Every finding on record at Clm Enterprises, Inc

An unannounced Complaint survey (#62204) and Agency vaccination requirement survey was conducted by the Michigan Department of Licensing and Regulatory Affairs on 3/30/22 through 4/6/22 at: Interim Health Care 1971 E Beltline Ave. NE, Suite 225 Grand Rapids, MI 49525 The Agency does not maintain any branch locations. There were 9 allegations in total, allegations #1, #3, #5 (condition level) and #9 (standard) were found to be substantiated. Allegations #2, #4, #6, #7, and #8 were found to be unsubstantiated due to lack of sufficient evidence. Clinical records reviewed for this survey include: 2 active records without home visits, 1 active record with a home visit, and 2 discharged records, for a total of 5 records reviewed. The Agency was in compliance with CMS vaccination requirements for all staff. The following condition level deficiency was identified during the investigation: 42 CFR §484.60 Care planning, coordination of services, and quality of care. As a result of the Condition level noncompliance on 3/31/22, the Agency is prohibited for 2 years from offering a Home Health Aide training and competency evaluation or a competency evaluation program as specified in 42 CFR §484.80(f)(3).

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to monitor for pressure sores which resulted in a poor outcome for 1 (MR#1) of 4 patients reviewed with pressure ulcer wounds out of a total of 5 records reviewed (See G578); and failed to ensure the physician was notified of changes in the patient's condition for 1 (MR#1) of 1 patients reviewed with a significant change in condition out of a total of 5 sampled records, resulting in unidentified, and unmet care needs (See G590). The cumulative effect of these systemic problems resulted in a poor outcome and 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 484.60: Care Planning, Coordination of Services, and Quality of Care.

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 document review and interview, the Registered Nurse (RN #1) failed to monitor and provide interventions in conformance with physician orders in 1 (MR #1) of 4 records which required wound care, from a total of 5 sampled records reviewed, resulting in a poor patient outcome with the development and progression of a pressure ulcer wound. Findings include: Agency Policy: "Implementing the Plan of Care/Service Plan" Chapter 6-Care Delivery (updated 4/2/21) stated, "Interim Healthcare provides care/services in accordance with the Plan of Care/Service Plan and standards of practice... To ensure that the written plan of care/service plan is implemented... Precautions to prevent and control infection... Education provided as appropriate to the patient's disease, physical condition and mental status." MR #1: The referral dated 12/7/21, ordered PSN (psychiatric skilled nursing) services due to increased aggression, both verbally and physically toward staff. The patient's start of care (SOC) to the home health agency (HHA) was 12/8/21 with diagnoses that included specified degenerative diseases of nervous system, dementia, schizoaffective disorder-bipolar type, and diabetes. The plan of care (POC) effective 12/8/21, ordered skilled nursing (SN) at a frequency of 2w2 (twice a week times two weeks) followed by 1w6 with 3 PRN (as needed) visits for falls, medication changes and other complications. Record review on 3/30/22 noted SN performed the home visit frequency as ordered above with an early discharge to hospice on 1/3/22. Review of SN visits made from 12/8/21 through 1/3/22 (7 of 7), found no evidence of the patient having any wound(s). Further review of all physician orders and communication notes found no documentation concerning wound(s) or skin breakdown. During survey activities, it was discovered the patient resided at an Adult Foster Care (AFC) home with submitted documentation (11/7/21 through 1/12/22) which reflected clinical care the patient received while at the AFC. Review of this documentation noted the following significant findings. On 12/24/21 under “Nurse’s Note” staff documented, “I washed up his would (sic) and applied some antibiotic ointment to prevent further infection.”The 12/25/21 “Nurses Note” documented, “Resident has open area near coccyx, applied zinc oxide to area. Resident also has scrotal/pelvic edema. Area is mapped out if swelling increases or resident doesn’t urinate, resident will be sent to hospital to be assessed.”On 1/1/22, the “Nurses Note” documented, “Residents buttocks appears to be worse than a few days ago, applied zinc ointment to area." The patient was discharged from the home health agency on 1/3/22 and admitted to hospice the next day on 1/4/22. During review of submitted documentation concerning the hospice SOC initial assessment performed by SN dated 1/5/22, the following wound documentation was noted: "Location: Sacrum, Status: Open, Type: Pressure Ulcer, Stage: Suspected Deep Tissue Injury, Size: Length 6 cm., Width: 5 cm., Depth: 0.2 cm., Drainage: Bloody, Amount: Scant, Odor: Foul, Treatment: No treatment prior to hospice sign on apparently." Review of the POC for MR#1 noted the following documentation under “Orders and Treatments”. “Patient will be monitored for pressure sores. Patient/caregiver will be instructed on pressure relief measures and prevention of pressure sores. Clinician will assess skin for s/s (signs and symptoms) of breakdown each visit. Notify MD of any new areas of skin breakdown or s/s of infection.” All visit notes documented the patient’s skin as, “WNL (within normal limits), warm, dry, and turgor (elasticity of skin) as good/elastic.” No other documentation was found which attested the above measures were performed as specified above in the patient's POC. Additional information was utilized from a submitted investigation report by LARA (Licensing and Regulatory Affairs) on 3/4/2022 (#2022A0467019) concerning the care provided to MR#1 by the AFC. During review of this report, the following significant findings were noted. "(Surveyor) reviewed a copy of a "Physician Order Sheet," signed by (MD#1) on 12/28/21 stating, "please d/c psych nursing. Eval for wound care services. Dx: buttocks wound." MD#1 at the AFC is also the same physician listed on MR#1's POC at the HHA. Review of the HHA's documentation concerning MR#1's physician orders to discontinue psychiatric nursing and start wound care services was not found in the clinical record. No evidence was found explaining how the physician's order on 12/28/21 failed to be incorporated into MR#1's POC at the HHA. Subsequently, no wound care measures were implemented early on, with documentation showing on 1/5/22 (hospice admission) the progression of the pressure ulcer wound. The agency failed to coordinate care between the AFC and HHA and failed to meet the clinical needs of the patient. During an interview with Adm#1 and DHS#1 on 3/31/22 at 2:10 PM, the above findings were reviewed and acknowledged. Both Adm#1 and DHS#1 stated the agency had no prior knowledge of the patient forming a wound while under the agency's 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 and interview, the agency failed to ensure the physician was notified of a significant change in condition in 1 (MR#1) of 1 record reviewed with a new wound, out of a total sample of 5 records, resulting in a poor patient outcome for this one patient. Findings include: MR #1: The patient's start of care (SOC) was 12/8/21 with diagnoses that included specified degenerative diseases of nervous system, dementia, schizoaffective disorder-bipolar type, heart failure, and diabetes. The plan of care (POC) effective 12/8/21, ordered skilled nursing (SN) at a frequency of 2w2 (twice a week times two weeks) followed by 1w6 with 3 PRN (as needed) visits for falls, medication changes and other complications. Record review on 3/30/22 noted SN performed the home visit frequency as ordered above with an early discharge to hospice on 1/3/22. Review of SN visits made from 12/8/21 through 1/3/22 (7 of 7), found no evidence of the patient having any wound(s). Further review of all physician orders and communication notes found no documentation concerning wound(s) or skin breakdown. During survey activities, it was discovered the patient resided at an Adult Foster Care (AFC) with submitted documentation (11/7/21 through 1/12/22) which reflected clinical care the patient received while at the ALF. Review of this documentation revealed the following significant findings. On 12/24/21 under “Nurse’s Note” staff documented, “I washed up his would (sic) and applied some antibiotic ointment to prevent further infection.”The 12/25/21 “Nurses Note” documented, “Resident has open area near coccyx, applied zinc oxide to area. Resident also has scrotal/pelvic edema. Area is mapped out if swelling increases or resident doesn’t urinate, resident will be sent to hospital to be assessed.”On 1/1/22, the “Nurses Note” documented, “Residents buttocks appears to be worse than a few days ago, applied zinc ointment to area. The patient was discharge from the home health agency on 1/3/22 and admitted to hospice the next day on 1/4/22. Review of the POC for MR#1 noted the following documentation under “Orders and Treatments”. “Patient will be monitored for pressure sores. Patient/caregiver will be instructed on pressure relief measures and prevention of pressure sores. Clinician will assess skin for s/s (signs and symptoms) of breakdown each visit. Notify MD of any new areas of skin breakdown or s/s of infection.” All visit notes documented the patient’s skin as, “WNL (within normal limits), warm, dry, and turgor (elasticity of skin) as good/elastic.” No other documentation was found which attested the above measures were performed. In addition to the new wound, the agency failed to notify the physician concerning MR#1's significant weight loss. Record review on 3/30/22 noted RN#1 performed the OASIS (Outcome and Assessment Information Set) SOC on 12/8/21. RN#1 documented, “Weight: 160. Actual.” The OASIS discharge from the agency on 1/3/2022 (non-billable) was 2 days prior to the SOC hospice initial assessment. The home health agency (HHA) and hospice are under the same corporate umbrella, and for billing purposes cannot bill on the same day. Therefore, the HHA deferred the discharge assessment to the SOC hospice assessment the following day after hospice consents were signed by MR#1s wife on 1/4/22. Review of the 1/5/22 hospice assessment noted MR#1’s weight as 115 (45-pound loss in 28 days). Review of the HHA's skilled nursing (SN) visit notes for MR#1on 12/10/21 through 12/29/21, documented no patient weights. All routine visit notes (5 of 5) on 12/10/21, 12/13/21, 12/15/21, 12/22/21, and 12/29/21 documented the following narrative in describing the patient: “His appearance and mannerisms are normal”. However, the 12/29/21 visit note also documented, “Staff (AFC) reports the patient has become much more less motivated, they report that he does not want to get up and move much he sits in the chair all day.” (sic) No evidence was found in the clinical record of SN communicating or coordinating care among the physician or other team members concerning the patient’s significant weight loss. SN failed to document accurate reflections of the patient’s well-being with a noted poor outcome of a hospice admission (1/5/22) and death (1/17/22). During an interview with DHS#1 on 4/6/22 at 10:46 AM, the above findings were reviewed and acknowledged. DHS#1 stated, “This is going to be a good opportunity for us to communicate better.”

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, it was determined that the agency failed to ensure the clinical record was complete, including assessments, notes, and evaluations, for 1 (MR #1) of 5 records reviewed, from a total sample of 5 records, resulting in an incomplete record, an incomplete depiction of the patient's health status, and the potential for unmet care needs. Findings include: MR #1: The patient's start of care (SOC) was 12/8/21 with diagnoses that included specified degenerative diseases of nervous system, dementia, schizoaffective disorder-bipolar type, heart failure, and diabetes. The plan of care (POC) effective 12/8/21, ordered skilled nursing (SN) at a frequency of 2w2 (twice a week times two weeks) followed by 1w6 with 3 PRN (as needed) visits for falls, medication changes and other complications. The complainant stated in the intake documentation that, “…. I was alarmed because I had just reviewed his medical records from two ER visits in the month of December…” Furthermore, an email communication provided from the complainant on 3/30/22 documented two ER visits. The first ER visit was on 12/9/21 stating, “Chief Complaint: Fall.” The second ER visit was on 12/16/21 stating. “Chief Complaint: Altered Mental Status, Covid-19.” During record review on 3/30/22, it was noted that RN#1 completed visits on 12/10/21, 12/13/21, 12/15/21, 12/22/21, 12/29/21, and a phone discharge to hospice on 1/3/22. A file titled “CT head.pdf” was uploaded into the Electronic Medical Record (EMR) on 12/16/21 that contained a “Radiology Report” dated 12/9/21 stating, “CT Head WO (without) Contrast – 12/9/2021. Indication: trauma fall.” There is no ER documentation within the six visits completed by RN#1 after the first ER visit on 12/9/21 or any acknowledgement of a second ER visit on 12/16/21. Additionally, the POC dated 12/8/21 documented 17 SN goals that included, “Patient will have no falls throughout treatment plan and Patient/cg (caregiver) will be able to verbalize fall risk interventions and prevention by end of treatment period, Patient will remain free from pressure ulcers by end of treatment period, and Patient skin integrity will remain intact during this episode.” RN#1 completed an OASIS (Outcome and Assessment Information Set) discharge on 1/3/22 that stated, “Goal Summary. Met Goals (17).” Conversely, the patient sustained a fall requiring an ER visit on 12/9/21 and review of submitted documentation concerning the hospice SOC initial assessment performed by SN dated 1/5/22, the following wound documentation was noted: "Location: Sacrum, Status: Open, Type: Pressure Ulcer, Stage: Suspected Deep Tissue Injury, Size: Length 6 cm., Width: 5 cm., Depth: 0.2 cm., Drainage: Bloody, Amount: Scant, Odor: Foul, Treatment: No treatment prior to hospice sign on apparently." Furthermore, the discharge documented, “Care Summary: (care given, progress, regress including therapies) Services Provided: Skilled Nursing. Patient seen by psych nursing for signs or symptoms of depression or insanity, changes in cognitive status, coping mechanisms, staff education. Specific discharge instructions given: Follow up with hospice with any changes. Goals not met: Na.” The agency failed to document the ER visits, appropriately address goals and illustrate the patient’s decline that required hospice. Additional record review was performed on 3/31/22 with Adm#1 at 10:20 AM to ascertain the process and events that led to the decision to transfer the patient to hospice as the SN visit frequency was shortened 3 weeks early. No evidence or explanation was found in the clinical record as to why the patient abruptly was admitted to hospice. At the end of the record review at 10:45 AM, Adm#1 stated, "I agree, there's really no story of what happened with the transfer to hospice." The agency failed to ensure the clinical record was complete and detailed the events leading up to discharge. During an interview with Adm#1 and DHS#1 on 3/31/22 at 2:20 PM, the above findings were reviewed and acknowledged. Both Adm#1 and DHS#1 stated the agency had no prior knowledge of the patient’s ER visits and forming a wound while under the agency's care.