Every finding on record at A-1 International Homecare, Inc

From 1/3/23 through 1/5/23, the Michigan Department of Licensing and Regulatory Affairs conducted a recertification survey at A-1 International Homecare. This was a standard survey. The requirements for participation in Medicare at 42 CFR 484.102 Emergency Preparedness were not reviewed.

A Medicare recertification survey was conducted by the Michigan Department of Licensing and Regulatory Affairs from 1/3/23 through 1/5/23 at: A-1 International Homecare 7150 Dixie Hwy., Suite 4A Clarkston, MI 48346 This agency has no branches or sub-units. All vaccination requirements were met. 7 discharge records reviewed. The agency has 0 active patients. 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.

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, the agency failed to ensure the registered nurse conducted the initial assessment of the patient for 1 of 7 (MR #1) records reviewed in which Skilled Nursing services were ordered, which has the potential to negatively affect the health and well-being of these patients. Findings include: MR#1: The Start of Care (SOC) was dated 2/21/21. The Plan of Care (POC) identified diagnoses of Pancreatic Cancer and Hypertension. During record review on 1/4/21, it was noted that the “Patient Care Communication Orders” stated, “Order: Home Care/Outpatient Services Prescription. Services: Skilled Nursing.” On 2/21/21, the Physical Therapist completed a SOC OASIS (Outcome and Assessment Information Set). The Registered Nurse failed to complete the initial assessment visit. These findings were reviewed with and acknowledged by the Administrator (Adm.#1) during an interview on 1/5/23 at 11:30 am.

Patient's needs CFR(s): 484.55(c)(4) The patient's medical, nursing, rehabilitative, social, and discharge planning needs; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to incorporate an individual Emergency Preparedness Plan into the Comprehensive Patient Assessment for 3 of 7 records reviewed (MR#’s 1, 3 and 5) for Emergency Preparedness from a total of 7 sampled records reviewed, resulting in the potential for negative patient outcomes in the event of an actual emergency for the agency's patients. Findings include: MR#1: The Start of Care (SOC) was dated 2/21/21. The Plan of Care (POC) identified diagnoses of Pancreatic Cancer and Hypertension. During record review on 1/4/21, it was noted that the individualized Emergency Preparedness Plan in the chart was blank. The agency failed to complete the Emergency Preparedness in the case of emergencies or disasters. MR#3: The Start of Care (SOC) was dated 6/19/21. The Plan of Care (POC) identified diagnoses of Brain Cancer, Weakness and Hypertension. During record review on 1/4/23, it was noted that the individualized Emergency Preparedness Plan in the chart was blank. The agency failed to complete the Emergency Preparedness in the case of emergencies or disasters. These findings were reviewed with and acknowledged by the Administrator (Adm.#1) during an interview on 1/5/23 at 11:20 am. MR #5: This 74-year-old patient was admitted to the agency on 1/18/21 with diagnoses which included heart failure; type 2 diabetes with poor circulation to extremities; and muscle spasm. The clinical record was reviewed on 1/4/23 and it was noted that the Emergency Preparedness Plan in the chart was left blank. There was no other documentation in the clinical record indicating that the Emergency Preparedness plan had been completed in the event of an emergency or disaster. These findings were reviewed and acknowledged by the Administrator (Adm.#1) during an interview on 1/5/23 at 9:52 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 record review and interview, it was determined the agency failed to have a registered nurse (RN) perform a comprehensive drug review to identify any potential adverse effects and drug reactions in 6 of 7 records (MR #1, 3, 4, 5, 6, and 7) reviewed potentially resulting in undetected or harmful medication effects for all patients serviced by this agency. Findings included: Agency Policy: Policy named “Medication Reconciliation”, Medications p.13 stated: “1… A RN will reconcile any discrepancies with the patient’s physician. Discrepancies include duplications, omissions, changes, contraindications and/or unclear information.” (sic) MR #5: This 74-year-old patient was admitted to the agency on 1/18/21 with diagnoses which included heart failure; type 2 diabetes with poor circulation to extremities; and muscle spasm. The clinical record was reviewed on 1/4/23. The start of care (SOC) was done by the physical therapist (PT) on 1/18/21 and it was documented within that medications were reviewed, and drug interactions assessed with no further documentation regarding drug interactions. The medication profile was completed and signed by the PT on 1/18/21. A Drug-Drug interactions report was displayed using the agency’s software and there were 7 moderate drug-drug interactions noted for this patient. No further documentation was found in the clinical record that an agency RN reviewed the medication profile or was aware of any potential adverse effects and drug reactions. MR #6: This 85-year-old patient was admitted to the agency on 3/28/21 with diagnoses which included encounter following surgery to digestive tract and chronic kidney disease. The clinical record was reviewed on 1/4/23. The SOC was done by PT on 3/28/21. There was no signed medication profile in the clinical record. A Drug-Drug interactions report was displayed using the agency’s software and there were 2 moderate drug-drug interactions noted for this patient. No further documentation was found in the clinical record that an agency RN reviewed the medication profile or was aware of any potential adverse effects and drug reactions. MR #7: This 81-year-old patient was admitted to the agency on 3/23/21 with diagnoses which included heart disease with heart failure; COPD and chronic pain. The clinical record was reviewed on 1/4/23. The SOC was done by PT on 3/23/21. The medication profile was completed and signed by the PT on 3/23/21. A Drug-Drug interactions report was displayed using the agency’s software and there was 1 major drug-drug interaction and 15 moderate drug-drug interactions noted for this patient. No further documentation was found in the clinical record that an agency RN reviewed the medication profile or was aware of any potential adverse effects and drug reactions. These findings were reviewed and acknowledged by the Administrator (Admin #1) during interview on 1/5/23 at 9:58 a.m. MR#1: The Start of Care (SOC) was dated 2/21/21. The Plan of Care (POC) identified diagnoses of Pancreatic Cancer and Hypertension. During record review on 1/4/21, it was noted that the Physical Therapist completed the “Medication Profile” on 2/21/21 and here was no documented evidence that the patient's medications had been reviewed by a registered nurse for possible drug interactions and duplicate drug therapy. MR#3: The Start of Care (SOC) was dated 6/19/21. The Plan of Care (POC) identified diagnoses of Brain Cancer, Weakness and Hypertension. During record review on 1/4/23, it was noted that the Physical Therapist completed the “Medication Profile” on 6/19/21 and here was no documented evidence that the patient's medications had been reviewed by a registered nurse for possible drug interactions and duplicate drug therapy. MR#4: The Start of Care (SOC) was dated 6/11/21. The Plan of Care (POC) identified diagnoses of Lupus and Sick Sinus Syndrome. During record review on 1/4/23, it was noted that the Physical Therapist completed the “Medication Profile” on 6/11/21 and here was no documented evidence that the patient's medications had been reviewed by a registered nurse for possible drug interactions and duplicate drug therapy. These findings were reviewed with and acknowledged by the Administrator (Adm.#1) during an interview on 1/5/23 at 11:30 am.

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 that each patient received an individualized plan of care that was signed by a doctor in 2 of 7 records (MR # 6 and 7) potentially resulting in the lack of physician oversight and unmet needs of the patient. Findings include: Agency Policy: Policy named “Plan of Care (485) and Physician Orders” Clinical p. 67 stated: “Each Plan of Care must be signed and dated by the physician.” MR #6: This 85-year-old patient was admitted to the agency on 3/28/21 with diagnoses which included encounter following surgery to digestive tract and chronic kidney disease. The clinical record was reviewed on 1/4/23. The plan of care (POC) was completed by the physical therapist (PT) on 3/28/21 and it was noted that a physician signed copy of the POC was not entered into the electronic or paper charting for this patient. MR #7: This 81-year-old patient was admitted to the agency on 3/23/21 with diagnoses which included heart disease with heart failure; COPD and chronic pain. The clinical record was reviewed on 1/4/23. The POC was completed by the PT on 3/23/21 and it was noted that a physician signed copy of the POC was not entered into the electronic or paper charting for this patient. These findings were reviewed and acknowledged by the administrator (Admin #1) during interview on 1/5/23 at 10:00 a.m.

Coordinate referrals; CFR(s): 484.105(c)(3) Coordinating referrals, This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to maintain a record of referral and acceptance of patients for services that were ordered for 3 of 7 (MR# 2, 3, and 6) records reviewed, resulting in unmet record maintenance and availability. Findings include: MR#2: The Start of Care (SOC) was dated 5/8/21. The Plan of Care (POC) identified diagnoses of Acute Pericarditis, Diabetes Type 2 and Hypertension. During record review on 1/4/23, it was noted that there was no documented referral within the chart. The agency failed to coordinate and maintain patient referrals, resulting in potential unmet needs. MR#3: The Start of Care (SOC) was dated 6/19/21. The Plan of Care (POC) identified diagnoses of Brain Cancer, Weakness and Hypertension. During record review on 1/4/23, it was noted that there was no documented referral within the chart. The agency failed to coordinate and maintain patient referrals, resulting in potential unmet needs. These findings were reviewed with and acknowledged by the Administrator (Adm.#1) during an interview on 1/5/23 at 11:10 am. MR #6: This 85-year-old patient was admitted to the agency on 3/28/21 with diagnoses which included encounter following surgery to digestive tract and chronic kidney disease. The clinical record was reviewed on 1/4/23 and it was noted that there was no documented referral within the chart. During interview on 1/4/23 at 3:30 p.m., the Administrator (Admin #1) was not able to locate a referral for this patient in the electronic or paper chart and acknowledged the finding.

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 observation, record review and interview, the agency failed to ensure clinical notes were accurate for 2 of 7 (MR# 1 and 4) records reviewed, resulting in the potential to negatively affect the health and well-being of these patients. Findings include: MR#1: The Start of Care (SOC) was dated 2/21/21. The Plan of Care (POC) identified diagnoses of Pancreatic Cancer and Hypertension. During record review on 1/4/21, it was noted the Skilled Nurse completed an add-on evaluation on 3/19/21. The evaluation contained the patient’s temperature, weight and oriented to person and place. The remaining documentation was blank. Additionally, the POC ordered a Physical Therapy frequency of 3w1 (3 times a week for 1 week), 2w8. It was noted that the records for 4/7/21, 4/9/21 and 4/13/21, were blank. The agency failed to ensure that the medical record was complete and accurate. MR#4: The Start of Care (SOC) was dated 6/11/21. The Plan of Care (POC) identified diagnoses of Lupus and Sick Sinus Syndrome. During record review on 1/4/23, it was noted that the POC ordered a Physical Therapy (PT) frequency of 1w1, 2w6. The PT visit on 7/12/21 was blank. The agency failed to ensure that the medical record was complete and accurate. These findings were reviewed with and acknowledged by the Administrator (Adm.#1) during an interview on 1/5/23 at 11:10 am.

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 days of discharge from the home health agency in 7of 7 records (MR # 1, 2, 3, 4, 5, 6, and 7) resulting in the potential for unidentified continuing health care concerns and unmet care needs. MR#1: The Start of Care (SOC) was dated 2/21/21. The Plan of Care (POC) identified diagnoses of Pancreatic Cancer and Hypertension. During record review on 1/4/21, it was noted that the agency failed to verify that the discharge summary was sent to the physician within 5 business days of the patient's discharge. MR#2: The Start of Care (SOC) was dated 5/8/21. The Plan of Care (POC) identified diagnoses of Acute Pericarditis, Diabetes Type 2 and Hypertension. During record review on 1/4/23, it was noted that the agency failed to verify that the discharge summary was sent to the physician within 5 business days of the patient's discharge. MR#3: The Start of Care (SOC) was dated 6/19/21. The Plan of Care (POC) identified diagnoses of Brain Cancer, Weakness and Hypertension. During record review on 1/4/23, it was noted that the agency failed to verify that the discharge summary was sent to the physician within 5 business days of the patient's discharge. MR#4: The Start of Care (SOC) was dated 6/11/21. The Plan of Care (POC) identified diagnoses of Lupus and Sick Sinus Syndrome. During record review on 1/4/23, it was noted that the agency failed to verify that the discharge summary was sent to the physician within 5 business days of the patient's discharge. These findings were reviewed with and acknowledged by the Administrator (Adm.#1) during an interview on 1/5/23 at 11:25 am. Agency Policy: policy named “Discharge Summary” Clinical p. 35 stated: “… a copy of the Discharge Summary will be sent to the physician within 5 business days of discharge.” MR #5: This 74-year-old patient was admitted to the agency on 1/18/21 with diagnoses which included heart failure; type 2 diabetes with poor circulation to extremities; and muscle spasm. The clinical record was reviewed on 1/4/23. The discharge summary was completed on 2/23/21 and it was noted that there was no documentation that the summary was sent to the primary care practitioner within 5 business days of discharge. MR #6: This 85-year-old patient was admitted to the agency on 3/28/21 with diagnoses which included encounter following surgery to digestive tract and chronic kidney disease. The clinical record was reviewed on 1/4/23. The discharge summary was completed on 4/16/21 and it was noted that there was no documentation that the summary was sent to the primary care practitioner within 5 business days of discharge. MR #7: This -year-old patient was admitted to the agency on 3/23/21 with diagnoses which included heart disease with heart failure; COPD and chronic pain. The clinical record was reviewed on 1/4/23. The discharge summary was completed on 5/7/21 and it was noted that there was no documentation that the summary was sent to the primary care practitioner within 5 business days of discharge. During interview with the Administrator (Admin #1) on 1/4/23 at 1:35 p.m. regarding the discharge summaries and physician notification, he stated that he was not able to find documented evidence in the electronic or paper charts that the discharge summaries had been sent to the primary care practitioners after discharge and acknowledged the findings.