Every finding on record at Michigan In-Home Partner-III, LLC

On 7/9/24 through 7/10/24, the Michigan Department of Licensing and Regulatory Affairs conducted a recertification survey at UP Health System Home Care and Hospice Portage. The agency was in compliance with the requirements for participation in Medicare at 42 CFR Part § 484.102 Emergency Preparedness.

A Medicare authorized Home Health Survey was conducted July 8th, 2024, through July 11th, 2024, at: UP Health System Home Care Portage-Houghton 901 W. Sharon Avenue, Suite 3 Houghton, MI 49931 For this survey 4 home visits were made and a total of 10 records reviewed. At the conclusion of the survey the following standard level citations were cited.

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 skilled nurse failed to provide baseline data in the Comprehensive Assessment to use in determining if the patient's Diabetes was improving or worsening with each visit assessment during the course of care in 1 of 7 records reviewed (P-3). Findings included: P-3: The Start of Care was dated July 2, 2023. The Plan of Care for the recertification period of 1/10/24 to 3/7/24 included diagnoses of Diabetes type 2, Right and Left Hand Pain, Left knee pain, Osteoarthritis, Poly arthropathy, History of Falling, Hypertension, Migraine Headaches, Sinusitis, Long-term use of smoking cigarettes, and Post-Traumatic Stress Disorder (PTSD). Upon review of the Comprehensive Assessment, it was noted there was no baseline data or range of the patient's blood sugar readings to use to determine if the patient's diabetes was stable, improving, or worsening. This finding was reviewed with and acknowledged by the Administrator (Staff A) and the patient care manager (Staff B) during an interview on 7/10/24 at 3:00 p.m.

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 include objectively measurable goals on the plan of care for 5 of 10 records reviewed (P-1, P-2, P-4, P-8, P-10) resulting in the inability to determine the patient's progress towards obtaining the goals. Findings include: P-1: The Start of Care (SOC) was dated 3/9/2024. The Plan of Care (POC) for the Certification Period 7/1/24 to 8/29/24 identified diagnoses of Diabetes type 2, Atrial Fibrillation, Alzheimer's Disease, Coronary Artery Disease, Hypertension, Depression, and Alzheimer's Disease. This patient was receiving Skilled Nursing and Physical Therapy Services. This patient was receiving Skilled Nursing (SN) services. Upon review of the Plan of Care, it was noted the goals were not objectively measurable to determine the patient's progress towards obtaining the goals. An example included: "Patient/Caregiver will demonstrate ability to administer medications via Planner Device by being compliant with medications by 8/24/24". These goals are not objectively measurable to determine the patient's progress towards obtaining the goals. P-2: The Start of Care was dated 4/28/2024. The Plan of Care for the Certification Period 4/28/24 to 6/26/24 identified diagnoses of Hypertensive Heart Disease with Heart Failure (HTN), Diabetes type 2 (DM2), Chronic Systolic and Diastolic Heart Failure (CHF), Anemia, Wheelchair Dependent, and History of Falling. The patient was receiving Skilled Nursing (SN) and Physical Therapy (PT) services. Upon review of the Plan of Care, it was noted the goals were not objectively measurable. Examples included: "Patient/Caregiver will Verbalize/Demonstrate adequate knowledge of safe provision of ADLs (Activities of Daily Living) as evidenced by appropriate home management without complications or injury by 6/25/24; Patient/Caregiver will understand and demonstrate compliance with treatment regimen for diabetes as evidenced by patient verbalizing definition of diabetes by 6/1/24; Patient will achieve highest functional level as outlined in Therapy Plan of Care Objective Goals with Active Range of Motion and/or muscle strength and performance of Home Exercise Program order to maximize lower extremity function by 8 weeks; Patient/Caregiver will verbalize/demonstrate understanding of recommended safety and fall risk reduction strategies by 8 weeks. These goals are not objectively measurable to determine the patient's progress towards achieving the goals. These findings were reviewed with and acknowledged by the Administrator (Staff A) and the patient care manager (Staff B) during an interview on 7/10/24 at 3:00 p.m. P-4: This patient was admitted to home care on 6/7/24 with diagnoses of Alzheimer's disease and dementia. The patient was receiving physical therapy services. During record review on 7/9/24 it was noted the 6/7/24 plan of care included the following goals: patient will achieve highest functional level, as outlined in therapy plan of care objective goals with safe transfer(s) with appropriate technique and equipment to allow for in home by 8 weeks; and patient will achieve highest functional level, as outlined in therapy plan of care objective goals, with gait quality, ability to ascend/descend steps/ramps and/or functional ambulation to navigate within the home by 8 weeks. These goals were not stated in measurable terms that would enable staff to perform an objective evaluation of the patient's progress towards her goals. The finding was reviewed with and acknowledged by the Administrator (Staff A) and the patient care manager (Staff B) during an interview on 7/10/24 at 12:35 p.m. P-8: This 69-year-old patient was admitted to home care on 4/16/24 with diagnoses of hemiplegia post stroke and type 2 diabetes. During record review on 7/9/24, it was noted that the plan of care failed to include measurable nursing goals that were individualized to address patient needs. For example, one goal stated, “patient will achieve highest functional level, as outlined in therapy POC (plan of care) objective goals with safe transfer(s) with appropriate technique and equipment to allow for in home by 8 weeks.” [sic] Another goal stated, “patient/caregiver will verbalize/demonstrate understanding of recommended safety and fall risk reduction strategies by 8 weeks.” There was no evidence of how these goals could be objectively measured to determine progress toward meeting the goals. P-10: This 88-year-old patient was admitted to home care on 6/24/24 with diagnoses of pneumonitis, benign prostatic hyperplasia, and hypertensive heart disease with heart failure. During record review on 7/10/24, it was noted that the plan of care failed to include measurable nursing goals that were individualized to address patient needs. For example, one goal stated, “patient will achieve highest functional level, as outlined in therapy POC objective goals, with AROM (active range of motion), and/or muscle strength and performance of HEP (home exercise program) order to maximize lower extremity function.” Another goal stated, “patient will achieve highest functional level, as outlined in therapy POC objective goals, with sitting and/or standing balance in order to reduce the risk for falls.” There was no evidence of how these goals could be objectively measured to determine progress toward meeting the goals. These findings were reviewed and acknowledged by the administrator (Staff A) and patient care manager (Staff B) during an interview on 7/10/24 at 12:25 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 skilled professionals provided services as ordered by the physician in the plan of care for 1 (P-8) of 10 records reviewed, resulting in the potential for unmet care needs. Findings include: P-8: This 69-year-old patient was admitted to home care on 4/16/24 with diagnoses of hemiplegia post stroke and type 2 diabetes. During record review on 7/9/24, it was noted that the plan of care ordered licensed professionals to report pain level greater than 5 to the primary care provider (PCP). On 5/24/24, the speech language pathologist documented sharp pain located in the center low back, rated as a 7 on a scale of 0-10. There was no evidence the PCP was notified. This finding was reviewed and acknowledged by the administrator (Staff A) and patient care manager (Staff B) during an interview on 7/10/24 at 12:25 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 transfer summary was sent to the receiving facility within 2 days of becoming aware of an unplanned transfer for 1 of 1 (P-6) records reviewed in which the patient was transferred, and failed to ensure a discharge summary was sent to the physician within 5 business days of the patient's discharge for 1 of 3 (P-6) records reviewed in which the patient was discharged from the agency, resulting in the physician or receiving facility not having knowledge of the patient's health status at the time of transfer/discharge and the potential for unidentified care needs. Findings include: P-6: This patient was admitted to home care on 4/26/24 with diagnoses of a toe amputation on the right foot, type 2 diabetes, and acute respiratory failure with hypoxia. During record review on 7/10/24, it was noted the patient was discharged/transferred to the hospital on 6/24/24. The discharge/transfer summary was faxed to the patient's physician and the receiving hospital on 7/1/24, which is 7 days post discharge/transfer. There was no evidence the hospital received a transfer summary within 2 days of the agency becoming aware of the transfer, and no evidence the physician was informed of the discharge within 5 days of discharge. The finding was reviewed with and acknowledged by the Administrator (Staff A) and the patient care manager (Staff B) during an interview on 7/10/24 at 12:35 p.m.

A Medicare approved complaint investigation was conducted by the Michigan Department of Licensing and Regulatory Affairs from 3/6/24 at: UP Health System Home Care and Hospice Portage 901 W. Sharon Avenue, Suite 3 Houghton, MI 49931 This agency has no branch sites. Records Reviewed: 10 records were reviewed. At the conclusion of the investigation, allegation #1 was substantiated with a standard level citation. Allegation #2 was unsubstantiated due to a lack of sufficient evidence.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to contact the physician in 1 of 10 records reviewed (P-10) for wound care, from a total of 10 records reviewed, resulting in the potential for unresolved healthcare concerns. Findings include: P-10: This patient was admitted to home health care on 8/9/2023, with diagnoses of hemiplegia (Recent stroke affecting right dominant side, occurred in July of 2023), urinary tract infection (UTI), type 2 diabetes, dysphagia (Difficulty swallowing), peripheral vascular disease (reduced blood flow to extremities), and long-term use of insulin. Record review on 3/6/24 showed the plan of care (POC) dated 8/9/23, had skilled nursing visits ordered at a frequency of 2 visits a week for 1 week, then 1 visit a week for 8 weeks. Physical Therapy was ordered at a frequency of 1 visit a week for 2 weeks, 2 visits a week for 2 weeks, then 1 visit a week for 2 weeks. Speech Therapy was ordered at a frequency of 1 visit for 1 week. Home Health Aid services were ordered at a frequency of 1 visit a week for 4 weeks. A Start of Care nursing assessment visit note dated 8/9/24, documented that the nurse was unable to obtain a weight. The patient was unable to walk or stand. The patient is confined to bed. The patient depends entirely upon someone else for all needs. A lower right leg amputation was observed. A blood glucose of 162 was documented. Blood glucose parameters were ordered on the POC, and to notify the physician of blood glucose below 70 or above 250. Caregiver is non-compliant with medication administration. Caregiver stated, “I do not give insulin if the blood sugar is below 200.” Patient is currently not taking any medications on the medication list. This was confirmed by the caregiver and patient’s primary care provider office. Caregiver was educated on medications and nutrition. Patient has a poor appetite and eats one third or less of food provided. No wound documented at this visit. Skilled nurse visit note dated 8/12/23 documented a new wound to left heel and MD was notified. Skilled nursing visit note on 8/17/23 documented an assessment of the left heel stage II pressure ulcer wound site. Educated caregiver on elevating the foot and keeping pressure off the wound. The caregiver was also educated on keeping the patient hydrated and signs and symptoms of dehydration. The caregiver acknowledged the teaching. Caregiver said they are happy with the aide services provided by the agency. A nursing visit note documented a visit scheduled for 8/25/23 and was declined by the patient’s caregiver due to other appointments. A skilled nursing visit note dated 8/28/23 documented that the patient saw the podiatrist last Friday, 9/22/23, due to wound, with orders obtained for skilled nursing to monitor wound weekly. Wound skin is intact, boggy to touch and dark purple. No open areas and no signs of infection. Caregiver educated on daily cleansing and drying area. Also educated on importance of offloading pressure to the wound area including using device/booty and floating heel with pillow. A skilled nursing visit note dated 8/29/23 documented the wound was assessed, no open area, dark in color, no signs of infection. Patient’s heels were floated upon arrival, but patient did kick off pressure boot. Caregiver educated. Blood sugar was 303 this morning, MD notified. A1C was obtained (Results came back at 9.6). A skilled nursing visit on 9/5/23 documented assessment, education and wound care done. Blood sugar is 350 at this time. Blood sugar was 395 at 10:30. Caregiver states blood sugar yesterday was 275 and ranging between 226-395 the past week. Caregiver states she would like to start using the insulin again. MD notified of blood sugar levels and inability to obtain blood draw, awaiting call back for follow-up. A skilled nurse note dated 9/6/23 documented the patient went to the ER for hyponatremia (Low blood sodium). Skilled nurse note dated 9/9/23 documented assessment of wound, no signs or symptoms of infection, still monitoring. Pressure relieving boot in place for wound. Order for wound to be left open to air with pressure boot in place. Skilled nurse note dated 9/15/23 documented no wound concerns at this time, no change in wound status, boot in place. Skilled nurse note dated 9/19/23 documented no wound concerns at this time, no change in wound status, boot in place. Skilled nurse note dated 9/26/23 documented no wound concerns at this time, boot in place. Nurse practitioner visit on 9/27/23, no new orders. Skilled nurse visit note dated 10/4/23 documented education on wound care and medications. Skilled nurse visit dated 10/11/23 documented no changes to wound. No concerns noted. Skilled nurse note dated 10/16/23 documented no wound concerns at this time, no necrotic tissue was documented, boot in place. Nurse Practitioner visit on 10/17/23. No new orders. Skilled nurse visit on 10/25/23. Wound is closed, necrotic with hard tissue. No documentation in the record that the physician was notified of the necrotic tissue. Orders were to notify the physician of any changes to the wound. Skilled nurse visit on 10/30/23 with no changes. No documentation in the record that the physician was notified of the necrotic tissue. Orders were to notify the physician of any changes to the wound. 11/7/23 podiatrist visit with orders to start Doxycycline for foot infection. 11/8/23 nurse visit note documented wound covered with necrotic tissue. Skilled nurse visit note dated 11/11/23, home health care on hold due to patient admitted to U.P. Health System with left foot osteomyelitis and hypokalemia. On 10/16/23 the wound had no necrotic tissue. On the 10/25/23 Skilled Nurse visit, necrotic tissue on the wound was documented with no evidence in the record of communication to the doctor. On 10/30/23 a Skilled Nurse visit note documented necrotic tissue covering the wound. There was no documentation in the record that the physician was notified of the necrotic tissue. On 11/7/23 the podiatrist saw the patient and started antibiotics for a foot infection. 11/11/23 order to hold home care services due to the patient had been admitted to the hospital for osteomyelitis and hypokalemia.

On 7/13/21 through 7/16/21, the Michigan Department of Licensing and Regulatory Affairs conducted a recertification survey at UP Health System Home Care and Hospice Portage. This was a standard survey. The requirements for participation in Medicare at 42 CFR 484.102 Emergency Preparedness were not reviewed.

A Medicare recertification survey and a COVID-19 focused infection control survey were conducted by the Michigan Department of Licensing and Regulatory Affairs from 7/13/2021 through 7/16/21 at: UP Health System Home Care and Hospice Portage 901 W. Sharon Avenue, Suite 3 Houghton, MI 49931 This agency has no branch sites. Records Reviewed: 4 records with home visits; 6 records without home visits, for a total of 10 records reviewed. At the conclusion of the survey the agency was found to be out of compliance with standard level deficiencies for the conditions of participation for home health agencies at: 42 CFR Part 484.

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, record review and interview, the agency failed to ensure patients were informed in advance of the disciplines that will furnish care and the proposed visit frequency in 9 of 10 (MR# 2, 3, 4, 5, 6, 7, 8, 9, 10) records reviewed, resulting in these patients not having knowledge regarding their plans for treatment. Findings include: On 7/14/21, the agency's patient consent and other forms were reviewed, and it was noted that the forms failed to include an area to note the disciplines that would furnish care and the frequency of visits. MR#7: This patient was admitted to the agency on 6/28/21. The plan of care dated 6/28/21, ordered weekly visits from skilled nursing, physical therapy, and home health aide services. During review of the clinical record on 7/14/21, it was noted that the consent forms signed by the patient failed to indicate the disciplines and proposed visit frequency of services to be provided. There were no other documents noted to include notification to the patient of the disciplines and proposed frequency of visits. During a joint surveyor home visit with the home health aide on 7/14/21 at 11:30 a.m., it was observed that the forms failed to indicate the disciplines and proposed visit frequency of services to be provided. MR#7 stated she never knows when staff are going to visit, and it makes it hard when family or friends want to visit. The findings were reviewed with CM-B (clinical manager) on 7/15/21 at 11:30 a.m. CM-B stated, the agency's previous consent forms had an area for the disciplines and frequency of visits to be filled in by staff and that the new consent forms do not. Staff are instructed to write down the disciplines and frequencies on the consent and to utilize the calendar included in the start of care documents. MR#4: This patient was admitted to the agency on 6/5/21. The plan of care dated 6/5/21, ordered weekly visits from skilled nursing, physical therapy, occupational therapy, and speech therapy services. During review of the clinical record on 7/15/21, it was noted that the consent forms signed by the patient failed to indicate the disciplines and proposed visit frequency of services to be provided. There were no other documents noted to include notification to the patient of the disciplines and proposed frequency of visits. MR#5: This patient was admitted to the agency on 5/6/21. The plan of care dated 5/6/21, ordered weekly visits from skilled nursing and physical therapy services. During review of the clinical record on 7/14/21, it was noted that the consent forms signed by the patient failed to indicate the disciplines and proposed visit frequency of services to be provided. There were no other documents noted to include notification to the patient of the disciplines and proposed frequency of visits. MR#6: This patient was admitted to the agency on 7/26/20. The plan of care dated 7/26/20, ordered weekly visits from skilled nursing, physical therapy, and occupational therapy services. During review of the clinical record on 7/14/21, it was noted that the consent forms signed by the patient failed to indicate the disciplines and proposed visit frequency of services to be provided. There were no other documents noted to include notification to the patient of the disciplines and proposed frequency of visits. MR#2: The plan of care dated 6-3-21 to 8-1-21 stated the patient was admitted for nursing, physical therapy,occupational therapy and home health aide services with varying visit frequencies ordered. During review of the clinical record on 7/15/21, it was noted that the consent forms signed by the patient failed to indicate the disciplines and proposed visit frequency to be provided. There were no other documents noted to include notification to the patient of the disciplines and proposed frequency of visits. During an interview on 7-15-21 at 3:40 PM, CM-3 stated, "the forms used to have a place for frequencies but now they are supposed to write it in the blank space on the consent form, but it isn't getting done." MR#3: The plan of care dated 5-12-21 to 7-10-21 stated the patient was admitted for nursing, physical therapy and occupational therapy services with varying visit frequencies ordered. During review of the clinical record on 7/15/21, it was noted that the consent forms signed by the patient failed to indicate the disciplines and proposed visit frequency to be provided. There were no other documents noted to include notification to the patient of the disciplines and proposed frequency of visits. During an interview on 7-15-21 at 3:40 PM, CM-3 stated, "the forms used to have a place for frequencies but now they are supposed to write it in the blank space on the consent form, but it isn't getting done." MR#8: The Start of Care (SOC) was dated 6/11/21. The Plan of Care (POC) identified diagnoses of Post Appendectomy and Muscle Weakness. During record review on 7/14/21, it was noted that the consent forms signed by the patient failed to indicate the disciplines and proposed visit frequency to be provided. There were no other documents noted to include notification to the patient of the disciplines and proposed frequency of visits MR#9: The Start of Care (SOC) was dated 4/23/21. The Plan of Care (POC) identified diagnoses of Left Shoulder Strain, Mild Confusion and Diabetes Type 2. During review of the POC on 7/15/21, it was noted that the consent forms signed by the patient failed to indicate the disciplines and proposed visit frequency to be provided. There were no other documents noted to include notification to the patient of the disciplines and proposed frequency of visits MR#10: The Start of Care (SOC) was dated 6/9/21. The Plan of Care (POC) identified diagnoses of Parkinson's, Diabetes Type 2, and Chronic Kidney Disease. During review of the POC on 7/14/21, it was noted that the consent forms signed by the patient failed to indicate the disciplines and proposed visit frequency to be provided. There were no other documents noted to include notification to the patient of the disciplines and proposed frequency of visits

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 ensure the comprehensive assessment accurately reflected the patient's current health status for 3 of 10 (MR# 8, 9, 10) records reviewed, resulting in incomplete clinical information to aid in determining the needs of this patient and for measuring the patient's progress toward goals/outcomes. Findings include: MR#8: The Start of Care (SOC) was dated 6/11/21. The Plan of Care (POC) identified diagnoses of Post Appendectomy and Muscle Weakness. During record review on 7/14/21, it was noted that the SOC comprehensive assessment dated 6/11/21, documented under "Primary Diagnosis and Other Diagnoses", all 13 diagnoses had the same date of exacerbation documented, 6/11/21. No onset, 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 4/23/21. The Plan of Care (POC) identified diagnoses of Left Shoulder Strain, Mild Confusion and Diabetes Type 2. During review of the POC on 7/15/21, it was noted that the SOC comprehensive assessment dated 4/23/21, documented under "Primary Diagnosis and Other Diagnoses", all 11 diagnoses had the same date of exacerbation documented, 4/21/21. No onset, 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 6/9/21. The Plan of Care (POC) identified diagnoses of Parkinson's, Diabetes Type 2, and Chronic Kidney Disease. During review of the POC on 7/14/21, it was noted that the SOC comprehensive assessment dated 6/9/21, documented under "Primary Diagnosis and Other Diagnoses", all 10 diagnoses had the onset or exacerbation date of 6/6/21 through 6/9/21, including Diabetes Type 2 and Chronic Kidney Disease with an onset date of 6/9/21. No prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented The CM-B was questioned on 7/15/21 at 1:00 "The onset and exacerbation dates should be more complete and accurate."

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, it was determined the agency failed to ensure the goals on the plan of care were patient specific and measurable in 10 of 10 records reviewed (MR# 1, 2, 3, 4, 5, 6, 7, 8, 9, 10) out of 10 total records sampled; and failed to include pertinent safety precautions and reportable parameters on the plan of care in 5 of 10 (MR# 1, 2, 3, 9, 10) records reviewed of a total sample of 10 records sampled; and failed to provide physical therapy services at the frequency ordered by the physician for 1 of 10 (MR #10) out of 10 total records sampled, resulting in the potential for unidentified goals, unmet patient goals and negative patient outcomes. Findings include: MR #1: The plan of care, for the period of 6/13/21 to 8/11/21, stated the patient was admitted with diagnoses that included diabetes with foot ulcer hypertensive chronic kidney disease and venous insufficiency. The plan of care included goals such as: "Patient will verbalize understanding of pharmacological and non pharmacological pain control measures as evidenced by improvement in pain levels by 8/11/21" and "Patient will demonstrate improved wound status as evidenced by decrease in size/drainage of wound, no S/S (signs and symptoms) of infection and decreased pain as a result of skilled intervention by 8/11/2021." These goals are not patient specific and quantifiably measurable. The plan of care did not include diabetes safety precautions. During an interview on 7-15-21 at 3:30 PM, the Clinical Manager stated, "The plan of care should include diabetes safety measures." MR #2: The plan of care, for the period of 6/3/21 to 8/1/21, stated the patient was admitted with diagnoses that included Aftercare following surgical amputation of the leg below the knee, diabetes, congestive heart failure and hypertension. The plan of care included goals such as: "Patient will verbalize and demonstrate compliance with treatment regime for hypertension by 8/1/21"; "Patient/Caregiver will verbalize/demonstrate understanding of home safety and fall prevention by 8/1/21" and "Patient/Caregiver will verbalize/demonstrate knowledge in preserving skin integrity. Physician will be contacted and orders obtained for support surface to preserve skin integrity by 7/1/21." These goals are not patient specific and quantifiably measurable. The plan of care did not include diabetes safety precautions. During an interview on 7-15-21 at 3:30 PM, the Clinical Manager stated, "The plan of care should include diabetes safety measures." MR #3: The plan of care, for the period of 5/12-21 to 7/1021, stated the patient was admitted with diagnoses that included kidney/bone/lung cancer and diabetes. The plan of care included goals such as: "Patient will verbalize understanding of pharmacological and non pharmacological pain control measures as evidenced by improvement in pain levels by 8/11/21" and "Patient/Caregiver will verbalize/demonstrate understanding of home safety and fall prevention by 8/1/21." These goals are not patient specific and quantifiably measurable. The plan of care did not include diabetes safety precautions. During an interview on 7-15-21 at 3:30 PM, the Clinical Manager stated, "The plan of care should include diabetes safety measures." MR#4: This patient was admitted to the agency on 6/5/21 with diagnoses of a recent stroke and high blood pressure. The 6/5/21 plan of care (POC) ordered weekly skilled nursing visits for this patient. The POC included the following skilled nursing goals: Patient will demonstrate proper use and administration of prescribed medications...will understand and demonstrate compliance with treatment regimen for high blood pressure...will verbalize/demonstrate understanding of home safety and fall prevention. There was no indication how these goals were to be measured that would enable nursing staff to accurately perform an objective evaluation of the patient's progress toward her goals. MR#5: This patient was admitted to the agency on 5/6/21 with diagnoses of coronary artery by-pass graft and high blood pressure. The 5/6/21 POC ordered weekly skilled nursing visits for this patient. The POC included the following skilled nursing goals: Patient will verbalize/demonstrate ability to care for edema...will verbalize/demonstrate understanding of home safety and fall prevention...will demonstrate proper use and administration of prescribed medications. There was no indication how these goals were to be measured that would enable nursing staff to accurately perform an objective evaluation of the patient's progress toward his goals. MR#6: This patient was admitted to the agency on 7/26/20 with diagnoses of chronic obstructive pulmonary disease, diabetes, and heart failure. The 7/26/20 POC ordered weekly skilled nursing visits for this patient. The POC included the following skilled nursing goals: Patient will demonstrate oxygen saturation within normal limits or to patient's optimal levels established by the physician...patient will maintain a stable weight. There was no indication of the patient's optimal level and no indication of what would be a stable weight range for this patient. The goals were not stated in measurable terms that would enable nursing staff to accurately perform an objective evaluation of the patient's progress toward his goals. MR#7: This patient was admitted to the agency on 6/28/21 with diagnoses of post-operative procedure to stabilize vertebral compression and clostridium difficile (severe diarrhea). The 6/28/21 POC ordered weekly skilled nursing visits for this patient. The POC included the following skilled nursing goals: Patient will exhibit optimal level of personal hygiene during illness...will verbalize/demonstrate understanding of home safety and fall prevention. There was no indication of the criteria used to measure personal hygiene, home safety, and fall prevention. The goals were not stated in measurable terms that would enable nursing staff to accurately perform an objective evaluation of the patient's progress toward her goals. The above findings were reviewed with and acknowledged by CM-B (clinical manager) during an interview on 7/15/21 at 11:30 a.m. MR#8: The Start of Care (SOC) was dated 6/11/21. The Plan of Care (POC) identified diagnoses of Post Appendectomy and Muscle Weakness. During record review on 7/14/21, it was noted that the goals on the POC were not measurable, for example the Skilled Nursing (SN) stated, "Patient/caregiver will verbalize/demonstrate adequate knowledge of gastrointestinal system by 8/9/21. Patient/caregiver will verbalize/demonstrate understanding of home safety and fall preventions by 8/9/21." There was no evidence of how these goals could be quantitatively measured. MR#9: The Start of Care (SOC) was dated 4/23/21. The Plan of Care (POC) identified diagnoses of Left Shoulder Strain, Mild Confusion and Diabetes Type 2. During review of the POC on 7/15/21, it was documented that the patient was a diabetic and there were no diabetic safety precautions on the POC. Additionally, the POC failed to contain parameters to notify the physician of blood sugar irregularities. The POC failed to contain the blood sugar parameters to notify the physician and diabetic safety precautions. Additionally, it was noted that the goals on the POC were not measurable, for example the SN stated, "Patient/caregiver will verbalize/demonstrate adequate knowledge of integumentary status by 6/21/21. Patient/caregiver will verbalize understanding of signs and symptoms and risk factors of circulatory compromise by 6/21/21." Additionally, the POC failed to include the safety measures of diabetic precautions. There was no evidence of how these goals could be quantitatively measured. MR#10: The Start of Care (SOC) was dated 6/9/21. The Plan of Care (POC) identified diagnoses of Parkinson's, Diabetes Type 2, and Chronic Kidney Disease. During review of the POC on 7/14/21, it was documented that the patient was a diabetic and there were no diabetic safety precautions on the POC. Additionally, the POC failed to contain parameters to notify the physician of blood sugar irregularities. The POC failed to contain the blood sugar parameters to notify the physician and diabetic safety precautions. Additionally, it was noted that the goals on the POC were not measurable, for example the SN stated, "Patient/caregiver will demonstrate compliance with treatment regimen prescribed for coronary artery disease by 7/7/21. Patient/caregiver will verbalize understanding of osteoarthritis including definition, signs and symptoms and measures to prevent or control by 7/7/21." Additionally, the POC failed to include the safety measures of diabetic precautions. There was no evidence of how these goals could be quantitatively measured. Furthermore, the POC had Physical Therapy (PT) frequency of 1w1 (1 time per week for 1 week), 2w3, 1w5. The visits scheduled for 6/24/21 and 7/1/21 were documented as missed visits, stating, "Cancel physical therapy regular visit for 6/24 due to staffing issue. Missed visit on 7/1/21 for physical therapy due to short staffing." There was no attempt to complete the frequency as ordered. The CM-B was questioned on 7/15/21 at 1:00 "Diabetic patients should have reportable parameters on the plan of care and safety precautions. We were having some staffing issues for therapy during that time."

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, it was determined that the agency failed to ensure the Home Health Aide provided services only as ordered by the physician in 1 of 8 records (MR's #16) out of a total sample of 17 records, which resulted in the Home Health Aide providing services not ordered by the physician. Findings include: MR#9: The Start of Care (SOC) was dated 4/23/21. The Plan of Care (POC) identified diagnoses of Left Shoulder Strain, Mild Confusion and Diabetes Type 2. The POC ordered Skilled Nursing (SN) services at a frequency of 1w3 (1 time a week for 3 weeks). During record review on 7/15/21, the SN documented on the third SN visit on 5/6/21, "She was scheduled for an RN (Registered Nurse) discharge this visit but nursing goals not met. Will postpone nursing discharge. She was also recently diagnosed with early Alzheimer's." There was no documented order to change the frequency of visits or to postpone the nursing discharge. Furthermore, on 5/26/21 the patient was discharged from nursing services without an order, 20 days from the last nursing visit. There was no documented evidence that the physician had authorized continued skilled nursing services. The CM-B was questioned on 7/15/21 at 1:15 "I am not sure why there was not a nursing order entered."

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on record review and interview, it was determined the Agency failed to ensure the Registered Nurse (RN) prepared complete written instructions for patient safety needs in 3 of 4 records in which aide services were provided, from a total of 10 records reviewed, (MR's #2, 8, 9) resulting in the potential for unsafe, substandard care and unmet care needs. Findings include: MR #2: The plan of care, for the period of 6/3/21 to 8/1/21, stated the patient was admitted with diagnoses that included Aftercare following surgical amputation of the leg below the knee, diabetes, congestive heart failure and hypertension. The HHa care plan created by the RN, dated 6/3/21, did not include diabetes or amputation precautions. During an interview on 7/15/21 CM-3 stated, "The aide care plan should have included all of the safety precautions listed on the agency plan of care, we need to do that." MR#8: The Start of Care (SOC) was dated 6/11/21. The Plan of Care (POC) identified diagnoses of Post Appendectomy and Muscle Weakness. The POC ordered Home Health Aide (HHa) services at a frequency of 1w4 (1 time a week for 4 weeks) effective 7/9/21 with the following safety precautions: Activity intolerance, ambulation precautions, bleeding precautions, environmental precautions, fall precautions, high risk medications, impaired metal status, incontinence precautions, lives alone, risk for hospitalization, and vision impairment. During record review on 7/14/21, the "Aide Care Plan" dated 7/12/21 completed by the Registered Nurse (RN) contained the following safety precaution, "Fall precautions." The HHa care plan failed to include the necessary safety measure and precautions to alert the aide of the patient's health concerns. MR#9: The Start of Care (SOC) was dated 4/23/21. The Plan of Care (POC) identified diagnoses of Left Shoulder Strain, Mild Confusion and Diabetes Type 2. The POC ordered HHa services at a frequency of 1w2 effective 4/25/21 with the following safety precautions: Activity intolerance, ambulation precautions, bleeding precautions, fall precautions, high risk medications, impaired metal status, lives alone, risk for hospitalization, and vision impairment. During record review on 7/15/21, the "Aide Care Plan" dated 4/23/21 completed by the RN contained the following safety precautions, "Fall precautions, bleeding precautions." The HHa care plan failed to include the necessary safety measure and precautions to alert the aide of the patient's health concerns. The CM-B was questioned on 7/15/21 at 1:15 "The aide care plan should have all of the safety precautions."

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview, it was determined that the agency failed to ensure the discharge summaries included the patient's status, specific care provided and response/outcomes in 2 of 3 discharged records (MR# 3, 6) ), resulting in the potential for unmet post-discharge needs. Findings include: MR #3: The plan of care, for the period of 5/12-21 to 7/1021, stated the patient was admitted for nursing, physical therapy and occupational therapy services with diagnoses that included kidney/bone/lung cancer, diabetes, depression and anxiety. During the review of the "Discharge Summary" form dated 7-10-21, it was noted that there was no status of problems identified by each discipline, the patient's over all status at admission and throughout care/discharge, a summary of the specific services that were provided, documentation of what specific goals were met, or a summary of the patient's response to care provided. There was no evidence the discharge summary was sent to the physician. During an interview on 7-15-21 at 3:50 PM CM-B (clinical manager) acknowledged and agreed with the above findings. MR#6: This patient was admitted to the agency on 7/26/20 with diagnoses of chronic obstructive pulmonary disease, diabetes, and heart failure. The 7/26/20 POC ordered skilled nursing, physical therapy, and occupational therapy services for this patient. The patient received home care services for approximately 8 weeks, from 7/26/20 through 9/21/20. The discharge summary dated 9/21/20 stated the patient's functional status was improved, the patient was independent, and medications were reconciled. There was no indication of the types and frequencies of services provided, blood sugar ranges, and patient outcomes in meeting goals established in the plan of care.