Every finding on record at Community Health Center of Branch County

On 5/2/22 through 5/5/22, the Michigan Department of Licensing and Regulatory Affairs conducted a recertification survey at Community Health Center of Branch County Home Health. 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 on 5/2/22 through 5/5/22 at: Community Health Center of Branch County Home Health (legal). Promedica Coldwater Home Health and Hospice (DBA). 300 E. Chicago Street Coldwater, MI 49036At the time of the survey, the agency did not operate any branch offices or subunits.The services the agency provides are: Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), Medical Social Work (MSW), and Home Health Aide (HHa)For this survey: 3 home visits with record reviews, 2 active records without a home visit and 2 discharged records were reviewed 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 §484.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the Agency failed to ensure patients were informed in advance of the disciplines that will furnish care and the proposed visit frequency in 3 of 3 (MR#'s 1, 2, and 3) records reviewed with home visits, out of a total sample of 7 records, resulting in these patients not having knowledge regarding their plans for treatment. Findings include: On 5/4/22, the Agency's patient consent and other forms were reviewed, and it was noted that the forms failed to include an area to note the disciplines that would furnish care and the frequency of visits. MR#1: This patient was admitted to the Agency on 4/23/22. The plan of care (POC) dated 4/23/22, ordered weekly visits from Skilled Nursing (SN), Physical Therapy (PT), and Medical Social Worker services. During review of the clinical record on 5/4/22, it was noted that the consent forms signed by the patient failed to indicate the disciplines and proposed visit frequency of services to be provided. There were no other documents noted to include notification to the patient of the disciplines and proposed frequency of visits. During a joint surveyor home visit with PT on 5/3/22 at 1:30 PM, it was observed that the forms failed to indicate the disciplines and proposed visit frequency of services to be provided. The findings were reviewed with the Administrator (Adm.#1) on 5/4/22 at 2:45 PM., and Adm.#1 stated, "The consents are loaded up into Home Care Home Base (electronic medical record/EMR), and we can pull them up and see." At 2:45 PM., it was verified that the consent forms uploaded into the Agency's EMR failed to include the required information concerning the disciplines and the proposed visit frequency that would be furnished to the patient. MR#2: This patient was admitted to the Agency on 4/14/22. The POC dated 4/14/22, ordered weekly visits from SN, PT, Occupational Therapy (OT), and Home Health Aide services. During review of the clinical record on 5/4/22, it was noted that the consent forms signed by the patient failed to indicate the disciplines and proposed visit frequency of services to be provided. There were no other documents noted to include notification to the patient of the disciplines and proposed frequency of visits. At 2:50 PM., Adm.#1 confirmed and acknowledged the above findings. MR#3: This patient was admitted to the Agency on 4/19/22. The POC dated 4/19/22, ordered weekly visits from SN, PT, and OT services. During review of the clinical record on 5/4/22, it was noted that the consent forms signed by the patient failed to indicate the disciplines and proposed visit frequency of services to be provided. There were no other documents noted to include notification to the patient of the disciplines and proposed frequency of visits. At 2:55 PM., Adm.#1 confirmed and acknowledged the above findings.

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 document review and interview, the Agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status, past medical history, history of events leading to home care, baseline data for future assessments, and ascertained the patient's immediate care needs in 2 of 2 records (MR's #5 and #6) reviewed with therapy only cases, from a total sample of 7 records reviewed, resulting in the potential for unmet care needs. Findings include: MR #5: The patient was admitted on 11/18/21 for Physical Therapy (PT) and Occupational Therapy only services, with diagnoses that included hypertensive heart and chronic kidney disease with heart failure, dehydration, and ischemic (low blood supply) cardiomyopathy. On 5/4/22, review of the referral for home care from the hospital dated 11/8/21, noted "Active Problems" which included: Hypovolemic shock from severe dehydration, acute chronic renal failure, C. difficile colitis diarrhea with electrolyte imbalances. Past medical history also included congestive heart failure (CHF), and diabetes-type 2. During review of the comprehensive assessment (11/18/21) performed by PT, under the category of "Diagnoses/Procedures", PT documented the patient's CHF was a level 4: "Symptoms poorly controlled, history of re-hospitalizations." PT failed to assess and incorporate the patient's diagnosis of diabetes noted on the referral for home care. Additional opportunities to assess and document in the comprehensive assessment were found under the "Cardiovascular" section, which only mentioned hypertension as the only heart related issue. Further, the "Endocrine" assessment section failed to have any documentation which pertained to the patient's diabetes. All narrative found within the comprehensive assessment was void of any history of dates of onset, and exacerbation for any of the above diagnoses. Documented history of the past treatments for each of the listed diagnoses along with outcomes from those treatments were not found. MR #6: The patient was admitted on 1/10/22 for PT only services, with diagnoses that included hypertensive heart disease with heart failure, diabetes-type 2, and history of falling. During review of the comprehensive assessment (1/10/22) performed by PT, under the category of "Diagnoses/Procedures", PT documented the patient's CHF and diabetes were a level 3: "Symptoms poorly controlled, patient needs frequent adjustments in treatment and dose monitoring." All diagnoses (10 of 10) dates of onset were documented as 1/5/2022 through 1/10/22-with noted right total knee on 1/6/22. However, PT documented the patient had a right total knee replacement on 10/27/21 in the narrative summary. Review of the referral for home care noted past medical/surgical history diagnoses (27 in total) ranging from 1993 through 10/27/21. Additional opportunities to assess and document in the comprehensive assessment were found under the "Cardiovascular" section, which only mentioned hypertension as the only heart related issue. The Agency failed to ensure that therapy only assigned cases had conducted a patient-specific, initial comprehensive assessment that accurately reflected the patient's current health status, and pertinent past medical history. During an interview on 5/5/22 at 11:15 AM., these findings were reviewed and acknowledged by the Administrator (Adm.#1) and the Director of Professional Services (DPS#1).

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 that the Agency failed to ensure the comprehensive assessment included a review of all medications to determine any adverse effects, severe drug to drug interactions, and duplicate drug therapies in 1 record (MR# 4) from a total of 7 sampled records reviewed, resulting in the potential for harmful medication effects for all 36 active patients currently serviced by this Agency. Findings include: MR#4: This patient was admitted on 12/3/2021 with diagnoses which included open wound-right foot, pressure ulcer of sacral region-stage 2, diabetes, and chronic kidney disease. During record review on 5/3/22, it was noted under Section M2001 (medication review) of the initial comprehensive assessment performed by the Registered Nurse on 12/3/21 documented, "No issues found during review." The patient's 21 prescribed medications were entered in "Drugs.com" (online pharmaceutical encyclopedia used to provide drug information to healthcare professionals) and revealed the following: 7 major (most severe) interactions, 20 moderate interactions, and 4 duplicative drug therapies. In addition, multiple medications listed had contained Tylenol, with a potential total dose of 4550 mg./24 hours. The upper limit allowed is 4000 mg./24 hours to prevent liver damage. The patient's diagnosis of chronic kidney disease exacerbates this potential overdose further. During an interview on 5/5/22 at 10:50 AM., these findings were reviewed and acknowledged by the Administrator (Adm.#1) and the Director of Professional Services (DPS#1). DPS#1 then reviewed the listed safety concerns found in the Agency's electronic medical record (Home Care Home Base). Utilizing the same medication list, it showed only 2 major interactions. No documentation was found which alerted clinicians to the other major interactions, duplicative drug therapies or the excessive Tylenol dosages. Adm.#1 further noted that corporate (Promedica) expectations were that all interactions are to be passed on to the physician. However, no policy specific to this Home Health Agency was found concerning medication review. The Agency failed to ensure the comprehensive assessment included a review of all medications used by the patient to identify potential adverse effects and notify the physician of the findings.

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, safety precautions and objectively measurable goals specific to the needs of the patient for 3 (MR#'s 3, 5 and 6) of 7 sampled records reviewed, resulting in patients not receiving care specific to their individual needs and the potential for poor patient outcomes for all 36 patients currently admitted to this Agency. Findings include: MR #3: The patient was admitted on 4/19/22 with diagnoses that included hypertensive heart disease with heart failure, atrial fibrillation, and anxiety. Review of the clinical record on 5/3/22, noted the Plan of Care (POC) dated 4/19/22 ordered skilled nursing (SN), physical therapy (PT), and occupational therapy (OT) services to be provided. The POC ordered SN to "provide skilled teaching related to CHF (congestive heart failure) ..." There were no set reportable parameters in which to notify the Physician concerning exacerbation of CHF symptoms (edema or increased weight gain). Additionally, none of the listed SN goals (11 of 11) were written in measurable terms. Examples include: "Patient will receive medications as prescribed; Patient/caregiver will verbalize/demonstrate the ability to manage self-care for altered cardiovascular status by the end of the episode..." The Plan of Care failed to include pertinent cardiac parameters along with objectively measurable SN goals to help ensure the safety of the patient. MR #5: The patient was admitted on 11/18/21 for Physical Therapy (PT) and Occupational Therapy only services, with diagnoses that included hypertensive heart and chronic kidney disease with heart failure, dehydration, and ischemic (low blood supply) cardiomyopathy. On 5/4/22, review of the patient's POC (dated 11/18/21) by PT noted the POC ordered PT to "assess patient for risk factors pertaining to ER visits and hospitalization including history of... CHF..." There were no set reportable parameters in which to notify the Physician concerning exacerbation of CHF symptoms. MR #6: The patient was admitted on 1/10/22 for PT only services, with diagnoses that included hypertensive heart disease with heart failure, diabetes-type 2, and history of falling. On 5/4/22, review of the patient's POC (dated 1/10/22) by PT noted the POC ordered PT to "assess patient for risk factors pertaining to ER visits and hospitalization including history of... CHF..." There were no set reportable parameters in which to notify the Physician concerning exacerbation of CHF symptoms. In addition, the patient's POC ordered PT to "assess endocrine system... Therapist to promptly report abnormal blood glucose readings to physician," However, the no interventions were noted on the POC which stipulated PT to attain and report blood sugar values during each visit. No measurable goals concerning diabetes were evidenced within the POC. During an interview on 5/5/22 at 11:15 AM., these findings were reviewed and acknowledged by the Administrator (Adm.#1) and the Director of Professional Services (DPS#1).

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to include contact information for the Home Health Agency's Clinical Manager in the Patient Admission/Orientation Packet, resulting in the potential for unaddressed patient concerns. Findings include: On 5/2/22 at 10:15 AM., the Agency's Admission packet was reviewed. The packet included a consent form, admission agreement, Beneficiary notice and patient rights and responsibilities forms and Emergency Preparedness documents. Upon review, it was noted that there was no contact information for the Agency's Clinical Manager. These findings were reviewed with and confirmed by the Administrator (Adm. #1) during an interview on 5/3/22 at 10:45AM. Adm.#1 stated, "We'll get this fixed today."

Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This STANDARD is not met as evidenced by: Based on observation interview, and record review, the Agency failed to adequately assess and monitor the needs of 1 (MR #1) of 1 patient observed during a Physical Therapy home visit, and 2 (MR#'s 5 and 6) of 2 records reviewed with therapy only cases, from a total sample of 7 sampled records reviewed, resulting in the potential for poor patient outcomes and unmet care needs. Findings include: MR #5: The patient was admitted on 11/18/21 for Physical Therapy (PT) and Occupational Therapy only services, with diagnoses that included hypertensive heart and chronic kidney disease with heart failure, dehydration, and ischemic (low blood supply) cardiomyopathy. On 5/4/22, review of the patient's POC (dated 11/18/21) by PT noted the POC ordered PT to "assess patient for risk factors pertaining to ER visits and hospitalization including history of... CHF..." Review of the visit notes performed by PT and the physical therapy assistant (PTA) noted no documented weights or edema measurements throughout the admission episode. In addition, 3 of 3 visit notes (11/23/21, 11/26/21, and 12/16/21) by the PT documented the following under the "Cardiovascular" section: Cardiovascular System Assessed? NO; Indicate Reason Cardiovascular Status Not Assessed: Not Applicable." Further, PT failed to incorporate the patient's diagnosis of diabetes-type 2 from the referral into treatments and interventions to be furnished during the admission episode. Subsequently, no blood sugar readings were documented in the clinical record. The home visit note on 12/16/21 documented the following discharge assessment narrative: "Patient has been seen at home for physical therapy following admission to the hospital due to CHF. She has been seen nine times with the last visit being on 12/16. She had been doing well with all mobility and was starting to do some cooking in the kitchen. Started feeling poorly yesterday and had a low blood pressure. Blood pressure higher today (106/66) but still having reports of weakness and feeling "Blah". Recommended she increase her water intake and call the Dr. if not feeling better by the end of the day." During an interview on 5/5/22 at 11:05 AM., these findings were reviewed and acknowledged by the Administrator (Adm.#1) and the Director of Professional Services (DPS#1). Adm.#1 and DPS#1 both agreed it was potentially dangerous to give a post-hospitalization CHF patient who was feeling "Blah" and weakened the advice to push fluids. The Agency failed to ensure PT responsibly managed and appropriately advised the patient concerning health related needs. MR #6: The patient was admitted on 1/10/22 for PT only services, with diagnoses that included hypertensive heart disease with heart failure, diabetes-type 2, and history of falling. On 5/4/22, review of the patient's POC (dated 1/10/22) by PT noted the POC ordered PT to "assess patient for risk factors pertaining to ER visits and hospitalization including history of... CHF..." There were no set reportable parameters in which to notify the Physician concerning exacerbation of CHF symptoms. In addition, the patient's POC ordered PT to "assess endocrine system... Therapist to promptly report abnormal blood glucose readings to physician." Review of the visit notes performed by PT and the PTA, noted no documented weights or edema measurements throughout the admission episode (10 of 10 visits). In addition, 4 of 4 visit notes (1/24/22, 2/1/22, 2/3/22, and 2/15/22) by the PT documented the following under the "Cardiovascular" section: Cardiovascular System Assessed? NO; Indicate Reason Cardiovascular Status Not Assessed: Not Applicable." In addition, no blood sugar readings were evidenced in any of the 10 home visits. During an interview on 5/5/22 at 11:15 AM., these findings were reviewed and acknowledged by the Administrator (Adm.#1) and the Director of Professional Services (DPS#1). Adm.#1 and DPS#1 both agreed that an in-service concerning the management of medical needs when therapy only disciplines are assigned to a case needed to take place as soon as possible. MR #1: The patient's start of care (SOC) was 4/23/22 with diagnoses that included heart disease with heart failure, diabetes-type 2, and low back pain. The plan of care (POC) ordered weekly Skilled Nursing (SN), Physical Therapy (PT), and Medical Social Worker (MSW) services. On 5/2/22 at 1:30 PM., during a scheduled home visit with PT services, the home environment was observed to be dilapidated with bare plywood floors, and a significantly cluttered environment which posed an increased risk of patient falls. During the PT visit, the patient was interviewed to ascertain overall needs being met. The patient was noted as being conversational, alert, and oriented to person, place, and time. The patient continued stating she was depressed and that her husband was "very nice in front of others but can be very mean when it's just us." When queried if she mentioned this to the Social Worker, she stated, "She really didn't talk to me, just my husband over the phone." Upon exiting the patient's home, the PT was queried as to potential reasons why MSW services performed the initial evaluation remotely and through the husband and not the patient. The PT replied, "I was wondering that myself, I don't know why didn't make a home visit." During record review on 5/3/22, the initial MSW evaluation on 4/29/22 had documented the following: Husband states patient will not go to the Pines for counseling... Husband reports that without truck driving wages, they make a combined 2800 per month... Husband does not feel they would qualify for food stamps..." No direct narrative from the patient was found in MSW's initial evaluation of the patient. These findings were reviewed with and acknowledged by the Administrator (Adm #1) on 5/3/22 at 10:15 AM. Adm #1 stated, "We're short staffed in that area (MSW services) right now, we have a position currently posted." The Agency failed to ensure MSW services performed a comprehensive initial evaluation that was based directly on the needs of the patient.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on document review and interview, the Agency failed to ensure the Governing Body had reviewed and approved policies and procedures specific to the Home Health Agency, resulting in a lack of clear guidance concerning the Agency's expectations concerning the provision of home health care services, which has the potential to negatively affect all 36 patients currently admitted to the Agency. Findings include: On 5/5/22 at 10:40 AM., it was noted the Agency's policy and procedures that were submitted upon request, were not specific to the Home Health Agency (HHA). For example, the policy "Medication Reconciliation" (copyright 2020), was for "Heartland Home Health Care & Hospice" located at 333 N. Summit Street, Toledo, Ohio 43604. When the Administrator (Adm.#1) was queried about the finding, Adm.#1 stated, "We were bought out by Promedica back in early 2018, and they took over the hospital and all the other services. Our last Governing Body meeting specific for just home health was around April 2019. The Governing Body meetings now take place at the hospital, and the Home Health Agency is just portion of all the different divisions who are there." When Adm.#1 was asked if there was any documentation that showed the current Governing Body had reviewed and approved policy and procedures specific to the HHA within the last two years, Adm.#1 stated, "Not to my knowledge."