Every finding on record at 24 Seven Home Health Care Services, Inc.

On 4/4/22 through 4/7/22, the Michigan Department of Licensing and Regulatory Affairs conducted a recertification survey at 24-Seven Home Health Care Services. This was a standard survey. The requirements for participation in Medicare at 42 CFR 484.102 Emergency Preparedness were not reviewed.

On 4/4/22 through 4/7/22, the Michigan Department of Licensing and Regulatory Affairs conducted a recertification survey concurrent with a vaccine mandate review at: 24-Seven Home Health Care Services 26200 Lahser Road Southfield, MI 48033 The agency has no branch locations. Records reviewed: 3 records with home visits; 4 records without home visits; for a total of 7 records reviewed. At the conclusion of the survey the agency was found to be out of compliance with standard level deficiencies for the Conditions of Participation for Home Health Agencies at: 42 CFR Part 484.

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, it was determined the agency failed to ensure the comprehensive assessment included a review of all medications to determine any adverse effects, and failed to provide documented evidence that the physician was notified of identified drug interactions in 1 (MR# 2) of 7 sampled records reviewed, resulting in the potential for harmful medication effects for all 7 patients currently serviced by this Agency. Findings included: MR#2: The SOC was dated 3/22/2022. The POC for the certification period 3/22/2022 to 5/20/2022 identified diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Chronic Atrial Fibrillation (A-Fib), Atherosclerotic Heart Disease of Native Coronary Artery (CAD), and spondylosis with radiculopathy of Lumbar region. The patient was receiving SN and PT services. Upon review of the Comprehensive Assessment, it was noted under the category "(M2001): Drug Regimen Review," the skilled nurse documented "No issues found." However, a review of the patient's current medications via drugs.com revealed 2 major drug interactions as follows: The concurrent use of Diltiazem and Metoprolol can lead to increased side effects such as fatigue, headache, fainting, swelling of the extremities, weight gain, shortness of breath, chest pain, and increased and/or decreased heartbeat. Also, the concurrent use of diltiazem together with flecainide can increase the effects of these medications causing dizziness, weakness, chest pain, shortness of breath, fainting, coma, slurred speech or confusion. There was no evidence found in the patient's record that these interactions had been reported to the physician. These findings were reviewed and acknowledged by the clinical director (CD-C) and the alternate administrator (AADM-B) during an interview on April 7th, 2022 at 12:30 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 measurable skilled nursing goals specific to the needs of the patient, for 5 of 7 records reviewed (MR#s 1, 2, 3, 4, 5), resulting in the potential for poor patient outcomes due to a lack of quantifiable measures to determine patient progress towards achieving nursing goals. Findings include: MR#4: This patient was admitted to the agency on 2/8/22 with diagnoses of diabetes, high blood pressure, and chronic obstructive pulmonary disease. During record review on 4/5/22, it was noted that the 2/8/22 care plan failed to include measurable outcomes and goals for this patient. The skilled nursing goals included the following examples: Dyspnea (difficulty breathing) will decrease by 4 weeks and will demonstrate energy conservation techniques by 4 weeks. There was no indication as to how these nursing goals would be objectively measured to determine the patient's progress towards discharge. During an interview on 4/7/22 at 9:30 a.m., the findings were reviewed with and acknowledged by the clinical director (CD-C) and the alternate administrator (AADM-B). The clinical director was unable to explain how dyspnea and energy conservation techniques could be objectively measured. The agency failed to follow its own policy, Care Plan C-560 (revised March 2018), which states, "The care plan shall include...measurable, and realistic nursing...goals." MR#5: This patient was admitted to the agency on 2/5/22 with diagnoses of heart disease, high blood pressure, and left-sided weakness following a stroke. During record review on 4/5/22, it was noted that the 2/5/22 plan of care failed to include measurable outcomes and goals for this patient. The skilled nursing goals included the following examples: Dyspnea (difficulty breathing) will decrease by 4 weeks and will demonstrate energy conservation techniques by 4 weeks. There was no indication as to how these nursing goals would be objectively measured to determine the patient's progress towards discharge. **Agency Policy #C-560: "Care Plan," revised March 2018. The policy states, "The Care Plan shall include reasonable, measurable, and realistic nursing, therapy, and social services, client, and/or caregiver goals." MR#1: The Start of Care (SOC) was dated 3/25/2022. The Plan of Care (POC) for the certification period 3/25/22 to 5/23/2022 identified diagnoses of Diabetes type 2 (DM2), Hypertensive Heart disease, Radiculopathy, and bilateral secondary osteoarthritis of the knee. The patient was receiving Skilled Nursing (SN) and Physical Therapy (PT) services. The POC included the following Goals, ""Patient's blood sugar and blood pressure will be stable; Patient will demonstrate return to stable endocrine status related to DM2 with improvement/maintenance of maximal level of functioning by 5 weeks; Physical Therapy evaluation will be performed and a plan of care to increase functional independence will be established and countersigned by physician." These goals are not objectively measurable, nor specific to the patient's needs. MR#2: The SOC was dated 3/22/2022. The POC for the certification period 3/22/2022 identified diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Chronic Atrial Fibrillation (A-Fib), Atherosclerotic Heart Disease of Native Coronary Artery (CAD), and spondylosis with radiculopathy of Lumbar region. The patient was receiving SN and PT services. A review of the POC revealed the following Goals: "Patient/Caregiver will not go to the hospital; Patient's cardiopulmonary, behavioral status will be stable; Patient/Caregiver will know how to manage pain; Physical Therapy evaluation will be performed and a plan of care to increase functional independence will be established and countersigned by physician. These goals are not specific to the patient's needs, nor are these goals objectively measurable to determine the patient's progress toward goals. MR#3: The SOC was dated 12/18/21. The POC for the certification period 12/18/21 to 2/15/21identified diagnoses of Chronic Obstructive Pulmonary Disease with acute exacerbation (COPD), Atrial fibrillation, and Hypertension (HTN). The patient was receiving Skilled Nursing (SN), Physical Therapy, and Medical Social Work services. Upon review of the Goals on the Plan of Care it was noted that the goals were not objectively measurable to determine the patient's progress towards achieving the goals. Examples include: "Stabilization of CV/CP {sic} status; Pain level will decrease; Patient will demonstrate improvement from current functional level to prior functional level of independence before hospitalization, as evidenced by safe use of energy conservation techniques and adherence to cardiac regimen to increase functional activity by the end of certification period." These goals are not objectively measurable to determine the patient's progress toward achieving goals. These findings were reviewed and acknowledged by the clinical director (CD-C) and the alternate administrator (AADM-B) during an interview on April 7th, 2022 at 12:30 p.m. .

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the skilled nurse completed visits at the frequency ordered by the physician for 1 of 7 (MR# 5) records reviewed, resulting in the potential for poor patient outcomes for this patient. Findings include: MR#5: This patient was admitted to the agency on 2/5/22 with diagnoses of heart disease, high blood pressure, and left-sided weakness following a stroke. During record review on 4/5/22, it was noted that the 2/5/22 plan of care ordered the nurse to provide one visit each week for five weeks. Those visits were provided at the appropriate frequency from 2/5/22 through 3/1/22. On 3/1/22, the nurse (RN-U) documented a physician order to add 2 nursing visits due to patient anxiety. RN-U provided a visit on 3/8/22 and then there were no further documented nursing visits and no documentation the patient had cancelled or declined nursing services. It was unclear why the second additional nursing visit was not completed. During an interview on 4/7/22 at 9:30 a.m., the findings were reviewed with and acknowledged by the clinical director (CD-C) and the alternate administrator (AADM-B). AADM-B was unable to explain why the second nursing visit was not documented. An interview could not be conducted with RN-U who is no longer employed by the agency.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure to coordinate patient care for 3 of 7 (MR# 5, 6, 7) records reviewed, resulting in a lack of coordinated care delivery to meet the needs of these patients. Findings include: MR#5: This patient was admitted to the agency on 2/5/22 with diagnoses of heart disease, high blood pressure, and left-sided weakness following a stroke. The patient received skilled nursing and physical therapy services. During record review on 4/5/22, it was noted that the 2/5/22 plan of care ordered the nurse to provide one visit each week for five weeks and then on 3/1/22, the nurse (RN-U) wrote a physician order to add 2 nursing visits due to patient anxiety for a total of seven nursing visits. RN-U documented 6 nursing visits from 2/5/22 through 3/8/22. RN-U provided a visit on 3/8/22 and then there were no further documented nursing visits and no documentation the patient had cancelled or declined nursing services. There was no documentation to indicate the patient had met all nursing goals and was discharged from nursing care. It was unclear whether the patient's nursing care needs had been met. The agency failed to follow its own policy titled, Special Instructions C-360 (revised March 2018) which states, "When multiple disciplines are involved...a discharge care conference shall be conducted when necessary. The conference will review the client's discharge potential, determine whether continuing services is (sic) appropriate, and develop a discharge plan...The primary care nurse or therapist will assume responsibility for updating and changing the Care Plan and communicating changes to caregivers within 24 hours following the conference or changes. The physician will be contacted when his or her approval for a change is necessary." There was no documented evidence RN-U and the physical therapist conferenced regarding the patient's discharge from nursing care. There was no documentation to indicate the physician was aware skilled nursing services had stopped abruptly on 3/8/22. During an interview on 4/7/22 at 9:30 a.m., the findings were reviewed with and acknowledged by the clinical director (CD-C) and the alternate administrator (AADM-B). An interview could not be conducted with RN-U who is no longer employed by the agency. MR#6: This patient was admitted to the agency on 11/20/21 with diagnoses of chronic obstructive pulmonary disease, low oxygen concentration, and peripheral vascular disease. The patient received skilled nursing and home health aide services. The aide was to provide two visits each week for six weeks. During record review on 4/4/22, it was noted that for a five-week period (from 11/23/21 through 12/24/21) the aide documented missed visits for 7 of 10 visits. There was no documented evidence of coordination of care between the nurse and the aide regarding the many missed aide visits. Four of the seven aide visit notes indicate the visit was missed because there was no answer to a phone call. Possibly the patient was hard of hearing or slow to ambulate to the phone. The lack of care coordination between the nurse and aide resulted in the failure to meet the patient's personal hygiene needs. MR#7: This 69-year-old patient was admitted to home care on 11/13/19 with diagnoses of osteoarthritis of both knees and lumbar radiculopathy (pinched spinal nerve). The 11/13/19 plan of care ordered this patient to receive skilled nursing and physical therapy services. During record review on 4/4/22, it was noted that the registered nurse completed the start of care comprehensive assessment on 11/13/19. There were no further documented visits by nursing or physical therapy for this patient. It was unclear what had happened with this patient and her needs for skilled care. During an interview on 4/4/22 at 2:00 p.m., the alternate administrator (AADM-B) explained that care had been started for this patient and then it was learned the patient had changed insurance providers that the agency does not accept. AADM-B stated the physician was informed that home care services would have to be from another agency. AADM-B was unable to provide documentation that the patient's continued care had been coordinated with the physician and with the receiving home care agency.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the registered nurse prepared written patient care instructions for the aide for 1 of 1 (MR#6) records reviewed in which aide services were provided, resulting in a lack of direction regarding the care and safety measures pertinent to the needs of this patient. Findings include: MR#6: This 85-year-old patient was admitted to the agency on 11/20/21 with diagnoses of chronic obstructive pulmonary disease, low oxygen concentration, and peripheral vascular disease. The patient received skilled nursing and home health aide services. The 11/20/21 plan of care ordered the aide to provide two visits each week for six weeks. The aide documented visits were provided on 12/7/21, 12/11/21, and 12/16/21. During record review on 4/4/22, it was noted that there was no documented evidence that an aide care plan had been prepared by the registered nurse. The aide was providing patient care without any directions regarding the safety measures and care needs pertinent to this elderly patient. The findings were reviewed with the alternate administrator (AADM-B) and the clinical director (CD-C) during an interview at 9:30 a.m. on 4/7/22. AADM-B reviewed the electronic and paper medical records for this patient and confirmed the findings.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a discharge summary was sent to the primary care practitioner within 5 business days of the patient's discharge for 3 of 3 (MR#s 2, 6, 7) discharge records reviewed, and a transfer summary was sent to the receiving health care agency and the physician within 2 business days of transfer for 1 of 1 (MR#2) transfer records reviewed, resulting in the practitioner or health care agency not having knowledge of the patient's health status, progress towards goals, or continuing health care needs at the time of discharge or transfer for these patients. Findings include: MR#2: The Start of Care was dated 3/22/2022. The Plan of Care for the Certification Period of 3/22/2022 to 5/20/2022 identified diagnoses of Atherosclerotic heart disease of native coronary artery (CAD), Chronic Atrial Fibrillation (A-fib), Acute Respiratory distress (ARD), Monoplegia of lower limb following cerebral infarction of the right dominant side, history of falling. This patient was admitted to the agency on 3/22/2022, and Transferred to a hospital on 3/23/2022 for a severe nose bleed, The Transfer Oasis and Transfer summary failed to document the date the transfer summary was sent to the physician and the facility. In addition, during a prior episode of care with a Start of Care date of 10/25/21 for the certification period of 10/25/21 to 12/23/21 this patient was transferred and discharged from the agency on 12/11/2021 due to a "respiratory problem, and scheduled treatment or procedure" The Transfer OASIS stated there was Coordination of Care with the physician regarding transfer and discharge from home health care services, however, the Transfer/Discharge Oasis failed to document the date a copy of the transfer summary was sent to the physician or the facility, nor did it document the name of the facility the patient had been transferred to for care. It was also noted that there was no documented evidence the agency had sent a discharge summary to the physician within 5 days of the "transfer/discharge" from the agency. There was no evidence that the physician had been informed of the patient's health status or progress towards goals, or if the patient would need future home health care needs upon discharge from the hospital. These findings were reviewed and acknowledged by the alternate administrator (AADM-B) and Clinical Director (CD-C) during an interview at 12:30 p.m. on 4/7/2021. MR#6: This 85-year-old patient was admitted to the agency on 11/20/21 with diagnoses of chronic obstructive pulmonary disease, low oxygen concentration, and peripheral vascular disease During record review on 4/4/22, it was noted that the patient was discharged from the agency on 12/29/22. There was no documented evidence the agency ensured the physician was sent a discharge summary within 5 business days of discharge from the agency. The physician was not informed of the patient's health status at the time of discharge, progress towards goals, or the likely continuing health care needs for this patient. The findings were reviewed with the alternate administrator (AADM-B) and the clinical director (CD-C) during an interview at 9:30 a.m. on 4/7/22. AADM-B reviewed the electronic and paper medical records for this patient and confirmed the findings. The agency's policy titled, Discharge Summary C-760 (revised March 2018) states, a Discharge Summary form shall be completed by the registered nurse or therapist with a copy mailed to the physician upon request. This policy fails to align with Federal regulations which requires a discharge summary be sent to the primary care practitioner who will be responsible for providing care and services to the patient after discharge from the agency within 5 business days of the patient's discharge. MR#7: This 69-year-old patient was admitted to home care on 11/13/19 with diagnoses of osteoarthritis of both knees and lumbar radiculopathy (pinched spinal nerve). The 11/13/19 plan of care ordered this patient to receive skilled nursing and physical therapy services. During record review on 4/4/22, it was noted that the registered nurse completed the start of care comprehensive assessment on 11/13/19. There were no further documented visits by nursing or physical therapy for this patient. It was unclear what had happened with this patient and her needs for skilled care. During an interview on 4/4/22 at 2:00 p.m., the alternate administrator (AADM-B) explained that care had been started for this patient and then it was learned the patient had changed insurance providers that the agency does not accept. AADM-B stated the physician was informed that home care services would have to be from another agency. AADM-B was unable to provide documentation of a discharge summary that was sent to the physician. AADM-B was unable to provide documentation of a transfer summary that was sent to the receiving home care agency.