Every finding on record at Carenet Homecare Services, Inc

The Michigan Department of Licensing and Regulatory Affairs conducted a Medicare authorized Recertification survey along with a focused infection control survey and complaint survey on 4/21/2021 through 4/29/2021 at: Accredited We Are Homecare, Inc dba CareNet Homecare Services, Inc. 27733 Schoenherr Rd. Warren, MI 48088 Clinical records reviewed for this survey: 3 records with home visits and 4 records without home visits for a total of 7 records reviewed. The agency has no branch sites. At the conclusion of the survey, the agency was found to not be in compliance at the standard level for the conditions of participation for Home Health Agency at: 42 CFR Part §484.00

Content of the comprehensive assessment CFR(s): 484.55(c) 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: This STANDARD is not met as evidenced by: Based on record review and interview, the Agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status based on past and current medical history that included dates of onset, exacerbations, treatments and outcomes, measurable data to use as a baseline for future assessments, and history of events leading to current home care needs for 7 of 7 sampled records reviewed (MR#s 1, 2, 3, 4, 5, 6, and 7), resulting in incomplete clinical information to aid in determining the current and future care needs of the patient. Findings included: MR#1: The Start of Care (SOC) was dated 1/20/2021. The Plan of Care (POC) for the certification period 3/21/2021 to 5/19/21 identified diagnoses of diabetes type 2 (DM2), Hypertension (HTN), Atrial Fibrillation (A-fib), and Chronic Obstructive Pulmonary Disease (COPD). Upon review of the Comprehensive Assessment under the category of "Patient History and Diagnoses," documentation consisted of a list of diagnoses and identified the date as the admission date of 1/20/21 rather than dates of onset, exacerbations, past medical treatments and outcomes. There was no information found in the comprehensive assessment of the events that led to the need for current home care services. **Agency Policy: "Initial Assessments/Comprehensive Assessments", revised January 2020. The policy states, "Each patient admitted will receive a comprehensive assessment. The assessment will reflect the patient's current health status and include information to demonstrate the patient's progress toward achievement of desired outcomes. The Initial Comprehensive Assessment also includes relevant diagnoses and current health status including all active health and medical problems, and relevant medical history." In addition, the Skilled Nurse (RN#1) documented on the Recertification Comprehensive Assessment dated 3/19/21 under the category of Medications: Management of Injectable Medications, "NA {not applicable}, no injectable medications prescribed." However, the patient was currently prescribed "Lispro (insulin) 60 units twice per day via subcutaneous injection. RN#1 failed to accurately assess the patient's current health status. MR#2: The SOC was dated 12/19/20. The POC for the certification period 2/17/21 to 4/17/21 identified diagnoses of Sepsis, Encounter for change of non-surgical wound dressing, Diabetes type 2 (DM2), Congestive Heart Failure (CHF), Chronic Kidney Disease (CHF), and Atrial Fibrillation (A-fib). The patient was receiving Skilled Nursing (SN) and Physical Therapy (PT) Services. Upon review of the Comprehensive Assessment under the category of "Patient History and Diagnoses," documentation consisted of a list of diagnoses and identified the date as the admission date of 2/17/21 rather than dates of onset, exacerbations, past medical treatments and outcomes. There was no information found in the comprehensive assessment of the events that led to the need for current home care services. MR#3: The SOC was dated 2/19/21. The POC for the certification period 4/20/21 to 6/19/21 identified diagnoses of osteoarthritis (OA), chronic pain, hypertension (HTN), and Atrial Fibrillation. The patient was receiving Skilled Nursing (SN) and Physical Therapy (PT) services. Upon review of the Comprehensive Assessment under the category of "Patient History and Diagnoses," documentation consisted of a list of diagnoses and identified the date of onset as the admission date of 2/19/21 rather than the actual dates of onset, exacerbations, past medical treatments, and outcomes. There was no information found in the comprehensive assessment of the events that led to the need for current home care services. MR#4: The SOC was dated 1/2/20, The POC for the certification period 3/2/20 to 4/30/20 identified diagnoses of generalized osteoarthritis (OA), Basal Cell Skin Cancer of Left upper limb and right lower limb, and Hypertension (HTN). The patient was receiving Skilled Nursing (SN) and Physical Therapy (PT) services. Upon review of the Comprehensive Assessment under the category of "Patient History and Diagnoses," documentation consisted of a list of diagnoses and identified the date as the admission date of 1/2/21 rather than dates of onset, exacerbations, past medical treatments and outcomes. There was no information found in the comprehensive assessment of the events that led to the need for current home care services. These findings were reviewed and acknowledged by the Alternate Director of Nursing (ADON#3) on 4/28/21 at 3:30 p.m. MR #5: The plan of care, dated 12-16-20, stated the patient was admitted with the primary diagnosis of multiple rib fractures on the right side and secondary diagnoses that included lumbar vertebrae fracture and history of falls. On the start of care comprehensive assessment, dated 12-16-20, the nurse documented, the patient "had 2 falls in the last month. No injuries reported or noted." There was no documented assessment of the circumstances of the patient's falls such as when and how the falls occurred. There was no documented assessment of when or how the patient fractured her ribs and spine. There was no documented assessment of the events that led to this home care referral/admission. MR #6: The plan of care, dated 3-31-21, stated the patient was recertified for nursing and physical therapy services with diagnoses that included encounter for changing non-surgical wound dressing, Lymphedema, diabetes, venous insufficiency and cellulitis of the lower extremities. The plan of care also stated the patient's medications included injectable Insulin Glargine and Insulin Aspart. During the review of the recertification comprehensive assessment dated 3-26-21, it was noted that there was no documented assessment of the patient's current blood sugar or a summary of the patient's recent blood sugar ranges. MR #7: The plan of care dated, dated 1-9-21, stated the patient was admitted with diagnoses that included sacral fracture, hypertension, sacral pressure ulcer, history of falls and urinary tract infections. The Physician's face to face referral stated the patient also had a diagnosis of diabetes. During review of the start of care comprehensive assessment, dated 1-9-21, it was noted that there was no assessment of the status of the patient's diabetes and no assessment of the patient's baseline blood sugar. On the recertification comprehensive assessment, dated 3-9-21, it was noted that there was no assessment of the status of the patient's diabetes and no blood sugar findings or summary of blood sugar ranges during the first certification period.

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 covered all pertinent interventions with reportable parameters, and objectively measurable goals specific to the needs of the patient for 7 records reviewed (MR#s 1, 2, 3, 4, 5, 6, and 7) from a total sample of 7 sampled records reviewed, resulting in patients not receiving care specific to their individual needs and the potential for poor patient outcomes. Findings included: **Agency Policy: "Plan of Care-DMS#485 and Physicians Orders, revised March 2019. The policy states, "Each patient must receive an individualized written plan of care. 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." MR#1: The Start of Care was dated 1/20/2021. The Plan of Care (POC) for the certification period 3/21/21 to 5/19/21 identified diagnoses of diabetes type 2 (DM2), Hypertension (HTN), Atrial Fibrillation (A-fib), and Chronic Obstructive Pulmonary Disease (COPD). Upon review of the POC it was noted that goals were not objectively measurable to determine progress towards goals. Examples include: "Bowel status will be within normal limits (WNL) for patient by 5/19/21"; "Increased Activity Tolerance start 3/21/21"; "Patient will verbalize/demonstrate, medication management/alternative relief measures, behavior modification to reduce factors that increase pain/use of pain scale to identify intensity and determine pain goal." These goals are not objectively measurable to determine the progress towards goals. In addition, the Plan of care included an order to assess the patient's pain every visit, however, there were no reportable parameters included in the order to address the patient's pain issues. MR#2: The SOC was dated 12/19/20. The POC for the certification period 2/17/21 to 4/17/21 identified diagnoses of Sepsis, Encounter for change of non-surgical wound dressing, Diabetes type 2 (DM2), Congestive Heart Failure (CHF), Chronic Kidney Disease (CHF), and Atrial Fibrillation (A-fib). MR#3: The SOC was dated 2/19/21. The POC for the certification period 4/20/21 to 6/19/21 identified diagnoses of osteoarthritis (OA), chronic pain, hypertension (HTN), and Atrial Fibrillation. Upon review of the POC it was noted the goals were not individualized or objectively measurable. Examples include: "Respiratory: Dyspnea will decrease by___Achieve by 6/18/21"{sic}; "Cardiovascular: Peripheral Edema will improve from grade____ to grade____ "{sic}; "Pain: Pain level will be improved to ____ on a 1-10 scale. Achieve by 6/18/21." {sic}; "Return to optimal and safe functionality by discharge."{sic} MR#4: The SOC was dated 1/2/20, The POC for the certification period 3/2/20 to 4/30/20 identified diagnoses of generalized osteoarthritis (OA), Basal Cell Skin Cancer of Left upper limb and right lower limb, and Hypertension (HTN). Upon review of the POC it was noted the goals were not individualized or objectively measurable. Examples included: "The patient will verbalize/demonstrate understanding of symptom management, resource utilization, and medication management to reduce unplanned hospitalization or emergency department visits; patient will verbalize/demonstrate knowledge of medication management: dose, route, and schedule, actions, interactions, and contraindications/administration and compliance with pre-filled medications/adherence to diet impacting medications/safe preparation and storage of medications/side effects and symptoms to report by ___ Achieve by 5/29/21." {sic} These findings were reviewed and acknowledged during an interview with the Alternate Director of Nursing (ADON#3) on 4/28/21 at 3:30 p.m. ADON#3 stated, "the problem is they are just checking goals offered by our electronic record, and they don't remember to fill in the blanks with numbers to make the goals objectively measurable." MR #5: The plan of care dated 4-8-21 stated the patient was admitted with diagnoses that included cardiac arrhythmia, abnormalities of gait and mobility, fractured ribs and fractured spine. The activities permitted section of the plan of care included conflicting orders for both "complete bed rest" and "Up as tolerated." The plan of care included goals such as "Pt (patient) will demonstrate increased endurance by_____ Achieve date: 05/07/21"; Pt/Cg (caregiver) will state understanding of measures to manage disease band s/s (signs/symptoms) to report by____ Achieve by date: 05/07/21"; and "Independent with safety measures within 5 weeks." These goals are not patient specific and objectively measurable. MR #6: The recertification plan of care dated 3-31-21 stated the patient's diagnoses included non-surgical wound and diabetes. The plan of care also stated the patient's medications included Insulin Glargine and Insulin Aspart. The medication list on the plan of care included orders for "Insulin Glargine (Lantus) 100 unit/ml Subcutaneous 60 UI (units) Twice per day diabetes... Start Effective Date 01/29/21" and "Insulin Glargine (Lantus) 100 unit/ml Subcutaneous 60 iu (international units) every morning DM (diabetes)... Start Effective Date 01/29/21." The plan of care order was unclear as to whether the patient was to take Insulin Glargine 1, 2 or 3 times per day. The plan of care included an order for "Insulin Aspart (NovoLOG FlexPen) 100 UNIT/ML Subcutaneous 7ui/sliding scale PRN/As Needed diabetes." The plan of care did not include documentation of the details of how much insulin the patient should take for each level of increasing blood glucose levels. The plan of care also included an order for the nurse to "Assess/perform/instruct Pt/Pcg (patient/patient caregiver): blood glucose testing every____ and importance of recording and compliance Start Effective Date: 03/31/21." This order was incomplete and did not specify the frequency for which the patient's blood glucose level should be checked. The plan of care included goals such as "Pt will demonstrate increased endurance by ____ Start Effective Date 03/31/21"; "Bowel status will be WNL (within normal limits) for patient by 05/292021 (sic) Start Effective Date: 03/31/21"; and "Patient will verbalize/demonstrate understanding of symptom management, resource utilization, and medication management to reduce unplanned hospital or emergency department visits by: 05/29/21 Start Effective Date 03/31/21." These goals are not patient specific and objectively measurable. MR #7: The plan of care, dated 1-9-21, stated the patient was admitted with diagnoses that included sacral fracture, hypertension, sacral pressure ulcer, history of falls and urinary tract infections. The Physician's face to face referral stated the patient also had a diagnosis of diabetes. The plans of care, dated 1-9-21 and 3-10-21, did not include or address the patient's diagnosis of diabetes. There were no diabetes precautions on the plans of care.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review, observation and interview, it was determined the Agency failed to ensure the Physician was promptly notified, as ordered in the plan of care, of vital signs and blood sugar readings outside the reportable parameters, for 1 record (MR #1) in 1 of 7 total sampled records reviewed; and failed to notify the physician of new problems reported by the patient in 2 of 7 records reviewed of a total sample of 7 records (MR #5 and 6), resulting in the potential for unidentified, untreated health concerns and unmet care needs. Findings include: MR#1: The Start of Care (SOC) was dated 1/20/2021. The Plan of Care (POC) for the certification period 3/21/2021 to 5/19/21 identified diagnoses of diabetes type 2 (DM2), Hypertension (HTN), Atrial Fibrillation (A-fib), and Chronic Obstructive Pulmonary Disease (COPD). The Plan of Care dated 3/21/21 included the following order: "Notify Physician if blood glucose is over 200 mg/dl or less than 90 mg/dl fasting/random." Upon review of the skilled nurse visit notes by RN#1 it was noted that on 4/1/21 the patient had a blood sugar result of 374 and on 4/8/21 the patient had a blood sugar result of 337. RN#1 failed to have direct contact with the physician on 4/1/21 but left a voicemail message with no further documentation of any contact, conversation or new orders. During the exit conference on, the Alternate Director of Nursing stated, "I agree, the nurse should have spoken with someone directly." In addition, the patient was assessed to have a pain level of "3" on a 10 point scale on 3/19/21 as documented on the Recertification comprehensive assessment. However, a review of the records of the skilled nurse assessments by RN#1 on 3/24/21, 4/1/2, and 4/8/21, each documented pain levels of "8" on a 10 point scale. There was no evidence found in the record that RN#1 had notified the physician of the increased pain or obtained new orders for pain relief in an attempt to improve the patient's pain. MR#3: The SOC was dated 2/19/21. The POC for the certification period 4/20/21 to 6/19/21 identified diagnoses of osteoarthritis (OA), chronic pain, hypertension (HTN), and Atrial Fibrillation. The patient was receiving Skilled Nursing (SN) and Physical Therapy (PT) services. These findings were reviewed and acknowledged during an interview with the Alternate Director of Nursing (ADON#3) on 4/28/21 at 3:30 p.m. MR #5: The plan of care, dated 4-8-21, stated the patient was admitted with diagnoses that included cardiac arrhythmia, hypertension and history of falls. On the start of care comprehensive assessment, dated 4-8-21, the nurse documented the patient had a cardiac halter monitor, palpitations, dizziness and a history of falls. During nurse/surveyor joint visit on 4-22-21 at 4:00 PM, this surveyor observed the patient telling the nurse about a problem of waking up in the middle of the night with a sensation of someone pushing on her back and/or the feeling that the patient's mattress was floating in the air and moving around the room. During the home visit observation it was noted that the nurse did not call the physician to report the new symptoms reported by the patient. During the review of the nurse's visit note documentation for the home visits on 4-22-21, it was noted that there was no documentation that the nurse notified the physician of the newly report symptoms. During an interview on 4-27-21 at 4:15 PM, the Administrator stated, "The nurse should have let the physician know about that, the patient probably has a inner ear problem." MR #6: The recertification plan of care, dated 3-31-21, stated the patient was recertified with diagnoses that included nonsurgical wound dressing changes, diabetes, Lymphedema, venous insufficiency and cellulitis of the lower legs. On the nursing visit note, dated 4-6-21, the nurse documented "Pt (patient) c/o (complaining of) new burning ache in Rt (right) posterior calf, states it started a couple of days ago, no visible changes to the area..." There was no documented evidence that the nurse notified the physician of the patient's complaint of new calf pain. During an interview on 4-27-21 at 4:25 PM, the Administrator stated, "The nurse should have let the physician know about that."

Laboratory services/CLIA waivers CFR(s): 484.100(c)(1) Laboratory services. If the HHA engages in laboratory testing outside of the context of assisting an individual in self-administering a test with an appliance that has been cleared for that purpose by the Food and Drug Administration, the testing must be in compliance with all applicable requirements of part 493 of this chapter. The HHA may not substitute its equipment for a patient's equipment when assisting with self-administered tests. This STANDARD is not met as evidenced by: Based on observation, document review, and interview the agency failed to hold the appropriate CLIA (Clinical Laboratory Improvement Amendment) certification for laboratory services and was out of compliance with 42 CFR 484.100(c)(1), resulting in a lack of certification for patient laboratory services. Findings included: A request was made to produce a valid CLIA certificate. Upon presenting the CLIA certificate it was noted that the CLIA Waiver had expired on 7/8/2020. During an interview on 4/20/21 at 2:00 pm, Admin#1 (administrator) explained, "We didn't know our CLIA certificate had expired." The agency failed to hold the appropriate CLIA certification for laboratory services. These findings were reviewed and acknowledged during an interview with the Alternate Director of Nursing (ADON#3) on 4/28/21 at 3:30 p.m.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on record review, observation and interview, it was determined the agency failed to ensure clinical record documentation was complete in 1 of 7 records reviewed out of a total sample of 7 records (MR #5), resulting in potential for unidentified and unmet patient needs. Findings include: MR #5: The plan of care, dated 4-8-21, stated the patient was admitted with diagnoses that included cardiac arrhythmia, hypertension and history of falls. On the start of care comprehensive assessment, dated 4-8-21, the nurse documented the patient had a cardiac halter monitor, palpitations, dizziness and a history of falls. During nurse/surveyor joint visit on 4-22-21 at 4:00 PM, this surveyor observed the patient telling the nurse about a problem of waking up in the middle of the night with a sensation of someone pushing on her back and/or the feeling that the patient's mattress was floating in the air and moving around the room. It was also observed that the nurse and the patient had a discussion about the patient having dizzy spells that have improved since the last nursing visit. During the review of the nurse's visit note documentation for the home visits on 4-22-21, it was noted that there was no mention of the patient reporting new sensations waking her up at night or the discussion about the patient's dizziness. During an interview on 4-27-21 at 4:15 PM, the Administrator stated, "That should've been documented in the nurse's visit note. I don't know why its not there."