Every finding on record at Evergreen Health Services, Inc.

This was a standard survey, a Medicare emergency preparedness survey was not conducted. Evergreen Health Services, Inc. 6510 Town Center Drive suite B Clarkston, MI 48346 The agency has no branches or sub units. The agency was in compliance with COVID-19 vaccination requirements. For this survey 3 home visits with record reviews, 2 active records without a home visit and 2 discharged records were reviewed.

A Medicare recertification survey was conducted by the Michigan Department of Licensing and Regulatory Affairs from 5/31/22 through 6/2/22 at: Evergreen Health Services, Inc. 6510 Town Center Drive suite B Clarkston, MI 48346 The agency has no branches or sub units. The agency was in compliance with COVID-19 vaccination requirements. For this survey 3 home visits with record reviews, 2 active records without a home visit and 2 discharged records were 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 have skilled nursing perform a comprehensive drug review in 5 of 7 (MR #1, 2, 3, 4, 7) records reviewed, resulting in the potential for harmful medication effects for all patients currently serviced by this Agency. Findings include: **Agency Policy: III.17, Medication Management, undated, "Medications will be reviewed for potential adverse effects, drug reactions, ineffective drug therapy, significant drug interactions, duplicate drug therapy, and patient non-compliance." MR #7: The start of care SOC was dated 5/20/22, with diagnoses that included orthopedic aftercare, low back pain, and constipation. During record review on 6/1/22, it was discovered that the start of care (SOC) comprehensive assessment documented under medication review, "Medications reconciled, no potential drug interactions, no significant side effects, no significant drug interaction, and no duplicate drug therapy". On 6/1/22, the drugs were entered into the agency's electronic medical record (EMR) medication reconciliation section and resulted in 3 duplicate drugs, 2 moderate drug interactions, and 1 minor drug interaction. The patient's medications were also entered into "Drugs.com" to validate drug interaction/duplication severity, which resulted in 1 major drug interaction, 5 moderate drug interactions, 2 duplicate drugs, and 4 food/drug interactions. There was no documentation in the record indicating the physician was notified of the results. During an interview on 6/2/22 at 1:30 p.m., the administrator (Adm#1) acknowledged the above findings. MR#1: The Start of Care (SOC) was dated 6/9/21. The Plan of Care (POC) identified diagnoses of Multiple Sclerosis, Stage 1 Pressure Ulcer and Muscle Weakness. During record review on 5/31/22, it was noted that the medication profile dated 6/9/21 stated under Drug Regimen Review, "Medications reconciled, no potential drug interactions, no significant side effects, no significant drug interaction, and no duplicate drug therapy". On 6/2/22 the medication profile was entered into the agency’s electronic medical record (EMR) which resulted in 1 duplicate drug interaction. During the entrance interview with the Administrator (Adm#1) on 5/31/22 at 11:45 am, she stated, “All medication interactions get sent to the physician at the SOC.” There was no documentation in the record indicating the physician was notified of the results. MR#2: The Start of Care (SOC) was dated 5/10/21. The Plan of Care (POC) identified diagnoses of Rheumatoid Arthritis, Chronic Kidney Disease and Congestive Heart Failure. During record review on 6/1/22, it was noted that the medication profile dated 5/10/21 stated under Drug Regimen Review, "Medications reconciled, no potential drug interactions, no significant side effects, no significant drug interaction, and no duplicate drug therapy". On 6/2/22 the medication profile was entered into the agency’s EMR which resulted in 6 duplicate drug interactions and 4 moderate interactions. There was no documentation in the record indicating the physician was notified of the results. MR#3: The Start of Care (SOC) was dated 5/13/22. The Plan of Care (POC) identified diagnoses of Diverticulitis, Bowel Perforation and Flank Pain. During record review on 6/1/22, it was noted that the medication profile dated 5/13/22 stated under Drug Regimen Review, "Medications reconciled, no potential drug interactions, no significant side effects, no significant drug interaction, and no duplicate drug therapy". On 6/2/22 the medication profile was entered into the agency’s EMR which resulted in 3 duplicate drug interactions, 1 major drug interaction and 7 moderate drug interactions. There was no documentation in the record indicating the physician was notified of the results. MR#4: The Start of Care (SOC) was dated 4/23/22. The Plan of Care (POC) identified diagnoses of Mitral Valve Replacement and Congestive Heart Failure. During record review on 6/2/22, it was noted that the medication profile dated 4/23/22 stated under Drug Regimen Review, "Medications reconciled, no potential drug interactions, no significant side effects, no significant drug interaction, and no duplicate drug therapy". On 6/2/22 the medication profile was entered into the agency’s EMR which resulted in 4 duplicate drug interactions and 3 moderate drug interactions. There was no documentation in the record indicating the physician was notified of the results. These findings were reviewed with and acknowledged by the Adm#1 during an interview on 6/2/22 at 12:05 pm.

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, it was determined the Home Health Agency (HHA) failed to ensure the goals on the Plan of Care (POC) were measurable in 6 of 7 records reviewed (M.R.#s 1, 2, 3, 4, 5, 6), from a total of 7 records reviewed, resulting in the potential for a plan of care not meeting the patient's needs. Findings include: **Agency policy: III.7, Professional/ancillary care plans, undated. "The plan of care will include specific, individualized measurable goals..." MR#5: The start of care (SOC) was dated 12/31/20, with diagnoses that included malignant neoplasm of prostate, malignant neoplasm of bladder, and retention of urine. During record review on 5/31/22, it was discovered that the goals on the POC were not measurable, for example, one goal stated, "Patient/caregiver will verbalize understanding of disease process and signs and symptoms by end of care." Another stated, "Patient/caregiver will state understanding of measures to manage disease and identify signs/symptoms to report." There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. MR#6: The start of care (SOC) was dated 6/25/21, with diagnoses that included seizures, falls, and malignant neoplasm of prostate. During record review on 6/1/22, it was discovered that the goals on the POC were not measurable, for example, one goal stated, "Patient will be able to verbalize and demonstrate steps to reduce anxiety and problem solve by 12/18/21." Another stated, "Patient/caregiver can verbalize factors that increase or decrease pain with each assessment by 12/18/21." There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. During an interview on 6/2/22 at 1:30 p.m., the administrator (Adm#1) acknowledged the above findings. MR#1: The Start of Care (SOC) was dated 6/9/21. The Plan of Care (POC) identified diagnoses of Multiple Sclerosis, Stage 1 Pressure Ulcer and Muscle Weakness. During record review on 5/31/22, it was noted that the goals on the POC were not measurable, for example, one goal stated, "Patient/caregiver will verbalize/demonstrate understanding of symptom management to reduce unplanned hospital or emergency department visits." Another stated, "Patient will not have any new evidence of skin breakdown." There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. MR#2: The Start of Care (SOC) was dated 5/10/21. The Plan of Care (POC) identified diagnoses of Rheumatoid Arthritis, Chronic Kidney Disease and Congestive Heart Failure. During record review on 6/1/22, it was noted that the goals on the POC were not measurable, for example, one goal stated, "Patient/caregiver will verbalize understanding of disease process and signs and symptoms by end of care." Another stated, "Pt will demonstrate energy conservation techniques." There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. MR#3: The Start of Care (SOC) was dated 5/13/22. The Plan of Care (POC) identified diagnoses of Diverticulitis, Bowel Perforation and Flank Pain. During record review on 6/1/22, it was noted that the goals on the POC were not measurable, for example, one goal stated, "Patient/caregiver will verbalize/demonstrate understanding of symptom management to reduce unplanned hospital or emergency department visits." Another stated, "Patient will be free of s/s (signs and symptoms) of UTI." There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. MR#4: The Start of Care (SOC) was dated 4/23/22. The Plan of Care (POC) identified diagnoses of Mitral Valve Replacement and Congestive Heart Failure. During record review on 6/2/22, it was noted that the goals on the POC were not measurable, for example, one goal stated, " Patient will demonstrate medication management to reduce unplanned hospital or emergency department visits." Another stated, "Patient/caregiver will state understanding of measures to manage disease and identify signs/symptoms to report." There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. These findings were reviewed with and acknowledged by the Administrator (Adm#1) during an interview on 6/2/22 at 12:05 pm.

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, the agency failed to ensure clinical notes were accurate for 2 of 7 (MR# 3 and 4) records reviewed, resulting in the potential to negatively affect the health and well-being of these patients. Findings include: MR#3: The Start of Care (SOC) was dated 5/13/22. The Plan of Care (POC) identified diagnoses of Diverticulitis, Bowel Perforation and Flank Pain. During record review on 6/1/22, it was noted that the Skilled Nurse (SN) visits on 5/17/22, 5/20/22, 5/23/22 and 5/26/22 were “Pending” in the electronic medical record (EMR). The visit notes contained documentation regarding the visit but were blank under the “Narrative” sections. During the entrance interview on 5/31/22 at 11:45am, the Administrator (Adm#1) stated, “All visit notes for the week are to be completed by Monday of the following week.” The agency failed to ensure that the medical record was complete and accurate. MR#4: The Start of Care (SOC) was dated 4/23/22. The Plan of Care (POC) identified diagnoses of Mitral Valve Replacement and Congestive Heart Failure. During record review on 6/2/22, it was noted that the SN visits on 5/17/22, 5/18/22, 5/24/22 and 5/27/22 were “Pending” in the EMR. The visit notes contained documentation regarding the visit but were blank under the “Narrative” sections. 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 6/2/22 at 12:05 pm.