Every finding on record at Supreme Rehab, Inc.

The following deficiencies were identified during a Medicare authorized Emergency Preparedness survey conducted by the Michigan Department of Licensing and Regulatory Affairs on 5/27/25 through 5/30/25 at: Supreme Home Care & Rehab29930 W. 12 Mile Rd., Suite 3Farmington Hills, MI 48334 At the conclusion of the survey, this agency was determined to be out of compliance with the Condition of Participation at 42 CFR 484.102.

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for 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:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: Based on record review, and interview, the agency failed to incorporate an individualized Emergency Preparedness Plan into the Comprehensive Patient Assessment for 3 (P-5, P-6, P-7) records of patients who required individualized assessments in Emergency Preparedness from a total of 7 sampled records reviewed, resulting in the potential for overlooked patient needs in the event of an actual emergency for all patients services by this agency. Findings include: Patient #5 (P-5): This patient's start of care (SOC) was 12/6/24 with diagnoses that included CR(E)ST Syndrome (Scleroderma/Autoimmune Disease) and Fall with Left Ankle Fracture. During the clinical record review on 5/28/25 at 12:30 p.m., it was noted that the Initial Comprehensive Assessment documented that the patient had limited range of motion and was unable to walk. The patient's in-home Emergency Preparedness (EP) evaluation was not individualized and failed to include the aforementioned limitations or identified risks. P-6: This patient's SOC was 4/23/25 with diagnoses that included Sacroiliitis, Sciatica, Obesity and Schizophrenia. During the record review on 5/28/25 at 3:00 p.m., it was noted that the patient's in-home EP Assessment was blank and did not include any details that would aid personnel in assisting the patient in the event of an emergency. P-7: This patient's SOC was 4/14/25 with a diagnosis of Critical Illness Myopathy. During the record review on 5/29/25 at 12:10 p.m., the Initial Comprehensive Assessment revealed that the patient required supervision and assistance with mobility. The in-home EP Assessment was blank and did not include any detailed information that would aid personnel in assisting the patient in the event of an emergency. The Administrator (Adm #1) reviewed and acknowledged the above findings during an interview on 5/30/25 at 1:15 p.m.

A Medicare recertification survey was conducted by the Michigan Department of Licensing and Regulatory Affairs from 5/28/25 through 5/30/25 at: Supreme Home Care & Rehab 29930 West 12 Mile Rd., #3 Farmington Hills, Michigan 48334 This agency has no branch sites. Records Reviewed: 2 records with home visits (due to low census); 5 records without home visits, for a total of 7 records reviewed. At the conclusion of the survey the agency was found to be out of compliance for the conditions of participation for home health agencies at: 42 CFR Part 484.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the Agency failed to ensure that 2 (P-3, P-6) of 2 patients observed during home visits, from a total of 7 sampled records reviewed, were included in the overall planning of care including informing the patient/caregiver in advance of the days in which services would be provided, resulting lack of inclusion in planning, the potential for missed visits and unmet care needs. Findings include: P-6: The patient's start of care was 4/23/25 with diagnoses that included Sacroiliitis and Sciatica. During the record review on 5/28/25 at 3:00 p.m., it was noted that the Plan of Care ordered Physical Therapy services to be provided. On 5/29/25 at 3:30 p.m., a scheduled survey home visit was conducted with the Physical Therapist/Administrator (Adm #1). During the visit, the patient's admission packet was reviewed and found to be void of a completed calendar of proposed visits to be made by the Physical Therapist. These findings were reviewed with and acknowledged by Adm #1 during an interview on 5/30/25 at 12:40 p.m. P-3: This patient's Start of Care (SOC) was dated 4/7/2025. The Plan of Care for the certification period 4/7/2025 to 6/5/2025 identified diagnoses of Bilateral Primary Osteoarthritis, Scoliosis, Gastro-esophageal reflux disease, Hypertension, and Abnormalities of gait. The patient was receiving Physical Therapy Services 2xweekx3weeks, and 1xweekx6weeks. During a scheduled joint survey Home Visit on 5/29/25 at 10:00 a.m. with the Administrator/Physical Therapist, it was noted upon reviewing the patient's Home Admission Packet that the packet failed to include a calendar in which to document the patient's current and future physical therapy visits to allow the patient to be present and prepared for future visits. These findings were reviewed with and acknowledged by the Administrator (Adm #1) directly after the visit during an interview on 5/29/25 at 11:30 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 2 (P-5, P-7) patients assessed as needing assistance with grooming, from a total of 7 sampled records reviewed, resulting in the potential for poor hygiene, low self-esteem, and unmet care needs. Findings include: Patient #5 (P-5): The patient's start of care (SOC) was 12/6/24 with diagnoses that included CR (E) ST Syndrome (Scleroderma/autoimmune disease) and Fall with Fracture of left ankle. During the clinical record review on 5/28/25 at 12:30 p.m., it was noted that the Plan of Care (POC) ordered Physical Therapy (PT) services to be provided. Section M1100 of the Initial Comprehensive Assessment indicated the patient lived with other persons in the home around the clock, however, there was no documented willing or available caregiver who would provide assistance with Activities of Daily Living (ADL's). The section titled Musculoskeletal stated, Limited range of motion, balance poor, unable to walk, non-weight bearing, weakness bilateral lower extremities, left ankle, foot and both shoulders. Section M1800 revealed someone must assist with grooming, dressing and toileting. Upon further review of the clinical record, there was no documented evidence that a home health aide was either offered or provided. The Administrator (Adm #1) reviewed and acknowledged these findings during an interview on 5/30/25 at 11:50 a.m. P-7: The patient's SOC was4/14/25 with a diagnosis of Critical Illness Myopathy. During the record review on 5/29/25 at 12:10 p.m., it was noted that the POC ordered PT services to be provided. Section M1100 was void of an available, will caregiver who would provide assistance with ADL's. Section M1800 indicated someone must assist with grooming and toileting. Upon further review, there was no documented evidence that a home health aide was either offered or provided to assist with grooming needs. Adm #1 reviewed and confirmed the above findings during an interview on 5/30/25 at 1:15 p.m.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment included a review of all medications, including over the counter and herbal medications to determine any adverse effects in 2 (P-6, P-4) of 7 sampled records reviewed, resulting in the potential for harmful medication effects for all patients currently serviced by this Agency. Findings include: P-4: This patient was admitted to home care on 4/14/25 with diagnoses of chronic pain syndrome and obesity. During record review on 5/28/25, it was noted that the comprehensive assessment on 4/14/25 failed to note the patient's duplicate drug therapy. The patient's medications included Tylenol (Acetaminophen) 325 mg 2 tabs q6 prn pain and Hydrocodone Bitartrate/Acetaminophen 10mg-325mg 1-tab q6 prn pain. The findings were reviewed with Adm#1 during an interview on 5/28/25 at 2:50 p.m. Adm#1 explained that he thought duplicate medications meant the patient was receiving the same medication from 2 different doctors. P-6: The patient's SOC was 4/23/25 with diagnoses that included Sacroiliitis, Schizophrenia and Sciatica. During a review of the clinical record on 5/28/25 at 3:00 p.m., it was noted that the patient was ordered to receive Physical Therapy services. On 5/29/25 at 3:30 p.m., a scheduled survey home visit was conducted with the Physical Therapist/Administrator (Adm #1). During the visit, Adm #1 applied a topical pain relief gel (Biofreeze) to the patient's back. There was no medication profile available for review in the patient's admission packet. Upon further review of the clinical record, it was noted that Biofreeze was not listed on the Plan of Care and had not been included in the comprehensive drug review. These findings were reviewed with and acknowledged by Adm #1 during an interview on 5/30/25 at 12:40 p.m. who responded, "I didn't include it because you can buy it over the counter." The agency failed to ensure the comprehensive assessment included a thorough review of all the patient's medications, including over the counter and herbal medications.

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 goals on the Plan of Care were objectively measurable to determine the patient's progress towards obtaining the goals in 3 (P-1, P-2, and P-3) of 7 records reviewed; and failed to ensure the plan of care include reportable pain parameters for 1 (P-4) 1 patient with a primary diagnosis of chronic pain syndrome resulting in the potential lack of intervention regarding pain control. Findings include: P-4: This patient was admitted to home care on 4/14/25 with diagnoses of chronic pain syndrome and obesity. During record review on 5/28/25, it was noted that the 4/14/25 plan of care failed to include a reportable parameter for pain for this patient with a primary diagnosis of chronic pain syndrome. Using the pain scale 1 (low) to 10 (high), the patient rated her pain consistently from 4-8 throughout the episode of care from 4/14/25 to 5/27/25. The findings were reviewed with the administrator/clinical manager/physical therapist (Adm#1) during an interview on 5/28/25 at 2:50 p.m. Adm#1 acknowledged the findings and explained that there should've been a pain parameter for this patient. P-1: The Start of Care (SOC) was dated 4/14/2025. The Plan of Care identified a primary diagnosis of Chronic Pain Syndrome, and secondary diagnoses of Obesity, Sacroiliitis {sic}, Sarcoidosis, Gastro-esophageal reflux disease, Astha, Sciatica, fatigue, Dorsalgia, abnormality of gait and mobility, and Hypertension. The patient was receiving Physical Therapy (PT) services2xweekx2weeks, and 1xweekx6weeks. The patient was also receiving OT (Occupational Therapy) services 1xweekx8weeks for fall safety and prevention, teaching and training on bed mobility and transfers with body mechanics, ADL's, adoptive equipment and energy conservation, and general strengthening exercises. Upon review of the Plan of Care (POC), it was noted the goals on the POC were not objectively measurable to determine the patient's progress towards obtaining the goals. Examples included: "Patient/Caregiver will be able to recognize, verbalize and or demonstrate HEP (Home Exercise Program), fall safety, safe use of AD (Adaptive Devices), safety in ADLs, pressure ulcer prevention, infection prevention, medication safety and follow up with PCP (Primary Care Provider). Patient will be able to roll side to side, supine to sit and sit to supine by herself using side rails as needed in 9 weeks by 6-12-25; Patient will be able to verbalize energy conservation in 9 weeks." These goals are not objectively measurable to determine the patient's progress towards obtaining the goals. P-2: The Start of Care (SOC) was dated 2/6/2025. The Plan of Care identified a primary diagnosis of Type 2 Diabetes, and other pertinent diagnoses of Chronic Kidney Disease (CKD), Acute embolism and thrombus unspecified, other abnormalities of gait, Unspecified osteoarthritis, Presence of right artificial hip. The patient was receiving Physical Therapy (PT) services 1xweekx1week, 2xweekx3weeks, 1xweekx5weeks. Upon review of the Plan of Care (POC), it was noted the goals were not objectively measurable to determine the patient's progress towards obtaining the goals. Examples included: "Patient will be able to recognize, verbalize, and or demonstrate HEP (Home Exercise Program), fall safety, safe use of AD (Assistive Devise), Safety in ADL's (Activities of Daily Living). These goals are not objectively measurable to determine the patient's progress towards obtaining the goals. P-3: The Start of Care (SOC) was dated 4/7/2025. The Plan of Care identified diagnoses of Bilateral Osteoarthritis, Idiopathic Scoliosis, Gastro-esophageal reflux disease, Hypertension, and abnormality of gait. The patient was receiving Physical Therapy (PT) Services 2xweekx3weeks, and 1xweekx6weeks. Upon review of the Plan of Care (POC), it was noted the goals on the POC were not objectively measurable to determine the patient's progress towards obtaining the goals. Examples included: "Patient will be able to recognize, verbalize, and/or demonstrate HEP (Home Exercise Program), fall safety, safe use of AD, safety in ADL's, medication safety, infection prevention and follow-up with PCP (Primary Care Physician) in 9 weeks by 6-6-25 {sic}; Patients safety will be enhanced as evidenced by no falls, infections, or ER (emergency room) visits during the current episode of Home Health Care by 6-6-25. These goals are not objectively measurable to determine the patient's progress towards obtaining the goals. These findings were reviewed with and acknowledged by the Administrator (Adm #1) during an interview on 5/30/25 at 2:00 p.m.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure treatments and services were provided only as ordered by the Physician for 1 (P-5) patient who required skilled home health services, from a total of 7 sampled records reviewed, resulting in the potential for the rendering of substandard, unsafe care and unmet care needs. Findings include: Patient #5 (P-5): The patient's start of care was 12/6/24 with diagnoses that included CR(E)ST Syndrome (Scleroderma/autoimmune disease) and Fall with Left Ankle Fracture. The Plan of Care ordered Physical Therapy services to be provided. During the clinical record review on 5/28/25 at 12:30 p.m., it was noted that the patient was discharged from the agency's services on 1/14/25. Upon further review, it was noted that the Plan of Care had not been signed until after the patient was discharged from services. These findings were reviewed with and confirmed by the Administrator (Adm #1) during an interview on 5/30/25 at 11:50 a.m. who stated, "Yes, it was late. I sent it to the Physician late." The agency failed to ensure that services were only provided in accordance with the Physician's orders.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Physician was promptly notified of major drug to drug interactions in 2 (P-5, P-6) records, from a total of 7 sampled records reviewed, resulting in the potential for unidentified untreated health issues related to drug interaction effects. Findings include: Patient #5 (P-5): The patient's start of care was 12/6/24 with diagnoses that included CR(E)ST Syndrome (Scleroderma/autoimmune disease) and Fall with Left Ankle Fracture. During the record review on 5/28/25 at 12:30 p.m., it was noted that section M2001 (Drug Regimen Review) of the Initial Comprehensive Assessment documented, "Yes-issues found during review." The agency's Drug Interaction Report revealed major drug to drug interactions. Section M2003 asked: "Did the agency contact the Physician by midnight of the next calendar day?" Upon further review, there was no documented evidence that the Physician had been promptly notified of the identified drug interactions. The Administrator (Adm #1) reviewed and confirmed these findings during an interview on 5/30/25 at 11:50 a.m. P-6: The patient's SOC was 4/23/25 with diagnoses that included Sacroiliitis, Schizophrenia and Sciatica. During a review of the clinical record on 5/28/25 at 3:00 p.m., it was noted that section M2001 of the Initial Comprehensive Assessment documented, "Yes-Issues found during review." Section M2003 asked: "Did the agency contact a physician by midnight of the next calendar day?" Upon further review, there was no documented evidence that the Physician had been promptly notified of the identified drug interactions. Adm #1 reviewed and acknowledged these findings during an interview on 5/30/25 at 12:40 p.m.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, it was determined that the agency failed to provide 2 (P-6, P-3) of 2 patients observed during home visits, with a Medication Profile that included the names, dosages and frequencies of the patient's prescribed medications, in plain language, from a total of 7 sampled records reviewed, resulting in lack of direction for medication administration and the potential for improper use of medications. Findings include: P-6: The patient's start of care was 4/23/25 with diagnoses that included Sacroiliitis and Sciatica. During the record review on 5/28/25 at 3:00 p.m., it was noted that the Plan of Care ordered Physical Therapy services to be provided. On 5/29/25 at 3:30 p.m., a scheduled survey home visit was conducted with the Physical Therapist/Administrator (Adm #1). During a review of the patient's admission packet, it was noted that there was no Medication Profile in the admission packet that listed the patient's prescribed medications, dosages and side effects. These findings were reviewed with and acknowledged by Adm #1 during an interview on 5/30/25 at 12:40 p.m. who reported, the patient had not been provided with a Medication Profile from the agency. P-3: This patient's Start of Care (SOC) was dated 4/7/2025. The Plan of Care for the certification period 4/7/2025 to 6/5/2025 identified diagnoses of Bilateral Primary Osteoarthritis, Scoliosis, Gastro-esophageal reflux disease, Hypertension, and Abnormalities of gait. The patient was receiving Physical Therapy Services 2xweekx3weeks, and 1xweekx6weeks. During a scheduled joint survey Home Visit on 5/29/25 at 10:00 a.m. with the Administrator/Physical Therapist, it was noted upon reviewing the patient's Home Admission Packet that the packet failed to include the patient's medication profile which listed the patient's prescribed medications, including frequency, dosages, and side effects to report. These findings were reviewed with and acknowledged by the Administrator (Adm #1) during an interview on 5/30/25 at 2:00 p.m.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to include contact information for the Home Health Agency's Clinical Manager in the Patient Admission/Orientation Packet, resulting in the potential for unaddressed patient concerns. Findings include: On 5/29/25 at 10:40 a.m., the Agency's Admission packet was reviewed. The packet included a consent form, admission agreement, Beneficiary notice, patient rights and responsibilities forms and Emergency Preparedness documents. Upon further review, it was noted that there was no contact information for the Agency's Clinical Manager. The Administrator reviewed and acknowledged the above findings during an interview on 6/22/22 at 4:00 p.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 document the meaning of undefined abbreviations within the clinical records in 3 of 7 records reviewed (P-1, P-2, P-3), resulting in the inability to understand the documentation of the care provided to the patient. Patient: P-1: The Start of Care (SOC) was dated 4/14/2025. The Plan of Care (POC) identified a primary diagnosis of Chronic Pain Syndrome, and secondary diagnoses of Obesity, Sacroiliitis [sic], Sarcoidosis, Gastro-esophageal reflux disease, Astha, Sciatica, fatigue, Dorsalgia, abnormality of gait and mobility, and Hypertension. The patient was receiving Physical Therapy (PT) services2xweekx2weeks, and 1xweekx6weeks. The patient was also receiving OT (Occupational Therapy) services 1xweekx8weeks for fall safety and prevention, teaching and training on bed mobility and transfers with body mechanics, ADL's, adoptive equipment and energy conservation, and general strengthening exercises. Upon review of the record, the following undefined abbreviations were documented in the clinical record: "HEP, AD, ADLs, CGA, PCP, CG, DME, LE, RW, MI, ER, HHC, PT, PA, UE, wk, SBA, WNL, OTC, LBS, AHD, HTN, OA, DC, GERD, ROM, OT, WFL, LBS, B/B, Pt, MD, AAROM, GMC/FMC, BUES, COTA, WC, EOB, NA, IADL, Mod, MMT, LS, SOC, POC, BSC, TUG, POV, UTI, OTR." Patient: P-2: The Start of Care (SOC) was dated 2/6/2025. The Plan of Care identified a primary diagnosis of Type 2 Diabetes, and other pertinent diagnoses of Chronic Kidney Disease (CKD), Acute embolism and thrombus unspecified, other abnormalities of gait, Unspecified osteoarthritis, Presence of right artificial hip. The patient was receiving Physical Therapy (PT) services 1xweekx1week, 2xweekx3weeks, 1xweekx5weeks. Upon review of the record, the following undefined abbreviations were documented in the clinical record: "THR, HEP, PCP, AD, LE, ER, HHC, PT, NA, HHA, SOC, WNL, S/S, OTC, ADLs, IADLs, ROM, ROC, OA, WFL, CKD, DVT, Rt, NIDDM, CG, RW, SBA, WBAT, BIMs, MS BLE." Patient: P-3: The Start of Care (SOC) was dated 4/7/2025. The Plan of Care identified diagnoses of Bilateral Osteoarthritis, Idiopathic Scoliosis, Gastro-esophageal reflux disease, Hypertension, and abnormality of gait. The patient was receiving Physical Therapy (PT) Services 2xweekx3weeks, and 1xweekx6weeks. Upon review of the record, the following undefined abbreviations were documented in the clinical record: "MHP, ADLs, AD, PCP, LE, AF, HEP, ER, HHC, LBS, GERD, HTN, WFL, PT, OA, ROM. These findings were reviewed with and acknowledged by Adm #1 during an interview on 5/30/25 at 2:00 p.m.

Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a qualified alternate, was appointed, in writing, to function in the Administrator's absence, resulting in the potential for uncoordinated agency functions and unmet care needs for all 6 patients currently serviced by this agency. Findings include: On 5/30/25, the Administrator (Adm #1) was asked to provide documented evidence of the Governing board's appointment of an Alternate Administrator. Adm #1 presented a governing board letter dated December 2024 that documented, "The above excused himself from the position of Alternate Administrator due to some personal matters..." On 5/30/25 at 1:35 p.m., during a review of the presented documents with Adm #1 present, Adm #1 reported, "If I needed him, I'm sure he would be available to help out." Adm #1 further stated, "I hired a new Alternate." However, there was no evidence of the new hire's appointment as the Alternate Administrator. There was no documented evidence provided that an Alternate Administrator had been delegated to function in the absence of the Administrator. Adm #1 reviewed and acknowledged the above findings at the time of discovery during the above interview.

Skilled services furnished CFR(s): 484.105(f) Standard: Services furnished. Skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis, in a place of residence used as a patient's home. An HHA must provide at least one of the services described in this subsection directly, but may provide the second service and additional services under arrangement with another agency or organization. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure that at least one qualifying service was provided directly by Agency employees, resulting in the potential for interruption in continuity of care and unmet care needs for all 6 patients currently serviced by this agency. Findings include: On 5/30/25 at 1:55 p.m., during an interview, the Administrator (Adm #1) was asked what services were currently provided by the Agency and stated that Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), Medical Social Work (MSW) and Home Health Aide (HHa) services were provided. Adm #1 elaborated that the agency currently did not have any HHa's. When asked if the Agency utilized contract personnel, Adm #1 said, "Yes." When asked which of the above-mentioned services were provided directly by the agency, Adm #1 stated, "PT services." On 5/30/25 at 1:55 p.m., during a review of the Agency's contracts with Adm #1 present, it was noted that the Agency's contract listed PT as a contracted services to be provided. The Administrator (Adm #1) reviewed and acknowledged the above findings during the above interview.

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 completed discharge summary was forwarded to the Physician within 5 days of the date of discharge for 2 (P-2, P-5) of 2 patients discharged from the agency's services from a total of 7 sampled records reviewed, resulting in the Physician's inability to assess the patient's potential continuing health care needs. Findings include: P-5: The patient's start of care was 12/6/24 with diagnoses that included CR(E)ST Syndrome (Scleroderma/autoimmune disease) and Fall with Left Ankle Fracture. The Plan of Care ordered Physical Therapy services to be provided. During the clinical record review on 5/28/25 at 12:30 p.m., it was noted that the patient was discharged from the agency's services on 1/14/25. Upon further review, there was no documented evidence that the PT Discharge Summary dated 1/14/25 was sent to the Physician within 5 days of the date of discharge. These findings were discussed with and confirmed by the Administrator during an interview on 5/30/25 at 12:30 p.m. P-2: The Start of Care (SOC) was dated 2/6/2025. The Plan of Care identified a primary diagnosis of Type 2 Diabetes, and other pertinent diagnoses of Chronic Kidney Disease (CKD), Acute embolism and thrombus unspecified, other abnormalities of gait, Unspecified osteoarthritis, Presence of right artificial hip. The patient was receiving Physical Therapy (PT) services 1xweekx1week, 2xweekx3weeks, 1xweekx5weeks. Upon review of the record, it was noted the patient was discharged from the agency on March 17, 2025, with goals met and condition improved. However, there was no documented evidence that the PT Discharge Summary dated March 17, 2025 was sent to the physician within 5 days of the date of discharge. These findings were reviewed with and acknowledged by the Administrator (Adm #1) during an interview on 5/30/25 at 2:00 p.m.

A Medicare Emergency Preparedness survey was conducted by the Michigan Department of Licensing and Regulatory Affairs from 5/2/22-5/4/22 at: Supreme Home Care & Rehab 29930 W. 12 Mile Road, Suite 3 Farmington Hills, MI 48334 The agency has no sub-units. The agency had 1 active patient during the survey with the patient refusing a home visit. The agency had no discharged patients in the previous 12 months. Condition level citations at: 42 CFR §484.65-Quality Assessment/Performance Improvement. 42 CFR §484.70-Infection Prevention and Control. 42 CFR §484.105-Organization and Administration of Services. 42 CFR §484.22-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).

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, §485.625, §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 (HHA) failed to develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually (See E0004); failed to include strategies for addressing emergency events identified by the risk assessment (See E0006); failed to include a process for cooperation and collaboration with all pertinent emergency preparedness officials to maintain an integrated response during an emergency (see E0009); The agency failed to develop Emergency Preparedness policies and procedures that aligned with the emergency plan, risk assessment and communication plan. The policies and procedures must be reviewed and updated at least annually. (See E0013); The agency failed to develop and maintain an Emergency Preparedness communication plan and ensure the communication plan was reviewed and updated at least annually. (See E0029); 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 the communication plan. The training and testing program must be reviewed and updated at least annually. (See 0036). The cumulative effect of these systemic problems could potentially affect all occupants of the facility in the event staff is not properly prepared for an emergency for the condition of participation of 42 CFR§484.102, Emergency Preparedness.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop 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: (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 all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [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. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to develop an emergency preparedness plan that must be reviewed and updated at least annually. Resulting in no guidance for agency actions in the event of an actual emergency or disaster. This deficient practice could affect the health and safety of all agency patients in the event of natural, man-made, or facility-based emergency. Findings include: During review of the agency's Emergency Preparedness program on 5/4/22, it was discovered that no reviews or updates for 2020 or 2021 were documented. During an interview on 5/4/22, the administrator (Adm#1) stated, "We did not have any patients for 2020 or 2021. We were closed."

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), §485.625(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, it was determined the agency failed to develop an Emergency Preparedness program using a facility-based and community-based risk assessment, and utilizing an all hazards approach, resulting in the potential to negatively affect all patients and employees seen by the agency. Findings include: During review of the agency's Emergency Preparedness program on 5/4/22, it was discovered that the agency failed to utilize an all hazards approach when developing their facility based and community based risk assessment. During an interview on 5/4/22, the administrator (Adm#1) stated, "I was not aware that I was supposed to do that."

Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency. This STANDARD is not met as evidenced by: Based on record review and interview, the Home Health Agency (HHA) failed to include a process for cooperation and collaboration with local, regional, State and Federal emergency preparedness officials to maintain an integrated response during a disaster or emergency; and failed to document their efforts in contacting these officials to engage in planning for an integrated emergency response, resulting in ineffective Emergency Preparedness planning. Findings include: During review of the agency's Emergency Preparedness program on 5/4/22, it was discovered that that no efforts for cooperation and collaboration with local, regional, State and Federal emergency preparedness officials were documented. During an interview on 5/4/22, the administrator (Adm#1) stated, "I did not know I had to do that."

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), §485.625(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 develop Emergency Preparedness policies and procedures that aligned with the emergency plan, risk assessment and communication plan. The policies and procedures must be reviewed and updated at least annually. This deficient practice could affect the health and safety of all agency patients in the event of natural, man-made, or facility-based emergency. Findings include: During review of the agency's Emergency Preparedness program on 5/4/22, it was discovered that the agency's program failed to develop Emergency Preparedness policies and procedures that aligned with the emergency plan, risk assessment and communication plan as indicated in the State Operations Manual (SOM) under Appendix-Z. During an interview on 5/4/22, the administrator (Adm#1) stated, "I was not aware that I was supposed to do that."

Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (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]. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to develop and maintain an Emergency Preparedness communication plan and ensure the communication plan was reviewed and updated at least annually. This deficient practice could affect the health and safety of all agency patients in the event of a natural, man-made, or facility-based emergency. Findings include: During review of the agency's Emergency Preparedness program on 5/4/22, it was discovered that no communication plan had been developed. During an interview on 5/4/22, the administrator (Adm#1) stated, "I did not know about this requirement."

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), §485.625(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, 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 the communication plan. The training and testing program must be reviewed and updated at least annually. This deficient practice could affect the health and safety of all agency patients in the event of a natural, man-made, or facility-based emergency. Findings include: During review of the agency's Emergency Preparedness program on 5/4/22, it was discovered that no training or testing of the agency's program for 2020 or 2021 were documented. During an interview on 5/4/22, the administrator (Adm#1) stated, "We did not have any patients for 2020 or 2021. We were closed."

The Michigan Department of Licensing and Regulatory Affairs attempted to conduct a Medicare recertification survey on 3/14./22 at: Supreme Home Care & Rehab 29930 W. 12 Mile Road, Suite 3 Farmington Hills, MI 48334 Upon arrival at the agency on 3/14/22 at 9:15 a.m., there was no indication of an operational home health agency. There was no answer to knocking at the door. It was observed through the glass suite door that the office space was filled with a multitude of stacked boxes. No furniture or office equipment was observed. At 9:18 a.m. a phone call was placed to the phone number on record 248-254-3469, a voicemail message informs the caller that they have reached 248-624-0387 (?) and to leave a message. A message for a return phone call was completed. At 9:55 a.m. an interview was conducted with the building manager/physician (DR-A) at Farmington Medical Clinic, located in the same building in the suite above Supreme Home Care & Rehab. DR-A phoned the administrator (Admin-B) of Supreme Home Care & Rehab and asked Admin-B to call the surveyor. During a telephone interview at 9:57 a.m., Admin-B explained that Supreme Home Care & Rehab has had no staff or patients since March 2020 due to Covid-19 and that Admin-B was in the process of re-opening the business. Admin-B stated he was in the process of getting permission from NGS (National Government Services) to restart the home health agency. There was no indication the agency had been operational for the past 2 years. A recertification survey could not be conducted. ------------------------------- The Michigan Department of Licensing and Regulatory Affairs conducted a Medicare recertification survey from 5/2/22 to 5/4/22 at: Supreme Home Care & Rehab 29930 W. 12 Mile Road, Suite 3 Farmington Hills, MI 48334 The agency operated no branches or subunits. The agency had no records available for review and no home visits. At the conclusion of the survey the agency was found to be out of compliance at the condition level for the conditions of participation at: 42 CFR §484.65-Quality Assessment/Performance Improvement. 42 CFR §484.70-Infection Prevention and Control. 42 CFR §484.105-Organization and Administration of Services. 42 CFR §484.22-Emergency Preparedness. As a result of the Condition level noncompliance, the Agency is prohibited for 2 years (from the date of the initial survey conducted on 5/2/22) from offering a Home Health Aide training and competency evaluation or a competency evaluation program as specified in 42 CFR §484.80(f)(3).

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 record review and interview, the agency failed to develop a Quality Assessment Performance Improvement (QAPI) program to optimize patient outcomes and to have at least one performance improvement project this year. These practices could affect all of the agency's patients. The cumulative effect of these systemic problems resulted in the agency's inability to improve patient care, health outcomes, patient safety, and the agency's overall care performance resulting in the agency not providing quality health care. Findings include: 1. The agency (HHA) failed to develop a QAPI program that was at least capable of showing measurable improvements in indicators to enhance patient outcomes, safety, and quality of care in 2020 and 2021. (See G-642). 2. The agency failed to collect and monitor data for the QAPI program for 2020 and 2021. (See G-644). 3. The agency failed to initiate any performance improvement activities within their QAPI program for 2020 and 2021. (See G-646). 4. The agency failed to initiate any performance improvement activities within their QAPI program that focused on high risk, high volume or problem prone areas for 2020 and 2021. (See G-648). 5. The agency failed to initiate any performance improvement activities within their QAPI program that considered incidence, prevalence, and severity of problems in identified areas of focus. (See G-650). 6. The Governing Body failed to ensure the agency had an active and functioning QAPI program that fulfilled all the regulatory requirements of this section. (See G-660).

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 that the Agency (HHA) failed to develop a Quality Assessment Performance Improvement (QAPI) program that is at least capable of showing measurable improvements in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. The Agency's program also failed to 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 resulting in the potential for the rendering of substandard care and unmet care needs for all patients served by the agency. Findings include: During review of the agency's QAPI program on 5/3/22, it was discovered that no information for 2020 or 2021 was documented. During an interview on 5/4/22, the administrator (Adm#1) stated, "We did not have any patients for 2020 or 2021. We were closed."

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to collect and monitor data for the Quality Assessment and Performance Improvement (QAPI) program, to ensure the effectiveness and safety of services and quality of care to the patients, and to identify opportunities for improvement, and there was no documented evidence the governing body approved the QAPI frequency and data collection process. Findings include: On 5/4/22, during review of the agency's QAPI program and meeting minutes for 2020 and 2021, it was discovered that no data had been documented, and no meetings had occurred. During an interview on 5/4/22 at 1:30 p.m., the administrator (Adm#1) acknowledged the above findings and replied, "We did not have any patients for 2020 or 2021. We were closed."

Program activities CFR(s): 484.65(c) Standard: Program activities. The HHA's performance improvement activities must-- This STANDARD is not met as evidenced by: Based on interview, document review and policy review, it was determined the Agency (HHA) failed to initiate any performance improvement activities within their Quality Assessment Performance Improvement (QAPI) program, resulting in the potential for the rendering of substandard care and unmet care needs. Findings include: . During review of the agency's QAPI program on 5/3/22, it was noted that the program failed to develop and initiate any performance improvement activities as part of their QAPI program. During an interview on 5/4/22 at 1:30 p.m., the administrator (Adm#1) acknowledged the above findings and replied, "We did not have any patients for 2020 or 2021. We were closed."

High risk, high volume, or problem-prone area CFR(s): 484.65(c)(1)(i) (i) Focus on high risk, high volume, or problem-prone areas; This ELEMENT is not met as evidenced by: Based on interview and record review, it was determined the Agency (HHA) failed to initiate any performance improvement activities within their Quality Assessment Performance Improvement (QAPI) program that focused on high risk, high volume or problem prone areas, resulting in the potential for agency issues to go unresolved in high risk, high volume or problem prone areas that could affect all patients served by the agency. Findings include: During review of the agency's QAPI program on 5/3/22, it was noted that the program failed to develop and initiate any performance improvement activities as part of their QAPI program that focused on high risk, high volume or problem prone areas. During an interview on 5/4/22 at 1:30 p.m., the administrator (Adm#1) acknowledged the above findings and replied, "We did not have any patients for 2020 or 2021. We were closed."

Incidence, prevalence, severity of problems CFR(s): 484.65(c)(1)(ii) (ii) Consider incidence, prevalence, and severity of problems in those areas; and This ELEMENT is not met as evidenced by: Based on interview and record review, it was determined the Agency (HHA) failed to initiate any performance improvement activities within their Quality Assessment Performance Improvement (QAPI) program that considered incidence, prevalence, and severity of problems in identified areas of focus, resulting in the potential for the rendering of substandard care and unmet care needs. Findings include: During review of the agency's QAPI program on 5/3/22, it was noted that the program failed to develop and initiate any performance improvement activities as part of their QAPI program. Due to the agency having no active performance improvement activities, the agency was unable to consider incidence, prevalence, and severity of problems in identified areas of focus. During an interview on 5/4/22 at 1:30 p.m., the administrator (Adm#1) acknowledged the above findings and replied, "We did not have any patients for 2020 or 2021. We were closed."

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 on record review and interview, it was determined the Governing Body failed to ensure the agency had an active and functioning Quality Assessment and Performance Improvement (QAPI) program that fulfilled all the regulatory requirements of this section, that addressed priorities for improved quality of care and patient safety and was evaluated for effectiveness, resulting in the potential to adversely effect the quality of care to all patients receiving services. Findings include: During review of the agency's QAPI program on 5/3/22, it was noted that the program failed to document any information to address priorities for improved quality of care and patient safety, and was evaluated for effectiveness. During an interview on 5/4/22 at 1:30 p.m., the administrator (Adm#1) acknowledged the above findings and replied, "We did not have any patients for 2020 or 2021. We were closed."

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, the agency failed to maintain and document infection control tracking for employees, failed to gather infection control data, failed to analyze infections and track infection trends (G-684); and failed to provide infection control education (G-686). The cumulative effect of these systemic problems resulted in the agency's inability to improve patient care, health outcomes, patient safety, and the agency's overall care performance. 1: No employee infection data, infection control data, infection analysis, or infection trend tracking was documented for 2020 or 2021, see (G-684). 2: No infection control education was documented for 2020 or 2021, see (G-686).

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 document review, and interview, it was determined that the Agency (HHA) failed to coordinate an agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases as a part of the HHA's Quality Assessment Performance Improvement (QAPI) program, resulting in the potential for increased, untreated infections among the Agency's patient and staff population. Findings include: During review of the agency's Infection Control program on 5/3/2022, it was noted that the Agency failed to coordinate or document an Agency-wide Infection control program that identifies infectious and communicable disease problems and incorporates a plan for the appropriate actions that are expected to result in improvement and disease prevention, within the Agency's QAPI program for 2020 and 2021. During an interview on 5/4/22 at 1:30 p.m., the administrator (Adm#1) acknowledged the above findings and replied, "We did not have any patients for 2020 or 2021. We were closed."

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on record review and interview, it was determined the Agency (HHA) failed to provide documented evidence that infection control education was provided to all staff employed by the agency, and who were granted clinical privileges in 2020 and 2021, resulting in the potential for the development and spread of infections. Findings include: During review of the agency's infection control program on 5/3/22, it was discovered that no documented education was provided for staff, patients, or caregivers for 2020 and 2021. During an interview on 5/4/22 at 1:30 p.m., the administrator (Adm#1) acknowledged the above findings and replied, "We did not have any patients for 2020 or 2021. We were closed."

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure a governing body assumed responsibility for the operation of the agency, the provision of all home health services and its quality assessment and performance improvement program, resulting in a lack of overall leadership in the agency's provision of home health services. Upon review of the Governing Body folder on 5/3/22, it was discovered that no meetings were documented for 2020 or 2021. (See G-942).

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on document review and interview, it was determined the home health agency failed to have an active Governing Body that met at least annually, and assumed full legal authority and responsibility for the agency's overall management and operations, all services provided, the fiscal operations, review of the agency's budget and operations plans and it's quality assessment and performance improvement program, since 2019, resulting in the potential to adversely affect the quality of care to all patients receiving services. Findings include: Upon review of the Governing Body folder on 5/3/22, it was discovered that no meetings were documented for 2020 or 2021. During an interview on 5/4/22 at 1:30 p.m., the administrator (Adm#1) acknowledged the above findings and replied, "We did not have any patients for 2020 or 2021. We were closed."