Every finding on record at Seniors Home Health Care, Inc

Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to maintain an emergency preparedness plan centered on both agency-based and community-based risk assessments (See E0006); failed to maintain, review, and update written emergency preparedness policies and procedures that were based on an emergency preparedness plan, risk assessment, and communication plan (See E0013); failed to maintain, review, and update written emergency preparedness policies and procedures to follow up with on-duty staff and patients to determine needed services (See E0021); failed to maintain, review, and update written emergency preparedness policies and procedures to address surge needs during an emergency (See E0024); failed to maintain, review, and update written emergency preparedness communication plan (See E0030); failed to develop and maintain an Emergency Preparedness training and testing program that is based on the emergency plan, risk assessment, policies, procedures, and communication plan (See E0036), and failed to conduct exercises to test the emergency plan (See E0039). These deficient practices have the potential to negatively affect the health and safety of the agency's 16 current patients. The cumulative effect of these systemic problems results in the agency's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation at 42 CFR §484.102, Emergency Preparedness.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to maintain an emergency preparedness plan centered on both agency-based and community-based risk assessments, resulting in a lack of direction and duties for agency personnel in the event of an actual disaster. This deficient practice has the potential to negatively affect the health and safety of the agency's 16 current patients. Findings include: On 9/21/23, the agency’s Emergency Preparedness binder was reviewed. There was no documentation to indicate the agency had conducted a risk assessment in the past two years. During an interview on 9/21/23 at 12:27 p.m., the administrator (ADM-1) stated, “the emergency plan has not been updated since our last survey in 2020” and acknowledged the findings.

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to maintain, review, or update the written emergency preparedness policies and procedures that were based on an emergency preparedness plan, risk assessment, and communication plan, resulting in the agency's inability to implement appropriate emergency actions. This deficient practice has the potential to negatively affect the health and safety of the agency's 16 current patients. Findings include: On 9/21/23, the agency’s Emergency Preparedness binder was reviewed. There was no documentation to indicate the agency had reviewed or updated the policies and procedures in the past two years. During an interview on 9/21/23 at 12:27 p.m., the administrator (ADM-1) stated, “the emergency plan has not been updated since our last survey in 2020” and acknowledged the findings.

HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to maintain, review, and update written emergency preparedness policies and procedures to follow up with on-duty staff and patients to determine needed services, in the event there is an interruption in services during or due to an emergency, resulting in the agency's inability to implement appropriate emergency actions. This deficient practice has the potential to negatively affect the health and safety of the agency's 16 current patients. Findings include: On 9/21/23, the agency’s Emergency Preparedness binder was reviewed. There was no documentation to indicate the agency had reviewed or updated the policies and procedures in the past two years. During an interview on 9/21/23 at 12:27 p.m., the administrator (ADM-1) stated, “the emergency plan has not been updated since our last survey in 2020” and acknowledged the findings.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to maintain, review, and update written emergency preparedness policies and procedures to address surge needs during an emergency, resulting in the agency's inability to implement appropriate emergency actions. This deficient practice has the potential to negatively affect the health and safety of the agency's 16 current patients. Findings include: On 9/21/23, the agency’s Emergency Preparedness binder was reviewed. There was no documentation to indicate the agency had reviewed or updated the policies and procedures in the past two years. The agency’s policy 3.K Surge Plan states the agency will obtain assistance from the following companies to assist with a surge in patient volume: NTS, Achieve, and MRS. On entrance, the agency stated their only contract is with Achieve. During an interview on 9/21/23 at 12:27 p.m., the administrator (ADM-1) stated, “the emergency plan has not been updated since our last survey in 2020” and acknowledged the findings.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to maintain, review, and update written emergency preparedness communication plan, resulting in the agency's inability to implement appropriate emergency actions. This deficient practice has the potential to negatively affect the health and safety of the agency's 16 current patients. Findings include: On 9/21/23, the agency’s Emergency Preparedness binder was reviewed. There was no documentation to indicate the agency had reviewed or updated the communication plan in the past two years. The “SHHC Professional Employee list” was found to be out of date, missing the names of contract agency staff and containing names of staff no longer employed with the agency when compared to the current staff roster provided by the agency on entrance. During an interview on 9/21/23 at 12:27 p.m., the administrator (ADM-1) stated, “the emergency plan has not been updated since our last survey in 2020” and acknowledged the findings.

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to develop and maintain an Emergency Preparedness training and testing program that is based on the emergency plan, risk assessment, policies, procedures, and communication plan, resulting in the agency’s inability to ensure staff actions align with the emergency plan. This deficient practice has the potential to negatively affect the health and safety of the agency's 16 current patients. Findings include: On 9/21/23, the agency's Emergency Preparedness documentation was reviewed. There was no documentation to indicate staff participated in drills or education in the past two years. The staff list provided by the administrator (ADM-1) indicates that the agency has 9 staff members. During review of personnel files on 9/21/23, there was no documentation of initial training for 5 of 5 personnel files reviewed (RN-1, LPN-1, PT-1, OT-1, SLP-1). During an interview on 9/21/23 at 12:27 p.m., the administrator (ADM-1) and clinical manager (CM-1) reviewed and acknowledged the findings.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to conduct exercises to test the emergency plan, resulting in the agency's inability to implement appropriate emergency actions. This deficient practice has the potential to negatively affect the health and safety of the agency's 16 current patients. Findings include: On 9/21/23, the agency’s Emergency Preparedness binder was reviewed. There was no documentation to indicate the agency had conducted a community-based, facility-based, or table-top exercise to test the emergency plan. During an interview on 9/21/23 at 12:27 p.m., the administrator (ADM-1) stated, “the emergency plan has not been updated since our last survey in 2020” and acknowledged the findings.

The following Condition and Standard level deficiencies were identified during a Medicare authorized recertification survey, concurrent with an Emergency Preparedness survey, conducted by the Michigan Department of Regulatory Affairs on 9/19/23 through 9/21/23 at: Seniors Home Health Care 20755 Greenfield Rd., Suite 607 Southfield, MI 48075 This Agency had no additional locations. Records reviewed: 3 records with home visits; 4 records without home visits, for a total of 7 records reviewed. At the conclusion of the survey, the following Condition level deficiencies were identified: 42 CFR §484.65, Quality Assessment and Performance Improvement. 42 CFR §484.70, Infection Control. 42 CFR §484.75, Skilled Professional Services. 42 CFR §484.102, Emergency Preparedness. 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, interview and record review, the agency failed to ensure that 3 (P-3, P-2, P-6) of 3 patients observed during a home visit, were included in the overall planning of their care, including consulting with the patient and caregiver in advance of the days in which services would be provided, resulting in the lack of participation in planning, the potential for missed visits, and unmet care needs. Findings include: P-3: The patient's start of care (SOC) was 8/8/23 with diagnoses that included Nondisplaced Fracture of Right Femur and Bilateral Osteoarthritis of Knees. On 9/20/23 at 11:00 a.m., during the record review, it was noted that the patient was ordered to receive Physical Therapy (PT), Skilled Nursing (SN) and Occupational Therapy (OT) services. On 9/20/23 at 2:00 p.m., a scheduled home survey visit was conducted with the Physical Therapist (PT #1). During a review of the patient's admission packet, it was noted that there was no calendar of proposed visits to be made by the ordered disciplines. The table of contents in the packet stated that the calendar of proposed visits was located on page 31. The referenced page included diagrams and instructions regarding medications. There was no calendar included in the patient's admission packet. These findings were reviewed with and acknowledged by the Administrator (Adm #1) and Clinical Manager (CM #1) during an interview on 9/21/13 at 10:00 a.m. P-2: The patient's SOC was 8/17/23 with diagnoses that included Parkinson's Disease and Hemiplegia left side. On 9/19/23 at 3:50 p.m., during the record review, it was noted that the referral for home care dated 8/17/23 ordered SN, PT and OT services to be provided. On 9/20/23 a scheduled home survey visit was conducted with PT #2. During a review of the patient's admission packet, it was noted that there was no calendar of proposed visits to be made by the ordered disciplines. The table of contents in the packet stated that the calendar of proposed visits was located on page 31. The referenced page included diagrams and instructions regarding medications. There was no calendar included in the patient's admission packet. These findings were reviewed with and acknowledged by Adm #1 and CM #1 during an interview on 9/21/23 at 9:35 a.m. P-6: This 73-year-old patient was admitted to home care on 8/24/23 with a diagnosis of generalized osteoarthritis and weakness. During a home visit on 9/20/23 at 11:30 a.m., the patient’s son (primary caregiver), stated “we were disappointed that you (physical therapy assistant/PTA) had to cancel on us yesterday.” When examining the admission packet, it was noted that the visit calendar was blank. During an interview with the caregiver, on 9/20/23 at 12:30 p.m., the caregiver verbally stated that the agency will tell him when they will be coming next. The PTA did not include the patient or the caregiver in the planning of future visits by writing it on the calendar. The finding was reviewed and acknowledged by the administrator (ADM-1) and clinical manager (CM-1) during an interview on 9/21/23 at 10:30 a.m.

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the patient received proper written notice (Notice of Medicare Provider Non-Coverage) in advance of the agency terminating on-going care for 2 (P-1, P-4) of 3 discharged records, from a total of 7 sampled records reviewed, resulting in the patient being denied the right to appeal the decision to end Medicare covered services. Findings include: P-1: The patient's start of care was 3/9/23 with diagnoses that included Diabetes Mellitus. On 9/19/23 at 12:30 p.m., it was noted that the referral for home care dated 3/3/23 ordered Skilled Nursing, Physical Therapy and Occupational Therapy (OT) services to be provided. Further review revealed the patient was discharged from the agency's services on 5/1/23. There was no documented evidence that the patient was provided the "Notice of Medicare Provider Non-Coverage" prior to being discharged from the agency. These findings were reviewed with and acknowledged by the Administrator (Adm #1) and Clinical Manager (CM #1) during an interview on 9/21/23 at 9:25 a.m. P-4: This 89-year-old patient was admitted to home care on 6/16/23 with a diagnosis of atherosclerotic heart disease and a closed fracture of the right ankle. This patient was ordered skilled nursing, physical therapy, and occupational therapy services and was discharged from the agency on 8/3/23. During record review on 9/19/23 at 12:15 p.m., no documented evidence was found that the patient was provided the “Notice of Medicare Provider Non-Coverage” prior to discharge. The finding was reviewed and acknowledged by the administrator (ADM-1) and clinical manager (CM-1) during an interview on 9/21/23 at 10:30 a.m.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment accurately reflected the patient's current health status at the time of admission to home care for 5 (P-1, P-2, P-4, P-5, P-6, P-7) of 7 sampled records reviewed, resulting in incomplete clinical information to aide in determining the needs of these patients and for measuring the patient's progress toward goals/outcomes. Findings include: Policy: III.8 "Comprehensive Assessment and Oasis Data Collection Start of Care" undated, stated, "Care of patients is based upon a comprehensive assessment process. It is established by the Agency in coordination with regulatory requirements to gather and analyze specific data to determine the initial and continuing health care needs and services of the patient and patient care outcomes." P-1: The patient's start of care (SOC) was 3/9/23 with diagnoses that included Diabetes Mellitus. The clinical record review was conducted on 9/19/23 at 12:30 p.m. The Initial Comprehensive Assessment dated 3/9/23, completed by the Registered Nurse, revealed the following: Section 1021 Primary diagnosis listed diagnoses Diabetes Mellitus, Weakness, Vitamin Deficiency. Section M1023 "Other diagnoses" listed Hypertension and Iron Deficiency. All diagnoses were void of a date of onset or exacerbation and offered no history as to the status of the diagnoses. The "Integumentary Status" was left blank. The section titled "Endocrine" was void of a baseline blood sugar reading and only listed ranges. Additionally, there was no documented rationale of the events leading to the need for home care. These findings were reviewed with and acknowledged by the Clinical Manager (CM #1) during an interview on 9/20/23 at 11:40 a.m. who stated, "My expectation would be that there would be an actual blood sugar obtained at the start of care and not ranges. No response was offered regarding the other identified concerns. P-2: The patient's SOC was 8/17/23 with diagnoses that included Parkinson's Disease, Hemiplegia left side, Hypertension and Depression. The clinical record review was conducted on 9/19/23 at 3:50 p.m. The Initial Comprehensive Assessment dated 8/17/23, completed by the Registered Nurse, revealed the following: Section 1021 Primary diagnosis listed diagnoses Parkinson's Disease. Section M1023 "Other diagnoses" listed Hypertension and Iron Deficiency. Depression, Sleep Apnea, Atherosclerotic Heart Disease and Glaucoma. All diagnoses were void of a date of onset or exacerbation and offered no history as to the status of the diagnoses. Additionally, there was no documented rationale of the events leading to the need for home care. These findings were reviewed with and acknowledged by the Administrator (Adm #1) and CM #1 during an interview on 9/21/23 at 9:35 a.m. P-4: This 89-year-old patient was admitted to home care on 6/16/23 with a diagnosis of atherosclerotic heart disease and a closed fracture of the right ankle. During record review on 9/19/23 at 12:15 p.m., it was noted that the start of care assessment failed to include dates of diagnosis onset or exacerbation for the primary diagnosis (Section M1021) of atherosclerotic heart disease or the “other” (Section M1023) listed diagnoses: fracture of the right lower leg, unspecified ectropion of left lower eyelid, long term (current) use of anticoagulants, coronary angioplasty status, essential (primary) hypertension, hyperlipidemia, dependence on wheelchair, and arthrodesis status. The finding was reviewed and acknowledged by the administrator (ADM-1) and clinical manager (CM-1) during an interview on 9/21/23 at 10:30 a.m. P-5: This 96-year-old patient was admitted to home care on 2/21/23 with a diagnosis of stage 2 pressure ulcer of the right heel and retention of urine. During record review on 9/19/23 at 2:45 p.m., it was noted that the start of care assessment failed to include dates of diagnosis onset or exacerbation for the primary diagnosis (Section M1021) pressure ulcer of the right heel, stage 3 or the “other” (Section M1023) listed diagnoses: type 2 diabetes mellitus with diabetic neuropathy, heart failure, atherosclerotic heart disease, macular degeneration, retention of urine, dependence on wheelchair, hypertensive heart disease with heart failure, hemiplegia following cerebral infarction, vitamin B deficiency, subacute cough, long term aspirin use, encounter for change or removal of nonsurgical wound dressing, and encounter for fitting and adjustment of urinary device. The finding was reviewed and acknowledged by the ADM-1 and CM-1 during an interview on 9/21/23 at 10:30 a.m. P-6: This 73-year-old patient was admitted to home care on 8/24/23 with a diagnosis of generalized osteoarthritis and weakness. During record review on 9/20/23 at 9:30 a.m., it was noted that the start of care assessment failed to include dates of diagnosis onset or exacerbation for the primary diagnosis (Section M1021) of primary generalized osteoarthritis or the “other” (Section M1023) listed diagnoses: atopic dermatitis, gastroesophageal reflux disease, vitamin B deficiency, shortness of breath, long term (current) use of opioid analgesic, eosinophilia, essential (primary) hypertension, depression, repeated falls, long term (current) use of systemic steroids, and bed confinement status. The finding was reviewed and acknowledged by ADM-1 and CM-1 during an interview on 9/21/23 at 10:30 a.m. P-7: This 97-year-old patient was admitted to home care on 9/8/23 with a diagnosis of spondylosis with radiculopathy. During record review on 9/20/23 at 10:15 a.m., it was noted that the start of care assessment failed to include dates of diagnosis onset or exacerbation for the primary diagnosis (Section M1021) of cervical spondylosis with radiculopathy or the “other” (Section M1023) listed diagnoses: scoliosis, hypothyroidism, hyperlipidemia, insomnia, primary generalized osteoarthritis, repeated falls, vitamin B deficiency, malignant neoplasm of the prostate, and long term (current) use of opiate analgesic. The finding was reviewed and acknowledged by ADM-1 and CM-1 during an interview on 9/21/23 at 10:30 a.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 the patient's Activity of Daily Living needs were adequately met in the patient's home for one (P-1) patient who required assistance with grooming and bathing, from a total of 7 sampled records reviewed, resulting in the potential for poor hygiene and psychological decline. Findings include: P-1: The 90 year old patient's start of care was 3/9/23 with diagnoses that included Diabetes Mellitus. The referral for home care dated 3/3/23 ordered Skilled Nursing, Physical Therapy and Occupational Therapy services to be provided. On 9/19/23 at 12:30 p.m., during the clinical record review, it was noted that section M1800 of the Initial Comprehensive Assessment dated 3/9/23 reflected that the patient required assistance with grooming, toileting, dressing and transfers. Additionally, there was no documented willing caregiver who would provide the required assistance. The section titled supportive Assistance documented, "Patient lives alone Occasional/Short-Term Assistance..., ADL assistance needed." The section titled "Endocrine" documented, "Caregiver Availability: No willing/able caregiver." The agency failed to ensure the patient's Activity of Daily Living needs were adequately met in the patient's home. These findings were reviewed with and acknowledged by the Clinical Manager (CM #1) during an interview on 9/20/23 at 11:40 a.m. who reported, "A Home Health Aide should have been offered. "

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment reflected an accurate review of all patient medications to determine any adverse effects, failed to ensure the Registered Nurse provided oversight of the review process, and failed to provide documented evidence of the drug regime review in 7 (P-1, P-2, P-3, P-4, P-5, P-6, P-7) of 7 records, from a total of 7 sampled records reviewed, resulting in the potential for unidentified harmful medication effects for all patients currently serviced by this Agency. Findings include: Policy: III.8 Comprehensive Assessment and Oasis Data collection Start of Care, undated, stated "The comprehensive assessment will include, at a minimum: Review of medications the patient is currently using to identify potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and noncompliance with drug therapy..." P-1: The patient's start of care (SOC) was 3/9/23 with diagnoses that included Diabetes Mellitus. Section M2001 of the Initial Comprehensive Assessment documented, was completed by the Registered Nurse and documented "No issues found during review." There was no drug interaction report available for review. The patient's prescribed medications were entered in Drugs.com (online drug interaction checker) and revealed Moderate drug to drug Interactions and duplicate drug therapy. During the record review on 9/19/23 at 12:30 p.m., there was no documented evidence that the Registered Nurse had conducted the drug review as per this requirement. The agency failed to ensure the comprehensive assessment included an accurate review of the patient's medications conducted by an RN. These findings were reviewed with and acknowledged by the Clinical Manager (CM #1) during an interview on 9/20/23 at 11:40 a.m. who reported, "All of these things should have been done. I have informed staff to correct these issues. There's really nothing I can do at this point." P-2: The patient's SOC was 8/17/23 with diagnoses that included Parkinson's Disease, Heart Attack, Hemiplegia and Osteoarthritis. Section M2001 of the Initial Comprehensive Assessment documented, was completed by the Registered Nurse and documented "No issues found during review." There was no drug interaction report available for review. A drug review was conducted during the onsite survey, utilizing the agency's EMR (Electronic Medical Record) system and revealed Moderate drug to drug interactions. During the record review on 9/19/23 at 3:50 p.m., there was no evidence that the Registered Nurse had, in fact, conducted the drug review as per this requirement. These findings were reviewed with and acknowledged by the Clinical Manager CM #1 during an interview on 9/20/23 at 12:15 p.m. who acknowledged, the Comprehensive assessment should have reflected that there were issues identified during the review. P-3: The patient's SOC was 8/8/23 with diagnoses that included Fracture of Right Femur, Hypertension and Osteoarthritis. Section M2001 of the Initial Comprehensive Assessment documented, was completed by the Registered Nurse and documented "No issues found during review." There was no drug interaction report available for review. A drug review was conducted during the onsite survey, utilizing the agency's EMR system and revealed Moderate drug to drug interactions and moderate drug to food interactions. A comparison review was conducted using Drugs.com and revealed the same interactions. During the record review on 9/20/23 at 11:00 a.m., there was no evidence that the Registered Nurse had, in fact, conducted the drug review as per this requirement. These findings were reviewed with and acknowledged by the Administrator (Adm #1) and CM #1 during an interview on 9/21/23 at 10:00 a.m. who acknowledged, the Comprehensive assessment should have reflected that there were issues identified during the review. P-4: This 89-year-old patient was admitted to home care on 6/16/23 with a diagnosis of atherosclerotic heart disease and a closed fracture of the right ankle. During record review on 9/19/23 at 12:15 p.m., it was noted that the record did not include a medication interaction or duplicate drug therapy report. During an interview on 9/21/23 at 10:30 a.m., the clinical manager (CM-1) stated the “software checks for drug interactions but does not produce a report. Sometimes I will look them up on Drugs.com (online drug interaction checker). For major or severe interactions, the physician is notified.” All drugs listed on the plan of care were input into Drugs.com, which revealed one major interaction between Aspirin and Eliquis. The registered nurse completed the start of care assessment on 6/16/23 where section M2001 states no issues were found during review and there is no record that a physician was notified of the potential interaction. The finding was reviewed and acknowledged by the administrator (ADM-1) and CM-1 during an interview on 9/21/23 at 10:30 a.m. P-5: This 96-year-old patient was admitted to home care on 2/21/23 with a diagnosis of stage 2 pressure ulcer of the right heel and retention of urine. During record review on 9/19/23 at 2:45 p.m., it was noted that the record did not include a medication interaction or duplicate drug therapy report. All drugs listed on the plan of care were input into Drugs.com, which revealed one major interaction between ibuprofen and aspirin, as well as 7 moderate interactions. The recertification OASIS was completed by a Registered Nurse on 8/17/23 and states the medications were reconciled. There is no record that a physician was notified of the potential interaction. The finding was reviewed and acknowledged by ADM-1 and CM-1 during an interview on 9/21/23 at 10:30 a.m. P-6: This 73-year-old patient was admitted to home care on 8/24/23 with a diagnosis of generalized osteoarthritis and weakness. During record review on 9/20/23 at 9:30 a.m., it was noted that a Physical Therapist (PT) completed the comprehensive assessment and there was no record of a Registered Nurse reviewing the medications. The CM-1 stated “I’m not done with the chart yet. It still needs QA review” during and interview on 9/21/23 at 10:30 a.m. Additionally, the record did not include a medication interaction or duplicate drug therapy report. All drugs listed on the plan of care were input into Drugs.com, which revealed 3 major interactions: hydroxyzine and Ultram, hydroxyzine and Celexa, and Ultram and Celexa, as well as 7 moderate interactions. There is no record that a physician was notified of the potential interactions. The finding was reviewed and acknowledged by ADM-1 and CM-1 during an interview on 9/21/23 at 10:30 a.m. P-7: This 97-year-old patient was admitted to home care on 9/8/23 with a diagnosis of spondylosis with radiculopathy. During record review on 9/20/23 at 10:15 a.m., it was noted that the record did not include a medication interaction or duplicate drug therapy report. All drugs listed on the plan of care were input into Drugs.com, which revealed two major drug interactions between Xanax and Tramadol and Tramadol and pregabalin, as well as 7 moderate interactions. The registered nurse completed the start of care assessment on 9/8/23 where section M2001 states no issues were found during review and there is no record that a physician was notified of the potential interactions. The finding was reviewed and acknowledged by ADM-1 and CM-1 during an interview on 9/21/23 at 10:30 a.m.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the plan of care included appropriate interventions with objectively measurable goals specific to the individualized needs of the patient in 2 (P-5, P-7) of 7 sampled records reviewed, resulting in the potential for poor patient outcomes and unmet care needs. Findings include: P-5: This 96-year-old patient was admitted to home care on 2/21/23 with a diagnosis of stage 2 pressure ulcer of the right heel and retention of urine. During record review on 9/19/23 at 2:45 p.m., it was noted that the plan of care failed to include measurable goals for nursing stating, “patient will have promotion of healing and restoration of skin integrity without complications within time-period” [SIC]. This patient has a history of diabetes, stroke, dependence on wheelchair, and macular degeneration and the care plan also failed to include measures related to diabetes or safety to protect against injury. The finding was reviewed and acknowledged by the administrator (ADM-1) and case manager (CM-1) during an interview on 9/21/23 at 10:30 a.m. P-7: This 97-year-old patient was admitted to home care on 9/8/23 with a diagnosis of spondylosis with radiculopathy. During record review on 9/20/23 at 10:15 a.m., it was noted that the plan of care failed to include measurable goals for nursing stating, “patient’s activity level will improve due to effective pain control by/within time-period” [SIC]. The finding was reviewed and acknowledged by ADM-1 and CM-1 during an interview on 9/21/23 at 10:30 a.m.

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on interview and record review, it was determined the Agency failed to provide evidence of its efforts to measure, track and analyze its quality indicators in order to assess processes of care and services and failed to maintain a program that included surveillance of communicable diseases as part of its Quality Assessment Performance Improvement program, resulting in the inability to determine the scope of services provided, lack of infection control measures and the potential for unmet care needs for all patients currently serviced by this agency (G642); failed to develop Performance Improvement activities, as part of the Agency's Quality Assessment Performance Improvement program, in order to track and trend adverse patient events, analyze the cause and implement preventive interventions, resulting in the potential for the rendering of substandard care and unmet care needs (G654); failed to develop a Quality Assessment Performance Improvement program that documented the quality improvement projects, the reasons for conducting these projects with measurable progress achieved on these projects for the 2021 and 2022 calendar years, resulting in the Agency's inability to improve in patient care, health outcomes, patient safety, quality of care and the agency's performance (G658); and, failed to ensure the Agency had an active and functioning Quality Assessment and Performance Improvement program that addressed priorities for improved quality of care and patient safety, and was evaluated for effectiveness, resulting in the potential to adversely affect the quality of care rendered to all patients currently serviced by this agency (G660). 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 CFR§484.65 Quality Assessment and Performance Improvement (QAPI).

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on interview and record review, it was determined the Agency failed to provide evidence of its efforts to measure, track and analyze its quality indicators in order to assess processes of care and services and failed to maintain a program that included surveillance of communicable diseases as part of its Quality Assessment Performance Improvement program, resulting in the inability to determine the scope of services provided, lack of infection control measures and the potential for unmet care needs for all patients currently serviced by this agency. Findings include: On 9/21/23 at 1:45 p.m., during an interview, the Administrator (Adm #1) was asked for permission to review the Agency's QAPI (Quality Assessment Performance Improvement) documents. Upon review of the agency's QAPI data with Adm #1, it was noted that there was no data collection to review for the calendar years 2021 and 2022 that showed the agency's efforts to measure, track and analyze indicators in order to determine if care and services have been provided safely and appropriately. These findings were reviewed with and confirmed by Adm #1 at the time of discovery.

Track adverse patient events CFR(s): 484.65(c)(2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. This STANDARD is not met as evidenced by: Based on interview and record review, it was determined the Agency failed to develop Performance Improvement activities, as part of the Agency's Quality Assessment Performance Improvement program, in order to track and trend adverse patient events, analyze the cause and implement preventive interventions, resulting in the potential for the rendering of substandard care and unmet care needs. Findings include: On 9/21/23 at 1:45 p.m., during a review of the agency's QAPI (Quality Assessment Performance Improvement) documents, it was noted that there were no Performance Improvement Projects for the reviewed calendar years 2021 and 2022. These findings were reviewed with and acknowledged by the Administrator who was present at the time of discovery.

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on interview, it was determined the Agency failed to develop a Quality Assessment Performance Improvement program that documented the quality improvement projects, the reasons for conducting these projects with measurable progress achieved on these projects for the 2021 and 2022 calendar years, resulting in the Agency's inability to improve in patient care, health outcomes, patient safety, quality of care and the agency's performance. Findings include: On 9/21/23 at 1:45 p.m., during an interview, the Administrator (Adm #1) was queried about documentation of the Agency's QAPI (Quality Assessment Performance Improvement) program and Performance Improvement Projects, reasons for conducting the projects along with measurable progress achieved. Adm #1 was unable to provide the requested data and stated, "We don't have any projects in place at this time." Review of the agency's QAPI data revealed no evidence of any Performance Improvement Projects.

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based interview, it was determined the Governing Body failed to ensure the Agency had an active and functioning Quality Assessment and Performance Improvement program that addressed priorities for improved quality of care and patient safety, and was evaluated for effectiveness, resulting in the potential to adversely affect the quality of care rendered to all patients currently serviced by this agency. Findings include: During an interview with the Administrator (Adm #1) on 9/21/23 at 1:45 p.m., a request was made to review the agency's Quality Assessment Performance Improvement (QAPI) data for calendar years 2021 and 2022 and Governing Body meeting minutes for 2021 and 2022. Upon receipt and review of the agency's QAPI data, there was no data made available for review that determined or affirmed the Governing Body's oversight of the agency's QAPI program. These findings were reviewed with and acknowledged by Adm #1 at the time of discovery.

Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This CONDITION is not met as evidenced by: Based on record review and interview, it was determined that the Agency failed to coordinate an agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases as a part of its Quality Assessment Performance Improvement program, resulting in the potential for increased, untreated infections among staff and all patients currently serviced by this agency (G684); and, failed to provide documented evidence that infection control education and in-services was provided to all staff employed by this agency, including contracted staff, resulting in the potential for the development and spread of infection to staff and all patients currently serviced by this agency (G686). 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 42 CFR §484.70 Infection Prevention and Control.

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 record review and interview, it was determined that the Agency failed to coordinate an agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases as a part of its Quality Assessment Performance Improvement program, resulting in the potential for increased, untreated infections among staff and all patients currently serviced by this agency. Findings include: On 9/21/23 at 1:45 p.m., the Agency's Administrator (Adm #1) was queried about the Infection Control program. When asked if there was any documentation of the Agency's identification and surveillance of reported patient and staff infections and infection control meeting minutes, Adm #1 responded, "No. I can honestly say we don't have any of that." The agency failed to coordinate and agency-wide infection control program as per this requirement. These findings were reviewed with and acknowledged by Adm #1 at the time of discovery.

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on interview and record review, it was determined the Agency failed to provide documented evidence that infection control education and in-services was provided to all staff employed by this agency, including contracted staff, resulting in the potential for the development and spread of infection to staff and all patients currently serviced by this agency. Findings include: On 9/21/23 at 2:00 p.m., the Administrator (Adm #1) was asked for permission to review documentation of staff training, education, and in-services in infection control, however, was unable to provide the requested documentation. Adm #1 stated, "We haven't provided any education." The agency failed to ensure all staff, including contracted staff had received education in infection control. These findings were reviewed with and acknowledged by Adm #1 at the time of discovery.

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 record review and interview, the Agency failed to ensure the ordered Skilled disciplines performed initial and ongoing assessments of the patient's health status and needs in 2 (P-1, P-2) records of patients who required ongoing monitoring of their health status, from a total of 7 sampled records reviewed, resulting in the potential for unidentified health concerns, and poor patient outcomes (G706); failed to ensure skilled nursing, physical therapy, and occupational therapy services were provided as ordered by the physician for 5 (P-1, P-2, P-4, P-7, P-3) records with the ordered services, from a total of 7 sampled records reviewed, resulting in the potential for decline in physiological functioning, poor patient outcomes and unmet care needs (G710); failed to ensure the clinical record was completed and included detailed Physical Therapy notes for 2 (P-2, P-3) records with the ordered services, from a total of 7 sampled records reviewed, resulting in the potential for undocumented, unidentified health concerns, and unmet patient care needs (G716); ailed to ensure physical therapy communicated with the physician relating to services ordered within the plan of care for 1 of 7 (P-6); and, failed to ensure the Physician was notified of elevated pain levels for 1 (P-3) patient who experienced pain outside the reportable parameters, from a total of 7 sampled records reviewed, resulting in the potential for poor patient outcomes, unrelieved pain and unmet care needs (G718); and, failed to ensure skilled professionals participated in agency-sponsored in-service training, resulting in a lack of training and educational opportunities for 9 skilled professionals employed by the agency or under arrangement (G722). The cumulative effects of this systemic problem resulted in the Home Health 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 Professional Services.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the ordered Skilled disciplines performed initial and ongoing assessments of the patient's health status and needs in 2 (P-1, P-2) records of patients who required ongoing monitoring of their health status, from a total of 7 sampled records reviewed, resulting in the potential for unidentified health concerns, and poor patient outcomes. Findings included: P-1: The patient's start of care (SOC) was3/9/23 with a diagnosis of Diabetes Mellitus. During the clinical record review on 9/19/23 at 3:50 a.m., it was noted that the referral for home care ordered Skilled Nursing, (SN), Physical Therapy (PT) and Occupational Therapy (OT) services to be provided. The Plan of Care (POC) ordered SN to perform complete physical assessment each visit with emphasis on disease process, monitor blood sugar levels at each visit to assess efficacy of medication, coordinate care with physician..." Further review of the record revealed that SN services were only provided one time for one visit. The Initial Comprehensive Assessment was void of a baseline blood sugar and documented, "PRN (as needed) visits for diabetic complications.". further review revealed no documented evidence that the patient's blood sugars were assessed throughout the course of care as ordered in the POC. The Agency failed to ensure the patient's health status was continuously monitored. These findings were reviewed with and acknowledged by the Administrator (Adm #1) and Clinical Manager (CM #1) during an interview on 9/21/23 at 9:25 a.m. P-2: The patient's SOC was 8/8/23 with diagnoses that included Parkinson's Disease, Diabetes Mellitus, Hemiplegia and Osteoarthritis. During the clinical record review on 9/19/23 at 3:50 a.m., it was noted that the referral for home care ordered SN, PT and OT services to be provided. The POC ordered SN to "perform complete physical assessment each visit with emphasis on disease process, instruct on bladder training program, identify symptoms of impaired neurological function, perform medication review each visit and reconcile medications as indicated..." Further review of the record revealed that SN services were only provided one time for one visit. There was no documented evidence that the patient's identified needs were continuously assessed as per the POC. These findings were reviewed with and acknowledged by the Adm #1 CM #1 during an interview on 9/2/23 at 9:35 a.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 observation, record review and interview, the agency failed to ensure skilled nursing, physical therapy, and occupational therapy services were provided as ordered by the physician for 4 (P-1, P-2, P-4, P-7) records with the ordered services, from a total of 7 sampled records reviewed, resulting in the potential for decline in physiological functioning, poor patient outcomes and unmet care needs. Findings include: Policy: III.6 "Physician's Plan of Treatment/Change Orders" undated, stated, "The Agency will provide care/services consistent with the plan of treatment." P-1: The patient's start of care (SOC) was3/9/23 with a diagnosis of Diabetes Mellitus. During the clinical record review on 9/19/23 at 3:50 a.m., it was noted that the referral for home care ordered Skilled Nursing, (SN), Physical Therapy (PT) and Occupational Therapy (OT) services to be provided. The Plan of Care (POC) ordered SN to perform complete physical assessment each visit with emphasis on disease process, monitor blood sugar levels at each visit to assess efficacy of medication, coordinate care with physician..." Further review of the record revealed that SN services were only provided one time for one visit. The Agency failed to ensure that SN followed the POC/Physician's order in weekly assessments of the patient's health status. These findings were reviewed with and acknowledged by the Administrator (Adm #1) and Clinical Manager (CM #1) during an interview on 9/21/23 at 9:25 a.m. P-2: The patient's SOC was 8/8/23 with diagnoses that included Parkinson's Disease, Diabetes Mellitus, Hemiplegia and Osteoarthritis. During the clinical record review on 9/19/23 at 3:50 a.m., it was noted that the referral for home care ordered SN, PT and OT services to be provided. The Initial Comprehensive Assessment and POC documented the patient refused OT services. The POC ordered SN to "perform complete physical assessment each visit with emphasis on disease process, instruct on bladder training program, identify symptoms of impaired neurological function, perform medication review each skilled nursing visit and reconcile medications as indicated..." Further review of the record revealed that SN services were only provided one time for one visit. On 9/20/23 during a scheduled survey home visit, the patient was observed awake and sitting in a wheelchair. The patient had visible tremors to his left hand and ambulated with use of a walker. During the visit, the patient was queried regarding his refusal of OT services and reported, "I was never offered OT services." The agency failed to ensure that services were provided as ordered. These findings were reviewed with and acknowledged by the Adm #1 CM #1 during an interview on 9/2/23 at 9:35 a.m. Adm #1 reported, "Sometimes maybe PT will feel that OT will take over their visits. We just have to explain the benefits of all services ordered." CM #1 reported, "SN should have followed up with the patient." P-4: This 89-year-old patient was admitted to home care on 6/16/23 with a diagnosis of atherosclerotic heart disease and a closed fracture of the right ankle. During record review on 9/19/23 at 12:15 p.m., it was noted on the plan of care that nursing was order twice a week for two weeks. Nursing saw the patient once in week one (6/16/23) and attempted one visit in week two (6/23/23) and the patient refused and was discharged from nursing. There was no evidence the physician was notified of the missed visits. Additionally, this patient was ordered occupational therapy (OT) once a week for one week, then twice a week for 3 weeks. OT services were discontinued after six visits. The OT wrote in the discharge summary, “patient was discharged one session earlier since patient moved out of service area.” The findings were reviewed and acknowledged by the administrator (ADM-1) and case manager (CM-1) during an interview on 9/21/23 at 10:30 a.m. P-7: This 97-year-old patient was admitted to home care on 9/8/23 with a diagnosis of spondylosis with radiculopathy. During record review on 9/20/23 at 10:15 a.m., it was noted on the plan of care that physical therapy (PT) was ordered twice weekly for five weeks then once per week for two weeks. PT evaluated the patient on 9/12/23. There was no evidence of any additional visits taking place since the initial visit. The finding was reviewed and acknowledged by the ADM-1 and CM-1 during an interview on 9/21/23 at 10:30 a.m.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the clinical record was completed and included detailed Physical Therapy notes for 2 (P-2, P-3) records with the ordered services, from a total of 7 sampled records reviewed, resulting in the potential for undocumented, unidentified health concerns, and unmet patient care needs. Findings include: Policy: III.3 "Clinical Record Contents and Maintenance" undated, stated, "The patient’s clinical record will contain data including but not limited to: A complete physical assessment including vital signs, height, and weight as applicable, systems review, and other relevant information as well as ongoing assessments and reassessments, Clinical progress notes / visit notes, detailing services rendered and patient response to services..." P-2: The patient's start of care (SOC) was 8/17/23 with diagnoses that included Parkinson's Disease, Hemiplegia, Diabetes Mellitus and Osteoarthritis. During the record review on 9/19/23 at 3:50 p.m., it was noted that the patient was ordered to received Physical Therapy (PT) services at a frequency of 2x/wk. x 8 wks. Upon review of the record, PT last documented a visit note on 8/30/23. There were no further visit notes after this date. These findings were reviewed with and acknowledged by the Administrator (Adm #1) and Clinical Manager (CM #1) during an interview on 9/21/23 at 9:35 a.m. Adm #1 stated, "I think she (PT) had some dental issues, so she didn’t complete her notes for 2 weeks or so.” P-3: The patient's SOC was 8/8/23 with diagnoses that included Fractured Right Femur, Hypertension and Osteoarthritis. During the clinical record review on 9/20/23 at 11:00 a.m., it was noted that the patient was ordered to receive Physical Therapy (PT) services at a frequency of 1x/wk. x 1 wk., 2x/wk. x 6 wks., 1x/wk. x 1 wk. Upon review of the clinical record, the PT's last documented visit was 8/21/23. There were no further documented visits. The PT began a re-evaluation note on 9/8/23, however, the document was incomplete. Additionally, no PT visit notes had been produced for the above timeframe by the end of this survey. These findings were reviewed with and acknowledged by Adm #1 and CM #1 during an interview on 9/21/23 at 10:00 a.m.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure physical therapy communicated with the physician relating to services ordered within the plan of care for 1 of 7 (P-6); and, failed to ensure the Physician was notified of elevated pain levels for 1 (P-3) patient who experienced pain outside the reportable parameters, from a total of 7 sampled records reviewed, resulting in the potential for poor patient outcomes, unrelieved pain and unmet care needs. Findings include: P-3: The patient's start of care was 8/8/23 with diagnoses that included Nondisplaced Fracture right Femur Hypertension and Osteoarthritis. During the record review on 9/20/23 at 11:00 a.m., it was noted that the Plan of Care instructed disciplines to report pain levels greater than 6/10. On 8/14/23 the patient reported pain at 8/10, on 8/17/23 7/10, and 8/21/23 7/10. (There were no visit documented notes after 8/21/23). A review of the patient's visit notes revealed no documented evidence that the Physician had been notified of the patient increased pain levels outside the reportable parameters as ordered in the plan of care. These findings were reviewed with and acknowledged by the Administrator and clinical Manager during an interview on 9/21/23 at 10:00 a.m. P-6: This 73-year-old patient was admitted to home care on 8/24/23 with a diagnosis of generalized osteoarthritis and weakness. During record review on 9/20/23 at 9:30 a.m., it was noted that Physical Therapy (PT) was ordered twice weekly for 4 weeks, then once per week for 3 weeks. In the first 4 weeks of care (8 ordered visits), PT provided services 4 times. There is no evidence the PT communicated the missed visits with the physician. The finding was reviewed and acknowledged by the administrator (ADM-1) and case manager (CM-1) during an interview on 9/21/23 at 10:30 a.m.

Participate in HHA-sponsored in-service CFR(s): 484.75(b)(9) Participation in HHA-sponsored in-service training. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure skilled professionals participated in agency-sponsored in-service training, resulting in a lack of training and educational opportunities for 9 skilled professionals employed by the agency or under arrangement. Findings include: During review of five employee files on 9/21/23 at 11:45 a.m., there was no documented evidence of in-service education in 2022. The case manager (CM-1) stated that the agency had not provided any in-services for agency or contracted staff in 2022 during interview on 9/21/23 at 12:27 p.m.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure a discharge summary was complete, provided the patient's current health status at the time of discharge, progress toward goals, and forwarded to the physician within 5 days of the date of discharge in 2 (P-1, P-4) of 2 closed records from a total of 7 records reviewed, resulting in the potential for unidentified continuing health care concerns and unmet care needs. Findings include: Policy: III.11 Discharge Planning, Discharge Summary and discharge Oasis, undated, stated, "The discharge summary will include but is not limited to: Admission and discharge dates, Physician responsible for the home health plan of care, Reason for admission, Reason for discharge, Status of problems throughout the course of care, Types of care/services provided, including frequency of such services, Laboratory data, if applicable, Medications patient is on at time of discharge, The progress or lack of toward established goals, The patient’s overall status at time of discharge, Any continuing care needs, instructions, or referrals regarding the needs. All discharge summaries shall be sent to the patient’s physician within 5 days of the patient’s discharge from services." P-1: The patient's start of care was 3/9/23 with diagnoses that included Diabetes Mellitus. During the review on 9/19/23 at 12:30 p.m., it was noted that the patient received Skilled Nursing and Physical Therapy services during the course of care. The record reflected the patient complained of pain and had reportable parameters to notify the Physician for pain levels greater than 8/10. Further review revealed that Skilled Nursing only saw the patient one time. The patient was discharged from the agency's services on 5/1/23 by the Physical Therapist. The Discharge Summary dated 5/1/23, completed by the Physical Therapist, failed to include a summary of the course of care provided with responses to treatment, status at the time of discharge and any referrals as appropriate. The Nursing goals all reflected "Goal Unmet", however, there was no addition documentation or referrals that would aid in meeting the patient's goals. Further, there was no recorded pain level or blood sugar level at the time of discharge. Additionally, there was no documented evidence that the Discharge Summary had been forwarded to the Physician within 5 days of the date of discharge, as per this requirement. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 9/21/23 at 9:25 a.m. The Administrator reported, "I don't see that we sent it (Discharge Summary) to the Physican." P-4: This 89-year-old patient was admitted to home care on 6/16/23 with a diagnosis of atherosclerotic heart disease and a closed fracture of the right ankle. During record review on 9/19/23 at 12:15 p.m., it was noted that the patient was discharged from agency services on 8/3/23. There was no documented evidence that a detailed discharge summary report was sent to the physician within 5 days of the patient’s discharge. The administrator (ADM-1) acknowledged that no discharge summary was sent during an interview on 9/21/23 at 1:48 p.m.