of nursing) during an interview on 2/11/21 at 1630 hours. M.R. #3: This patient was admitted to the agency on 6/24/2020 with the diagnoses of, "Chronic Obstructive Pulmonary Disease, Stage 1 Sacral Pressure Ulcer, and Parkinson's Disease." The Comprehensive Assessment was dated 6/24/2020 and signed by RN-A (registered nurse). At the time of the 2/11/2021 record review it was noted the assessment documented, "(M2001) Drug regimen review-No issues found during review, (M2003) Medication Follow-Up: Did the agency contact a physician....No or Yes," nothing was checked. There was no evidence that a medication review had been completed by RN-A for this patient. A drug interaction report at Drugs.com completed on 2/11/2021 indicated major interaction between Pramipexole Dihydrochoride (anti-parkinson) and Quetipine Fumarate (anti-psychotic), and Carbidopa-Levodopa-Entacapone (anti-parkinson) and Quetipine Fumarate. The skilled nurse failed to identify and report to the physician the drug interactions for the 8 medications the patient was taking at the time of service.

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 the agency failed to include all necessary treatments in the plan of care for 2 of 7 records reviewed (MR# 5, 7) (G574); failed to ensure the skilled nurse documented the patient's treatments and medication as ordered by the physician for 2 of 2 (MR# 6, 7) records reviewed in which the treatment was not provided as ordered and failed to provide MSW (master of social work) services in 1 of 1 (MR# 6) records reviewed (G578); failed to ensure services were provided only as ordered by the physician in 1 of 7 (MR# 6) records reviewed (G580) and failed to ensure the patient's care plans were kept current and revised, as needed, for 1 of 1 records reviewed (MR# 6) (G586). The cumulative effect of these systemic problems resulted in the agency's inability to ensure the provision of quality health 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 agency failed to include all necessary treatments in the plan of care for 2 of 7 records reviewed (MR# 5, 7), resulting in the potential for patient decline. Findings include: **Agency policy "Care Plans" (reviewed 2020) stated, "Each client will have a care plan on file that outline care and services necessary to meet the patient specific needs identified in the comprehensive assessment, addresses their identified needs and the agency's plan to respond to those need. This plan is developed with the client and family, as indicated, and is based on services needed to achieve specific measurable goals." MR#5: This patient was admitted to the agency on 1/14/21 with diagnoses of osteoarthritis of bilateral knees, spondylosis of lumbar region, and type 2 diabetes mellitus. The plan of care dated 1/14/21 failed to specify the frequency the patient/caregiver was to complete glucose monitoring while taking Insulin Lispro (fast acting insulin) 5 units SQ 3 times a day with meals. MR#7: This patient was admitted to the agency on 3/13/20 with diagnoses of heart failure, chronic kidney disease, and type 2 diabetes mellitus. The plan of care dated 3/13/20 failed to specify the frequency the patient/caregiver was to complete glucose monitoring while taking Novolog (fast acting insulin) subcutaneous 34 u AM, 24 U dinner TID (3 times/day) (this order is unclear) and Basaglar Kwikpen subcutaneous 60 u bedtime. The above findings were reviewed and acknowledged by Admin-A (administrator) and DON-A (director of nursing) during an interview on 2/11/21 at 1630 hours.

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 agency failed to ensure the skilled nurse documented the patient's treatments and medication as ordered by the physician for 2 of 2 (MR# 6, 7) records reviewed in which the treatment was not provided as ordered and failed to provide MSW (master of social work) services in 1 of 1 (MR# 6) records reviewed in which services were ordered, resulting in no documentation that the physician order was completed and the potential for poor patient outcomes for these patient's. Findings include: **Agency policy "Care Plans" (reviewed 2020) stated, "Each client will have a care plan on file that outline care and services necessary to meet the patient specific needs identified in the comprehensive assessment, addresses their identified needs and the agency's plan to respond to those need. This plan is developed with the client and family, as indicated, and is based on services needed to achieve specific measurable goals." MR#6: This patient was admitted to the agency on 10/27/20 with diagnoses of hypertension, osteoarthritis of bilateral hips, and osteoarthritis of bilateral knees. The referral signed and dated by the physician on 10/26/20 stated, "Please contact the primary care physician if the BP (blood pressure) is >160/90 or ) 168 or less than () 98 or less than ( 3+..." The patient received skilled nursing with a frequency of one time a week for 3 weeks. The skilled nurse (SN) documented a stated weight of 273 pounds on the initial comprehensive assessment on 3/13/20. The referral dated 3/11/20 documented a weight of 290 pounds. The SN failed to document a weight on the two additional visits dated 3/17/20 and 3/24/20. The skilled nurse failed to follow the plan of care orders and monitor the patient's weight with a diagnosis of heart failure. The above findings were reviewed and acknowledged by Admin-A (administrator) and DON-A (director of nursing) during an interview on 2/11/21 at 1630 hours.

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 services were provided only as ordered by the physician in 1 of 7 (MR# 6) records reviewed, resulting in the potential to negatively affect this patient. Findings include: MR#6: This patient was admitted to the agency on 10/27/20 with diagnoses of hypertension, osteoarthritis of bilateral hips, and osteoarthritis of bilateral knees. The initial comprehensive assessment completed on 10/27/20 by RN-B (registered nurse) stated that endocrine was within normal limits. The plan of care dated 10/27/20 failed to list diabetic medication or orders for blood glucose monitoring. During record review on 2/11/21 it was noted RN-B documented the patient's blood glucose levels on 11/3/20, 11/17/20, and 11/24/20. There was no evidence that the physician ordered blood glucose monitoring by the SN. The above findings were reviewed and acknowledged by Admin-A (administrator) and DON-A (director of nursing) during an interview on 2/11/21 at 1630 hours.

Review and revision of the plan of care CFR(s): 484.60(c) Standard: Review and revision of the plan of care. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the patient's care plan were kept current and revised, as needed, for 1 of 1 records reviewed (MR# 6) resulting in missed visits without physician orders and a potential for poor patient outcomes. Findings include: MR#6: This patient was admitted to the agency on 10/27/20 with diagnoses of hypertension, osteoarthritis of bilateral hips, and osteoarthritis of bilateral knees. The plan of care dated 10/27/20 specified skilled nursing, physical therapy (PT), and master of social work services. The physical therapy services ordered on 10/29/20 specified a frequency of, "1W1, 2W1, and 1W6." The PT provided the first 3 weeks of service as ordered. The clinical record documented missed visits week 4 (11/8/20-11/14/20) and week 5 (11/22/20 to 11/28/20). There was a communication note that the physical therapist had been exposed to Covid-19 and was in quarantine, and the patient had refused to have services from another physical therapist. The agency failed to update the physician orders for not providing PT services for week 4 and 5. The above findings were reviewed and acknowledged by Admin-A (administrator) and DON-A (director of nursing) during an interview on 2/11/21 at 1630 hours.

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on record review and interview, it was determined the agency failed to develop, implement, and maintain a quality assessment and performance improvement program (Refer to G 0642), failed to collect and use data to monitor the effectiveness, safety of services and quality of care and identify opportunities for improvement by the quality assessment and performance improvement program (Refer to G 0644), and the agency failed to document the quality improvement projects for 2018, 2019 and 2020 and document the reasons for conducting these projects and the measurable progress achieved each year (Refer to G 0658). The cumulative effect of these systemic problems resulted in the agency's inability to ensure the provision of quality health care in a safe environment for the condition of participation of 42 CFR§484.65 Quality Assessment and Performance Improvement (QAPI).

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on record review and interview, it was determined the agency failed to develop, implement, and maintain a quality assessment and performance improvement program which had the potential to negatively affect all 155 patients that were admitted during the past 12 months, resulting in a potential for poor patient outcomes due to the provision of substandard care. Findings include: During an interview on 2/11/2021 at 11 AM a request was submitted to review the QAPI (quality assessment performance improvement) documents for 2018, 2019, and 2020. After a brief time, Administrator-A stated, "I'm sorry, I am unable to locate the QAPI documents for 2018 and 2019. I phoned the previous owner, and they don't have it (QAPI reports for 2018). I will check for 2019 and 2020." A large binder was submitted for my review at 11:45 AM with several documents. During a review of the binder, it was noted there was no data collected or analysis of any data QAPI data for 2018, 2019 and 2021, for any of the identified PIPs (performance improvement projects). During an interview on 2/11/2021 at 3:40 PM it was queried who was responsible for the QAPI reports, the Director of Nursing-A (DON-A) replied, "I am." It was queried to identify the PIPs for 2020 and 2021 the DON-A replied, "We're working on infection control, both employee and patient, UTIs (Urinary Tract Infection), Respiratory Infection and any other infections-hospital or otherwise acquired and staff transferred." A request was submitted to review the Infection Control data collected for 2019 and 2020 the DON-A replied, "We didn't have any employee or patient infections last year, so I didn't have any data to collect." During a review of the agency's Unduplicated Census report for 2/9/2020 to 2/9/2021 there were five patients noted to have the following infectious diagnoses: COVID-19, Cough, UTI (urinary tract infection) and other Unspecified Inflammations the DON-A stated, "Oh, this information didn't get pulled over from Kinnser (the electronic medical record program), so I didn't have that information to add to the QAPI report, I will have to go back and review it." There was no data available for review for any of the other QAPI PIPs for 2018, 2019 and 2020. The agency provided no data collection, tracking of adverse events, data analysis, improvement activities or performance improvement projects for review for 2018, 2019 or 2020. For the years of 2018, 2019, and 2020 it was noted that the governing body failed to ensure: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained. (2) That the HHA-wide (home health agency) quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness. (3) That clear expectations for patient safety are established, implemented, and maintained. (4) That any findings of fraud or waste are appropriately addressed. During an interview on 2/11/2021 the Director of Nursing agreed with the above findings and stated, "I know I have to start collecting some data."

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on record review and interview, it was determined the agency failed to collect and use data to monitor the effectiveness, safety of services and quality of care and identify opportunities for improvement by the quality assessment and performance improvement program, which had the potential to negatively affect all patients serviced by the agency, resulting in a potential for poor patient outcomes due to the provision of substandard care. Findings include: During an interview on 2/11/2021 at 11 AM a request was submitted to review the QAPI (quality assessment performance improvement) documents for 2018, 2019, and 2020. After a brief time, Administrator-A stated, "I'm sorry, I am unable to locate the QAPI documents for 2018 and 2019. I phoned the previous owner, and they do not have it (QAPI reports for 2018). I will check for 2019 and 2020." A large binder was submitted for my review at 11:45 AM with several documents. During a review of the binder, it was noted there was no data collected or analysis of any data QAPI data for 2018, 2019 and 2021, for any of the identified PIPs (performance improvement projects). During an interview on 2/11/2021 at 3:40 PM it was queried who was responsible for the QAPI reports, the Director of Nursing-A (DON-A) replied, "I am." It was queried to identify the PIPs for 2020 and 2021 the DON-A replied, "We're working on infection control, both employee and patient, UTIs (Urinary Tract Infection), Respiratory Infection and any other infections-hospital or otherwise acquired and staff transferred." A request was submitted to review the Infection Control data collected for 2019 and 2020 the DON-A replied, "We didn't have any employee or patient infections last year, so I didn't have any data to collect." During a review of the agency's Unduplicated Census report for 2/9/2020 to 2/9/2021 there were five patients noted to have the following infectious diagnoses: COVID-19, Cough, UTI (urinary tract infection) and other Unspecified Inflammations the DON-A stated, "Oh, this information didn't get pulled over from Kinnser (the electronic medical record program), so I didn't have that information to add to the QAPI report, I will have to go back and review it." There was no data available for review for any of the other QAPI PIPs for 2018, 2019 and 2020. The agency provided no data collection, no monitoring of data to track the effectiveness, safety of services and quality of care, and to identify opportunities for improvement by the QAPI program for 2018, 2019 or 2020. During an interview on 2/11/2021 the Director of Nursing agreed with the above findings and stated, "I know I have to start collecting some data."

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and interview it was determined, the agency failed to document the quality improvement projects for 2018, 2019 and 2020 and document the reasons for conducting these projects and the measurable progress achieved each year, which had the potential to negatively affect all patients serviced by the agency, resulting in a potential for poor patient outcomes due to the provision of substandard care. Findings include: During an interview on 2/11/2021 at 11 AM a request was submitted to review the QAPI (quality assessment performance improvement) documents for 2018, 2019, and 2020. After a brief time, Administrator-A stated, "I'm sorry, I am unable to locate the QAPI documents for 2018 and 2019. I phoned the previous owner, and they do not have it (QAPI reports for 2018). I will check for 2019 and 2020." A large binder was submitted for my review at 11:45 AM with several documents. During a review of the binder, it was noted there was no data collected or analysis of any data QAPI data for 2018, 2019 and 2021, for any of the identified PIPs (performance improvement projects). During an interview on 2/11/2021 at 3:40 PM it was queried who was responsible for the QAPI reports, the Director of Nursing-A (DON-A) replied, "I am." It was queried to identify the PIPs for 2020 and 2021 the DON-A replied, "We're working on infection control, both employee and patient, UTIs (Urinary Tract Infection), Respiratory Infection and any other infections-hospital or otherwise acquired and staff transferred." A request was submitted to review the Infection Control data collected for 2019 and 2020 the DON-A replied, "We didn't have any employee or patient infections last year, so I didn't have any data to collect." It was queried to explain why the same infections were being maintained each year as one of the PIPs if the data continues to be zero infections each year the DON-A replied, "Because there is always a potential for infection, so we continue to monitor it." During a review of the agency's Unduplicated Census report for 2/9/2020 to 2/9/2021 there were five patients noted to have the following infectious diagnoses: COVID-19, Cough, UTI (urinary tract infection) and other Unspecified Inflammations the DON-A stated, "Oh, this information didn't get pulled over from Kinnser (the electronic medical record program), so I didn't have that information to add to the QAPI report, I will have to go back and review it." There was no data available for review for any of the other QAPI PIPs for 2018, 2019 and 2020. There was no documented evidence of quality improvement for the identified PIPs for 2018, 2019 and 2020 and no documented evidence of measurable progress achieved each year. During an interview on 2/11/2021 the Director of Nursing agreed with the above findings and stated, "I know I have to start collecting some data."

Home health aide services CFR(s): 484.80 Condition of participation: Home health aide services. All home health aide services must be provided by individuals who meet the personnel requirements specified in paragraph (a) of this section. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure the home health aide (HHA competency evaluation addressed each of the listed subject subject (Refer to G768), the agency failed to ensure the registered nurse included safety measures in the patient care instructions for the home health aide (Refer to G798), the agency failed to ensure the aide provided services as ordered by the physician and at the frequency ordered on the plan of care (Refer to G0800), the agency failed to ensure on-site supervisory visits to the patient's home were made at least every 14-days to supervise the care provided by the home health aide (Refer to G0808), and the registered nurse failed to make an annual on-site home health aide supervisory visit to the location where the patient was receiving care along with the home health aide (Aide-A), to observe and assess the aide while performing care (Refer to G0812). The cumulative effect of these systemic problems resulted in the agency's inability to ensure the provision of safe and quality services by competent home health aides, for all patients receiving aide services, for the Condition of Participation of 42 CFR §484.80, Home Health Aide Services.

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the home health aide (HHA competency evaluation addressed each of the listed subject areas (Aide-A) from a total sample of 1 home health aide personnel file reviewed, resulting in the potential of substandard aide services that could negatively affect all patients receiving aide services. Findings include: Agency Policy, "Competency Assessment," not dated stated, "Competency of all staff will be assessed during the interview process, orientation program and ongoing throughout employment, (Direct Care Staff will be assessed for competencies annually). During the home health aide personnel file review on 02/09/2021 the following was noted: HHa-A (Home Health Aide): Date of hire was 10/17/2018. The aide's certification was from "Career Advancement Studies in Healthcare Institute dated 3/29/2012. There was no documented evidence a registered nurse completed all the aide's competencies prior to the aide performing services. The Competency Demonstration checklist documented each task was dated 10/17/18. There was no documented evidence the aide's competency evaluation addressed the following subjects: (b)(3)(i), (iii), (ix), sponge, tub, and shower bath. There was no documentation on the competency form that the aide completed competency on Hair Shampooing in the tub. And there was no documentation to determine the location where the tasks were performed (e.g., patient home, lab, classroom, etc.) and no documentation to identify the patient used for each task. The above findings were reviewed and acknowledged by the Director of Nursing during an interview on 02/11/2021 at 3:30 PM.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the registered nurse included safety measures in the patient care instructions for the home health aide in 2 of 3 (MR# 3 and 7) records reviewed in which the patient received home health aide services, resulting in the potential for the provision of unsafe care for this patient. Findings include: **Agency policy "Home Health Aide: Assignment" (reviewed 2020) stated, "The need for home health aide services is determined during the assessment by the nurse or therapist...To provide direction and supervision of care provided by the Home Health Aide..." MR#7: This patient was admitted to the agency on 3/13/20 with diagnoses of heart failure, chronic kidney disease, and type 2 diabetes mellitus. The 3/13/20 plan of care ordered the aide to provide two visits each week for 3 weeks. The plan of care specified the following safety precautions: keep pathway clear, slow position change, fall precautions, anticoagulant precautions, support during transfer and ambulation, sharps safety, and infection control...The aide care plan developed by RN-A (registered nurse) on 3/13/20 failed to contain safety precautions and diabetic precautions for the aide to be aware of while providing care to the patient. The findings were reviewed and acknowledged by Admin-A (administrator) and DON-A (director of nursing) during an interview on 2/11/21/at 1630 hours. M.R. #3: This patient was admitted to the agency on 6/24/2020 with the diagnoses of, "Chronic Obstructive Pulmonary Disease, Stage 1 Sacral Pressure Ulcer, and Parkinson's Disease." The Plan of Care (POC) dated 6/24/2020 specified, "HHA (home health aide) 2X4 for assistance for personal care." The Safety Measures on the POC were documented as: Slow position change, Mobility safety, Support during transfer and ambulation, Anticoagulant Precautions, Safety in ADLs (activities in daily living), Proper position during meals, Fall Precautions, Use of assistive devices and Infection Control." The aide care plan dated 6/24/2020, developed by RN-A (registered nurse) failed to contain safety precautions for the aide to be aware of while providing care to the patient to prevent possible injuries. The findings were reviewed and acknowledged by the DON-A (Director of Nursing) during the Exit Conference on 2/11/2021.

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 agency failed to ensure the aide provided services as ordered by the physician and at the frequency ordered on the plan of care for 1 of 3 (MR#3) record reviewed in which aide services were ordered, resulting in the potential for unmet personal care needs for this patient and potentially negatively affecting all the patients receiving aide services. Findings include: M.R. #3: This patient was admitted to the agency on 6/24/2020 with the diagnoses of, "Chronic Obstructive Pulmonary Disease, Stage 1 Sacral Pressure Ulcer, and Parkinson's Disease." The Plan of Care (POC) dated 6/24/2020 specified, "HHA (home health aide) 2X4 (twice a week for four weeks) for assistance for personal care." And the Aide Care Plan signed by RN-A (registered nurse) and dated 6/24/20 instructed the aide to document "No bowel movement in 3 days." At the time of the record review on 2/11/2021, it was noted Aide-A (home health aide) documented five visits from 7/7/20 to 7/29/20, there was no documented evidence Aide-A documented the patient's bowel movements on any of the five visit notes. And it was also noted there were no documented home visits for the first two weeks (06/24/20 to 07/04/20) of this certification period. There was no documented communication that the patient or caregiver refused aide visits for the first two weeks of service. During the Exit Conference on 2/11/2021 at 4:35 PM, the above information was reviewed and acknowledged by the Director of Nursing.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure on-site supervisory visits to the patient's home were made at least every 14-days to supervise the care provided by the home health aide for 2 of 3 (MR#3 and 7) record reviewed in which aide services were provided for a period of time greater than 2 weeks, resulting in a lack of oversight of aide care and services for this one patient. Findings include: **Agency policy "Home Health Aide: Assignment" (reviewed 2020) stated, "The need for home health aide services is determined during the assessment by the nurse or therapist...To provide direction and supervision of care provided by the Home Health Aide..." MR#7: This patient was admitted to the agency on 3/13/20 with diagnoses of heart failure, chronic kidney disease, and type 2 diabetes mellitus. The 3/13/20 plan of care ordered skilled nurse visits weekly for 3 weeks and the aide was to provide two visits each week for 3 weeks. RN-A (registered nurse) provided visits on 3/13/20, 3/17/20, and 3/24/20. The aide provided 2 visits weekly starting 3/17/20 to 4/2/20. DON-A (director of nursing) documented the aide supervision on 3/26/21, which failed to be provided on a physician ordered skilled nursing home visit. The registered nurse failed to document an on-site home visit to complete the home health aide supervision. The findings were reviewed and acknowledged by Admin-A (administrator) and DON-A (director of nursing) during an interview on 2/11/21/at 1630 hours. M.R. #3: This patient was admitted to the agency on 6/24/2020 with the diagnoses of, "Chronic Obstructive Pulmonary Disease, Stage 1 Sacral Pressure Ulcer, and Parkinson's Disease." The Plan of Care (POC) dated 6/24/2020 specified, "SN (skilled nurse) 1X6 (once a week for six weeks) and HHA (home health aide) 2X4 (twice a week for four weeks) for assistance for personal care." At the time of the record review on 2/11/2021, it was noted RN-A (registered nurse) documented six visits: 6/24/20, 7/1/20, 7/7/20, 7/16/20, 7/21/20 and 7/31/20. And Aide-A (home health aide) documented seven visits: 7/7/20, 7/14/20, 7/18/20, 7/23/20, 7/25/20, 7/29/20 and 8/1/20. The DON-A (Director of Nursing) documented two aide supervisions on 7/14/20 and 7/25/20, which failed to be provided during a physician ordered and a scheduled skilled nursing home visit. During the Exit Conference on 2/11/2021 at 4:30 PM, the above findings were reviewed and acknowledged by Admin-A (Administrator) and DON-A (Director of Nursing).

Direct observation every 12 months CFR(s): 484.80(h)(1)(iii) A registered nurse or other appropriate skilled professional must make an annual on-site visit to the location where a patient is receiving care in order to observe and assess each aide while he or she is performing care. This ELEMENT is not met as evidenced by: Based on record review and interview, the registered nurse failed to make an annual on-site supervisory visit to the location where the patient was receiving care along with the home health aide (Aide-A), to observe and assess the aide while performing care for 1 of 1 home health aide providing care, for a potential of an aide providing services that could negatively affect all patients receiving aide services. Findings include: During the personnel file review on 02/09/2021, the following information was noted: HHa-A (Home Health Aide) date of hire was 10/17/2018. There was no documented evidence a registered nurse completed an Annual On-site Aide's Supervisory review for HHa-A for 2019 and 2020. A request was submitted to review the 2019 and 2020 annual aide's supervisory review the Director of Nursing (DON-A) replied, "Sure, okay." During the Exit Conference conducted on 02/11/2021 at 4:35 PM, it was queried to identify the location of the documented Aide's annual supervisory visits, the Director of Nursing (DON-A) replied, "You will find it documented on the visit note." During the home health aide personnel file review on 02/11/2021 there was no documented annual onsite supervisory visit for 2019 or 2020 in the aide's file. And during the clinical record review from 02/09/2020 to 02/09/2021 there was no documented evidence a registered nurse completed an Aide's Annual On-site Supervisory review for HHa-A.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a discharge summary was sent to the physician within 5 business days of the patient's discharge for 3 of 4 (MR# 3, 6 and 7) records reviewed in which the patient was discharged from the agency, resulting in the physician not having knowledge of the patient's health status at the time of discharge. Findings include: MR#6: This patient was admitted to the agency on 10/27/20 with diagnoses of hypertension, osteoarthritis of bilateral hips, and osteoarthritis of bilateral knees. The plan of care dated 10/27/20 specified skilled nursing, physical therapy, and master of social work services. The skilled nurse dicharged the patient on 11/24/20. The master of social work failed to discharge the patient. The physical therapist discharged the patient on 12/19/20 with a discharge OASIS-D including a discharge summary dated 12/19/20. There was no evidence that the discharge summary was sent to the ordering physician within 5 business days of the patient's discharge. MR#7: This patient was admitted to the agency on 3/13/20 with diagnoses of heart failure, chronic kidney disease, and type 2 diabetes mellitus. The plan of care dated 3/13/20 specified skilled nursing, home health aide, and physical therapy. The skilled nurse discharged the patient from nursing services on 3/24/20. Home health aide services were provided thru the fourth week. Physical therapy discharged the patient week 7 on 4/23/20 completing OASIS-D. There was no evidence that the discharge summary was sent to the ordering physician within 5 business days of the patient's discharge. The agency failed to follow its own policy titled, Discharge Policy & Summary (reviewed 2020), which states that all discharge summaries shall be sent to the patient's physician within 5 days of the patient's discharge from services. The findings were reviewed with the DON-A (director of nursing) during an interview on 2/11/21 at 1630 hours. M.R. #3: This patient was admitted to the agency on 6/24/2020 with the diagnoses of, "Chronic Obstructive Pulmonary Disease, Stage 1 Sacral Pressure Ulcer, and Parkinson's Disease." The Plan of Care dated 6/24/2020 ordered Skilled Nursing (SN), Physical Therapy (PT) and Home Health Aide (HHa) services. The SN Discharge Summary was dated 7/31/2020. The PT's last visit was dated 7/30/2020 and the PT's Discharge Summary was dated 8/13/2020. There was no documented evidence the Discharge OASIS summary was sent to the physician within 5 business days of the patient's discharge.