Every finding on record at Mymichigan Medical Center Midland

A Medicare recertification survey was conducted by the Michigan Department of Licensing and Regulatory Affairs from 9/6/23 through 9/8/23 at: MidMichigan Homecare 6810 Eastman Ave. Midland, MI 48642 The agency has three branch locations located at: 609 Quarter Street Suite 6 Gladwin, MI 48624 703 N. McEwan Street Clare, MI 48617 2597 S. Meridian Road Mount Pleasant, MI 48858 This was a standard survey. The conditions fof participation for Emergency Preparedness were not reviewed.

A Medicare recertification survey was conducted by the Michigan Department of Licensing and Regulatory Affairs from 9/6/23 through 9/8/23 at: MidMichigan Homecare 6810 Eastman Ave. Midland, MI 48642 The agency has three branch locations located at: 609 Quarter Street, Suite 6 Gladwin, MI 48624 703 N. McEwan Street Clare, MI 48617 2597 S. Meridian Road Mount Pleasant, MI 48858 For this survey 7 home visits with record reviews, 5 active records without a home visit and 5 discharged records were 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, interview and record review, the Agency failed to ensure that 1 (P-11) patient observed during a home visit, was included in the overall planning of their care including informing the patient/caregiver in advance of the days in which services would be provided, from a total of 17 sampled records reviewed, resulting lack of inclusion in planning, the potential for missed visits and unmet care needs. Findings include: P-11: The patient's SOC was 9/5/23 with diagnoses that included Chronic Pain left buttock, back and hip. During a review of the patient's record on 9/7/23 at 8:30 a.m., the POC documented, "Patient will participate in creation of care plan, discipline visit frequency..., Establish visit schedule and instruct visit frequency..." On 9/7/23 at 11:30 a.m., a scheduled survey home visit was conducted with the Physical therapist. During the visit, the patient's admission packet was reviewed. The patient's calendar of proposed visits was void of dates that visits would occur. The PT interjected and stated, "If you turn the page, there is another calendar." The calendar in reference was dated by the PT but again, was void of visit frequencies. Upon completion of the visit, the PT stated, "Let me pop open my schedule for next week and see what's available. I have Monday and Wednesday...., should be between 11:00 a.m. and 12:00 p.m." The patient responded, "I guess I could do that." The PT did not include the patient in the planning of her visits, in advance, as per this requirement. These findings were reviewed with and acknowledged by the Nurse Manager during the above interview.

Content of the comprehensive assessment CFR(s): 484.55(c) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to conduct a patient-specific, comprehensive assessment including baseline data for future assessments, in 1 of 17 records reviewed (P-3) out of a total of 17 records reviewed, resulting in the potential for unmet care needs. Findings included: **Agency Policy: P-3: The patient was admitted on 7/24/23 with diagnoses of pleural effusion, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and type 2 diabetes mellitus (DM). Upon review of the comprehensive assessment on 9/7/23, it was noted that the skilled nurse failed to obtain objective data for future assessments to measure the patient's specific status. For example, the registered nurse (RN) failed to obtain a baseline blood sugar, under the endocrine assessment, for a diabetic patient. There was also no blood sugar documented in the record until 9/7/23. A blood sugar was not documented by the agency until the 20th visit. During an interview on 9/8/23 at 12:30 p.m., the administrator (Staff-A) and the nursing manager (Staff-B) acknowledged the above findings.

Patient's needs CFR(s): 484.55(c)(4) The patient's medical, nursing, rehabilitative, social, and discharge planning needs; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient's Activity of Daily Living needs were adequately met in the patient's home for 1 (P-10) of 1 patient who required assistance with grooming, from a total of 17 sampled patient's reviewed, resulting in the potential for poor grooming and psychological decline. Findings include: P-10: The patient's start of care was 8/2/23 with diagnoses that included Polyosteoarthritis, pain left hip and laceration left forearm. During the clinical record review on 9/6/23 at 3:40 p.m., it was noted that section M1800 of the Initial comprehensive Assessment, completed by the Physical Therapist documented, "the patient required assistance with grooming and dressing, unable to use shower or tub, but able to participate in bathing self in bed, someone must help the patient to maintain toileting hygiene..." Further review of the assessment revealed no documented willing caregiver. Additionally, there was no evidence that the agency offered the assistance of a Home Health Aide to ensure the patient's grooming needs were adequately met in the patient's home. These findings were reviewed with and acknowledged by the Administrator and Nurse Manager during an interview on 9/7/23 at 2:09 p.m.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment included an accurate review of all medications to determine any adverse effects, failed to ensure the Registered Nurse provided oversight of the review process, and failed to ensure the physician was notified of potential drug interactions in 6 (P-4, P-5, P-9, P-10, P-11, P-14) of 17 sampled records reviewed, resulting in the potential for harmful medication effects for all patients currently serviced by this Agency. Findings include: P-5: The Start of Care (SOC) was dated 9/4/2022. The Plan of Care (POC) for the certification period 9/4/2022 to 11/2/2022 identified diagnoses of Diabetes, type 2 (DM2), Chronic Kidney Disease (CKD), Atrial Fibrillation (A-fib), Chronic Obstructive Pulmonary Disease (COPD), Open Wound Left Lower Leg, Squamous Cell Carcinoma of skin. Upon review of the patient's prescribed medications, it was noted a major drug interaction between the concurrent use of low dose aspirin (81 grams) and Eliquis. The combined use of these two drugs increases the risk of bleeding. There was no evidence found in the record that the physician had been notified of this drug interaction. The above findings were reviewed with and acknowledged by the Administrator (Staff A) and Nurse Manager (Staff B) during a group interview on 9/8/23 at 1:30 p.m. **Agency policy: Medication administration workflow safety policy and procedure, home care: XIII. Medication Review (B), "...problems are reported to the physician and documented in the record." P-4: The patient was admitted on 7/24/23 with diagnoses of type 2 diabetes mellitus (DM). Upon review of the comprehensive assessment on 9/8/23, it was noted that the medication reconciliation dated 7/24/23 indicated a severe medication interaction between Citalopram and Omeprazole. There was no documentation in the record that the physician was notified of the severe interaction. During an interview on 9/8/23 at 12:30 p.m., the administrator (Staff-A) and the nursing manager (Staff-B) acknowledged the above findings. P-14: This 69-year-old patient was admitted to home care on 8/11/23 with a diagnosis of acute kidney failure and acute myeloid leukemia. During record review on 9/6/23 at 3:50 p.m., it was noted that the medical record did not include a drug interaction report. During interview on 9/8/23 at 10:50 a.m., the analyst/quality improvement manager (Staff-H) produced the drug interaction report which included two contraindicated drug combinations (Xarelto/posaconazole and Apixaban/Xarelto) as well as four severe interaction drug combinations (Zithromax/Levaquin, advAIR Diskus/posaconazole/voriconazole, Jakafi/Posaconazole, and voriconazole/Eliquis/Posaconazole). The nursing manager (Staff-B) explained the nurse will call the physician when severe drug interactions are found, and a message is sent for any moderate interactions. The Medication Administration Workflow and Safety Policy and Procedure (MyMichigan Health Policy ID: 13953664) states under medication review, “problems are reported to the physician and documented in the record.” Staff B and Staff H reviewed the medical record and acknowledged the initial nursing assessment states there were “no issues” documented under medications and there was no documentation to indicate the physician was informed of the 2 contraindicated drug combinations or the 4 potential major interactions. During home visit on 9/7/23 at 10:00 a.m., the physical therapist performed a medication review with P-14’s sister (primary caregiver). Upon review, the caregiver noted that two medications were missing from the list (magnesium & budesonide). The caregiver stated, “my sister started these medications last week and I told the RN when she was here on Sunday (9/3/23).” The skilled nursing visit from 9/3/23 did not include an update of the medication profile. The Medication Administration Workflow and Safety Policy and Procedure (MyMichigan Health Policy ID: 13953664) states, “ongoing medication review and monitoring at revisits by home health nurses includes reviewing the in-home medication list for accuracy at each visit with the patient.” The finding was reviewed and acknowledged by Staff-B and Staff-H during an interview on 9/8/23 at 10:50 a.m. P-9: The patient's start of care (SOC) was 8/9/23 with diagnoses that included Chronic Pain Syndrome. Section M2001 of the Initial Comprehensive Assessment, completed by the Physical Therapist (PT), documented "No issues found during review." However, the agency's drug interaction report documented, "Undetermined Severity: vision changes, tongue swelling, hard to swallow; Drug Class Match: sores all over, swelling..." During the record review on 9/6/23 at 2:10 p.m., there was no documented evidence that the Registered Nurse (RN) had conducted the drug review as per this requirement. P-10: The patient's SOC was 8/21/23 with diagnoses that included Polyosteoarthritis, pain left hip and laceration left forearm. During the record review on 9/6/23 at 3:40 p.m., it was noted that the Physical Therapist had conducted the drug review. There was no documented evidence that the RN had conducted the drug review as per this requirement. P-11: The patient's SOC was 9/5/23 with diagnoses that included Chronic Pain. During the record review on 9/7/23 at 8:30 a.m., it was noted that the Physical Therapist had conducted the drug review. There was no documented evidence that the RN had conducted the drug review as per this requirement. The agency failed to ensure the comprehensive assessment included an accurate review of the patient's medications that had been conducted by an RN. The above findings were reviewed with and acknowledged by the Administrator and Nurse Manager during a group interview on 9/7/23 at 2:09 p.m.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review, policy review, and interview, the agency failed to ensure the Plan of Care included objectively measurable assessments and goals to determine the patient's progress towards the achievement of goals, and failed to ensure the plan was individualized in 9 of 17 records (P-5, 6, 7, 8, 10, 11, 12, 13, 14) reviewed. Findings included: P-12: This 68-year-old patient was admitted to home care on 8/11/23 with a diagnosis of acute cystitis without hematuria. During record review on 9/7/23 at 2:30 p.m., it was noted on the plan of care that skilled nursing, physical therapy, occupational therapy, and speech language pathology (SLP) are listed as disciplines assessing the flu/pneumonia vaccine and the supervisory visit. SLP was not involved in the care of this patient. The finding was reviewed and acknowledged by the analyst/quality improvement manager (Staff-H) and nursing manager (Staff-B) during an interview on 9/8/23 at 10:50 a.m. P-13: This 77-year-old patient was admitted to home care on 5/26/23 with a diagnosis of left total knee arthroplasty and coronary artery disease. During record review on 9/6/23 at 2:15 p.m., it was noted on the plan of care that skilled nursing, physical therapy, occupational therapy, and speech language pathology (SLP) are listed as disciplines assessing the flu/pneumonia vaccine. SLP was not involved in the care of this patient. The finding was reviewed and acknowledged by Staff-B and Staff-H during an interview on 9/8/23 at 10:50 a.m. P-14: This 69-year-old patient was admitted to home care on 8/11/23 with a diagnosis of acute kidney failure and acute myeloid leukemia. During record review on 9/6/23 at 3:50 p.m., it was noted on the plan of care that skilled nursing, physical therapy, occupational therapy, and speech language pathology (SLP) are listed as disciplines assessing the flu/pneumonia vaccine and the plan of care updates/patient representative/advance directive along with a medical social worker (MSW). SLP and MSW were not involved in the care of this patient. The finding was reviewed and acknowledged by Staff-B and Staff-H during an interview on 9/8/23 at 10:50 a.m. P-10: The patient's start of care (SOC) was 8/21/23 with diagnoses that included Polyosteoarthritis, Pain left hip and laceration left forearm. During the clinical record review on 9/6/23 at 3:40 p.m., it was noted that the plan of care (POC) ordered Physical Therapy (PT) and Occupational Therapy services to be provided. Upon review of the POC, Skilled Nursing (SN) and Speech Language Pathology (SLP) were listed for Flu/Pneumonia Vaccine interventions, to begin services on 8/21/23. These were not ordered services and did not accurately reflect the needs of the patient. P-11: The patient's SOC was 9/5/23 with a diagnosis of Chronic Pain left buttock, back and hip. During the clinical record review on 9/7/23 at 8:30 a.m., it was noted that the POC ordered PT services to be provided. Upon review of the POC, SN, SLP, Medical Social Work (MSW) and Occupational Therapy (OT) services were listed for falls management interventions, to begin services on 9/5/23. These were not ordered services. The agency failed to ensure the POC accurately reflected the services as ordered in order to meet the needs of the patient. These findings were reviewed with and acknowledged by the Nurse Manager during an interview on 9/7/23 at 2:30 p.m. who reported, "We've been having a problem with that issue." **Agency Policy #14293098: Plan of Care and Physician Orders Policy, Home Care, revised September 2023. The policy states, "A plan of care will be developed based on patient goals derived from identified problems and needs, conditions, wishes, and ability to respond to care or service. The Care plan will include appropriate interventions, assessments, referrals, and teaching to meet the identified patient goals for home health; ...and measurable outcomes anticipated as a result of implementing and coordinating the plan of care." P-5: The Start of Care (SOC) was dated 9/4/2022. The Plan of Care (POC) for the certification period 9/4/2022 to 11/2/2022 identified diagnoses of Diabetes, type 2 (DM2), Chronic Kidney Disease (CKD), Atrial Fibrillation (A-fib), Chronic Obstructive Pulmonary Disease (COPD), Open Wound Left Lower Leg, Squamous Cell Carcinoma of skin. Upon review of the record, it was noted the assessments and goals on the POC were not objectively measurable to determine the patient's progress towards obtaining the goals. Examples of goals included: "Patient receives adequate care; Patient demonstrates improved functional use of upper extremity; Patient demonstrates adequate knowledge of diabetes monitoring and treatment; Patient verbalizes understanding of infection prevention strategies and methods to prevent development or worsening pressure injuries; Patient/caregiver demonstrates ability to administer insulin using correct techniques and site rotation." These goals are not objectively measurable to determine the patient's progress towards obtaining the goals. In addition, the agency failed to include measurable assessments to use in determining whether the status of lower extremity edema was improving or worsening. The agency was using subjective measurements for edema such as +1, +2, +3 rather than using an objective measurement via a measuring tape to determine the status of the patient's lower extremity edema. P-6: The SOC was dated 7/31/2023. The Plan of Care for the period 7/31/23 to 9/28/23 included diagnoses of Hypertensive Heart Disease with Heart Failure (HHF), Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD), Lymphedema, Chronic Respiratory Failure (CRF), and Bipolar-Disorder (BPD). Upon review, it was noted that the Goals on the Plan of Car were not objectively measurable to determine the patient's progress towards obtaining the goals. Examples included: "Wound will heal without complications or signs/symptoms of infection; Patient has valid advance directive and/or needed legal documents; Patient Cardiac care needs met without complications; Patient receives adequate care; Increased understanding of available community resources." These goals are not objectively measurable to determine the patient's progress towards goals. P-7: The SOC was dated 8/16/2023. The Plan of Care for the period 8/16/23 to 10/14/2023 included diagnoses of Hypertensive Heart Disease with Heart Failure (HF), Congestive Heart Failure, Arterial Hypertension, Respiratory Failure with Hypoxia, Atrial Fibrillation, and Diabetes, type 2. Upon review of the record, it was noted the Goals on the Plan of Care (POC) were not objectively measurable to determine the patient's progress towards achieving the goals. Examples included, "Patient cardiac care needs met without signs and symptoms of complications; Patient Pulmonary care needs met without signs and symptoms of complications; Patient demonstrates improved ability to perform ADL's (activities of daily living) and IADL's (Instrumental Activities of Daily Living); Patient demonstrates adequate knowledge of diabetes monitoring and treatment; "Patient reduces Fall injury risk and frequency." These goals are not objectively measurable to determine the patient's progress towards goals. In addition, the agency failed to include measurable assessments to use in determining whether the status of lower extremity edema was improving or worsening. The agency was using subjective measurements for edema such as +1, +2, +3 rather than using an objective measurement via a measuring tape to determine the status of the patient's lower extremity edema. P-8: The SOC was dated 8/31/2023. The POC for the certification period 8/31/23 to 10/29/23 identified diagnoses of Laceration of Foreign Body of left upper arm, Pain in Shoulder, Chronic Obstructive Pulmonary Disease (COPD), Hypertension (HTN), Malignant neoplasm of Prostate. Upon review of the record, it was noted the Goals on the Plan of Care (POC) were not objectively measurable to determine the patient's progress towards achieving the goals. Examples included, "Wound will heal without complications or signs/symptoms of infection; Patient will participate in creation of care plan, discipline visit frequency and home health goals; Patient pulmonary care needs met without signs/symptoms of complications; Increased understanding or available community resources; Patient reduces fall injury risk and frequency; Patient remains safe and free from harm." These goals are not objectively measurable to determine the progress toward obtaining the goals." The above findings were reviewed with and acknowledged by the Administrator (Staff A) and Nurse Manager (Staff B) during a group interview on 9/8/23 at 1:30 p.m.

Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This STANDARD is not met as evidenced by: Based on observation, interview and record review, the Physical Therapist failed to utilize professional standards of practice during the provision of care and services for 1 (P-11) of 1 patient observed during a home visit, from a total of 17 sampled records reviewed, resulting in the potential for injury, decline in physical functioning and unmet care needs. Findings included: Policy: Gait Belt Use, Revised May 22, 2023, stated, "The device provides a secure grasping surface to aid with patient transfer and ambulation. A gate bet is commonly used for patients who are at risk for falling..." P-11: The patient's start of care was 9/5/23 with diagnoses that included Chronic Pain left buttock, back and hip. During the record review on 9/7/23 at 8:30 a.m., it was noted that the plan of care ordered Physical Therapy (PT) services to be provided at a frequency of 2x/wk. x 4 wks. The record further indicated the patient had a history of lung surgery and cardiac surgery and was identified as a falls risk. On 9/7/23 at 11:30 a.m., during a scheduled survey home visit with the PT, the following observations were made: The PT checked the patient's vital signs (blood pressure, oxygen saturation and pulse). The PT then instructed the patient to walk throughout her home with the assistance of her walker. The PT did not apply a gait belt (safety belt applied to the patient's waist to prevent falls) to ensure the patient's safety. During the visit, the patient reported, "I get a little wobbly sometimes" and was observed exhibiting an unsteady gait during ambulation. The patient was observed while laying on her sofa performing the instructed exercises. Once completed, the patient attempted to stand, waved her hand in the air and reported, "Hold on for a second, I have to get my balance. The patient was noted to be unsteady upon standing. After exiting the patient's home, the PT was queried about the observations made during the visit. When queried about the use of a gait belt to ensure the patient's safety, the PT "I know the agency's policy is to use a gait belt for patient safety." These findings were reviewed with and acknowledged by the Administrator and Nurse Manager during an interview on 9/7/23 at 2:09 p.m. who both confirmed the use of a gait belt would have been appropriate in this case.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the occupational therapist and physical therapist performed an assessment of the patient's health status and therapy needs in 2 of 12 (P-4, P-15) records reviewed with occupational therapy and physical therapy services, and the skilled nurse failed to perform daily weights for a patient diagnosed with Congestive Heart Failure (P-5) in 1 of 17 records reviewed with Skilled Nursing services, resulting in a delay in identifying health concerns and the potential for poor outcomes for these patients. Findings include: P-15: This 68-year-old patient was admitted to home care on 7/24/23 with diagnoses of status post coronary artery by-pass graft, high blood pressure, and heart disease. The 7/24/23 plan of care ordered skilled nursing, physical therapy, aide services, and occupational therapy (OT) to assess and evaluate the patient's functional status. During record review on 9/7/23, it was noted that the OT cancelled visits with the patient on 7/27/23 and 7/31/23. These visits were cancelled by the provider (OT). There was no documentation that the visits had been cancelled by the patient. The OT conducted the evaluation on 8/1/23 which was 8 days after the start of care. The OT failed to follow the agency's policy titled, Assessments Policy, Home Care (rev. 8/2023) which states, "...Additional discipline assessment and care/services will be initiated as follows: Within 5 days of the initial assessment/start of care, or as requested by the ordering physician, when discipline orders are noted on the initial referral." During an interview on 9/8/23 at 8:55 a.m., the findings were reviewed with and acknowledged by the Administrator (Staff A) and the nursing manager (Staff B). **Agency policy: Assessments Policy, Home Care (rev. 8/2023) states, "...Additional discipline assessment and care/services will be initiated as follows: Within 5 days of the initial assessment/start of care, or as requested by the ordering physician, when discipline orders are noted on the initial referral." P-4: The patient was admitted on 7/24/23 with diagnoses of type 2 diabetes mellitus (DM). Upon review of the patient's record on 9/8/23, it was noted that the physical therapist (PT) was ordered on the plan of care, to start care on 8/7/23. The PT's first visit was not until 8/14/23, seven days after the start of care. There was no documentation in the record indicating the physician was notified of the late start of care. During an interview on 9/8/23 at 12:30 p.m., the administrator (Staff-A) and the nursing manager (Staff-B) acknowledged the above findings. P-5: The Start of Care (SOC) was dated 9/4/2022. The Plan of Care (POC) for the certification period 9/4/2022 to 11/2/2022 identified diagnoses of Diabetes, type 2 (DM2), Chronic Kidney Disease (CKD), Atrial Fibrillation (A-fib), Chronic Obstructive Pulmonary Disease (COPD), Open Wound Left Lower Leg, Squamous Cell Carcinoma of skin. The Plan of Care included the following orders, "Instruct patient/caregiver to take blood pressure, pulse, and weight daily; if appropriate; have patient record daily readings and report any significant changes. Assess Patient/Caregiver compliance with taking blood pressure, pulse, and weight daily. Upon review of the record, it was noted the Skilled Nurse (SN) failed to document or record any daily weights for this patient diagnosed with Congestive Heart Failure in the patient's medical record, possibly resulting in deterioration in the patient's health status. The above findings were reviewed with and acknowledged by the Administrator (Staff A) and Nurse Manager (Staff B) during a group interview on 9/8/23 at 1:30 p.m.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure skilled nursing provided services as ordered by the physician in the plan of care for 1 of 17 (P-14) records reviewed, resulting in the potential for poor patient outcomes for this patient. Findings include: P-14: This 69-year-old patient was admitted to home care on 8/11/23 with a diagnosis of acute kidney failure and acute myeloid leukemia. During record review on 9/6/23 at 3:50 p.m., it was noted that the initial nursing assessment stated the patient presented with 2+ edema on bilateral lower extremities and orders were obtained for thromboembolic deterrent (TED) hose. The plan of care states to assess “weight gain of 2 lbs. in 24 hours or 4-5 lbs. in 1 week.” There was no documentation found in the medical record of the patient’s weight being monitored on admission or for the following 4 visits. The finding was reviewed and acknowledged by the analyst/quality improvement manager (Staff-H) and nursing manager (Staff-B) during an interview on 9/8/23 at 10:50 a.m.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the home health aide provided services at the frequency ordered by the physician in the plan of care for 1 of 3 (P-15) records reviewed in which aide services where provided, resulting in a lack of personal care services for this patient. Findings include: P-15: This 68-year-old patient was admitted to home care on 7/24/23 with diagnoses of status post coronary artery by-pass graft, high blood pressure, and heart disease. The 7/24/23 plan of care ordered skilled nursing, physical therapy, occupational therapy, and aide services. During record review on 9/7/23, it was noted that the 7/24/23 care plan ordered the aide to provide 1 visit the first week, then 2 visits every week for 3 weeks, and then 1 visit every week for 5 weeks. In week 1, the patient declined the visit on 7/27/23. In week 2, the aide provided visits on 8/2/23 and 8/4/23. In weeks 3 and 4, the aide provided one visit each week (8/7/23 and 8/14/23) and not two visits as ordered. There was no indication the patient had declined the visits and no documentation that the physician was informed of the change in aide frequency. During an interview on 9/8/23 at 8:55 a.m., the findings were reviewed with and acknowledged by the Administrator (Staff A) and the nursing manager (Staff B).

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 transfer/discharge summaries were sent to the physician in 2 of 5 records (P-1, P-9) who were discharged/transferred from a total of 17 records reviewed, resulting in the potential for unidentified continuing health care concerns and unmet care needs. Findings include: P-9: The patient's start of care was 8/9/23 with diagnoses that included Chronic Pain Syndrome. During the clinical record review on 9/6/23 at 2:10 p.m., it was noted that the patient was ordered to receive Physical Therapy, Occupational therapy and Medical social work services. At the time of this review, there was no documented evidence that the MSW Discharge Summary dated 8/29/23, had been forwarded to the Physician within 5 days of the discharge from services. These findings were reviewed with and acknowledged by the Analyst during an interview on 9/7/23 at 2:09 p.m. who reviewed the record in the presence of the Administrator and reported, "I don't see any evidence that it was sent to the Physician." P-1: The start of care (SOC) was dated 3/22/23 with diagnoses that included sepsis, congestive heart failure, and chronic obstructive pulmonary disease. During record review on 9/6/23, it was discovered there was no documented evidence that the transfer summary was sent to the physician, or that the physician was notified of the transfer. During an interview on 9/8/23 at 12:30 p.m., the administrator (Staff-A) and the nursing manager (Staff-B) agreed that the record should have documentation that the summaries were sent to the physician.