Every finding on record at Kare Masters Home Health, LLC

A Medicare emergency preparedness survey was conducted by the Michigan Department of Licensing and Regulatory Affairs from 9/30/24 through 10/3/24 at: Kare Masters Home Health 32401 West 8 Mile Rd. Livonia, MI 48152 The agency had no additional locations at the time of survey. For this survey 4 home visits with record reviews, 3 active records without a home visit and 3 discharged records were reviewed. At the conclusion of the survey the agency was found to be out of compliance with the conditions of participation at: 42 CFR 484.102, Emergency Preparedness.

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, it was determined the home health agency failed to develop an Emergency Preparedness Plan using a facility-based and community-based risk assessment, and utilizing an all-hazards approach, resulting in the potential to negatively affect all patients and employees seen by the agency. Findings include: During an interview on 10/3/24, at 10:00 a.m., a request was submitted to review the agency's Emergency Preparedness program, including the facility-based and community-based assessment. Review of the agency's Emergency Preparedness program found no documented evidence of an all-hazards risk assessment. When asked about the assessment, the administrator (Adm-1) stated, "We do not have that."

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to develop and maintain an Emergency Preparedness training and testing program that is based on the emergency plan, risk assessment, policies, procedures, and the communication plan. The training and testing program must be reviewed and updated at least annually. This deficient practice could affect the health and safety of all agency patients in the event of a natural, man-made, or facility-based emergency. Findings include: During review of the agency's emergency preparedness program on 10/3/24, it was discovered that there was no documented evidence the agency had developed a training and testing program to guide personnel and agency actions during an emergent situation. All agency patients could be impacted by the agency's failure to develop and maintain an emergency preparedness training and testing program. During an interview on 10/3/24 at 3:45 p.m., the administrator (Adm-1) acknowledged the above findings.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "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 PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE 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 and interview, it was determined the agency failed to provide training in emergency preparedness policies and procedures based on an all-hazards risk assessment, to agency staff, including contract employees and volunteers, and failed to maintain documentation of training, resulting in the potential for inappropriate, unprepared responses to emergencies and interruption in the provision of needed patient care and services. Findings include: On 10/3/24, at 10:00 a.m., during review of the agency's Emergency Preparedness program, it was discovered there was no indication that Emergency Preparedness training, based on an all-hazards risk assessment, had been provided to all staff as required. During an interview on 10/3/24 at 3:45 p.m., the administrator (Adm-1) acknowledged the above findings.

A Medicare recertification survey was conducted by the Michigan Department of Licensing and Regulatory Affairs from 9/30/24 through 10/3/24 at: Kare Masters Home Health 32401 West 8 Mile Rd. Livonia, MI 48152 The agency had no additional locations at the time of survey. For this survey 4 home visits with record reviews, 3 active records without a home visit and 3 discharged records were reviewed. At the conclusion of the survey the agency was found to be out of compliance with the conditions of participation for home health agencies at: 42 CFR Part 484.

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, it was determined the Home Health Agency (HHA) failed to ensure the frequency of visits ordered on the Plan of Care (POC) were followed in 3 of 10 records reviewed (P-1, 4, 6) from a total sample of 10 records reviewed, resulting in the potential for unmet patient needs. Findings include: P-1: The SOC was dated 3/6/24. The POC identified the diagnoses of diabetes mellitus, hypertension, and paraplegia. The POC dated 3/6/24, ordered physical therapy services at a frequency of 1 visit a week for 1 week, and 1 visit a week for 9 weeks. During record review on 9/30/24, it was found there was a missed visit for week 8 and week 9. There was no documented evidence in the record of any attempt to make up the missed visits. There was no documented evidence that the patient declined the visits or if the physician was notified of the missed visit. P-4: The SOC was dated 9/9/24. The POC identified the diagnoses of diabetes mellitus, joint replacement, and amputation. The POC dated 9/9/24, ordered physical therapy services at a frequency of 1 visit a week for 1 week, and 2 visits a week for 5 weeks. During record review on 10/2/24, it was found there was a missed visit for week 2. There was no documented evidence in the record of any attempt to make up the missed visit. There was no documented evidence that the patient declined the visit or if the physician was notified of the missed visit. P-6: The SOC was dated 3/21/24. The POC identified the diagnoses of pneumonia, and embolism. The POC dated 3/21/24, ordered physical therapy services at a frequency of 1 visit a week for 1 week, 1 visit a week for 4 weeks, and 1 visit a week for 2 weeks with 3 as needed visits. During record review on 10/3/24, it was found there was a missed visit for week 5, week 7, and week 8. There was no documented evidence in the record of any attempt to make up the missed visits. There was no documented evidence that the patient declined the visits or if the physician was notified of the missed visits. During an interview on 10/3/24 at 3:45 p.m., the administrator (Adm-1) acknowledged the above findings.

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 included objectively measurable goals specific to the individualized needs of the patient in 10 (MR's # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10) records, from a total of 10 sampled records reviewed, resulting in the potential for poor patient outcomes and unmet care needs. Findings include: P-1: This patient was admitted to the agency on 3/26/24, with diagnoses of congestive heart failure, paraplegia, hypertension, and diabetes. During record review on 9/30/24, it was discovered that the nursing goals on the plan of care (POC) were not measurable. For example, "Patient demonstrate [SIC] ability to manage medication regimen by 5/5/24." Another stated, "Patient will be able to demonstrate pain relief measures to mitigate pain by 3/26/24." There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-2: This patient was admitted to the agency on 9/16/24, with diagnoses of necrotizing fasciitis, myopathy, and diabetes. During record review on 10/2/24, it was discovered that the nursing goals on the POC were not measurable. For example, "Patient will verbalize understanding of proper use of pain medication by 2 weeks." Another stated, "Patient's mobility will be improved with assistance of physical therapist." There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-3: This patient was admitted to the agency on 9/23/24, with diagnoses of hypertension, Parkinson's, and gait abnormality. During record review on 10/2/24, it was discovered that the nursing goals on the POC were not measurable. For example, "The patient caregiver will verbalize understanding of symptoms of cardiac complications and when to call 911." Another stated, "Patient will remain free of adverse medication reactions during the episode." There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-4: This patient was admitted to the agency on 9/9/24, with diagnoses of joint replacement, diabetes, and amputation. During record review on 10/2/24, it was discovered that the nursing goals on the POC were not measurable. For example, "Patient will attain optimal effectiveness of pain management regimen by discharge." Another stated, "Patient will demonstrate return to stable cardiovascular status regarding hypertension and verbalize improvement to symptoms by discharge." There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-5: This patient was admitted to the agency on 2/8/24, with diagnoses of hypertension, low back pain, and chronic obstructive pulmonary disease. During record review on 10/3/24, it was discovered that the nursing goals on the POC were not measurable. For example, "Patient will demonstrate return to stable genitourinary status regarding urinary tract infection (UTI) and verbalize improvement to symptoms." Another stated, "Patient/Caregiver will be able to verbalize signs of UTI to report and demonstrate proper infection precautions." There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-6: This patient was admitted to the agency on 3/21/24, with diagnoses of pneumonia, and embolism. During record review on 10/3/24, it was discovered that the nursing goals on the POC were not measurable. For example, "Patient will be able to verbalize signs and symptoms of cardiac complications, when to call physician, nurse or 911 by discharge." Another stated, "Identify signs/symptoms necessitating contact with medical professionals, diet regimen guidelines, activity compliance and symptom management by discharge." There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. During an interview on 10/3/24, the administrator (Adm-1) acknowledged the above findings. P-7: The Start of Care (SOC) was dated 6/17/24. The Plan of Care (POC) for the certification period 6/17/24 to 8/15/24 identified diagnoses of Hemiplegia following cerebral infarction affecting left nondominant side, Unspecified encounter for fall, abnormal gait and mobility, Malignant neoplasm of brain, Malignant neoplasm of left kidney, hyperlipidemia, gastrointestinal reflux, Vitamin D deficiency, and Major depressive disorder. Upon review of the POC it was noted the goals on the POC were not objectively measurable. examples include: "Patient's activity level will improve due to effective pain control by the end of episode of care; Patient will attain optimal effectiveness of pain management regimen by the end of episode of care; Patient will attain optimal effectiveness of pain management regimen by the end of episode of care. These goals are not objectively measurable to determine the patient's progress towards obtaining the goals. P-8: The Start of Care (SOC) was dated 8/23/24. The Plan of Care (POC) for the certification period 8/23/24 to 10/21/24 identified diagnoses of Essential Hypertension (HTN), Respiratory Failure, Dependence on enabling machines and devices, Acute myeloblastic leukemia, Diabetes type 2 (DM2), and Chronic Pain. The patient was receiving Skilled Nursing (SN) services. A review of the POC revealed goals that were not objectively measurable to determine the patient's progress towards achieving the goals. Examples include: "Patient will verbalize understanding of proper use of pain medication by 4 weeks; Patient will verbalize an understanding of emergency plan by week 2; Patient will verbalize an understanding of energy conserving measures by week 3." These goals are not objectively measurable to determine the patient's progress towards achieving the goals. P-9: The Start of Care (SOC) was dated 9/12/2024. The Plan of Care (POC) for the certification period 9/12/24 to 11/10/24 identified diagnoses of Traumatic subarachnoid hematoma with Loss of Consciousness of unspecified duration, Cerebral Edema, Aphasia, reduced mobility, and major depressive disorder. Upon review of the POC, it was noted the Skilled Nurse goals were not objectively measurable to determine the patient's progress towards achieving the goals. Examples include: "Patient caregiver will verbalize understanding of seizure precautions - Target date: 11/10/24"; "Patient caregiver will verbalize understanding of medication regimen, dose, route, frequency, indications, and side effects by 11/10/24. There was no indication of how these goals could be objectively measured to determine the patient's progress towards achieving the goals. In addition, there were no goals found on the plan of care that addressed Physical Therapy, Speech Therapy, or Medical Social Work Services. The following information was included on the POC under Rehab Potential: "Good to achieve stated goals with skilled intervention and patient's compliance with the plan of care. Discharge Plans: Discharge when medical condition is stable, and patient is no longer in need of skilled services; Discharge to caregiver; Discharge caregiver willing and able to manage all aspects of patient's care; Discharge when goals met." {sic}. There were no goals that specifically addressed Speech Therapy or Medical Social Work services, and the goals for physical therapy were vague and not measurable. P-10: The Start of Care (SOC) was dated 9/11/24. The Plan of Care (POC) for the certification period 9/11/24 to 11/09/24 identified diagnoses of Congestive Heart Failure (CHF), Cirrhosis of the Liver, Osteoarthritis, Hypertension, Fatty Liver, Hyperlipidemia, and Hemiplegia. The patient was receiving Skilled Nurse (SN), Physical Therapy (PT), Medical Social Work (MSW) and Speech Therapy (ST) Services. Upon review of the POC, it was noted the goals on the POC were not objectively measurable to determine the patient's progress towards achieving goals. Examples include: "Physical Therapy Evaluation will be performed and a plan of care to increase functional independence will be established and countersigned by the physician." This goal is not measurable nor specific to the patient's individualized PT needs. There were no goals on the plan of care to address goals for the PT, OT, or ST services. "Patient will verbalize understanding of individualized emergency plan by the end of episode of care"; Patient will demonstrate proper pursed lip breathing techniques by the end of episode of care";" Patient will be able to verbalize understanding of medication regimen, dose, route, frequency, indications, and side effects by 10/6/24. {sic}. These goals are not objectively measurable to determine the patient's progress towards achieving the goals. These findings were reviewed and acknowledged during an interview on 10/3/24 at 2:45 pm, with the administrator (Adm-1).

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 occupational therapy (OT) services were provided as ordered by the physician in the plan of care for 1 of 2 (P-5) records reviewed with OT services ordered from a total of 10 records reviewed, resulting in the potential for physical decline and negative patient outcomes. Findings include: P-5: The SOC was dated 2/8/24. The POC identified diagnoses of low back pain, and chronic obstructive pulmonary disease. During record review on 10/3/24, it was discovered that OT services were ordered for an evaluation. No visits from OT were documented in the record. There was no documentation to indicate the patient had declined OT visits, and no documentation that the physician was informed that OT and services were not provided. The findings were reviewed with and acknowledged by the administrator (Adm-1) during an interview on 10/3/24 at 3:45 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 the transfer/discharge summaries were complete, provided the patient's current health status at the time of transfer/discharge, and progress toward goals in 1 of 3 (P-5) records in which the patient was discharged/transferred from the agency's services, from a total of 10 sampled records reviewed, resulting in the potential for unidentified continuing health concerns and unmet care needs. Findings include: P-5: The SOC was dated 2/8/24. The POC identified diagnoses of low back pain, and chronic obstructive pulmonary disease. During record review on 10/3/24, it was discovered that the discharge summary dated 2/16/24, under the "Patient goals section" was blank. There was no information available to the physician related to the patient's goals and progress toward goals. During an interview on 10/3/24 at 3:45 p.m., the administrator (Adm-1) acknowledged the findings.

The following Condition and Standard level deficiencies were identified during a Medicare authorized complaint investigation (107509, 107843), conducted by the Michigan Department of Licensing and Regulatory Affairs on 7/8/24 through 7/9/24 at: Kare Masters Home Health 32401 8 Mile Rd. Livonia, MI 48152 This agency had no additional locations. For this investigation, 2 active records were reviewed, including 1 home visit, and 1 discharged record for a total of 3 sampled records reviewed. At the conclusion of the survey, this agency was determined to be out of compliance with the following Conditions of Participation: 42 CFR §484.50 Patient Rights 42 CFR §484.80 Home Health Aide 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).

Condition of Participation: Patient rights. CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on record review and interview the agency failed to ensure that a patient observed during a home visit was free from abuse from home health staff for 1 of 3 records reviewed, resulting in misappropriation of the patient's property, violation of the patient's right to safety and unmet care needs (G430); failed to ensure the patient received written Notice of Medicare Provider Non-Coverage in advance of the agency terminating on-going care for 1 (P-3) of 1 discharged record resulting in the patient being denied the right to appeal the decision to end covered services (G442); failed to ensure that all complaints were fully investigated in 1 (P-1) of 1 complaints reviewed, resulting in unresolved concerns and the potential for the provision of substandard care (G478); failed to provide documented evidence of the existence of complaints received, details of the investigation and the resolution of the complaints resulting in the potential for unaddressed patient/family concerns, continuation of the alleged concern, inability to exercise one's rights and unmet care needs (G484). 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 §484.50 Patient Rights.

Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure 1 (P-1) of 1 patient observed during a home visit was free from abuse from home health staff and failed to ensure the patient was safe pending the outcome of the investigation, from a total of 3 sampled records reviewed, resulting in misappropriation of the patient's property, violation of the patient's right to safety and unmet care needs. Findings include: P-1: On 7/8/24 P-1's record was selected for review. After multiple requests, the Administrator (Adm #1) granted access to the clinical record. During the record review on 7/8/24 at 11:20 a.m., it was noted that the patient's start of care was 5/16/24 with diagnoses that included Hemiplegia following stroke and congestive Heart Failure. The plan of care (POC) ordered Skilled Nursing (SN) and Physical Therapy (PT) services. Home Health Aide (HHa) services were to be provided at a frequency of 2x/wk. x 9 wks. During the review, an additional request was made to review the agency's Complaint Log. Upon entering the agency's office suite, Adm #1 was observed making entries onto the complaint log and stated, "We usually have all the complaints in the EMR (electronic medical record) system, but our Nurse Consultant (NC #1) told us we had to write them out." There was no documentation of any complaints received prior to the 7/8/24 complaint investigation. Adm #1 then stated, "We have a complaint on her (P-1) because she said the aide (HHa #1) was stealing from her. We removed that aide (from the home)." At 12:10 p.m., Adm #1 presented a folder that contained a document dated 6/6/24 titled "Disciplinary Action 1st Written Warning", a typed document dated 6/6/24, titled "HHa #1's Statement Regarding Patient (P-1)", which documented HHa #1 apologized for not communicating with the Agency as he thought (P-1's allegations) were tasks not related to care..., HHa #1 stated that she (P-1) paid him two $1000 checks that cleared and 1 $800 that did not clear the bank..." The folder also contained a letter from Adult Protective Services (APS) dated 6/7/24 addressed to Adm #1 acknowledging receipt of the APS referral regarding P-1, and a handwritten document dated June 6th that documented a series of events. The document was unsigned and stated, "She (P-1) wanted HHa #1 to help her move to Arizona, packing, travel expenses, offered vehicle, $200/ a day agreement, Friday 31st May things getting worse, $3-4K (thousand) checks only, 16 days, 3 checks for $1000, 1 check for $800..." No conclusion could be drawn based on the above document. At 1:30 p.m., Adm #1 was queried as to when the patient first complained about HHa #1 but was unable to recall. When queried about the above documentation and the rationale for HHa #1's statement, Adm #1 then acknowledged "The patient initiated the complaint first" but could not remember the date. Our Nurse Consultant told us we needed to follow up. There was no documentation of the patient's complaints. Adm #1 then recalled she also communicated with the patient via text messages and further reported that "HHa #1 went on to do the same thing to another patient." When asked to clarify, Adm #1 reported that HHa #1 convinced another patient on the agency's private duty side to hire and pay him directly. Adm #1 provided copies of text messages from P-1 which documented the following: (6/1/24) P-1 sends, "When are you sending a bath person? I need one now!" Adm #1 responds, "My understanding HHa #1 was doing it as he is already there..." 6/2/24 P1: "My insurance cover it. Can you send me all the days and hours he (HHa #1) worked and what you have paid him. He is billing me for quite a lot of hours. I need to compare what I have paid him and what you have paid him, I have checks from the bank." Adm #1: "Why are you paying him? My employee are not allowed to be paid directly by you..., I think I need to stop by and discuss details avoid any further misunderstanding and pick up check." P-1 then texts a list of expenditures, checks and ATM withdrawals such as "ATM withdrawal 5/31 500.00; 5/23 debit 503.00; 5/23 10.84 Little Caesars; 5/20 check (ck#) 1283 1,000.; 5/20 ck# 1282 1,000.; ck# 1281 1,000.; 5/20 ck# 1280 800..." P-1 then writes, "3-$1000 checks and 1 $800 check plus he used my debit card and charge. He is supposed to give me a bath, but under the circumstances I am afraid for him to give me a bath..." 6/4 P-1 texts "There was $2403 withdrawals from my atm bank of America in May. My purse had $380 in it. HHa #1 kept taking my ATM cards out of my purse and took them home. He also charged popcorn and hamburgers on them. I thought I was going to move to Arizona. He (HHa #1) was going to charge me my car, my brand-new freezer, my brand-new whirlpool washer, and dryer for taking me out there. He kept asking for my things." 6/5 P-1: "When is caregiver coming. I need you to call." Adm #1: "Will do give me 15 min." P-1: What is going on? When are you sending someone? He owes me close to $5000. Your company is responsible for his behavior. This is abuse at its least I will have to report your company to APS (Adult Protective Services)..." P-1: This is unbelievable and unconscionable. Your caregiver fraudulently took over $5000 in money, food, and items from my house. He was continually late and left early and insisted I pay him directly. You said you would come over to my house and review the checks and account. You have not done so. You have left me alone and at risk..."(sic). Further review of the clinical record revealed that HHa #1 worked outside of his assigned/scheduled frequency of 2x/wk. and saw the patient 2 to 7 times per week. The 4 "HHA Weekly Visit Timesheet" was reviewed and revealed the following: week ending 5/18/24, HHa #1 saw the patient a total of 4 times and submitted 13 hours to be paid; week ending 5/25/24, HHa #1 billed for 28 hours and saw the patient a total of 7 times; week ending 6/1/24, HHa #1 saw the patient daily for 2 weeks and submitted 28 hours to be paid; week ending 6/8/24, HHa #1 made a total of 6 visits and submitted a total of 12 hours to be paid by the agency. During an interview with the Administrator, "He (HHa #1) was not to work or submit that many hours. We are only reimbursed for one hour of care during a visit." On 7/9/24 at 10:15 a.m., a scheduled joint survey home visit was conducted with the Nurse Consultant (NC #1). The patient was observed seated in a motorized wheelchair and wore a brace to her left upper extremity. The patient reported she had no movement of her left side. During the visit, the patient was asked if she required assistance with grooming to which she responded, "I had a caregiver until he started stealing from me. He stole monies and food from me then he just stopped coming. I called the police and informed the Administrator, but she hasn't done anything about it." Adm #1 was asked if HHa # 1 was still employed by the agency and responded, "No. We had to let him go." When asked if HHa #1 was removed from patient care pending investigation of the above allegations, Adm #1 stated HHa #1 was instructed to no longer care for P-1, however, the record revealed that HHa #1 made visits to the patient's home on 6/2, 6/3 and 6/8/24. Upon review of a series of emails between Adm #1 and HHa #1, it was noted that HHa #1 remained employed with the Agency through 6/20/24. Based on the above information, it was determined the Agency failed to ensure the patient was free from abuse, which included misappropriation of property and failed to ensure the patient was kept safe, pending the outcome of the investigation. These findings were reviewed with and acknowledged by the Adm #1 and NC #1 throughout the investigation and during the exit conference on 7/9/24.

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the patient received written notice/Notice of Medicare Provider Non-Coverage, in advance of the agency terminating on-going care for 1 (P-3) of 1 discharged record, from a total of 3 sampled records reviewed, resulting in the patient being denied the right to appeal the decision to end covered services. Findings include: P-3: The patient's start of care was 4/2/24 with diagnoses that included Sigmoid Diverticulitis and Pelvic Abscess. During the clinical record review, it was noted that the patient was discharged from the agency's services on 4/22/24. There was no documented evidence that the patient was provided with the Notice of Medicare Provider Non-Coverage in advance of the agency terminating services. These findings were reviewed with and acknowledged by the Administrator and Nurse consultant during an interview on 7/9/24.

Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) The HHA must— (i) Investigate complaints made by a patient, the patient's representative (if any), and the patient's caregivers and family, including, but not limited to, the following topics: (A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; (B) Mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record review and interview, it was determined the Agency failed to ensure that all complaints were fully investigated in 1 (P-1) of 1 complaint reviewed, resulting in unresolved concerns and the potential for the provision of substandard care. Findings include: On 7/8/24 at 9:15 a.m., the Office Manager (OM #1) was asked for permission to review the agency's complaint log. At 9:55 a.m., the Administrator (Adm #1) was reminded of the request to review the agency's complaint log. After multiple requests, Adm #1 stated she was unable to locate the complaint log. Shortly thereafter, a complaint log showing 2 entries was uploaded into the State Dropbox. It was further noted that the log was dated for calendar year 2017. During the visit, Adm #1 acknowledged having received a complaint from one patient (P-1) on 6/2/24, who complained of misappropriation of property and alleged that staff had stolen monies and goods from her. There was no entry of the complaint at the time of review on 7/8/24. When asked if the complaint had been investigation at the time of receipt, Adm #1 reported, "Our consultant told us we should investigate it, so I interviewed him (Home Health Aide/HHa #1) on 6/6/24. When asked if HHa #1 was still employed with the agency and seeing patients, Adm #1 reported, "We had to eventually let him go because he did the same thing to another patient on our private duty side." Adm #1 then confirmed the last date of HHa #1's employment was 6/22/24. During the record review on 7/8/24, it was discovered that HHa #1 continued to make visits to the patient's home on 6/2/24 (day of patient's complaint), 6/3/24 and 6/8/24. When asked if there was a statement on record from the patient regarding the allegations, Adm #1 was unable to respond, then stated, "I usually communicated with her via text message." A review of provided text messages confirmed the patient's allegations made to the Adm #1 on 6/2/24. Based on the above information, it was determined the Agency failed to ensure that all complaints, investigative measures, and the resolutions, were documented. These findings were reviewed with and acknowledged by Adm #1 and the Nurse Consultant (NC #1) at the time of discovery.

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on document review and interview, the Agency failed to provide documented evidence of the existence of complaints received, details of the investigation and the resolution of the complaints, resulting in the potential for unaddressed patient/family concerns, continuation of the alleged concern, inability to exercise one's rights and unmet care needs for all of the patients serviced by the agency. Findings include: On 7/8/24 at 9:15 a.m., the Office Manager (OM #1) was asked for permission to review the agency's complaint log. At 9:55 a.m., the Administrator (Adm #1) was reminded of the request to review the agency's complaint log. After multiple requests, Adm #1 stated she was unable to locate the complaint log. Shortly thereafter, a complaint log showing 2 entries was uploaded into the State Dropbox. It was further noted that the log was dated for calendar year 2017. During the visit, Adm #1 acknowledged having received a complaint from one patient (P-1) who complained of misappropriation of property and alleged staff had stolen monies and goods from her. There was no entry of the complaint at the time of review. On 7/9/24 the Nurse Consultant completed and submitted a handwritten document titled "Patient Complaint Log" dated 6/2/24. It was acknowledged that the agency complaint log was void of any complaints at the time of review. The agency's policy titled; "Agency Grievance Policy/Process" (undated) states, " We will give full consideration to your issues and make an effort to resolve any issues to your satisfaction." The Agency failed to ensure that the all complaints, investigative measures and the resolutions. These findings were reviewed with and acknowledged by Adm #1 and the Nurse Consultant at the time of discovery.

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, agency failed to ensure all treatments and services were administered only as ordered by the physician for 1 (P-1) record, from a total of 3 sampled records reviewed, resulting in the potential for the rendering of unsafe, inappropriate, unauthorized care and poor patient outcomes for all patients currently serviced by this agency. Findings include: P-1: The patient's start of care was 5/16/24 with diagnoses that included hemiplegia following stroke, heart failure and polyneuropathy. During the clinical record review on 7/8/24 at 12:20 p.m., it was noted that there was no referral for home care that specified the ordered disciplines and overall care to be provided. On 7/9/24 during the clinical record review, a document titled "Restorative Physical Medication", dated 5/6/24 documented, "she (patient) already had a prescription for home care, and she is trying a new company..." When asked to review the initial referral referenced in this document the Administrator and Nurse Consultant acknowledged they could not locate any such document. The agency failed to ensure that all care and services were rendered only in accordance with Physician's orders. These findings were reviewed with and acknowledged by the Administrator and Nurse Consultant at the time of discovery.

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 2 of 2 home health aides employed by this agency were qualified to provide care and services and had completed a training and competency evaluation program, resulting in the potential for the provision of substandard, unsafe care and unmet care needs (G754); failed to ensure that the individuals who furnished Home Health Aide services on its behalf, met competency evaluation requirements, and were evaluated by a Registered Nurse who observed the Aide's performance with a patient in 2 of 2 Home Health Aide personnel records reviewed, resulting in the potential for the provision of substandard, unsafe care and unmet care needs (G768); failed to ensure that 2 of 2 home health aides employed by this agency, received 12 hours of annual in-service training, resulting in the potential for the rendering of substandard care and unmet care needs (G774); failed to ensure the Skilled Nurse prepared clear written patient care instructions for the assigned aide prior to the provision of care for 1 (P-1) of 2 patients who required assistance with grooming, from a total of 3 sampled records reviewed, resulting in the potential for the provision of unsafe, unauthorized care and unmet care needs: (G798); and failed to ensure the skilled discipline conducted onsite supervisory visits at least every 14 days for 1 (P-1) of 1 patient ordered to receive home health aide services, from a total of 3 sampled records reviewed, resulting in lack of needed oversight and the provision of unsupervised, unauthorized services (G808). 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 §484.80 Home Health Aide Services.

A qualified HH aide successfully completed: CFR(s): 484.80(a)(1)(i-iv) A qualified home health aide is a person who has successfully completed: (i) A training and competency evaluation program as specified in paragraphs (b) and (c) respectively of this section; or (ii) A competency evaluation program that meets the requirements of paragraph (c) of this section; or (iii) A nurse aide training and competency evaluation program approved by the state as meeting the requirements of §483.151 through §483.154 of this chapter, and is currently listed in good standing on the state nurse aide registry; or (iv) The requirements of a state licensure program that meets the provisions of paragraphs (b) and (c) of this section. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure 2 of 2 home health aides employed by this agency were qualified to provide care and services and had completed a training and competency evaluation program, resulting in the potential for the provision of substandard, unsafe care and unmet care needs. Findings include: Home Health Aide (HHa #1) date of hire was 10/28/23. During a review of this personnel file, it was noted that there was no documented evidence that HHa #1 had completed a training and competency evaluation program. Further, there was no documented evidence that HHa #1 had completed any home health aide training program that would satisfy this requirement. These findings were reviewed with and acknowledged by the Administrator and Nurse Consultant during an interview on 7/9/24 at 9:20 a.m. Home Health Aide (HHa #2) date of hire was 1/9/23. During a review of this personnel file, it was noted that there was no documented evidence that HHa #2 had completed a training and competency evaluation program. Further, there was no documented evidence that HHa #2 had completed any home health aide training program that would satisfy this requirement. These findings were reviewed with and acknowledged by the Administrator and Nurse Consultant during an interview on 7/9/24 at 12:41 p.m.

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 that the individuals who furnished Home Health Aide services on its behalf met competency evaluation requirements in 2 of 2 Home Health Aide personnel records reviewed, resulting in the potential for the provision of substandard, unsafe care and unmet care needs. Findings include: Home Health Aide (HHa #1) date of hire was 10/28/23. During a review of this personnel file, it was noted that there was no documented evidence that an Aide Competency Evaluation had been conducted prior to the provision of care. These findings were reviewed with and acknowledged by the Administrator and Nurse Consultant during an interview on 7/9/24 at 9:20 a.m. Home Health Aide (HHa #2) date of hire was 1/9/23. Upon review of the personnel file, it was noted that there was no documented evidence that an Aide Competency Evaluation had been conducted prior to the provision of care. These findings were reviewed with and acknowledged by the Administrator and Nurse Consultant during an interview on 7/9/24 at 12:41 p.m.

12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This STANDARD is not met as evidenced by: Based on record review and interview, it was determined the agency failed to ensure that 2 of 2 home health aides employed by this agency, received the required 12 hours of annual in-service training, resulting in the potential for the rendering of substandard care and unmet care needs. Findings include: Home Health Aide (HHa #1) date of hire was 10/28/23. Upon review of the personnel file, it was noted that there was no documented evidence that HHa #1 received 12 hours of annual in-services since his date of hire. These findings were reviewed with and acknowledged by the Administrator and Nurse Consultant during an interview on 7/9/24 at 9:20 a.m. Home Health Aide (HHa #2) date of hire was 1/9/23. Upon review of the personnel file, it was noted that there was no documented evidence that HHa #2 received 12 hours of annual in-service since her date of hire. These findings were reviewed with and acknowledged by the Administrator during an interview on 7/9/24.

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 Skilled Nurse prepared clear written patient care instructions regarding patient needs and safety precautions for 1 (P-1) of 2 patients who required assistance with grooming, from a total of 3 sampled records, resulting in the potential for the provision of unsafe, unauthorized care and unmet care needs. Findings include. P-1: The patient's start of care was 5/16/24 with diagnoses that included hemiplegia following stroke, heart failure and polyneuropathy. The plan of care ordered home health aide services to be provided at a frequency of 2x/wk. x 9 wks. to provide assistance with personal care and ADLs (activities of daily living). During the clinical record review on 7/8/24 at 12:20 p.m., it was noted that there was no aide plan of care available for review that directed the course of care and frequency in which services were to be provided. These findings were reviewed with and acknowledged by the Administrator during an interview on 7/8/24 and again on 7/9/24 with the Nurse Consultant present who reported, "I did not initiate the aide care plan. That was my oversight."

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (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) 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 paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the skilled discipline conducted onsite supervisory visits at least every 14 days for 1 (P-1) of 1 patient ordered to receive home health aide services, from a total of 3 sampled records reviewed, resulting in lack of needed oversight and the provision of unsupervised, unauthorized services. Findings include: P-1: The patient's start of care was 5/16/24 with diagnoses that included Hemiplegia following CVA (Stroke), Polyneuropathy, Dependence on Wheelchair and Congestive Heart Failure. During the record review on 7/8/24 at 12:20 p.m., it was noted that the plan of care (POC) ordered Skilled Nursing (SN) at a frequency of 1x/wk. x 5 wks.; Physical Therapy and Occupational Therapy to evaluate and treat, and Home Health Aide (HHa) services at a frequency of 2x/wk. x 9 wks. to "provide assistance with personal care and ADLs (Activity of Daily Living) ..." During the record review, it was further noted that there was no Aide plan of care available for review that directed the Home Health Aide's provision of care. The clinical record revealed that the HHa #1 made visits to the patient's home 3 to 7 days/wk. from 5/16/24 through 6/4/24, which was outside of the ordered frequency and performed tasks that included laundry, shopping, errands and meal prep in addition to assistance to bathroom, repositioning and dressing. There was no documented evidence that the Registered nurse provided the required supervision of care at least every 2 weeks. These findings were reviewed with and acknowledged by the Administrator and Nurse Consultant during an interview on 7/9/24 at 9:20 a.m., and again at 12:41 p.m.