Every finding on record at Omni Home Health Care, Inc

A Medicare recertification survey was conducted by the Michigan Department of Licensing and Regulatory Affairs on 7/23/24 through 7/25/24 at: Omni Home Health Care 25932 Dequindre Rd., Suite A Warren, MI 48091 The agency has no branches. Clinical records reviewed for this survey included 3 records with home visits and 4 additional records.

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure patients received written notice in advance of the agency terminating care for 2 of 2 (P-4, P-6) discharge records reviewed, resulting in the inability of this Medicare beneficiary to exercise his/her right to dispute the termination of home care services. Findings include: P-6: The patient's start of care was 2/8/24 with diagnoses that included Congestive Heart Failure and Hypertensive Heart Disease. During the record review on 7/23/24, it was noted that the patient was discharged from the agency's services on 3/28/24. The "Notice of Medicare Non-Coverage documented, "The effective date coverage of your current home health services will end: 2/29/24" and was signed by the patient on 2/29/24. This information was inaccurate as the patient was discharged one month later that the date signed. This deficiency declined the patient's right to dispute the termination of ongoing services. These findings were reviewed with and acknowledged by the Administrator during an interview on 7/25/24 at 11:07 a.m. P-4: This 79-year-old patient was admitted to home care services on 3/27/24 with diagnoses of status post fall resulting in a fracture of the left humerus and left thumb. During record review on 7/23/24, it was noted that the patient was discharged from home health services on 5/9/24. There was no documented evidence that the patient had received written notice in advance of terminating services. The findings were reviewed with the Administrator (Staff-A) and the Quality Assurance nurse (Staff-B) during an interview on 7/25/24 at 11:45 a.m. Staff-A reviewed the medical record and acknowledged the findings.

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 include baseline information on the Comprehensive Assessment to use to determine if the patient's health status is improving or worsening during the course of care in 2 of 7 (P-1, P-6) records reviewed. Findings included: P-6: The patient's start of care was 2/8/24 with diagnoses that included Congestive heart Failure and Hypertensive Heart Disease with Heart Failure. During the clinical record review on 7/23/24, it was noted that the Initial Comprehensive Assessment documented the patient's weight as 209 pounds (lbs.). There was no indication if this was an actual or stated weight. The assessment failed to accurately reflect the health status of the patient at the time of admission. These findings were reviewed with and confirmed by the Administrator during an interview on 7/25/24 at 11:07 a.m. P-1: The Start of Care was dated 6/21/2024. The Plan of Care (POC) for the certification period 6/21/24 to 8/19/24 identified diagnoses of "Orthopedic Aftercare, Fracture of Base of Neck of right femur, presence of right artificial hip joint, Parkinson's Disease, Systolic and Diastolic congestive heart failure, Type 2 Diabetes, and Hypertension. During a review of the Comprehensive Assessment under the category of "Plan of Care: Vital Signs", it was noted there were no reportable weight parameters on the Comprehensive Assessment or Plan of Care to address the patient's Congestive Heart Failure. This finding was reviewed and acknowledged by the Administrator (Staff-A) and Quality Assurance nurse (Staff-B) during an interview on 7/25/24 at 1:45 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 a review of all medications to determine significant drug interactions and failed to ensure the physician was notified of potential drug interactions in 1 of 7 (P-3) records reviewed, resulting in the potential for harmful medication effects for this patient. Findings include: P-3: This patient was admitted to home care services on 7/15/24 with diagnoses of enterocolitis due to clostridium difficile, gastrostomy malfunction, and dementia. During record review on 7/24/24, it was noted that the 7/15/24 comprehensive assessment completed by the registered nurse indicates that medication issues were identified. There was no documentation to indicate the nature of the medication issue. During an interview with the Administrator (Staff-A) on 7/25/24 at 9:10 a.m., Staff-A was asked to provide a drug interaction report. The agency utilizes the website Drugs.com to check for medication interactions and duplicate medications. The interaction report notes one potential major drug interaction between the patient's medications: Potassium Chloride and Losartan. Staff-A reviewed the medical record and explained that the physician should have been notified by fax and the medical record should contain a copy of the fax report. There was no evidence the physician was notified.

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 accurately reflected the individualized needs of the patient, and failed to ensure the goals on the Plan of Care were objectively measurable to determine the patient's progress towards obtaining the goals in 4 (P-1, P-2, P-3, P-6) of 7 records reviewed, resulting in the inability to determine the patient's progress towards achieving the goals. Findings include: Agency Policy: "Care Plans" The policy states, "Each client will have a care plan on file that outlines care and services necessary to meet the patient specific needs identified in the comprehensive assessment, addresses their identified needs and the agency's plan to respond to those needs. The plan is developed with the client and family, as indicated, and is based on services needed to achieve specific measurable goals." P-6: The patient's start of care was 2/8/24 with diagnoses that included Congestive Heart Failure and Hypertensive Heart Disease with Heart Failure. During the clinical record review on 7/23/24, it was noted that the plan of care was void of any interventions to address the patient's chief diagnosis of Congestive Heart Failure. There was no frequency in which to monitor weights and no patient teaching. Additionally, there were no associated goals that addressed the patient's diagnoses. Additionally, on admission, the patient complained of pain at 6/10. The plan of care was void of any measurable pain goals. These findings were reviewed with and acknowledged by the Administrator during an interview on 7/25/24 at 11:07 a.m. P-3: This patient was admitted to home care services on 7/15/24 with diagnoses of enterocolitis due to clostridium difficile, gastrostomy malfunction, and dementia. The patient has a PEG tube (percutaneous endoscopic gastrostomy to allow nutrition through the stomach), was taking nothing by mouth, and was on aspiration precautions. The 7/15/24 plan of care failed to contain measurable goals related to the patient's enterocolitis, PEG tube malfunction, and aspiration precautions. The plan of care included the following nursing goals: patient will be free of falls/injury, will remain free of any type of infection, will adapt optimally and develop effective coping skills related to change in body image or limitations, and patient will have no acute care hospitalizations. There was no indication how these skilled nursing goals would be measured to determine the patient's progress towards discharge. The findings were reviewed with and acknowledged by the Administrator (Staff-A) and Quality Assurance nurse (Staff-B) during an interview on 7/25/24 at 11:45 a.m. P-1: The Start of Care was dated 6/21/2024. The Plan of Care (POC) for the certification period 6/21/24 to 8/19/24 identified diagnoses of "Orthothopedic Aftercare, fracture of base of neck of right femur, presence of right artificial hip joint, Parkinson's Disease, Systolic and Diastolic congestive heart failure, Type 2 Diabetes, and Hypertension. Upon reviewing the Plan of Care, it was noted the goals on the Plan of Care were not objectively measurable to determine the patient's progress towards achieving the goals. Examples included: "Patient/Caregiver will be able to verbalize signs and symptoms of respiratory complications, when to call physician, nurse, seek urgent or emergency care (i.e. 911) by End of Certification {sic}; Patient/Caregiver will verbalize understanding and demonstrate compliance with prescribed care to improve health status and minimize long-term debilitating diabetes complications by {sic}; Physical Therapy evaluation will be performed and a Plan of Care to increase functional Independence will be established and countersigned by physician {sic}." These goals are not objectively measurable to determine the patient's progress towards achieving the goals. P-2: The Start of Care was dated 2/3/2024. The Plan of Care for the certification period 2/3/2024 to 4/2/2024 identified diagnoses of "Type 2 Diabetes with hyperglycemia and diabetic neuropathy, Osteoarthritis, Foot drop-left foot, Hypertension, Alzheimer's disease, Atrial Fibrillation, Dependence on supplemental oxygen. The patient was receiving Skilled Nursing and Physical Therapy Services. Upon reviewing the Plan of Care, it was noted the goals were not objectively measurable. Examples included: "Patient/Caregiver will demonstrate measures to prevent skin breakdown; Skin integrity will be maintained throughout this episode of care; Patient's activity level will improve due to effective pain control by discharge; Patient will attain optimal effectiveness of pain management regimen by discharge; Physical Therapy evaluation will be performed and a plan of care to increase functional independence will be established and countersigned by physician {sic}." These goals are not objectively measurable to determine the patient's progress towards achieving the goals. These findings were reviewed and acknowledged by the Administrator (Staff-A) and Quality Assurance nurse (Staff-B) during an interview on 7/25/24 at 1:45 p.m.

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to provide annual infection control education to 1 of 1 (Staff-C) contracted staff personnel files reviewed, resulting in a lack of education regarding current infection prevention and treatment practices in the home setting. Findings include: Personnel files were reviewed on 7/24/24. The agency utilizes agency staff and contracted staff. Staff-C: Contracted occupational therapist. Date of hire: 1/9/23. There was no documentation of infection control education in 2023 or 2024 for this employee. The findings were reviewed with the Administrator (Staff-A) during an interview on 7/24/24 at 3:45 p.m. Staff-A explained that there is no infection control education for this contracted employee.

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 skilled disciplines performed baseline and ongoing assessments of the patient health status for 2 (P-6, P-7) patients who required ongoing monitoring of weights and edema, from a total for 7 sampled records, resulting in the potential for unidentified health concerns, decline in health status and unmet care needs. Findings include: P-6: The patient's start of care was 2/8/24 with diagnoses that included Congestive Heart Failure (CHF) and Hypertensive Heart Disease with Heart Failure. The plan of care ordered Skilled Nursing (SN) and Physical Therapy (PT) services to be provided. During the clinical record review on 7/23/24, it was noted that the Initial Comprehensive Assessment dated 2/8/24 documented a baseline weight of 209 pounds (lbs.). There was no indication if this was an actual or stated weight, and there was no baseline assessment of edema. Upon review of the SN visit notes dated 2/15/24, 2/22/24 and 2/29/24, there were no documented weights or assessments/measurements of edema. During the entrance conference on 7/23/24, the Administrator was asked if the agency staff carried scales to weigh the patients diagnosed with CHF and reported, "No." When asked how staff monitored CHF patient's weights and edema, the Administrator reported, "They (patients) have to weigh themselves. We measure legs for edema. I think right now, they're (staff) using the tape to measure edema." Based on the above findings, the agency failed to provide needed baseline and ongoing assessments and monitoring of the patient's health status. These findings were reviewed with and acknowledged by the Administrator during an interview on 7/25/24 at 11:07 a.m. P-7: The patient's start of care was 7/17/24 with a diagnosis of Right Knee Replacement. The Plan of Care ordered SN and PT services to be provided. During a brief review of the record on 7/24/24, prior to a scheduled home visit, it was documented that the patient refused her second PT visit. On 7/24/24 at 12:00 p.m., during the scheduled survey home visit with the SN, the patient reported that she'd declined her PT visits due to excessive swelling to her right knee. The patient's right knee was visibly swollen. The SN did not measure or assess the patient's right knee for the reported swelling but briefly placed the palms of her hands over the top of the patient's knee and continued on with the visit. Upon completion of the visit, the SN was queried on the process for determining increase in swelling and reported, "It didn't look as swollen as it did before. I should have measured it (right knee). I'll do that next time." These findings were reviewed with and acknowledged by the Administrator during an interview on 7/25/24 at 11:50 a.m., who reported, "She (RN) should have measured the patient's knee. When you report to the doctor, they need to know the initial measurements to determine increase or decrease in swelling."

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 provide services as ordered in the plan of care for 1 of 7 records reviewed (P-1) resulting in the patient not receiving a complete assessment of services as ordered by the physician. Findings included: P-1: The Start of Care was dated 6/21/2024. The Plan of Care (POC) for the certification period 6/21/24 to 8/19/24 identified diagnoses of "Orthopedic Aftercare, Fracture of Base of Neck of right femur, presence of right artificial hip joint, Parkinson's Disease, Systolic and Diastolic congestive heart failure, Type 2 Diabetes, and Hypertension. It was noted the Plan of Care included the following orders: "Notify physician of vital sign parameters out of range: Heart Rate greater than 100 or less than 50. Temperature greater than 100.5 or less than 96. Respirations greater than 28 or less than 12. Pain level greater than 7. O2 saturation less than 88. Systolic Blood Pressure greater than 160 or less than 90; Diastolic Blood Pressure greater than 100 or less than 50; Blood Sugar, Fasting Greater than 250 or less than 70; Blood Sugar Random greater 300 or less than 70." A review of the Skilled Nurse (SN) Nursing notes revealed the following vital signs that were outside the physician ordered parameters with no documentation that the physician was notified as ordered: SN Visit 6/26/24: No Blood Sugar Result was documented. SN Visit 7/3/2024: No Blood Sugar Result was documented. SN Visit 7/10/2024: O2 Saturation was 76% on Room Air. There was no documentation that the physician was notified the patient's O2 saturation was 76% this day, nor was there any documentation of the patient's Blood Sugar result. SN Visit 7/17/2024: No Blood Sugar Result was documented. SN Visit 7/24/2024: O2 Saturation documented as: "On Room Air", with no documented O2 saturation result; Also, there was no Blood Sugar result documented. These findings were reviewed and acknowledged by the Administrator (Staff-A) and Quality Assurance nurse (Staff-B) during an interview on 7/25/24 at 1:45 p.m.

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the competency evaluation accurately reflected the aides ability to furnish Home Health Aide services on its behalf, by ensuring the subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section were evaluated by a Registered Nurse who observed the Aide's performance of the required tasks with a patient/pseudo patient in 1 of 1 Home Health Aide personnel record reviewed, resulting in the potential for the provision of substandard care and unmet care needs. Findings include: On 7/23/24 at 2:35 p.m., a review of 1 of 1 Home Health Aide personnel file revealed the following: HHa #1: Initial Date of Hire was 8/12/10. Rehire date was 3/27/24. A document titled "Personnel file Checklist" was originally dated for 8/12/10. The checklist included documentation from 2010 and 2024 and therefore, was unclear. A document titled, “Competency Evaluation - Home Health Aide" dated 2024 contained the Home Health Aide's name at the top. Next to the required learning was an occasional date entered and lines drawn through the remaining learning objectives. Further, the evaluation did not include any of the required elements under section (ix) such as bed bath, sponge, tub, and shower bath, hair shampooing in sink, tub, and bed, nail and skin care... The section titled "On-Site Evaluation of Skills" such as Range of Motion and Positioning were left blank. Additionally, the document contained illegible handwriting and upon further review, it could not be determined which if any of the tasks were performed with an actual or pseudo-patient. These findings were reviewed with and acknowledged by the Administrator during an interview on 7/25/24 who responded, "Education needs to be provided."

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure an onsite supervisory visit was conducted at least every 14 days for 1 of 1 (P- 4) records reviewed with aide services, resulting in a lack of supervision and oversight of aide services for this patient. Findings include: P-4: This 79-year-old patient was admitted to home care services on 3/27/24 with diagnoses of status post fall resulting in a fracture of the left humerus and left thumb. During record review on 7/23/24, it was noted that the 3/27/24 plan of care ordered the aide to provide 1 visit each week for 5 weeks. Aide services began on 3/28/24 and the aide documented that visits were provided weekly on 4/4/24, 4/10/24, 4/19/24, and 4/22/24. The first documented aide supervisory visit was documented on 4/22/24, which is 25-days after the start of aide services. The findings were reviewed with and acknowledged by the Administrator (Staff-A) and the Quality Assurance nurse (Staff-B) during an interview on 7/25/24 at 11:45 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 the discharge summary was complete and detailed the course of care provided and the health status of the patient at the time of discharge for 1 (P-6) of 2 discharged records, from a total of 7 sampled records, resulting in the Physician not having a clear clinical picture of the status of the patient and the potential for lack of continuing care needs. Findings include: P-6: The patient's start of care was 2/8/24 with diagnoses that included Congestive Heart Failure (CHF) and Hypertensive Heart Disease with Heart Failure. The plan of care ordered Skilled Nursing (SN) and Physical Therapy (PT) services to be provided. During the clinical record review on 7/23/24, it was noted that the patient was discharged from SN services on 2/29/24 and discharged from PT services on 3/28/24. During a review of the SN Discharge Summary dated 2/29/24, it was noted that the summary was void of a summary which detailed the course of care provided with responses, health status at the time of discharge and any continuing needs. There was no mention of the patient's weight, status of edema, or pain levels at the time of discharge. The summary failed to capture the health status of the patient at the time of discharge. These findings were reviewed with and acknowledged by the Administrator during an interview on 7/25/24 at 11:07 a.m.

On 7/20/21 through 7/22/21, the Michigan Department of Licensing and Regulatory Affairs conducted a recertification survey at Omni Home Health Care. 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 was conducted by the Michigan Department of Licensing and Regulatory Affairs from 7/20/2021 through 7/22/21 at: Omni Home Health Care 25932 Dequindre Rd., Suite A Warren, MI 48091 This agency has no branch sites. Records reviewed: 3 records with home visits; 5 records without home visits, for a total sample of 8 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.

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 that accurately reflected the patient's current health status, past medical history, history of events leading to home care, baseline data for future assessments, and ascertained the patient's immediate care needs in 7 of 7 records reviewed (MR 1, 2, 3, 4, 5, 6, and 7) out of a total of 7 records reviewed, resulting in the potential for unmet care needs. Findings included: **Agency Policy "Comprehensive Client Assessment" (no date), pg 59, stated, "To collect data about the client's health history, (Physical, functional and psychological) and their needs as appropriate to the home care setting." MR #5: The patient was admitted on 7/6/21 with diagnoses of osteoarthritis, muscle weakness, and type 2 diabetes mellitus (DM). Upon review of the comprehensive assessment on 7/20/21, under the category of "Patient History", the RN failed to document a complete and detailed past medical history. There was no history of dates of onset for any of the above diagnoses. There was no history of the treatments for each of the past medical history problems and the outcomes from the treatments. MR #6: The patient was admitted on 6/29/21 with diagnoses of gastroenteritis, muscle weakness, and cardiac arrythmia. Upon review of the comprehensive assessment on 7/21/21, under the category of "Patient History", the RN failed to document a complete and detailed past medical history. There was no history of dates of onset for any of the above diagnoses. There was no history of the treatments for each of the past medical history problems and the outcomes from the treatments. MR #7: The patient was admitted on 6/29/21 with diagnoses of brain tumor, chronic kidney disease, and cardiac arrythmia. Upon review of the comprehensive assessment on 7/23/21, under the category of "Patient History", the RN failed to document a complete and detailed past medical history. There was no history of dates of onset for any of the above diagnoses. There was no history of the treatments for each of the past medical history problems and the outcomes from the treatments. The findings were reviewed with and confirmed by the Clinical Manager (CM #1) during an interview on 7/22/21 at 1:30 PM. MR #1: The patient was admitted on 9/8/20 for PT (physical therapy) only services, with diagnoses that included back pain, chronic obstructive pulmonary disease, and hypertension. During review of the comprehensive assessment (9/8/20), under the category of "Patient History", PT failed to document a complete and detailed past medical history. There was no history of dates of onset for any of the above diagnoses. There was no history of the treatments for each of the past medical history problems and the outcomes from the treatments. MR #2: The patient was admitted on 6/6/21 with diagnoses that included alcohol abuse with liver failure, hypertension, and chronic instability of the left knee. During review of the comprehensive assessment (6/6/21), under the category of "Patient History", SN (skilled nursing) failed to document a complete and detailed past medical history. There was no history of dates of onset for any of the above diagnoses. There was no history of the treatments for each of the past medical history problems and the outcomes from the treatments. MR #3: This patient was admitted to the agency on 1/18/21 with diagnoses of Alzheimer's disease with dementia, abnormalities of gait and mobility, and insomnia. During review of the comprehensive assessment (1/18/21), under the category of "Patient History", PT failed to document a complete and detailed past medical history. There was no history of dates of onset for any of the above diagnoses. There was no history of the treatments for each of the past medical history problems and the outcomes from the treatments. MR #4: The patient was admitted on 6/22/21 with diagnoses that included hypertensive chronic kidney disease, low back pain, and diabetes. During review of the comprehensive assessment (6/22/21), under the category of "Patient History", SN failed to document a complete and detailed past medical history. There was no history of dates of onset for any of the above diagnoses. There was no history of the treatments for each of the past medical history problems and the outcomes from the treatments. These findings were reviewed with and confirmed by the Clinical Manager (CM #1) during an interview on 7/22/21 at 11:30 AM.

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, it was determined the agency failed to ensure the comprehensive assessment included a review of all medications to determine any adverse effects; failed to document the findings of the drug regime review as required, and failed to ensure the physician was notified of potential severe drug interactions and duplicative drug therapies in 2 of 7 (MR #1, 7) sampled records reviewed, and failed to have skilled nursing perform a comprehensive drug review in 2 of 2 (MR #1 and 3) records which therapy only cases were assigned, resulting in the potential for harmful medication effects for all 38 patients currently serviced by this Agency. Findings include: Policy: "Medication Profile & reconciliation" pages 68-70, (undated) stated, "Due to the complexity of assessment and services provided to skilled clients/patients, the Medication profile and medication reconciliation process is the documentation tool to meet Professional Standards of medication management. The standard is that the agency staff check all medications a patient may be taking to identify possible ineffective drug therapy, adverse reactions, significant side effects, drug allergies, contraindicated, and duplicated medication/s, and promptly report to physician/s." MR #1: The patient was admitted on 9/8/20 for PT (physical therapy) only services, with diagnoses that included back pain, chronic obstructive pulmonary disease, and hypertension. During record review on 7/20/21, the patient's "Medication List" on the physician referral (8/27/20) listed 17 active medications. When compared to the start of care (SOC) comprehensive assessment (9/8/20) "Medication Profile" filled out and reviewed by PT, only 5 medications were listed. Examples of pertinent medications found on the referral not included on the SOC "Medication Profile" include: "Keflex (antibiotic) 500 mg. capsule-1 capsule by mouth twice a day, Metoprolol (blood pressure) 25 mg. twice a day, and Isosorbide Mononitrate (treat chest pain caused by heart disease) 60 mg-take 1 tablet twice a day. Further, when the SOC "Medication Profile" was compared to the patient's Plan of Care (POC) list, additional discrepancies were found. Three additional medications were added to the POC (8 total) which matched part of the 17 found on the referral. Documentation explaining the medication discrepancies between the referral, SOC medication profile, and POC medication list was not found. Review of section M2001 of the Initial Comprehensive Assessment/Oasis dated 9/8/20, completed by PT, indicated "No issues found during review." In addition, an attached sheet titled, "Comprehensive Medication Review" signed by PT on 9/8/20 documented "None" concerning significant side effects, drug interactions, duplicate drug therapy, ..." However, when the patient's 17 active medications listed on the physician referral were entered into "Drugs.com" (online drug interaction checker) the following was revealed: 1 major/severe, and 6 moderate drug to drug interactions, 1 duplicative therapy and 6 drug to food interactions. There was no documented evidence that the agency notified the physician concerning the above findings as stipulated by agency policy referenced above. Additionally, no evidence was found that indicated skilled nursing had reviewed the patient's medication profile as required when therapy only cases have been assigned. MR #3: This patient was admitted to the agency on 1/18/21 with diagnoses of Alzheimer's disease with dementia, abnormalities of gait and mobility, and insomnia. During review of the clinical record on 7/21/21, it was documented that the patient's medication review at the SOC was performed by PT, which was the only discipline assigned to the case. No evidence of a subsequent review by a registered nurse (RN) was found in the medical record. These findings were reviewed with and confirmed by the Clinical Manager (CM #1) during an interview on 7/22/21 at 11:30 AM. CM #1 stated, "I know this is an issue, the paperwork doesn't come in on time which causes the meds not lining up. Also, they're not taking the time to compare the home meds with what the physician has ordered on the referral. As far as the therapy only cases, I'll make sure nursing signs off on the med list when they're admitted." MR #7: The SOC was dated 6/29/21. The POC, reviewed on 7/21/21, had diagnoses of gastroenteritis, cardiac arrythmia, and Type 2 diabetes mellitus (DM). During review of the record on 7/21/21, it was found that no medication reconciliation had been documented in the comprehensive assessment, or anywhere else in the record. The findings were reviewed with and confirmed by the Clinical Manager (CM #1) during an interview on 7/22/21 at 1:30 PM.

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 skilled nursing goals on the plan of care were patient specific and measurable in 5 of 5 records reviewed (MR# 2, 4, 5, 6, and 7) out of a total sample of 7 records, resulting in the potential for unidentified goals, unmet patient goals and negative patient outcomes. Findings include: Policy: "Care Plans" (undated) stated, "Reasonable, measurable, and realistic goals as determined by the assessment and client expectations. The plan of care includes patient-specific measurable outcomes as a result of the plan of care preparation." MR #2: The patient was admitted on 6/6/21 with diagnoses that included alcohol abuse with liver failure, hypertension, and chronic instability of the left knee. During record review on 7/21/21, the plan of care (POC) included skilled nursing (SN) goals such as: "Patient will demonstrate understanding of individual emergency preparedness plan by eoc (end of care)", and "Patient will demonstrate ability to effectively manage medication regimen by eoc." All SN goals listed (3 of 3), were not patient specific and quantifiably measurable. In addition, the POC failed to list any goals which related to the patient's primary medical needs concerning alcohol abuse with liver failure and hypertension. MR #4: The patient was admitted on 6/22/21 with diagnoses that included hypertensive chronic kidney disease, low back pain, and diabetes. During record review on 7/22/21, the POC included goals such as: "By discharge, the patient will report an increase in sense of control over their current situation.", and "Patient/Caregiver will verbalize understanding and demonstrate compliance with prescribed care to improve health status and minimize long-term debilitating diabetes complications by EOC." All SN goals listed (3 of 3), were not patient specific and quantifiably measurable. During an interview on 7/22/21 at 11:30 AM, the Administrator (Adm #1) acknowledged the above findings and stated, "We will work on making sure the goals are measurable." MR #5: The start of care (SOC) was dated 7/6/21. The plan of care (POC), reviewed on 7/20/21, had diagnoses of osteoarthritis, muscle weakness, and type 2 diabetes mellitus (DM). During review of the POC, it was found that the goals were not measurable, for example, one goal stated, "Patient demonstrate [sic] ability to effectively manage medication regimen by EOC." Another stated, "Patient will demonstrate return to stable endocrine status by EOC." There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. MR #6: The SOC was dated 6/29/21. The POC, reviewed on 7/21/21, had diagnoses of gastroenteritis, cardiac arrythmia, and Type 2 DM. During review of the POC on 7/21/21, it was found that the goals on the POC were not measurable, for example, one goal stated, "Patient will demonstrate knowledge of pain medication and proper administration by EOC." Another stated, "Patient's activity level will improve due to effective pain control by ROC [sic]." There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. MR #7: The patient was admitted on 3/25/21 with diagnoses of brain tumor, chronic kidney disease, and type 2 DM. Upon review of the POC on 7/23/21, it was found that the goals on the POC were not measurable, for example, one goal stated, "Patient will demonstrate return to stable endocrine status related to disease process with improvement/maintenance of maximal level of functioning by 7/22/21." Another stated, "Patient/caregiver will be able to demonstrate pain relief measures to mitigate pain by 5/23/21." There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. The findings were reviewed with and confirmed by the Clinical Manager (CM #1) during an interview on 7/22/21 at 1:30 PM.

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 physical therapist (PT) failed to adequately assess and monitor the needs of the patient in 1 of 2 records reviewed for therapy only cases (MR#1) from a total sample of 7 records reviewed, resulting in the potential for unidentified care needs. Findings included: Policy: "Comprehensive Client Assessment" pages 59-61 (undated) stated, "A thorough, well-organized, comprehensive and accurate assessment, consistent with the client's immediate needs will be completed for all clients... The assessment identifies facilitating factors and possible barriers to client reaching his or her goals including presenting problems." Policy: "Client Reassessment/Update" pages 60-61 (undated) stated, "Clients are reassessed to determine their response to care... are conducted every visit based on physician orders, client conditions, and/or professional judgement." MR #1: The patient was admitted on 9/8/20 for PT (physical therapy) only services, with diagnoses that included back pain, chronic obstructive pulmonary disease (COPD), and hypertension. During record review on 7/20/21, the referral noted additional pertinent patient history when considering potential assessments to ascertain the patient's health status such as: "Chronic respiratory failure... The patient also complains of COPD... difficulties with COPD treatment... difficulties with increase in physical activities." Review of the start of care comprehensive assessment on 9/8/20 by PT (section M1400) documented under "Respiratory Assessment" the following: "Dyspnea (difficulty in breathing), Cough, nonproductive." Under the "Comments" section, PT documented Hx (history) of COPD, asthma, chronic resp. failure." No evidence was found that PT performed an oxygen saturation level at any time during the assessment. Further record review noted 12 of 12 home visits (9/10/20 through 10/20/20) failed to ascertain the patient's baseline oxygen level or when working with the patient. For example, PT documented during a home visit on 9/29/20, "Pt. (patient) needed frequent rest periods today, c/o fatigue and becoming SOB (short of breath)." All 12 home visits documented "Severe SOB upon exertion" under "Homebound Reason." Review of the OASIS Discharge assessment performed by PT on 10/20/20 documented under "Respiratory Assessment, M1400" the following: "Dyspnea, Cough, nonproductive" with no evidence that an oxygen level was obtained at any time during the assessment. The plan of care (POC) on 9/8/20 had oxygen parameter orders in which to notify the physician if the oxygen level ever fell below 88% saturation. No oxygen levels were obtained throughout the certification period despite the above findings. These findings were reviewed with and confirmed by the Clinical Manager (CM #1), Administrator (Adm #1), and co-Administrator (PT #1) during an interview on 7/22/21 at 11:30 AM. PT #1 stated after a home visit on 7/21/20 at 1:05 PM, "You're this first to bring this up in thirteen years, I now see your point why it should be done."