Every finding on record at Prime Homecare Agency, LLC

On 1/23/25 through 1/29/25 an Emergency Preparedness survey was conducted by the Michigan Department of Licensing and Regulatory Affairs. At the conclusion of the survey, Prime Homecare Agency was found to be in compliance with Federal certification requirements for participation in Medicare at 42 CFR §484.102, Emergency Preparedness.

A Medicare recertification survey was conducted by the Michigan Department of Licensing and Regulatory Affairs on 1/23/25 through 1/12925 at: Prime Homecare Agency 44004 Woodward Avenue, Suite 305 Bloomfield Hills, MI 48302 This agency has no additional branch locations. Record reviews included 3 records with home visits, 1 home visit without record review, and 10 records without home visits. The agency was unable to arrange the fifth home visit. At the conclusion of the survey, Prime Homecare Agency was not in compliance with the Conditions of Participation for Home Health Agencies at: 42 CFR Part 484.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to conduct the initial assessment visit within 48 hours of the referral, resulting in a delay of the patient's home health care needs in 1 of 15 records reviewed. Findings included: P-7: The Start of Care was dated 8/1/2024. The Plan of Care identified a primary diagnosis of Diabetes Type 2, and secondary diagnoses of Sarcoidosis, Hemiplegia of left side following cerebral infarction, Heart Failure, Chronic Kidney Disease, and Depression. Upon review of the record, it was noted the referral was dated July 23, 2024. However, the Start of Care date documented on the Plan of Care was August 1, 2024, 9 days after the referral and physician ordered Start of Care date. There was no further evidence found in the record that the physician had ordered a delayed start of care. This finding was reviewed and acknowledged by the Administrator (Admin-A) and Clinical Manager (CM-C) on 1/29/25 at 3:15 p.m.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) 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: (1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment accurately reflected the patient's current health status for 2 (P-10, P-6) of 13 records reviewed, resulting in either no clinical information or incorrect clinical information necessary to determine the needs of this patient. Findings include: P-10: This patient was admitted to home care on 1/9/25 with diagnoses of aphasia (language disorder that affects ability to understand and express language) following a cerebral infarct (stroke) and dysphasia (language disorder that affects ability to understand or use spoken language). The patient was hospitalized for worsening dysphasia from 12/30/24 to 1/8/25. During record review on 1/24/25, it was noted that the 1/9/25 comprehensive assessment completed by the registered nurse listed the patient's primary diagnosis of aphasia following a stroke and 22 secondary/other diagnoses all with an onset date of 12/30/24, which is the date the patient was hospitalized. The diagnoses included chronic kidney disease stage 3, chronic pain, history of nicotine dependence, and history of infectious and parasitic diseases. These diagnoses indicate a long history of illness, not a current onset as indicated in the comprehensive assessment. The findings were reviewed with and confirmed during an interview with the administrator (Admin-A) and the clinical manager (CM-C) on 1/29/25 at 2:05 p.m. P-6: The Start of Care (SOC) dated 1/6/2025 included diagnoses of Congestive Heart Failure, Coronary Artery Disease, Cardiomyopathy, Heart Arrythmia, Myocardial Infarction, and Falls. The patient also had a history of osteoarthritis, gait problems, Chronic Kidney Disease, Anemia, Diabetes type 2, and Coronary Artery Disease. Upon review of the record, it was noted there were no blood sugar results or normal blood sugar ranges, documented on the Comprehensive Assessment to use as a baseline for treating the patient's diabetes. Further review of the Comprehensive noted the following documentation, "Edema Bilateral legs - dependent and pitting", however there were no objective or subjective measurements taken to use as a baseline measure for future assessments to determine if the edema was improving or becoming worse. These findings were reviewed with and confirmed during an interview with the administrator (Admin-A) and the clinical manager (CM-C) on 1/29/25 at 3:00 p.m.

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 that activity of daily living needs were adequately met in the patient's home for 1 (P-1) patient who required assistance with grooming, from a total of 13 sampled records reviewed, resulting in the potential for poor grooming, psychological decline and unmet care needs. Findings include: P-1: The patient's start of care was 7/24/24 with diagnoses that included Hemiplegia and Dysphagia. The referral for home care dated 7/19/24 ordered Skilled Nursing, Physical Therapy, Home Health Aide and Speech Therapy services to be provided. A Physician's order dated 7/24/24 ordered Occupational Therapy and Medical Social Work services to be provided. During the record review on 1/23/25 at 1:35 p.m., it was noted that section M1800 of the Initial Comprehensive Assessment documented, "Someone must assist with grooming, dressing upper and lower body, unable to participate in bathing and is bathed totally by another person, is totally dependent in toileting..." There was no documented, available and willing caregiver listed who would provide assistance with grooming. The patient's "Admission Consent", signed by the patient and the agency representative on 7/24/24, documented that Home Health Aide services would be provided at a frequency of 1x/wk. x 1wk., 2x/wk. x 3wks., 1x/wk. x 2wks. A Medical social Work visit note dated 8/7/24 documented, "Patient's daughter currently is assisting with showers, however, her ability to continue to do so will become less and less as she is overwhelmed." At the time of this review, there was no documented evidence that Home Health Aide services were provided as ordered. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 1/29/25 at 1:10 p.m.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure that services were provided at the ordered frequency and as ordered in the Plan of Care for 1 (P-1) patient who required Occupational Therapy, Medical social work and speech Therapy services, from a total of 13 sampled records reviewed, resulting in the potential for unmet care needs. Findings include: P-1: The patient's start of care was 7/24/24 with diagnoses that included Hemiplegia (paralysis) following cerebral infarction (stroke) and Dysphagia (difficulty swallowing). The referral for home care dated 7/19/24 ordered Skilled Nursing (SN), Physical Therapy (PT), Home Health Aide (HHa) and Speech Therapy (ST) to be provided. A Physician's order dated 7/24/24 ordered Occupational Therapy and Medical Social Work Services to also be provided. during the record review on 1/23/25 at 1:35 p.m., it was noted that the OT missed 1 of the 2 visits ordered for the week of 8/4/24 with a documented rationale of "no answer to locked door or phone." There was no evidence that the OT attempted to honor the ordered visit frequency the remainder of the week as per this requirement. A Physician's order dated 7/24/24 ordered MSW to begin services the week of 7/24/24 (the 1st week of service). A notation within the record documented that the patient requested services to begin the 2nd week of service. However, upon further review, ST and MSW services were not provided until the 3rd week of service. There was no documented rationale for the additional delay in needed care and services. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 1/29/25 at 1:10 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 and interview, the agency failed to ensure the plan of care included parameters to notify the physician for 1 (P-10) of 13 records reviewed, resulting in no assurance the physician is notified of excessive pain ratings. Findings include: P-10: This patient was admitted to home care on 1/9/25 with a primary diagnosis of aphasia following a stroke and secondary diagnoses of low back pain and other chronic pain. During record review on 1/24/25, it was noted that the 1/9/25 plan of care failed to include parameters to notify the physician regarding the patient's pain. The speech therapy visit note dated 1/13/25, noted that the patient reported a pain intensity of 8/10 (scale 0 none to 10 extreme) in his back and legs. The plan of care failed to include reportable pain parameters for this patient with pain issues. There was no documentation to indicate the physician was informed of the patient's elevated pain level. The findings were reviewed with and confirmed during an interview with the administrator (Admin-A) and the clinical manager (CM-C) on 1/29/25 at 2:05 p.m. CM-C stated we report pain greater than 6 to the physician.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Physician was promptly notified of 2 (P-1, P-4) patients who experienced a significant change in condition with resultant hospitalization, from a total of 13 sampled records reviewed, resulting in lack of continuity of care and the potential for unmet care needs. findings include: P-1: The patient's start of care (SOC) was 7/24/24 with diagnoses that included Hemiplegia (one-sided paralysis) and Dysphagia (difficulty swallowing). During the clinical record review on 1/23/25 at 1:35 p.m., it was noted that the patient was transferred to an inpatient facility on 8/12/24 due to "headache, daughter states hospital noted bleed on brain." Upon further review, there was no documented evidence that the patient's Physician had been promptly notified of the transfer to an inpatient facility with resultant hospitalization. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 1/29/25 at 1:10 p.m. P-4: The patient's SOC was 12/30/24 with diagnoses that included Polyarthritis, Gout and Diabetes Mellitus. During the record review on 1/28/25 at 11:45 a.m., it was noted that the patient was transferred to an inpatient facility on 1/6/25 due to "extreme joint pain due to Rheumatoid Arthritis." Upon further review, there was no documented evidence that the patient's Physician had been promptly notified of the transfer to an inpatient facility with resultant hospitalization. These findings were reviewed with and confirmed by the Administrator and Clinical Manager during an interview on 1/29/25 at 1:55 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 professionals provided services as ordered by the physician in the plan of care for 1 (P-10) of 13 records reviewed, resulting in the potential for a poor outcome for this patient. Findings include: P-10: This patient was admitted to home care on 1/9/25 with diagnoses of aphasia following a stroke and dysphasia. The 1/9/25 plan of care ordered skilled nursing (SN) to provide 2 visits per week for 2 weeks and then once a week for 3 weeks (2w2, 1w3); physical therapy (PT) and speech therapy (ST) were to evaluate and treat this patient. After their respective evaluations, PT was to provide visits at a frequency of 2w3, 1w5, and ST was to provide visits at a frequency of 1w1, 2w4. During record review on 1/24/25, it was noted that the SN had a missed visit note dated 1/22/25 that stated the patient had an appointment. There was no documentation of attempts to make the home visits the 3 remaining days of the week. The PT failed to document 2 visits had been conducted the week of January 19, 2025. There was no documentation that the patient declined the visits or that the physician was informed that the visits had not been conducted as ordered in the plan of care. On 1/15/25, ST documented a missed visit note that the ST was unable to complete a visit on this date due to being unavailable. It was unclear as to who was unavailable, the ST or the patient. There was no documentation of attempts to make the home visits the 3 remaining days of the week. The SN, PT, and ST failed to provide services at the frequency and duration ordered by the physician in the plan of care. The findings were reviewed with and confirmed during an interview with the administrator (Admin-A) and the clinical manager (CM-C) on 1/29/25 at 2:05 p.m. Admin-A explained that they have been working with staff and conducting in-service education regarding this matter.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on interview and record review, the Agency failed to ensure Skilled Nursing prepared clear written patient care instructions for the home health aide regarding client needs, and safety precautions prior to the provision of care in 1 (P-3) record in which Home Health Aide services were ordered, from a total of 13 sampled records reviewed, resulting in the potential for the provision of unsafe care and unmet care needs. Findings include: P-3: The patient's start of care was 1/7/25 with diagnoses that included artificial abdominal opening/wound, failure to thrive and polyneuropathy. The Plan of Care ordered Home Health Aide services to be provided at a frequency of 1x/wk. x 1 wk., 2x/wk. x 3 wks. During the clinical record review, it was noted that the Aide Care Plan was void of any instructions or guidance on what measures to take during bathing/showering in light of the patient's abdominal wound. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 1/29/25 at 1:41 p.m.

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 its skilled disciplines conducted the required Home Health Aide supervisory visits at least every 14 days to ensure the adequate provision of care and services for 1 (P-3) patient ordered to receive Aide services, from a total of 13 sampled records reviewed, resulting in the potential for the rendering of unsafe care and unmet care needs. Findings include: P-3: The patient's start of care was 1/7/25 with diagnoses that included Abdominal wound, Failure to thrive and Polyneuropathy. During the record review on 1/24/25 at 1:35 p.m., it was noted that Home Health Aide (HHa) services were ordered at a frequency of 1x/wk. x 1 wk., 2x/wk. x 3 wks. The record reflected that HHa services began on 1/10/25. Upon further review, no HHa supervisory visits had been conducted by the survey's exit date of 1/29/25. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 1/29/25 at 1:41 p.m.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the medical record contained all clinical notes for 1 (P-11) of 13 records reviewed, resulting in a lack of information for the physician and all agency staff caring for this patient. Findings include: P-11: This 70-year-old patient was admitted to home care services on 1/10/25 with diagnoses of status post left knee joint replacement, falls, and chronic pain. The 1/10/25 plan of care ordered the skilled nurse (SN) to make one visit the first week, two visits each week for two weeks, and then one visit each week for two weeks. During record review on 1/24/25, it was noted that two SN clinical notes dated 1/13/25 and 1/15/25 were blank of information. There was no documentation to indicate the patient had declined these visits. During the entrance conference on 1/23/25 at 11:10 a.m., the administrator (Admin-A) explained that clinical notes are completed within 5 days of the visit. The agency has no policy regarding the completion of clinical notes for agency personnel. The findings were reviewed with and confirmed during an interview with Admin-A and the clinical manager (CM-C) on 1/29/25 at 2:05 p.m. Admin-A explained that the nurse has been on vacation and the notes are late.

On 1/24/22 through 1/27/22, an Emergency Preparedness survey was conducted by the Michigan Department of Licensing and Regulatory Affairs. At the conclusion of the survey, Prime Homecare Agency was found to be in compliance with Federal certification requirements for participation in Medicare at 42 CFR §484.102, Emergency Preparedness.

The following Condition and Standard level deficiencies were identified during a Medicare recertification survey along with a concurrent Focused Covid-19 Infection Control survey conducted on 1/24/22 through 1/27/22 by the Michigan Department of Licensing and Regulatory Affairs at: Prime Homecare Agency 44004 Woodward Ave. Bloomfield Hills, MI 48302 At the time of the survey, the agency did not operate any branch offices or subunits. The services the agency provides are: Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), Medical Social Work (MSW), Speech Therapy (ST), and Home Health Aide (HHa). Clinical records reviewed for this survey: 7 records with home visits and 10 records without home visits for a total of 17 records reviewed. Condition level deficiencies were noted at: 42 CFR §484.55 Comprehensive Assessment of Patients. As a result of the Condition level noncompliance, the agency is prohibited for 2 years from offering a home health aide training and competency evaluation or a competency evaluation program as specified in 42 CFR §484.80 (f)(3).

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the Agency failed to ensure that 1 (MR #5) of 1 patient observed during a home visit, who required assistance with grooming, was included in the overall planning of care including informing the patient/caregiver in advance of the days in which Home Health Aide services would be provided, from a total of 17 sampled records reviewed, resulting lack of inclusion in planning, the potential for missed visits, poor grooming and unmet care needs. Findings include: MR #5: The patient's start of care (SOC) was 1/7/22 with diagnoses that included Stenosis of Carotid Arteries, Stroke, Diabetes Mellitus and Failure to Thrive. During the clinical record review on 1/26/22 at 9:00 a.m., it was noted that the patient was ordered to receive Home Health Services upon Resumption of Care on 1/20/22. (patient was previously hospitalized). On 1/26/22 at 1:00 p.m., during a home visit with the Speech Therapist, The patient's Wife and Daughter were queried about the services provided by this agency. The patient's daughter responded, "The (Agency) told us we would be getting some help and that a Home Health Aide would be coming but they never told us anything about when they would be coming so we're just waiting." These findings were reviewed with the Clinical manager (CM #1) during an interview on 1/27/22 at 2:00 p.m. who reported, "The Aide hasn't started yet." The Agency failed to ensure the patient/family was included in the patient's overall planning of care.

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: Based on record review and interview, it was determined that the agency failed to ensure the comprehensive assessment accurately reflected the patient's current health status and included the events leading to the need for home care services in 8 (MR’s #5, 4, 1, 2, 10, 11, 12, 14) of 8 records, from a total of 17 sampled records reviewed, resulting in incomplete clinical information to aid in determining the needs of the patient (G528); failed to ensure the patient's Activity of Daily Living needs were adequately met in the patient's home for 2 (MR #5, 7) of 7 patients assessed as needing assistance with ADLs; and failed to ensure that 1 (MR #7) of 3 patient's Medical Social Work needs were met, resulting in the potential for poor hygiene, psychological decline, injury, lack of resources, and unmet care needs (G534); failed to ensure the Comprehensive Assessment included an accurate review of all medications to determine any adverse effects and failed to ensure the Physician was notified of potential drug interactions in 5 (MR's #2, 3, 4, 6 and 9) of 9 records reviewed, from a total of 17 sampled records reviewed, resulting in the potential for harmful medication effects for all patients for all patients currently serviced by this Agency (G536); and failed to ensure the Comprehensive Assessment was updated and accurately reflected the patient's health status upon Resumption of Care for 1 (MR #5) of 1 patient who returned to the agency's services, following hospitalization, with multiple wounds and difficulty swallowing, from a total of 17 sampled records reviewed, resulting in the delay in needed care and services and the potential for decline in nutritional status, aspiration, worsening of wounds and unmet care needs (G544). The cumulative effect of these systemic problems resulted in the Agency's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR§484.55 Comprehensive Assessment of Patients.

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, it was determined that the agency failed to ensure the comprehensive assessment accurately reflected the patient's current health status and included the events leading to the need for home care services in 8 (MR’s #5, 4, 1, 2, 10, 11, 12, 14) of 8 records, from a total of 17 sampled records reviewed, resulting in incomplete clinical information to aid in determining the needs of the patient. Findings include: Policy: "Initial Assessment" C310 stated, "An initial patient assessment which accurately reflects the patient’s current health status will be performed and documented in the patient’s clinical record by an RN." Policy: "Assessments" C:7 stated, "THE COMPREHENSIVE ASSESSMENT MUST ACCURATELY REFLECT THE PATIENT’S STATUS AND MUST INCLUDE: Current health, psychosocial, functional & cognitive status/diagnosis, Identification of additional health problems or pertinent health history, Data items collected at in patient facility admissions..., Patient medication, nursing, rehab, social & discharge planning needs..., Systems assessment including: Integumentary status." MR 5: The patient’s start of care (SOC) was 1/7/22 with diagnoses that included CVA/Stroke, Pneumonia, Carotid Artery Stenosis, Diabetes Mellitus and Failure to Thrive. The clinical record review was conducted on 1/26/22 at 9:00 a..m. The referral for home care dated 1/4/22 revealed that the patient was admitted to the hospital on 12/25/21 for Healthcare-Associated Pneumonia and Altered Mental Status. During the hospital stay, the patient was noted to have the following:) Pressure Injury (Pressure Sore) Left Heel Pressure Injury Right Heel Pressure Injury Coccyx Medial Pressure Injury Left Anterior Foot Pressure Injury Right Anterior Foot All the above injuries were documented as being present upon arrival to the hospital. The Initial Comprehensive Assessment dated 1/7/22 completed by the Registered Nurse revealed the following: Section 1021 "Primary Diagnosis" listed diagnoses of Occlusion and stenosis carotid arteries, Adult failure to thrive, Diabetes Mellitus, Anemia, retention and history of falls. There was no mention of the patient's pressure sores and no mention of the hospital admitting diagnosis of Pneumonia. "Past Medical History" listed CVA/stroke and Diabetes. The Pressure Ulcer option was left blank. The section titled "Integumentary (Skin) Status documented, "Skin: Dry-Warm." There was no diagram that acknowledged or noted the location of the patient's ulcers. The section titled "Cardiovascular" documented, "Edema: Lower legs." There was no quantitative measurement of edema. The Comprehensive Assessment failed to accurately reflect the health status of the patient at the time of admission to home care. These findings were reviewed with and acknowledged by the Administrator (Adm #1) and the Clinical Manager (CM #1) during an interview on 1/27/22 at 2:00 p.m. CM #1 responded, "We'll need to send another nurse out to assess the patient." MR #4: The patient's SOC was 1/4/22 with diagnoses that included Fractured left ankle, Fractured left Fibula, Syncope and ORIF (open reduction internal fixation). During the clinical record review on 1/25/22, it was noted that sections M1021/M1023 of the Initial Comprehensive Assessment dated 1/4/22 completed by the Registered Nurse, listed diagnoses such as Mixed hyperlipidemia, Depression, Spondylosis, Atrioventricular block, Essential Hypertension, Sleep Apnea and Disease of Spinal Cord with the same onset date of 1/1/2021. These findings were deemed to be unreasonable to have occured on the same date. Further, there was no indication if the diagnoses were controlled, ongoing, resolved or required continue treatment. The Comprehensive Assessment did not accurately reflect the patient's status or history of illnesses at the time of admission. These findings were reviewed with and acknowledged by Adm #1 and CM #1 during an interview on 1/27/22 at 1:13 p.m. MR #1: The patient's SOC was 10/12/21 with diagnoses that included Acute CVA (stroke), Multiple Sclerosis, diabetes Mellitus and Hypertension. During the record review on 1/24/22 at 12:15 p.m., it was noted that sections M1021/M1023 of the Comprehensive Assessment listed diagnoses such as Multiple Sclerosis, Diabetes Mellitus, Essential Hypertension, Meniere's Disease, Restless Leg Syndrome, Falls and Hyperlipidemia. All the listed diagnoses had an onset date of 1/1/21. The Comprehensive Assessment did not accurately reflect the patient's status or history of illnesses at the time of admission. These findings were reviewed with and acknowledged by Adm #1 and CM #1 during an interview on 1/27/22 at 12:46 p.m. MR #2: The patient's SOC was 10/13/21 with diagnoses that included Covid-19, Pneumonia and diabetes Mellitus. During the review on 1/24/22 at 1:39 p.m., it was noted that sections M1021/M1023 of the Comprehensive Assessment listed diagnoses such as Diabetes Mellitus, Hypertensive Chronic Kidney Disease, Stage 3 Chronic Kidney Disease, Hypercholesterolemia and Acquired Absence of other specified parts of digestive tract. All of the listed diagnoses had an onset date of 10/3/21. It was unclear as to whether the diagnoses were resolved or required ongoing treatment. The Comprehensive Assessment did not accurately reflect the patient's status, history of illnesses at the time of admission or the events leading to the need for home care. MR #10: The patient was admitted on 1/4/22 with diagnoses that included congestive heart failure, chronic kidney disease and repeated falls. During record review on 1/25/22, it was noted that sections M1021/M1023 of the Comprehensive Assessment listed the above diagnoses and 12 more with the onset dates of 12/14/21 and 1/1/21. These onset dates were shown to be inaccurate when compared to the documented patient history found in the hospital referral dated 12/13/21. The patient history found in the referral for example documented, "The patient has had numerous hospitalizations in the past 6 months... extensive ORIF (open reduction and internal fixation) for pelvic fractures this past summer. The Comprehensive Assessment did not accurately reflect the patient's status or history of illnesses at the time of admission. MR #11: This patient was admitted to home care on 12/22/21, with diagnoses which included chronic obstructive pulmonary disease (COPD), pneumonia, acute respiratory failure, and heart failure. During record review on 1/25/22, it was noted that sections M1021/M1023 of the Comprehensive Assessment listed a total of 12 diagnoses with onset dates of 12/16/21 and 1/1/21. These onset dates were shown to be inaccurate when compared to the documented patient history found in the hospital referral dated 12/20/21. The past medical history prior to hospitalization (12/16/21) documented the following: "93-year-old male with past medical history significant for CKD (chronic kidney disease), COPD, HTN (hypertension)…" The Comprehensive Assessment failed to accurately reflect the patient's onset dates concerning primary and secondary diagnoses at the time of admission. MR #12: The start of care (SOC) date for this patient was 11/5/21 with diagnoses that included hypertensive heart disease with heart failure, chronic obstructive pulmonary disease (COPD), and diabetes-type 2, and tobacco use. During record review on 1/25/22, it was noted that sections M1021/M1023 of the Comprehensive Assessment listed a total of 18 diagnoses with onset dates of 1/1/21 and 11/5/21. These onset dates were shown to be inaccurate when compared to the documented patient history found in the hospital referral dated 11/3/21. The past medical history prior to hospitalization (10/28/21) documented the following: "This 71 y.o. female with chronic diastolic heart failure... Pt. admits to smoking 1 pack per day since she was a teenager…" The Comprehensive Assessment failed to accurately reflect the patient's onset dates concerning primary and secondary diagnoses at the time of admission. MR #14: The patient was admitted on 12/30/21 with diagnoses that included left sided colitis, left clavicle fracture, and chronic kidney disease (CKD). During record review on 1/26/22, it was noted that sections M1021/M1023 of the Comprehensive Assessment listed 21 of 23 diagnoses with onset dates of 1/1/21. These onset dates were shown to be inaccurate when compared to the documented patient history found in the hospital referral dated 12/28/21. The past medical history prior to hospitalization (12/23/21) documented the following: "95 y.o. female with PMH (past medical history) below... CKD date: 11/12/2013, heart attack date: 6/1996..." The Comprehensive Assessment failed to accurately reflect the patient's onset dates concerning primary and secondary diagnoses at the time of admission. These findings were reviewed and acknowledged by the Clinical Manager (CM #1) during an interview on 1/27/22 10:25 AM.

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 observation, interview and record review, it was determined the Agency failed to ensure the patient's Activity of Daily Living needs were adequately met in the patient's home for 2 (MR #5, 7) of 7 patients assessed as needing assistance with ADLs; and failed to ensure that 1 (MR #7) of 3 patient's Medical Social Work needs were met, resulting in the potential for poor hygiene, psychological decline, injury, lack of resources, and unmet care needs. Findings include: MR #5: The patient's start of care (SOC) was 1/7/22 with diagnoses that included Stenosis of Carotid Arteries, Stroke, Diabetes Mellitus and Failure to Thrive. During the clinical record review on 1/26/22 at 9:00 a.m., it was noted that the patient was ordered to receive Home Health Services upon Resumption of Care on 1/20/22. (patient was previously hospitalized). The Initial Comprehensive Assessment dated 1/7/22 along with the Resumption of Care Assessment dated 1/20/22 documented, "Someone must assist the patient to groom self, Someone must assist with dressing upper and lower body, totally dependent in toileting, depends entirely upon another person to maintain toileting hygiene..." On 1/26/22 at 1:00 p.m., during a home visit with the Speech Therapist, The patient's Wife and Daughter were queried about the services provided by this agency. The patient's daughter responded, "The (Agency) told us we would be getting some help and that a Home Health Aide would be coming but they never told us anything about when they would be coming so we're just waiting." These findings were reviewed with the Clinical manager (CM #1) during an interview on 1/27/22 at 2:00 p.m. who reported, "The Aide hasn't started yet." The Agency failed to ensure the patient's needs were adequately met in the patient's home. MR #7: The patient's SOC was 1/3/22 with diagnoses that included CVA (stroke), Hemiplegia (paralysis), Congestive Heart Failure and Diabetes Mellitus. During the clinical record review on 1/26/22, it was noted that the referral for home care dated 12/22/21 documented, "Patient is wheelchair bound. Patient has history of stroke leading to left side weakness, need help with Adl (activities of daily living) and she is unable to stand..., right knee buckles when trying to stand...," Section M1800 of the Initial Comprehensive Assessment documented "Someone must assist the patient to groom self." Section M1910 stated, "does indicate a risk for falls." There was no documented evidence that Home Health Aide services had been provided or offered. The Musculoskeletal section of the assessment documented, "need Hoyer (transfer lift), motorized scooter, hospital bed..., MSW (Medical Social Work) referral: No." There was no evidence of MSW referral for resources for the aforementioned equipment. These findings were reviewed with the Administrator (Adm #1 and Clinical Manager (CM #1) during an interview on 1/27/22 at 1:40 p.m. CM #1 reported, A Home Health Aide should have been offered to meet the needs of the patient. Adm #1 then reported, "We have a communication note ("HomeHealthNotify"/inner office text system used by staff) regarding the bed and the lift." Upon review, a note dated 1/3/22, submitted by Adm #1, generated by the Physical Therapist read, "She needs hospital bed, hoyer lift and motorized scooter. What happens next?..." A follow up note dated 1/5/22 read, "pcp (Primary Care Physician) needs to write script. contact (Alternate Administrator/Adm #2) she can help..." There was no follow up information or any other documented evidence that the Agency notified the Physician or consulted MSW to meet the patient's needs.

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 an accurate review of all medications to determine any adverse effects and failed to ensure the Physician was notified of potential drug interactions in 5 (MR's #2, 3, 4, 6 and 9) of 9 records reviewed, from a total of 17 sampled records reviewed, resulting in the potential for harmful medication effects for all patients for all patients currently serviced by this Agency. Findings include: Policy: "Assessment" C:7 stated, "THE COMPREHENSIVE ASSESSMENT MUST ACCURATELY REFLECT THE PATIENT’S STATUS AND MUST INCLUDE: Review of all medications (current, including OTC & supplements)/medication instruction, to ID potential adverse effects & drug reactions, including ineffective drug therapy, significant s/e & drug interactions, duplicate drug therapy & noncompliance." MR #2: The patient's start of care (SOC) was 10/13/21 with diagnoses that included Covid-19, Pneumonia and Diabetes Mellitus. During the record review on 1/24/22 at 1:39 p.m., it was noted that section M2001 of the Initial Comprehensive Assessment dated 10/13/21, completed by the Registered Nurse (RN) documented, "No issues found during review." During an interview with the Administrator (Adm #1) and the Clinical Manager (CM #1) on 1/27/22 at 12:54 p.m., CM #1 produced the Agency's "Medication Interactions" report which revealed "Duplicate Drug Therapy" and "ew Suggested" in light of 2 drug to food interactions." The Agency failed to ensure a comprehensive drug review was conducted at the SOC. MR #3: The patient's SOC was 1/6/22 with diagnoses that included Cervical Fracture, Lumbar Vertebrae Fracture and Hypertension. During the record review on 1/24/22 at 2:30 p.m., it was noted that section M2001 of the Initial Comprehensive Assessment dated 1/6/22, completed by the RN documented, "No issues found during review." The patient's 10 prescribed medications were entered in "Drugs.Com" (online drug interaction checker) and revealed 2 moderate drug to drug interactions, 5 drug to food interactions and 2 duplicate drugs. During an interview with Adm #1 and CM #1 on 1/27/22 at 1:06 p.m., CM #1 conducted an onsite review of the patient's medications which revealed, "1 drug to drug interaction with Review Suggested and 2 drug to food interactions with Review Suggested." The Agency failed to ensure a comprehensive drug review was conducted at the SOC. MR #4: The patient's SOC was 1/4/22 with diagnoses that included Displaced Fracture Left Ankle, Syncope (dizziness) and Closed Fracture Left Fibula. During the record review on 1/25/22, it was noted that Section M2001 of the Initial Comprehensive Assessment dated 1/4/22, completed by the RN documented, "No issues found during review." The patient's 6 prescribed medications were entered in Drugs.Com and revealed 2 major drug to drug interactions, 3 moderate drug to drug interactions and 4 drug to food interactions. During an interview with Adm #1 and CM #1, CM #1 conducted an onsite drug review which revealed 2 drug to food interactions and a total of 6 potential interactions risks between drug/drug and drug/food. CM #1 was queried as to how section M2001 was answered with "No issues found" in light of the Medication Interactions report, yet was unable to explain. There was no evidence which indicated a comprehensive drug review had been conducted at the SOC. MR #6: The patient's SOC was 12/20/21 with diagnoses that included Pneumonia and Cervical Fractures. During the record review on 1/25/22, it was noted that Section M2001 of the Initial Comprehensive Assessment dated 12/20/21, completed by the RN documented, "No issues found during review." The patient's 12 prescribed medications were entered in Drugs.Com and revealed 2 major drug to drug interactions, 15 moderate drug to drug interactions, 7 drug to food interactions and 2 duplicate drugs. These findings were revealed and acknowledged during an interview on 1/27/22 at 1:21 p.m. During the interview CM #1 conducted an onsite drug review and reported positive drug interactions. (the physical report was not provided). Adm #1 then submitted a document titled, "Medication Reconciliation and Acknowledgement" dated 1/27/22 (Date of the Interview). The document merely listed the patient's medications, dosages and frequencies. There was no documented evidence that a comprehensive drug review had been conducted at the SOC to identify any untoward interactions. MR #9: The patient's SOC was 1/5/22 with diagnoses that included Lumbar Stenosis with Spinal Fusion. During the record review on 1/25/22, it was noted that Section M2001 of the Initial Comprehensive Assessment dated 1/5/22, completed by the RN documented, "No issues found during review." The patient's 15 prescribed medications were entered in Drugs.Com and revealed 2 major drug to drug interactions, 9 moderate drug to drug interactions, 6 drug to food interactions and 1 duplicate drug. These findings were reviewed with and acknowledged by Adm #1 and CM #1 during an interview on 1/27/22 at 2:35 p.m. At the time of the interview, no evidence was provided to support that a drug review had been conducted at the SOC tot identify any untoward reactions. Additionally, there was no documented evidence that any of the above findings were reported to the Physician.

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on record review and interview, it was determined that the Agency failed to ensure the Comprehensive Assessment was updated and accurately reflected the patient's health status upon Resumption of Care for 1 (MR #5) of 1 patient who returned to the agency's services, following hospitalization, with multiple wounds and difficulty swallowing, from a total of 17 sampled records reviewed, resulting in the delay in needed care and services and the potential for decline in nutritional status, aspiration, worsening of wounds and unmet care needs. Findings include: Policy: "Assessments" C:7 4/2021 stated, "All Patients referred to our Agency will receive a patient-specific, comprehensive assessment according to the Physician services ordered, to determine the immediate care and support needs of the patient..., THE COMPREHENSIVE ASSESSMENT MUST ACCURATELY REFLECT THE PATIENT’S STATUS AND MUST INCLUDE: Current health, psychosocial, functional & cognitive status/diagnosis, Identification of additional health problems or pertinent health history, Data items collected at in patient facility admissions, Patient medical, nursing, rehab, social & discharge planning needs..., Systems assessment including: a. Integumentary status, Nutrition." MR #5: The patient's start of care (SOC) was 1/7/22 with diagnoses that included Stenosis of Carotid Arteries, Stroke, Diabetes Mellitus and Failure to Thrive. During the clinical record review on 1/26/22 at 9:00 a.m., it was noted that the patient was transferred to the hospital on 1/10/22 for reported Pneumonia. The patient resumed Home Health services with this Agency on 1/20/22. The hospital "After Visit Summary", Resumption of Care/Referral orders dated 1/13/22 and 1/18/22 ordered the following: "Adult Diet - Diet Consistency: Dysphagia (difficulty swallowing); Dysphagia Diet: soft Ground; Fluid consistency: Nectar Thick..., Dietary Nutrition Supplements: Renal.." "Home Care Services: Skilled Nursing, Home Health Aide, Physical Therapy and Occupational Therapy" "Wound care consulted for multiple wounds to gluteal fold and buttocks: Sacrococcygeal DTI (Deep Tissue Injury) (9X12 cm /centimeters): Purple maroon discoloration with full thickness wound. Scant serosanguinous drainage, no odor; Left heel DTI (5X6 cm): Purple/maroon discoloration, intact skin but boggy. Eucerin cream BID (twice a day) and off load pressure with heel boots. Right heel DTI (3X4 cm) maroon discoloration, intact skin but boggy. Eucerin cream BID (twice a day) and off load pressure with heel boots; Left forth [sic] toe & right big toe DTI: Purple/maroon discoloration, intact skin. Eucerin cream BID and off load pressure with heel boots..." There was no mention of the patient's wounds or skin issues in the Resumption of Care Assessment dated 1/20/22. A review of the patient's Resumption of Care comprehensive Assessment dated 1/20/22, completed by the Registered Nurse revealed the following: Sections M1021 and M1023 (diagnoses) were left blank. The section titled "Safety Measures" read "Dysfagia [sic] (difficulty swallowing), swallowing precautions." The section titled "Integumentary (Skin) status documented, "Pink/WNL (within normal limits), Skin: Dry, Warm." The choices "wound, and ulcer were left blank. In section M1324, the Registered Nurse checked, "Patient has no pressure ulcers/injuries or no stageable pressure ulcers/injuries." There was no diagram noting the location of the patient's wounds. On 1/26/22 at 1:00 p.m., during a home visit with the Speech Therapist, The patient's Wife and Daughter were queried about the services provided by this agency. The patient's wife reported, "The nurse came out but she didn't look at his (patient) skin. She said she would look at it during her next visit." When asked if the patient had any wounds to his buttocks, the patient's wife "responded, "Yes. He has sores on his butt. One of them is sort of open, but the one in the middle is..." (Unable to describe and displayed a facial grimace). The Agency failed to ensure the Resumption of Care Assessment accurately reflected the patient's health status upon return to the agency's services. These findings were reviewed with and acknowledged by the Administrator (Adm #1) and the Clinical Manager (CM #1) during an interview on 1/27/22 at 2:00 p.m. Adm #1 stated, "The nurse didn't document anything and the QA (Quality Assurance/Assessment) didn't catch it. There is no excuse." CM #1 reported, "We missed the whole wound care. We need to send another nurse out."

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 covered all pertinent interventions with reportable parameters and objectively measurable goals specific to the needs of the patient for 5 (MR's #5, 10, 11, 12, 14) of 5 records reviewed in which skilled nursing was ordered, from a total sample of 17 records reviewed, resulting in patients not receiving care specific to their individual needs and the potential for poor patient outcomes. Findings include: Agency Policy: "Plan of Care (POC)" Policy Number: C:49 (Effective Date: 4/2021) stated, "Plan of Care (POC) is: A written plan that specifies the care and services necessary to meet the patient-specific needs identified in the comprehensive assessment, and the measurable outcomes that the agency anticipates would occur as a result of implementing & coordinating the plan of care. Safety measures to protect against injury. Measurable outcomes & goals identified by the patient & Agency." MR #10: The patient was admitted on 1/4/22 with diagnoses that included congestive heart failure, chronic kidney disease and repeated falls. Review of the referral for home care (1/3/22) noted recent hospital documentation dated 12/9/21 which documented the following: "New onset non-ischemic cardiomyopathy (heart disease)- EF (ejection fraction) was 60% 2 weeks prior to admission, now 15% (severe heart failure)." During review of the patient's Plan of Care (POC) on 1/25/22, no evidence was found that directed Skilled Nursing (SN) to monitor for increasing heart failure. No cardiac parameters were found in which to notify the physician in the event the following fell outside the patient's acceptable range: weight, circumference measurements, or edema (swelling). In addition, it was noted that SN goals (10 of 10) were not written in measurable terms. For example: "Patient will not develop any signs and symptoms of dehydration during the episode; The patient will have no hospitalizations during the certification period; Patient will maintain Heart Healthy diet compliance during the episode." There was no evidence of how these goals could be quantitatively measured to objectively track the patient's progress. MR #11: This patient was admitted to home care on 12/22/21, with diagnoses which included chronic obstructive pulmonary disease (COPD), pneumonia, acute respiratory failure, and heart failure. During record review on 1/25/22, it was noted that the SN goals on the POC were not measurable (12 of 12), for example: "The patient/caregiver will verbalize understanding of individualized emergency plan by end of episode.; Patient/caregiver will verbalize understanding of medication regimen, dose, route, frequency, indications, and side effects by 2/19/22. There was no evidence of how these goals could be quantitatively measured to objectively track the patient's progress. In addition, no goals were found which addressed the patient's primary diagnoses of COPD and heart failure. MR #12: The start of care (SOC) date for this patient was 11/5/21 with diagnoses that included hypertensive heart disease with heart failure, chronic obstructive pulmonary disease (COPD), and diabetes-type 2. During record review on 1/25/22, it was noted that the SN goals on the POC were not measurable (9 of 9), for example: "Patient will not be readmitted to the hospital during home care episode; The patient/caregiver will be independent with glucometer use by 11/15/21; Patient/caregiver will verbalize understanding of medication regimen, dose, route, frequency, indications, and side effects by 11/29/21. There was no evidence of how these goals could be quantitatively measured to objectively track the patient's progress. MR #14: The patient was admitted on 12/30/21 with diagnoses that included left sided colitis, left clavicle fracture, and chronic kidney disease. During record review on 1/25/22, it was noted that the SN goals on the POC were not measurable (12 of 12), for example: "The patient will be free from injury during the certification period; Patient/caregiver will verbalize understanding of medication regimen, dose, route, frequency, indications, and side effects by 2/27/22. There was no evidence of how these goals could be quantitatively measured to objectively track the patient's progress. In addition, no goals were found which addressed the patient's primary diagnoses of colitis, and left clavicle fracture. These findings were reviewed and acknowledged by the Clinical Manager (CM #1) during an interview on 1/27/22 10:25 AM. CM #1 stated, "We've been working on having better measurable goals, looks like we have more work to do." MR 5: The patient’s start of care (SOC) was 1/7/22 with diagnoses that included CVA/Stroke, Pneumonia, Carotid Artery Stenosis, Diabetes Mellitus and Failure to Thrive. The clinical record review was conducted on 1/26/22 at 9:00 a..m. The referral for home care dated 1/4/22 revealed that the patient was admitted to the hospital on 12/25/21 for Healthcare-Associated Pneumonia and Altered Mental Status. During the hospital stay, the patient was noted to have the following:) Pressure Injury (Pressure Sore) Left Heel Pressure Injury Right Heel Pressure Injury Coccyx Medial Pressure Injury Left Anterior Foot Pressure Injury Right Anterior Foot All the above injuries were documented as being present upon arrival to the hospital. There was no mention of the patient's identified skin issues noted on the Plan of Care. Additionally, there were no interventions with reportable parameters in which to notify the Physician, or any measurable goals regarding the patient's wounds. These findings were reviewed with and acknowledged by the Administrator (ADM #1) and the Clinical Manager (CM #1) during an interview on 1/27/22 at 2:00 p.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 Occupational Therapy services were provided as ordered by the physician for 2 (MR#'s 10, 12) of 13 records reviewed with Occupational Therapy from a total sample of 17 records reviewed, resulting in a lack of services and the potential for poor patient outcomes for this patient. Findings include: MR #10: The patient was admitted on 1/4/22 with diagnoses that included congestive heart failure, chronic kidney disease and repeated falls. The Plan of Care (1/4/22) ordered Skilled Nursing, Physical Therapy, Occupational Therapy (OT) and Home Health Aide services for this patient. During record review on 1/25/22, it was noted the OT evaluation occurred on 1/13/22, 9 days after the start of care. There was no documentation to indicate the patient or care giver had declined or delayed OT services. In addition, no documentation was found that the physician had been notified that services were not provided as ordered. MR #12: The start of care (SOC) date for this patient was 11/5/21 with diagnoses that included hypertensive heart disease with heart failure, chronic obstructive pulmonary disease (COPD), and diabetes-type 2. The Plan of Care (11/5/22) ordered Skilled Nursing, Physical Therapy, and OT services for this patient. During record review on 1/25/22, it was noted the OT evaluation that was scheduled on 11/8/21, never occurred due to no answer at the home by the patient. There was no documentation to indicate the patient or care giver had declined or delayed OT services. Further review revealed no evidence of any attempts to make up for the missed visit and no documentation that the physician had been notified. Review of the medical record noted the patient was transferred to the hospital for heart failure on 11/13/21 (8 days after the SOC). The Agency failed to ensure OT services were provided timely as ordered. These findings were reviewed with and acknowledged by the Clinical Manager (CM #1) during an interview on 1/27/22 at 10:15 AM. CM #1 stated, "I don't see anything in the records that explains why OT didn't get out and see the patient on time." During entrance interview on 1/24/22 at 9:50 AM, the Administrator (Adm #1) and CM #1 were queried concerning the timeframe when other disciplines need to evaluate the patient once the order had been received. Adm #1 replied, "They're supposed to see the patient in two to three days, no more than five."

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, The Agency failed to ensure the Skilled Nurse updated/revised the Plan of care in 1 (MR #5) of 2 records of patients who were transferred to an inpatient and resumed care under the Agency's services with a change in health condition, resulting in the patient not receiving care and services specific to his individualized needs and the potential for poor patient outcomes. Findings include: . Policy: "Plan of Care (POC)" C: 49, 4/2021 stated, "PLAN OF CARE (POC) IS: A written plan that specifies the care and services necessary to meet the patient-specific needs identified in the comprehensive assessment, and the measurable outcomes that the agency anticipates would occur as a result of implementing & coordinating the plan of care..., The POC is: Revised or added to at intervals as necessary to continue to meet patient care needs-SOC (Start of Care), ROC (Resumption of Care). Agency professional staff will revise the plan of care, as necessary, to reflect current information from the patient’s updated comprehensive assessment, and to record the patient’s progress towards meeting the patient-specific measurable outcomes and goals selected by the Agency and patient, as specified in the plan of care." MR #5: The patient's start of care (SOC) was 1/7/22 with diagnoses that included Stenosis of Carotid Arteries, Stroke, Diabetes Mellitus and Failure to Thrive. During the clinical record review on 1/26/22 at 9:00 a.m., it was noted that the patient was transferred to the hospital on 1/10/22 for reported Pneumonia. The patient resumed Home Health services with this Agency on 1/20/22. The hospital "After Visit Summary", Resumption of Care/Referral orders dated 1/13/22 and 1/18/22 ordered the following: "Adult Diet - Diet Consistency: Dysphagia (difficulty swallowing); Dysphagia Diet: soft Ground; Fluid consistency: Nectar Thick..., Dietary Nutrition Supplements: Renal.." The Plan of Care documented: "Nutritional Requirements - No Added Salt. No Concentrated Sweets. Heart Healthy. Low Cholesterol. Low Fat." The Plan of Care had not been updated to reflect the patient's current diet. "Wound care consulted for multiple wounds to gluteal fold and buttocks: Sacrococcygeal DTI (Deep Tissue Injury) (9X12 cm /centimeters): Purple maroon discoloration with full thickness wound. Scant serosanguinous drainage, no odor; Left heel DTI (5X6 cm): Purple/maroon discoloration, intact skin but boggy. Eucerin cream BID (twice a day) and off load pressure with heel boots. Right heel DTI (3X4 cm) maroon discoloration, intact skin but boggy. Eucerin cream BID (twice a day) and off load pressure with heel boots; Left forth [sic] toe & right big toe DTI: Purple/maroon discoloration, intact skin. Eucerin cream BID and off load pressure with heel boots..." The Plan of Care made no mention of the patient's existing wounds or the required treatment. These findings were reviewed with and acknowledged by the Administrator (Adm #1) and the Clinical Manager (CM #1) during an interview on 1/27/22 at 2:00 p.m.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on observation, document review, and interview, the Agency failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control of infectious and communicable diseases including Covid-19 as an integral part of the agency's quality assessment and performance improvement program, and failed to utilize a method of screening visitors and staff employed by the Agency, resulting in the potential development and spread of the Covid-19 infection between staff and the Agency's 208 current patients. Findings include: Upon arrival to the Agency on 1/24/22 at 9:10 AM, it was observed that there was no sign or information posted on the suite door that directed visitors and staff concerning infection control measures upon entering. Two of two surveyors were escorted to a conference room without first being screened for Covid-19 (temperature check, Covid questionnaire). Several hours after survey entrance, the Administrator (Adm.#1) was interviewed at 11:40 AM concerning the protocol for Covid-19 screening utilized for visitors and clinical staff. Adm.#1 stated, "We don't keep track of that unless staff are symptomatic. Then we have a form they fill out, but otherwise there's no screening logs to show you daily." At the end of the survey on 1/27/22, no documentation was evidenced of the Agency's clinical staff of performing Covid-19 infection control screenings prior to providing patient care. On 1/26/22, the Agency's QAPI (quality assessment and performance improvement) program documentation concerning Infection Control was reviewed for the last 3 years. Documentation (numerical data) was evidenced concerning infection. However, meaningful arrangement and analysis of the data reviewed was not evidenced. The Clinical Manager (CM#1) was later queried at 3:20 PM to explain how the data observed was utilized to improve care practices concerning infection control. CM#1 was unsure, and offered no evidence that data collected was tracked and trended for the purpose of meeting a pre-established goal concerning Infection Control. The Agency failed to produce documented evidence for the surveillance and screening for Covid-19 on a routine/daily basis and failed to analyze and apply infection control data for the purpose of improved patient outcomes.

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: Based on document review and interview, the Agency failed to ensure Skilled Nursing adequately assessed and monitored the needs of the patient in 1 of 2 records (MR #10) reviewed with heart failure, out of a total sample of 17 records, resulting in the potential for a poor outcome. Findings include (G704); failed to ensure the registered nurse performed complete assessments and reassessments of the patient's health status and needs in 2 (MR's #8 and 10) of 2 records of patients with diagnoses of Congestive Heart Failure, and 1 (MR #4) of 1 patient who had a fall with fracture and resultant edema, from of a total sample of 17 records reviewed, resulting in the potential for unidentified health concerns and unmet care needs (G706); failed to ensure the clinical record was completed and included detailed Skilled Nursing notes for 1 (MR #5) of 1 admitted with skin issues, required a transfer with resultant hospitalization and resumed care post hospitalization with pressure sores and difficulty swallowing, from a total of 17 sampled records reviewed, resulting in incomplete documentation of the patient's health status and the potential for unidentified, untreated health concerns, and unmet care needs (G716). The cumulative effect of these systemic problems resulted in the Agency's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR§ 484.75 Skilled Professinal Services.

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 document review and interview, the Agency failed to ensure Skilled Nursing adequately assessed and monitored the needs of the patient in 1 of 2 records (MR #10) reviewed with heart failure, out of a total sample of 17 records, resulting in the potential for a poor outcome. Findings include: Agency Policy: "Assessments" Policy Number C:7 (effective 4/2021) stated, "All Patients referred to our Agency will receive a patient-specific, comprehensive assessment according to the Physician services ordered, to determine the immediate care and support needs of the patient... Follow-Up is also performed when a patient's condition significantly improves/declines, with the patient's Physician contacted timely regarding the change." MR #10: The patient was admitted on 1/4/22 with diagnoses that included congestive heart failure, chronic kidney disease and repeated falls. Review of the referral for home care (1/3/22) noted recent hospital documentation dated 12/9/21 which documented the following: "New onset non-ischemic cardiomyopathy (heart disease)- EF (ejection fraction) was 60% 2 weeks prior to admission, now 15% (severe heart failure)." The Plan of Care (POC) dated 1/4/22, ordered SN (skilled nursing) at a visit frequency of 1W1, 2W2 (twice a week times two weeks), and 1W1. The POC stipulated SN to "educate patient/caregiver to notify Nurse/Dr. of wt. (weight) gain of 2-3 lbs. in one day or 5 lbs. in 5 days. SN to instruct the Patient and care giver on measures to recognize cardiac dysfunction and relieve complications." Review of the SN visit notes on 1/25/22 revealed the following concerning 4 of 4 scheduled visits: 1/7/22-SN evaluation had no documented weight, 1/11/22-no weight obtained, 1/18/22-missed visit due to no answer to phone call, and 1/21/22-missed visit due to patient "not feeling well." Review of a home health aide note dated 1/12/22 documented the following: "HHA (aide) informed nurse case manager that the patient had increased edema in her legs." No visits were evidenced in the record from 1/14/22 through 1/25/22 by any of the ordered services (SN, Physical Therapy, Occupational Therapy, and Home Health Aide). No documentation was found in the medical record as of 1/25/22 indicating the Agency had performed a follow-up assessment to ascertain the well-being of the patient despite the above findings. Physician notification concerning the above findings was not found. The Clinical Manager (CM #1) acknowledged the above findings during an interview on 1/27/22 at 10:15 AM. CM #1 stated, "I'm surprised by this, usually this nurse is very good. We'll learn from this and improve."

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 observation, interview and record review it was determined that the Agency failed to ensure the registered nurse performed complete assessments and reassessments of the patient's health status and needs in 2 (MR's #8 and 10) of 2 records of patients with diagnoses of Congestive Heart Failure, and 1 (MR #4) of 1 patient who had a fall with fracture and resultant edema, from of a total sample of 17 records reviewed, resulting in the potential for unidentified health concerns and unmet care needs. Findings included: Agency Policy: "Coordination of Care/Patient Education" Policy Number C:10 (effective 4/2021) stated, "All skilled professionals who provide service to Agency patients directly or under arrangement must participate in the coordination of care for the patient." Agency Policy: "Assessments" Policy Number C:7 (effective 4/2021) stated, "All Patients referred to our Agency will receive a patient-specific, comprehensive assessment according to the Physician services ordered, to determine the immediate care and support needs of the patient... Follow-Up is also performed when a patient's condition significantly improves/declines, with the patient's Physician contacted timely regarding the change." MR #10: The patient was admitted on 1/4/22 with diagnoses that included congestive heart failure, chronic kidney disease and repeated falls. Review of the referral for home care (1/3/22) noted recent hospital documentation dated 12/9/21 which documented the following: "New onset non-ischemic cardiomyopathy (heart disease)- EF (ejection fraction) was 60% 2 weeks prior to admission, now 15% (severe heart failure)." The Plan of Care (POC) dated 1/4/22, ordered SN (skilled nursing) at a visit frequency of 1W1, 2W2 (twice a week times two weeks), and 1W1. The POC stipulated SN to "educate patient/caregiver to notify Nurse/Dr. of wt. (weight) gain of 2-3 lbs. in one day or 5 lbs. in 5 days. SN to instruct the Patient and care giver on measures to recognize cardiac dysfunction and relieve complications." Review of the SN visit notes on 1/25/22 revealed the following concerning 4 of 4 scheduled visits: 1/7/22-SN evaluation had no documented weight, 1/11/22-no weight obtained, 1/18/22-missed visit due to no answer to phone call, and 1/21/22-missed visit due to patient "not feeling well." Review of a home health aide note dated 1/12/22 documented the following: "HHA (aide) informed nurse case manager that the patient had increased edema in her legs." Documentation of the case manager coordinating a follow-up assessment with other team members based on the new findings reported by the aide was not found. No visits were evidenced in the record from 1/14/22 through 1/25/22 by any of the ordered services (SN, Physical Therapy, Occupational Therapy, and Home Health Aide). Physician notification concerning the above findings was not found. The Clinical Manager (CM #1) acknowledged the above findings during an interview on 1/27/22 at 10:20 AM. CM #1 stated, "There should have been at least some documented follow-up based on what the aide reported given the patient's history." The Agency failed to ensure the patient's needs were timely and appropriately assessed and failed to coordinate care concerning a new clinical finding. Policy: "Assessments" C: 7 stated, "Every skilled visit will have a physical assessment and routine assessment of patient’s home for potential safety issues done and documented." MR #4: The patient's start of care (SOC) was 1/4/22 with diagnoses that included Syncope (dizziness), Displaced Fracture left Malleolus (left ankle), Closed Fracture left Fibula and ORIF (Open Reduction Internal Fixation). The clinical record review was conducted on 1/25/22. The plan of care (POC) order Skilled Nursing (SN) to assess/evaluate wound at each dressing change and PRN (as needed) for signs/symptoms of infection and report to Physician. During the review it was noted that patient had a non-removable cast/dressing to his left lower extremity with "edema" to his left toes upon admission. A Skilled Nursing visit note dated 1/11/22 documented that the patient's cast was removed on 1/7/22 and measured the length of the patient's incision as 13 cm (centimeters). On 1/25/22 at 10:30 a.m., a scheduled home visit was conducted with the Registered Nurse (RN #1) During the visit, RN #1 provided teaching about the patient's medications and assessed the patient's left ankle wound. During the conversation between the patient and RN #1, the level of the patient's swelling was discussed. Rn #1 stated, "It doesn't look as swollen as it did before." The patient replied, "Yes. It went down some." When asked if there was a baseline measurement of swelling, RN #1 replied, "He had a cast on when he was admitted so I couldn't measure it then." Further review of the clinical record and SN visit notes dated 1/13/22, 1/18/22 and 1/20/22, revealed no documentation of the patient's left ankle circumference in order to determine the presence of increased swelling. These findings were reviewed with and acknowledged by the Administrator (Adm #1) and the Clinical Manager (CM #1) during an interview on 1/27/22 at 1:13 p.m. CM #1 responded, "If the site wasn't available to measure at the SOC, it should have been measured when it became available, when the cast was removed." MR #8: The patient's SOC was 1/13/22 with diagnoses that included Congestive Heart Failure, Chronic Kidney Disease and Shortness of Breath. During the clinical record review on 1/26/22 at 4:39 p.m., it was noted that the POC ordered SN at a frequency of 1x/wk. x 1 wk., 2x/wk. x 2 wks, 1x/wk. x 2 wks. to "educate patient/patient caregiver to document daily weight at same time each day, notify Nurse/Dr. of wt (weight) gain of 2-3 lbs in one day or 5 lbs in 5 days, create a daily cardiac log to document daily weight, document lower extremity edema daily or abdominal distention..., SN to assess patient for signs/symptoms of fluid overload." During the review, it was noted that SN captured the patient's baseline weight of 177 pounds at the SOC. There were no additional weights recorded at the time of this review. Additionally, there was no assessment of abdominal distention and no documented evidence that the patient was assessed for fluid overload. These findings were reviewed with and acknowledged by Adm #1 and CM #1 during an interview on 1/27/22 at 2:15 p.m. No response was offered.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the Agency failed to ensure the clinical record was completed and included detailed Skilled Nursing notes for 1 (MR #5) of 1 admitted with skin issues, required a transfer with resultant hospitalization and resumed care post hospitalization with pressure sores and difficulty swallowing, from a total of 17 sampled records reviewed, resulting in incomplete documentation of the patient's health status and the potential for unidentified, untreated health concerns, and unmet care needs. Findings include: Policy: "Assessments" C: 7 stated, "Every skilled visit will have a physical assessment and routine assessment of patient’s home for potential safety issues done and documented." MR 5: The patient’s start of care (SOC) was 1/7/22 with diagnoses that included CVA/Stroke, Pneumonia, Carotid Artery Stenosis, Diabetes Mellitus and Failure to Thrive. The clinical record review was conducted on 1/26/22 at 9:00 a..m. The referral for home care dated 1/4/22 revealed that the patient was admitted to the hospital on 12/25/21 for Healthcare-Associated Pneumonia and Altered Mental Status. During the hospital stay, the patient was noted to have the following:) Pressure Injury (Pressure Sore) Left Heel Pressure Injury Right Heel Pressure Injury Coccyx Medial Pressure Injury Left Anterior Foot Pressure Injury Right Anterior Foot All the above injuries were documented as being present upon arrival to the hospital. Upon review of the record, there was no documentation of the above findings noted in the Skilled Nursing visit notes or in the admission assessment. Additional review revealed the patient was transferred to the hospital on 1/10 22 and resumed to care with this Agency on 1/20/22. According to the hospital discharge paperwork, the patient required treatment and a wound consult for the existing wounds. Additionally, during hospitalization, the patient's diet was downgraded to Thickened liquids and mechanically soft texture due to difficulty swallowing. None of the aforementioned information had been captured in the visit notes. On 1/26/22 at 1:00 p.m., during a home visit with the Speech Therapist, the patient's wife and daughter were present and queried about the services received by the Agency. The patient's daughter responded, "The nurse came out today but she didn't look at his wounds, she said she would look at them (wounds) during the next visit." The Skilled Nurse failed to prepare clinical visit notes that documented the patient's health status at the time of admission and again upon resumption of care. These findings were reviewed with and acknowledged by the Administrator (Adm #1 and the Clinical Manager (CM #1) during an interview on 1/27/22 at 2:00 p.m.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on observation, interview and record review, it was determined the Agency failed to ensure Skilled Nursing prepared clear written patient care instructions for the home health aide regarding client needs, and safety precautions prior to the provision of care in 5 (MR#'s 3, 5, 8, 9 and 10) of 7 records in which Home Health Aide services were ordered, from a total of 17 sampled records reviewed, resulting in the potential for the provision of unsafe care and unmet care needs. Findings include: MR #10: The patient was admitted on 1/4/22 with diagnoses that included congestive heart failure, chronic kidney disease and repeated falls. The Plan of Care (POC) dated 1/4/22, ordered the following services: Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT) and Home Health aide (HHa). The HHa care plan was created by the Physical Therapist (PT) on 1/4/22. No documentation was found which explained why PT created the HHa POC instead of SN, which was assigned to the case at the start of care. In addition, the HHa POC failed to include bleeding precautions which were noted on the patient's 485/Plan of Care under "Safety Precautions". Further, the instructions on the aide care plan were not specific and gave the aide choices (as needed) concerning elimination (incontinent care), or "per patient request" regarding bed linen change, personal care (combing hair), and shampooing hair, allowing the aide rather than the SN to determine how patient care services would be furnished. CM #1 acknowledged the above findings during an interview on 1/26/22 at 10:05 AM. MR #3: the patient's start of care (SOC) was 1/6/22 with diagnoses that included Cervical Fracture, Trauma Brain Injury, Fracture of Lumbar Vertebrae and Hypertension. During the clinical record review on 1/4/22 at 2:30 p.m. it was noted that Home Health Aide (HHa) services were ordered to provide care. The "Aide Care Plan" completed by the Skilled Nurse documented, "As Requested" for tasks such as Pericare, Skin Care, Shower and Oral Hygiene. There was no clear instruction for the Aide to follow. On 1/25/22 at 9:00 a.m. during a scheduled home visit with the Home Health Aide (HHa #1), the following observations were made: HHa #1 observed the patient as he showered himself. HHa #1 did not offer to assist with any of the ordered tasks. The Skilled Nurse failed to provide definitive instructions on what tasks were to be performed during the Home Health visit. These findings were reviewed with the Administrator (Adm #1) and Clinical Manager (CM #1) during an interview on 1/27/22 at 1:06 p.m. MR #5: the patient's SOC was 1/7/22 with diagnoses that included Carotid Artery Stenosis, Pneumonia, Diabetes Mellitus and Failure to Thrive. During the clinical record review on 1/26/22 at 9:00, it was noted that HHa services were ordered to be provided. The plan of care (POC) listed bleeding precautions and diabetic precautions. The Skilled Nurse failed to include these precautions on the HHa Care Plan. Additionally, the frequency of assigned tasks was noted to be "per pt request." There was no clear instructions provided for the HHa to follow. These findings were reviewed with and acknowledged by Adm #1 and CM #1 during an interview on 1/27/22 at 2:00 p.m. MR #8: The patient's SOC was 1/13/22 with diagnoses that included Congestive Heart Failure and Chronic Kidney Disease. During the clinical record review on 1/26/22 at 4:39 p.m., it was noted that the POC ordered Home Health Aide services to be provided. The Aide Care Plan provided vague instructions such as, per patient request for tasks such as foot care, pericare, oral hygiene. The Skilled Nurse failed to provide clear instructions for the Aide to follow. These findings were reviewed with and acknowledged by Adm #1 and CM #1 during an interview on 1/27/22 at 2:15 p.m. MR #9: The patient's SOC was 1/5/22 with diagnoses that included Lumbar Stenosis and Spinal Fusion. During the review review on 1/27/22 at 10:00 a.m., it was noted that the POC ordered Home Health Aide services to be provided. The Aide Care Plan provided vague instructions such as, per patient request for tasks such as foot care, pericare, shower, assist to dress. The Skilled Nurse failed to provide clear instructions for the Aide to follow. These findings were reviewed with and acknowledged by Adm #1 and CM #1 during an interview on 1/27/22 at 2:35 p.m.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure that a transfer summary was completed and sent to the receiving facility for 1 (MR #5) of 2 patients who were transferred to an inpatient facility and required hospitalization, from a total of 17 records reviewed, resulting in lack of continuity of care and the potential for unmet care needs. Findings include: Policy: "Transfers" C: 60 4/2021 stated, "A Transfer Summary will be completed for all patients, and will include at a minimum: Reasons for transfer, Destination of patient transferred, Significant health history, Brief description of services provided, Ongoing needs that cannot be met, A copy of the most current Plan of Care, Status of patient at the time of transfer." MR #5: The patient's start of care (SOC) was 1/7/22 with diagnoses that included Stenosis of Carotid Artery, Diabetes Mellitus and Failure to Thrive. On 1/26/22 at 9:00 a.m. during a review of the clinical record, it was noted that the patient was transferred to an inpatient facility and subsequently hospitalized on 1/10/22. There was no documented rationale for the transfer and no transfer summary had been completed. Additionally, there were no communication notes detailing the reason for the inpatient transfer. These findings were reviewed with and acknowledged by the Administrator (Adm #1) and Clinical Manager (CM #1) during an interview on 1/27/22 at 2:00 p.m. During the interview, the requirements for this Condition of Participation was explained. Adm #1 then replied, "I'll be honest. I don't believe we do that. We just send them (receiving facility) a copy of the Plan of Care."

Medicare complaint survey (MI00121885) and Infection Control survey were conducted on 9/21/21 and 9/22/21 by the Michigan Department of Licensing and Regulatory Affairs at: Prime Homecare Agency 44004 Woodward Ave. Bloomfield Hills, MI 48302 The Agency does not Operate any branch offices. One active record and three closed records were reviewed.

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: Based on document review and interview, it was determined the agency nurse failed to reassess the patient after collecting a urine sample for testing related to a possible urinary tract infection in 1 of 4 records reviewed out of a total sample of 4 records reviewed (MR #1), resulting the possible failure to treat a patient with a urinary tract infection (See G706); and failed to stay with a patient to assess for changes in the patient's health status following a fall to the floor, until EMS arrived to take over care of the patient in 1 of 1 records in which EMS was called for the patient out of a total sample of 4 records reviewed (MR #2), resulting in the possibility of significant decline in the patient's health status and poor patient outcomes (See G706). MR #1: The agency nurse failed to reassess the patient after collecting a urine sample for testing related to a possible urinary tract infection. MR #2: The agency nurse failed to stay with a patient to assess for changes in the patient's health status following a fall to the floor, until EMS arrived to take over care of the patient.

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 document review and interview, it was determined the agency nurse failed to reassess the patient after collecting a urine sample for testing related to a possible urinary tract infection in 1 of 4 records reviewed out of a total sample of 4 records reviewed (MR #1), resulting the possible failure to treat a patient with a urinary tract infection; and failed to stay with a patient to assess for changes in the patient's health status following a fall to the floor, until EMS arrived to take over care of the patient in 1 of 1 records in which EMS was called for the patient out of a total sample of 4 records reviewed (MR #2), resulting in the possibility of significant decline in the patient's health status and poor patient outcomes. Findings include MR #1: The patient was admitted on 7/7/21 for nursing, aide, physical therapy and occupational therapy services with a primary diagnosis of obstructive and reflux uropathy (blockage of the urinary tract affecting urine flow). On the nursing visit note, dated 8/9/21, the nurse documented, "SN (skilled nurse) got a call from daughter that pt (patient) looks very confused and lethargic today. Pts daughter is suspecting UTI (urinary tract infection). So SN called MD (doctor) office... and got a verbal order to collect the UA (urine analysis) sample for the pt. SN made a visit today and collected UA sample via strait cath (catheter) and drop off at quest lab for processing...(sic)" On the next documentation in the record from the nurse, a "Discharge Summary" form dated 8/20/21, the nurse documented, "SN made a visit to the patients house as per the schedule, however patient had an eye doctor appointment at the same time and daughter forgot to inform SN. So SN provided DC (discharge) SN performed discharge instructions with the pt... (sic)" There was no documentation to explain why the nurse did not provide any visits to re-assess the patient between 8/9/21 and discharge of the patient on 8/20/21. There was no evidence the registered nurse re-assessed the patient's health status, the lab results or the treatment plan after the urinary tract infection was suspected and tested for. There was no evidence the nurse re-assessed the patient's confusion and lethargy after the visit during which the urine sample was taken on 8/9/21. MR #2: The patient was admitted on 6/26/21 for nursing and physical therapy services with diagnoses that included open wounds and dehiscence (separation/opening of surgical incision) of amputation stump. During the review of the record it was noted that SN #1 documented the following on the nursing visit note dated 7/9/21: “SN about to leave the pts (patient’s) house, however, pt stated that she wants to sit on a wc (wheelchair).SN refused her to transfer, as pt is 2 person assist. Pt was confidently stated that if SN can get wheelchair real close to the bed, she caneasily slides into the wc and she does this all the time. So SN got the wc because pt insisted. Pt was sitting onto the edge of the bed andSN assisted pt to slide on the wheelchair. Pt one leg is amputed and another leg could not stayed on the floor due to slippery socks. Pt wasbetween bed and chair with the leg on the floor, so she requested SN to put her slowly onto the floor. SN did put pt on the floor slowly withno injury. Pts grand daughter was home, so SN called pts grand daughter, however, she refused to help. So SN asked her to call EMSwhile SN making pt comfortable on the floor as pt has too many tubes attached to her such as wound vac, catheter, etc. EMS has beencalled. Pt asked for pillow to rest her arm, SN gave her a pillow, pt moved to fit the pillow and also wants to sit on the another pillow…. SN left the house as EMS already on its way and no ptwas not showing any s/s of discomfort (sic).” On a “Patient Communication” note, dated 7/9/21 at 8:30 PM, the Administrator documented he investigated the situation and summarized the statement RN #1 gave him explaining her version of the events. ADM #1 documented RN #1 stated the following: “Per (RN #1): After roughly 1.5 Hours, she was concluding her visit and getting ready to leave the patient’ room/home. As she was walking out the patient started ‘begging’ for (RN #1’s) assistance in transferring to her wheelchair… Feeling that (RN #1) was straining the Patient Requested that (RN #1put her on the ground. (RN #1) LOWERED and guided her onto the ground… the (patient #2’s) catheter bag came disconnected, (RN #1) simply reconnected it. Catheter NEVER came out. RN called EMS, explained the entire situation, and remained on the phone with dispatch and with patient until dispatch said EMS was on the street and patient’s granddaughter stated her and cg (caregiver) would deal with EMS and that since she (granddaughter) knew (RN #1) had another patient to see she (RN #1) could go…(sic)” During a telephone interview on 9/21/21 at 5:00 PM, RN #1 stated, “I had been there (patient #2’s home) about 2 hours for catheter care and wound care. The patient begged me to transfer her to her wheelchair. The patient had one leg amputated and could not bear weight on her good leg due to slipping sock. The patient asked to be put on the floor and her Foley bag disconnected…We had to call EMS… I called EMS and explained everything that happened, but the granddaughter was put on the phone with EMS to give them the address. I stayed on the phone until dispatch said EMS would be there in about 3-4 minutes… Granddaughter asked If I was leaving and I said ‘Yes I have to leave because I have been here longer than my visit time is supposed to be already’… I saw EMS on the road as I was leaving.” It was determined that the patient did end up on the floor while RN #1 was transferring patient #2 to her wheelchair and the nurse left the patient’s home, with the patient still on the floor, and before EMS arrived. The nurse failed to stay with the patient, who was laying on the floor, to assess for any changes in the patient's health status until EMS arrived to take over the patient's care.