Health Choice Home Care Service, LLC

“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 ensure policies and procedures were developed based on the agency- and community-based risk assessment and communication plan, resulting in the potential for an unprepared staff response in the event of an actual emergency. Findings include: The agency’s Emergency Preparedness (EP) binder was reviewed on 8/8/24. During review of the documentation, it was noted the binder included generic policies on how patients should handle various emergencies in their homes, however, there were no policies detailing agency-specific procedures for staff to follow regarding agency operations during an emergency. Findings were reviewed with and acknowledged by the Administrator (Staff A) during an interview on 8/12/24 at 12:00 PM.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure the plan of care included appropriate interventions with objectively measurable goals specific to the individualized needs of the patient in 5 (P-1, P-2, P-3, P-4, P-6) of 7 records reviewed, resulting in the potential for poor patient outcomes and unmet care needs for these patients. Findings include: P-1: This 84-year-old patient was admitted to home care on 10/3/23 with diagnoses of congestive heart failure, hypertension, and type 2 diabetes. During record review on 8/6/24, it was noted that the plan of care failed to include measurable nursing goals that were individualized to address patient needs. For example, one goal stated, “patient’s cardiovascular and pulmonary condition will be stabilized by four weeks.” Another goal stated, “patient will verbalize understanding of disease process of hypertension and other health conditions that arise, requiring attention and instruction including all aspects of associated care by four weeks.” There was no evidence of how these goals could be objectively measured to determine progress toward meeting the goals. P-2: This 63-year-old patient was admitted to home care on 4/11/24 with diagnoses of type 2 diabetes, hypertension, and cerebrovascular disease. During record review on 8/7/24, it was noted that the plan of care failed to include measurable nursing goals that were individualized to address patient needs. For example, one goal stated, “patient/caregiver will state understanding of DM (diabetes) disease process and management by three weeks.” Another goal stated, “patient/caregiver will state understanding of HTN (hypertension) disease process and management by three weeks.” There was no evidence of how these goals could be objectively measured to determine progress toward meeting the goals. P-3: This 77-year-old patient was admitted to home care on 8/6/24 with diagnoses of seizures, hypertension, and stroke. During record review on 8/7/24, it was noted that the plan of care failed to include measurable nursing goals that were individualized to address patient needs. For example, one goal stated, “patient/caregiver will state understanding of HTN (hypertension) disease process and management by 3 weeks.” Another goal stated, “patient’s home environment will be clean and safe as evidenced by 3 weeks.” [sic] There was no evidence of how these goals could be objectively measured to determine progress toward meeting the goals. P-4: This 79-year-old patient was admitted to home care on 6/19/24 with diagnoses of multiple lacerations with wound care and type 2 diabetes. During record review on 8/8/24, it was noted that the plan of care failed to include measurable nursing goals that were individualized to address patient needs. For example, one goal stated, “patient will state understanding of multiple lacerations on right upper arm, right lateral chest, right buttocks, left thumb, left hand fourth digit disease process and management by nine weeks.” Another goal stated, “patient will state understanding of DM (diabetes mellitus) disease process and management by nine weeks.” There was no evidence of how these goals could be objectively measured to determine progress toward meeting the goals. These findings were reviewed and acknowledged by the administrator (Staff A) and the Quality Assurance nurse (Staff B) during an interview on 8/12/24 at 11:00 a.m. **Policy titled “Care Planning Process” (revised 2/2021) stated, “3. Based on the assessment and conclusions, the plan of care will include, but will not be limited to:....C. Reasonable, measurable, and individualized goals and outcomes identified by the organization and the patient....” P-6: This 72-year-old patient was admitted to this agency on 7/30/24 with the diagnoses of hypertension (high blood pressure), muscle weakness, and knee instability. During record review on 8/8/24, the following examples of skilled nursing goals were noted on the plan of care dated 7/30/24: “Patient’s pain will be controlled and managed at the patient’s own comfort level by two weeks.” “Patient/caregiver will verbalize understanding of disease process of HTN (hypertension) and other health conditions that arise, requiring attention and instructions including all aspects of associated care by patient/caregiver.” [sic] “The Patient/caregiver will demonstrate behavioral modifications of lifestyle and appropriate use of therapeutic interventions by two weeks.” These goals are vague, not measurable, and not patient-specific. Additionally, it was noted the physical therapy evaluation dated 8/1/24 had a goal that stated: “Patient will have an increase in Tinetti Balance score to 21/28 within 6 weeks.” Upon further review of the record, it was determined there was no Tinetti Balance test score recorded at the evaluation to determine an appropriate, patient-specific goal. Another goal stated: “Improve balance score to _________________ using ________________ test.” The spaces were left blank, so it was unclear what the goal was referring to. The Administrator (Staff A) and Quality Assurance nurse (Staff B) were queried regarding these findings during an interview on 8/12/24 at 12:00 PM. Staff A stated the physical therapist usually attached document with the initial Tinetti score, however, she was not able to find one for this patient and acknowledged the findings. Staff A also acknowledged the finding of the other goal being incomplete.”

“State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This Element is not met as evidenced by: Based on record review and interview, the agency failed to inform all patients that they could voice concerns/complaints at any time by calling the State of Michigan’s toll-free hotline number, resulting in misleading information to enable patients or caregivers to voice complaints or ask questions. This deficient practice has the potential to negatively affect the health and well-being of all 205 patients admitted to the agency in the past 12 months. Findings include: On 8/6/24, the agency’s start of care booklet was reviewed. On pages 13 and 14 of the booklets, the complaint procedure is explained to patients as the following: “the patient, family, or caregiver may report problems to the staff assigned to the case…if not resolved… contact the clinical manager…if not resolved…contact the administrator…if the grievance has not been resolved after working with the agency personnel, he/she will be informed of his/her right to notify the State of Michigan complaint hotline.” The patient with a concern or complaint is instructed to go through many steps with the agency before contacting the state’s toll-free hotline. A patient with a complaint is not required to go through steps with the agency. The patient is free at any time to contact the state’s toll-free hotline number to voice concerns or complaints. On page 14 of the booklet, the patient is instructed to also contact the CHAP (Community Health Accreditation Partner) hotline phone number. The agency’s deemed status with CHAP was withdrawn on 6/9/24 and CHAP no longer has oversight regarding patient complaints. These findings were reviewed and acknowledged by the administrator (Staff A) and the Quality Assurance nurse (Staff B) during an interview on 8/12/24 at 11:00 a.m.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the initial assessment visit was completed within 48 hours of the referral in 1 (P-1) of 7 records reviewed resulting in the potential for unmet care needs. Findings include: P-1: This 84-year-old patient was admitted to home care on 10/3/23 with diagnoses of congestive heart failure, hypertension, and type 2 diabetes. During record review on 8/6/24, it was noted that the physician order for home care was dated 9/25/23. The start of care assessment was conducted 8 days after the date of referral. There was no evidence the physician had been notified for the reason for the delay. This finding was reviewed and acknowledged by the administrator (Staff A) and the Quality Assurance nurse (Staff B) during an interview on 8/12/24 at 11:00 a.m.”

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment was completed within 5 calendar days after the start of care in 2 (P-4, P-5) of 7 records reviewed, resulting in the potential for unmet care needs and poor patient outcomes. Findings include: P-4: This 79-year-old patient was admitted to home care on 6/19/24 with diagnoses of multiple lacerations with wound care and type 2 diabetes. During record review on 8/8/24, it was noted that the referral for home care, dated 6/28/24, ordered skilled nursing, physical therapy (PT), and occupational therapy (OT). PT evaluated the patient on 6/21/24. OT evaluated the patient on 7/22/24, 34 days after the start of care. There was no evidence the physician was notified. During an interview on 8/12/24 at 11:00 a.m., this finding was reviewed with the administrator (Staff A) who stated the patient had initially refused OT but failed to chart the refusal or notify the physician. **Policy titled “Initial and Comprehensive Assessment” (revised 2/2021) stated, “A comprehensive patient assessment will be completed within 5 calendar days of the patient’s start of care.” P-5: This 92-year-old patient was admitted to this agency on 7/21/24 with the diagnoses of spondylosis without radiculopathy (back pain), gait abnormalities, congestive heart failure, and type 2 diabetes. During record review on 8/8/24, it was noted the referral (dated 7/11/24) ordered physical therapy and occupational therapy. Upon further review of the record, it was determined no occupational therapy evaluation was completed as of 8/8/24 – 18 days after the start of care. The Administrator (Staff A) and Quality Assurance nurse (Staff B) were queried regarding this finding during an interview on 8/12/24 at 12:00 PM. Staff A and Staff B thought the patient had refused occupational therapy services or had difficulty scheduling due to family conflicts, however, they were unable to provide documented evidence of this or communication with the physician regarding the change in orders. Staff A and Staff B acknowledged the findings.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment accurately reflected the patient’s current health status at the time of admission to for 4 (P-1, P-4, P-5, P-6) of 7 records reviewed, resulting in incomplete clinical information to aide in determining the needs of these patients to assist in developing the plan of care. Findings include: Policy-Pain Assessment (dated 2/21). When the patient or the clinician identifies pain, the following in depth pain assessment information should be obtained…pain intensity, pain location, pain quality, pain onset, effects of pain. P-1: This 84-year-old patient was admitted to home care on 10/3/23 with diagnoses of congestive heart failure, hypertension, and type 2 diabetes. During record review on 8/6/24, it was noted that the comprehensive assessment, dated 10/3/23, conducted by the registered nurse, failed to accurately reflect the patient’s health status. The following was noted: a blank musculoskeletal assessment; allergies listed as “no known allergies” while the medication profile indicates an allergy to sulfa; no assessment of genitourinary status; pain rated as a “7” on a scale of 0-10 with no pain assessment (location, onset, frequency, etc.); no initial vital sign assessment; no initial height/weight assessment; a blank cardiopulmonary assessment with an admitting diagnoses of heart failure and hypertension; a blank endocrine/hematology assessment with a history of type 2 diabetes; and a blank integumentary status assessment. P-4: This 79-year-old patient was admitted to home care on 6/19/24 with diagnoses of multiple lacerations with wound care and type 2 diabetes. During record review on 8/8/24, it was noted that the comprehensive assessment, dated 6/19/24, conducted by the registered nurse, failed to assess the patient’s pain. The pain was rated as a “7” on a scale of 0-10 but failed to include a pain assessment (location, onset, pain description, etc.). The agency failed to follow their policy on pain assessment. These findings were reviewed and acknowledged by the administrator (Staff A) and the Quality Assurance nurse (Staff B) during an interview on 8/12/24 at 11:00 a.m. P-5: This 92-year-old patient was admitted to this agency on 7/21/24 with the diagnoses of spondylosis without radiculopathy (back pain), gait abnormalities, congestive heart failure and type 2 diabetes. During record review on 8/8/24, it was noted the Outcome and Assessment Information Set (OASIS) dated 7/21/24 reported under “Section I – Active Diagnoses” the patient had “Type 2 diabetes with diabetic peripheral angiopathy w/o gangrene” [sic]. Also, under “Endocrine/Hematology” on the OASIS, the box next to diabetes was checked. Furthermore, under “DME Supplies” at the end of the OASIS report, it was noted the patient was diabetic and had chemstrips and a glucometer to test her blood sugar. During a home visit with the patient on 8/7/24 at 2:00 PM, the patient was asked about her diabetes. The patient and the patient’s daughter stated the patient is not diabetic and does not have a glucometer to measure her blood sugar. The Administrator (Staff A) and Quality Assurance nurse (Staff B) were queried regarding this finding during an interview on 8/12/24 at 2:00 PM. Staff A provided documentation from the patient’s history and physical from the physician that the patient was diabetic, however, Staff A acknowledged staff should have reviewed the past medical history with the patient at the start of care. Staff A and Staff B acknowledged the findings. Additionally in the record for P-5, the OASIS stated under “M2001. Drug Regiment Review” that “No issues were found during review.” The drug interaction report on the agency’s electronic medical record (EMR) system also confirmed no drug interactions. However, under “Summary Checklist” at the bottom of the Start of Care report, the boxes for “Significant drug interactions” and “Significant side effects” were checked. Also, on the “Medication Profile” in the paper record, “Yes” was checked next to the statement “The patient reports experiencing 1 or more significant side effects to current drug regimen.” No further details were included regarding this. The information is conflicting; therefore, it does not give an accurate representation of the patient’s status. P-6: This 72-year-old patient was admitted to this agency on 7/30/24 with the diagnoses of hypertension (high blood pressure), muscle weakness, and knee instability. During record review on 8/8/24, it was noted the OASIS under “M2001. Drug Regimen Review” that “No issues were found during drug review.” The drug interaction report on the agency’s electronic medical record (EMR) system confirmed no drug interactions. However, on the “Medication Profile” in the paper record, “Yes” was checked next to the statement “The patient reports experiencing 1 or more significant side effects to current drug regimen.” No further details were included regarding this. The information is conflicting; therefore, it does not give an accurate representation of the patient’s status. These findings were reviewed with and acknowledged by Staff A and Staff B during an interview on 8/12/24 at 12:00 PM. Staff A and Staff B were unable to provide an explanation for the discrepancies.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment included a review of all medications to determine any potential adverse effects and drug reactions and failed to include a review of patient allergies in 3 (P-1, P-4, P-7) of 7 records reviewed, resulting in the potential for harmful medication effects for all patients serviced by this agency. Findings include: P-1: This 84-year-old patient was admitted to home care on 10/3/23 with diagnoses of congestive heart failure, hypertension, and type 2 diabetes. During record review on 8/6/24, it was noted that the comprehensive assessment, dated 10/3/23, conducted by the registered nurse, indicated a drug regimen review was complete and “no issues were found during review” and that the patient had “no known drug allergies.” The medication profile completed on admission indicated the patient has an allergy to sulfa and that “the patient reports experiencing 1 or more significant effects to current drug regimen” but fails to describe the problem/symptoms and action taken. P-4: This 79-year-old patient was admitted to home care on 6/19/24 with diagnoses of multiple lacerations with wound care and type 2 diabetes. During record review on 8/8/24, it was noted that the comprehensive assessment, dated 6/19/24, conducted by the registered nurse, indicated a drug regimen review was complete and “no issues were found during review.” The medication profile completed on admission indicated “the patient reports experiencing 1 or more significant effects to current drug regimen” but fails to describe the problem/symptoms and action taken. These findings were reviewed and acknowledged by the administrator (Staff A) and the Quality Assurance nurse (Staff B) during an interview on 8/12/24 at 11:00 a.m. **Policy titled “Medication Monitoring/Orders/Teaching/Documentation” (revised 2/2021) stated, “1. Agency staff shall check all medications the patient is taking to identify and promptly report to the physician any significant side effects or contraindications including the following: A. Known allergy or previous adverse reaction to a medication, B. Medication incompatibility for potential interaction….” P-7: This 53-year-old patient was admitted to this agency on 6/21/24 with the diagnoses of type 2 diabetes with hyperglycemia (high blood sugar) and hypertension (high blood pressure). During record review on 8/8/24, it was noted the Outcome Assessment Information Set (OASIS) stated under “M2001. Drug Regiment Review” that “No issues were found during review.” Upon further review of the record, it was noted the drug interaction report run on the agency’s electronic medical record (EMR) system noted that there were 13 moderate drug interactions. There was no indication the physician was contacted per agency policy regarding the interactions. The Administrator (Staff A) and Quality Assurance (Staff B) were queried regarding this finding during an interview on 8/12/24 at 12:00 PM. Staff A and Staff B were unable to provide documentation to show the physician was contacted per their policy. Staff A and Staff B acknowledged the findings.”

“Within 48 hours of the patient’s return CFR(s): 484.55(d)(2) Within 48 hours of the patient’s return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment was updated after hospital admission for 1 (P-1) of 1records reviewed in which the patient was transferred, resulting in the potential for unmet care needs and an inaccurate reflection of the patient’s health status. Findings include: P-1: This 84-year-old patient was admitted to home care on 10/3/23 with diagnoses of congestive heart failure, hypertension, and type 2 diabetes. During record review on 8/6/24, it was noted the patient was hospitalized from 10/18/23 to 10/23/24 and the registered nurse completed a resumption of care assessment (ROC) on 10/24/24. It was noted that the ROC assessment failed to include vital sign assessment, systems review (height and weight), pain assessment, neuro/emotional/behavior status assessment, musculoskeletal assessment, and endocrine assessment while the patient was ordered new medications for diabetes. These findings were reviewed and acknowledged by the administrator (Staff A) and the Quality Assurance nurse (Staff B) during an interview on 8/12/24 at 11:00 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 record review and interview, the agency failed to ensure the skilled professionals provided services as ordered by the physician in the plan of care for 3 (P-1, P-2, P-5) of 7records reviewed, resulting in the potential for unmet care needs. Findings include: **Policy titled “Staff Guidelines/Missed Visits” (revised 2/2021) stated, “4. Home visit staff documents reason for missed visits and informs prescribing physician and agency.” P-5: This 92-year-old patient was admitted to this agency on 7/21/24 with the diagnoses of spondylosis without radiculopathy (back pain), gait abnormalities, congestive heart failure and type 2 diabetes. During record review on 8/8/24, it was noted the patient missed a physical therapy visit on 8/2/24. According to the record, the reason for the missed visit was “daughter called today to cancel visit as patient is not feeling well.” However, there was no indication the missed visit was communicated with the physician according to agency policy. The Administrator (Staff A) and Quality Assurance nurse (Staff B) were interviewed regarding this finding on 8/12/24 at 12:00 PM. Staff A was unable to provide evidence of the missed visit being communicated with the physician and acknowledged the findings. P-1: This 84-year-old patient was admitted to home care on 10/3/23 with diagnoses of congestive heart failure, hypertension, and type 2 diabetes. During record review on 8/6/24, it was noted that the plan of care ordered physical therapy (PT) twice a week for three weeks, then once a week for one week. The PT documented three missed visit notes on 10/5/23, 10/12/23, and 11/17/23. The patient was hospitalized from 10/18/23 to 10/23/23 with a resumption of care assessment on 10/24/23. There was no evidence of PT visits during week 4. There was no evidence the physician was notified of the missed visits or if alternate visit dates were offered. P-2: This 63-year-old patient was admitted to home care on 4/11/24 with diagnoses of type 2 diabetes, hypertension, and cerebrovascular disease. During record review on 8/7/24, it was noted that the plan of care ordered physical therapy (PT) twice a week for three weeks, then once a week for one week. The PT documented a missed visit on 4/25/24. There was no evidence the physician was notified of the missed visits or if alternate visit dates were offered. These findings were reviewed and acknowledged by the administrator (Staff A) and the Quality Assurance nurse (Staff B) during an interview on 8/12/24 at 11:00 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 complete and included detailed skilled nursing and physical therapy notes for 5 (P-1, P-2, P-4, P-5, P-7) of 7 records reviewed, resulting in lack of continuity of care and undocumented health concerns. Findings include: Policy: Ongoing Assessments (dated 2/21). Using the standards of care identified by the organization, the clinician will reassess the patient for: blood pressure, pulse, respirations, temperature, weight (once each week if indicated by disease process), pain status… P-1: This 84-year-old patient was admitted to home care on 10/3/23 with diagnoses of congestive heart failure, hypertension, and type 2 diabetes. During record review on 8/6/24, it was noted that the plan of care ordered skilled nursing once a week for 4 weeks and physical therapy (PT) twice a week for three weeks then once a week for one week. The PT notes from 10/10/23, 11/2/23, 11/9/23, and 11/14/23 failed to include vital sign assessments. The PT notes from 10/10/23, 11/2/23, and 11/9/23 failed to include a pain assessment. The skilled nursing notes from 10/10/23, 11/2/23, 11/7/23, 11/15/23, and 11/20/23 failed to include a weight or a detailed measurement of edema (+1, +2, or ankle circumference measurement) to monitor potential worsening of congestive heart failure. During the entrance interview with the administrator (Staff A) on 8/6/24 at 9:45 a.m., Staff A stated that patients with congestive heart failure are monitored with a weight with every nursing visit and clinicians use “+1 or +2” to document evidence of edema. P-2: This 63-year-old patient was admitted to home care on 4/11/24 with diagnoses of type 2 diabetes, hypertension, and cerebrovascular disease. During record review on 8/7/24, it was noted that the plan of care ordered physical therapy (PT) twice a week for three weeks then once a week for one week. The PT notes from 4/18/24, 4/23/24, 4/30/24, 5/2/24, and 5/7/24 failed to include a pain assessment. P-4: This 79-year-old patient was admitted to home care on 6/19/24 with diagnoses of multiple lacerations with wound care and type 2 diabetes. During record review on 8/8/24, it was noted that the plan of care ordered physical therapy (PT) once a week for one week, twice a week for 5 weeks, then once a week for one week. The PT notes from 6/26/24, 6/28/24, 7/3/24, 7/6/24, 7/10/24, 7/13/24, 7/17/24, 7/24/24, and 7/26/24 failed to include vital sign assessments. These findings were reviewed and acknowledged by the administrator (Staff A) and the Quality Assurance nurse (Staff B) during an interview on 8/12/24 at 11:00 a.m. P-5: This 92-year-old patient was admitted to this agency on 7/21/24 with the diagnoses of spondylosis without radiculopathy (back pain), gait abnormalities, congestive heart failure and type 2 diabetes. During record review on 8/8/24, it was noted there were no vital signs recorded on the physical therapy daily notes dated 7/24/24, 7/26/24, and 7/31/24. During a home visit with the patient and physical therapist on 8/7/24 at 2:00 PM, it was observed the physical therapist took vital signs, including blood pressure, pain rating, heart rate, and pulse oximetry, however, none of these values were recorded on daily notes. P-7: This 53-year-old patient was admitted to this agency on 6/21/24 with the diagnoses of type 2 diabetes with hyperglycemia (high blood sugar) and hypertension (high blood pressure). During record review on 8/8/24, it was noted blood pressure was not recorded on the physical therapy daily notes dated 6/28/24, 7/3/24, 7/5/24, 7/10/24, 7/12/24, 7/17/24, 7/19/24, 7/23/24, 7/26/24, 7/31/24, 8/2/24 and 8/5/24. Additionally, it was noted on the physical therapy evaluation dated 6/28/24 the patient had a pain level of 6 out of 10 in her low back. Upon further review of the record, it was noted pain levels were not documented on the physical therapy notes dated 7/3/24, 7/10/24, 7/12/24, 7/17/24, 7/23/24, and 7/31/24. The Administrator (Staff A) and Quality Assurance nurse (Staff B) were queried regarding these findings during an interview on 8/12/24 at 12:00 PM. Staff A stated there is not a spot on the therapy notes to document vital signs or pain. Staff B reported some therapists record vitals in the objective section of the note, however, Staff A and Staff B acknowledged this was not the case in the examples above and acknowledged the findings.”

“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 skilled nursing communicated assessment findings with the physician for 1 (P-3) of 7 records reviewed, resulting in the potential for poor patient outcomes. Findings include: P-3: This 77-year-old patient was admitted to home care on 8/6/24 with diagnoses of seizures, hypertension, and stroke. During record review on 8/7/24, it was noted that the plan of care included parameters to notify the physician for a blood pressure greater than 160/90. The comprehensive assessment, dated 8/6/24, completed by the registered nurse, indicated the blood pressure was 140/100 and included a note, “patient with elevated blood pressure level and Carvedilol and Spironolactone was administered a few minutes ago.” There was no evidence the physician was notified or of a repeat blood pressure assessment. This finding was reviewed and acknowledged by the administrator (Staff A) and the Quality Assurance nurse (Staff B) during an interview on 8/12/24 at 11:00 a.m.”