Every finding on record at Northern Home Care, Inc

On 1/22/24 through 1/25/24, the Michigan Department of Licensing and Regulatory Affairs conducted a recertification survey at Northern Home Care. This was a standard survey. The requirements for participation in Medicare at 42 CFR Part § 484.102 Emergency Preparedness were not reviewed.

On 1/22/24 through 1/25/24, the Michigan Department of Licensing and Regulatory Affairs conducted a recertification survey at: Northern Home Care 42 W. 2nd St. #3 Pentwater, MI 49449 The agency is in the process of obtaining branch approval for: 308 River Street, Manistique, Mi 49660 Onsite visits were made to both locations. 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.

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure patients were informed of the administrator's name and phone number, resulting in the potential for patient complaints or concerns to go unaddressed which could negatively affect the quality of care for all patients serviced by this agency. Findings include: During review of the agency’s start of care booklet on 1/22/24, it was noted the back page of the booklet had a blank space after “administrator name” that was to be filled in by staff. During joint survey home visits for P-7 with the PT/RN on 1/23/24 at 10:30 a.m. and for P-9 with the PT/RN on 1/24/24 at 10:00 a.m., it was observed that the administrators name was blank on the back pages of both start of care booklets. This finding was reviewed and acknowledged during an interview with the alternate administrator (Staff-A) on 1/25/24 at 8:45 a.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 a review of all medications to determine any duplicate therapy or adverse effects, and failed to ensure the physician was notified of potential drug interactions in 3 of 10 (P-6, 7, 1) records reviewed, resulting in the potential for harmful medication effects for all patients serviced by this agency. Findings include: P-1: This patient was admitted to home care on 7/25/23 with diagnoses of stage 1 pressure ulcer of right posterior upper thigh, multiple sclerosis, and paraplegia. During record review on 1/22/24, it was noted that the 7/25/23 comprehensive assessment completed by the registered nurse states that no issues were found during the drug regimen review. The same comprehensive assessment documents one possible major drug interaction between the patient's medications: Ibuprofen and Paxil. There was no evidence the physician was notified. The findings were reviewed with the alternate administrator (Staff-A) and the director of clinical services (Staff-B) during an interview on 1/25/24 at 9:15 a.m. Staff-A reviewed the medical record, acknowledged the findings, and explained that staff are to contact the physician by phone and document such contact in the medical record. Agency Policy 8.15.1-Medication Reconciliation (February 2021) states the agency will reconcile patient’s medications at time of admission and on an ongoing basis in order to identify and potential adverse effects and drug reactions… At the time of admission, the admitting RN, PT, or SLP will create and document a complete list of medications that patient is taking at home, including dose, strength, route, and frequency. P-6: This 83-year-old patient was admitted to home care on 6/26/23, with a diagnosis of type 2 diabetes with foot ulcer. During record review on 1/22/24, it was noted that the skilled nursing recertification assessment, dated 6/26/23, stated no issues were found during medication review while the same document indicated two major interactions between omeprazole & Plavix and between amiodarone & atorvastatin. There was no evidence that the physician was notified of the interactions. P-7: This 93-year-old patient was admitted to home care on 1/18/24, with diagnoses of pneumonia, hypertensive heart disease, and congestive heart failure. During a home visit on 1/23/24 at 10:30 a.m., a medication review was conducted comparing the medications listed on the plan of care and with a medication administration record obtained by the assisted living facility, Village House of Ludington. It was noted that the patient receives furosemide 40mg daily and metoprolol succinate 25mg twice per day, and neither medication was listed on the plan of care. During record review on 1/23/24, it was noted that the discharge summary from the hospital, dated 1/16/24, states the patient is to start taking furosemide and metoprolol. There was no documented evidence that a drug review was conducted on these medications. These findings were reviewed and acknowledged during an interview with the alternate administrator (Staff-A) and the director of clinical services (Staff-B) on 1/25/24 at 8:45 a.m.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the plan of care included appropriate interventions with objectively measurable goals specific to the individualized needs of the patient in 3 of 7 (P-6, 9, 10) records reviewed, resulting in the potential for poor patient outcomes and unmet care needs for these patients. Findings include: P-6: This 83-year-old patient was admitted to home care on 6/26/23, with a diagnosis of type 2 diabetes with foot ulcer. During record review on 1/22/24, it was noted that the plan of care failed to include measurable nursing goals that are individualized to address patient needs. The plan of care contained the following goals “patient will verbalize understanding of fall risk and all aspects of associated care” and “patient’s pain will be managed at the patient’s own comfort level.” There was no evidence of how these could be objectively measured to determine progress toward meeting the goals. P-9: This 70-year-old patient was admitted to home care on 1/2/24 with diagnoses of type 2 diabetes, chronic venous ulcer, and lymphedema. During record review on 1/23/24, it was noted that the plan of care failed to include measurable nursing goals that are individualized to address patient needs. The plan of care contained the following goals, “patient will remain complaint with medication safety” and “patient will verbalize understanding of diabetes mellitus and all aspects of associated care.” There was no evidence of how these could be objectively measured to determine progress toward meeting the goals. P-10: This 74-year-old patient was admitted to home care on 12/8/23 with diagnoses of chronic obstructive pulmonary disease, chronic respiratory failure, and congestive heart failure. During record review on 1/24/24, it was noted that the plan of care failed to include measurable nursing goals that are individualized to address patient needs. The plan of care contained the following goals, “patient will remain complaint with medication safety” and “patient will be able to verbalize knowledge regarding food and fluid restrictions.” There was no evidence of how these could be objectively measured to determine progress toward meeting the goals. It was also noted that the plan of care failed to include bleeding precautions as the patient is on Eliquis, an anticoagulant medication that can cause bleeding. These findings were reviewed and acknowledged during an interview with the alternate administrator (Staff-A) and the director of clinical services (Staff-B) on 1/25/24 at 8:45 a.m.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure skilled professionals notify the physician of findings that fell outside the parameters ordered in the patient’s plan of care in 2 of 10 (P-8, 9) records reviewed, resulting in the potential for physical decline and unmet care needs for these patients. Findings include: P-8: This 72-year-old patient was admitted to home care on 1/7/24 with diagnoses of orthopedic aftercare post laminectomy and lumbosacral disc disorder. During record review on 1/23/24, it was noted that the plan of care orders disciplines to notify the physician when the patient’s pain is greater than 7 (scale 0 low to 10 high). During the physical therapy (PT) visit on 1/11/24, the PT documented the current pain level of 8 in the lumbar region on the right side. There was no evidence to indicate the PT notified the physician of the patient’s elevated pain level as ordered in the plan of care. P-9: This 70-year-old patient was admitted to home care on 1/2/24 with diagnoses of type 2 diabetes, chronic venous ulcer, and lymphedema. During record review on 1/23/24, it was noted that the plan of care orders disciplines to notify the physician when the patient’s pain is greater than 7 (scale 0 low to 10 high). During the start of care assessment, dated 1/2/24, the registered nurse documented the current pain level of 8 in the right arm and right leg. There was no evidence to indicate the RN notified the physician of the patient’s elevated pain level as ordered in the plan of care. These findings were reviewed and acknowledged during an interview with the alternate administrator (Staff-A) and the director of clinical services (Staff-B) on 1/25/24 at 8:45 a.m.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure patients were informed of the clinical managers name and phone number, resulting in the potential for patient concerns to go unaddressed which could negatively affect the quality of care for all patients serviced by this agency. Findings include: During review of the agency’s start of care booklet on 1/22/24, it was noted the back page of the booklet had a blank space after “clinical manager name” that was to be filled in by staff. During joint survey home visits for P-7 with the PT/RN on 1/23/24 at 10:30 a.m. and with the PT/RN for P-9 on 1/24/24 at 10:00 a.m., it was observed that the clinical managers name was blank on the back pages of both start of care booklets. This finding was reviewed and acknowledged during an interview with the alternate administrator (Staff-A) on 1/25/24 at 8:45 a.m.

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 physical therapy performed an assessment of the patient's health status and needs in 1 of 8 (P-2) records reviewed with physical therapy services ordered, resulting in the potential for unidentified health concerns, decline in physical functioning, and poor patient outcomes for this patient. Findings include: P-2: This patient was admitted to home care on 1/15/24 with diagnoses of angioneurotic edema (swelling under the skin) and pneumonia. During record review on 1/23/24, it was noted that the physical therapy evaluation dated 1/16/24 was blank of information regarding this patient's physical functioning and needs. The findings were reviewed with the alternate administrator (Staff-A) during an interview on 1/25/24 at 9:15 a.m. Staff-A reviewed the medical record and acknowledged that the physical therapy evaluation was blank 9 days after the evaluation was conducted. Staff-A explained that staff are expected to have documentation completed within 48 hours.

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 registered nurse provided services as ordered by the physician in the plan of care for 1 of 10 (P- 9) records reviewed, resulting in the potential for physical decline and unmet care needs for this patient. Findings include: P-9: This 70-year-old patient was admitted to home care on 1/2/24 with diagnoses of type 2 diabetes, chronic venous ulcer, and lymphedema. During record review on 1/23/24, it was noted that the plan of care orders clinicians to assess/detect fluid overload, assess cardiovascular status and to notify the physician of a weight variation of 2 pounds in a day or 5 pounds in a week. An initial weight was documented on the nursing start of care assessment dated 1/2/24. There was no evidence of documented weights on the following three nursing visits (1/9/24, 1/16/24, and 1/23/24). This finding was reviewed and acknowledged during an interview with the alternate administrator (Staff-A) and the director of clinical services (Staff-B) on 1/25/24 at 8:45 a.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 detailed discharge summary was sent to the physician within 5 business days of discharge for 1 of 3 (P-6) discharge records reviewed, and failed to ensure a detailed transfer summary was sent to the physician for 1 of 1 (P-10) transfer records reviewed, resulting in a lack of information to ensure continuity of care. Findings include: Agency Policy 9.31.1: Discharge Summary (revised 2/2021) states a discharge summary will be sent within 5 business days of patient discharge to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient. P-6: This 83-year-old patient was admitted to home care on 6/26/23, with a diagnosis of type 2 diabetes with foot ulcer. During record review on 1/22/24, it was noted that the patient was discharged from agency services on 10/13/23. There was no documented evidence that a detailed discharge summary report was sent to the physician within 5 days of the patient’s discharge. P-10: This 74-year-old patient was admitted to home care on 12/8/23 with diagnoses of chronic obstructive pulmonary disease, chronic respiratory failure, and congestive heart failure. During record review on 1/24/24, it was noted that the patient was transported to the hospital on 1/2/24 and admitted with diagnoses of acute urinary tract infection with sepsis, diarrhea, acute hyponatremia, and acute hyperkalemia. The transfer summary dated 1/4/24 failed to include reason for admission to home health care, the frequency of services provided, and medications the patient was on at time of transfer. These findings were reviewed and acknowledged during an interview with the alternate administrator (Staff-A) and the director of clinical services (Staff-B) on 1/25/24 at 8:45 a.m.

On 1/4/21 to 1/7/21, the Michigan Department of Licensing and Regulatory Affairs conducted a Medicare authorized recertification survey at: Northern Homecare 42 W. 2nd Street Pentwater, MI 49449 This was a standard survey. The requirements for participation in Medicare at 42 CFR 484.102 Emergency Preparedness were not reviewed

On 1/4/21 to 1/7/21, the Michigan Department of Licensing and Regulatory Affairs conducted a Medicare authorized recertification survey at: Northern Homecare 42 W. 2nd Street Pentwater, MI 49449 Records reviewed: 3 discharged records and 4 records with home visits and 3 active records reviewed, for a total of 10 records reviewed. The agency had 118 active patients at the time of the survey. The agency has no branch sites. 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, Home Health.

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, policy review, and interview, the Agency failed to conduct a patient-specific, comprehensive assessments that accurately reflected the patient's current health status, past medical history, history of events leading to home care, and ascertained the patient's immediate care needs in 8 of 10 records reviewed (MR#s 2, 3, 4, 5, 6, 7, 8 and 9) out of a total sample of 10 records, resulting in the potential for unmet care needs. Findings included: Agency Policy: Initial Assessments/Comprehensive Assessments, reviewed March 2018. The policy states: "The Assessment will reflect the patient's current health status and will include information to demonstrate the patient's achievement toward desired outcomes...will also include current health status including all active health and medical problems and relevant medical history." MR#2: The SOC was dated 6/3/2019. The Plan of Care for the certification periods of 9/25/20 to 11/23/20 and 11/24/20 to 1/22/21 were both recertifications and both identified diagnoses of Rotator Cuff Tear of Right Shoulder, Gout, Congestive Heart Failure (CHF), Diabetes Type 2 (DM2), and Chronic Kidney Disease stage 3 (CKD3). The patient was receiving Skilled Nursing (SN) services. The re-certification assessments did not include documentation of the the events leading to the need for recertification of home care services, patient response/outcomes, or the current related needs for this patient. It was noted that the diagnoses in the Plans of Care for both these recertifications (9/25/20 to 11/24/20 and 11/24/20 to 1/22/20) were unchanged and had no new additions from the original certification period dated 6/3/25. MR#3: The SOC was dated 6/30/20. The Plan of Care (POC) for the certification period 6/30/20 to 8/28/20 identified diagnoses of Hemiplegia following Cerebral Infarction (CVA); Pressure Ulcer Right Buttock Stage 2, Chronic Kidney Disease stage 4 (CKD4), Osteoarthritis (OA), and Atrial Fibrillation (A-fib). The patient was receiving SN, and Home Health Aide (HHa) services. Upon review of the record, it was noted the patient was recertified for two additional certification periods dated 8/29/20 to 10/27/20, and 12/27/20 to 2/24/21. The re-certification assessments did not include documentation of the the events leading to the need for recertification of home care services, new patient response/outcomes, or the current related needs for this patient. It was noted that the diagnoses in the Plans of Care for all three recertifications (6/30/20 to 8/28/20, 8/29/20 to 10/27/20, and 12/27/20 to 2/24/21) were the same and the two follow-up certifications were unchanged and had no new additions from the original certification period dated 6/3/25. MR#4: The SOC was dated 5/8/2020. The Plan of Care for the certification period 7/7/2020 to 9/4/2020 was a recertification that identified diagnoses of Amyotrophic Lateral Sclerosis (ALS), Hypertension (HTN), Degeneration of Nervous System due to Alcohol, Atrial Fibrillation (A-fib). It was noted upon review, that the Recertification failed to include documentation of the need for recertification of Home Health Services. It was noted that the diagnoses in the Plans of Care for both Certifications were the same with no changes. MR#5: The SOC was dated 12/03/2019. The POC for the certification period 12/03/19 to 01/31/20 identified diagnosis of Fracture of Right Femur, Alcohol Abuse, Chronic Obstructive Pulmonary Disease (COPD), Disease of Blood-forming (Liver) Organs. Upon review of the record, it was noted the patient was recertified for two additional certification periods dated 2/01/20 to 03/31/20/20, and 04/01/20 to 05/30/20. The re-certification assessments did not include documentation of the the events leading to the need for recertification of home care services, new patient response/outcomes, or the current related needs for this patient. It was noted that the diagnoses in the Plans of Care for all three recertifications (04/01/20 to 05/30/2020 , 2/01/20 to 03/31/20/20, and 04/01/20 to 05/30/20) were the same; and the two re-certifications were unchanged and had no new additions from the original certification period dated 12/03/19. These findings were reviewed and acknowledged during an interview with the Clinical Manager (CM#1) on January 7th, 2021 at 2:00 p.m. MR #6: The plan of care dated for the certification period of 12-4-20 stated the patient was recertified with diagnoses that included Hemiplegia, anxiety, arthritis, hypertension, gastric reflux, hypothyroidism, left knee cap fracture and hypercholestrolemia. During the record review on 1-6-21 it was noted that the recertification comprehensive assessment dated 11-30-20, documented "No changes since previous assessment." The assessment did not include an assessment of the patient's health status that suggested the patient needed continued home care services or what the related patient needs were. During an interview on 1-7-21 at 2:55 PM the Administrator stated, "I agree the assessment should have a complete picture of the patient's condition and why they need to be recertified." MR #7: The plan of care, dated 10-28-20, stated the patient was admitted with the diagnoses of diabetes, dementia, vertebral (spine) fracture, hypertension, history of urinary tract infections and heart murmur. On the start of care comprehensive assessment, dated 10-28-20, there was no documentation of the history of the patient's diabetes such as onset date, treatment history, when blood sugar or A1c was last checked/what the results were and the patient's/caregiver's ability to perform glucose monitoring procedure. The start of care assessment did not include the date the patient's vertebral fracture occurred, or the details of how it happened. During an interview on 1-7-21 at 2:55 PM the Administrator stated, "The comprehensive assessments need to have a more complete picture of the patient's health history and why they need home care." MR #8: The plan of care, dated 11-20-20, stated the patient was admitted with the diagnoses of lung cancer, secondary cancer of the bone (metastasis), chronic obstructive pulmonary disease, dehydration, anemia, malaise/fatigue and diarrhea. On the start of care comprehensive assessment, dated 11-20-20, there was no documentation of the history of the patient's lung cancer such as onset date, treatment history, response to treatment, where metastasis is located in the bones, history of events leading to home care and related patient's needs. During an interview on 1-7-21 at 2:55 PM the Administrator stated, "The comprehensive assessments need to have a more complete picture of the patient's health history and why they need home care." MR #9: The plan of care, dated 12-1-20, stated the patient was admitted with the diagnoses of diabetes, chronic obstructive pulmonary disease, kidney disease, heart failure, pulmonary fibrosis, depression and heart attack. On the start of care comprehensive assessment, dated 12-1-20, there was no documentation of the history of the patient's diabetes such as onset date, treatment history, when blood sugar or A1c was last checked/what the results were and the patient's/caregiver's ability to perform glucose monitoring procedure and insulin injections. The start of care assessment did not include history of events leading to home care and related patient's needs. During an interview on 1-7-21 at 2:55 PM the Administrator stated, "The comprehensive assessments need to have a more complete picture of the patient's health history and why they need home care."

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician may choose to include. This ELEMENT is not met as evidenced by: Based on document review and interview, the agency failed to ensure the plan of care covered all pertinent interventions with reportable safety parameters, and objectively measurable goals specific to the needs of the patient for 8 records (MR#s 1, 2, 3, 4, 5, 6, 7 and 9) from a total sample of 10 records reviewed, resulting in patients not receiving care specific to their individual needs and the potential for poor patient outcomes. Findings included: MR#1: The Start of Care was dated 12/26/20. The Plan of Care for the certification period 12/26/20 to 2/23/21 identified diagnoses of Covid-19, Viral Pneumonia, Acute embolism and thrombosis of deep veins of right upper extremity, hypertension (HTN), Diabetes type 2 (DM2). The patient was receiving Skilled Nursing (SN), Physical Therapy (PT), and Occupational Therapy (OT) Services. Upon review of the record, it was noted that the goals on the Plan of Care were not objectively measurable. Examples included: SN goal: "Patient will be knowledgeable of Covid-19, signs and symptoms, and precautions". This goal was not objectively measurable. In addition, the PT goals included: "Patient will verbalize signs/symptoms of infection and plan of action", which is not objectively measurable; "Blood Pressure will remain within parameters; pulse will remain within parameters; respirations will remain within parameters." However, the POC did not include reportable parameters for blood pressure, pulse, or respiration to identify whether those measurements would be outside the parameters. MR#2: The SOC was dated 6/3/2019. The Plan of Care for the certification period 11/24/20 to 1/22/21 identified diagnoses of Rotator Cuff Tear Right Shoulder, Gout, Congestive Heart Failure (CHF), Diabetes Type 2 (DM2), and Chronic Kidney Disease stage 3 (CKD3). The patient was receiving Skilled Nursing (SN) services. Upon review of the record, it was noted that the goals on the Plan of Care were not objectively measurable. Examples included: "Patient/Caregiver will report issues with DM2, CKD3, Covid-19, and all aspects of associated care within Cert Period"; "The patient/caregiver will verbalize which meds to order from Pharmacy when low."; "Patient will verbalize importance of clean apartment with low clutter to prevent falls within 4 weeks." These goals are not objectively measurable. MR#3: The SOC was dated 6/30/20. The Plan of Care (POC) identified diagnoses of Hemiplegia following Cerebral Infarction (CVA); Pressure Ulcer Right Buttock Stage 2, Chronic Kidney Disease stage 4 (CKD4), Osteoarthritis (OA), and Atrial Fibrillation (A-fib). The patient was receiving SN, and Home Health Aide (HHa) services. Upon review of the record, it was noted that the goals on the Plan of Care were not objectively measurable. Examples included: "Patient/Caregiver will verbalize understanding of Hypertension, atrial fibrillation, cerebral infarction and all aspects of associated care within 4 weeks."; "Patient/Caregiver will be knowledgeable of COVID-19 signs/symptoms and precautions, good handwashing, masks, social distancing." The Home Health Aide Goals included: "The patient's hygiene and personal care needs will be met this cert period with the assistance of the home health aide"; Aide will complete the assigned duties with instruction and education from the skilled nurse." These goals are not objectively measurable, nor are they individualized to the patient's needs. MR#4: The SOC was dated 5/8/2020. The Plan of Care for the certification period 7/7/2020 to 9/4/2020 identified diagnoses of Amyotrophic Lateral Sclerosis (ALS), Hypertension (HTN), Degeneration of Nervous System due to Alcohol, Atrial Fibrillation (A-fib). The patient was receiving SN, PT, OT, Speech Therapy (ST), and HHa services. Upon review of the record, it was noted that the goals on the Plan of Care were not objectively measurable. Examples included: "The patient's balance will improve"; "The patient's strength will improve"; "The Patient/Caregiver will verbalize understanding of ALS and all aspects of associated care"; The documented HHa goal: "Aide will complete assigned duties with instruction and education from RN and or Therapy." These goals are not objectively measurable, nor are they individualized to the patient's specific needs. MR#5: The SOC was dated 12/03/2019. The POC for the certification period 04/01/20 to 05/30/2020 identified diagnosis of Fracture of Right Femur, Alcohol Abuse, Chronic Obstructive Pulmonary Disease (COPD), Disease of Blood-forming (Liver) Organs. The patient was receiving SN, HHa, and ST services. Upon review of the record, it was noted that the goals on the Plan of Care were not objectively measurable. Examples included: "Patients muscle strength, balance, and gait will improve"; "Patient will reach maximum functional potential as evidenced by less pain, increased endurance within 9 weeks"; "Patient to follow bowel protocol treatment" {sic}; These goals were not objectively measurable, nor are they individualized to the patient's specific needs. MR #6: The plan of care for the recertification period of 12-4-20 to 2-1-21 stated the patient had the diagnoses of hemiplegia, scoliosis, anxiety, arthritis, hypertension, depression, gastric reflux, left knee cap fracture, and hypercholesterolemia. The plan of care included goals such as: "Patient/caregiver will verbalize understanding of anxiety, CVA (stroke) and all aspects of associated care within cert period."; and "Patient will be knowledgeable of COVID, signs and symptoms, and precautions." These goals are not objectively measurable. During an interview on 1-7-21 at 2:53 PM the Administrator stated, "The goals need to be more measurable." MR #7: The plan of care dated 10-28-20 stated the patient was admitted for the primary diagnosis of diabetes and included orders for "Glucometer testing to be performed by: Patient or caregiver once a week." The plan of care did not include diabetic safety precautions or reportable blood glucose parameters. During an interview on 1-7-21 at 2:53 PM the Administrator stated, "the plan of care should have both of those." MR #9: The plan of care dated 12-1-20 stated the patient was admitted for the primary diagnosis of diabetes and included orders for "Insulin Lispro inject 3 times a day." The plan of care did not include the dosage for the insulin, diabetic safety precautions, orders for monitoring the patient's blood sugar or reportable blood glucose parameters. During an interview on 1-7-21 at 2:53 PM the Administrator stated, "the plan of care should have both of those."

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on record review and interview, the Agency (HHA) failed to ensure that all entries in the medical record were complete and legible in 6 record (MR#s 1, 2, 4, 5, 6 and 7) out of a total of 10 records reviewed resulting in difficulty deciphering the care provided during the course of care for the potential of negative patient outcomes, uncoordinated patient care, and unmet care needs. Findings included: MR#1: The Start of Care was dated ;12/26/20. The Plan of Care for the certification period 12/26/20 to 2/23/21 identified diagnoses of Covid-19, Viral Pneumonia, Acute embolism and thrombosis of deep veins of right upper extremity, hypertension (HTN), Diabetes type 2 (DM2). The patient was receiving Skilled Nursing (SN), Physical Therapy (PT), and Occupational Therapy (OT) Services. Upon review of the Comprehensive Assessment, documented by RN#1 it was noted that the handwriting was illegible making it difficult to understand the patient's health issues documented on the comprehensive, and the care provided during the visit. MR#2: The SOC was dated 6/3/2019. The Plan of Care for the certification period 11/24/20 to 1/22/21 identified diagnoses of Rotator Cuff Tear Right Shoulder, Gout, Congestive Heart Failure (CHF), Diabetes Type 2 (DM2), and Chronic Kidney Disease stage 3 (CKD3). The patient was receiving Skilled Nursing (SN) services. Upon review of the re-certification Comprehensive Assessment, documented by RN#1, it was noted that the handwriting was illegible making it difficult to understand the patient's health issues documented on the comprehensive and the care provided during the visit. In addition, the Follow-up Comprehensive for the recertification period of 9/25/20 was also illegible. Upon review, it was noted that RN#1 failed to authenticate her signature with a date. MR#4: The SOC was dated 5/8/2020. The Plan of Care for the certification period 7/7/2020 to 9/4/2020 identified diagnoses of Amyotrophic Lateral Sclerosis (ALS), Hypertension (HTN), Degeneration of Nervous System due to Alcohol, Atrial Fibrillation (A-fib). The patient was receiving SN, PT, OT, Speech Therapy (ST), and HHa services. A review of the record revealed difficulty reading the Physical Therapy (PT) Evaluations dated 11/12/20 and the PT evaluations dated 11/18/20 and 12/20/20 which were not only illegible but were not authenticated with a date. In addition, the PT notes dated 11/18/20, 12/8/20, 12/15/20, 12/20/20, and the Discharge Summary dated 12/30/20 were all illegible as documented by PT#1. MR#5: The SOC was dated 12/03/2019. The POC for the certification period 12/03/19 to 01/31/20 identified diagnosis of Fracture of Right Femur, Alcohol Abuse, Chronic Obstructive Pulmonary Disease (COPD), Disease of Blood-forming (Liver) Organs. Upon review of the Comprehensive Assessment, documented by RN#1 it was noted that the handwriting was illegible making it difficult to decipher the patient's health issues documented on the comprehensive assessment, and the care provided during the visit. A review of the SN visit notes for this certification period dated 12/5/20 and 1/24/31 were also illegible. Additionally, review of the following two recertification periods dated 2/01/20 to 03/31/20/20, and 04/01/20 to 05/30/20 included SN notes that were illegible on the following dates: 4/16/21, 5/1/21, 5/15/21, and the discharge summary dated 5/27/21 was also illegible. These findings were reviewed and acknowledged boy the Clinical Manager (CM#1) during an interview on January 7th, 2021. MR #6: The plan of care for the period of 12-4-20 to 2-1-21 stated the patient was admitted with diagnoses of hemiplegia following cerebral infarct (stroke) scoliosis, anxiety, arthritis, hypertension, depression and left knee cap fracture. The plan of care also included an order for the patient to take Pregabalin (Lyrica) two times per day (treats pain). The record contained a physician's order dated 12-14-20 that stated "Stop taking prescribed Lyrica." There was no documentation to explain why the Lyrica was discontinued. During an interview on 1-7-21 at 3:00 PM, the Administrator stated, "The record should have an explanation documented, it's not complete without that information." MR #7: The plan of care dated 10-28-20 stated the patient was admitted with the diagnoses of diabetes, dementia, vertebral fracture, hypertension, history of urinary tract infections and heart murmur. On the nursing visit note, dated 11-20-20, the nurse documented, "stitches asymp (asymptomatic- without symptoms) yellow green bruise around left eye." There was no documentation in the record of how or when the patient received the bruise and stitches. During an interview on 1-7-21 at 3:03 PM the Administrator stated, "The record is not complete without that information. The nurse should have documented on that visit note what happened to the patient." On the nursing "Missed Visit Communication" note, dated 11-6-20, the nurse documented, "Has MRI (magnetic resonance imaging study) scheduled for today, will be unavailable." There was no documentation in the record to indicate why the patient needs the MRI or what part of the body they need the test for. During an interview on 1-7-21 at 3:03 PM the Administrator stated, "That information should have been documented by the nurse."