Maple Home Health Care, LLC

“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 that all services furnished under arrangement by 2 of 2 (RN-C, PTA-D) individuals met the requirements of section 1861(w) of the Act (42 U.S.C. 1395x(w)) (see G976); failed to have written agreements with 2 of 2 (RN-C, PTA-D) contracted employees (see G978); and failed to ensure that at least one qualifying service was provided directly by agency employees (see G982). Findings include: The cumulative effect of these systemic problems results in the agency’s inability to ensure the provision of quality health care in a safe environment for the Condition of Participation at 42 CFR 484.105, Organization and Administrative Services.”

“Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This Condition is not met as evidenced by: Based on record review and interview, the agency failed to ensure the medical record contained all physical therapy visit notes for 1 of 7 (P-5) records reviewed (see G1012); and failed to ensure a discharge summary was sent to the physician within 5 business days of the patient’s discharge for 2 of 4 (P-5, P-7) records reviewed (see G1022). Findings include: The cumulative effect of these systemic problems resulted in the Home Health Agency’s inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR §484.110: Clinical Records.”

“EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure all staff including contracted staff received initial training and training at least every two years in the agency’s Emergency Preparedness Plan for 2 of 2 (RN-C and PTA-D) contracted staff, resulting in the agency’s inability to ensure staff actions align with the emergency plan. These deficient practices could have negatively affected the health and safety of the 50 patients admitted to the agency in the past 12 months. Findings include: The agency’s emergency preparedness documentation and personnel files were reviewed on 11/13/24. Review of the documents indicates that there was no evidence that 2 of the agency’s contracted field staff RN-C (registered nurse, date of hire 2/1/23) and PTA-D (physical therapy assistant, date of hire 4/1/24) had received initial training in the agency’s Emergency Preparedness Plan. There was no evidence that these same field staff, RN-C and PTA-D, had received emergency preparedness training in 2023 or 2024. The findings were reviewed with and acknowledged by CM-B (clinical manager) during an interview on 11/13/24 at 2:30 p.m. CM-B explained that there is no training or emergency preparedness drills for the contracted field staff.”

“Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This Standard is not met as evidenced by: Based on record review and interview, the agency failed to provide infection control education for 4 of 4 (Admin-A, CM-B, RN-C, and PTA-D) personnel files reviewed, resulting in a lack of education regarding current infection prevention and treatment practices in the home setting. Findings include: Personnel files were reviewed on 11/13/24. The agency utilizes agency staff and contracted staff. There was no documentation of infection control education in 2023 or 2024 for these employees. Admin-A (administrator, physical therapist, owner): Date of hire 12/2022. There was no documentation of infection control education in 2023 or 2024 for this physical therapist. CM-B (clinical manager. registered nurse): Date of hire 11/6/23. There was no documentation of infection control education in 2023 or 2024 for this registered nurse. RN-C (contracted registered nurse): Date of hire 2/1/23. There was no documentation of infection control education in 2023 or 2024 for this registered nurse. PTA-D (contracted physical therapy assistant): Date of hire 4/1/24. There was no documentation of infection control education at orientation or at any time in 2024 for this physical therapy assistant. During an interview on 11/13/24 at 1:45 p.m., CM-B was queried regarding infection control education. CM-B explained that infection control education was not done in 2023 or 2024. The agency failed to follow its own policy entitled, In-service Education/Staff Development (no date) which states, “In-service training or continuing education programs will be provided and documented for employees... All staff members must attend or provide proof of having participated in mandatory in-service programs. The mandatory in-service training programs include...Bloodborne Pathogens and Infection Control...””

“Services under arrangement CFR(s): 484.105(e)(1) The HHA must ensure that all services furnished under arrangement provided by other entities or individuals meet the requirements of this part and the requirements of section 1861(w) of the Act (42 U.S.C. 1395x (w)). This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure that all services furnished under arrangement by 2 of 2 (RN-C, PTA-D) individuals met the requirements of section 1861(w) of the Act (42 U.S.C. 1395x(w)), resulting in the potential to adversely affect the finances of all patients that receive contracted services. Findings include: Personnel files were reviewed on 11/13/24, and the following was noted: RN-C (registered nurse) is a 1099 employee (contractor, self-employed) that was hired by the agency on 2/1/23. There was no contract or written agreement for review. PTA-D (physical therapy assistant) is a 1099 employee that was hired by the agency on 4/1/24. There was no contract or written agreement for review. There was no evidence that the services furnished by RN-C and PTA-D met the requirements of section 1861(w) of the Act (42 U.S.C 1395x(w)). The agency failed to have a policy regarding contracted services. The findings were reviewed with and acknowledged by the clinical manager (CM-B) during an interview on 11/13/24 at 1:00 p.m.”

“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 agency contracting for each qualified patient care service. Findings include: During the entrance conference on 11/12/24 at 10:00 a.m., Admin-A (administrator/physical therapist/owner) explained that the agency provides skilled nursing and physical therapy services. The staff roster provided by Admin-A on 11/12/24 indicates the following: that 2 individuals are W-2 employees, and 2 individuals are independent contractors (1099) providing patient services. Admin-A is a W-2 employee (employed by Maple Home Health Care) CM-B (clinical manager/registered nurse) is a W-2 employee. RN-C (registered nurse) is a 1099 employee (self-employed/contractor). PTA-D (physical therapy assistant) is a 1099 employee. The agency provides nursing and physical therapy services which are provided by a mix of both W-2 and 1099 employees. There was no documented evidence the agency provides at least one qualifying service directly by agency employees. The findings were reviewed with and acknowledged by Admin-A during an interview on 11/14/24 at 12:30 p.m.”

“Make complaints to the HHA CFR(s): 484.50(c)(3) Make complaints to the HHA regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the HHA; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure patients or caregivers were furnished with accurate information to lodge a complaint to the agency, resulting in the potential to negatively affect the health and well-being of all patients admitted to the agency. Findings include: On 11/12/24, the agency’s start of care booklet titled, “Patient Home Healthcare Orientation Handbook” and 5 additional loose documents were reviewed. The 57-page booklet and documents failed to note accurate information to contact the agency to lodge a complaint. The section of the booklet with the heading “Complain Resolution” (pages 12 & 13 of the booklet) contained 3 different phone numbers to contact the agency. The following was noted: On page 12, “You may report problems, concerns and complaints... during normal business hours at 1-800-716-8258.” Page 13, “...you may register complaints about home care to the Community Health Accreditation Program (CHAP) at 1-800-656-9656.” This agency is not accredited by CHAP. Page 13, “You may call our office at (248)-728-4462 for complaints or grievances.” During an interview on 11/12/24 at 11:15 a.m., the findings were reviewed with the clinical manager (CM-B) and OM-E (office manager). OM-E reviewed the booklet and explained that these 3 phone numbers were no longer in use by this agency. They were old phone numbers from the previous owners of the agency. The agency was purchased by the current owner Admin-A (administrator/physical therapist) in December of 2022.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: (1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment accurately reflected the patient’s current health status for 3 of 7 (P-1, P-5, P-7) records reviewed, resulting in incomplete clinical information necessary to determine the needs of these patients and the potential for unmet care needs. Findings include: P-5: This 82-year-old patient was admitted to home care on 9/28/24 with diagnoses of aftercare for a left total knee arthroplasty and diabetes mellitus. During record review on 11/13/24, it was noted that the start of care assessment was conducted by Admin-A (administrator/physical therapist) on 9/28/24. Admin-A documents on page 2 of 25 of the assessment that the patient has diabetes mellitus without complications and has long term (current) use of oral hypoglycemic drugs. The endocrine assessment (page 16 of 25) indicates by a check mark “no problems identified”. The box to indicate the patient does have diabetes is unchecked. There is no further information detailing the patient’s diabetes/endocrine status such as: how long the patient has been a diabetic, does the patient monitor blood sugars, current blood sugar reading, typical range of readings, and is the patient able to manage diabetes medications. The area for the patient’s nutritional requirements (page 17 of 25) indicates the patient is on a regular diet and not a diet for those with diabetes. It was unable to be determined if the patient had any care needs related to diabetes. The findings were reviewed with and acknowledged by Admin-A and CM-B (clinical manager) during an interview on 11/14/24 at 12:30 p.m. P-7: This patient was admitted to home care on 12/20/23 with diagnoses of aftercare following surgery on the digestive system, gallstones, and stenosis (narrowing) of the larynx. During record review on 11/12/24, it was noted that the face-to-face physician’s orders (no date) documents that the patient is dependent on tube feedings, experiences blood sugar spikes when tube fed, glucose level elevated when tube fed, and check glucose. The start of care assessment was conducted by the registered nurse (RN) on 12/20/23. The endocrine assessment (page 16 of 21) fails to note a baseline blood sugar reading for this patient and instead documents blood sugar ranges. The nutrition assessment notes that the patient has a jejunostomy (J-tube) with 4 bolus feedings each day. There is no documentation that the RN noted the time of the patient’s next feeding and checked for residual. There is no documentation describing the J-tube site and dressing. On pages 2 & 3 of the assessment, the comments note that the skilled nurse is “to perform FS (fasting) blood sugar every visit using patient’s glucometer.... hold feeding if residual is grater (sic) than 30 to 100 ml (milliliter) and notify physician.” The RN failed to accurately reflect the patient’s current endocrine and nutritional health status. P-1: The Start of Care (SOC) was dated 1/31/24. The Plan of Care (POC) for the certification period 1/31/24 to 3/30/24 identified the principal diagnoses of Diabetes Type 2 (DM2), and other diagnoses of intervertebral disc degeneration of lumbar region, and pain in unspecified lower leg. The patient was receiving Skilled Nursing (SN) services 1xweekx1 and 2xweekx2; and Physical Therapy (PT) services to Evaluate and Treat. Upon review of the medications listed on the Plan of Care, it was noted the patient was prescribed Eliquis (an anticoagulant), Lubiprostone (used for constipation), and Norco (pain reliever). There were no medications prescribed to address the patient’s diabetes. The Plan of Care did include reportable parameters and orders for the SN to assess diabetic status, and to report changes to physician, however there were no diabetic measurements found in the visit notes of the SN or PT. Also, there were no goals found on the POC to address the patient’s diabetic status. These findings were reviewed with and acknowledged by Admin-A and CM-B (clinical manager) during an interview on 11/14/24 at 2:30 p.m.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the plan of care included all medications, measurable outcomes and goals for 5 of 7 (P-5, P-6, P-1, P-2, P-3) records reviewed, resulting in patients not receiving care specific to their individual needs and the potential for poor patient outcomes. Findings include: P-5: This 82-year-old patient was admitted to home care on 9/28/24 with diagnoses of aftercare for a left total knee arthroplasty and diabetes mellitus. During record review on 11/13/24, it was noted that the 9/28/24 plan of care failed to include all the patient’s medications. The 9/28/24 medication profile documented by Admin-A (administrator/physical therapist) indicates the patient is taking aspirin, Metformin, Oxycodone, and Farxiga. The plan of care failed to include the medication Farxiga. The plan of care also failed to include measurable goals related to the patient’s pain. The homebound narrative states the patient has severe pain in the left knee. The plan of care lists the patient’s personal goal to reduce pain to a more tolerable level. The goals listed by Admin-A include the following: patient will obtain optimal effectiveness of pain management regiment within 3 weeks and patient will demonstrate a favorable outcome using thermal-cold therapy in order to decrease pain in left knee within 3 weeks. These goals were not stated in measurable terms that would enable staff to perform an objective evaluation of the patient’s progress towards his goals. The findings were reviewed with and acknowledged by Admin-A and CM-B (clinical manager) during an interview on 11/14/24 at 12:30 p.m. P-6: This patient was admitted to home care on 10/28/24 with diagnoses of lumbar radiculopathy and low back pain. During record review on 11/13/24, it was noted that the 10/28/24 plan of care failed to include measurable goals related to the patient’s pain. The plan of care lists the patient’s personal goal to feel better and get around better. The goals listed by Admin-A include the following: patient will demonstrate a favorable outcome using thermal-cold therapy in order to reduce hip pain within 3 weeks and patient will attain optimal effectiveness of pain management regimen within 3 weeks. These goals were not stated in measurable terms that would enable staff to perform an objective evaluation of the patient’s progress towards her goals. P-1: The Start of Care (SOC) was dated 1-31-24. The Plan of Care (POC) for the certification period 1/31/24 to 3/30/34 identified the principal diagnoses of Diabetes Type 2 (DM2), and other diagnoses of intervertebral disc degeneration of lumbar region, and pain in unspecified lower leg. The patient was receiving Skilled Nursing (SN) services 1xweekx1 and 2xweekx2; Physical Therapy (PT) services to Evaluate and Treat. Upon review of the goals on the 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 demonstrate competence with self-management of shortness of breath as evidenced by adherence to medication regimen, ability to identify s/s necessitating contact with medical professionals, diet regimen guidelines, activity compliance and symptom management by 3 weeks”; “Patient/Caregiver demonstrate ability to effectively manage medication regimen”; “Patient able verbalize {sic} Emergency Preparedness and plan, infection control measures, handwashing, universal, diabetic & corona virus precautions, disposal sharps within 2 weeks” {sic}. These goals are not objectively measurable to determine the patient’s progress towards obtaining the goals. P-2: The SOC was dated 4/24/24. The POC for the certification period 4/24/24 to 6/22/2024 identified the principal diagnosis of Diabetes Type 2 (DM2); and other diagnoses of Pain in right leg; Polyosteoarthritis, Muscle Weakness, Other reduced mobility, and Log-term use of aspirin. The patient was receiving Physical Therapy (PT) services 2xweekx7weeks. Upon review of the goals on the POC, it was noted the goals were not objectively measurable to determine the patient’s progress towards obtaining the goals. Examples include: “Patient will demonstrate a favorable outcome using Thermal - Heat therapy in order to reduce pain in left ankle within 7 weeks; Patient will be from falls/injury during this episode of care {sic}. These goals are not objectively measurable to determine the patient’s progress towards achieving the goals. P-3: The SOC was dated 1/31/2024. The POC for the certification period 1/31/24 to 3/3/24 identified diagnoses of Diabetes type 2, and other diagnoses of intervertebral disc degeneration, lumbar region and pain in unspecified lower leg. The patient was receiving Skilled Nursing and Physical Therapy services. Upon review, the goals on the POC were not objectively measurable. Examples included: “Patient/Caregiver demonstrate ability to effectively manage medication regimen; Patient able to verbalize ER preparedness & plan, infection control measures, hand washing, universal, diabetic & corona virus precautions, disposal sharps within two weeks. These goals are not objectively measurable to determine the patients progress towards goals.”

“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 services were provided as ordered by the physician in 1 of 7 (P-6) records reviewed, resulting in the potential to negatively affect the health and well-being of this patient. Findings include: P-6: This patient was admitted to home care on 10/28/24 with diagnoses of lumbar radiculopathy and low back pain. The 10/28/24 plan of care orders physical therapy services 3 times per week for 2 weeks and then 2 visits each week for 4 weeks. During record review on 11/13/24, it was noted that there was no documented third physical therapy visit in the first week. Admin-A (administrator/physical therapist) documents visits on 10/28/24 and 10/29/24. There was no documentation of a third visit that week. There was no documented evidence the patient had declined the third visit and no documentation that the physician was informed that the physical therapist did not make a third visit as ordered by the physician. The findings were reviewed with and acknowledged by Admin-A and CM-B (clinical manager) during an interview on 11/14/24 at 12:30 p.m.”

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits 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 the agency failed to provide the patient and caregiver with a copy of written instructions that include the visit schedule, including frequency of visits by the Home Health Agency personnel and personnel acting on behalf of the Home Health Agency in 1 of 3 (P-1) records reviewed with home visits. Findings included: P-1: The Start of Care was dated 11/2/2024. The Plan of Care identified diagnoses of Aftercare following joint replacement surgery, Primary Osteoarthritis of left knee, Encounter for change or removal of surgical wound dressing, muscle weakness, Diabetes Type 2, and long-term use of oral hypoglycemic drugs. During the home visit, the patient was asked if the agency had created a folder that contained a written calendar that documented time and dates of scheduled visits. The patient responded, “no”. The Physical Therapist, who was also the owner of the agency, stated, “No we just give the patients a call and coordinate what the best date and time would work for their next visit and sometimes we make that arrangement during the current visit. The agency failed to provide a Home Health Care Folder that contained information or a calendar for scheduling Home Care visits with the patients to ensure the patient was informed of the date and time of therapy visits. These findings were reviewed, acknowledged, and confirmed by the Administrator on 11/12/24 after the joint survey home care physical therapy visit.”

“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 observation, record review, and interview, the agency failed to ensure patients were provided written information with the name and contact information of the clinical manager, resulting in a lack of information to enable the 9 current patients to contact the clinical manager. Findings include: On 11/12/24, the agency’s start of care booklet titled, “Patient Home Healthcare Orientation Handbook” and 5 additional documents were reviewed. The 57-page booklet and documents failed to note the inclusion of the clinical manager’s (CM-B) name and contact information. The finding was reviewed with the clinical manager (CM-B) during an interview on 11/12/24 at 11:15 a.m. CM-B explained that her name and phone number were not in the booklet. P-4: A joint surveyor home visit with the physical therapist was conducted on 11/12/24 at 3:00 p.m. During the visit the same agency booklet was observed in the patient’s home. The booklet was reviewed and there was no evidence the patient was informed in writing of the clinical manager’s name and contact information.”

“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 physical therapist prepared clinical notes for 1 of 7 (P-5) records reviewed, resulting in a lack of information regarding the health status of this patient. Findings include: P-5: This 82-year-old patient was admitted to home care on 9/28/24 with diagnoses of aftercare for a left total knee arthroplasty and diabetes mellitus. During record review on 11/13/24, it was noted that the following physical therapy visit notes were blank of information: 10/22/24, 10/28/24, 10/30/24, 11/4/24. The patient was discharged on 11/6/24 and the discharge summary was also blank of information. There was no documented evidence that Admin-A (physical therapist) had prepared clinical notes on the visit dates mentioned. During the entrance conference with Admin-A on 11/12/24 at 10:05 a.m., Admin-A explained that visit notes are completed within 24 hours of the visit. The agency has no policy regarding the completion of clinical notes for agency personnel. The findings were reviewed with and acknowledged by Admin-A and CM-B (clinical manager) during an interview on 11/14/24 at 12:30 p.m.”

“Must have a written agreement CFR(s): 484.105(e)(2)(i-iv) An HHA must have a written agreement with another agency, with an organization, or with an individual when that entity or individual furnishes services under arrangement to the HHA’s patients. The HHA must maintain overall responsibility for the services provided under arrangement, as well as the manner in which they are furnished. The agency, organization, or individual providing services under arrangement may not have been: (i) Denied Medicare or Medicaid enrollment; (ii) Been excluded or terminated from any federal health care program or Medicaid; (iii) Had its Medicare or Medicaid billing privileges revoked; or (iv) Been debarred from participating in any government program. This Element is not met as evidenced by: Based on record review and interview, the agency failed to have written agreements with 2 of 2 (RN-C, PTA-D) contracted employees, resulting in a lack of overall responsibility by the agency for the services provided under arrangement. Findings include: The staff roster provided by the Administrator (Admin-A) on 11/12/24 indicates that 2 individuals were independent contractors (1099) providing patient services. Personnel files were reviewed on 11/13/24. The personnel files for contract employees RN-C (registered nurse, date of hire 2/1/23) and PTA-D (physical therapy assistant, date of hire 4/1/24) failed to contain the required written agreements to ensure Maple Home Health Care maintained overall responsibility for the services provided under arrangement as well as the manner in which services are furnished. The agency failed to have a policy regarding contracted services. The findings were reviewed with and acknowledged by the clinical manager (CM-B) and the office manager (OM-E) during an interview on 11/13/24 at 1:00 p.m.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the medical record contained all physical therapy visit notes for 2 of 7 (P-1, P-5) records reviewed, resulting in a lack of information for the physician and all agency staff caring for this patient. Findings include: P-5: This 82-year-old patient was admitted to home care on 9/28/24 with diagnoses of aftercare for a left total knee arthroplasty and diabetes mellitus. During record review on 11/13/24, it was noted that physical therapy was ordered to provide 1 visit in week one, 3 visits each week for 2 weeks, and then 2 visits each week for 4 weeks. The following physical therapy visit notes were blank of information: 10/22/24, 10/28/24, 10/30/24, and 11/4/24. The patient was discharged on 11/6/24 and the discharge summary was also blank of information. There was no documented evidence that Admin-A (administrator/physical therapist) had prepared clinical notes on the visit dates mentioned. During the entrance conference on 11/12/24 at 10:05 a.m., Admin-A explained that visit notes are completed within 24 hours of the visit. The agency has no policy regarding the completion of clinical notes for agency personnel. The findings were reviewed with and acknowledged by Admin-A and CM-B (clinical manager) during an interview on 11/14/24 at 12:30 p.m. P-1: The Start of Care (SOC) was dated 11-2-24. The Plan of Care for the certification period 11-2-24 to 12-31-24 identified diagnoses of Aftercare following joint replacement surgery, Osteoarthritis of left knee, Presence of left artificial knee joint, and type 2 Diabetes. The Plan of Care included orders for Physical Therapy frequency of visits as follows: “2 times a week for 3 weeks. Upon review of the record, it was noted the SOC Assessment dated 11/2/2024 was completed and submitted into the patient’s electronic record. A Home Health PT visit was conducted with this surveyor on November 12, 2024. However, upon review of the record, the Physical Therapy visit note for November 4, 2024, was completely blank. The Physical Therapy note for the November 6, 2024, visit was not found in the patient record. There was no evidence that the PT (Admin-A) had prepared clinical visit notes for November 4th or November 6th. When asked when the agency expects clinical notes to be submitted, the response was, “within 24 hours of the visit.” The findings were reviewed with and acknowledged by Admin-A and CM-B (clinical manager) during an interview on 11/14/24 at 2:00 p.m.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure Transfer and Discharge summaries were sent to the physician within 5 business days of the patient’s discharge for 4 of 4 (P-2, P-3, P-5, P-7) records reviewed in which the patient was transferred or discharged from the agency, resulting in the physician not having knowledge of the patient’s health status at the time of transfer or discharge including a summary of the care received. Findings include: P-5: This 82-year-old patient was admitted to home care on 9/28/24 with diagnoses of aftercare for a left total knee arthroplasty and diabetes mellitus. The patient received physical therapy services for 7 weeks. The patient was discharged from agency services by Admin-A (physical therapist) on 11/6/24. During record review on 11/13/24, it was noted that there was no discharge summary for review and no evidence that a discharge summary was sent to the physician within 5 business days of discharge. The finding was reviewed with Admin-A and CM-B (clinical manager) during an interview on 11/14/24 at 12:30 p.m. CM-B reviewed the medical record and explained that no discharge summary had been created, and no discharge summary was sent to the physician. P-7: This patient was admitted to home care on 12/20/23 with diagnoses of aftercare following surgery on the digestive system, gallstones, and stenosis (narrowing) of the larynx. The patient received one nursing visit on 12/20/23 and was then discharged from the agency on 12/26/23. The discharge summary dated 12/26/23 states the patient refused any further visits. There was no evidence the discharge summary was sent to the physician within 5 business days of discharge. P-2: The Start of Care was dated 4/24/2024. The Plan of Care for the certification period 4/24/24 to 6/22/24 identified a primary diagnoses of Diabetes type 2, with diabetic neuropathy, and secondary diagnosis of “Other abnormalities of gait and mobility. The patient was receiving Physical Therapy Services at a frequency of 2 x week x 7 weeks to increase the patient’s strength and endurance, for implementation of safety measures, and for evaluation of assistive device due to impaired functional ability due to weakness. The patient was transferred to a hospital due to urine retention on 6/16/24. The patient’s 9 goals were unmet. It was noted upon review the PT documented “copy of Transfer Summary Sent to: Inpatient receiving facility (with no date and without providing the name and address of the hospital), and it was documented that the Transfer Summary was also sent to the patient’s physician on 6/16/24”. During an interview on 11/14/24 at 2:30 p.m. with the Clinical Manager, the Clinical Manager stated, “staff are supposed to document the name and address of the facility whenever a patient is transferred and to notify the physician. When asked if the Home Health Care agency had any evidence, such as a fax, to confirm that the physician had been notified of the Transfer. The response was “no we do not have a faxed copy of the notification.” P-3: The Start of Care was dated 5/14/24. The Plan of Care for the certification period 7/16/24 to 9/13/24 identified diagnoses of Diabetes Type 2, Intervertebral disc degeneration-lumbar region, Pain in unspecified Lower Leg. The patient was receiving Skilled Nursing and Physical Therapy Services. Upon review of the record, it was noted the patient was transferred to Detroit Medical Center Hospital due to nausea on 8-7-24 and patient was admitted. The patient was not discharged from the agency. However, upon review, the Physical Therapist documented the patient was transferred to an inpatient facility, but patient was not discharged from the agency. The Physical Therapist documented that a copy of the Transfer summary was sent to the physician on 8/7/24. During an interview on 11/14/24 at 2:30 p.m. with the Clinical Manager, the Clinical Manager stated, “staff are supposed to document the name and address of the facility whenever a patient is transferred and to notify the physician. When asked if the Home Health Care agency had any evidence, such as a fax, to confirm that the physician had been notified of the Transfer. The response was “no we do not have a faxed copy of the notification.” The findings were reviewed with and acknowledged by Admin-A (Administrator-A) and CM-B (Clinical Manager-B) during an interview on 11/14/24 at 2:30 p.m.””