Safe Care Home Health Services

“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), §485.542(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 ensure their emergency preparedness plan was reviewed and updated at least every 2 years. These practices could negatively affect the health and safety of the agency’s 7 current patients in the event of an agency-based emergency or community disaster. Findings include: The agency’s white binder titled, Emergency Disaster Plan, was reviewed with ADM-1(administrator) during an interview on 3/28/25 at 11:00 a.m. During the review it was noted that the agency’s hazard and vulnerability assessment was last reviewed or revised on 2/26/21. The binder contained a form titled, Biennial (every 2 years) Evaluation of Hazard Vulnerability Analysis, to indicate the plan was reviewed and/or revised. This form was signed by ADM-1 and dated 2/26/21. ADM-1 acknowledged the finding and explained he did not realize that the plan must be reviewed and updated every 2 years.”

“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 reviewed and updated at least every 2 years. These practices could negatively affect the health and safety of the agency’s 7 current patients in the event of an agency-based emergency or community disaster. Findings include: The agency’s white binder titled, Emergency Disaster Plan, was reviewed with ADM-1(administrator) during an interview on 3/28/25 at 11:00 a.m. During the review it was noted that the agency’s hazard and vulnerability assessment was last reviewed or revised on 2/26/21. The binder contained a form titled, Biennial (every 2 years) Evaluation of Hazard Vulnerability Analysis, to indicate the plan was reviewed and/or revised. This form was signed by ADM-1 and dated 2/26/21. There was no documentation to indicate when the policies and procedures were last reviewed or updated. ADM-1 acknowledged the finding and explained that the policies were probably last reviewed in 2021.”

“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 includes objectively measurable goals to use to determine the patient’s progress towards achieving the goals in 7 (P-1, P-2, P-3, P-4, P-5, P-6, P-7) of 7 records reviewed, resulting in the inability to determine when the patient is ready for discharge. Findings include: P-5: This 90-year-old patient was admitted to home care on 1/29/25 with diagnoses of left hemiplegia following a cerebral infarct and congestive heart failure. During record review on 3/26/25, it was noted that the 1/29/25 POC ordered physical therapy services twice a week for six weeks. The goals listed in the POC included the following physical therapy goals: caregiver will verbalize understanding of the need to be appropriately immunized to decrease risk, patient will improve bed mobility to independence to caregiver’s goal, and patient will demonstrate safe gait stability with decreased risk for injury. 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. The findings were reviewed with and acknowledged by ADM-1 during an interview on 3/28/25 at 1:00 p.m. P-6: This patient was admitted to home care on 3/9/25 with diagnoses of bilateral osteoarthritis of the knees and congestive heart failure. During record review on 3/26/25, it was noted that the 3/9/25 POC ordered skilled nursing for the start of care assessment and physical therapy to evaluate and treat this patient. The POC documented the patient’s personal health care goal: Able to check my blood glucose by next week and take my injection without help. The POC failed to include measurable goals related to the patient’s personal goals regarding diabetes management. The findings were reviewed with and acknowledged by ADM-1 during an interview on 3/28/25 at 1:00 p.m. P-7: This 79-year-old patient was admitted to home care on 3/13/25 with diagnoses of type 2 diabetes, congestive heart failure, and high blood pressure. During record review on 3/26/25, it was noted that the POC ordered once weekly nursing visits for four weeks. The goals listed in the POC included the following: patient will be able to demonstrate strategies for symptom management of hypoglycemia; and verbalize understanding and demonstrate compliance with prescribed care to improve health status and minimize long-term debilitating diabetes complications. 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 ADM-1 during an interview on 3/28/25 at 1:00 p.m. P-1: The Start of Care (SOC) was dated 6/10/2024. The Plan of Care (POC) for the certification period 6/10/2024 to 8/8/2024 identified diagnoses of Diabetes Type 2 (DM2), Congestive Heart Failure (CHF), Hyperlipidemia, Peripheral Vascular Disease (PVD), Hypertension (HTN), and Atherosclerotic Heart Disease (AHD). The patient was receiving Skilled Nursing (SN) and Physical Therapy (PT) services. Upon review of the record, it was noted the goals on the Plan were not objectively measurable to determine the patient’s progress towards attaining the goals. Examples included: “Patient/Caregiver will demonstrate competence with self-management of HTN, HLD, DM, PAD, CAD, CHF, Polyneuropathy 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 /within time- period; Patient will be able to verbalize signs and symptoms of cardiac complications, when to call physician, nurse or 911 within time-period; Patient and caregiver will be able to identify fall risk factors within time-period.” 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 February 11, 2025. The Plan of Care (POC) for the certification period 2/11/2025 to 4/11/2025 identified diagnoses of Diabetes type 2 (DM2), Heart Failure (HF), Hypertension (HTN), Coronary Artery Disease (CAD), and Hyperlipidemia. The patient was receiving Skilled Nursing (SN) services 1xweekx4 weeks. Upon review of the record, it was noted the goals on the POC were not objectively measurable. Examples included: “Achieve Optimal Blood Pressure Control, Improve Overall Cardiovascular Health; Prevent complications such as heart disease, kidney damage, and stroke through blood pressure management; Achieve glycemic control.” These goals are not objectively measurable to determine the patient’s progress towards achieving the goals. P-3: The Start of Care (SOC) was dated 3/14/2025. The Plan of Care for the certification period 3/14/2025 identified diagnoses of Diabetes Type 2 (DM2), Deep Vein Thrombosis of bilateral distal lower extremity, Atrial Fibrillation (A-fib), Pulmonary Hypertension, Coronary Artery Disease (CAD), Peripheral Vascular Disease, Left-sided Hemiplegia, and Morbid Obesity. The patient was receiving Skilled Nursing (SN) and Physical Therapy (PT) services. Upon review of the record, it was noted the goals on the POC were not objectively measurable. Examples included: “Patient will demonstrate return to stable endocrine status related to (Blank) with improvement/maintenance of maximal level of functioning by/within time-period 3 w 4s” {sic}. These goals are not objectively measurable to determine the patient’s progress towards obtaining the goals. It was also noted that there were no Physical Therapy Goals on the Plan of Care. P-4: The Start of Care (SOC) was dated 3/14/2025. The Plan of Care (POC) for the certification period 3/14/2025 to 5/15/2025 identified diagnoses of Encounter for Change or Removal of Surgical Wound Dressing, Coronary Artery Disease (CAD), Heart Failure (HF), and Hypertension (HTN). Upon review of the record, 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 demonstrate competence with self-management of disease process as evidenced by adherence to medication regimen, ability to identify signs and symptoms necessitating contact with medical professionals, diet regimen guidelines, activity compliance and symptom management.” These goals are not objectively measurable to determine the patient’s progress towards obtaining the goals. These findings were reviewed and acknowledged by the Administrator (ADM-1) and Office Manager (OM-2) during an interview on 3/28/2024 at 3:15 pm.”

“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 patients and caregivers of the correct state toll free home health hot line phone number, resulting in a lack of information to voice concerns or questions regarding Safe Care Home Health Services. Findings include: On 3/26/25, the agency’s booklet titled “Patients Guide” was reviewed. The booklet advises the patient to report a complaint to the state’s home health agency hotline number at 734-744-9683. This is the phone number for the agency, Safe Care Home Health Services. This is not the toll-free home health telephone hot line phone number for the state of Michigan. On that same page, the patient is instructed to contact CHAP (Community Health Accreditation Partner) to voice concerns. The agency is no longer affiliated with CHAP as of 3/3/2025. The findings were reviewed with and acknowledged by ADM-1 (administrator) during an interview on 3/26/25 at 11:25 a.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 observation, record review, and interview, the agency failed to ensure the comprehensive assessment included a review of all medications to determine any duplicate therapy, drug interactions, or adverse effects; and failed to ensure the physician was notified regarding potential medication interactions for 2 (P-6, P-7) of 7 records reviewed, resulting in the potential for harmful medication effects for these patients. Findings include: P-6: This 57-year-old patient was admitted to home care on 3/9/25 with diagnoses of bilateral osteoarthritis of the knees and congestive heart failure. During record review on 3/26/25, it was noted that the 3/9/25 POC (plan of care) ordered skilled nursing for the start of care assessment and physical therapy to evaluate and treat this patient. The POC documented the patient’s personal health care goal: Able to check my blood glucose by next week and take my injection without help. A joint surveyor home visit was conducted with the physical therapist on 3/27/25 at 11:00 a.m. During the visit the patient was queried regarding diabetes medications. The patient presented for review two medications to assist in managing diabetes: Ozempic (weekly injectable) and Jardiance (daily pill). The POC failed to include these medications. There was no evidence to indicate the comprehensive assessment included a review of all of the patient’s medications to determine any duplicate therapy, drug interactions, or adverse effects. The findings were reviewed with and acknowledged by ADM-1 (administrator/RN) during an interview on 3/28/25 at 1:00 p.m. P-7: This 79-year-old patient was admitted to home care on 3/13/25 with diagnoses of type 2 diabetes, congestive heart failure, and high blood pressure. During record review on 3/26/25, a drug-drug interaction report was generated utilizing the agency’s software. The report indicates a potential major interaction between Aspirin and Brilinta, which may have an additive antiplatelet effect. During the entrance conference on 3/26/25 at 10:15 a.m., ADM-1 explained that the physician is notified of all interactions, and a copy of the medications is sent to the physician. There was no evidence that the physician was informed of the potential major interaction. During an interview on 3/28/25 at 1:00 p.m., ADM-1 reviewed the medical record and acknowledged that the physician was not notified of the potential major interaction.”

“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 a frequency and duration of nursing visits for 1 (P-6) of 6 records reviewed with nursing services, resulting in uncertainty of nursing visits and nursing care for this patient. Findings include: P-6: This patient was admitted to home care on 3/9/25 with diagnoses of bilateral osteoarthritis of the knees and congestive heart failure. During record review on 3/26/25, it was noted that the 3/9/25 plan of care ordered the following skilled nursing frequency and duration: soc (start of care), prn (as needed). The use of “soc” is not a frequency or duration of nursing visits. The use of “prn” fails to indicate how many prn visits are ordered and fails to indicate which health care circumstances would prompt a prn visit, such as pain management or diabetes monitoring. The findings were reviewed with and acknowledged by ADM-1 (administrator/RN) during an interview on 3/28/25 at 1:00 p.m.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on record review and interview and interview, the agency failed to document the patient’s blood sugar results in 2 of 4 records reviewed (P-2, P-3) for patients with a primary diagnosis of Diabetes. Findings included: Policy: Assessment and Reassessment Guidelines, revised March 2025. The policy states, “Assessment data gathered by each discipline will be used to assess the patient’s needs and problems initially and on an ongoing basis.” P-2: The Start of Care (SOC) was dated February 11, 2025. The Plan of Care (POC) for the certification period 2/11/2025 to 4/11/2025 identified a primary diagnosis of Diabetes type 2 (DM2), and additional diagnoses of Heart Failure (HF), Hypertension (HTN), Coronary Artery Disease (CAD), and Hyperlipidemia. The patient was receiving Skilled Nursing (SN) services 1xweekx4 weeks. Upon review of the record, the POC included an order stating, “SN to perform complete physical assessment each visit with emphasis on disease process. SN to assess other co-morbidities including Diabetes Mellitus and Hypertension and other conditions that present themselves during this episode of care.” During review of the patient record, it was noted that the Skilled Nursing note dated 2/19/25 documented a range for the blood sugar as from 80 to 140. There was no specific blood sugar result documented. Skilled Nurse visit dated 2/26/25 documented under the category of “Endocrine/Hematologic a range for the patient’s Fasting Blood Sugar from 90 to 200. There was no specific blood sugar result. The Skilled Nurse documented on the discharge summary dated 3/5/25 a range for the blood sugar as 120 to 140. There was no specific blood sugar results documented in the patient’s record. P-3: The Start of Care (SOC) was dated 3/14/2025. The Plan of Care for the certification period 3/14/2025 identified a primary diagnosis of Diabetes Type 2 (DM2), Deep Vein Thrombosis of bilateral distal lower extremity, Atrial Fibrillation (A-fib), Pulmonary Hypertension, Coronary Artery Disease (CAD), Peripheral Vascular Disease, Left-sided Hemiplegia, and Morbid Obesity. The patient was receiving Skilled Nursing (SN) and Physical Therapy (PT) services. Upon review of the record, it was noted there was no documentation of specific blood sugar results to address the patient’s primary diagnosis of Diabetes. The plan of care included reportable parameters to address the primary diagnosis of diabetes as follows: “Fasting Blood Sugar: greater than (>) 180 mg/dL less than () 200 mg/dL less than (<) 70 mg/dL.” The Plan of Care also included the following goal, “Patient will demonstrate return to stable endocrine status related to with improvement/Maintenance of maximal level of functioning by/within time-period of 2 weeks x4.” {sic}. There was no documentation of specific daily blood sugar results in the patient record to determine the status of the patient’s diabetes. These findings were reviewed and acknowledged by the Administrator (ADM-1) and Office Manager (OM-2) during an interview on 3/28/2024 at 3:15 pm.”

“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 that visit notes were completed and submitted into the patient’s record as required during the course of care in 1 of 7 records reviewed. Findings included: **Agency Policy: Timely Submission of Patient Documentation. The policy states, “The Agency will ensure the timely and proper submission of patient documentation. Itineraries with all visit reports attached, must be submitted the next scheduled wok day, not exceeding three business days. All patient visit reports from contract personnel must be submitted within three business days from the date of the visit, e.g., PT< SLP< etc. {sic}. P-3: The Start of Care (SOC) was dated 3/14/2025. The Plan of Care for the certification period 3/14/2025 to 5/12/2025 identified diagnoses of Diabetes Type 2 (DM2), Deep Vein Thrombosis of bilateral distal lower extremity, Atrial Fibrillation (A-fib), Pulmonary Hypertension, Coronary Artery Disease (CAD), Peripheral Vascular Disease, Left-sided Hemiplegia, and Morbid Obesity. The patient was receiving Skilled Nursing (SN) and Physical Therapy (PT) services. Upon review of the record, it was noted the visit note dated 3/20/2025 submitted by the physical therapy assistant was completely blank. There was no further documentation or explanation found in the record to indicate if the patient had received physical therapy services on 3/20/25, if the visit was cancelled or rescheduled, or if the physical therapy assistant had failed to document the visit. These findings were reviewed and acknowledged by the Administrator (ADM-1) and Office Manager (OM-2) during an interview on 3/28/2025 at 3:15 pm.”