Every finding on record at Integrity Home Health Care, Inc

The following deficiencies were identified during a Medicare authorized Emergency Preparedness survey conducted by the Michigan Department of Licensing and Regulatory Affairs on 9/30/24 through 10/3/24 at: Integrity Home Health Care 530 Stephenson Hwy. Suite 110 Troy, MI 48083 This agency had no additional locations. Records: 5 records with home visits, 4 discharged records, 4 records without home visits, for a total of 13 records reviewed. At the conclusion of the survey, this agency was determined to be out of compliance with the Conditions of Participation at 42 CFR 484 Emergency Preparedness.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on record review and interview, the Agency failed to develop an emergency preparedness plan that had been reviewed and updated, at least every 2 years, resulting in lack of direction for Agency personnel in the event of an actual emergency or disaster. This deficient practice could negatively affect the health and safety of all directly employed staff, regularly utilized contracted staff and all patients currently serviced by this Agency in the event of a facility emergency or disaster. Findings include: On 10/1/24 at 2:55 p.m., a request was made to review the agency's Emergency Preparedness Plan. Upon receipt and review of the provided documents, it was noted that the plan had not been updated. A Hazardous Vulnerability Assessment/Risk Assessment was dated for 11/2018. During an interview on 10/1/24 at 3:15 p.m., the Clinical Manager stated, "It (Emergency Preparedness Plan) has not been updated since 2018 because I didn't know how to get the updated forms to complete the Risk Assessment. The agency failed to ensure the Emergency Preparedness Plan had been reviewed and updated at least every 2 years as per this requirement. These findings were reviewed with and acknowledged by CM #1 at the time of discovery.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on record review and interview, the Agency failed to ensure an emergency plan existed that was based on a documented facility and community-based risk assessment from an all-hazards approach, resulting in the potential for lack of preparedness and poor patient and staff outcomes, in the event of an actual emergency. Findings include: On 10/1/24 at 2:55 p.m., a request was made to review the agency's Emergency Preparedness Plan. Upon receipt and review of the provided documents, it was noted that the plan had not been updated. A Hazardous Vulnerability Assessment/Risk Assessment was dated for 11/2018. During an interview on 10/1/24 at 3:15 p.m., the Clinical Manager (CM #1) stated, "It (Emergency Preparedness Plan) has not been updated since 2018 because I didn't know how to get the updated forms to complete the Risk Assessment. The agency failed to ensure the Emergency Preparedness Plan was based on an updated facility/community-based risk assessment utilizing an all-hazards approach. These findings were reviewed with and acknowledged by CM #1 at the time of discovery.

The following deficiencies were identified during a Medicare authorized recertification survey conducted by the Michigan Department of Licensing and Regulatory Affairs on 9/30/24 through 10/3/24 at: Integrity Home Health Care 530 Stephenson Hwy. Suite 110 Troy, MI 48083 This agency had no additional locations. Records: 5 records with home visits, 4 discharged records, 4 records without home visits, for a total of 13 records reviewed. At the conclusion of the survey, this agency was determined to be out of compliance with the Conditions of Participation at 42 CFR 484 Home Health Agencies.

Patient's needs CFR(s): 484.55(c)(4) The patient's medical, nursing, rehabilitative, social, and discharge planning needs; This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure the patient's Activity of Daily Living needs were adequately met in the patient's home for 1 (P-1) of 1 patient observed during a home visit, who required assistance with grooming, from a total of 13 sampled records reviewed, resulting in the potential for loss of self-esteem, poor hygiene and unmet care needs. Findings include: Policy: "Patient Admission Criteria", undated, stated, "Patients will be accepted for care only if Agency can meet a patient's identified needs." P-1: The patient's start of care (SOC) was 9/21/24 with diagnoses that included Lymphedema and Congestive Heart Failure. During the record review on 9/30/24 at 12:30 p.m., it was noted that section M1800 of the Initial Comprehensive Assessment documented, "Patient depends entirely upon someone else for grooming needs..., dressing upper body..., lower body..., someone must help to maintain toileting hygiene." Section M1100 stated the patient lives with other persons in the home, however there was no listed, designated caregiver or persons willing to assist with ADL care. On 9/30/24 at 2:15, during a scheduled survey home visit with the Registered Nurse (RN #1), the patient's daughter, who was present during the visit, expressed her concerns about the patient not being bathed/showered and not knowing who to contact to receive assistance with grooming. During additional review of the record, there was no documented evidence that Home Health Aide services had been offered or provided as part of the patient's health care coverage. These findings were reviewed with and acknowledged by the Clinical Manager (CM #1) during an interview on 10/3/24 at 8:58 a.m.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the plan of care was complete and included all the required diagnoses, interventions and associated measurable goals to address the identified needs of the patient in 1 (P-1) record of a patient who required specialized care and monitoring from a total of 13 sampled records reviewed, resulting in the potential for untreated health concerns, decline in health and unmet care needs. Findings include: Policy: 'Plan of Care-CMS #485 and Physician Orders", undated, stated, "The Plan of Care includes: Diagnoses (primary and secondary), types of services and equipment required, expected goals or outcomes to be achieved." P-1: The patient's start of care was 9/21/24. According to the hospital documents, the patient was admitted with diagnoses that included Lymphedema bilateral lower extremities and Congestive Heart Failure. During a review of the clinical record on 9/30/24 at 12:30 p.m., it was noted that Plan of Care (POC) was incomplete and void of any diagnoses. Further, there were no interventions, patient teaching, reportable parameters or associated measurable goals that addressed the patient's diagnosis of Congestive Heart Failure. These findings were reviewed with and acknowledged by the Clinical Manager during an interview on 10/3/24 at 8:58 a.m.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure verbal physician orders were accepted only by personnel authorized to do so according to agency policy in 1 (P-8) of 13 sample records reviewed resulting in unqualified personnel receiving physician referral orders and potentially resulting unmet needs for the patient. Findings include: Agency policy titled “Plan of Care-CMS #485 and Physicians Orders” revised 11/14/2018, was reviewed on 10/3/24. On page 2., it stated “8. Verbal orders are: Spoken to appropriate clinicians and later put in writing, signed, timed and dated with date of receipt by a RN or therapist responsible for furnishing or supervising ordered services.” Agency policy titled “Patient Admission Criteria” revised 03/26/24, was reviewed on 10/3/24. On page 2., it stated “When a telephone referral is received by the Agency, a referral form is completed by a RN.” P-8: This 63-year-old patient was admitted on 9/30/24 with diagnoses including joint replacement of the left knee; atrial fibrillation (abnormal heart rhythm), and high blood pressure. The clinical record was reviewed on 10/2/24. During review, it was noted that the physician referral dated 9/27/24 included orders for Skilled Nursing and Physical Therapy (PT) services. On 9/27/24, a “Patient Communication” note was entered by the agency intake coordinator which stated that clarification was made of the homecare orders from the physician’s office and the patient would be receiving PT services only. The PT completed the comprehensive assessment of the patient on 9/30/24 and no nursing visits were scheduled. During interview with the Clinical Manager (CM#1) on 10/3/24 at 1:30 p.m., CM#1 was queried to whether the intake coordinator had appropriate credentials to take a verbal physicians order or change of referral orders over the phone. CM#1 stated that the intake coordinator is not a licensed nurse and acknowledged that the registered nurse was the appropriate personnel to take the referral clarification per agency policy.

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 its disciplines utilized Infection Control standards of practice during the provision of care and services for 2 (P-1 and P-8) of 5 patients observed during home visits, from a total of 13 sampled records reviewed, resulting in the potential for the development and spread of infection. Findings include: P-1: The patient's start of care was 9/21/24 with diagnoses that included Lymphedema bilateral lower extremities with drainage and Congestive Heart Failure. During the record review on 9/30/24 at 12:30 p.m., it was noted that the Plan of Care ordered Skilled Nursing (SN) for the following wound care orders: Cleanse with wound cleanser, pat dry, apply Unna boot then Kerlix and Coban then secure with tape. On 9/30/24 at 2:15 p.m., a scheduled survey home visit was conducted with the Registered Nurse (RN #1). During the visit, RN #1 donned a pair of gloves and continued to apply additional pairs of gloves, creating an overlay. RN #1 proceeded to clean the patient's right leg with wound cleanser and gauze. RN #1 then removed the outer pair of gloves and applied the Unna boot gauze to the patient's right leg. RN #1 then removed a pair of gloves and applied Kerlix gauze. RN #1 then covered the dressing with Coban elastic wrap. After applying the Coban wrap to the patient's right leg, RN #1 removed a pair of gloves and donned additional pairs of gloves to his hands. RN #1 did not wash his hands or use hand sanitizer between the donning of gloves. With a remaining pair of gloves on his hands, RN #1 applied additional pairs of gloves to his hands and repeated the process as before. Upon completion of the dressing applications, RN #1 removed the final pair of gloves and sanitized his hands. RN #1 then applied a clean pair of gloves and discarded the dirty items from the floor. Wearing the same gloves used to discard items from the floor, RN #1 retrieved a cleansing wipe and began wiping his stethoscope, blood pressure cuff and pulse oximeter and placed all the items in his bag. RN #1 failed to utilize Infection Control standards of practice during the provision of care and services. These findings were reviewed with and acknowledged by the Clinical Manager during an interview on 10/3/24 at 8:58 a.m. P-8: This 63-year-old patient was admitted on 9/30/24 with diagnoses including joint replacement of the left knee; atrial fibrillation (abnormal heart rhythm), and high blood pressure. On 10/1/24 at 2 p.m., a joint visit was conducted with the Physical Therapist (PT). During the visit, it was observed that the PT brought a bag from his vehicle and into the home which contained shared patient PT equipment (exercise/safety equipment). The PT retrieved a pair of gloves from the bag he brought, donned them, and began providing direct care to the patient (handling the patient and patient surroundings). It was also observed that the PT reached for items in the bag 3 separate times without first removing the dirty gloves or performing hand hygiene. This finding was reviewed and acknowledged during review with the Clinical Manager (CM#1) on 10/3/24 at 1:30 p.m.

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on interview and record review, it was determined the Agency failed to provide documented evidence that Infection Control education was provided to all staff employed by the agency, including contracted staff, resulting in the potential for the development and spread of infection to staff and all patients currently serviced by this agency. Findings include: On 10/1/24 at 2:10 p.m., the Clinical Manager (CM #1) was asked for permission to review the agency's Infection Control in-services. At 2:15 p.m., upon receipt and review of the provided documents, it was noted that all staff, according to the provided staff list, had not received in-services or training in Infection Control. CM #1 provided a document titled, "Bag Technique." dated for the month of June 2024, however, all staff were not in attendance and did not receive this education. Further, CM #1 provided a list of typed names of employees reported to have received this training. When asked why all staff had not attended the in-service, CM #1 responded, "They just didn't attend the meeting." No other documentation was provided by the end of the survey. The agency failed to ensure all staff, including those granted clinical privileges, received Infection Control in-services and training. The above findings were reviewed with and acknowledged by CM #1 at the time of discovery.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on record review and interview, the Agency failed to ensure Occupational Therapy (OT) services were authorized only by the health care professional qualified to do so in 4 (P-5, P-6, P-9 and P-12) of 13 sample records reviewed resulting in a lack of appropriate skilled assessment, and the potential for unmet needs of the patient. Findings include: P-5: The patient's start of care (SOC) was 9/16/24 with diagnoses that included Fractured Pubis and Fractured Greater Trochanter. During the clinical record review on 10/3/24 at 10:13 a.m., it was noted that the referral for home care dated 9/14/24 ordered Skilled Nursing (SN), Physical Therapy (PT), Home Health Aide (HHa) and Occupational Therapy (OT) services to be provided. Upon further review, it was noted that the Plan of Care (POC) documented, "PT to evaluate for the need for OT." It was unclear as to what methodology would be used for PT to determine the need for OT services. Additionally, no OT services had been provided at the time of this review. P-6: The patient's SOC was 9/2/24 with diagnoses that included Covid-19 and Acute Respiratory Failure. During the clinical record review on 10/3/24 at 11:30 a.m., it was noted that the referral for home care dated 8/27/24 ordered PT, OT, SN and OT services to be provided. The POC documented, "PT to evaluate for the need for OT." It was unclear as to what methodology would be used for PT to determine the need for OT services. Additionally, at the time of this review, no OT services had been provided as ordered. Agency job description for an Occupational Therapist (undated) was reviewed on 10/3/24. On page 1., it stated “Occupational Therapist Reporting to: Nursing Supervisor and/or VP of Operations and/or Administrator… The Occupational Therapist is responsible for providing in home Occupational Therapy services to Agency patients, as prescribed by the attending physician…” P-9: This 92-year-old was admitted to the agency on 8/29/24 with diagnoses including hypertensive heart disease (heart problems associated with high blood pressure); heart failure; and acute kidney failure. The medical record was reviewed on 10/2/24. The physician referral order dated 8/14/24 included orders for the following skilled services: Nursing; Occupational Therapy (OT); and Physical Therapy (PT). The plan of care (POC) developed by the agency on 8/29/24 included orders for PT to evaluate and treat, and for PT to evaluate the need for OT. PT completed an evaluation on 8/30/24 and documented “no need for OT services able to address all therapy needs” [sic]. OT did not perform an assessment of the patient to determine if OT services would benefit the patient. It was unclear how the PT determined that a different skilled professional service (OT) was not needed. P-12: This 56-year-old was admitted to agency on 9/21/24 with diagnoses including chronic pain; back pain; and pain to left shoulder. The medical record was reviewed on 10/2/24. The physician referral order dated 9/18/24 included orders for the following skilled services: Nursing; OT; and PT. The POC developed by the agency on 9/21/24 included orders for PT to evaluate and treat, and for PT to evaluate the need for OT. PT completed an evaluation on 9/23/24 and documented “no need for OT services able to address all therapy needs with PT only” [sic]. OT did not perform an assessment of the patient to determine if OT services would benefit the patient. It was unclear how the PT determined that a different skilled professional service (OT) was not needed. These findings were reviewed and acknowledged during review with the Clinical Manager (CM#1) on 10/3/24 at 1:30 p.m.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the patient received services as ordered by the physician and indicated in the plan of care for 3 (P-1, P-7, P-12) of 13 sampled records reviewed potentially resulting in unmet care needs for the patient. Findings include: P-1: The patient's start of care was 9/21/24 with diagnoses that included Lymphedema and Congestive Heart Failure. During the clinical record review on 9/30/24 at 12:30 p.m., it was noted that the referral for home care dated 9/19/24, ordered Skilled Nursing, Physical Therapy and Occupational Therapy services to be provided. At the time of this review, no Occupational Therapy services had been provided as ordered. These findings were reviewed with the Clinical Manager (CM #1) during an interview on 10/3/24 at 8:58 a.m. P-7: The patient's start of care was 9/2/24 with diagnoses that included Malignant Neoplasm of Brain and Cognitive Disorder. During the record review on 10/3/24 at 1:00 p.m., it was noted that the referral for home care dated 8/30/24, ordered Physical Therapy, Occupational Therapy and Speech Therapy services to be provided. At the time of this review, no Speech Therapy services had been provided as ordered. These findings were reviewed with and acknowledged by CM #1 during an interview on 10/3/24 at 2:14 p.m. Agency policy titled “Plan of Care-CMS #485 and Physicians Orders” revised 11/14/2018, was reviewed on 10/3/24. On page 3., it stated “12. The Agency alerts the physician to any changes that suggests a need to alter the plan of care. If the Agency provides fewer visits than the physician orders, it has altered the plan of care and the physician must be notified.” P-12: This 56-year-old was admitted to agency on 9/21/24 with diagnoses including chronic pain; back pain; and pain to left shoulder. The medical record was reviewed on 10/2/24. Physical Therapy (PT) completed an evaluation on 9/23/24 and included a frequency of 2 times a week for 3 weeks, and then 1 time a week for 1 week. During the first week of care (9/22/24 through 9/28/24), the PT made only 1 visit on 9/23/24. The PT entered a “Missed Visit” note on 9/26/24 and documented that the patient refused the visit due to having back soreness (diagnosis warranting home health care). Additionally, the PT marked “No” to the question of whether the physician was notified of the missed visit. There was no evidence that the PT attempted to reschedule the visit to meet frequency for the week. This finding was reviewed and acknowledged during review with the Clinical Manager (CM#1) on 10/3/24 at 1:30 p.m.

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 completed Discharge/Transfer summary was sent to the Physican within the required time frame, for 2 (P-3, P-7) patients who were either transferred to an inpatient facility or discharged from the agency's services, from a total of 13 sampled records reviewed, resulting in the Physician not having a clear clinical picture of the status of the patient at the time of transfer/discharge and the potential for unidentified continuing health needs. Findings include: Policy: "Transfer/Referral Criteria" undated, stated, "A written Transfer Summary concerning the agency's involvement with the patient, e.g., summary of care/services provided, patient's current physical and psychosocial status, reconcile and review medication list, advance directives, any continuing symptom management needs, e.g., pain, nausea or dyspnea and reasons for transfer or referral will be forwarded to the new health care provider." P-3: The patient's start of care (SOC) was 6/5/24 with diagnoses that included Radiculopathy and Low Back Pain. During the record review on 9/30/24, it was noted that Physical Therapy services were ordered to be provided. The patient was discharged from PT services on 6/26/24. There was no documented evidence that the PT Discharge Summary dated 6/26/24 was sent to the Physician within 5 days of the patient's date of discharge. These findings were reviewed with and acknowledged by the Clinical Manager (CM #1) during an interview on 10/3/24 at 9:30 a.m. who reported, "The summary went out on 7/8/24, so it was after 5 days." P-7: The patient's SOC was 9/2/24 with diagnoses that included Malignant Neoplasm of Brain and cognitive Disorder. During the record review on 10/3/24 at 1:00 p.m., it was noted that the patient was transferred to an inpatient facility on 9/18/24 due to convulsions. Upon further review, there was no documented evidence that the Transfer Summary, dated 9/18/24, had been sent to the receiving facility within 2 days of becoming aware of the transfer to an inpatient facility. On 10/324 at 2:14 p.m., during an interview, CM #1 reported, "I thought we only had to send it to the Physician. I guess I misinterpreted it." CM #1 then stated, "We sent the summary/notification to the Physician the following week on 9/26/24.

An unannounced on-site complaint investigation for federally authorized complaint #61185 was conducted on 12/8/21 at: Integrity Home Health Care 530 Stephenson Hwy., Suite 110 Troy, MI 48083 At the time of the survey, the agency did not operate any branch locations. The allegation was substantiated. Clinical records reviewed for this survey included: 5 active records without home visits for a total of 5 records reviewed. The agency was found to be in not in compliance at the standard level, with 42 CFR §484 Conditions of Participation for Home Health Agencies.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, it was determined that the Agency failed to ensure Skilled Nursing, Occupational Therapy and Medical social Work services were provided as ordered in 1 (MR# 4) of 5 records reviewed, resulting in the potential for physical and psychological decline and unmet care needs. Findings include: Policy: "Patient Admission Criteria" 4/29/20, stated, "Patients are accepted for treatment on the basis of a reasonable expectation that the patient's medical, nursing and social needs can be met adequately by the Agency in the patient's place of residence. Patients will be accepted for care only if Agency can meet a patient's identified needs." MR#4: The Start of Care (SOC) was dated 11/2/21. The Plan of Care (POC) identified diagnosis of Instability of Internal Left Knee Arthroplasty. During record review on 12/8/21, it was noted that the POC ordered Skilled Nursing (SN) at a frequency of 1w1 (1 time a week for 1 week) and Physical Therapy (PT) at a frequency of 2w1. RN#2 completed the comprehensive assessment on 11/2/21. PT#2 completed and evaluation on 11/3/21. A phone interview was completed on 12/7/21 at 3:00 pm with the complainant (MR#4) and stated, “The physical therapist (PT#2) set up an appointment to return on 11/5/21. I received a call on 11/5/21 from PT#2 who told me they needed to reschedule for 11/6/21. PT#2 never showed for the appointment on 11/6/21, and I have not heard from the agency since.” PT#2 documented a “Communication Note” on 11/6/21 and stated, “Called patient several times, no answer. Intake notified. MD office left a message.” The discharge completed by PT#2 on 11/6/21 documented the “Reason For Discharge” as “Per patient/family request”. Furthermore, under the “Care Summary (care given, progress, regress including therapies):” documented, “Only initial evaluation was done. Patient refused further PT visit as she will be going to outpatient next week. The Patients status is same of initial evaluation.” The agency failed to meet the scheduled order frequency. The DQ#1 was questioned on 12/8/21 at 2:20 pm and confirmed the findings stating, "Yes, the frequency was not met.”

During a Recertification survey conducted by the Michigan Department of Licensing and Regulatory Affairs on 10/26/21 through 10/29/21, it was determined that Integrity Home Health Care was in substantial compliance with the Conditions of Participation at 42 CFR §484.102 Emergency Preparedness.

The following Condition and Standard level deficiencies were identified during a Recertification survey conducted by the Michigan Department of Licensing and Regulatory Affairs on 10/26/21 through 10/29/21 at: Integrity Home Health Care530 Stephenson Hwy, Suite 110Troy, MI 48083This Agency has no additional branch locations. Services Offered: Skilled Nursing, Physical Therapy, Home Health Aide, Speech Therapy, Medical Social work, Registered Dietician. Records reviewed: 5 records with home visits; 8 records without home visits for a total of 13 records reviewed. The following conditions were identified: 42 CFR §484.75 Skilled Professional Services. As a result of the Condition level noncompliance, 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).

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 observation, interview and record review, the Agency failed to ensure that 4 (MR's #1, 4, 5 and 6) of 4 patients observed during home visits were included in the overall planning of care including informing the patient/caregiver in advance of the days in which services would be provided, from a total of 13 sampled records reviewed, resulting lack of inclusion in planning, the potential for missed visits and unmet care needs. Findings include: MR #1: The patient's start of care (SOC) was 10/14/21 with diagnoses that included Cervical Herniated Discs and Heart Failure. During the clinical record review on 10/26/21 at 3:08 p.m., it was noted that Skilled Nursing (SN) Physical Therapy (PT) and Occupational Therapy services were ordered to be provided. On 10/26/21 at 12:30 p.m., a home visit was conducted with the Occupational Therapist (OT #1). During a review of the patient's admission packet, it was noted that there was no calendar of proposed visits to be made by either of the ordered disciplines. MR #4: The patient's SOC was 9/7/21 with diagnoses that included Subdural Hematoma, Weakness, Dementia and Hypertension. During the clinical record review on 10/27/21, it was noted that Skilled Nursing (SN), Home Health Aide (HHa), Physical Therapy (PT), OT and Speech Therapy (ST) services were ordered to be provided. On 10/27/21 at 10:00 a.m., during a scheduled home visit with the Physical Therapist (PT #1), it was noted that the patient's admission packet was void of a calendar of proposed visits to be made by all the above ordered disciplines. MR #5: The patient's SOC was 10/15/21 with diagnoses that included Congestive Heart Failure and Acute Respiratory Failure. During a clinical record review, it was noted that SN, PT and OT services were ordered to be provided. On 10/27/21 at 11:30 a.m., during a scheduled home visit with the Skilled Nurse (RN #1), it was noted that the patient's admission packet was void of a calendar of proposed visits to be made by all the above ordered disciplines. MR #6: The patient's SOC was 10/22/21 with a diagnosis of Right Knee Replacement. During the clinical record review on 10/28/21, it was noted that SN and PT services were ordered to be provided. On 10/27/21 at 12:30 p.m., during a scheduled home visit with RN #2, it was noted that the patient's admission packet was void of a calendar of proposed visits to be made by the above ordered disciplines. The agency failed to ensure a calendar of proposed visits had been provided at the SOC to assist the patient with participating in planning his care and daily routine. The above findings were reviewed with and acknowledged by the Clinical Manager (CM #1) during an interview on 10/29/21 at 11:10 a.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 history of events leading to current home care needs in 6 of 13 records reviewed (MR#s 8, 9, 10, 11, 12, and 13), resulting in incomplete clinical information to aid in determining the needs of the patient and determining progress towards goals. Findings included: MR#8: The Start of Care (SOC) was dated 7/26/21. The Plan of Care (POC) identified diagnoses of Cystostomy and Chronic Kidney Disease. During record review on 10/29/21, it was noted that the SOC comprehensive assessment dated 7/26/21, documented under "Primary Diagnosis and Other Diagnoses", of the 15 diagnoses, 10 had the exacerbation date of 7/26/21 and 5 were blank with the date of 7/26/21. No prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. MR#9: The Start of Care (SOC) was dated 10/17/21. The Plan of Care (POC) identified diagnosis of Left Knee Replacement. During record review on 10/29/21, it was noted that the SOC comprehensive assessment dated 10/17/21, documented under "Primary Diagnosis and Other Diagnoses", of the 17 diagnoses, 2 had an exacerbation date of 7/26/21, 1 had an onset date of 7/26/21, and 14 were blank under onset/exacerbation with the date of 7/26/21. No prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. MR#10: The Start of Care (SOC) was dated 8/11/21. The Plan of Care (POC) identified diagnoses of Myocardial Infarction, Gastrointestinal Bleed and Anemia. During record review on 10/28/21, it was noted that the SOC comprehensive assessment dated 8/11/21, documented under "Primary Diagnosis and Other Diagnoses", of the 14 diagnoses, 9 had an exacerbation date of 8/11/21 and 5 were blank under onset/exacerbation with the date of 8/11/21. No prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. MR#11: The Start of Care (SOC) was dated 1/12/21. The Plan of Care (POC) identified diagnoses of Spondylosis, Spinal Stenosis and Congestive Heart Failure (CHF). During record review on 10/28/21, it was noted that the SOC comprehensive assessment dated 1/12/21, documented under "Primary Diagnosis and Other Diagnoses", all 14 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 6/15/21. The Plan of Care (POC) identified diagnoses of Right Pubis Fracture, Contusion of Left Hip and Pain in Left Hip. During record review on 10/28/21, it was noted that the SOC comprehensive assessment dated 6/15/21, documented under "Primary Diagnosis and Other Diagnoses", of the 13 diagnoses, 11 had an exacerbation date of 6/15/21 and 2 were blank under onset/exacerbation with the date of 6/15/21. No 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 1/2/21. The Plan of Care (POC) identified diagnoses of Calculus of Bile Duct, Atrial Fibrillation and Congestive Heart Failure (CHF). During record review on 10/28/21, it was noted that the SOC comprehensive assessment dated 1/2/21, documented under "Primary Diagnosis and Other Diagnoses", of the 10 diagnoses, 9 had an exacerbation date of 1/2/21 and 1 was blank under onset/exacerbation with the date of 1/2/21. No prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to have the individualized written plan of care signed by the physician for 3 of 13 records reviewed (MR# 8, 10 and 11), resulting in services and care being provided by the agency without a physician’s signature. Findings include: **Agency policy "Plan of Care – CMS #485 and Physician Orders" (Revised 11/14/2018) stated, "Procedure. 5. The total Plan of Care will be reviewed and signed by the attending physician and Agency personnel involved in the patient’s care as often as the severity of the patient’s condition requires, but at least once every sixty (60) days. The agency professional staff will promptly alert the physician to any changes that suggest a need to alter the Plan of Care." MR#8: The Start of Care (SOC) was dated 7/26/21. The Plan of Care (POC) identified diagnoses of Cystostomy and Chronic Kidney Disease. During record review on 10/29/21, it was noted that the Plan of Care dated 7/26/21 was unsigned by the physician within the EMR (Electronic Medical Record), 35 days late per the agency policy. MR#10: The Start of Care (SOC) was dated 8/11/21. The Plan of Care (POC) identified diagnoses of Myocardial Infarction, Gastrointestinal Bleed and Anemia. During record review on 10/28/21, it was noted that the Plan of Care dated 8/11/21 was unsigned by both the Registered Nurse and the physician within the EMR, 17 days late per the agency policy. MR#11: The Start of Care (SOC) was dated 1/12/21. The Plan of Care (POC) identified diagnoses of Spondylosis, Spinal Stenosis and Congestive Heart Failure (CHF). During record review on 10/28/21, it was noted that the Plan of Care dated 1/12/21 was unsigned by the physician within the EMR, 229 days late per the agency policy. DQ #1 was questioned on 10/29/21 @ 1:25pm and stated, “They are completed timely, per Medicare.”

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, it was determined that the agency failed to provide 3(MR#'s 1, 4 and 6) of 5 patients observed during home visits, with a Medication Profile that included the names, dosages and frequencies of the patient's prescribed medications, in plain language, from a total of 13 sampled records reviewed, resulting in lack of direction for medication administration and the potential for improper use of medications. Findings include: MR #1: The patient's start of care (SOC) was 10/14/21 with diagnoses that included Cervical Herniated Disc and Heart Failure. During the clinical record review on 10/26/21 at 3:08 p.m., it was noted that Skilled Nursing (SN), Physical Therapy (PT) and Occupational Therapy (OT) services were ordered to be provided. On 10/26/21 at 12:30 p.m., a joint home visit was conducted with the Occupational Therapist (OT #1). During a review of the patient's admission packet, it was noted that there was no Medication Profile in the patient's admission packet that listed the patient's prescribed medications, dosages and side effects. The patient was queried and expressed no knowledge of ever having a Medication list provided by the Agency. MR #4: The patient's SOC was 9/17/21 with diagnoses that included Subdural Hematoma, Weakness and Dementia. During the clinical record review on 10/27/21, it was noted that SN, PT, OT, Home Health Aide (HHa) and Speech Therapy (ST) services were ordered to be provided. On 10/27/21 at 10:00 a.m., a joint home visit was conducted with the Physical Therapist (PT #1). During a review of the patient's admission packet, it was noted that there was no Medication Profile in the patient's admission packet that listed the patient's prescribed medications, dosages and side effects. The patient's sister-in-law, who was present during the visit, was queried and expressed no knowledge of ever having a Medication list provided by the Agency and stated, "They (Agency) never gave me one." MR #6: The patient's SOC was 10/22/21 with a diagnosis of Right Knee Replacement. During the clinical record review on 10/28/21 at 9:00 a.m., it was noted that SN and PT services were ordered to be provided. On 10/27/21 at 12:30 p.m., a joint home visit was conducted with the RN #2. During a review of the patient's admission packet, it was noted that there was no Medication Profile in the patient's admission packet that listed the patient's prescribed medications, dosages and side effects. The findings identified in the above records were reviewed with and acknowledged by the Clinical Manager (CM #1) during an interview on 10/29/21 at 11:10 a.m.

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Physical Therapists, Speech Therapist, Occupational Therapists and Medical Social Work assisted the Physician in evaluating the patient's level of functioning and helped to develop the Plan of Care for 5 (MR#'s 4, 5, 7, 11 and 12) of 7 patients reviewed with ordered Therapy services, from a total of 13 sampled records reviewed, resulting in the potential for decline in physiological functioning and unmet care needs (G708); failed to ensure Occupational Therapy and Medical social Work services were provided in 4 (MR#'s 1, 4, 5, and 7) of 7 records reviewed, from a total of 13 sampled records reviewed, resulting in the potential for poor hygiene, physical and psychological decline and unmet care needs (G710); failed to ensure the clinical record was completed and included detailed Physical Therapy and Skilled Nursing notes for 2 (MR #7 and 9) of 2 records reviewed with the ordered services, from a total of 13 sampled records reviewed, resulting in the potential for undocumented, unidentified health concerns, and unmet patient needs (G716). The cumulative effects of this systemic problem resulted in the Home Health Agency's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR 484.75 Skilled Professional Services.

Development and evaluation of plan of care CFR(s): 484.75(b)(2) Development and evaluation of the plan of care in partnership with the patient, representative (if any), and caregiver(s); This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Physical Therapists, Speech Therapist, Occupational Therapists and Medical Social Worker assisted the Physician in evaluating the patient's level of functioning and helped to develop the Plan of Care for 5 (MR#'s 4, 5, 7, 11 and 12) of 7 patients reviewed with ordered Therapy services, from a total of 13 sampled records reviewed, resulting in the potential for decline in physiological functioning and unmet care needs. Findings include: MR #4: This patient was admitted to the agency on 9/17/21 with diagnoses of Subdural Hematoma, Weakness, Dementia and Hypertension. The clinical record review was conducted on 10/27/21. During the review, it was noted that the Plan of Care ordered Skilled Nursing (SN) services to be provided, and Physical Therapy (PT), Occupational Therapy (OT) and Speech Therapy (ST) to evaluate and treat. During the review, it was noted that there was no documented evidence that the ordered disciplines (PT, OT, ST) had conducted an evaluation of the patient as ordered by the physician, in order to assist with the Plan of Care. Further, there was no documented evidence that the patient or caregiver had declined the ordered services. Additionally, there was no documented evidence that the physician had been informed that the ordered services not had not been provided. MR #5: The patient's start of care (SOC) was 10/15/21 with diagnoses that included Congestive Heart Failure, Acute Respiratory Failure and Pulmonary Edema. During the clinical record review on 10/28/21, it was noted that the plan of care ordered PT and OT to evaluate and treat. At the time of this review, there was no documented evidence that OT conducted an evaluation of the patient as ordered by the Physician, in order to assist with the Plan of Care. Further, there was no documented evidence that the patient or caregiver had declined the ordered services. Additionally, there was no documented evidence that the physician had been informed that the ordered service had been delayed and or not provided. MR #7: This patient was admitted to the agency on 9/22/21 with diagnoses that included Quadriceps tendon repair and heart failure. During the clinical record review conducted on 10/28/21 at 1:15 p.m., it was noted that the referral for home care dated 9/20/21 ordered PT and OT to evaluate and treat. At the time of this review, there was no documented evidence that OT conducted an evaluation of the patient as ordered by the Physician, in order to assist with the Plan of Care. Further, there was no documented evidence that the patient/caregiver had declined services. Additionally, there was no documented evidence that the Physician had been informed that the ordered service had not been provided. The deficient findings identified in the above records were reviewed with and acknowledged by the Clinical Manager during an interview on 10/29/21 at 2:40 p.m. MR#11: The Start of Care (SOC) was dated 1/12/21. The Plan of Care (POC) identified diagnoses of Spondylosis, Spinal Stenosis and Congestive Heart Failure (CHF). During record review on 10/28/21, the referral dated 1/12/21 documented, "HHC (RN (Registered Nurse), PT (Physical Therapy), OT (Occupational Therapy), CNA (Home Health Aide), MSW (Medical Social Worker)." There was no documentation of the patient refusing OT services within the comprehensive assessment dated 1/12/21. MR#12: The Start of Care (SOC) was dated 6/15/21. The Plan of Care (POC) identified diagnoses of Right Pubis Fracture, Contusion of Left Hip and Pain in Left Hip. During record review on 10/28/21, the referral dated 6/12/21 documented, "Home Care: Integrity Home Care. Physical Therapy, Occupational Therapy, Social Services (MSW), RN, Evaluate need for Home Health Aide." There was no documentation of the patient refusing MSW services within the comprehensive assessment dated 6/15/21. DQ #1 was questioned on 10/29/21 @ 1:45pm and stated, “I do not see where they refused those services.”

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 observation, interview and record review, it was determined that the Agency failed to ensure Skilled Nursing, Occupational Therapy and Medical social Work services were provided as ordered in 4 (MR#'s 1, 4, 5, and 7) of 7 records reviewed, from a total of 13 sampled records reviewed, resulting in the potential for poor hygiene, physical and psychological decline and unmet care needs. Findings include: Policy: "Patient Admission Criteria" 4/29/20, stated, "Patients are accepted for treatment on the basis of a reasonable expectation that the patient's medical, nursing and social needs can be met adequately by the Agency in the patient's place of residence. Patients will be accepted for care only if Agency can meet a patient's identified needs." MR #1: The patient's start of care (SOC) was 10/14/21 with diagnoses that included Cervical Herniated Disc and Heart Failure. During the clinical record review on 10/26/21 at 3:08 p.m., it was noted that the referral for home care ordered Skilled Nursing (SN), Physical Therapy (PT) and Occupational Therapy (OT) therapy services to be provided. Upon review of the Initial Comprehensive Assessment dated 10/14/21, it was noted that SN was to provide services at a frequency of 2x/wk. x 1 wk. During the review, it was noted that the SN only saw the patient one time. The SN failed to follow the specified frequency in the provision of care of services. MR #4: The patient's SOC was 9/17/21 with diagnoses that included Subdural Hematoma, Weakness and Dementia. The clinical record review was conducted on 10/27/21. During the review, it was noted that the referral for home care services, dated 9/15/21, ordered SN, PT, OT, Home Health Aide (HHa) and Speech Therapy (ST) services to be provided. At the time of the clinical record review, HHa, OT and ST services had not been provided. On 10/27/21 at 10:00 a.m. a scheduled home visit was conducted with the Physical Therapist (PT #1). During the visit, it was noted that the patient ambulated with an unsteady gait and required the use of an assistive device when ambulating. It was also noted that the patient spoke with a slow low tone. The patient's sister-in-law was present during the visit and when queried as to whether she provides assistance with grooming, replied, "No. I just come by to clean his apartment sometimes. I think he tries to do it (grooming) himself." There was no evidence that the above ordered services had been provided by the end of the survey or that the patient had declined the ordered services. These findings were reviewed with and acknowledged by the Clinical Manager (CM #1) during an interview on 10/29/21 at 10:07 a.m. and again at 2:35 p.m. MR #5: The patient's SOC was 10/15/21 with diagnoses that included Congestive Heart Failure, Acute Respiratory Failure and Pulmonary Edema. The clinical record review was conducted on 10/27/21. During the review, it was noted that the referral for home care services, dated 10/8/21, ordered "CENA (Home Health Aide/HHa), OT, PT, SN, RN and Medical Social Work (MSW) services to be provided. At the time of the clinical record review, HHa, OT and MSW services had not been provided. There was no documented evidence that the patient declined the ordered services. These findings were reviewed with and acknowledged by CM #1 during an interview on 10/29/21 at 10:15 a.m. MR #7: The patient's SOC was 9/22/21 with diagnoses that included Quadriceps Tendon repair and Heart Failure. The clinical record review was conducted on 10/28/21 at 1:15 p.m. During the review, it was noted that the referral for home care dated 9/20/21 order RN, PT and OT services to be provided. The patient's Hospital discharge paperwork dated 9/21/21 ordered HHa services to be provided. At the time of this record review, neither OT or HHa services had been provided as ordered. Additionally, there was no documented evidence that the patient/caregiver had declined/refused the ordered services. These findings were reviewed with and acknowledged by CM #1 during an interview on 10/29/21 at 2:40 p.m.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the clinical record was completed and included detailed Physical Therapy and Skilled Nursing notes for 2 (MR #7 and 9) of 2 records with the ordered services, from a total of 13 sampled records reviewed, resulting in the potential for undocumented, unidentified health concerns, and unmet patient needs. Findings include: MR#9: The Start of Care (SOC) was dated 10/17/21. The Plan of Care (POC) identified diagnosis of Left Knee Replacement. During record review on 10/29/21, it was noted that the POC ordered Skilled Nursing (SN) at a frequency of 1w2 (1 visit every week for 2 weeks) and Physical Therapy (PT) at a frequency of 3w1, 2w1. The Electronic Medical Record (EMR) contained the SN SOC on 10/17/21 and the PT evaluation on 10/18/21. A joint PT discharge visit was completed on 10/28/21. As of 10/29/21, there were no other completed SN or PT visit notes. DQ #1 was questioned on 10/29/21 at 1:55pm and stated, “We are using the blanket waivers on documentation timeliness.” Policy: "Medical Record Content" 4/29/20 stated, "The Agency will provide an accurate and current medical record for every patient seen by the Agency..., to ensure documentation of patient status, home care services and outcomes." MR #7: The patient's start of care was 9/22/21 with a diagnoses that included Quadriceps tendon repair and Heart Failure. During the clinical record review on 10/28/21 at 1:15 p.m., it was noted that the patient was ordered to receive Skilled Nursing (SN) services at a frequency of 1w1 and Physical Therapy (PT) services at a frequency of 1w1, 2w3, 1w1. The clinical record revealed that the SN conducted the SOC assessment on 9/22/21. PT conducted the initial evaluation visit on 9/22/21. PT documented visits on 9/24/21, 9/27/21, 9/29/21 and 10/4/21. There were no other PT visit notes documented in the clinical record after 10/4/21 at the time of this review. Additionally, a Physician's Order dated 10/4/21 ordered SN 2w3 effective 10/10/21; PT 2w3 effective 10/10/21. There were PT or SN visit notes available for review. Additionally, no visit notes had been made available by the end of the survey. These findings were reviewed with the Clinical Manager (CM #1) during an interview on 10/29/21 at 11:30 a.m. who reported, "I'll look into this." No further documentation had been presented.

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 provide documented evidence that the discharge summaries were complete and forwarded to the Physician within 5 days of the date of discharge for 5 (MR# 4, 10, 11, 12 and13) of 5 records in which the patient was discharged from services, from a total of 13 records reviewed, resulting in the potential for unidentified continuing health care concerns and unmet care needs. Findings include: Policy: "Discharge Summary", undated stated, "A complete discharge summary shall be 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..., within 5 business days of the patient [sic] discharge." MR #4: The patient's start of care (SOC) was 9/17/21 with diagnoses that included Subdural Hematoma, Weakness and Dementia. During the clinical record review on 10/27/21, it was noted that the Plan of Care (POC) ordered for Skilled Nursing (SN), Home Health Aide (HHa), Physical Therapy (PT), Occupational Therapy (OT) and Speech Therapy (ST) services to be provided. Further review revealed that the patient was discharged from SN services on 10/6/21. There was no documented evidence that the discharge summary had been forwarded to the Physician within 5 days of the patient's discharge. These findings were reviewed with and acknowledged by the Clinical Manager (CM #1) during an interview on 10/29/21 at 10:07 a.m. MR#10: The Start of Care (SOC) was dated 8/11/21. The Plan of Care (POC) identified diagnoses of Myocardial Infarction, Gastrointestinal Bleed and Anemia. The Physical Therapist (PT) completed a discharge OASIS (outcome and assessment information set) on 9/28/21. During record review on 10/28/21, it was noted that there was no documented evidence a discharge summary was sent to the physician within 5 business days of the patient's discharge. MR#11: The Start of Care (SOC) was dated 1/12/21. The Plan of Care (POC) identified diagnoses of Spondylosis, Spinal Stenosis and Congestive Heart Failure (CHF). The Registered Nurse (RN) completed a discharge OASIS on 1/25/21. During record review on 10/28/21, it was noted that there was no documented evidence a discharge summary was sent to the physician within 5 business days of the patient's discharge. MR#12: The Start of Care (SOC) was dated 6/15/21. The Plan of Care (POC) identified diagnoses of Right Pubis Fracture, Contusion of Left Hip and Pain in Left Hip. The Speech Therapist (ST) completed a discharge OASIS on 7/13/21. During record review on 10/28/21, it was noted that there was no documented evidence a discharge summary was sent to the physician within 5 business days of the patient's discharge. MR#13: The Start of Care (SOC) was dated 1/2/21. The Plan of Care (POC) identified diagnoses of Calculus of Bile Duct, Atrial Fibrillation and Congestive Heart Failure (CHF). The PT completed a discharge OASIS on 1/28/21. During record review on 10/28/21, it was noted that there was no documented evidence a discharge summary was sent to the physician within 5 business days of the patient's discharge. DQ #1 was questioned on 10/29/21 @ 1:35pm and stated, “They are in workflow; I cannot answer that. That is not our practice.”

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on record review and interview, it was determined that the Agency failed to ensure all clinical record entries were appropriately signed and authenticated, including the names and titles of the disciplines who authored the documents, in 7 (MR#'s 1, 2, 3, 4, 5, 6 and 7) of 7 records, from a total of 13 sampled records reviewed, resulting in the potential for inaccurate information. Findings include: Policy: Medical Record Entries: Authentication, 4/29/20, stated, "All medical record entries will be dated and authenticated..., All entries in the medical records will be authenticated by staff by signing first name or initial, last name and title. By authenticating entries in the patient's record, staff is validating the correctness of the information." MR#'s 1-7: During the review of Medical Records MR#1 through MR#7, it was noted that the Plans of care (POC) for each of the identified records had not been signed/authenticated and dated by the disciplines who authored the documents. These findings were reviewed with and acknowledged by the Clinical Manager (CM #1) during an interview on 10/29/21 at 11:30 a.m.